Antioxidants – Good or Bad?

For Linus Pauling, it all started to go wrong when he changed his breakfast routine. In 1964, at the age of 65, he started adding vitamin C to his orange juice in the morning. It was like adding sugar to Coca Cola, and he believed – wholeheartedly, sometimes vehemently  – that it was a good thing.

Before this, his breakfasts were nothing to write about. Just that they happened early every morning before going to work at California Institute of Technology, even on weekends. He was indefatigable, and his work was fruitful.

At the age of 30, for instance, he proposed a third fundamental way that atoms are held together in molecules, melding ideas from both chemistry and quantum mechanics. Twenty years later, his work into how proteins (the building blocks of all life) are structured helped Francis Crick and James Watson decode the structure of DNA (the code of said building blocks) in 1953. 

The next year, Pauling was awarded a Nobel Prize in Chemistry for his insights into how molecules are held together. As Nick Lane, a biochemist from University College London, writes in his 2001 book Oxygen, “Pauling… was a colossus of 20th Century science, whose work laid the foundations of modern chemistry.”

Image result for linus pauling cc0 image

Linus Pauling was one of our most influential scientists, yet his belief in the power of antioxidants may have set us down a dangerous path

But then came the vitamin C days. In his 1970 bestselling book, How To Live Longer and Feel Better, Pauling argued that such supplementation could cure the common cold. He consumed 18,000 milligrams (18 grams) of the stuff per day, 50 times the recommended daily allowance.

In the book’s second edition, he added flu to the list of easy fixes. When HIV spread in the US during the 1980s, he claimed that vitamin C could cure that, too.

In 1992, his ideas were featured on the cover of Time Magazine under the headline: “The Real Power of Vitamins”. They were touted as treatments for cardiovascular diseases, cataracts, and even cancer. “Even more provocative are glimmerings that vitamins can stave off the normal ravages of ageing,” the article claimed.

Sales in multivitamins and other dietary supplements boomed, as did Pauling’s fame.

But his academic reputation went the other way. Over the years, vitamin C, and many other dietary supplements, have found little backing from scientific study. In fact, with every spoonful of supplement he added to his orange juice, Pauling was more likely harming rather than helping his body. His ideas have not just proven to be wrong, but ultimately dangerous. 

Pauling was basing his theories on the fact that vitamin C is an antioxidant, a breed of molecules that includes vitamin E, beta-carotene, and folic acid. Their benefits are thought to arise from the fact that they neutralise highly reactive molecules called free-radicals.

In 1954, Rebeca Gerschman then at the University of Rochester, New York, first identified these molecules as a possible danger – ideas expanded upon by Denham Harman, from the Donner Laboratory of Medical Physics at UC Berkeley in 1956, who argued that free radicals can lead to cellular deterioration, disease and, ultimately, ageing.

Throughout the 20th Century, scientists steadily built on his ideas and they soon became widely accepted.

Here’s how it works. The process starts with mitochondria, those tiny combustion engines that sit within our cells. Inside their internal membranes food and oxygen are converted into water, carbon dioxide, and energy. This is respiration, a mechanism that fuels all complex life.

‘Leaky watermills’

But it isn’t so simple. In addition to food and oxygen, a continuous flow of negatively charged particles called electrons is also required. Like a subcellular stream downhill powering a series of watermills, this flow is maintained across  four proteins, each embedded in the internal membrane of the mitochondria, powering the production of the end product: energy.

This reaction fuels everything we do, but it is an imperfect process. There is some leakage of electrons from three of the cellular watermills, each able to react with oxygen molecules nearby. The result is a free radical, a radically reactive molecule with a free electron. 

Oxygen is the breath of life, but it also holds the potential to make us old, decrepit, and then dead

In order to regain stability, free radicals wreak havoc on the structures around them, ripping electrons from vital molecules such as DNA and proteins in order to balance its own charge. Although inconceivably small in scale, the production of free radicals, Harman and many others posited, would gradually take its toll on our entire bodies, causing mutations that can lead to ageing and age-related diseases such as cancer.

In short, oxygen is the breath of life, but it also holds the potential to make us old, decrepit, and then dead.

(Credit: Alamy)

Clinical trials are the only ways to reveal the effects of a drug – and investigations into antioxidants have produced some shocking results (Credit: Alamy)

Shortly after free radicals were linked to ageing and disease, they were seen as enemies that should be purged from our bodies. In 1972, for example, Harman wrote, “Decreasing [free radicals] in an organism might be expected to result in a decreased rate of biological degradation with an accompanying increase in the years of useful, healthy life. It is hoped that [this theory] will lead to fruitful experiments directed toward increasing the healthy human lifespan.” 

He was talking about antioxidants, molecules that accept electrons from free radicals thereby diffusing the threat. And the experiments he hoped for were sown, nurtured, and replicated over the next few decades. But they bore little fruit.

The results were the largely the same: an excess of antioxidants didn’t quell the ravages of ageing, nor stop the onset of disease

In the 1970s and into the 80s, for example, many mice – our go-to laboratory animal – were prescribed a variety of supplementary antioxidants in their diet or via an injection straight into the bloodstream. Some were even genetically modified so that the genes coding for certain antioxidants were more active than non-modified lab mice. 

Although different in method, the results were the largely the same: an excess of antioxidants didn’t quell the ravages of ageing, nor stop the onset of disease.

“They never really proved that they were extending lifespan, or improving it,” says Antonio Enriquez from the Spanish National Centre for Cardiovascular Research in Madrid. “Mice don’t care for [supplements] very much.”

(Credit: Alamy)

Far from protecting us from disease, one study found that vitamin supplements increased the incidence of lung cancer among smokers (Credit: Alamy)

What about humans? Unlike our smaller mammalian kin, scientists can’t take members of society into labs and monitor their health over their lifetime, while controlling for any extraneous factors that could bias the results at the end. But what they can do is set up long-term clinical trials.

The premise is pretty simple. First, find a group of people similar in age, location, and lifestyle. Second, split them into two subgroups. One half receives the supplement you’re interested in testing, while the other receives a blank – a sugar pill, a placebo. Third, and crucially to avoid unintentional bias, no one knows who was given which until after the trial; not even those administering the treatment. 

The incidence of lung cancer increased by 16% in the group given vitamin supplements

Known as a double-blind control trial, this is the gold standard of pharmaceutical research. Since the 1970s, there have been many trials like this trying to figure out what antioxidant supplementation does for our health and survival. The results are far from heartening.

In 1994, for example, one trial followed the lives of 29,133 Finish people in their 50s. All smoked, but only some were given beta-carotene supplements. Within this group, the incidence of lung cancer increased by 16%.

A similar result was found in postmenopausal women in the U.S. After 10 years of taking folic acid (a variety of B vitamin) every day their risk of breast cancer increased by 20%relative to those women who didn’t take the supplement. 

It gets worse. One study of more than 1,000 heavy smokers published in 1996 had to be terminated nearly two years early. After just four years of beta-carotene and vitamin A supplementation, there was a 28% increase in lung cancer rates and a 17% increase in those who died.

These aren’t trivial numbers. Compared to placebo, 20 more people were dying every year when taking these two supplements. Over the four years of the trial, that equates to 80 more deaths. As the authors wrote at the time, “The present findings provide ample grounds to discourage use of supplemental beta-carotene and the combination of beta-carotene and vitamin A.”

Fatal ideas

Of course, these notable studies don’t tell the full story. There are some studies that do show benefits of taking antioxidants, especially when the population sampled doesn’t have access to a healthy diet. 

But, according a review from 2012 that noted the conclusions of 27 clinical trials assessing the efficacy of a variety of antioxidants, the weight of evidence does not fall in its favour.

Just seven studies reported that supplementation led to some sort of health benefit from antioxidant supplements, including reduced risk of coronary heart disease and pancreatic cancer. Ten studies didn’t see any benefit at all – it was as if all patients were given the sugar pill also (but, of course, they weren’t). That left another 10 studies that found many patients to be in a measurably worse state after being administered antioxidants than before, including an increased incidence of diseases such as lung and breast cancer.

The idea that antioxidant supplements are a miracle cure is completely redundant – Antonio Enriquez

“The idea that antioxidant [supplementation] is a miracle cure is completely redundant,” says Enriquez. Linus Pauling was largely unaware of the fact that his own ideas could be fatal. In 1994, before the publication of many of the large-scale clinical trials, he died of prostate cancer. Vitamin C certainly wasn’t the cure-all that he cantankerously claimed it was up until his last breath. But did it contribute to a heightened risk? 

(Credit: Alamy)

Dosing up on vitamin C does not even help us fight the common cold (Credit: Alamy)

We’ll never know for sure. But given that multiple studies have linked excess antioxidants to cancer, it certainly isn’t out of the question. A study published in 2007 from the US National Cancer Institute, for instance, found that men that took multivitamins were twice as likely to die from prostate cancer compared to those who didn’t. And in 2011, a similar study on 35,533 healthy men found that vitamin E and selenium supplementation increased prostate cancer by 17%.

Ever since Harman proposed his great theory of free radicals and ageing, the neat separation of antioxidants and free radicals (oxidants) has been deteriorating. It has aged.

Antioxidant is only a name, not a fixed definition of nature. Take vitamin C, Pauling’s preferred supplement. At the correct dose, vitamin C neutralises highly charged free radicals by accepting their free electron. It’s a molecular martyr, taking the hit upon itself to protect the cellular neighbourhood. 

But by accepting an electron, the vitamin C becomes a free radical itself, able to damage cell membranes, proteins and DNA. As the food chemist William Porter wrote in 1993, “[vitamin C] is truly a two-headed Janus, a Dr Jekyll-Mr Hyde, an oxymoron of antioxidants.”

Thankfully, in normal circumstances, the enzyme vitamin C reductase can return vitamin C’s antioxidant persona. But what if there’s so much vitamin C that it simply can’t keep up with supply? Although such simplifying of complex biochemistry is in itself problematic, the clinical trials above provide some possible outcomes.  

Divide and conquer

Antioxidants have a dark side. And, with increasing evidence that free radicals themselves are essential for our health, even their good side isn’t always helpful.

Without free radicals, cells would continue to grow and divide uncontrollably

We now know that free radicals are often used as molecular messengers that send signals from one region of the cell to another. In this role, they have been shown to modulate when a cell grows, when it divides in two, and when it dies. At every stage of a cell’s life, free radicals are vital.

Without them, cells would continue to grow and divide uncontrollably. There’s a word for this: cancer.

We would also be more prone to infections from outside. When under stress from an unwanted bacterium or virus, free radicals are naturally produced in higher numbers, acting as silent klaxons to our immune system. In response, those cells at the vanguard of our immune defense – macrophages and lymphocytes – start to divide and scout out the problem. If it is a bacterium, they will engulf it like Pac-Man eating a blue ghost.

It is trapped, but it is not yet dead. To change that, free radicals are once again called into action. Inside the immune cell, they are used for what they are infamous for: to damage and to kill. The intruder is torn apart.

From start to finish, a healthy immune response depends on free radicals being there for us, within us. As geneticists Joao Pedro Magalhaes and George Church wrote in 2006: “In the same way that fire is dangerous and nonetheless humans learned how to use it, it now appears that cells evolved mechanisms to control and use [free radicals].”

Put another way, freeing ourselves of free radicals with antioxidants is not a good idea. “You would leave the body helpless against some infections,” says Enriquez.

(Credit: Getty Images)

Few would dispute that a balanced diet is essential for good health, but most of us don’t need supplements to meet our nutritional needs (Credit: Getty Images)

Thankfully, your body has systems in place to keep a your inner biochemistry as stable as possible. For antioxidants, this generally involves filtering any excess out of the bloodstream into urine for disposal. “They go in the toilet,” says Cleva Villanueva from Instituto Politécnico Nacional, Mexico City, in an email.

“We’re very good at balancing things out so that the affect [of supplementation] is moderate whatever you do, which we should be grateful for,” says Lane. Our bodies have been selected to balance the risk of oxygen ever since the first microbes started to breathe this toxic gas. We can’t change billions of years of evolution with a simple pill.

No one would deny that vitamin C is vital to a healthy lifestyle, as are all antioxidants, but unless you are following doctor’s orders, these supplements are rarely going to be the answer for a longer life when a healthy diet is also an option. “Administration of antioxidants is justified only when it is evident that there is a real deficiency of a specific antioxidant,” says Villanueva. “The best option is to get antioxidants from food because it contains a mixture of antioxidants that work together.”

“Diets rich in fruits and vegetables have been shown generally to be good for you,” says Lane. “Not invariably, but generally that’s agreed to be the case.” Although often attributed to antioxidants, the benefits of such a diet, he says, might also hail from a healthy balance of pro-oxidants and other compounds whose roles aren’t yet fully understood.

