My Humble Opinion on Nutrition

Food for Life distributes food on an internati...

I have taken part recently in some interesting conversations on nutrition and I thought I would put down my current views on the topic. I will preface this with the fact that as an internal medicine physician my formal training in nutrition is minimal at best. The level of education on nutrition offered in even the most prestigious medical schools these days is embarrassing. We did not have even one course on nutrition and the whole topic was summed up in a few lectures over the course of my four years of medical school. In residency it was hardly ever mentioned. For something as important as what we put in our bodies multiple times a day and given that it in my opinion has the largest effect on health than any other behavior, this is appalling. So what I have learned about nutrition has been learned through my wife who is a naturopathic doctor and had extensive education on nutrition during her training, from self research and reading. There are two books that I have recently read that I highly recommend. Whole by T Colin Campbell (the researcher behind the famous China Study) which discusses not only nutrition and its role in our health but much of what is wrong with our current medical research and medical care delivery system. The second is In Defense of Food by Michael Pollan who also wrote The Omniovore’s Dilemma.

 

In my research I have found a few key facts. First, there has been very little research on food and nutrition. Again, I blame this mostly on the lack of profit incentive for the research to be done. No patented drug or medical device can come from the research hence no money. Therefore the investment simply is rarely made. Second, is that nutrition is far more complex than most of us think it to be, therefore studies that are done in test tubes or rats are often mistakenly and with disappointing results generalized to humans. Studies showed that foods high in vitamin C were good for you so supplementing vitamin C must be good for you. But experience has not shown this to be the case. Food high in beta carotene seemed to prevent cancer but supplementing it increased cancer. Same for vitamin E. So what is the problem? How come our research never seems to allow us to get to those isolated chemicals in food that make us so healthy? How come we are no closer to that pill that can make us healthy no matter what we eat now than we were 20 years ago?

 

The problem is complexity. With the micro-nutrients (minerals and vitamins) that we have isolated so far we have only scratched the surface of the over 10,000 phytochemicals in foods. Phytochemicals are plant made chemicals that have biologic functions in our body. So why can’t we simply isolate these and take them in pill form to achieve immortality and perpetual youth? Because we don’t even know what all of them are, or what they do to the body.

 

When you eat one piece of fruit you are likely taking in hundreds of phytochemicals. The quantity depends on the health of the soil that plant was grown in, how the growing season was that year, rainfall, sunshine, pests, symbiotic fungi and other organisms in the soil, how ripe the fruit was when it was picked, and even what time of day it was picked. Then when you eat that piece of fruit those chemicals will act on each other. Some blocking the absorption of others and others facilitating the absorption. Then as they act on your body some will deplete other nutrients in your body or increase them. And your body will change what it takes from the food based on its needs and current health. If the body needs more of a nutrient it will take in more and if it does not need it will not. Or absorption may be impaired by an infection or damaged gastrointestinal tract.

 

So when we see that a specific nutrient has antioxidant capabilities in a test tube, that does not mean that it will when combined in food form or in our bodies, or even that more antioxidant intake is what our body needs at that time. The only way to tell if an isolated nutrient of food is good or bad for us is to randomize a group of people to either receive the nutrient or food or not and compare the two groups. However, these studies are rarely done due to many issues I have discussed before. But these are really the only studies conclusions can be absolutely drawn from and that is why those studies are the final and necessary step before approving any pharmaceutical drug. But even pharmaceutical drugs prove the point as even though they are designed to have one desirable effect such as lower cholesterol or blood pressure they all have a long list of side effects because our knowledge of the complexity of the human body is still in its infancy.

 

So in the face of all this complexity what is one to do when deciding what to eat? Well in everything I have learned and come to believe I think it comes down to the basics of eating what evolved to eat as much as possible. Our diet has changed dramatically in the last 10,000 years since the spread of agriculture. And with industrialization our diet has changed even more in the last 100 years than in any other time in history. The problem is evolution does not act that fast and so our bodies are unable to adjust to such rapid change. And our changes in diet are based on taste preference and convenience, not on what is healthy for us. And the few health related food choices we make are based on very superficial and limited information.

