OnCore Nutrition - Two Peas in a Podcast

Coronavirus 

The WHO COVID-19 Situation Report as of March 5 reports 95,333 confirmed cases globally, including 3,282 deaths

Our immune systems declines by about 2-3% a year from our 20s, which is why older people are more susceptible to infections

Mortality rates from diseases like pneumonia and bronchitis are three times higher among elderly people.

Our top 10 tips to optimise your immune system

1. Spice up your life. 

Use of garlic (allicin may boost our immune system), onions, ginger, turmeric, cayenne pepper, chilli, cinnamon, cloves, star anise, ginger, cumin in your cooking will boost your antioxidant intake. They may also assist with natural detoxification processes and may possess antimicrobial properties.

2. Get plenty of polyphenols. These can help in numerous ways to activate our immune system and initiate immune responses. 

• Drink green or black tea, red wine
• Use herbs in cooking (Peppermint, oregano, sage, rosemary, thyme, basil, lemon verbena, parsley, marjoram), dark choc, berries (the darker the colour the better)
• Add nuts and seeds to salad, brekky, snacks
• Cook with EVOO and enjoy olives
• Eat plenty of fresh fruit + veg 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5925142/pdf/JIR2018-1264074.pdf

3. Sweet dreams

7-9hrs sleep can boost the spread of T-cells which fight infection in the body. One study also showed that just one night of 4 hours’ sleep depleted the body’s natural killer cells by 70%.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3256323/

https://www.ncbi.nlm.nih.gov/pubmed/8621064

4. Remember that you’re sweet enough

Eating or drinking high GI carbohydrates and simple sugars can reduce our immune response. Studies have suggested that after a dose of sugar, certain white blood cells called neutrophils were far less aggressive in attacking bacteria. Some viral studies suggest sugar may help!

The body, and immune system needs glucose - we;re best off getting it from complex, slow release or low GI CHOs so we don’t have spikes in BGL. And if you’re keen to indulge, you might be better off doing so after exercise, so the uptake goes to the liver and muscles to replenish what you’ve used. 

https://academic.oup.com/ajcn/article-abstract/26/11/1180/4732762

https://www.theatlantic.com/science/archive/2016/09/glucose-inflammation/498965/

5. Get your vitamins and minerals - but don’t jump for a pill.

Various micronutrients are essential for immunocompetence, particularly vitamins A, C, D, E, B2 (riboflavin), B6 (poultry, seeds, fish, chickpeas), and B12, folic acid, iron, selenium, and zinc.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6212925/

https://www.frontiersin.org/articles/10.3389/fimmu.2018.03160/full

Include brightly coloured fruits and vegetables, including berries, citrus fruits, kiwi, apples, red grapes, kale, onions, spinach, sweet potatoes, and carrots.

Omega-3 fats - nuts, seeds, oily fish (and shellfish for Zn), avo

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6834330/

6. Take care of your gut

• Our intestines encounter more antigens than any other part of the body
• As many pathogens enter the body via the intestinal mucosa, it is vital the gut-associated lymphoid tissues (GALT) can provide effective immune responses when necessary.
• GALT represents almost 70% of the entire immune system and about 80% of plasma cells (mainly IgA-bearing cells) reside in GALT.
• Probiotics, prebiotics and gut health -  Imbalances in the gut microbiota may dysregulate immune responses.
• Listen in to our next few weeks where we’re planning an extra special gut loving episode

https://www.nature.com/articles/nri3738

https://www.immunology.org/public-information/bitesized-immunology/organs-and-tissues/immunity-in-the-gut

7. Stress less Easier said than done if you’re running out of toilet paper!

The brain and the immune system are buddies. They’re  in constant communication. When we’re stressed, the brain produces more cortisol to  prepare the body for emergency situations. But in doing so it depresses our immune system. Relaxation exercises like yoga, meditation, mindful colouring, get into nature, paint your nails, walk the dog, play with puppies take a bath, light a candle, whatever works for you!

8. Exercise - studies suggest you’re more likely to get colds if you don’t exercise. The impact that exercise has on sleep quality might also indirectly strengthen our immune systems. We know CV is a virus which attacks our lungs, the better our lung function is the better you will be able to cope with the virus. If you don’t exercise, now is a great time to get started!

9. Keep warm 

Cold viruses may be more infectious at temperatures lower than 37°C, which is the average core body temperature. Despite this, most health experts agree that the reason winter is "cold and flu season" is not that people are cold, but that they spend more time indoors, in closer contact with other people who can pass on their germs.

Some experiments with mice suggest that cold exposure might reduce the ability to cope with infection.

10. Drink up! Staying hydrated helps your body naturally eliminate toxins and other bacteria that might cause illness. Aim for 35-45ml/kg/day.

We’ve spoken about this before - chicken veggie soup kill multiple birds with one stone - warm liquid, protein, vitamins and minerals. 

Supplements:

• Many over-the-counter products claim to ‘boost’ your immune system, but there is little evidence to show that they do. 
• If you have a poor diet, it may help to take a daily multivitamin, but the preference is to get all your nutrients, including vitamins, minerals and bioactive compounds from food, negating the need for supplements
• If you include a diet with lots of veg, fruit, wholegrains or legumes, nuts, seeds or oily fish – your immune system should have everything it needs to run optimally.
• NAC or N-Acetyl Cysteine is the supplemental form of cysteine, a semi-essential amino acid. It’s considered semi-essential because your body can produce it from other amino acids, methionine and serine, and it only becomes essential when we don’t get enough methionine and serine. NAC and glutathione also boost immune health.
• A test-tube study indicated that in other immune-compromised situations, such as the flu, NAC may hamper the virus’s ability to replicate. https://www.ncbi.nlm.nih.gov/pubmed/19732754
• Most protein-rich foods, such as chicken, turkey, yogurt, cheese, eggs, sunflower seeds and legumes contain cysteine
• For your body to make the amino acid cysteine, you need adequate amounts of folate, vitamin B6 and vitamin B12, which you can get from beans, lentils, spinach, bananas, salmon and tuna.
• NAC has low bioavailability as an oral supplement, meaning that it’s not well absorbed. High doses can cause GI upset. 
• Zinc - An analysis of several clinical trials show that short-term use of zinc lozenges may reduce the length of a cold if started within 24 hours of cold symptoms.
• Blends such as ‘Armaforce’ - blend of herbal and nutritional ingredients andrographis, echinacea, olive leaf, vitamin C and zinc
• Andrographis - Indian Echinacea - may reduce reduce duration and severity of cold and flu symptoms
• Echinacea - studies are mixed and generally don’t support its use. One clinical trial supports the use of echinacea for reducing the length of colds, but not the severity of symptoms. One large trial suggests a specific echinacea formulation could be as effective as a prescription drug to treat influenza, with fewer side effects.
• Olive leaf extract - In vitro studies show that OLE has antimicrobial activities against some infective agents including E. coli, Pseudomonas aeruginosa, Staph. aureus, Klebsiella pneumoniae and Candida albicans 

https://www.ncbi.nlm.nih.gov/pubmed/12870202

https://www.ncbi.nlm.nih.gov/pubmed/17873849

• Vitamin C - Absorption is also to some extent dependent on the dosing regimen, e.g, there would be better absorption with 250 mg taken four times daily than 1,000 mg taken once daily. 1000 is the prudent upper limit and it’s very easy to get the RDI of 45mg/d with fruit + veg 
• AVOID vitamin E supplements - no significant evidence that supplements support the immune system and research suggests possibly more harm than good (stroke and cardiac issues)
• Essential oils  - Some EOs have demonstrated immune enhancing properties but caution in pregnancy, blood pressure issues or epilepsy

Most supplements have dosage and interaction warnings. If you have any medical conditions or take any medications or supplements please check with your doctor, pharmacist or dietitian to ensure no interactions. 

https://www.mskcc.org/cancer-care/diagnosis-treatment/symptom-management/integrative-medicine/herbs/search

Definition: https://www.nationaleatingdisorders.org/learn/by-eating-disorder/other/orthorexia

What is orthorexia?

A fixation/preoccupation with so-called ‘healthy eating’ or ‘clean eating to a point where it becomes obsessional and begins in infiltrate their life - causing anxiety, stress and impacting in relationships. More common with the rise of the #cleaneating #sugarfree #dairyfree, etc.. phenomenon on social media. 

It is an eating disorder, however  there are no diagnostic criteria at present. There is a lot of work happening at the moment to help characterise it. Hopefully it will be able to be incorporated in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition)in the future. This makes it increasingly difficult for doctors or dietitians to characterise this condition, particularly those who work within a weight centric paradigm.

It’s difficult to pick up because there are so many food and nutrition fads. Orthorexia can be quite easy to hide behind because a person can appear as if they are focused on ‘health’ and ‘wellbeing’ where as they’re battling a mental illness people may not know about. A person may often be at a healthy weight and not have any nutrient deficiencies (others will) - everyone is different depending on their restrictions. 

