Making Sense Of Modifiable Personal Lifestyle Factors
It seems reasonable that a general understanding of food and nutrition would be a critical part of understanding and improving your health. However, as many us have discovered, once you begin to study nutrition is becomes an area that gets more difficult to understand the more you know about. Personal and professional bias, agendas from sponsors that design nutrition studies, self-proclaimed experts and conflicting information in the literature all contribute to this confusion. In the end, there should be a sense of logic and consistency when thinking about nutrition. Although all aspects of nutrition cannot be covered in a brief article, I hope to clear up some of the confusion about the most popular food plans that are often associated with improved health and vitality.
NUTRITION VS NUTRITIONISM
Nutrition simply stated is the process of providing or obtaining the food necessary for health and growth. It is based on intelligently choosing all that you need to live your best life possible. This branch of science deals with the nutrients within foods and teaches what these nutrients do and more importantly what they’re for. Most scientists agree that there are seven main classes of nutrients that the body needs. These are carbohydrates, proteins, fats, vitamins, minerals, fiber and water. Arguments can be made over more nutrients (alcohol, bacteria, etc.) or even if all of these nutrients are essential, but for the sake of simplicity we will focus on these seven in the article.
Nutritionism, on the other hand, is very different. Nutritionism is more of an ideology or paradigm that believes the nutrients in food determine the value of that food. In other words, it is the idea that the nutritional value of a food is the sum of all its individual nutrients. Originally referenced Gyorgy Scrinis his book “Nutritionism: The Science and Politics of Dietary Advice”, the notion was made popular by journalist Michael Pollan in his best-selling book “In Defense of Food”. Nutritionism is the widely shared but unexamined assumption that the key to understanding food is reducing the food to the sum of its nutrients. Unfortunately, this assumption understanding seems to have made something as simple as eating food incredibly complicated. Certainly, understanding nutrients of food is important, but it is equally important to see food more than the sum of all its nutrients.
Searching through the evidence of nutrition and global eating habits is equally challenging. Although nutrition studies have the potential to add important perspectives to public health, they are often full of flaws and pitfalls. Many large nutrition studies are observational in nature and cannot truly provide causality (why something does or does not happen). In addition, nutrition studies suffer from self-recall bias and often use inaccurate methodology to collect information. Lastly, nutrition studies tend to be funded by special interest groups and sensationalized in the media. It is therefore important to scrutinize a study’s methodology and determine if similar studies have been done in order to ensure their validity and accuracy.
Lest we lose all hope, some wonderful studies have been done, some for many years, to help point us towards a pattern of eating that is at least helpful. The China–Cornell–Oxford Project, the United Kingdom Food Survey study and The Framingham Heart Study are just some of the larger studies that help us determine some of the factors that influence our health through nutrition.
With that in mind, there are a few agreed upon guidelines when it comes to the rules of nutrition and healthy eating. They may seem obvious, but they are worth formally mentioning:
- Calories Matter: Although the idea of calories in and calories out may be an oversimplification of the role of food… in the end calorie intake is important. Over eating and large portions contribute to weight gain no matter what the quality of food. Incorporating the Japanese concept “hara hachi bu” (which is a Confucius-inspired teaching that advises us to stop eating when we are 80% full) is a helpful too to keep calories limited and optimal. Ultimately it is recommended that calories be tracked in some way, even for a short period of time, to be accurate with the caloric content within any food plan.
- Quality is Key: This is the concept that food quality should be a large factor in determining what we eat and what we avoid in order to achieve and maintain optimal health. Rather than simply choosing foods based solely only on caloric value, choosing high-quality, healthy foods, and minimizing low-quality foods is best
- High-quality foods include unrefined, minimally processed foods such as vegetables and fruits, whole grains, healthy fats and healthy sources of protein.
- Low-quality foods include highly processed snack foods, sugar-sweetened beverages, refined (white) grains, refined sugar, fried foods, foods high in saturated and trans fats, and high-glycemic index foods.
- Manage your Macros: Understanding the ratio of your Carbohydrates, Proteins and Fats within your day is helpful… but not as important as the amount of food or the quality of food. To that end, we will break down the most popular food plans based on macronutrients to help choose the best plan for each person. There is general consensus with the idea that moderate protein content, low-glycemic index carbohydrates and fewer saturated fats lead to the best outcomes in health. However, variations within macronutrient plans may have their own health benefits as shown by some nutrition studies. To summarize, paying attention to your macronutrients does matter, but not as much as caloric content and quality of food matter.