After decades of unlocking the baroque biochemistry of free radicals and antioxidants, hundreds of thousands of volunteers, and millions of pounds spent on clinical trials, the best conclusion that 21st Century science has to offer is also found within a child’s classroom – eat your five-a-day.

By Alex Riley

8 December 2016

Obtaining all of the nutrients you need

Does it ever cross your mind that you may not be obtaining all of the nutrients you need for outstanding health and energy from your food?

Whether that is due to too many poor food choices, decreasing nutrient levels in the soil – so therefore in our food – or because of digestive system problems or age, getting enough nutrients through diet is becoming more of a challenge for people these days.

It is important to make as many mouthfuls as possible count in supplying your body with the essential substances it needs each day – vitamins, minerals, antioxidants – for example.

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One way to do this is by choosing more nutrient-dense foods, which provide more nutritional bang for your buck. Rather than focusing on what to avoid, shift your focus to increasing the nutrient density of your meals, and as a result, some of the less-nourishing things often tend to fall away. Here are eight ways you can increase the nutrient density of your diet.

DRINK YOUR LEAFY GREENS

With the increase in special occasions around Christmas time and the often not so nourishing food options, juicing veges or making smoothies is a wonderful way to amp up your nutrition when you’re in charge. Incorporate some organic leafy greens for an extra boost and some nourishing whole food fats such as avocado, nuts or seeds and you have an easy but nourishing snack.

SNACK ON VEGES

One of the goals with a nutrient dense diet is to increase your vegetable intake to at least 5-7 servings daily. Adding a vegetable snack will certainly bring you much closer to this target.Try carrot sticks with hummus, cherry tomatoes with almond butter, or simply a platter of assorted colourful raw veges such as cabbage, tomatoes, cucumber, and carrots when you need a crunchy snack.

DECREASE YOUR RELIANCE ON FILLER FOODS

Bread, pasta, crackers, potato chips are just some examples of foods that many use to “fill” up. They take up a significant proportion of dietary energy but yet don’t give much back nutritionally, particularly from a micronutrient perspective. Instead swap these out for more vegetables such as broccoli or leafy greens or starchy vegetable options such as kumara, pumpkin, carrots, or beetroot. That way you will still get that feeling of fullness the other carbohydrate options offer, but you’re also increasing the phytochemical, vitamin and mineral density of your meal.

TOP YOUR MEALS WITH NUTS AND SEEDS

Sprinkle mineral-rich nuts or seeds such as chia seeds, sesame seeds, almonds, cashew, sunflower or pumpkin seeds. They’re easily added to salads, main meals or even sprinkled on top or your breakfast porridge or eggs. Keep a blend on hand in a glass jar so you can easily incorporate them.

EAT AN ADDITIONAL SERVING OF VEGETABLES WITH EVERY MEAL

Incorporate more vegetables by changing the way you plate your meals, build the meal around the vegetables as opposed to the carbohydrate or protein options. Aim for around half your plate to be filled up with vegetable content. If this makes you panic, start by aiming for a quarter of the plate. Options like a simple herby slaw as a side as well as steamed or stir-fried vegetables are a great way to boost the vegetable content of your meal.

CHANGE YOUR BREAKFAST

Breakfasts provide another opportunity for nourishment yet far too often we can rely on not so nourishing options such as toast or cereal! Start your day off right with a nutrient boost by adding in a green smoothie, adding leafy greens and avocado to your typical poached eggs and toast, or by making a vegetable packed frittata.

INCORPORATE PROTEIN

In today’s world many people struggle with blood glucose regulation, ranging from hypoglycemia to insulin resistance to type-2 diabetes. One of the best ways to maintain stable blood glucose levels is to eat protein with each meal. Depending on your dietary preference this can be fish, meat, poultry and eggs, or vegetarian/vegan sources such as beans or lentils, nuts and seeds.

COLOUR IS KEY

When it comes to nutrient density the more colour you can incorporate the better. For example the beautiful bright purple in purple cabbage comes from anthocyanins whereas the bright red pigment in tomato comes from lycopene – each have their own unique health properties. Some of the most colourful foods have very high levels of antioxidants for example, turmeric, pomegranate, beetroot, spinach, kales and kumara to name a few.

Dr Libby is a nutritional biochemist, best-selling author and speaker. The advice contained in this column is not intended to be a substitute for direct, personalised advice from a health professional. Visit drlibby.com

It’s all lies!

Author Jeff Scot Philips makes some damning claims about ‘healthy’ food in his new book.

Larry Getlen – New York Post

IN SEPTEMBER, the Journal of the American Medical Association’s Internal Medicine publication revealed that many of Americans’ most prevalent beliefs about nutrition might be bunk.

The sugar industry financed nutritional studies, released in 1967, that downplayed the sweetener’s relation to heart disease, placing the blame on saturated fats instead. Those highly influenced findings have stuck for five decades.

One of the scientists involved even helped develop the government-issued nutrition guidelines which contained cautions on the evils of red meat while scarcely mentioning the dangers of sugar, if at all.

These revelations make the release of a new book by food-industry expert Jeff Scot Philips, Big Fat Food Fraud: Confessions of a Health-Food Hustler (Regan Arts), well-timed. Philips was a personal trainer who founded a health-food manufacturing company that prepackaged healthy meals. He is now reformed from that industry, and spends his time educating people on how almost everything we hear about nutrition — including from medical experts — may be false. Much of it, he says, is specially designed not to improve our health, but to separate us from our money.

In the book, Philips outlines a slew of ways we have been — and are still being — conned by the food industry. Here are just a few.

The yolk’s on eggs

Eggs have had a bad name in the past.

Eggs have had a bad name in the past.Source:istock

If you want to see how long inaccurate nutritional information can persevere, just take a look at eggs.

When Kellogg marketed its first food product, Cornflakes, in 1906, Philips writes that the company “mounted a vicious marketing campaign against the egg industry … claim[ing eggs] led to heart attacks.” The information was baseless fiction designed to sell cereal, but fear of eggs continues to this day.

“Are eggs healthy” and “Are eggs bad for you” are two of the top Google searches for this breakfast staple, despite the American Heart Association declaring eggs healthy in 2000, a finding reaffirmed by the government, in even stronger language, earlier this year.

Sometimes the food regulators are complicit

Philips shows that in some cases the food regulators may actively be making our food less healthful. A USDA (US Department of Agriculture) agent who worked with Philips’s company said he couldn’t approve calling a salmon dish “healthy” because the fat content was too high. The agent offered a solution: not to lower the fat content, but rather to add sugar or carbs to the meal.

“It’s the nutrition label,” the agent told him. “The guideline is about the ratio of fat grams to total grams in a serving.”

“That has nothing to do with health!” Philips said.

“Have you ever seen a Lean Cuisine meal without some bread or pasta in it?” the agent said, explaining, “The total grams of food go up while the fat grams stay the same; this evens out the ratio.”

The cover of Jeff Scot Philips’ new book.

The cover of Jeff Scot Philips’ new book.Source:Supplied

It’s a numbers game

Given the growing interest in eating healthfully, finding trans fat-free and sugar-free food is a top concern for many people. But the sad fact is that many foods marketed as trans fat-free or sugar-free might actually be loaded with them.

“Legally, as long as the trans fats-per-serving is equal to or less than 0.5 grams, we were allowed to list them as zero on the label,” Philips writes of his former company. But he also notes that brands are legally allowed to set the serving sizes on their packaging (1 serving, 3½ servings per bag, etc.) however they want.

So if a food contains too much trans fat or sugar to be considered healthy, a marketer can make it seem like far less by creating smaller portion sizes.

“If one of our meals contained 20 grams of sugar, we simply chopped the serving size down to four per container, and listed five grams of sugar on the nutrition label,” Philips writes.

Since health-food marketers need to be able to claim their foods are trans fat-free, they simply play with portion sizes until the math works.

“Nobody could stop us from marking a food that actually had 5 grams of trans fats at zero grams,” he writes, “simply by listing the servings-per-container at 10.”

Author Jeff Scot Philips.

Author Jeff Scot Philips.Source:Supplied

Doctors drink the Kool-Aid

Even the nutrition information you get from your physician might be false — because the doctor might be getting that information from marketers like Philips.

In the book, he mentions a computer program called Infusionsoft that handles all ends of the consumer-marketing process in order to target local health and nutrition pros with the newest findings — which are typically sponsored, created or manipulated by marketers — so that these experts can then promote these findings to their patients and clients.

Philips cites an example of a marketing campaign he used to sell more smoothies and protein bars. He knew of one doctor in particular who prided herself on knowing all the new info; one of her patients was also a Philips customer. Philips bombarded the doctor with messages about “new research” that found calorie counting was paramount to weight loss, and therefore, supplements like smoothies and protein bars could be more effective than “real” food if they had fewer calories.

He saw the success in his campaign via his customer, who, based on her doctor’s advice, started buying more of his smoothies and protein bars — and gained 23 pounds in the process.

Given all he knows about the industry, Philips’s own philosophy on food is to stick to the basics: eat more protein and less sugar, avoid processed food or anything that comes in a box, and, most of all, ignore marketing terms and nutrition labels, because they aren’t educating us the way we think they are.

“The cold truth is: Food labels aren’t there to educate you,” he writes. “They’re there to help market to you.”

This article originally appeared on The New York Post.

Drinking water before a meal – we separate fact from fiction

There’s an old dieter’s adage that you should drink a full glass of water before a meal, to reduce your appetite and prevent yourself from eating too much.

There are also claims that drinking water during meals is a bad idea, because it may have negative effects on digestion.

Medical professionals, on the other hand, keep telling us to chug down all the water we can, no matter what time of day.

When it comes to water and meals, what’s true, and what’s a myth?

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Let’s start with that sage advice from dieters, because it’s actually based firmly in scientific research.

Drinking two glasses (around 500ml in total) of water before mealtimes has been proven by numerous studies as a weight loss aid. A 2016 study published in Obesity journal found overweight adults ate 40 less calories per meal after 500ml of H2O “pre-loading”, and other research has shown slightly higher results.

In fact, two studies (both from the Journal of Clinical Endocrinology and Metabolism) have found that your metabolic rate and energy expenditure are increased by 30 per cent and 24 per cent (respectively) within 10-60 minutes of drinking 500ml of water.

WEIGHT LOSS

Using the same metrics, another study by the University of Birmingham found the average weight loss over a course of three months was between two and four kilograms.

That’s without changing your diet at all, although there’s some suggestion that because high water consumption requires more frequent bathroom breaks, study participants could be walking more, and thus burn more calories that way.

The suggestions that drinking water and eating simultaneously during one meal could negatively affect your health are misleading.

There’s the myth that drinking water dilutes the digestive enzymes and acid in the stomach, making it more difficult for to process what you’re eating. This claim populates natural health and beauty blogs and spouted by some dieticians.

Moreover, there’s also the misguided argument that drinking water while eating speeds up the exit of foods (and their nutrients) through the body, thus disallowing maximum nutritional benefit and enabling poorer digestion.

According to the journals Digestive Diseases and Sciences and Clinical Nuclear Medicine, both claims are not scientifically sound. There’s no reliable evidence-based proof to support either argument.

The takeaway here is actually a nice little lesson in human biology: your digestive system simply and efficiently adapts its secretions to best suit a food’s consistency, and will digest as appropriate for the conditions it has been given.

There’s one exception where this doesn’t necessarily happen, but all it tells us is that there are some people who should take sips of water throughout their mealtimes, not that they shouldn’t.

THE CHEW FACTOR

Those that don’t chew their food thoroughly enough often end up swallowing large chunks, which makes digestion harder and leads them to feelings of pain and bloating. Water breaks these chunks up as soon as they go down the throat and into the stomach, meaning water can help digest food.

What’s more, water is essential in softening stools and helping them glide through the body. This means you’re less likely to experience constipation.

The only scientific evidence that suggests people should not drink water with their food concerns those with gastric reflux (also known as acid reflux). As a study in Surgical Endoscopy journal confirmed, extra liquid in the stomach emulates the feeling of being over-full, and may trigger their reflux symptoms. Such people may feel more comfortable drinking and eating separately.

We must note that there is no scientific evidence to say that people who chew adequately and eat at a regular (i.e. not Labrador-like) pace must drink water with meals. There’s no data to confirm that water consumed with food interferes with your digestive enzymes, neither positively or nor negatively.

It’s up to you and your personal choice. As such, unless you’re one of the previously-mentioned exceptions, you can drink your required daily dose of water – which still remains at eight glasses/two litres – whenever you want throughout the day.