There can be many ways which orthorexia can develop e.g. previously mental illness or ED (many clients can transition from anorexia to orthorexia - meaning they may restore weight and start eating but the obsessions thoughts continue to infiltrate) or a health condition (e.g. autoimmune disease or bowel issues) or it may be a desire to just feel better and because we are inundated with health messages everywhere we go, it can be difficult to escape.

Warning signs and symptoms

• Compulsive checking of ingredient lists and nutritional labels
• An increase in concern about the health of ingredients
• Cutting out an increasing number of food groups (all sugar, all carbs, all dairy, all meat, all animal products)
• An inability to eat anything but a narrow group of foods that are deemed ‘healthy’ or ‘pure’
• Unusual interest in the health of what others are eating
• Spending hours per day thinking about what food might be served at upcoming events
• Showing high levels of distress when ‘safe’ or ‘healthy’ foods aren’t available
• Obsessive following of food and ‘healthy lifestyle’ blogs on Twitter and Instagram
• Body image concerns may or may not be present

Ref: https://www.nationaleatingdisorders.org/learn/by-eating-disorder/other/orthorexia

Common theme of when it becomes a problem:

• It’s impacting your mood
• Impacting your social life
• Compulsive checking of ingredient lists and nutritional labels
• You’re cutting out food groups or consistently skipping meals
• You feel guilty if you miss a training session or eat out of plan
• You fear losing control.
• You feel stressed or anxious about straying from your plan/usual actions
• It becomes too high on your ‘priority list’. Absorbs too much of your brain time. E.g. choose between brother’s bday dinner and gym / eating your planned meal and you choose the latter
• You skip work, school, or social events to exercise or to avoid particular foods/eating behaviours
• You feel the need to hide your behaviour - eating / training in secret
• You continue to exercise when injured or sick
• Friends, family, or your provider are worried about your eating or exercise habits.
• Food and exercise are no longer fun
• You are overly critical of friend and family food choices + exercise habits
• Obsessively checking food labels

Bottom line: If food is causing anxiety/stress- alarm bells. If you can’t eat a slice of cake on your boyfriend's birthday because it’s ‘unhealthy’, then there is a problem. Being healthy means being flexible and eating intuitively.

Treatment

At present there are no clinical treatments developed for orthorexia. We are reliant on the skills/experience from eating disorder clinicians to manage this condition - strong links with AN and OCD. Treatment team usually involved a psychologist (psychotherapy & anxiety/stress mx) and dietitian (aim to increase the variety of foods and manage anxiety relating to foods). Weight restoration may be required if the patient is underweight.

At the core it is an inability to deviate and a sense of feeling ‘out of control’ if the rules and restrictions set can not be adhered to. One of my favourite lines that I heard from Dr. Stefanie Reinold (who also has her own brilliant podcast which we will link in the show notes) is “It’s not about the food”, there is a lot more going on underneath that we need to uncover to get to the core of the obsessive need to control food. 

Strategies:

• Understand what is at the root of the obsession, as we know it’s not about the food so what is it about? Is it feeling out of control in your life and therefore feeling the need to control food? Are you having a stressful time with a loved one? Did something happen in your past?
• Adoption of a balanced mindset (which is easier said than done) - it would be important to seek professional help and work to increase flexibility with eating. Develop strategies to help manage anxiety or stress around food.
• Rules = guilt/shame - be more liberal with rules you put on yourself
• Acknowledge everyone is different, what works for one doesn’t work for another - social media detox and following positive people.
• Knowing recovery is challenging, because rigidity and rules have been created and you need support to help break those down and remodel. Sticking to a particular diet can make you feel safe (even though it is not safe or ‘healthy’).

Further information and support

https://www.nationaleatingdisorders.org/learn/by-eating-disorder/other/orthorexia

https://thebutterflyfoundation.org.au/

https://headspace.org.au/

https://daa.asn.au/

What makes something worth reading?

• Population
• Findings
• Types of studies - epidemiological, vs clinical trial etc..

To really understand a study you need to read more than just the abstract. The abstract is a great introduction however doesn’t give us enough context or information.

Each of the different studies have their own strengths and weaknesses. 

To summarise: 

• Evidence Summaries (Systematic Reviews and Meta-analysis)
• Experimental studies (RCT’s and non-RCT’s)
• Observational studies (case control, case report, cohort study)

Source: https://www.researchgate.net/publication/311504831_Options_for_basing_Dietary_Reference_Intakes_DRIs_on_chronic_disease_endpoints_report_from_a_joint_US-Canadian-sponsored_working_group

CASP (and other critical appraisal) tools

https://casp-uk.net/casp-tools-checklists/

• Type of study - RCT vs cohort/observational vs systematic review vs case control. In vitro (test tube) vs in vivo, Animal vs human
• Randomized, double-blind, placebo-controlled trials = gold standard 
• Aims and study qn
• How were subject recruited?
• Randomisation and blinding
• Population size + power of the findings - the bigger the sample size, the more reliable the study is.
• Demographics - age, sex, health status - this will help you indetify if the paper is relevant to you or your client group. No point in drawing inferences from a paper which looks at muscle mass in an elderly population group if the group you work with are <30 years old.
• Confounder - a factor that may influence the results. E.g. if you’re looking at Vitamin C levels and immune function, you would want to ensure the group you’re looking at aren’t already on supplements while the others aren't on anything. These people should be excluded from the study as they may influence the results.
• If not RCT, measures to minimise bias? Observer and subject bias. Social conformity.
• What methods were used? The methods section should have a clear endpoint - we want to clearly know what the researchers are trying to find - e.g. effect of the keto diet on weight loss or resistance training on muscle gain.
• Similarity of the groups at baseline - heterogeneous sample size
• Did anything else differ between groups other than the intervention?
• Size of the effect - clinical vs statistical significance. This can be confusing for the general population. E.g. we may see improvements in clinical outcomes when looking at nutrition interventions prior to cancer surgery, however the results were not ‘statistically significant’.
  • P-value (probability of obtaining the observed results of a test)
• How long was the intervention or follow up? E.g. 6/12 for weight loss - perhaps not long enough! What happens in 5 years?
• Consistency with other high quality evidence
• Application of results to local population or groups
• Harms and costs
• Funding 
• COI - often mentioned at the end of the pape

What to do when you’re not sure if something is being honest or true: Fight back against the click bait.

• Warning signs
  • Selling something - food or supplement companies often cherry pick information - be aware of this!
  • Lack of credentials
  • Lack of references - skeptical even if accurate 
  • Alarmist 
  • Promise to cure / prevent 

Is loaded with ‘testimonials’ (did you know that registered health professionals is Australia aren’t allowed to include

testimonials? This is because we base our advice on best-practice evidence rather than individual cases. What works for Sam won’t necessarily be right for Sally!)

• Makes no mention of seeking individual advice
• If it sounds too good to be true, it probably is!
• Headlines
• How to cross check when you’re not sure.
  • The best advice? Check anything you’re interested in trying, taking, applying with your training, governed health care professionals. And if you don’t get an answer from one, as, another! 
  • If you’re game, read a number of studies on the same topic 

Social conformity

https://www.npr.org/2016/09/17/494360187/industry-influence-in-nutrition-research

https://www.google.com/amp/s/amp.theguardian.com/lifeandstyle/2016/dec/12/studies-health-nutrition-sugar-coca-cola-marion-nestle

https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2548255

Three applied examples

https://www.medicalnewstoday.com/articles/327046.php#1

https://www.sciencedaily.com/releases/2014/12/141203161134.htm

https://www.telegraph.co.uk/news/2017/08/29/low-fat-diet-linked-higher-death-rates-major-lancet-study-finds/

Disease prevention

Heart disease

• Vitamin E (almonds, peanuts, hazelnuts, sunflower seeds, avocado) and Beta Carotene (sweet potato, dark leafy greens, cantelope, capsicum) are often studied as it is hypothesized that these antioxidants can prevent the accumulation of atherosclerotic plaques.
• Results of larger trials haven’t shown as profound as we had hoped for, however we have rational for this!
  • Women’s Health Study - 39,876 healthy women took 600 IU of natural source vitamin E or a placebo every other day for 10 years. 
  • The study did not see a reduction in CVD events, however it did find a 24% reduction in total cardiovascular mortality. 
• Women’s Antioxidant Cardiovascular Study - 8,171 women randomised.
• looked at beta-carotene, vitamin E, vitamin C.
• Modest benefit for vitamin E among women with existing cardiovascular disease.
• Women in the active vitamin C and E experienced fewer strokes 
• Patients taking vitamin E had significantly more heart failure. Vitamin E was linked to a 13% higher risk of heart failure and a 21% increased risk of hospitalization for heart failure
• Lott, E. The Journal of the American Medical Association, March 16, 2005; vol 293: pp 1338-1347. Brown, B.G. The Journal of the American Medical Association, March 16, 2005; vol 293: pp 1387-1390.
• .https://academic.oup.com/ajcn/article/69/6/1322S/4715025
• a recently published analysis of clinical trials involving nearly 136,000 people who took vitamin E for one reason or another found that the overall risk of dying was greater in those who took higher doses, compared to those who took lower doses.
• https://www.health.harvard.edu/press_releases/facts_about_vitamine
• Not a huge benefit when it comes to supplementation - this was also supported in a very highly regarded medical journal called The Lancet. We know that antioxidants in fruits and vegetables, which also contain valuable fibre can have a profound impact on heart health and prevention of heart disease.