 

Human history has shown us that humans can survive on a wide variety of foods. From Eskimos to Bedouins the climates we can survive in and the diets associated with the climates are amazingly diverse. But surviving on a diet and thriving on it are two very different things. Animals can adapt to survive on new food sources quickly as those that cannot survive on it die off and only those that can survive to reproduce. But the selective pressure between those that thrive on the diet and look healthier and have more energy get more mating opportunities separating them from those that merely survive but do not thrive on the diet can take hundreds of thousands if not millions of years. To put the time scale of evolution in perspective if you took all the time since the beginning of dinosaurs to now and compressed it into one day the dinosaurs would have existed for the equivalent of 18 hours. Humans would have been on earth now for the equivalent of 10 minutes. So the selective pressures on humans from evolution have been minimal at best. Most of our evolution happened before humans walked the earth.

 

With this in mind I find the best reference for what we should eat to be Chimpanzees and Bonobos. We share a common ancestor with these primates in the not too distant past and genetically they are the most similar to us than any other living thing on the planet. We share over 98% of our DNA with Chimpanzees. However, while our diet has changed dramatically in the last 10,000 years and even more so in the last 100, chimpanzees and Bonobos eat very similar diets to what our common ancestor would have eaten.

 

So what is this diet? It is the exact same diet that most of the research done on diet is showing us is healthy. A mostly plant-based diet with as wide a variety of plants as possible and very little lean meat. Chimpanzees eat about 60% fruit, 38% vegetables, nuts, seeds, leaves, and 2% meat (usually in the form of monkeys). There are usually well over 100 different types of plants in a Chimpanzee’s diet. And there are no refined grains in this diet such as wheat, corn or rice.

 

Given this I do not find it surprising that study after study shows that plant-based food decrease the risk for cancer and heart disease. That vegetarians and vegans have lower risk for diabetes and hypertension. That eating meat increases the risk for heart disease and cancer. In fact one study I have highlighted before showed that a vegan diet was better for diabetics by every health measure they looked at than the American Diabetes Association Diet.

 

Chimpanzees and their ancestors have had time to adapt so that they not only survive but thrive on this diet. Over millions of years mammals have been eating adaptations to this diet and with each generation those that are healthier, more robust appearing, stronger, and had more energy had more chance to mate and increase their numbers. This subtle pressure takes a long time, much longer than the 10,000 years that agriculture has been prevalent.

 

Only after the widespread use of agriculture did refined grains such as rice, wheat, and corn enter our diet in large amounts. And only after farming came about did we start to eat meat that was from domesticated animals such as cows and pigs that is much fattier and has much more omega 6 fatty acids which are inflammatory than omega 3 fatty acids which are anti inflammatory. The animals we ate prior to this we monkeys, deer, rabbit, squirrel and a myriad of other lean, wild and much healthier animals. Our ancestors used to eat about 50% omega 6 fatty acids and 50% omega 3. Today that ratio is about 15 to1 in the average Western diet. And only after farming did meat become such a large proportion of our calories.

 

There is no doubt we have evolved to the point where we can survive on this diet but given the increasing spread of heart disease, diabetes, cancer, and obesity it is clear we have not evolved to thrive on it.

 

I feel much more research on a microscopic scale will need to be done before we even have what we could consider a beginning to understanding the effect food has on our body. And I would love to see far more studies that randomize people to certain diets so we can actually draw some conclusions from them. Lets do a study randomizing people to a diet with naturally occurring foods with no refined grains or processed food and very little meat (preferably lean meat high in omega 3) and compare that to the American Heart Association diets, or ADA, or TLC, or Atkins diets. Diet is the most important health recommendation we make to a patient so it should be evidence based.

 

Until that happens I think we are best suited to staying on the diet we have evolved to thrive on. Clearly eating what we can survive on is not working.