FUNCTIONAL MEDICINE FOOD PLANS: Recognizing that there is not one “best food plan” and not every food plan can fit every person… let’s review some of the more widely used plans in the field of functional medicine.
MODIFIED MEDITERRANEAN PLAN:
The modified Mediterranean plan and the Mediterranean plan have had the most amount of research and have received several accolades like the highest ranked diet for health and the easiest diet to follow. This food plan consists of large amounts of fresh vegetables and moderate amounts of fresh fruit. In addition, whole grains, legumes, nuts, and seeds are plentiful in this plan. Fish, and to a lesser extent lean meat and poultry, are eaten in moderation to improve levels of proteins. Polyunsaturated fats and monounsaturated fats (mostly from olive oil) are also added into the plan. The plan limits and discourages fried foods, hydrogenated oils, refined carbohydrates (baked goods from refined flour and sugar), beverages with added sweeteners (sodas and juices), high-fructose corn syrup, and fatty, processed meats, such as lunch meat.
Observational studies and population studies support an anti-inflammatory and protective effect from this kind of plan. Most of the research also supports the use of this food plan in the management and even treatment of cardiovascular disease, cardiometabolic disease, diabetes, hypertension, elevated cholesterol, obesity and cancer.
At New England Center for Functional Medicine, this plan is best exemplified in our own FOOD MATRIX plan. Macronutrient ratios of foods in this plan are often kept at 40% of the caloric energy from Carbohydrates, 30% of the caloric energy from Proteins and 30% of the caloric energy from Fats. We have found this type of Mediterranean plan to be the most varied and easiest to sustain among our patients. A higher protein alternative of this plan can increase the energy from Proteins to 40% while decreasing the energy from Fats to 20%. Our more athletic and active population seems to like this type of plan more due to the higher protein levels.
As stated earlier in this article, caloric content is kept consistent in this plan for best results. Equally high-quality food choices are recommended over low-quality food choices for optimal results on benefiting health.
Mediterranean recipes can be found on most major food websites like www.epicurious.com, www.foodnetwork.com, www.allrecipes.com and www.bluezones.com/recipes/ . However, you may need to put in key words like Mediterranean or use the guidelines described to find the correct recipes to fit the Mediterranean plan.
The Paleolithic plan, or “Paleo” plan, is based on the notion that eating patterns before agriculture and farming were better for our health as humans. In other words, eating like hunter gatherers is more along the lines of what we were designed to eat. Although there are some flaws to the theories of paleolithic eating, many hunter/gather nations in modern times have very few Western civilization diseases. This logical observation is probably the most convincing argument to include paleolithic eating plans into the mix of healthy eating plans.
Unfortunately, many of the guidelines of paleolithic plans are variable and may consist of a variety of macronutrient ratios as well as calorie content. However, high-quality food is generally consistent within these types of plans. Paleolithic plans can be best viewed as teaching what to eat and what not to eat when it comes to healthy eating. In its most basic form, paleolithic plans teach us to do the following:
Eat: Meat, chicken, fish, eggs, vegetables, fruits, nuts, seeds, herbs, spices, healthy fats and oils.
Avoid: Processed foods, sugar, soft drinks, grains, most dairy products, legumes, artificial sweeteners, vegetable oils, margarine and trans fats.
Many of the carbohydrates in this plan are found in starchy vegetables rather than grains and legumes which are prevalent in the Mediterranean plan. This is the major difference between the two plans. Usually the macronutrient ratios are similar to the Mediterranean plan of 40% Carbohydrate, 30% Protein and 30% Fat… but there is no hard and fast rule for this. Some plans encourage high proteins and animal products while others focus more on carbohydrates and plants. These variations will in turn create variability in the macronutrients…and perhaps the focus of this plan should remain on the quality of the food rather than the macronutrient ratios.
Although there are no long-term studies involving the paleolithic diet, a number of randomized clinical trials have compared the paleo diet to other eating plans, such as the Mediterranean plan and the classic Diabetes plan. Overall, these trials suggest that a paleo diet may provide some specific benefits including: greater weight loss, improved glucose tolerance, improved blood pressure, lower triglycerides and better appetite management. Paleolithic plans, due to their concrete and simple instructions as well as specific limitation, may be an easier way to begin a restrictive type food plan focusing on high quality foods.