Cognitive conditions (dementia, alzheimers)

• Oxidative stress caused by free radical damage can contribute to brain aging, cognitive deterioration and conditions such as alzheimers or dementia. .
• The literature has some mixed results, however again we know there is more to this complex puzzle.
• Prevention of Alzheimer's Disease by Vitamin E and Selenium Trial (PREADViSE).
• This study aimed to determine if vitamin E or selenium supplements used alone or in combination can prevent dementia older men.
• 3,700 men aged 60 or older for 6 years
• Unfortunately the antioxidant supplements did not prevent the onset of Alzehimers disease.
• Physicians' Health Study II (PHSII), - 5,956 men age greater than 65 years.
• The average treatment duration was 18 years - very long!
• Subjects were given 50 mg beta-carotene supplements or a placebo.
• Long term supplementation showed positive cognitive outcomes.

Statement by the Alzheimers Society regarding use of antioxidants:

“Though lab-based experiments on different types of antioxidants seem promising, there is only limited support for the claims that antioxidants may protect against Alzheimer's disease from studies involving people.

However, increasing fresh fruit and vegetables in the diet has numerous benefits aside from increasing antioxidant intake and is highly recommended, especially as part of a Mediterranean diet”

We know there is data to suggest that eating a Med type diet (which is rich in antioxidants) is beneficial in reducing the risk of dementia.

Cancer 

• Carotenoids and breast cancer risk
• Dietary patterns and bladder cancer- looks at fruit and veg rather than supplements
• Dietary Soy Isoflavones (flavanoid family) and colon cancer
• http://oncorenutrition.com/dont-fight-yo-nutrients/

We know that eating a diet rich in antioxidant rich fruit and vegetables and protective against a range of different cancers. Whilst there are some gaps in the literature there are some really exciting trials currently underway.

Longevity & anti-aging 

If we can prevent the onset of chronic diseases through increasing our intake of antioxidants, we can lead a healthier life for longer!

“Free Radical Theory of Aging” (FRTA), also known as “oxidative damage theory of ageing” is a concept that free radicals and other reactive oxygen species are a byproduct of metabolism and occurs as a result of a number of exogenous factors; and it is the accumulation of damaged cells are the reason we experience age-related diseases and aging. Why antioxidants are of interest in terms of aging and longevity, is because they can block or downregulate these damaging pathways.

http://www.actabp.pl/pdf/2_2000/281.pdf

There are a number of different antioxidants that are of interest when we focus on anti-aging. These include - Ascorbic acid (Vit C), alpha-tocopherol (Vit E), Ubiquinol (Coenzyme Q10), Melatonin, Curcumin, resveratrol, etc.. 

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3982418/

Ubiquinol (Coenzyme Q10)

• It is a unique lipid-soluble antioxidant and is essential for mitochondrial electron transport chain (ETC), which is a fancy way of referring to energy production within our cells.
• Benefits from heart disease risk, kidney disease, inflammation, fertility, aging, metabolic syndrome.
• In regard to CVD a cochrane review in 2014 found that supplementing with Co-Q10 showed a significant reduction in systolic blood pressure without improvements in other CVD risk factors, such as diastolic blood pressure, total cholesterol, LDL- and high-density lipoprotein (HDL)-cholesterol, and triglycerides.
• Endothelial function
• Inflammation - Meta-analysis explored the effect of CoQ10 on C-reactive protein (inflammatory measure), interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-α) in patients with inflammatory conditions such as multiple sclerosis, obesity, rheumatoid arthritis, diabetes, etc... It found that Co-Q10 doses between  60 to 500 mg/day for a 1-week -4-months significantly reduced production of inflammatory cytokines. 

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5807419/#B39

Food sources:

• Organ meats: Heart, liver and kidney
• Some muscle meats: Pork, beef and chicken
• Fatty fish: Trout, herring, mackerel and sardine
• Vegetables: Spinach, cauliflower and broccoli
• Fruit: Oranges and strawberries
• Legumes: Soybeans, lentils and peanuts
• Nuts and seeds: Sesame seeds and pistachios
• Oils: Soybean and canola oil

Resveratrol (RSV) - A polyphenolic compound that stimulates cell defense pathways.

• Protects these plants against UV rays and some fungal infections.
• It has been hypothesised that it is RSV that is responsible for  the ‘French paradox’ - low rates of heart disease in France, despite a diet rich in cheese and red wine.
• There is evidence that resveratrol may be beneficial in the context of diabetes, CVD and cancer.
• Meta Analysis which looked at the evidence regarding RSV across a number of different species. It found that there are a few species that found life extension in response to RSV.
• Metabolic function
  • https://academic.oup.com/biomedgerontology/article/67/12/1307/605425
  • https://www.sciencedirect.com/science/article/pii/S155041311100386X
• Be careful of high doses of resveratrol if history of breast cancer
• Food sources: Red wine, grapes, peanuts, pistachios, dark choc, cacao, strawberries 

SHOW NOTES

Why?

• Ethical
• Environmental - A vegetarian, pescetarian or flexitarian diet  with an increased intake of plants and reduced reliance on animal-based products (so not just a vegan diet) has been associated with significant reductions in premature mortality and environmental impact.  https://www.thelancet.com/action/showPdf?pii=S2542-5196%2818%2930206-7
• Health - https://academic.oup.com/jn/article/148/4/624/4965931  Dietary changes to balanced flexitarian, pescatarian, vegetarian, and vegan diets led to reductions in premature mortality of 19% (95% CI 18–20) for the flexitarian scenario to 22% (18–24) for the vegan scenario https://www.thelancet.com/action/showPdf?pii=S2542-5196%2818%2930206-7
• https://www.ncbi.nlm.nih.gov/pubmed/28446499
• Self-experiment
• Financial 
• Combination 

Nutrients to be aware of 

If you’re planning on going fully plant-based, vegan, then there are some important nutritional considerations

• Vit B12 - most will need a supplement. Check your levels.

Mushrooms, tempeh, miso and sea vegetables are often claimed to be a source of B12. However, this is not accurate. They contain a compound with a similar structure to B12, but it doesn’t work like B12 in the body.

• Don’t forget fats - mouthfeel
• Milk alternative

Bon Soy (25mg calcium per 100mL) vs VitaSoy CalciPlus (160mg per 100ml = 50% RDI) 

Impressed Plant Milk (almond, cashew, pea, fava bean) (117mg per 100ml) or oat milk

Listen to our milk ep and find a fortified alternative

• And if not - calcium

Low oxalate dark green leafy veg - kale over spinach (the oxalates bind to the calcium), almonds, soy, white beans, edamame, broccoli, bok choy, okra  

• Selenium - include just one brazil nut per day 
• Iron - listen to ep 5
• Iodine - iodised salt or miso/seaweed products 
• Omega-3s - you’ll get some from flaxseed meal, ground chia, walnuts → grinding enhanced the bioavailability which is still poor!). Consider a yeast or algae derived omega-3 supplement 0 chat to an APD or doctor.   
• Protein - it’s not hard to get enough protein. 0.8g/kg/d = 60kg person = 48g per day = 1 tin beans (15g) + glass plant milk (8.5g) + 2 cups broc or veg (15g) + ½ cup quinoa (4g) + handful nuts (5.2g)

Plant foods are lower in certain amino acids than animal products and it is important to get a complete AA profile across the day. This is fairly easy to do so long as we include a variety of plant foods daily - eg rice + beans or tofu + peanut satay sauce or soy milk + chia seeds. 