 

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Vitamin B3- Niacin or Nicotinamide

Ball-and-stick model of the niacin molecule, a...

niacin molecule, also known as Vitamin B 3 and nicotinic acid

Vitamin B3 is another one of the water-soluble B vitamins. It was first discovered in 1873 by Hugo Weidel during his studies of nicotine. Vitamin B3 is essential in multiple steps in metabolism and is needed for good adrenal gland and nervous system function. It is mostly obtained in the diet from animal sources such as chicken, beef, and fish. Liver and kidney and heart have the highest amounts. The best plant sources include shiitake mushrooms, nuts, whole grains, beans, avocados and dates. The body can also synthesize Vitamin B3 using the amino acid tryptophan.  Interestingly vitamin B3 deficiency became epidemic when corn started being adopted by Europeans as a food source after the discovery of the Americas (corn is native to central america and therefore was unknown in Europe until the 1500s). The Mayans and other native americans that ate corn did not have vitamin B3 deficiency. This was because they cooked the corn using a process called nixtamalization where they cook it in a limewater (calcium oxide lime, not the fruit) making it very alkaline. This made the corn more easy to grind and improved the flavor. However, it also released the Vitamin B3 which is otherwise bound and not bioavailable in corn and allowed it to be absorbed by the body, hence preventing vitamin B3 deficency in Mayans and other native americans. However, the Europeans who adopted corn did not understand the benefit of nixtamalization and therefore did not use this process, and an epidemic of vitamin B3 deficiency ensued.

The recommended daily allowance is approximately 14 to 16 mg/day. The upper tolerable limits is about 35 mg/day but the only side effect to this is skin flushing. Not until doses as high as 2000 mg or more are significant side effects seen, and even then are rare. Some liver toxicity, skin irritation or eczema, heart arrhythmias, increased blood glucose, eye problems, birth defects if given to pregnant women, and indigestion have all been reported. Supplements of Vitamin B3 come in two forms. Niacin is what is used most commonly by physicians to decrease cholesterol. It is used at very high doses (sometimes as much as 3000 mg) and can cause significant side effects at those doses and almost always causes flushing. Nicotinamide is what is used in most dietary supplements found in stores without a prescription. Niacin is converted into nicotinamide by the body so it has the same nutritional value. However that conversion plays a key role in lowering the cholesterol and causing flushing so nicotinamide does neither of these. Nicotinamide has much lower risk for toxicity as well.

Mild niacin deficiency can slow the metabolism causing fatigue and intolerance to cold. Severe deficiency causes what is referred to as pellagra. Pellagra causes a constellation of symptoms including diarrhea, skin irritation and darkening, inflammation of the mouth, dementia and other mental disturbances, and eventually death if not treated.

Niacin has been used since the 1950s as a cholesterol drug. Many studies have been done on the topic the best of which is likely the multicenter placebo controlled trial by Canner et al. With 3 grams of niacin a day subjects saw a 27% reduction in heart attack and 26% reduction in stroke and the cholesterol panel improved significantly as compared to placebo. 9 year follow-up of subjects showed an 11% reduction in mortality as compared to placebo. Overall the benefits seem clear but its role in combination with other cholesterol lowering drugs, more specifically with statins such as Lipitor,Zocor, and Crestor, is still being worked out. Also, the very high doses needed for cholesterol lowering does cause significant flushing which decreases compliance. However, it has not been looked at yet to see if lower doses that may not have as dramatic effect on cholesterol levels may still show stroke and heart attack prevention by other mechanisms. I feel this is an open question that should be addressed.

Test tube studies are showing evidence that vitamin B3 deficiency may increase the risk for cancer. Vitamin B3 deficiency seems to be associated with instability of genes which is a first step to forming cancer. A 1999 study by Jacobson et al from the University of Kentucky showed that one part of this may be vitamin B3’s role in supporting the tumor suppressor gene p53. They also showed a clear correlation of low vitamin B3 in tissues of people who had increased skin tumors such as squamous cell carcinoma. Kirkland from the University of Guelph in Canada also further explained how Vitamin B3 may decrease the risk for cancer (see link below).  A study done by Dr. Yong with OSHA (the national institute of occupational safety and health) in 2011 of 81 pilots who were exposed routinely to ionizing radiation due to their work found that those with the higher intake of Vitamin B3 had a significantly lower rate of DNA damage. However this was merely observation and not a randomized controlled trial so the effect cannot be definitively linked to Vitamin B3. Similar studies looking at Vitamin B3 intake in those with esophageal and throat cancer found a 40% reduction in risk in those eating 5 to 6 mg more per day.