The Ketogenic plan was originally designed to offer a dietary solution to treat seizure disorders by mimicking the biochemistry of prolonged fasting. The plan does this by manipulating macronutrients to force the body to run on an alternative fuel created by starvation: ketones. Fortunately, ketones need not be created through starvation alone. Ketogenic plans create ketones by decrease the levels of carbohydrates in our diet while increasing the levels of fats. As a result, there are some interesting and creative things that happen to the body while in ketosis, not the least of which is a decrease is systemic inflammation as well as insulin related and insulin dependent conditions such as obesity and diabetes.
Ketogenic plans rely heavily on the consumption of fats. In general, over 65% and up to 80% of the caloric energy within the day must be consumed as fat. To accomplish this, the ketogenic diet is a low-carbohydrate, moderate protein, and high-fat diet plan where you must limit your carbohydrates to succeed. It works to shift your body from using carbohydrates and a fuel source and instead use fat, and the byproduct, ketones, as a fuel source.
However, as logic would dictate, it may not be ideal to just eat fatty meats and cheese and call that a ketogenic plan. Greater benefits from ketogenic plans occur when the quality of foods is again emphasized. To that end, choosing plant-based fats like nuts and seeds, higher quality fatty meats and fish as well as olives and avocados will help keep the fats chosen for the plan at a high quality.
In addition to high quality fats and proteins, a high quality and variety of non-starchy vegetables needs to be added into the plan regularly. A risk of the ketogenic plan is a low fiber content. However, that can be avoided by incorporating an adequate amount of non-starchy vegetables.
Fruits, in general, are to be avoided with some exceptions, namely berries. Tubers and starchy vegetables as well as grains and legumes must also be avoided to keep carbohydrate levels below 5% (recommendations being somewhere between 20g to 50g of carbohydrates per day as a maximum).
Transitioning to a plan like the ketogenic plan can put a person at risk for dehydration and depletion of sodium through diuresis and urination. For that reason, adequate levels of water as well as salt (natural sources like Himalayan, Truffle or Sea salts are best) are highly recommended so that flu like symptoms that can happen in the early stages of ketosis do not occur or become bothersome.
Of interest, there are several versions of the ketogenic diet. In this way, there may be more variety to the standard ketogenic plan then is popularly viewed. These variations include:
- Standard ketogenic diet: This is a very low-carb, moderate-protein and high-fat diet. It typically contains 75% fat, 20% protein and only 5% carbohydrate.
- Cyclical ketogenic diet: This diet involves periods of higher-carb refeeds, such as 5 ketogenic days followed by 2 high-carb days. However, there is no long-term research on this type of ketogenic plan.
- Targeted ketogenic diet: This diet allows you to add carbs around workouts. Equally there is no long-term research on this type of ketogenic plan.
- High-protein ketogenic diet: This is similar to a standard ketogenic diet, but includes more protein. The ratio is often 60% fat, 35% protein and 5% carbs.
At New England Center for Functional Medicine, an introductory form of the ketogenic plan is well presented in our KETO MATRIX. Macronutrient ratios of foods are kept at 40%-55% of the caloric energy from Fats, 40%-25% of the caloric energy from Proteins and 20-5% of the caloric energy from Carbohydrates. The variation and choices in this plan are meant to help people transition into a standard ketogenic plan but are more similar to a high protein ketogenic plan. Our KETO MATRIX is based on a combination of the MITO PLAN created by the Institute of Functional Medicine as well as the Healthy Transformation plan created by Metagenics: https://necfm.metagenics.com/healthy-transformation-weight-loss-program. We have found this type of Modified Ketogenic plan to have many of the benefits of true Ketogenic plans. They also are the least restricting as well as the easiest to sustain among our patients desiring a Ketogenic plan. However, true Ketogenic plans offer other metabolic benefits and require a higher content of fat than the three aforementioned plans.
Implementation of the ketogenic diet in animal as well as human interventional studies demonstrate anti-inflammatory effect, improved insulin sensitivity as well as improved metabolic function in specific populations. The ketogenic plan has been best studied in the treatment of obesity, type II diabetes, elevated cholesterol and seizure disorders. In addition, there is evidence that the ketogenic diet is helpful in treating polycystic ovarian syndrome, acne, some forms of cancer as well as some neurological diseases.
Elimination plans are often done to determine if a patient is suffering from food sensitivities or food intolerances. This is a short-term plan that helps identify foods your body does not tolerate well and then removes them from your diet. An elimination plan usually lasts 4 to 8 weeks, however symptoms should begin to change within the first 2 weeks if the correct foods are eliminated. There are several variations of this plan which involve removing specific foods known to cause gastrointestinal as well as inflammatory problems.