Complete = soybeans, quinoa, chia, hemp, seitan  

Important to know that it’s not inherently healthier to be vegan/vegetarian vs omnivorous. What’s unanimously healthy is a diet rich in plant foods, but it doesn’t have to be a diet devoid of animal foods. You can be a vegan and also not have a healthy or balanced diet

Report: -  World Health Organization Collaborating Centre on Population Salt Reduction, The George Institute for Global Health

https://www.georgeinstitute.org/sites/default/files/meat_alternatives_key_findings_report.pdf

Other Key References:

https://www.thelancet.com/action/showPdf?pii=S2542-5196%2818%2930206-7

https://www.ncbi.nlm.nih.gov/pubmed/28446499

Causes and triggers

• Brain-gut axis - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4367209/pdf/AnnGastroenterol-28-203.pdf
• Gut microbiome - https://onlinelibrary.wiley.com/doi/full/10.1111/apt.12728
• Environmental factors 
• Post infection - (e.g. gastroenteritis infection or campylobacter pylori) 
• Beatty JK, Bhargava A, Buret AG. Post-infectious irritable bowel syndrome: mechanistic insights into chronic disturbances following enteric infection. World J Gastroenterol. 2014;20(14):3976-3985.
• Enck P, Aziz Q, Barbara G, et al. Irritable bowel syndrome. Nat Rev Dis Primers. 2016;2:16014.
• Thabane M, Marshall JK. Post-infectious irritable bowel syndrome. World J Gastroenterol. 2009;15(29):3591-3596.
• Thompson JR. Is irritable bowel syndrome an infectious disease? World J Gastroenterol. 2016;22(4):1331-1334.

Investigations and Diagnosis: 

• Blood tests, stool samples, family history, colonoscopy, gastroscopy 
• Hydrogen Breath Tests

https://onlinelibrary.wiley.com/doi/pdf/10.1111/jgh.13689

http://shepherdworks.com.au/fodmaps-breath-testing-are-you-blowing-your-money/

• Rome Criteria

https://irritablebowelsyndrome.net/clinical/new-rome-iv-diagnostic-criteria/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5704116/#!po=31.2500

Dietary interventions

• Low FODMAP diet (Fermentable, Oligosaccharides, Disaccharides,Monosaccharides and Polyols)
  • Management: 6-8 week elimination diet and slow reintroduction (under close guidance from a DT)
• Fibre
  • Soluble vs Insoluble - depends on your symptoms.
  • Soluble fibre (e.g., psyllium husk) may assist in the management of IBS and can improve symptoms of patients.
  • Supps may cause bloating - important to introduce this gradually. 
• Probiotics/Prebiotics
  • Some evidence for use of probiotics in the context of GIT infections and diarrhoea. About 7–30% of patients with infectious diarrhoea can develop IBS. Probiotics may help to improve the barrier that lines our gut.
  • There is no specific probiotic that is recommended. If you choose a probiotic, take the same strain and dose for 4-weeks. If you feel better, continue with the same probiotic. If you do not feel better after 4-weeks, try a different dose or strain. We can guide you where to start depending on your Sx. 

Summary: Diets for the treatment of IBS symptoms are complex and multifactorial. Due to huge amounts of patient variation in severity of symptoms and intolerances, it can challenge to point point an exact method. 

Many different diets have been studies in the treatment of IBS, however there have been huge limitations in many of those published. At present the diet with the best level of evidence is the elimination diet (low fodmap and reintroduction) under the guidance of an APD.

https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1365-2036.2004.02267.x

Medical management references:

• American Gastroenterological Association Institute Technical Review on the Pharmacological Management of Irritable Bowel Syndrome- https://www.gastrojournal.org/article/S0016-5085(14)01090-7/fulltext
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5291563/
• American Gastroenterological Association Institute Guideline on the Pharmacological Management of Irritable Bowel Syndrome - https://www.gastrojournal.org/article/S0016-5085(14)01089-0/fulltext 

Dr Carly Ymer

Dr Carly Ymer is a clinical psychologist who practices holistic psychotherapy, using her passion for mental and emotional wellbeing to help clients be their best. She believes and practices within an integrative and holistic framework of the synergy between thinking, emotions, and behaviour. Carly is passionate about working with children, teenagers and young adults, with a range of emotional, social and behavioural difficulties. 

https://beingwellclinic.com/

KETOGENIC DIET

What is it?

• Very low-carb, moderate-protein and high-fat diet. It typically contains 75% fat, 20% protein and only 5% carbs.
• 20g CHO per day  - Eg 1 apple + ½ cup peas + 4tbsp milk  OR sk latte + ¼ cup chickpeas OR 1 small banana   OR 1 small slice sourdough bread 

Does it work?

• Weight loss - very low CHO intake leads to increased fat metabolism for ketones. 
• The rise in fat burning does not necessarily mean loss of fat stores given the intake of fat in the diet has significantly increased. 
• Studies suggest that the overall body fat balance is equal if not in favour of fat storage!
• CHO insulin model - reduced insulin so less fat stored. Good in theory but a very intensive $40 million study of 17 men were admitted to metabolic wards for intensive monitoring for 2 months - one month high carb, one month ketogenic. Matched calories on both. Subjects spent 2 consecutive days each week residing in metabolic chambers to measure changes in exergy expenditure and underwent DEXA to measure body composition. The study found that the subjects lost more body weight on the ketogenic diet, but rate of fat loss was 50% slower on the keto diet and instead the on the ketogenic diet that subjects lost more water weight and suffered more LBM (muscle protein) catabolism. Interestingly, this was a study funded to explore their hypothesis which was the opposite!

https://academic.oup.com/ajcn/article/104/2/324/4564649

• Epilepsy that is refractory to medication - often as third or fourth line therapy. 
• Cancer - theory based on Warburg effect that cancer’s preferred fuel source is sugar and that by reducing CHO intake we can deplete tumour tissue of the glucose required for tumour cell metabolism. Unfortunately, that’s the case of most of the healthy cells in our body. Sugar fuels everything and cancer can feed off everything, including ketones. 
• As it stands, there are no clinical trials demonstrating a benefit of a ketogenic diet in cancer patients. Studies underway exploring the ability to slow the growth of certain brain tumours. 
• What our best practice guidelines do specify though is that while it may be difficult to induce tumour responses with a ketogenic diet, this does not argue against preferring fat to supply energy to patients with advanced cancer and inflammation-induced insulin resistance - so more avo, nuts, seeds and extra virgin olive oil and less refined sugars. 

DRAWBACKS

Gut Health

• Our carbohydrate sources in our food supply don’t just provide energy. Think about a chickpea. Yeah it’s got carbs, but it’s also loaded with fibre, protein, folate and iron.
• One important factor that we miss when we significantly restrict CHO intake is fibre, prebiotics and the impact on our gut. 
• Bowel cancer risk + digestive health 

Diabetes (T2DM)

• Some proponents suggest ketogenic diet to manage diabetes
• Managing the symptoms - high blood glucose levels - rather than the cause - insulin resistance (may be as a result of being overweight, lack of PA + poor dietary patterns).
• Ketogenic diet has been associated with development of NAFLD and associated hepatic insulin resistance in mice. This can induce or worsen insulin resistance
• Some human studies show an initial improvement in insulin response on a ketogenic diet but this seems to only be temporary - which makes sense given the KD is reducing the symptoms (high blood glucose levels), but may actually be worsening the cause (fatty deposits in the liver and cells)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5452247/

Cardiovascular disease 

• KD are often high in saturated fats
• Breakfast of egg, bacon, bullet coffee; lunch and dinner of M/C, small amount of veg and some cream for dessert...it’s no surprise that this will take its toll.  
• The majority of animal studies suggest that when KD are rich in saturated fats they negatively impact blood lipid profiles and cardiovascular disease risk 
• In human studies, there are really varied results, often depending on the length of time subjects are followed and the profile of their fat intake.
• Some studies highlight that even in cases where KD show a reduction in total and LDL cholesterol, these were significantly more reduced with a high-protein medium-carbohydrate diet than with a KD

Compliance

• Hard! 
• Even in retractable epilepsy compliance may drop to 50% after a few months. For epilepsy this is disappointing for ability to gain disease control, but for the general population this could be a protective mechanism...children have died from scurvy and selenium deficiency and the long term implication for cardiovascular and gut health just might not be what your human control centre wants. 
• 20g CHO per day 
• Eg 1 apple + ½ cup peas + 4tbsp milk OR 1 small banana  OR 1 small slice sourdough bread 

Exogenous ketones

• Introducing ketones from external source can mean you will test positive for the presence of ketones - suggesting you're in “ketosis”. Simply because the ketones exist doesn’t mean you’ve gone through the pathways to get there.
• The presence of ketones signals to the body that you’ve been making them, and therefore may slow or even stop it’s own production of ketones from fat stores. This is a particularly important safety mechanism because ketone blood levels become too high, your blood can become dangerously acidic.
• Therefore, taking exogenous ketones may prevent body fat from being used as fuel, at least in the short term
• One benefit of exogenous ketone esters or slats - often taken as a drink - is that they may reduce circulating levels of our hunger hormone ghrelin. One study of 17 people found reportedly lower levels of hunger after taking the ketone drink. But only effective after a fast, not after a meal
• You’ve also got to bare in mind that ketones contain calories. A single serving of exogenous ketone salts typically contains less than 100kcal or 420kJ, but to maintain a state of ketosis, you’ll need several servings each day = could add up to the energy in a main meal! 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5813183/

• Bulletproof coffee/ MCT oil - contains medium-chain triglycerides, can help keto dieters add more fat to their diets and stay in ketosis. It’s digested more rapidly than traditional fats but can have digestive side effects and again a caloric load.