Lee Suckling has a masters degree specialising in personal health reporting. Do you have a health topic you’d like Lee to investigate? Send us an email to [email protected] with Dear Lee in the subject line.

How your microbiota affects you

The gut microbiota is the community of bugs, including bacteria, that live in our intestine. It has been called the body’s “forgotten organ” because of the important role it plays beyond digestion and metabolism.

You might have read about the importance of a healthy gut microbiota for a healthy brain. Links have been made between the microbiota and depression, anxiety and stress. Your gut bacteria may even affect how well you sleep.

But it can be difficult to work out exactly how far the science has come in this emerging field of research. So what evidence is there that your gut microbiota affects your brain?

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HOW DOES YOUR GUT TALK TO YOUR BRAIN?
When you’re healthy, bacteria are kept safely inside your gut. For the most part, the bacteria and your gut live in harmony. (The gut has been known to nurture or even control the behaviour of the bacteria for your well-being.)

So how do the bacteria get their signal out? 

The best evidence is that the normal channels of communication from your gut are being hijacked by the bacteria.

The gut has a bi-directional relationship with the central nervous system, referred to as the “gut-brain axis”. This allows the gut to send and receive signals to and from the brain.

A recent study found that the addition of a “good” strain of the bacteria lactobacillus (which is also found in yoghurt) to the gut of normal mice reduced their anxiety levels. The effect was blocked after cutting the vagus nerve – the main connection between brain and gut. This suggests the gut-brain axis is being used by bacteria to affect the brain.

This link was clarified in a study where bacterial metabolites (by-products) from fibre digestion were found to increase the levels of the gut hormone and neurotransmitter, serotonin. Serotonin can activate the vagus, suggesting one way your gut bacteria might be linked with your brain.

There are many other ways gut bacteria might affect your brain, including via bacterial toxins and metabolites, nutrient-scavenging, changing your taste-receptors and stirring up your immune system.

HOW CAN THE GUT AFFECT YOUR MENTAL HEALTH?
Two human studies looked at people with major depression and found that bacteria in their faeces differed from healthy volunteers. But it’s not yet clear why there is a difference, or even what counts as a “normal” gut microbiota.

In mouse studies, changes to the gut bacteria from antibiotics, probiotics (live bacteria) or specific breeding techniques are associated with anxious and depressive behaviours. These behaviours can be “transferred” from one mouse to another after a faecal microbiota transplant.

Even more intriguingly, in a study this year, gut microbiota samples from people with major depression were used to colonise bacteria-free rats. These rats went on to show behavioural changes related to depression.

Stress is also likely to be important in gut microbiota and mental health. We’ve known for a long time that stress contributes to the onset of mental illness. We are now discovering bi-directional links between stress and the microbiota.

In rat pups, exposure to a stressor (being separated from their mums) changes their gut microbiota, their stress response, and their behaviour. Probiotics containing “good” strains of bacteria can reduce their stress behaviours.

HOW GUT MICROBIOTA AFFECTS YOUR MOOD
Medical conditions associated with changes in mood, such as irritable bowel syndrome (IBS) and chronic fatigue syndrome (CFS), might also be related to gut microbiota.

IBS is considered a “gut-brain disorder”, since it is often worsened by stress. Half of IBS sufferers also have difficulties with depression or anxiety.

Ongoing research is investigating whether gut bacteria are one reason for the mood symptoms in IBS, as well as the gastrointestinal pain, diarrhoea and constipation.

Similarly, CFS is a multi-system illness, with many patients experiencing unbalanced gut microbiota. In these patients, alterations in the gut microbiota may contribute to the development of symptoms such as depression, neurocognitive impairments (affecting memory, thought and communication), pain and sleep disturbance.

In a recent study, higher levels of lactobacillus were associated with poorer mood in CFS participants. Some improvements in sleep and mood were observed when patients used antibiotic treatment to reduce gut microbial imbalance.

The exact contributions of stress and other factors such as intestinal permeability (which allows nutrients to pass through the gut) to these disorders are not understood. But the downstream effects seem to be involved in IBS, inflammatory bowel conditions, CFS, depression and chronic pain.

HOW OUR GUT AFFECTS OUR SLEEP
Our mental health is closely linked to the quality and timing of our sleep. Now evidence suggests that the gut microbiota can influence sleep quality and sleep-wake cycles (our circadian rhythm).

A study this year examined patients with CFS. The researchers found that higher levels of the “bad” clostridium bacteria were associated with an increased likelihood of sleep problems and fatigue, but this was specific to females only. This suggests that an unbalanced gut may precipitate or perpetuate sleep problems.

There is emerging evidence that circadian rhythms regulate the gut immune response. The effect of immune cells on the biological clock could provide insights into the possible bi-directional relationship between sleep and the gut. For example, data from animal studies suggests that circadian misalignment can lead to an unbalanced gut microbiota. But this effect can be moderated by diet.

There is growing concern that disruptions to our circadian timing of sleep leads to a range of health issues, such as obesity, metabolic and inflammatory disease, and mood disorders. This is particularly important for shiftworkers and others who experience changes to their sleep/wake patterns.

WHAT THIS MEANS FOR TREATMENT
In terms of using interventions directed at the gut to treat brain disorders – so called “psychobiotics” – there is a lot of promise but little clear evidence.

Probiotic (live bacteria) treatments in mice have been shown to reduce cortisol, an important stress hormone, and decrease anxious and depressive behaviours.

Probiotic (live bacteria) can be found in yoghurt.

Probiotic (live bacteria) can be found in yoghurt.

But there are very few studies in humans. A recent systematic review of all the human studies showed the majority do not show any effect of probiotics on mood, stress or symptoms of mental illness.

On the plus side, large studies show us that people who eat a balanced diet with all the usual good stuff (fibre, fresh fruit and vegetables) have lower rates of mental illness as adults and adolescents.

Clearly, diet affects both the gut microbiota and mental health. Research is ongoing to see whether it is a healthy gut microbiota that underlies this relationship.

A healthy gut microbiota is linked to a healthy brain. However there are only a handful of human studies demonstrating real-world relevance of this link to mental health outcomes.

There is still a way to go before we can say exactly how best to harness the microbiota in order to improve brain function and mental health.

– The Conversation

Seven things to eat or avoid to lower your blood pressure

Rolled oats are full of fibre, and great for lowering blood pressure.

Rolled oats are full of fibre, and great for lowering blood pressure.

High blood pressure is called the silent killer. That’s because it has no symptoms. Having high blood pressure (hypertension) increases your risk of heart disease, stroke, heart failure and kidney disease.

In New Zealand, about 16 per cent of adults take medication for high blood pressure – 140/90 millimetres of mercury (mmHg) or more.

There is some good news. High blood pressure can be treated or prevented. Eating oats, fruit and vegetables – and beetroot, in particular – helps. So does avoiding salt, liquorice, caffeine and alcohol.

Optimal blood pressure is 120 mmHg or less over 80 mmHg or less. Lowering it by 1-2 mmHg can have a big impact on reducing your risk of heart disease and stroke, and the nation’s health care costs.

WHAT TO EAT TO LOWER YOUR BLOOD PRESSURE

Rolled oats

A review with five research trials included tested the impact of oats on systolic blood pressure (the first blood pressure number, which is the pressure at which the heart pumps blood) and diastolic blood pressure (the second number, which is when the heart relaxes) in about 400 healthy adults.

The researchers found that systolic blood pressure was 2.7  mmHg lower and diastolic blood pressure was 1.5 mmHg lower when participants ate around 60 grams of rolled oats (a packed half-cup raw oats) or 25 grams of oat bran per day.

This quantity of oats or oat bran contains around four grams of a type of fibre called beta-glucan.

For each extra one gram of total daily fibre, there was an extra 0.11 mmHg reduction in diastolic blood pressure.

Recommended minimum daily adult fibre intakes are 30 grams for men and 25 grams for women.

While some of fibre’s effect is due to weight loss, soluble fibres produce bioactive products when they’re fermented in the large bowel. These work directly to lower blood pressure.

To improve your blood pressure, eat rolled oats or oat bran for breakfast, add to meat patties, or mix with breadcrumbs in recipes that call for crumbing.

Beetroot

Try a beetroot juice. It’s full of goodness.

Beetroot is extremely rich in a compound called inorganic nitrate. During digestion, this gets converted into nitric oxide, which causes arteries to dilate. This directly lowers the pressure in them.

A review of 16 trials of mostly healthy young men found drinking beetroot juice was associated with a 4.4 mmHg reduction in systolic blood pressure. But it found no change in diastolic blood pressure.

However, a recent US trial in 68 adults who already had high blood pressure found beetroot juice reduced systolic and diastolic blood pressure.

The men were randomly assigned to drink 250ml (one cup) of beetroot juice daily for four weeks or a non-active placebo.

Blood pressure in the men who drank the beetroot juice reduced over 24 hours, with systolic blood pressure 7.7 mmHg lower and diastolic blood pressure 5.2 mmHg lower.

Try wrapping whole fresh beetroot in foil and baking in the oven until soft, or grate beetroot and stir-fry with red onion and curry paste and eat as a relish.

Vitamin C

Citrus fruits are a good source of vitamin c.

Vitamin C, or ascorbic acid, is found in fresh vegetables and fruit. An average serve contains 10-40mg of vitamin C.

In a review of 29 short-term trials of vitamin C supplements, people were given 500 mg of vitamin C per day for about eight weeks.

Blood pressure significantly improved, with an average reduction in systolic blood pressure of 3.84 mmHg and 1.48 mmHg for diastolic blood pressure.

When only those with existing high blood pressure were considered, the drop in systolic blood pressure was 4.85 mmHg.

However, those at risk of kidney stones need to be cautious about taking vitamin C supplements. Excess vitamin C is excreted via the kidneys and can contribute to the formation of kidney stones.

One advantage of getting more vitamin C from eating more vegetables and fruit is that you boost your potassium intake, which helps counter the effects of sodium from salt.

WHAT TO AVOID TO LOWER BLOOD PRESSURE

Salt

Salt might enhance flavour, but too much can raise blood pressure.

Salt or sodium chloride has been used to preserve foods and as a flavour enhancer for centuries.

High salt intakes are associated with higher blood pressure.

Adults need between 1.2 to 2.4g of salt each day (one-quarter to a half teaspoon), which is equivalent to 460 to 920mg of sodium.

If you add salt to food yourself this pushes your sodium intake even higher.

A review of studies involving 3230 people showed that reducing salt intakes by 4.4 grams a day could reduce systolic blood pressure by about 4.2 mmHg and diastolic by 2.1 mmHg.

In those who had high blood pressure there were even bigger reductions of 5.4 mmHg (systolic) and 2.8 mmHg (diastolic).

Avoid foods high in sodium. Don’t add salt and try to choose lower-salt versions of processed foods.

Alcohol

One galss of wine is ok.

Consuming one or more alcoholic drink a day is associated with systolic blood pressure that is about 2.7 mmHg and diastolic blood pressure 1.4 mmHg higher than non-drinkers.

Interestingly, when you first drink an alcoholic beverage, blood pressure goes down, only to rise later.

A rise in blood pressure after drinking alcohol is more likely to happen when you’re awake, rather during sleep.

The bad news is that larger amounts of alcohol increase your risk of high blood pressure, especially in men, but also to a lesser extent in women.

Liquorice

Most liquorice lollies actually contain very little liquorice root.

High blood pressure due to eating black liquorice is rare, but case reports have occurred.

Most liquorice lollies sold currently contains very little true liquorice root and therefore, little glycyrrhizic acid (GZA), the active ingredient.

Occasionally, liquorice candy does contain GZA in large amounts. GZA causes sodium retention and potassium loss, which contributes to high blood pressure.

So check liquorice food labels. Take care if it contains liquorice root.

Caffeine

Coffee pushes up the blood pressure. Don’t drink too much of it.

Caffeine is most commonly consumed in coffee, tea, cola and energy drinks.

High intakes of caffeine from coffee increase blood pressure in the short term.

In a review of five trials, people given one to two cups of strong coffee had an increase in their systolic blood pressure of 8.1 mmHg and 5.7 mmHg for diastolic blood pressure, up to about three hours after drinking it.

But three studies that lasted two weeks found drinking coffee did not increase blood pressure compared with decaffeinated coffee or avoiding caffeine. So you need to monitor your individual response to caffeine.

10 diet tips backed by science and research

The 10 diet strategies proven by science doesn’t include burgers everyday. Sadly.

EACH and every day there are headlines screaming the benefits of various diet and exercise regimes.