Early data did show promise for Vitamin B3 to possibly treat and/or prevent type 1 diabetes. However this was followed up with good randomized trials including by Lampeter et al. and Greenbaum et al and unfortunately they found no benefit. The data when taken together show that it is possible that Vitamin B3 actually does help prevent destruction pancreatic insulin secreting cells that leads to diabetes type 1. However Greenbaum’s study showed that this effect may be offset by an increase in insulin resistance caused by high dose Vitamin B3. Basically you may be trading type 1 diabetes for type 2. This is still an open question.

The association of mental issues with pellagra has led some to look into niacin and mental conditions such as schizophrenia. Interestingly it was found that Schizophrenics do show less tendency to flushing when treated with niacin. Messamore from the Portland VA in a 2012 study showed that severity of schizophrenia correlated well with less tendency to flushing with niacin. Dr Puri in 2001 showed that this reaction has a 90% sensitivity and 75% specificity to schizophrenia and it has actually been proposed to use it as a diagnostic tool for schizophrenia. A randomized controlled trial of Vitamin B3 supplementation by Dr. Ramsay et al in 1970 was done with newly admitted schizophrenic patients and found no benefit, however I found no mention of the number of patients. Conversely, Hoffer et al in 1957 did a trial of 30 schizophrenics and found a 80% recovery in the vitamin B3 group vs 30% recovery with placebo. In a follow-up study by Dr. Hoffer he found 79.5% vs 41.9% recovery in the niacin group vs placebo group respectively. Morris et al in a 2004 study also showed that higher dietary intake of Vitamin B3 decreased the risk for Alzheimer’s disease dramatically. And studies as far back as 1953 and one in the 1970s showed some benefit of nicotinamide on depression but have never been followed up with any good randomized controlled trials.

A study by Dr. Melton all the way back in 1943 also showed a dramatic improvement in asthma is subjects treated with niacin. However, to the best of my knowledge this study was never followed up with a randomized controlled trial. In fact the only other trial I can find exploring the matter was a 1974 study by Dr. Bekier that showed a decreased allergic response in guinea pigs treated with nicotinamide.

Also a 2006 study out of the University of Pittsburg laid out the benefits of nicotinamide for inflammatory skin conditions such as acne and rosacea.

Overall vitamin B3 shows a lot of promise. I feel one main issue may be our overemphasis on niacin while neglecting the less toxic nicotinamide. I feel we need to investigate to see if we can get the same heart attack and stroke prevention (our real goal) from nicotinamide as we do with niacin. And nicotinamide’s role in the treatment of Alzheimer’s, schizophrenia, depression, bipolar disorder and other common psychiatric disorders needs to be determined. Lastly, vitamin B3’s role in treating acne and rosacea is definitely needs to be investigated further.

References

Vitamin B3 and tumor suppressor gene p53

Kirkland study on Vitamin B3 and cancer formation

OSHA pilot study

Vitamin B3  and throat cancer

Vitamin B3 and esophageal cancer

1998 Lampeter Diabetes type 1 and vitamin B3 study

Greenbaum study showing increased insulin resistance with Vitamin B3 high dose

Schizophrenia and skin flushing from Vitamin B3

Schizophrenia skin flushing Dr. Puri study

Vitamin B3 and Alzheimer’s

Dr. Melton 1943 study on Asthma and niacin

Guinea pig asthma and Vitamin B3 study

Article on Dr. Hoffer’s studies on Vitamin B3 and schizophrenia

Nicotinamide for acne and rosacea

Food- Our Most Powerful Medicine

Tasty Food Abundance in Healthy Europe

The food we eat is well known to be the number one cause of many of the preventable diseases we struggle with today. Despite this doctors everywhere are spending little or no time reviewing what patients eat and what they should be eating. Nutritionists are spending their time concentrating on fat, protein, and carbohydrates often times ignoring the other and likely more important aspects of food such as phytochemicals, vitamins, fiber and the medicinal effects of food.

Our relation to food in our modern society is amazingly messed up from the soil to our plate. We seem to have forgotten that we are just as reliant on the nutrients from the soil and energy from the sun to survive as plants are. We just get these things from the food we eat rather than directly.