Action

• If you’re going keto, prioritise unsaturated fats - avo, nuts, seeds, EVOO
• Make your carbs count
• Don’t rely solely on the white ones (white bread, white rice, white potatoes, white pasta)
• Choose CHO sources that offer something else: fibre, protein, vit, min 
• Eg 
  • Fibre: wholegrains such as barley, bulghur, freekeh, spelt, quinoa, oats, legumes, peas, corn, pulse pasta  
  • Protein: legumes, ricotta or cottage cheese
  • Vitamins: sweet pot, peas, corn
  • Minerals: greek yoghurt, milk, ricotta, cottage cheese

OnCore Nutrition 15 min free phone consults

https://oncorenutrition.com/15-minutes-free/

Turmeric, active ingredients are turmerone oil and water-soluble curcuminoids, among which curcumin has been the focus of research

• Native to south Asia
• Orange colour used in cosmetics and as a food colouring agent
• Absorption is poor and it’s metabolised rapidly. Absorption can be improved if taken with pepper (piperine) or fat, but this depends on if you have a therapeutic goal. 
• A meta-analysis of randomized clinical trials revealed that curcumin is effective in decreasing the concentration of tumor necrosis factor-alpha, a key mediator in many inflammatory diseases.

Gut 

• Turmeric may help alleviate symptoms of irritable bowel syndrome or ulcerative colitis,

Joints

• Turmeric extract was found to be safe and equally effective as a non-steroidal anti-inflammatory drug for the treatment of osteoarthritis of the knee. Need to absorb it so take with piperine/fat. 

Cancer

• Curcumin has been studied to have anticancer properties through really the 3 main pathways of cancer development: 

1. It’s antioxidant properties and protection against DNA mutations and cell damage

2. It’s antiproliferative properties that reduce tumour growth and spread including inducing apoptosis (programmed cell death) and 

3.Curcumin has shown ability to kill cancer cells directly by activating “execution enzymes” that destroy cancer cells from within. 

• As an added benefit, curcumin seems to focus on the cancer cells and leave our healthy cells alone, unlike chemotherapy and RT that can’t distinguish between malignant and healthy cells.
• Several animal studies suggest that turmeric helps to prevent colon, stomach, and skin cancers in rats exposed to carcinogens. 
• Human studies are underway to validate these findings in humans
• What’s interesting is that while curcumin shows benefit in breast cancer, pancreatic cancer, colon cancer, multiple myeloma, myelogenous leukaemia and skin, kidney and colorectal cancer, turmeric as a whole food has in some cases been shown to be even more effective!
• In fact, a study was undertaken with turmeric where they removed the active component curcumin, and it was found to be just as effective!!
• Topical turmeric-based cream has shown some ability to reduce radiotherapy-induced dermatitis in patients with head and neck cancer; and oral mucositis
• Can interfere with some chemotherapy agents 

Other

• May improve concentrations of liver enzymes
• Some but insufficient evidence for treatment of kidney stones and reduction in stomach and intestinal gas

When it’s not a good idea

• Can interfere with many drugs, blood thinners and chemo agents when taken as a supplement. 
• One study  - These findings support the hypothesis that dietary curcumin can inhibit chemotherapy-induced apoptosis through inhibition of ROS generation and blockade of JNK function, and suggest that additional studies are needed to determine whether breast cancer patients undergoing chemotherapy should avoid curcumin supplementation, and possibly even limit their exposure to curcumin-containing foods. https://www.ncbi.nlm.nih.gov/pubmed/12097302

Other spices with similar impact 

It’s not the only option...Other anti-inflammatory and health promoting spices

1. Cumin

• May improve digestion by increasing activity of digestive enzymes and increase release of bile from liver. 
• May assist IBS - a low level study explored cumin essential oil and found it reduced abdominal pain, bloating, fecal urgency and presence of mucus discharge during and after treatment with Cumin extract.
• May improve BG control in Diabetes - still unclear the exact mechanisms or exactly how much is required to obtain the desired therapeutic outcomes.
• Some studies suggest that supplementation may improve chol profile
• The salicylic acid and other phenolic acids may have a anti-inflammatory and free-radical reducing properties to reduce cancer risk 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3210012/

https://www.sciencedirect.com/science/article/pii/S0308814608002483

https://www.ncbi.nlm.nih.gov/pubmed/24829694

https://www.ncbi.nlm.nih.gov/pubmed/25766448

https://www.ncbi.nlm.nih.gov/pubmed/27664636

https://nutritionfacts.org/2019/12/26/the-foods-with-the-highest-aspirin-content/?utm_source=NutritionFacts.org&utm_campaign=b4e7d340b4-RSS_BLOG_DAILY&utm_medium=email&utm_term=0_40f9e497d1-b4e7d340b4-26955981&mc_cid=b4e7d340b4&mc_eid=b327dd2e50

1. Cinnamon - coined gift fit for kings

• Anti-inflammatory properties similar to that of turmeric  - high concentration of antioxidants (polyphenols). 
• Reduce insulin resistance - Cinnamon has shown to be able to improve insulin sensitivity, which means better able to reduce our BGLS.
• Cinnamon  contains contains enzymes which work  in our GIT which slowing down the breakdown of CHO’s. This reduces the amount of glucose in our blood after a meal.
• 120mg per day can reduce total chol, LDL, TGs 
• May help protect neurons, normalize neurotransmitter levels and improve motor function - researchers interested for Alzheimer'. Human studies are lacking, however watch this space..

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4003790/

https://www.ncbi.nlm.nih.gov/pubmed/14633804

https://www.ncbi.nlm.nih.gov/pubmed/24019277

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2901047/

https://www.ncbi.nlm.nih.gov/pubmed/19433898

https://www.ncbi.nlm.nih.gov/pubmed/23531502

https://www.ncbi.nlm.nih.gov/pubmed/24349472

1. Ginger

• Ginger root contains compounds that may help relieve or prevent nausea and vomiting. These substances can increase the flow of saliva and digestive juices and may also help calm the stomach and intestines. Some studies have found ginger may help nausea caused by chemotherapy, but larger studies are needed to confirm these effects.
• Eating fresh ginger in high doses can have blood-thinning effects by preventing platelets from sticking together. 
• Laboratory studies suggest that ginger can protect brain cells from the plaques that cause Alzheimer’s disease, but this effect has not been studied in humans.
• Some data in OA and RA 
• May reduce BGL 
• May reduce drug dependence! 
• May improve digestive health - reduce diarrhoea, gas and bloating
• Supplemental doses can interfere with warfarin or blood thinners, NSAIDs, insulin, during pregnancy or pre-surgery. Stick to the real food! 

https://www.mskcc.org/cancer-care/integrative-medicine/herbs/ginger

1. Ashwaghandha (Indian or asian Ginseng)

• May assist with angina, T2DM management, immune function and…
• Sexual dysfunction benefits for erectile dysfunction 
• Some reports of manic and psychotic episodes with supplements - stick to the food! Make into a tea or add to asian soups 

https://www.mskcc.org/cancer-care/integrative-medicine/herbs/ginseng-asian

Supplemental doses of many of these spices can interfere with warfarin or blood thinners, NSAIDs, insulin, during pregnancy or pre-surgery or cause nasty side effects so stick to the real food! 

Chili

• What is it: Capsaicin is the active ingredient in chilli, cayenne pepper, capsicum 
• What for: Neuropathic pain and neuropathy, OA pain, weight loss, psoriasis, cluster headaches 
• Caution: GIT lining, reflux 

Health benefits of capsaicin 

• Weight loss: There is evidence to suggest intake of chilis (containing capsaicin) can enhance fat burning potential and reduce appetite, which of course can assist with weight loss. As always the literature suggested that regular ingestion of capsaicin compounds in conjunction with a healthy diet & lifestyle showed the most promising outcomes.
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3257466/
• Pain management: There is some low level evidence to support that Capsaicin has the ability to bind to pain receptors to reduce the pain sensation. However these were small studies and effects were not lasting.

Be cautious of:

• GIT upset (abdominal pain/cramping or diarrhoea) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4102147/
• Cancer: There is some suggestion of chemoprotective effects however the evidence of safety vs risk is mixed regarding chili consumption. As mentioned, adding too much chili may have the ability to burn the lining of our GIT and this has been seen in some observational studies.
• Long term topical use may increase risk of skin cancer - eat don’t rub it Look out for capsaicin as active ingredient in some topical creams and nasal sprays. It is also available in a prescription-strength patch. 
  • https://academic.oup.com/aje/article-abstract/139/3/263/63603?redirectedFrom=fulltext
  • https://www.mskcc.org/cancer-care/integrative-medicine/herbs/capsaicin

In summary: See what agrees with your body! If you love chilli, enjoy it! If you don’t moderate the amounts you eat.