Go Paleo, cut the carbs, fast occasionally or do a juice cleanse are just a few of the more recent diet trends to do the rounds.

But when it comes to what the evidence shows are sustainable ways to lose weight and keep it off, the results can be a little sparse when it comes to proving the benefits of these regimes long term.

Here are some of the strategies that science shows do work when it comes to long term weight loss success.

1) Eat less at night for weight loss

While it is often debated by health professionals, there is growing evidence to show that eating less at night, or at least having relatively long periods overnight without food is beneficial when it comes to weight loss.

Try and limit the amount of food you eat at night.

Try and limit the amount of food you eat at night.Source:istock

A recent study published in the British Journal of Nutrition found that healthy men who restricted their calorie intake between the hours of 7pm and 6am consumed more than 200 fewer calories per day. The moral of the story, eat for fewer hours each day to support calorie control and weight loss.

2) Eat like the Italians

Of all the dietary regimes sprouted, few, if any have the scientific evidence base that supports disease prevention and longevity the way the Mediterranean diet does.

You heard it — eat like an Italian would!

You heard it — eat like an Italian would!Source:istock

Packed full of fresh fruit, vegetables and plenty of good fats thanks to lashings of olive oil, nuts and avocado, not only is your heart likely to be healthier eating this way, but your risk of developing a number of other diseases — including cancer — as well.

3) Watch your liquid calories

Few foods are directly linked to weight gain the way soft drinks, juices and other sources of non-nutritive liquid calories are.

Avoid soft drink at all costs.

Avoid soft drink at all costs.Source:istock

High sugar liquids deposit fat in the liver more readily than other foods and are easily overconsumed. Any time you see sugar in a liquid form, you are best to avoid it.

4) Concentrate on eating

Studies have repeatedly shown the benefits of mindful eating, including fewer total calories consumed, increased satiety and less calories consumed at the next meal.

This means it is time to ditch lunch in front of the computer for a few minutes and instead focus on what you are eating, and how much you are putting in your mouth.

5) Focus on fibre

Another old school dietary approach that many of us continue to ignore is getting enough fibre. Many of us are failing to reach the recommended intake thanks to an inadequate consumption of fresh fruit and vegetables. Instead, we are over indulging in more processed carbs, such as white bread, white rice and pasta.

Incorporate more fibre in your diet, such as fruits, vegetables and legumes.

Incorporate more fibre in your diet, such as fruits, vegetables and legumes.Source:istock

Adults should aim for 30g of dietary fibre each day through 2-3 cups salad and vegetables, a couple of pieces of fruit and wholegrains like corn, brown rice, quinoa and legumes.

6) Ditch the diet drinks

While diet soft drinks may appear to be a healthier option, and while they may contain no added sugar, they remain an exceptionally sweet food and one that is linked to increased hunger, sweet cravings and hormonal issues.

For this reason, consuming them occasionally rather than thinking they are a good swap for regular soft drink is the key.

7) Sleep more

The more you sleep, the fewer hours there are to eat. When it comes to chronic sleep deprivation, getting less than five hours a night of shut eye is linked to increased body weight likely due to hormonal imbalances which can be impacted by lack of sleep.

The more you sleep, the less time you have to eat. So try and get as much shut-eye as you can.

The more you sleep, the less time you have to eat. So try and get as much shut-eye as you can.Source:istock

Ideally aim for at least six to seven hours a night to avoid this effect.

8) Be consistent

No diet needs to be perfect to get good results. Data from the US Weight Control Registry — which tracks the progress of more than 5000 Americans who have lost more than 15kg and kept it off — has shown that consistency is the key when it comes to weight control.

Consistency is key. A chocolate treat here and there isn’t going to ruin your hard work.

Consistency is key. A chocolate treat here and there isn’t going to ruin your hard work.Source:istock

This means a one off treat is not the issue when it comes to weigh gain. The problem is what you are having for breakfast, lunch and dinner most days of the week.

9) Keep moving

Exercise is great but even more important is the need to keep active. The biggest shift in modern life is that we find ourselves sitting down for many hours each day. In turn this means we need to clock up some serious steps in an attempt to counter act these long periods of inactivity.

Make your move, and try to make at least 10,000 steps a day.

Make your move, and try to make at least 10,000 steps a day.Source:istock

For many of us this means moving at least 10,000 steps a day in addition to regular exercise. Research has shown that Individuals who have lost weight long term and kept it off clock up at least 60 minutes of activity every day

10) Get enough protein

Diets higher in protein have been shown to help regulate appetite, blood glucose levels and heart disease risk factors.

Opt for a protein snack such a Greek yoghurt and berries to help regulate your appetite.

Opt for a protein snack such a Greek yoghurt and berries to help regulate your appetite.Source:istock

As a general rule of thumb, teaming each meal with a combo of slowly digested carbs such as wholegrains or fruit with a protein rich food is an easy dietary mantra. Try tuna on crackers, Greek yoghurt and fruit or brown rice with chicken next time you’re preparing a meal or snack.

Susie Burrellnews.com.au@SusieBDiet

10 things you need to know about iron

Iron – we know we need it, but perhaps we don’t know exactly why, what exactly iron is, how to get the amount we need, or even what that amount is.

Dr Cathy Stephenson shares all the key facts.

1. Iron deficiency is the most common dietary deficiency in the world. It is thought that up to 20 per cent of New Zealand women, and 3 per cent of men, may be lacking in this essential nutrient.

2. The rate of iron deficiency in children is not clear, but is likely to be high. Studies have reported rates as high as 8-14 per cent in New Zealand babies aged 6-24 months. Teenage years (around 11-14) are a risky time as well, because of rapid growth, and the onset of menstruation. In this group, the highest prevalence is in Maori and Pacific Island girls.

READ MORE:
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3. Iron is incredibly important for our bodies and minds. It enables blood cells to carry oxygen to our muscles and brains. It keeps us mentally fit, strong and able to fight infections. A lack of iron will cause anaemia, tiredness, lethargy, pallor, increased susceptibility to infections such as coughs, colds or thrush, irritability or grumpiness, and poor concentration. In children especially, being iron deficient can contribute to difficulties in learning and retaining information.

4. Average daily requirements of iron vary throughout life depending on the stage you are in. For example, we know that babies and teenagers have much greater iron needs to cope with the rate of growth of their bodies. Women who are pregnant or breast-feeding need extra iron to cope with the baby’s demands; the same is true for women who are menstruating – they need extra iron to replace the iron lost each month with their period. Athletes may also need to be aware of their iron intake, as regular intense exercise will increase the body’s requirements.

5. In terms of recommended daily amounts, the guidelines are:

* Menstruating women – 18 milligrams per day (more if their periods are heavy)
* Pregnant women – 27mg per day
* Breast-feeding women – 10mg per day
* Other adults (male and female) – 8mg per day
* Children – depending on age, 7-10mg per day
* Babies – newborn babies have enough iron stores to last for the first 6 months of life; formula is fortified with iron, but breast milk isn’t so it is crucial that beyond 6 months of age, babies who are exclusively breast fed are also given iron-rich solids (such as fortified cereal).

6. Certain medical conditions can lead to iron deficiency, including Coeliac disease, kidney failure, heavy periods (known as menorrhagia), bleeding into the gut (example: from bowel cancer or ulcers) and chronic malabsorption. If you are a frequent blood donor, especially if you are female, you are at risk of becoming iron deficient – this is something the New Zealand Blood Service will screen you for.

7. Being vegetarian, especially if you are vegan, carries a higher risk of iron deficiency, if you have other risk factors such as heavy periods or pregnancy. Vegetarians need to eat about 80 per cent more iron in their diet than meat eaters do, as it is harder to absorb the iron found in vegetarian foods.

8. Iron in food comes in two forms – “haem” iron and “non-haem” iron. The body absorbs haem iron, much more readily than it can absorb non-haem iron. Foods containing high levels of haem iron include kidneys, liver, lamb, beef, canned sardines and tuna, chicken, pork and some fish. Foods containing non-haem iron include lentils, split peas, silverbeet, broccoli, spinach, kale, puha, eggs, wholemeal bread, raisins, dried apricots, porridge and other breakfast cereals with added iron, baked beans, tofu and nuts.

9. If you drink a lot of tea, coffee, coke or red wine with your food, it will inhibit the body’s ability to absorb iron. Adding something containing vitamin C will do the reverse – so either drinking real fruit juice or eating vitamin C-laden fruit (kiwi, blueberries, citrus fruit) with your meal is a great idea.

10. Iron deficiency can be diagnosed by a simple blood test which checks the level of iron stores (ferritin) in your body. If you are deficient, and there is no serious underlying cause, simple iron supplements available on prescription will correct the deficiency and make you function noticeably better!

DR CATHY STEPHENSON

Foods you should never eat again

Frozen baked goods should be banished from your diet. Do yourself a favour and eat the fresh version instead.

WHILE it is often said that there are no individual “good” and “bad” foods, rather dietary patterns that predict health and weight outcomes, there are some foods so lacking in positive nutritional attributes that they are best avoided entirely.

Here are a few of the worst foods for you nutritionally and foods your health will not miss if you choose to never eat again.

Soft drink

Soft drinks ... more trouble than they’re worth.

Soft drinks … more trouble than they’re worth.Source:News Limited

No surprises here. Not only are soft drinks one of the most concentrated sources of added sugars in the diet with a 600ml bottle giving you 13 teaspoons of the white stuff but they are highly acidic which means a nightmare for dental health. And just in case you thought the diet option was a safe bet, while diet soft drinks contain no sugar, rather a range of sweeteners, there is more evidence building to link the consumption of diet soft drink to increased blood glucose levels, greater appetite and cravings for sweet foods and overweight and obesity. So stick to water when it comes to hydration and skip soft drinks completely.

Rice snacks

Don’t be tricked into thinking that rice crackers are a ‘healthy’ snack.

Don’t be tricked into thinking that rice crackers are a ‘healthy’ snack.Source:News Limited

While brown rice is a wholegrain and offers a number of key nutrients, processed white rice used to make rice crackers and snacks concentrates the starches resulting in highly refined snacks that send blood glucose levels soaring. If you consider that just 10 rice crackers, or a single row in a packet contains more carbohydrate than two small slices of wholegrain bread, it is easy to see how easy it can be to overconsume these carbohydrate rich snacks. The other thing not frequently considered is that a number of processed rice snacks, including those marketed to children contain added MSG, used to flavour a number of BBQ, chicken and pizza flavoured snacks. The less of these added flavours in the diet the better as evidence suggests that strong flavours programs the palate to seek out other rich flavours in the diet.

Vegetable oils

Try and give vegetable oil a wide berth.

Try and give vegetable oil a wide berth.Source:Supplied

Now we are not talking about extra virgin olive oil in this case, rather blended oils simply listed as vegetable oil on food labels. Not only do vegetable oils offer little nutritionally compared to extra virgin olive oil or nut oils but often the primary oil in the blend is palm oil, an oil primarily made up of saturated fat, the type of fat known to increase heart disease risk factors. Palm oil plantations are also causing much environmental damage. Vegetable oils are often listed among the first ingredients on margarines and other spreads including chocolate nut spreads and offer nothing positive nutritionally to the diet.

Frozen baked goods

Frozen party pies ... not a healthy option.

Frozen party pies … not a healthy option.Source:Supplied

The most popular foods in the frozen section of the supermarket — meat pies, doughnuts, cakes, sausage rolls, Danishes, apple pies and other desserts are not only baked full of saturated fats but often trans fats as well. Trans fats are particularly damaging to the body and are formed in foods when vegetable oils are heated to extremely high temperatures which is the case with commercial baked goods as the ovens used to make these products can be heated to exceptionally high temperatures, much higher than could ever be reached when we bake at home. So if you enjoy baked pies and cakes, homemade is a much better option and the less pastry we eat, the better it is in an attempt to keep our intake of nasty trans fats minimal.

Packaged noodles and pasta

Sure pot noodles are convenient, but they’re not doing your body any good.

Sure pot noodles are convenient, but they’re not doing your body any good.Source:istock

If you check out the list of ingredients on a packet of 2 minute noodles, or boxed pasta and sauce you will get the drift. Not only are pre-packaged noodle and pasta dishes packed full of preservatives, flavours and additives but nutritionally they tend to be a high carb, high salt meal options. The average bowl of noodles can contain more salt than is recommended to eat in an entire day, while the pasta and sauce combos are often high in fat, salt and flavours. MSG is often added as are thickeners, preservatives, flavours and colours to help the food resemble what it is supposed to look like when reconstituted. Do yourself a favour and eat your noodles or pasta fresh, the way they are supposed to be enjoyed.