In general, elimination plans consist of two phases: elimination and reintroduction. In the elimination phase, foods that can cause problems are taken out of the dietary plan. Different practitioners and plans take out different foods, but in general foods that are most commonly removed during the elimination phase include:
- Gluten based grains and foods: Avoid foods containing barley, rye, processed oats, wheat, spelt and other gluten containing grains.
- Dairy products: Eliminate all dairy, including milk, cheese, yogurt and ice cream.
- Sugar and sweets: Avoid sugar (white and brown), honey, maple syrup, corn syrup and high-fructose corn syrup, agave nectar and sweet desserts.
However other foods like soy, peanuts, eggs, nightshades, histamine containing foods, lectin containing foods, animal products, alcohol, coffee and chocolate may also be removed in some more restrictive plans.
In addition to removing foods, elimination plans are rich in fiber as well as phytonutrients. These nutrients assist with repair of the gastrointestinal tract as well as reducing inflammatory processes. Foods commonly used in the elimination plan include:
- Fruits: Most fruits, sometimes excluding citrus fruits.
- Vegetables: Most vegetables, excluding nightshades.
- Grains: Including gluten free grains such as buckwheat, millet, whole oats, quinoa, and rice.
- Selected meat and fish: Including turkey, lamb, wild game and cold-water fish like salmon.
- Dairy substitutes: Including almond milk (if nuts are allowed), coconut milk and rice milk.
- Fats: Including cold-pressed olive oil, flaxseed oil and coconut oil.
- Beverages: Water and herbal teas.
- Spices, condiments and others: Including black pepper, fresh herbs and spices (excluding cayenne pepper and paprika) and apple cider vinegar.
Some elimination plans are more specific to assist with greater levels of inflammation and symptoms. The Low FODMAP diet, the Specific Carbohydrate diet, the Anti-Candida diet and the Elemental diet are a few of these specific plans. These plans are more restrictive and remove significantly more potentially irritating foods based on the guidelines of the diet. These specific food plans are available at our office and through the Institute of Functional Medicine guidelines of these plans. There are also several books and websites that can help implement these more restrictive plans.
After the 4 to 8-week process of eliminating the specific foods recommended, reintroduction of the eliminated foods is performed. Foods should be reintroduced one food at a time over the course of 3 days to determine if there is a relationship between the food and the symptoms. Sometimes symptoms can be related to foods even after they have been reintroduced longer than 3 days. Foods that are associated with symptoms should be once again be removed from the plan in order to minimize symptoms.
At the office we teach a variation of our own FOOD MATRIX plan and call it the ELIMINATION FOOD MATRIX. Although in most elimination plans macronutrient ratios vary, we encourage a Mediterranean /Paleo style of macronutrient ratios. Our ELIMINATION FOOD MATRIX foods are kept at 40% of the caloric energy from Carbohydrates, 30% of the caloric energy from Proteins and 30% of the caloric energy from Fats. We have found this type of plan to also be the most varied and easiest to sustain among our patients.
Interventional studies using the elimination plan or plans that contain an elimination style of eating have been shown to have improvement in gastrointestinal problems, irritable bowel syndrome, rashes and other skin conditions, ADD/ADHD, migraines, asthma as well as other inflammatory and autoimmune related disorders.
Elimination plan guidelines and recipes can be found throughout the internet…and each one has its own style and differences. We often recommend searching the popular recipe sites like www.epicurious.com, www.foodnetwork.com, www.allrecipes.com and use the specific advance search engine in order to eliminate the specific foods recommended by your particular elimination plan.
WHOLE FOOD PLANT-BASED PLANS
A whole food plant-based plan in a way sounds self-explanatory…and truly it is. Although there are few clear guidelines to these types of plans, whole food plant-based plans are based on the following principles:
- Emphasizing minimally processed foods and focused on whole foods
- Avoiding or limiting animals and animal products
- Focusing on plants as the majority of the food plan including: vegetables, fruits, whole grains, legumes, seeds and nuts, which should make up the majority of the food plan
- Eliminating refined foods like added sugar, processed flour and processed oils.
The definition of a whole food plant-based diet can vary significantly, even within professionals and experts. As stated earlier, it is an eating style that emphasizes real, whole foods that may or may not include animals and animal products. However, the majority of foods eaten on these types of plan come from plants, including:
- Whole grains
- Plant-based protein like seitan, tofu and tempeh
- Nuts and Seeds
- Plant-based oils
- Spices and herbs
- Unsweetened beverages: coffee, tea, sparkling water, etc.
Some plans completely eliminate animals all together. In these cases, the plans are often classified as vegetarian. However, there are several variations of these types of vegetarian plans.