Eat your spices

• Add cinnamon and turmeric to oats - try our carrot cake bircher or make this into balls with some dates. Add yoghurt if you need to absorb it. 
• Ginger tea or water, stir fry, bliss balls, 
• Chilli, cumin, paprika, turmeric to your evening meals - veg chilli con carne, dhal or curry  
• Ginseng tea or add to your soup 
• TO DO: buy minced chilli, garlic, ginger, dried cumin, paprika, chilli, turmeric 

SHOW NOTES

WEIGHT  LOSS

• In order to lose weight we do need to be at a caloric deficit
• This is calories in vs calories out, but the in and out are far more complicated than you think
• Energy in: fat, alcohol, carbs, protein. Fibre not absorbed 
• Energy out: BMR, non-exercise energy, activity factor, thermic effect of food (protein 30%, carbs 8-10%, fat 2-3%, fibre 30%) 
• For fat loss, we need to access fat stores = lipolysis (very complex), gluconeogenesis or ketogenesis
• For weight loss we need a negative energy balance

1. Reduce energy in - (water, fibre)
2. Increase BMR - enhance lean body mass, heat, cold, glycaemic index, green tea, oolong tea, capsaicin, sleep (insulin, ghrelin, leptin balance), coffee, MCT vs LCT
3. Increase thermic effect of food - increase protein, reduce fat = increased energy output
4. Increase non-active energy expenditure and activity factor - increase energy output. HIIT has the added benefit of burning energy and enhancing LBM.

Golden rules

1. Aim for <1% body weight loss per week (0.5-1kg).  Any quicker than this and the body adjusts - alterations to our metabolism and hunger make more than this detrimental - i.e. metabolic slowing and increased appetite that accompanies rapid weight loss, sustained weight loss requires a persistent calorie deficit that isn’t sabotaged by our slowed metabolic rate and increased hunger. Hunger is a biological drive - to tell someone with increased hunger to not eat is like asking someone to not breathe. Nothing to do with will power. Managing hunger is vital - alterations to types of carbs and fats, amount and timing of protein and fibre and fluid intake is really important. 
2. Increase your BMR - lean body mass, sleep. Tea, chilli and some other compounds can help but the impact is minute. 
3. Increase activity factors - both incidental and planned

ADRENAL FATIGUE

Adrenal fatigue… does it exist?

Adrenal glands

• Mayo clinic: ‘Perched atop each of your kidneys, your adrenal glands produce hormones that help regulate your metabolism, immune system, blood pressure and other essential functions.’They produce a variety of hormones including adrenaline and the steroids aldosterone and cortisol
  • https://www.mayoclinic.org/adrenal-glands/img-20008674

The Theory

• To keep it simple, the concept around adrenal fatigue is that under ongoing stress our body places pressure on our adrenal glands and over produces our stress hormone known as cortisol which essentially causes our adrenal glands to burn out and not work properly.
• As our adrenal glands don’t work properly, this means they are unable to produce the necessary hormones to help our bodies function properly and therefore result in symptoms such as fatigue, trouble sleeping, weakness, brittle nails, weight gain/loss and alopecia. 
• Sadly this is a diagnosis given to patients from many alternative practitioners which gives them hope and a diagnosis for their problems/health issues.. 
• Many supplements on the market targeted at ‘adrenal support’ with an expensive price tag

The evidence: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4997656/

• Large systematic review published in 2016.
• From 3,470 articles found, only 58 studies met criteria for proposed adrenal fatigue.
  • 33 were carried in healthy individuals, and 25 in symptomatic patients. 
  • The researchers found it difficult to draw conclusions, this is because there were many different methods used amongst the studies (when it comes to research consistent methodology & the use of validated tools are important) and this made it difficult to draw conclusions, the measures of fatigue were poorly documented and standardised tools were not used, the way cortisol was assessed was not endorsed by endocrinologists and I could keep going.
  • As a result of these findings (or lack of findings) this systematic review concluded that adrenal fatigue is not a true medical diagnosis.
• So if you are someone who has had this diagnosis, don’t feel lost, rather focus on managing your stress levels rather than putting a label on the way you feel.
• Eg. Try to get into bed earlier and get more sleep, try meditation or yoga, make an effort to eat a more balanced diet.
• Be careful when it comes to supplements, many of the drugs are not regulated or tested for safety.
• If you’re unsure, contact your healthcare provider, GP, Endo, dietitian, etc..

FRESH VS FROZEN VEGETABLES

https://www.sciencedirect.com/science/article/abs/pii/S0889157517300418

• The study mimics typical consumer purchasing and storage patterns of produce.
• The study compares key nutrients in fresh, fresh-stored, and frozen produce.
• Fresh produce loses vitamins over time during refrigerated storage.
• Consumers’ assumption that fresh produce has much more nutritional value than frozen is incorrect.
• In some situations, frozen produce is more nutritious than its 5-day fresh-stored counterpart.
• Reduced food waste

Benefits of frozen

• Nutritional profile - same if not better
• Convenience
• Reduced food waste
• Lower cost
  • Cost - e.g. broccoli -  true cost by weight of fresh vs frozen = $7.38/kg fresh ($4.70 if use every single bit!) vs $5 frozen

Downsides of frozen:

• Variety
• Carbon footprint - look for local produce. Reduced waste may counterbalance this. 
• Packaging 
• Starchy veg
• Less inspiring 

Tips 

• Frozen winter veg, kale, spinach, stir fry mixes
• Big packs vs little steam fresh - need about 4 of these for one serve!
• Good way to eat more which is really the moral of the story - A recent meta-analysis into fruit and vegetable intake and the risk of cardiovascular disease, cancer and total mortality, by scientists, published in the International Journal of Epidemiology suggests that while disease risk can be reduced by consuming 5 portions of fruit and vegetables a day – the ‘5-a-day’ campaign – the largest benefit can be gained by eating around 800g, approx. 10 portions, per day. https://academic.oup.com/ije/article/46/3/1029/3039477

SHOW NOTES

Australian Bushfire Donations:

Wires

Red Cross

CFA

Food Bank

OnCore Intermittent Fasting Guides - https://store.oncorenutrition.com/collections/all

Physiological benefits

http://oncorenutrition.com/to-fast-or-not-to-fast/

Coffee https://www.ncbi.nlm.nih.gov/pubmed/28177691

Practicalities / sustainability / contraindications

http://oncorenutrition.com/the-fast-and-the-furious/

Guides: http://oncorenutrition.com/intermittent-fasting/

https://store.oncorenutrition.com/collections/all

IF and calorie deficit similar weight loss outcomes
Some find IF mentally challenging than consistent cal deficit, others find the opposite

• Science currently unclear if IF vs CR is responsible for the body composition changes and good health.
• Why the evidence is unclear is that many studies have been conducted in animal based models which we know has limitations
• Human studies have been relatively poor (e.g. short duration) and mainly focused around weight loss (in the short term) rather than aging and disease risk.
• https://www.ncbi.nlm.nih.gov/pubmed/28459931
• 100 obese participants - 6 women and 14 men, aged between 18–64 (the mean age was 44). Note they did not have metabolic conditions (e.g. T2DM).
• Looked at different dieting patterns
  • Alternate-day fasting - consumed 25% of their daily energy requirements on fast days and 125% of their daily requirements on alternate days.
  • Calorie restriction diet plan where the subjects consumed slightly less than their energy need (~75%) each day.
  • Another group with no dietary intervention.
  • Results: With regard to the two dieting groups, they both lost a similar amount of weight and showed no significant difference regarding, blood pressure, heart rate, triglycerides, fasting glucose, fasting insulin, insulin resistance & inflammatory markers at month 6 or 12.
  • Of note there was a higher drop out rate within the alternate fasting day group, which may indicate adherence and consistency may be a challenge with this method,
  • Our recommendation: No real difference between the fasting vs calorie restriction group. There is no magic pill when it comes to weight loss. Do what works best for you and work with a professional who understands your needs.
• https://onlinelibrary.wiley.com/doi/full/10.1111/j.1467-789X.2011.00873.x
• Intermittent CR and daily CR diets appear to be equally as effective in decreasing body weight, fat mass, and potentially, visceral fat mass. However, intermittent calorie restriction protocols may be superior in that they help conserve lean mass at the expense of fat mass. More research + longer term studies are required.

Circadian rhythms

According to your circadian rhythm, nighttime is for resting, not eating.

On average - we eat every 3hrs and 6 minutes and for a duration of approx 15hrs per day

Mice that eat in opposition to their circadian rhythm gain significantly more weight than mice that only eat during waking hours, even if they eat the same amount of food. Not all studies in humans support this notion.

At night, you may be more likely to choose unhealthy, calorie-dense foods.