‘Yes, you can eat bread, just don’t live on it’

It's important to select the correct type of bread.

It’s important to select the correct type of bread.

OPINION: I frequently get asked about bread. Elite athletes and the general public alike all seem to want to know if it is OK to eat.

I can understand the confusion; bread has become something of an enemy which may be attributed to low carbohydrate trends as well as its gluten content.

Bread comes in many forms, but for the most part contains flour, yeast, salt and water. Not all breads are equal and some varieties contain far more nutrients than others. Two slices of white bread (although very yummy) contain only 1.5g of fibre, whereas multigrain breads contain 5.2g fibre (depending on brand), more protein, and healthy fats and vitamins due to the seeds and grains. The higher fibre content makes these breads more filling too, meaning you eat fewer slices to feel satisfied.

Performance nutritionist Lillian Morton.

Supplied

Performance nutritionist Lillian Morton.

I think this is where the confusion arises.

If one uses bread as a food rather than a filler you eat smaller amounts. Many people use bread as a quick and easy alternative to making something else.

I’ll use an example to explain what I mean. I see time and time again in food diaries how bread used as a quick fix. You are feeling hungry, you scan the pantry and decide toast is easiest, with perhaps peanut butter or jam. Two slices are not filling enough so you make an extra slice.

Yes, toast is a quick and easy option but if one lives on toast as a snack then you miss out on other key nutrients that you may have eaten if you had perhaps made a smoothie (milk, yoghurt, banana, and berries), or had a pottle of yoghurt and a piece of fruit.

Another example is the humble sandwich. I frequently see sandwiches in food diaries that contain bread, ham, chicken or luncheon with some lettuce and mayo. Not very filling and so three to four sandwiches are eaten.

A better way to use bread is as a small part of the meal rather the primary ingredient. A good sandwich is made from multigrain bread, filled with salad ingredients such as lettuce, tomato, grated carrot, avocado, beetroot, sliced red onion, cucumber, and ham, chicken or some other protein source. This kind of sandwich is far more filling – and it’s yummy too.

There are some people unable to eat standard breads due to conditions such as coeliac disease and gluten intolerance. However, there are many bread alternatives available, and the same rules apply.

So, yes, you can eat bread, just don’t live on it.

Take a moment and think about how you use bread. If you are using bread as a substitute for other foods because you are too busy, too lazy, or too tired to prepare something else, then take some time to think about how you can change this.

Eat plenty of fresh vegetables and fruit, eat healthy snacks and avoid toast for dinner.

Lillian Morton is a performance nutritionist and senior academic staff member. She holds an MSc in sport and exercise science and is currently working towards her PhD.

Is omega-3 the holy grail of health?

Is there any other substance that offers a remedy for as many of our health foibles as omega-3?

Sourced from two polyunsaturated fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and to a lesser extent alpha-linolenic acids (ALA), these essential fatty acids are considered vital to maintaining optimum brain function, heart health and even said to help inflammation and aid in easing the pain of arthritis.

In fact, to hear Dr William Harris speak about them, omega-3s are the holy grail of health and overall wellbeing:

“There are two main essential fats: omega-6 and omega-3 and both have their uses – but omega 3 is the big one,” he says.

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“The primary source for these is oily fish, but they can come in plant form – things like flaxseed and soybean – but these produce a different kind of omega-3 source, ALA, which isn’t as easily converted into omega-3 as EPA and DHA.”

A professor at the Sanford School of Medicine at the University of South Dakota, Harris has spent the past 30 years studying and testing the seemingly endless benefits that come from these essential fatty acids.

“Unlike a lot of other vitamins and mineral fads – like vitamin E and beta carotene – omega-3 has stayed the course and each new study shows the benefits it has on our health,” he says.

“Each study clarifies what it does. It’s been shown to help brain health, depression, dementia and there is something there that omega-3 helps with. It just needs to be worked out. We’re just about to start this.”

THE NEW CHOLESTEROL

Currently in Australia to launch a national omega-3 level-testing scheme called the omega-3 Index, Harris doesn’t pull any punches when it comes to expressing just how important these substances are as an indicator to our health.

“I view omega-3 as the new cholesterol,” he says.

“It’s a risk indicator for heart disease that you can actually do something about without the need for drugs. In fact, I would bet that omega-3 levels are the most important indicator of risk factors for heart disease.”

Once rolled out, the omega-3 Index will be as simple as pricking finger with a pin. According to Harris, all one needs to do is request the test from a doctor or naturopath. The sample will be forwarded on to a lab where the level of omega-3s in the blood will be tested and recorded as a percentage (“Health target levels are between eight and 12 and low is considered below four,” says Harris).

According to Harris, this will help doctors and health professionals keep track of a patient’s heart health to prevent the possibility of heart attacks.

But for all the this amazing goodness that omega-3s offer, there’s just one catch – our body doesn’t produce them naturally.

A FISHY STORY INDEED

You see, like some sort of biological joke, it seems that for all omega-3s’ benefits to the body, we can only ever get them from external sources. And the primary source of this, is fish.

Fatty, or oily, fish such as salmon with the skin on, sardines, mackerel and herring are the best sources of omega-3.

“Fish is our primary source of EPA and DHA,” says Harris.

“These have higher potency, are much more easily converted into omega-3 and there is more evidence that shows EPA and DHA are better for heart health and brain function overall.”

Obviously something that the average vegan or vegetarian might have something of an issue with. And while fish oil supplements may seem like an easy solution to making sure your brain and heart are being fed the nutrients they need, consumer advocate Choice has already pointed out that the potency of many of these isn’t high enough to offer any benefits.

So what alternatives do our non-animal eating fellows have?

Dietitian and nutritionist Lauren Blair says that, while not offering as intense a hit as their marine alternatives, there are several plant-based sources of omega-3 that vegans and vegetarians can tap into.

“Plant-based sources of omega 3 are only marginally as effective as marine-based sources of omega-3,” she explains to Fairfax.

“So vegetarians and vegans need to take a few extra steps in order to maximise their omega-3 intake. I recommend eating good sources of whole-food, plant-based omega-3 (ALAs) including walnuts, chia seeds, linseeds, hemp seeds, soy beans, seaweeds and tofu while reducing the omega-6 foods in your diet as omega-6 can prevent omega-3 from being used properly in the body.”

According to Blair, you can do this by replacing sunflower, safflower and corn oils with mustard, walnut or chia seed oil.

And while it probably won’t appeal to those who embrace an ardent natural food philosophy, Harris says that there are several exciting developments in the GM industry that could help people who either can’t or won’t eat fish get the daily dose of omega-3.

“There are some GM oils made by Monsanto, one called Soy Mega, which is a derivative of the soybean and contains SDA, a compound one step closer to EPA than ALA. But, the crux is that it’s GM food which most vegans are not inclined to eat and also made by Monsanto, which doesn’t have the best of reputations.

“There is also the possibility of a supplement for vegans that uses an algae called OVEGA 3  and this has half a gram of EPA and DHA in each capsule.”

BENJAMEN JUDD

Extreme clean eating claims put to the test

Clean eating is associated with the healthy lifestyle and body beautiful that is promoted by many online bloggers. While the term is heavily used in social media, there has never been any agreement on what it really means or any comprehensive studies examining the potential benefits of a clean eating lifestyle as a whole.

However, the core principles that the big names in this movement champion appear to be: eliminate processed food; reduce salt intake; eat more vegetables; choose whole grains; eliminate refined sugar; reduce alcohol. For some, you also need to be gluten, dairy, and soya free and to eat raw (depending on how militant you are, food has to be entirely uncooked or only mildly heated). And if you want to be completely “clean” you should probably be vegan, too. Quite a list, then.

And there are also some big players online – including Food Babe, who was voted by Time as one of the 30 most influential people on the internet – who have significantly influenced this trend.

While some of the principles of clean eating are in line with the best available evidence for losing weight or preventing ill health – such as eating plenty of fruit and vegetables, sticking to wholegrains and limiting processed food – there are plenty of others that don’t stand up to scrutiny. It has been repeatedly proven that dietary restrictions such as a dairy-free diet or gluten-free diet are nutritionally substandard and studies have linked the introduction of a gluten-free diet with increased levels of psychological distress in coeliacs including depression and anxiety.

Some people find it difficult to understand why dietitians and doctors are against the clean eating phenomenon when there are still people eating burgers for breakfast and obesity is on the rise. However, some clean eating is sensationalist promotion of non-evidence based, and extremely restrictive, lifestyles that demonise everyday food essentials. And that can lead followers into having a sense of shame and failure for not eliminating “unclean” foods 100 per cent of the time – so you can see where the negativity from healthcare professionals stems from.

READ MORE:
* Clean eating versus orthorexia: what’s the difference?
Orthorexia nervosa: Do you have an unhealthy obsession with health?
When clean eating spirals out of control
Instagram’s ‘eat clean’ lifestyle may be doing more harm than good

There is significant research disproving many of the principles of the diet. Below are some of the big claims and why they don’t stack up.

CLEAN EATING CAN CURE DISEASE

Some clean eating bloggers claim to have cured themselves of diseases. The kinds of medical conditions that clean eating is supposed to cure are often conditions that are not well understood, such as chronic fatigue, which leaves sufferers desperate for a solution. And where there is desperation there is always someone willing to sell help – however unscientific.

One of the big names in clean eating who believes her diet controls her postural tachycardia syndrome (PoTs) – where standing up causes a drop in blood supply to the heart and brain and the heart races to compensate – intestinal issues and headaches through her method of a dairy free, gluten free vegan diet is Deliciously Ella. PoTS, however, has no proven link with food except that a higher salt intake is recommended to help keep blood pressure up. Having too little salt in the diet can exacerbate the problem. The reason that Ella is so much better now is much more likely to be age-related as we know that for 80 per cent of sufferers, symptoms disappear between the ages of 19-24. Ella was diagnosed aged 19 in 2011 and has been blogging about diet for four years.

One thing diet may have helped with though is Ella’s gastroinestinal issues. Her method of eating has a diet that is very low in fermentable carbohydrates or FODMAPs which have been robustly proven to be a cause of Irritable Bowel Syndrome (IBS) which affects up to one in five people.

CLEAN EATING MAKES YOU HAPPY!

Many of the clean eating bloggers promote themselves as a model of how you could look if you follow their lifestyle. But it is important to remember that it is their job to look the way they do. If you have a full-time job and a busy life, the chances of you cooking every meal from scratch, never having to grab a sandwich from the supermarket for lunch and being able to work out for two hours a day are very slim. If you try to model your life on theirs you are more than likely to end up feeling like a failure because it is simply not realistic.

Interestingly, many clean eating bloggers claim to have been depressed before clean eating. There has been lots of research into dietary treatments for depression by increasing an amino acid called tryptophan which is a precursor for serotonin production in the brain, which in turn influences good mood. To date, no trial has conclusively proven that increasing dietary tryptophan improves serotonin production or depressive symptoms but a diet in line with clean eating actually has the potential to be low in essential amino acids such as tryptophan.

What is more likely is that all the attention and apparent public approval received for losing weight and improving their appearance has temporarily improved their self-worth.

Clean Eating Is A Good Way To Lose Weight

Clean Eating Alice, 23, is another big name in the game. Alice isn’t vegetarian but her diet is very low in carbohydrate. She claims that her diet and exercise regime has immeasurably improved her health and happiness. It was reported that through her version of clean eating and intensive exercise, she dropped 16kg and reduced her body fat percentage from 30 per cent to just 15 per cent. 

Alice’s reported body fat percentage is concerning. The minimum essential fat for a woman is between 10-13 per cent – we need this amount to maintain our immune system and maintain healthy hormone levels. Many professional athletes will have a body fat percentage of up to 20 per cent with the normal healthy level around 25 per cent. So holding herself up as a realistic and achievable role model is highly misleading.

CLEAN EATING IS GOOD FOR GUT HEALTH

The Helmsley Sisters were some of the first to bring the clean eating trend to our attention. Their philosophy aims to help people with their digestion and relationship with food, and teach the importance of gut health. Their recipes eliminate gluten, grains and refined sugar (and minimise natural sugars). However, the majority of people tolerate gluten very well – the exceptions are for people with conditions such as coeliac disease – sugar is absorbed so efficiently it has no impact on digestion and grains provide high levels of prebiotics to feed the good bacteria in your gut. The best thing for gut health is a good, balanced diet.

CLEAN EATING PREVENTS AGEING

Many bloggers state that clean eating will keep you looking youthful. There is some compelling evidence that antioxidants found in fruit and vegetables can prevent premature skin ageing.