Modern agriculture practices abuse plants and by proxy abuse ourselves as well. Through planting huge monocultures of plants we have eliminated the synergy between plants that allows nutrients in the soil to be constantly repleted. These large groups of one single crop completely deplete the soil of nutrients and are a huge advantage for any pest that feeds on that crop. Add to this that the depletion of nutrients compromises the immune system of the plants and their ability to fight off pests. This leads to the widespread use of pesticides and fertilizers. The problem with fertilizers is that it only repletes what is absolutely necessary for plant survival and growth but does not replete the wide array of nutrients that help make the plant truly healthy, making us unhealthy as well. As for the pesticides, we are all told to believe they are not harmful and no study has shown them to be harmful. However, all we have proven is that they are not fatal. They may very well be harmful to us as long term studies have never been done. We can all remember cases before when we were told chemicals were safe until they were proven harmful (DDT, BPA, asbestos). Our current system is set up to say chemicals are safe until proven harmful, not the other way around as it should be. Not to mention that the harm may not be to us directly but to other organisms in the environment. There is new research showing that the dying out of bees in massive numbers in a disorder coined colony collapse may likely be due to a fungicide that was presumed to be safe for bees but is now found to compromise the bees’ immune system leaving it vulnerable to parasites. Bee pollen has been tested and usually shows on average 9 to 21 different pesticides in it. This chemical stew’s effect on the environment and our bodies has never been tested. Also these chemicals take away the job of fighting off pests from the plant as this is done for them. Therefore the plant no longer needs to make these naturally occurring pest deterrents which happen to be many of the same chemicals that make plants so healthy for us.

Then after we harvest these sickly, nutritionally depleted, chemical laden plants rarely do we eat it in its whole form which is the most nutritious way for us to take it in. In fact this is the only way our digestive system has evolved to eat. Millions of years of evolution adapted us to be hunter gatherers. Gathering up wild fruits, vegetables and nuts and eating them and occasionally supplementing this with wild animal meat which is far more lean and has more omega 3 fats. Instead we take this food from the earth and often times ship it thousands of miles from where it was farmed giving it more time to nutritionally deteriorate. Or, even worse, the food may be sent for processing, separating it into isolated parts depleting it of almost all phytochemicals and vitamins and is made into some food product that has almost no similarities to anything our ancestors would have eaten. In fact there have been theories put forth that overeating is due to the body craving nutrients it still in deficient in despite eating a lot of calories. The body continues to send hunger signals despite lots of fat and having taken in plenty of calories in an effort to get the person to eat the nutrients it is lacking. So far there is only some observational data supporting this and to the best of my knowledge it has never been tested but it does make logical sense and may explain the failure of many other attempts to treat weight gain such as using leptin. Lastly, and possibly even worse than processing food, we feed it to livestock to fatten it up and eat it. The problem is that these animals never evolved to eat corn, soybeans or whatever cheap crop we choose to feed them. Corn is far to high in sugars for cows and is the main reason their intestines are now filled with dangerous E. coli bacteria that lead to gastrointestinal infections in humans as food borne illnesses and why we have to treat our meat like it is radioactive in the kitchen to avoid getting sick. Feed a cow only grass as it was evolved to do and the E. coli in its gut disappears and its meat becomes leaner and has far higher omega 3 fats making it much healthier. But this is not what we do. We abuse our livestock just like we abuse our plants, damning them lives to overcrowded, sedentary, nutritional deprived lives leading to sick animals that when eaten by us lead to sick people.

We have forgotten our connection to the soil, plants and animals. We spend less time than any other culture in history obtaining and preparing our food. Just a few hundred years ago most of our day was spent in these efforts. It is a huge luxury and advancement that we no longer have to devote so much time to meeting our basic needs. But there seems to be an inner desire that is fulfilled when we obtain this food ourselves. So much technology and industrialization of the food process has been set up to allow us more free time. And what do we do with that free time? We go fishing, or hunting, or we garden. We clearly have an evolved drive to cultivate and obtain food, and it brings us satisfaction to do so. So many of our psychological and health related problems could be helped by simply having a garden to grow some of our own nutritional food. Sharing that experience of growing food with our children and showing them first hand our connection to the soil and sun, and to our planet. Or spending time hunting, sitting in nature and admiring animals first hand and seeing their sacrifice for our nutrition up close. Many animal rights activists may criticize hunting and I certainly do as well if it is hunting only for sport and not for food. I have no moral objection to hunting a deer and eating it if it substitutes for the meat of a cow or pig that was raised on a livestock yard in inhumane conditions. The deer at least was able to survive and thrive in the wild for its whole life until it was killed for food. This seems far more humane and natural. And the meat obtained from the deer is much leaner and has far more omega 3 fats and likely many more nutritional aspects to it that we have yet to understand that make it far healthier than a farm raised cow or pig.