• Access
• Convenience
• High risk time for high fat, calorie dense foods
• Emotional / non-hungry eating
• Appetite changes when tired - https://www.ncbi.nlm.nih.gov/pubmed/20357041 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3763921/
• Restriction/insufficient intake during the day → compensation

The first RCT in humans was published half way through 2019 to determine how meal timing affects 24-hour energy metabolism when food intake and meal frequency are matched

• Small n= 11 men + women aged 25-45
• two groups of people who ate the same three meals per day for 4 days but with different timings: the early time-restricted feeding (eTRF) schedule and the control schedule.
• 8am - 2pm (18hr fast) vs 8am - 8pm (12hr fast)
• On the fourth day, 24‐hour energy expenditure and substrate oxidation were measured by whole‐room indirect calorimetry, in conjunction with appetite and metabolic hormones
• No effect on 24hr energy expenditure
• May enhance fatty acid oxidation - i.e. using fat for fuel rather than carbohydrates
• TRF Decreased ghrelin levels, enhanced fullness, decreased desire to eat
• Meal‐timing interventions facilitate weight loss primarily by decreasing appetite rather than by increasing energy expenditure. eTRF may also increase fat loss by increasing fat oxidation.

https://onlinelibrary.wiley.com/doi/full/10.1002/oby.22518

Another study 6am-7pm

• Nothing unless than the hrs to adhere to - no type, amt of food, no record keeping
• Ate fewer calories and lost weight

Another study

• Same kJ at BF vs dinner - when given at BF = less weight gain
• https://www.ncbi.nlm.nih.gov/pubmed/23512957

Another study

• 3 meals vs 1 meal - same calories
• Normal-weight subjects are able to comply with a 1 meal/d diet. When meal frequency is decreased without a reduction in overall calorie intake, modest changes occur in body composition, some cardiovascular disease risk factors, and hematologic variables. Diurnal variations may affect outcomes.
• Both late eating
• Improvement in weight loss, but blood pressure and chol levels suffered!
• https://www.ncbi.nlm.nih.gov/pubmed/17413096

Early TFR

• eTRF (6-hr feeding period, with dinner before 3 p.m.) or a control schedule (12-hr feeding period) for 5 weeks and later crossed over to the other schedule.
• eTRF improved insulin sensitivity, β cell responsiveness, blood pressure, oxidative stress, and appetite.
• We demonstrate for the first time in humans that eTRF improves some aspects of cardiometabolic health and that IF's effects are not solely due to weight loss.
• https://www.ncbi.nlm.nih.gov/pubmed/29754952
• Even 10-11hrs TRF beneficial - weight loss, improved energy levels, improved sleep

https://www.ncbi.nlm.nih.gov/pubmed/31808043

https://www.ncbi.nlm.nih.gov/pubmed/26693661

IF and breast cancer risk

https://www.ncbi.nlm.nih.gov/pubmed/26305095

These findings suggest that eating more frequently, reducing evening energy intake, and fasting for longer nightly intervals may lower systemic inflammation and subsequently reduce breast cancer risk. Randomized trials are needed to validate these associations.

Breast cancer prognosis

- 2413 women (mean [SD] age, 52.4 [8.9] years)

- mean (SD) fasting duration of 12.5 (1.7) hours per night.

- fasting less than 13 hours per night was associated with an increase in the risk of breast cancer recurrence compared with fasting 13 or more hours per night but wasn’t associated with mortality rates

NO RCTs YET!

https://www.ncbi.nlm.nih.gov/pubmed/27032109

Diabetes

• Very small study n = 3 men who had had type 2 diabetes for 10-25 years.
• Medical supervision
• Fasted every other day or 3 days a week.
• Within a month, all of the men were able to stop taking insulin. And in less than a year, they were able to cut down on or stop other diabetes medications.
• Another small study, 10 obese men with type 2 diabetes followed a time-restricted eating plan. They improved their fasting glucose and lost weight over 6 weeks.
• Bigger studies are needed to confirm those findings and to see how long the results last
• The American Diabetes Association notes that if you’re overweight or obese, weight loss can help lower your HbA1c level (a gauge of your blood sugar control over the last 2-3 months) and lower your risk for heart disease.

Important to:

• Talk to Dr/endocrinologist first
• Adjust your insulin
• Monitor for lower BGL
• Beware of large carbohydrate load on first meal

Cell Metabolism: “Early Time-Restricted Feeding Improves Insulin Sensitivity, Blood Pressure, and Oxidative Stress Even without Weight Loss in Men with Prediabetes."

BMJ Case Reports: “Therapeutic use of intermittent fasting for people with type 2 diabetes as an alternative to insulin."

Joslin Diabetes Center: “Yom Kippur and Diabetes.”

BMJ Open Diabetes Research & Care: “Recommendations for management of diabetes during Ramadan: update 2015."

SHOW NOTES

Food labels

• Labels must also have a list of ingredients. Ingredients must be listed by weight in descending order (i.e. the first ingredient contributes the largest amount to the product and the last ingredient contributes the least).
• Regarding additives, products must show the number or the name of any additives they contain (e.g. monosodium glutamate may appear as MSG or 621). If you know you have sensitivities to any additives, it’s important you know their corresponding numbers so you can keep an eye out for them,
• If the product contains any major allergens such as nuts (peanuts, cashews, almonds, walnuts, etc.), shellfish, fish, eggs, sesame seeds, soybeans, wheat, gluten, they must be declared on the label.
• Sugar No added sugar: No added sucrose, glucose, honey, malt, fruit juice, etc.
• Un-sweetened: No added intense (artificial) sweeteners, sucrose, glucose, honey, malt, fruit juice etc.    Diet: At least 40% less kJ than regular product
• Comparative claims eg ‘reduced’, ‘increased’, ‘light’ or ‘lite’ must refer to the reference food 

Look out for:

• Sugar aliases    - dietitian colleague of ours has put together a list of 48 sugar aliases! Some derived from cane sugar, some from fruit, corn, beets, alternative sweeteners like agave and rice malt syrup, 
• Don’t be fooled by fancy marketing, sugars can have many different names, and we will put this list in the show notes for you all to have a look at. Just because a food contains rice malt syrup or coconut sugar, this is still sugar.

(https://foodwatch.com.au/blog/carbs-sugars-and-fibres/item/48-shades-of-hidden-sugars.html)

• Foods containing more than 10mg sulphite preservatives/kg must be labelled as containing sulphite as this is the level that may trigger 

Health claims 

• These are claims about something in a food and how it can affect your health. E.g. ‘Fibre helps keep you regular ’;.  ‘This food is low in sodium (salt). A diet low in sodium may help reduce blood pressure’. Only pre-approved ‘food-health relationships’ for high level health claims are allowed to be made. All health claims must be supported by scientific evidence. Can’t  refer to the prevention, diagnosis, cure or alleviation of a disease, disorder or condition 

https://www.legislation.gov.au/Details/F2017C00711

https://foodregulation.gov.au/internet/fr/publishing.nsf/Content/31BDC68CEC4A1964CA25801B00166C1F/$File/Getting-Your-Claims-Right-2018.pdf

https://daa.asn.au/smart-eating-for-you/smart-eating-fast-facts/food-labels/what-are-health-claims-and-what-do-they-mean/

Health Star Rating 

• The Health Star Rating is a front-of-pack labelling system that rates the overall nutritional profile of packaged food and assigns it a rating from ½ a star to 5 stars.
• Aims to provide a quick, easy, standard way to compare similar packaged foods.
• Developed by Aus Gov with collaboration from industry and public 

Drawbacks

• Opt in, voluntary, all, some or none of their products
• Compares products of the same category eg cereals with cereals 
• Food manufacturers and retailers are responsible for the correct and accurate use of the Health Star Rating system
• Nutrients in isolation do not represent the value of a food 
• Doesn't differentiate between whole foods and processed / packaged foods
• Putting a health star rating on a processed food undermines message of good nutrition 
• Added sugars are not differentiated from natural sugars - eg a muesli bar with oats and dried fruit vs bar with tonnes of sugar 
• Products containing additional dietary fibre can get bonus points which can be used to offset negative points they get for saturated fat or sugar,
• This is how Nutrigrain - 4 stars  despite the fact it's still literally 27 per cent sugar. Add inulin = bonus points. Very easy to manipulate. 
• Milo (4.5 stars, only IF consumed with a specific amt of skim milk, otherwise 1.5 stars if eaten alone!) literally receives a higher health star rating if eaten with ice-cream
• Certain brands of clean, unsweetened Greek yoghurts sit at 1.5 stars. Some lolly bags sit at 2.5.
• Salmon sits at 3 stars, beer battered chips sit at 4.