You do, however, also need plenty of good quality protein to maintain the integrity of your skin and therefore extreme clean eating could easily undermine the benefits of the antioxidants.

CLEAN EATING WILL DETOX YOUR BODY

Detox diets are all the rage and the clean eating crew all have their own version of a detox diet. Fortunately, no one needs a detox diet because our liver and our kidneys are always already doing this. Everyone would agree that excessive consumption of highly processed food with lots of additives is not a healthy way to eat. However, neither is following a highly restrictive diet for any amount of time and there is certainly no health benefits associated with “detoxing”.

Some clean eaters promote an alkaline diet to prevent excess acidity in the body. Ironically, our stomach acid is only slightly less acidic than battery acid so anything you eat will be immediately placed into a highly acidic environment where the pH is tightly controlled. You cannot manipulate your body’s pH through diet (as the below tweet suggests) and you don’t need to try.

 

 

 

CLEAN EATING MAKES YOU HEALTHIER

There are even more extreme examples of clean eating out there including Freelee The Banana Girl who promotes a raw vegan diet of 15 bananas, 40 pieces of fruit and a couple of kilograms of potatoes a day. She claims that eating this way has cured her weight issues, depression, irritable bowel syndrome, chronic fatigue, poor digestion and acne.

It is hard to pin down the most concerning thing about this diet but the fact that Freelee is consuming 6.5 times more potassium than is recommended and encourages others to do so is a big one. She even consumes 30 per cent more potassium than is shown to cause excess potassium in the blood, which can lead to deadly changes in heart rhythm. That said, whether or not she is absorbing any of the nutrients in her food due to the amount of fibre she is taking in is questionable and if her bowel habits are normal and healthy it is a medical miracle.

Anyone can call themselves a nutritionist and there are many quick courses that give a false air of credibility. There are also no regulations around what people can and can’t recommend as being healthy. It should be very hard to maintain a voice of authority in an area in which you are totally unqualified and in a world where your self worth depends on “likes” and “views” and “followers”.

An obsession with clean eating and the shame that is often associated with eating foods considered to be dirty can also lead to mental health issues such as orthorexia, an eating disorder associated with obsessive healthy eating. Emmy Gilmore, clinical director of eating disorders clinic Recover, even suggested in a recent BBC documentary that many UK clean eating bloggers had sought help from her clinic. So rather than watch videos of supposedly physically healthy girls as gospel, it’s better to develop healthy eating habits that come from sound scientific advice and which balance all the nutrients your body needs.

And if you’re seeking professional advice, find a nutritionist with a degree or a registered dietitian – it’s a protected title so you can be certain that the advice you’re given will be scientifically robust.

The Conversation

Do you really need to eat breakfast?

Eating an English breakfast will certainly keep you hunger-free until lunchtime.

iSTOCK

Eating an English breakfast will certainly keep you hunger-free until lunchtime.

How good is sitting down to a plate of organic eggs, smashed avo and grilled mushrooms paired with a decent mug of petrol coffee first thing in the morning? Sounds delish.

But is eating breakfast integral to a healthy diet or have we simply become habitualised feeders?

For many adults, the message that breakfast is the most important meal of the day has been drummed into us from an early age. Television commercials, government-funded food guidelines and dietitians are determined to have us believe that a good, healthy diet starts with a morning meal.

But a growing number of experts, and a growing body of research, question the validity of these claims if not reject them all together.

READ MORE:
Ask Dr Libby: Ideas for nutritious breakfasts to fuel your body
Is it OK to eat breakfast at work? 
Which yoghurt is the healthiest?

Apple porridge is the perfect cereal fruit combo.

Emma Boyd

Apple porridge is the perfect cereal fruit combo.

SO WHAT IS THE TRUTH?

Earlier this year, professor of pediatrics at Indiana University School of Medicine Aaron E. Carroll wrote an article for the New York Times questioning the push for breakfast in the media.

He pointed out that much of the data released in favour of eating breakfast was funded by groups, like Kellogg, who had a vested interest.

In fact, the phrase that breakfast is ‘the most important meal of the day’ was a 1944 marketing campaign launched by American company General Foods to encourage people to, you guessed it, buy more cereal.

But probably the most fascinating and poignant argument Carroll makes is how this research was – and still is – targeted towards children.

A fruit smoothie.

123RF

A fruit smoothie.

A good breakfast is regularly touted as being an essential part of their daily routine, particularly because it helps them perform better in school. But as Carroll points out, this research failed to take into account the general nutritional intake of the children being studied.

As Carroll noted, hunger “affects almost one in seven households in America, or about 15 million children”. So it makes sense then that kids who were going hungry at home would respond better when fed in the morning.

Carroll was also critical of studies that suggested kids who skip breakfast were more likely to be overweight than children who eat two breakfasts for the same reason – if you’re being nourished at home, you’re probably not starving at school.

SCIENCE VS PROFITS

Writing for Good Health (“the oldest health magazine in the world”) in 1917, Lenna F. Cooper stated that “in many ways, the breakfast is the most important meal of the day, because it is the meal that gets the day started.”

Not so coincidentally, Good Health also happened to be edited by Dr John Harvey Kellogg, the father of modern day flaked cereals. To say that Kellogg had an agenda when this was put into his magazine is an understatement.

But it’s also part of a bigger picture surrounding the science of breakfast and how research can be skewed to benefit the aims of the author.

Muesli and strawberry porridge.

Muesli and strawberry porridge.

In 2013, a paper published by The American Journal of Clinical Nutrition studied the literature surrounding links between breakfast and obesity. What they found was that scientists showed regular bias in their interpretation of research, favouring the notion there was a link between skipping breakfast and obesity even when no such evidence was apparent.

And only in a 2014 study conducted by Monash University, researchers found that skipping breakfast as part of intermittent fasting not only helped weight loss but also helped blood pressure and various forms of liver damage.

But this isn’t to say breakfast is bad and you shouldn’t be eating it. In fact, if you wake up hungry like those 15 million US school children then you most definitely should be eating it.

But eating it just out of habit? You can probably swap it out for an extra 30 minutes sleep.

Juicedaily.com.au

Surely you can’t drink any alcohol when you quit sugar?

I Quit Sugar - Can I drink alcohol when i quit sugar?

Surely you can’t drink any alcohol when you quit sugar? It’s chockers full of the white stuff, right?!

We have some good news for you – you absolutely can still enjoy a glass of wine at dinner. Or even a beer on the weekend. Because quitting sugar doesn’t mean quitting the things you enjoy! The trick is to drink in moderation, and pick the right ones. Here’s what you need to know.

1. Can I drink alcohol when I quit sugar?

  • ✔️ Beer: While this beverage does contain a lot of sugar, it’s in the form of maltose (not fructose) which our bodies can metabolise just fine. Read more about our stance on fructose.
  • ✔️ Spirits: Dry spirits like gin, vodka and whiskey are very low in fructose.
  • ✔️ Wine: Believe it or not but wine contains very minimal amounts of fructose. See question two below.
  • ❌ Champagne or “sparkling”: Though similar in the fermentation process of red and white wine (as mentioned above), Champagne does tend to retain quite a lot of the fructose from the grapes. Which is why we don’t think this is the best option.
  • ❌ Dessert wine: A stack of sugar remains unfermented in these wines. Avoid!

2. What about the fructose in wine?

  • Believe it or not, but wine actually contains minimal fructose. How?
  • The fructose in the grapes is what ferments to become alcohol, leaving the finished product low in sugar.
  • If the wine has been fermented to “dry” (red or white) it contains very low levels of residual sugar (less than 1g per litre).
  • Red wine is lower in fructose than white wine and is definitely the better option in our opinion.
  • Read our interview with Rosemount Estate to find out even more.

3. Can you drink alcohol on the I Quit Sugar: 8-Week Program?

  • During our Program, we allow one glass of wine (preferably red) with dinner a few nights a week. Why? Because quitting sugar doesn’t have to mean quitting the things you enjoy.
  • While quitting sugar, your liver is under a little strain as you detox all the toxins (and addiction) out. Drinking any more than one glass of alcohol with a meal per day will only tax your liver more.
  • You may also find once you cut out sugar, that your tolerance for alcohol is much lower and wish to avoid it while going through the 8-Week Program.
  • Check out all the other things you are still allowed to do while on our Program.

4. Tips for sugar-free boozing.

  • Alcohol-free is always going to be your safest bet.
  • Soda or plain mineral water with a squeeze of lemon or lime is surprisingly satisfying. We love asking the bartender to jazz it up with a slice of cucumber or some fresh mint.
  • Clear spirits like vodka and gin mixed with soda water and fresh lemon and lime are probably the lowest sugar alcoholic drinks you’re going to be able to get.
  • Gin, soda water and fresh cucumber is one of our favourites. So refreshing.
  • STAY AWAY FROM SOFT DRINKS AND TONIC WATER… they are loaded with sugar!

5. A FEW WORDS OF CAUTION…

A few more words of caution before you take a tipple.

  • Alcohol still has a multitude of metabolism and health issues that come with excessive consumption, not to mention it’s an addictive substance.
  • Although most alcohol is low in fructose, it’s still very high in empty calories.
  • Only ever drink spirits with soda water. Mixers, including tonic water, are full of sugar – about 8–10 teaspoons in one tall glass. Ditto fruit juices.
  • Remember, when it comes to alcoholic drinks, once you have too many it’s very hard to make sensible food choices. You’re far more likely to reach for that slice of cake after a few drinks than you would be sober. Just something to keep in mind.

We originally published this post in February 2014. We updated it in July 2016. 

Foods that can help boost your eye health

Foods that can help boost your eye health

Coloured vegetables and fruit contain carotenoids, which is good for eye health.

Investing in your eye health is potentially one of the most important investments you can make.

From having regular eye checks and monitoring any degeneration through to supporting your eye health with a diet full of fresh whole foods – there are many different ways you can support these amazing organs.

The eyes connect to the body in various ways. Certain vitamins and minerals can protect against and, in some cases, even help prevent numerous diseases such as cataracts, glaucoma, and age-related macular degeneration.

READ MORE:
Dr Libby: The psychology of eating – when food becomes your comfort

Dr Libby: Try forming these small habits to boost your health
Dr Libby: Daily habits to help keep your gut healthy
Dr Libby: 10 foods that help sugar cravings

Citrus fruits are a great source of vitamin C, which is critical to eye health.

Piccianeri | Dreamstime

Citrus fruits are a great source of vitamin C, which is critical to eye health.

VITAMIN A

Vitamin A has many functions, not only can it help maintain a strong immune system, but it’s also absolutely critical for keeping the retina healthy.

In fact in many third-world countries vitamin A deficiency is the leading cause of night-blindness, where you’re unable to see at night or in dim light. Night blindness is caused by a disorder of the cells in the retina that are responsible for vision in dim light.

Vitamin A is sometimes used to treat hereditary retina deformities and according to some studies supplementing with vitamin A may help slow the progression of the disease.

However, we also get vitamin A itself through the diet plus our bodies can convert plant chemicals (carotenoids) such as beta-carotene and alpha-carotene into vitamin A.

Coloured vegetables and fruit contain many carotenoids. A recent study conducted over a 10-year period found that consumption of fruits and vegetables, but in particular orange or yellow fruits and vegetables are the most protective against cardiovascular disease.

The same study named carrots as one of the most heart healthy vegetables because of its deep orange colour and therefore concentration of protective antioxidants and nutrients.

BETA-CAROTENE

Carotenoids are antioxidants that are plant pigments. This category of nutrients is considered by many eye-care experts to be the most protective for eye health.

One of the best recognised of the carotenoid family is beta-carotene. Beta-carotene has antioxidant effects and aids in maintaining good vision, as well as night vision. It is because of this function that we often hear the phrase eat your carrots, as they help you see at night.

Research indicates it may play a role in cataract prevention. Luckily, beta-carotene, which is converted into vitamin A in the body, is easily obtained through the diet. However, the conversion of these plant forms to retinol, a better-absorbed form of vitamin A, is not as well absorbed as it is from animal sources.

So there is no need to be concerned about eating too many foods that are a rich source of beta-carotene, as the body regulates how much is converted. In fact, they’re a wonderful inclusion in your diet for a number of health benefits. These foods include carrots, kumara, kale, spinach, papaya, capsicums, and pumpkin to name a few.

KEEP AN EYE ON THESE FOODS

1. Kale. Leafy green vegetables, like kale, are superstars for eye health! Particularly as they’re a good source of lutein and zeaxanthin, two antioxidants known to support healthy eye function. Evidence suggests that people with diets high in lutein were up to 23 per cent less likely to develop cataracts than those whose diets were low in this nutrient. If kale isn’t your thing, choose other dark leafy green vegetables, like spinach and silverbeet as they’re also good sources of lutein and zeaxanthin, as are egg yolks.