- Flexitarian includes eggs, dairy foods, and occasionally meat, poultry, ﬁsh, and seafood.
- Pescatarian includes eggs, dairy foods, ﬁsh, and seafood, but no meat or poultry.
- Vegetarian includes eggs and dairy foods, but no meat, poultry, ﬁsh, or seafood.
- Vegan includes no animal foods or animal products.
Within these types of vegetarian plans there can sometimes be a concern about getting adequate protein. To be clear, all the necessary amino acids to build proteins can be found in plants. However, it may be reasonable to track your food to determine that you are getting adequate protein from your diet if you are completely plant based. The article in our resources “But what if I’m a vegan?” http://necfunctionalmedicine.com/2018/10/03/but-what-if-im-a-vegan/ is helpful to find the highest sources of plant based proteins. However, many non-starchy vegetables have adequate protein such as green peas, broccoli, mushrooms, kale, spinach and artichokes.
Of equal concern in pure plant-based plans is getting the adequate levels of Vitamin B12. Generally, it is not found in plants so it is best to take a supplemental B12 source if a complete plant-based diet is followed.
Of note, Whole Food Plant-Based diets are often the foundation of Detoxification style plans. Detoxification food plans are done for a short period of time and include a fiber rich and phytonutrient rich food plan that helps with many processes to reduce inflammation and remove unwanted and accumulated toxicity in the body. Both the Institute of Functional Medicine Detoxification plan and the Metagenics Clear Change plan https://necfm.metagenics.com/clear-change-28-day-program-with-ultraclear-renew are examples of these types of detoxification plans.
The Whole Foods Plant-Based diet has been shown in both large population studies and randomized clinical trials to reduce the risk of heart disease, metabolic syndrome, diabetes, certain cancers (specifically colon, breast, and prostate cancer), depression, and in older adults, a decreased risk of frailty, along with better mental and physical function.
Whole Food Plant-Based plans can be found in a variety of sources throughout the internet: some practical and some fanatical. It is still reasonable to use the popular recipe sites like www.epicurious.com, www.foodnetwork.com, www.allrecipes.com and use the specific advance search engine in order to focus on vegetarian, vegan or plant-based recipes. Some other helpful sites are The Whole 30 plan: https://whole30.com/ and Plant Based Cooking: https://www.plantbasedcooking.com/.
THE BIG PICTURE ON NUTRITION:
Although all of the previous plans have their merits and flaws, it is important to remember that there is not merely one perfect nutrition plan for everybody. I would like to reiterate the major guidelines for the best nutrition plans and re-emphasize some practical ideas:
- Calories Matter: Although the idea of calories in and calories out may be oversimplifying the role of food… in the end calorie intake is important. Over eating and large portions contribute to weight gain no matter what the quality of food. Incorporating a Japanese concept “hara hachi bu” (which is a teaching of Confucius that advises to stop eating when you are 80% full) is a helpful too to keep calories limited and optimal. Ultimately it is recommended that calories be tracked in some way, even for a short period of time, to be accurate with the caloric content within any food plan.
- Quality is Key: The higher quality of food should be a large factor in determining what we should eat and what we should avoid in order to achieve and maintain optimal health. Rather than simply choosing foods based solely only on caloric value, choosing high-quality, healthy foods, and minimizing low-quality foods is best
- High-quality foods include unrefined, minimally processed foods such as vegetables and fruits, whole grains, healthy fats and healthy sources of protein.
- Low-quality foods include highly processed snack foods, sugar-sweetened beverages, refined (white) grains, refined sugar, fried foods, foods high in saturated and trans fats, and high-glycemic foods such as potatoes.
- Manage your Macros: Understanding the ratio of your Carbohydrates, Proteins and Fats within your day is helpful… but not as important as the amount of food and quality of food. To that end, we will break down the most popular food plans based on macronutrients to help choose the best plan for each person. There is general consensus with the idea that moderate protein content, low-glycemic index carbohydrates and fewer saturated fats lead to the best outcomes in health. However, variations within macronutrient plans may have their own health benefits as shown by some nutrition studies. To summarize, paying attention to your macronutrients matter, but not as much as caloric content or quality of food does.
When it comes to your health, food and nutrition play a big role, but it is important to be able to prioritize the factors that we have reviewed. If a plan gets too complicated for you to follow, it is not the right plan for you. Start with the foundations and move your way up through other factors until you have mastered those skills. In this way you can achieve the consistency and balance you need to truly maximize your health…all while doing it simply and practically.
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