After all this food is planted, raised, harvested, processed, fed to livestock we then often eat it in solitude as fast as possible and in far too much quantity. The sit down family meal is slowly being replaced by the solitary meal in front of the television or the fast food behind the wheel of a car. We used to leisurely eat at a table with others giving our stomachs time to know it is full and allowing us to respond more to internal queues telling us how much and what to eat rather than external queues. When watching television the queue to stop eating is often the end of the show as your attention is drawn away from the food itself.

Diet experts and nutritionists are constantly tweaking the ratio of fats, protein, and carbohydrates to make for the perfect diet that will allow for optimal health and weight loss. However food is far more complicated than these three macronutrients. Very VERY slowly science is respecting the importance of vitamins and other micronutrients. Initially they were only considered to be important to prevent extreme deficiencies as seen in rickets, scurvy, or beriberi. Now slowly science is understanding that less severe deficiencies may also play are role in disease such as low vitamin D leading to osteoporosis or increasing risk for cancer. However this science is still in its early stages and there is still far too little of it. And we are just beginning to understand the importance of the 10,000 other phytochemicals in plants that may have a potential effect on the human body such as lycopene or selenium. Our understanding of food is in its infancy and to think we know enough to mess around with the soil, pest killing chemicals, and the diet of the animals we eat is not only arrogant, it is completely wrong. The safest thing to do when there is such a huge lack of knowledge would be to keep our diets as close to what we found in nature as we evolved. Our bodies have had millions of years to not only survive but to thrive on this diet. Our genetics are set up to be at our best on a diet of wild nuts, berries, and vegetables with the occasional lean meat.

Due to this organic fruits and vegetables not only have the advantage of exposing us to less chemicals. It also makes for plants that are under more stress producing more nutrients that our body needs including many more of those 10,000 phytochemicals that our body needs than their nonorganic counterparts. This is already well known in the wine industry. Grapes that are put under some stress as they grow make far better wine than grapes that had everything they needed and were grown under perfect conditions. The stress makes the grape make a far greater array of phytochemicals to ward off pests and resist draught. This makes for a richer, fuller taste that our palate enjoys. We crave this taste of the earth.

Our idea of nutrition has to change dramatically. Food is not merely a conduit for calories in a ratio of protein, carbohydrates and fats. They are also the delivery system for vitamins and thousands of other phytochemicals that we need. One day in the far off future we may have a full understanding of food and be able to get all the vitamins, nutrients, and phytochemicals we need from supplements, but that day is no where near. For now our best path to health is to match the diet as closely as possible that we have evolved to thrive on. The diet should consist predominantly of fresh, whole fruits and vegetables with minimal cooking or processing (none if possible). This should be supplemented with a small amount of animal meat or fish that are raised in as close to wild type settings as possible. Grass fed cows, wild fish, free range chickens and eggs. It may seem like this would be far too expensive for anyone to sustain but keep in mind you should be eating FAR less meat than you do. Meat is not only the most expensive part of our diet, it is also the least efficient use of our energy. Plants give us far more bang for our buck. And if everyone were eating far less meat we could afford to pay more for it and devote sufficient amount of land to allow them to be pasture raised. Our plants need to be not only organic but grown in close proximity to different types of plants. Monocultures are not found in nature and for good reason. They deplete the soil and make for a perfect environment for pests. Our plants need to be able to naturally struggle with pests in a sustainable diverse environment.

We all need to reconnect with the soil and our ecosystem. We need to grow some of our own food even if it is only some herbs in a window box. Our children need to understand that our current system is not sustainable and is poisoning us. With this approach much of the modern day diseases would be far less frequent and we could all feel much more healthy while enjoying our food more at the same time.