2. Salmon. There is evidence to suggest that diets rich in omega-3 fatty acids from fresh, cold-water fish like salmon and sardines, reduce the risk of developing eye disease later in life. If you’re a vegetarian or vegan include plant sources of omega-3 fatty acids such as flaxseeds or chia seeds.

3. Citrus fruit. Citrus fruits are a wonderful source of vitamin C, an antioxidant that is critical to eye health. Oranges, lemons, grapefruit and tangerine are all delicious and beneficial additions to the diet.

Dr Libby

Where’s the evidence for the gluten-free lifestyle?

With food allergies on the rise we probably all know someone who has to avoid one foodstuff or another for medical reasons. Now, though, there is also the rise of the “gluten-free” lifestyle, removing most breads, pastas and cakes from the menu, writes Dr Chris van Tulleken.

It’s estimated that 8.5 million people in the UK have now gone “gluten free” and it’s a very fast-growing section of the supermarket with an expanding (and expensive) range of gluten-free alternative foods on sale. So, what’s behind it all?

If you’re one of those who sigh and tut at the perceived fussiness of the new gluten-free brigade, spare a thought for the 1% of the population who suffer from coeliac disease.

Is going gluten-free good for me?

Coeliac sufferers have a lifelong autoimmune disease which means that gluten causes their immune system to turn on their own bodies, destroying the delicate linings of their guts and causing painful digestive symptoms as well as malnutrition and serious complications. The current boom in gluten-free products and gluten-awareness from restaurants is a huge benefit to them.

The vast majority of gluten-avoiders today, though, are doing it either as a diet to lose weight (not being able to eat most bread, pasta or cakes limits snacking options), or because they believe that avoiding gluten makes them feel better. What, then, is the evidence for that?

“Non-coeliac gluten sensitivity” is not a widely-recognised medical condition. Although many people who do not have coeliac disease claim to suffer gut symptoms like bloating and nausea when they eat gluten – and even other things like “brain fog” and tiredness – these have not been linked to any physiological changes that can be measured and hence used to make a clinical description and diagnosis.

The Trust Me, I’m a Doctor team signed up 60 (non-coeliac) volunteers willing to go gluten-free in the name of science. These included a good proportion of people who felt that they suffered symptoms when they ate gluten, and a good proportion of cynics, happy to go gluten-free in the hope of discovering that those who complained were merely hypochondriacs.

By performing the trial “double-blinded”, we tried to stop either camp from being able to influence the results. That meant that although all 60 volunteers were asked to remove gluten entirely from their everyday diet, we provided them with a daily meal of pasta.

Most of the time this was gluten-free pasta, but we secretly slipped each of them gluten-containing pasta for two weeks within the trial period – but no one knew which two weeks each volunteer had been eating gluten, until the results were analysed. This meant that we could compare the volunteers’ symptoms in the weeks they were eating gluten and the weeks they were gluten free and see whether they differed.

What, then, could we measure to try to determine whether some people really do suffer when they eat gluten?

Firstly, of course, there are the symptoms they felt – so we asked each volunteer to fill out a questionnaire each fortnight assessing the state of their gut and of their general health and wellbeing.

Then we wanted to measure any physiological markers that might indicate a cause for their symptoms.

Allergies are caused by a reaction in the immune system, specifically antibodies called IgE. Therefore, in order to check whether there might be any allergic reaction to gluten, we tested their IgE antibodies and other immune system markers every fortnight.

Intolerances, such as lactose intolerance, are quite different. Food intolerances are often due to a person not having the enzyme necessary to break down certain foodstuffs, although they may also be caused by substances in the foods themselves such as histamine content or additives.

A reaction because of intolerance is usually a slower onset than an allergy, sometimes taking hours or even days to manifest, and can lead to symptoms such as diarrhoea and bloating.

Many people feel that their problems with gluten are down to some kind of intolerance. These sort of gut symptoms usually cause some inflammation in the gut.

Recently Italian and American research groups claimed to have found biochemical markers of gut inflammation that were higher in people with “gluten sensitivity”, when they ate gluten. We therefore measured three different markers of gut inflammation in our volunteers each fortnight.

So, how did our volunteers get on?

Well, they almost universally enjoyed the experiment. Many found it made them eat more healthily, lose weight and feel better. None of that, though, could definitively be ascribed to the lack of gluten in particular – it’s possible we were just forcing them to consider what they ate more carefully.

Most, though, also felt that by the end of the experiment they could tell which weeks they were eating pasta containing gluten – overall, they reported significantly more gut symptoms in the fortnight that each was given gluten compared with the weeks when they were truly gluten-free.

As for the “health” symptoms such as tiredness and low mood, many did also report more adverse effects in the weeks they were being given gluten, but overall this was not statistically significant.

Admittedly it’s difficult to find gluten-free pasta that is indistinguishable from “normal”, and the Trust Me team had to have a few team dinners to road-test different options. The participants certainly couldn’t have been sure which was which, but their guesses may well have influenced their self-reported symptoms.

What, then, of the objective blood test results? Well, here there were no significant differences between any of the markers we measured in the weeks they were having gluten and the weeks they were gluten free.

Nor were the levels of inflammatory markers higher in people who reported symptoms when eating gluten than those who didn’t.

So, does “non-coeliac gluten sensitivity” exist?

Well, many of our participants clearly thought so – but their guesses at which pasta contained gluten may have biased their opinions of their symptoms.

Our biochemical measures showed nothing at all – but that could mean that we were just measuring “the wrong things”. The immune and inflammation systems are, after all, among the most complex aspects of the human body, and we have much yet left to understand.

On top of that, we are only just scratching the surface about understanding our relationship with our gut bacteria. There is the possibility that some people have gut bacteria that create symptoms when fed gluten-containing foods – something that might not have shown up in the markers we tested.

We, then, have found no test that could be used to diagnose “gluten intolerance” or “non-coeliac gluten sensitivity” and equally there is no evidence from any study anywhere to back up the use of popular home testing kits for “intolerances” – many expert groups around the world have spoken out against their marketing. Whatever they claim to measure, it hasn’t been shown to be strongly linked with symptoms, so don’t waste your money on them.

If you feel that you definitely suffer, then the advice is to first rule out coeliac disease. It is vital you continue to eat gluten before visiting your GP for this test.

Once coeliac disease and wheat allergy have been ruled out, the next step would be to try an “elimination diet”, ideally under the supervision of your GP or trained practitioner. This involves cutting gluten out of your diet for at least two weeks and then reintroducing it – at the same time monitoring symptoms (and this is true of any food that you feel might be causing you problems). You may feel better simply because it makes you eat more carefully and healthily, but that’s no bad thing.

It’s important that if you are excluding foods from your diet that you do so under the supervision of your GP, a dietician or a trained practitioner. There is a danger when eliminating food groups that vital elements of nutrition are lost. This is especially important in growing children. Another concern is that without expert advice, you may end up eliminating particular food groups unnecessarily.

So, whether you are convinced non-coeliac gluten sensitivity exists, or think that the 6% of the population who claim to suffer from it are purely hypochondriacs, then the Trust Me, I’m a Doctor study will probably give you something to discuss over the dinner table with your friends – whilst you argue over the gluten content of the bread.

Chris van Tulleken presents Trust Me, I’m A Doctor

Don’t fight your cravings

It’s time to stop focusing on what foods you can’t have and instead focus on the ones you can.

If I told you “don’t think of the Eiffel Tower”, it would be the first thing that comes into your mind.

Similarly if I told you not to eat cake, most people can’t stop thinking about it.

This phenomenon can be summed up in one phrase: “what you resist persists”. So rather than fighting against your cravings and making it a battle, simply let it go.

What does this mean? I hear you ask.

The minute you make it a battle there is only ever going to be one winner and it’s not you. When you can relax, stop fighting and understand that you deserve to be happy and healthy, all of these battles become choices and the choices become easy.

The key is not focusing and thinking about what you can’t have and instead focus on what you can have. And here’s the thing – most people think healthy means a steamed chicken breast and a bowl of dust or lettuce leaves with stale tofu. It’s just not.

Healthy is actually delicious – it is a whole new world of flavours, textures, tastes and aromas that will leave you feeling not just healthier but genuinely happy and satisfied. Don’t just feed your body but feed your soul as well.

There are so many rules everywhere – don’t eat gluten, don’t eat sugar, limit how much meat you eat, don’t eat too many carbs. With so much restriction everywhere it is very easy to see why people give up on their quest to eat healthily.

So often health is focused on what you can’t have when actually it’s  about enjoying amazing food which improves how you feel and once you’ve experienced that, there’s no going back. You might slip off the wagon but “nothing tastes as good as healthy feels” (yes, perhaps I am the Kate Moss of wellness).

When you can make the connection between what you eat and how you feel, everything changes. You may be one of the growing number of people who does understand that what you eat affects how you feel and if not, you may be part of the huge number of people that haven’t yet made that connection.

So if you take nothing else away from what I say here, understand this: what you eat affects how you feel. Your body is constantly talking to you; if you are bloated, gassy, tired, miserable, there is a good chance it has a lot to do with what you are eating.

So if you’re choosing foods that work for you, that make you feel good, that taste delicious, are you on a diet? Or are you just living a happier, healthier, more intelligent life?

How about instead of going on a diet you decide to finally be kind to yourself and completely change your life. There is a caveat to all of this – most people don’t know they’re sick because they’ve never been healthy.

They think that waking up feeling tired, achey, depressed, exhausted, bloated is normal. It’s not normal, it’s just common.

It doesn’t have to be this way and the power to change all of that is in your hands. So when I say be kind to yourself, it’s more than just a slogan or a cliche, what I mean is let go of shame and guilt, understand that your past doesn’t equal your future, if you have failed before use it as a lesson and see failure as feedback.

Accept yourself so that you can create a powerful platform from which to move forward towards a happier, healthier you.

Are you still thinking about the Eiffel Tower? Now you are. That’s why diets don’t work.

Juicedaily.com.au

Quality, not food type, say nutrition experts

Tired of the old argument pitting carbohydrates against fats? Seems you’re not alone.

Don’t knock all carbs and fats – that’s the message from a new report from The Lancet.

Nutrition experts are saying that debate is not what’s important – rather we should focus on the quality of the food in our diets.

A report just released by the prestigious medical UK journal The Lancet, which includes information from leading nutrition and public health researchers in New Zealand, says there’s a clear recommendation that we should be cutting our intakes of poor-quality foods containing lots of free sugars and saturated fats.

Instead of focusing on low fat versus low carb we should be eating a wider range of healthy fats and carbohydrates, says Professor Mann from the University of Otago’s Edgar Diabetes and Obesity Research Centre (EDOR).

“There are good fats, just as there are good carbohydrates that are associated with a reduced risk of heart disease, diabetes and colon cancer,” he says.

“Pitting one nutrient against another – such as fat versus carbs – risks confusing the public, health professionals and policy makers, and undermines confidence in evidence-based nutrition advice.”

The commentary, which also includes research from the University of Auckland and the Healthier Lives National Science Challenge, is based on the “totality of international evidence from objective, systematic and thorough expert reviews” of a range of different types of studies that evaluate the effects of foods and nutrients on health outcomes.

Prof Mann says the recommendations can be met easily by culturally diverse dietary patterns – from the traditional high-carbohydrate, low-fat diet of Japan, which is associated with longevity, to relatively high-fat, high-carbohydrate Mediterranean diets, which are associated with low risk of non-communicable diseases.

“What dietary patterns associated with the lowest risk of non-communicable diseases all have in common is that they tend to include lots of fibre-rich fruit and vegetables, legumes, pulses, nuts, wholegrains, and plant oils.”

Why you crave sugar after a workout

You’ve just finished an intense workout but instead of reaching for that protein rich chicken salad you prepared earlier, you find yourself staring longingly at the tub of ice-cream in the freezer.

Or maybe you did eat that salad but as soon as you put that knife and fork down, the first thing you think about are some choc chip biscuits stashed away in the cupboard.

It’s okay, you’re not a bad person. And there’s science to back it up.

A new study published in the Journal of Health Psychology found that exercising actually makes us more susceptible to craving sugary treats.

Led by Christine N. May from the University of Massachusetts, researchers recruited 88 university students to take part in what’s called an “approach avoidance task” where they tested each volunteer’s automatic response to different forms of stimuli.

The students were asked to hold on to a joystick and look at images of desserts mixed in with pictures of random objects. When each image appeared, researchers noted the participant’s hand movements, checking to see if they would pull it closer to their body in a motion that would suggest positive responses.

After this first round was complete, the group was then split into two with one half doing memory games and the other half jumping on bikes and doing moderate aerobic workout.

Then they did the test again. Sure enough, the group that did the workout were more inclined to respond positively to the sight of desserts while the group that played memory games showed no measurable differences in their responses.

So what is it about doing exercise that makes us want to make such bad choices?

REPAIR AND RECOVER

According to Ashleigh Brunner, a Sports Dietitian and owner of Body Fusion in Sydney, these sugar cravings are basically your body simply trying to replace fuel and repair itself in the quickest way possible.

“Our preferential energy for fuelling muscle during exercise is carbohydrates… and during exercise we create many micro-tears in our muscles which require protein for repair,” Brunner said.

“These sugar cravings are more likely to be driven by our muscles’ need to replenish our carbohydrate stores and repair our muscles after exercise. So this is the thing, many desserts are high in fast releasing carbohydrates or sugar which usually isn’t the best quality nutrition but will help replenish quickly, hence cravings! We just need to take a minute to prepare a healthier post workout snack/meal or have one organised and ready to go.”

Which may sound easier said than done, and as a self-confessed cookie addict I have taken the easy way out more than I care to admit.

As a way of appeasing both the nutritional requirements of your body along with the demands of your taste buds, Brunner does offer a few handy tips.

“There are many better quality alternatives post exercise which can still hit your sweet tooth,” says Brunner.

“Foods that are naturally sweet but are also bundled in with an adequate amount of protein would be your best bet such as a smoothie with milk, fruit and honey. If you are on the run or in-between meals, a date based bliss ball or healthy muffin with a latte would also be a great choice. My favourite breakfast after exercise in the morning is two pieces of grainy toast with natural peanut butter and honey and a homemade milky chai.”

Another way of overcoming the cravings is to eat something before you start your workout.

“Most of the time, having a small snack that digests well and is primarily carbohydrate based before a workout is a great idea ie. a banana or a cereal (not nut!) based bar. It also means you are more likely to have sustained energy for your workout.”

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I Tried a Medieval Diet

The Regimen Sanitatus Salernum was the Middle Ages’ most famous health manual. How does it hold up?

A kingly feast, from the Bayeux Tapestry. (Image: Public domain)

It can seem sometimes like all diet advice boils down to the same basic ideas. Eat vegetables, healthy proteins, avoid processed snack food and hydrate, hydrate, hydrate.

This was not, however, the case in medieval times.

The Regimen Sanitatis Salernitanum was created, allegedly, by famous doctors for English royalty and disseminated in the form of a poem. It recommends, very specifically, red wine, fresh eggs, figs and grapes. It has little to say about vegetables. In many ways, it’s the antithesis of today’s health fads—it celebrates wheat, emphasizes meat, and involves two significant meals, with no mention of snacking. Water is looked on with suspicion, and juice is nowhere to be found.

But from the 1200s through the 1800s, the Regimen was one of the most well known guides to health in Europe, at a time when the stakes of staying healthy were much higher than they are now. Getting sick could be a death sentence; this regimen promised to keep people well.

Could we be ignoring some great advice? Is water really all that? I decided to test the Regimen Sanitatis Salernitanum out myself. For a week and a half, I followed, to the best of my ability, the advice of the doctors of Salerno. I drank diluted wine at dinner, and sometimes at lunch; I ate bread at almost every meal; I sought out richly stewed meat whenever I could. The regimen was not just about what to eat, though, and I also followed its prescriptions for daily life.

I felt like I was living the Game of Thrones life; some days, I felt I was living like a 13th century king. Despite the amount of wine I was consuming, I never got drunk! In fact, I felt great.

The Rules

The Salerno health regimen was based in the humoral theory of medicine, which is focused on keeping balance among the body’s four humours—blood, phlegm, yellow bile and black bile. Foods were thought to possess qualities that could help maintain that balance: each hot or cool, dry or moist. These ideas originated in the ancient Mediterranean world, most prominently with the Greek physician Galen, and were passed to doctors in the Arab world, before returning to Europe.

Although medieval doctors legitimized their recommendations with these ideas about how the body worked, their medical advice wasn’t as random as it might seem.  “They justified their practice by humours, but they had arrived at these ideas by trial and error,” says Noga Arikha, the author of Passions and Tempers, a history of the humours. These doctors had one major disadvantage compared to modern doctors—they didn’t know about germs, so they didn’t know what caused sickness. But their ideas about how to keep healthy, particularly by controlling a person’s diet, weren’t so different from our ideas today. “The idea of balancing out—that remains and it makes complete sense,” says Arikha.

The school at Salerno. (Image: Public domain)

The Regimen’s top line advice is simple and sensible. Don’t get stressed out—let go of “heavy cares” and “refrain from anger.” Don’t eat too much; don’t take afternoon naps. Don’t drink too much undiluted wine. To stay healthy, you just need “a joyful mind, rest, and a moderate diet.”

The advice isn’t always so clear. One 17th century commentary goes through each line of the poem and explains its intention. Why eat moderately, for instance? “Eating and drinking excessively causes us to be unlusty, drowsy and slothful, hurting and enfeebling the stomach.” What’s the advantage of white wine? “White wine makes you piss better than any other wine.”

There are a few specifically recommended foods, though: fresh eggs, red wine and rich gravies or broths. Fresh figs and grapes are good; apples, pears and peaches less so, as they are “melancholic,” the humour associated with black bile. Wheat and all sorts of meat are “nourishing and fattening.” Fresh cheese is also “nourishing” but aged cheese is out: it’s “cold, constipating, crude and hard.”

Its advice on vegetables is practical: garlic and radish are antidotes to poison, cabbage broth has laxative properties, and turnips cause both gas and urine. Peas, though, are “rather good.”

Medieval bread baking. (Image: Public domain)

The selection of vegetables in medieval Europe was relatively small, to begin with. It would not have included plants native to North or South America, which means no potatos, no corn, no tomatoes, no avocados, no peppers, and no beans (with the exception of fava beans). Spinach came from Persia, via Arab conquests of southern Europe, in the 800s, and gradually replaced other greens, like sorrel. Sugar first reached Europe in 1148, when Crusaders brought it back from their war, but it was a luxury product, with limited availability, for centuries. Coffee didn’t come regularly until the 17th century (a historical fact which I had to ignore).

The poem has other advice to offer, but most of it is less prescriptive or is targeted to specific ailments. There is a whole section on bleeding—in the spring, blood should be taken from veins on the right side of the body. That, I will straight up ignore, because I want to believe that modern medicine has really truly proven that arbitrarily letting blood out of your body doesn’t do much. It’s not that we’re so much smarter about how we cleanse our insides, but compared to a blood-letting, a juice cleanse or enema looks tame.

Day 1

I wake up in the morning, and start with Salerno’s steps for the morning routine. First, I wash my hands and face with cold water. I comb my hair and brush my teeth. I spend some time stretching. All this is supposed to “relax my brain.” Is my brain relaxed? I don’t know, but I am more awake than after my usual routine of spending 20 minutes in bed scrolling through social media.

The greatest success of my first day is lunch: chicken with mushroom sauce, along with bread, grapes and cheese. Having read too many medieval-influenced fantasy books as a kid, this is basically the simple lunch I have always dreamed of having at a town tavern. Salerno recommends ending the meal with cheese, which feels very civilized, probably because French people never forgot this advice.

Day 2

One of the more mysterious pieces of advice Salerno gives is to wait to eat until the food has left your stomach. How do you know food has left your stomach? You’ll know, is basically what they tell you. “You will be able to know for sure whether you are hungry, by judging your desire for food,” the poem says.

Meat, basted. (Image: Public domain)

I spend a lot of time wondering: Am I hungry? Do I desire food now? Google informs me that it takes 4 to 5 hours for food to leave the stomach, so when my stomach starts rumbling 2ish hours after my last meal, I wait to eat. And wait, and wait, until I feel less specifically hungry and more lightheaded. Dinner is bread and cheese, which is apparently fine if you’re healthy (and poor).

Day 4

By now, I have figured out how to eat more like a rich person. “Rich gravies,” which I take to mean meaty, saucy stews, are hard to come by in New York in 2016—at least without tomatoes and potatoes. American cuisine has mostly abandoned the idea; the rich gravies we eat are mostly likely to come from Thai or Indian restaurants or Central American spots, and be full of spicy peppers, tomatoes, or potatoes, all of which are off limits. Without cooking myself, I find the best place to find rich gravies is at hot bars—Whole Foods makes a decent chicken fricassee—or hip bone broth joints.

I get a chance to test the “don’t stress” part of the advice when I find out my car’s been towed. I can’t imagine that the upper class of Europe had to deal with New York Police Department bureaucracy. But probably their horses ran away? It does seem like a much better choice to shrug it off than to stew. I am somewhat successful.

Day 5

One giant difference between diet advice of 1200s and diet advice now is that Salerno never mentions losing weight or keeping skinny. In fact, all the foods Salerno smiles on, the poem describes as “fattening.” When you’re liable as not to face a famine, or at least a food shortage, at basically any time, fattening is good.

A Flemish pig slaughter. (Image: Public domain)

Pork meat, for example, is fattening, although it’s more complicated than that. Here’s what Salerno has to say about pork: “If you eat pork without wine, it is worse than mutton. If you add wine to pork, then it is food and medicine.”

They’re right. My pork stew with red wine is great. I sleep 10 hours. I feel great.

Day 7

I am eating plenty of eggs and gravies. I realize I am not drinking enough red wine.

Day 8

Diluted wine is a revelation. It tastes a lot like a Vitamin water—fruity and sugary, in a cloudy, unspecific way—but alcoholic. Manageably alcoholic. I drank diluted wine for lunch and dinner, I was not drunk. I was not unable to work. I may have been unable to legally drive. I felt a bit light-headed and perhaps a bit less anxious than usual.

French wine-making. (Image: Public domain)

The idea behind diluting wine is a good example of how humoural theory worked in practice. Water is cooling, and therefore bad for digestion. Wine was heating, and helped digestion along. But it could be too hot. Mix wine and water together, and you had a balanced drink. Conveniently, wine’s antiseptic properties probably made the water safer.

I never managed to drink quite the volume of wine that medieval people are reputed to, but I’m now convinced that most people were not drunk-drunk, just pleasantly buzzed. Considering the percentage of America’s population that’s regularly taking some mood-enhancing drug, we shouldn’t judge medieval people too harshly.

Day 9

For a week and a half, I have been faithfully following Salerno’s morning regime. I have been following the advice to stand or walk around after meals. I have avoided afternoon naps. I have been eating bread, wine, grapes, cheese, and gravies. But there is one part of the medieval regime that I have been shirking.

Back in the Middle Ages, breakfast was not exactly a thing, except for the weak, which included old people, kids, and sick people. Salerno doesn’t say anything explicit about how many meals one should eat. But it does hint that there are only two meals in the day. (“Do not eat a second time until your stomach has been purged.”)

I try it. I really do. It is terrible. By noon, I am light-headed and starving. For lunch, I have bread, cheese, grapes, and chicken stewed with wine, prunes and olives waiting for me. I have my diluted wine at the ready. But it feels gross to have the first thing I put in my mouth be chicken. I eat too much bread first. I eat the chicken too fast, and am suddenly full. And then, it comes—the urge to nap. I fight it. It’s hard. For the first time, I understand exactly why some of the advice in the poem is there.

The Results

There’s a lot to be said for the Salerno regime. The morning routine is refreshing. Because it precludes sugar, a lot of the worst of our modern vices are eliminated. Because it doesn’t have anything spicy in it—the hottest foods in Europe at the time were mustard, horseradish and imported black pepper—it’s easy on the stomach. Plus, you get to feel like a medieval lord, which is never a bad thing.

How did it stack up from a modern point of view? I asked Andrea Grandson, a nutritional therapist who specializes in metabolic health, to go over the Salerno prescriptions with me. “It sounds very healthy, with eggs, wine, and broth,” she says. Eggs are a complete protein and one of the easiest to digest. Red wine is valuable for its resveratrol and antioxidants. Broths and stews extract the nutrients from the bones and organs of animals. “They were on the right track in terms of looking for nutrient density,” she says.

But, most importantly, she said, how did I feel? Was I sleeping ok? Did I feel an afternoon slump?

The truth is, I felt great eating this food. It was simple, hearty, and filling, but I never stuffed myself. I would recommend keeping breakfast. And snacks. And coffee. But, otherwise, maybe eating like a medieval king could be a great way to stay healthy.

Special thanks to Arlene Shaner at the New York Academy of Medicine, who introduced me to the Salerno regimen.