Shelf, fridge and freezer life

https://www.foodsafety.gov/food-safety-charts/cold-food-storage-charts

• Serve size vs Per 100g

We look for (depending on the food of course) 

1. Total kJ
2. Total protein per 100g
3. Sugar per 100g - check ingredients list to explore if natural vs added
4. Saturated / trans fats
5. Sodium
6. Fibre / Vit / Min 

https://livelighter.com.au/Assets/resource-vic/wallet-and-postcard/traffic-lights-wallet-card.pdf

Food Switch App 

Source of product and ingredients

Source : https://www.accc.gov.au/consumers/groceries/country-of-origin

Source: https://www.australianmade.com.au/media/477079/amcl_code_of_practice_2017.pdf

Remember, some of the healthiest foods may not have labels or health claims (e.g. fresh fruit and vegetables, nuts, lentils, beans, fresh meat and fish).

Trends in the New Year

Google trends data

Source https://noobgains.com/gym-membership-statistics/

https://fitness.org.au/articles/fitness-australia-annual-reports/fitness-australia-annual-report-2018-19/14/1880/19

Behaviour change

• According to well known Clinical Psychologist Dr. Howard Rankin, who is an expert on behavioral change, a large part of the problem is that we think we have control over our behavior, when really we don’t.
• Lauren and I see this regularly in practice. It’s wonderful to have goals and aspirations, but the psychology and motivation behind behaviour change in complex.
• We know that habits (which often take 21 days to break) and stress, reduce our conscious control over the choices we make
• What drives our behaviour is not always logical, as humans we are emotional! You guys would know, sometimes we do things we know aren’t good for us, but we don’t know what drives us to pursue them!
• Quote by Dr Rankin: The more primitive, emotional brain generally has precedence over the newer, more rational brain.
• This is really important to note when it comes to setting achievable goals for the new year.
• Knowing this, we want to make sure you set yourself up for setting positive and realistic goals in the new year!

Why New Year's resolutions don’t work

• Abrupt change too quickly
• Expectations too large therefore setting self up for failure
• To successfully achieve these resolutions, small, short-term goals are the most effective and taking resolutions one step at a time is the best way to succeed
• Fear is such a powerful emotion it can override our priorities and goals we set. Fight/flight. We run away from fear before we run towards pleasure. We can have a fear of failure, success, or just fear of change—stepping outside our comfort zones—that stops may of us in our tracks before resolution become habits.

How to make them stick

• Make resolutions tangible and achievable. For example, instead of stating you will 'lose 20kg in 2020,' plan that you will 'walk everyday for 2 weeks' or ‘avoid choc after 8pm for 2 weeks’.
• Say it out loud. Write it down. Tell someone. Anyone. Be accountable. 
• Enlist a support crew. Cheerleaders 
• Make your goals EXTREMELY SMALL. Like stupid small. For example, she suggests instead of aiming to workout three times a week, you start with two squats a day. The change is so small, you won’t stop with just two. Walk only to the letter box. No chocolate on Tuesdays. Walk only to the letterbox.  And that's how these small habits grow from ridiculously small to big. It's hard to resist not doing more, because it's just so easy. 
• Anchor it to something. Your squats for eg, tether it to something you already do every day, like brushing your teeth. It’s only 2 mins. And all of a sudden it’s achievable.
• Opt in vs opt out. What are the things you always do? Eat lunch, brush your teeth, attend your specialist appts, go to work. Put your goals in that category. A MUST DO unless something major trumps it. Physically put them on your to do list, your calendar, your reminder list on repeat.  
• More positive less negative. - Set your phone calendar to give you positive messages or reminders about your goals a few times per day. Remind yourself to walk. Set an alarm that call your 8pm cut off time. 
• Time - it takes 17 to 21 days to form a habit; therefore, keeping a goal for those 21 days will support success

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC535950/

https://insights.ovid.com/article/00006205-201501000-00002

https://www.ncbi.nlm.nih.gov/m/pubmed/26671434/?i=6&from=/15604158/related

Top Tips for navigating Festive Feasts

1. Don’t overthink it. So you ate too much cheese. Acknowledge it then move on. 😊

2. Move when you can. A brisk walk with the fam is a wonderful way to pull yourself out of a pudding nap. 🚶🏽‍

3. Food envy? Have a little bit of everything. But just a little bit. Recruit a friend and remember sharing is caring 👫

4. Eat mindfully. Listen to your body. Stop when you’re satisfied. 🧠

5. Savour every mouthful. The festive season is delicious. Enjoy it with your loved ones! 🕯🎄💝

6. Refer to point 1. 🧀😉

FREE Mindful Eating Guide

FREE Mindful Eating Meditation 

Overeating is completely normal. It is our thoughts, feelings, and reactions to overeating that can be damaging beyond the overeating moment

Overcompensating by restricting is not the solution...

Our bodies need a regular supply of food to stay alive and perform all of the various chemical reactions and daily bodily functions (like keeping our heart beating, allowing our diaphragm to expand and relax with each breath, our kidneys as they remove our waste, our growing nails, cell turnover in our gut...etc).

Restriction → deprivation → protection through overcompensating

When our bodies feel the threat of scarcity (i.e. starvation from a evolutionary perspective)- even if that is in the form of intentional restriction- our bodies will look to protect us through eating more to compensate. This is a natural biological reaction..

Our suggestion is to in fact NOT skip breakfast! Many people skip breakfast in anticipation of the big festive meal, but in many cases that just makes it more likely that you'll be ravenous at lunch or dinner time meaning you're less likely to actually enjoy the food (i.e. scoff it!)and more likely to eat to the point of discomfort.

Give yourself permission to eat how you would want a loved one to eat. Should they skip the xmas pudding? Should they feel bad about enjoying the xmas ham? And therefore should you?

Revisit your values and goals. Give yourself the time and space to allow your actions to align your behaviours with these values

Feel and respect your fullness - but I would add a big caveat to this one: it’s okay if you eat past the point of fullness.There’s a lot of delicious food and a lot of food that we don’t get a chance to eat very often and we want to enjoy it all with the people who put the thought and care into making it. Notice and check in with how your body is feeling but know that it’s okay if you eat past the point of comfortable fullness. Notice it. Be curious but do not be judgemental! You’re allowed to eat for more reasons than just pure hunger.

Honour your fullness. Give yourself permission to not eat also! Social pressure, “eating for others”

Some tips:

• “Thank you, this looks great but I’m actually feeling satisfied already.”
• Postpone, save for later

SHOW NOTES

Green Powders 

https://www.budgetdirect.com.au/home-contents-insurance/research/average-grocery-bill-statistics.html

http://oncorenutrition.com/eat-or-drink-your-greens/

Cheese 

http://oncorenutrition.com/the-bees-knees-of-cheese/

Why we might not weigh you

http://oncorenutrition.com/weight-bias-what-are-we-weighting-for/

SHOW NOTES

If it fits your macros (IIFYM)

What is this diet?

• Tracking energy (kJ/calories) and macronutrients (protein, carbohydrates and fats).
• Calculating basal metabolic rate based on predicted equations (BMR is how much energy your body uses at rest). Add activity +/- stress factor to estimate your total daily energy expenditure (TDEE).
• Depending on goals, establish a calorie deficit, maintenance or surplus.
• Apply macro percentages to your end calorie number, e.g. 30% energy from protein, etc…
• Once you have your macro calories and split you then build this into a meal plan and track it all

Potential Benefits 

• Nutrition knowledge
• Eye opening 
• Label reading
• Goal oriented 
• No forbidden foods 
• Effective for weight loss ...but there is far more to health than number on scales.

Some drawbacks 

• It may promote an obsessive way of eating, body dysmorphia, disordered eating patterns
• Psychosocial limitations
• Does not encourage intuitive eating 
• Practically arduous - weighing
• Low food variety 
• Not necessarily an enjoyable or sustainable way to live life. 

Bottom line

• When starting an eating plan, think about sustainability and true flexibility!
• Think about your sanity, relationships with loved ones and allow yourself to enjoy food in the moment!
• Listen to your body, eat when you’re hungry and stop when you’re full.
• There is so much more to life and enjoyment of food than calorie or macro counting.

Food variety score

Aim for >30 per week 

http://www.nutritionaustralia.org/sites/default/files/Food%20Variety%20Checklist_0.pdf

Frankenfield D, Roth-Yousey L, Compher C. Comparison of predictive equations for resting metabolic rate in healthy nonobese and obese adults: a systematic review. J Am Diet Assoc. 2005;105(5):775–89.

SHOW NOTES

Diet soft drinks

Diet soft drinks often replace sugar with artificial sweetener, often aspartame. Aspartame is around 200 times sweeter than sugar, so a very small amount is all that is needed to sweeten a product.

Aspartame safety

Studies performed in 1980 by Joint Expert Committee of Food and Agricultural Organization + World Health Organization (JECFS) established the Acceptable Daily Intake (ADI) of Aspartame as 40mg per kg of body weight, meaning that the average person can safely consume around 3400mg of aspartame daily without any adverse side effects. Can of Diet Cola is around 180mg = 18 cans per day. 

Health impact of artificial sweeteners

• Some observational studies have found high intake of artificial sweeteners and diet soft drink is associated with an increased risk of obesity and metabolic syndrome
• Diet soft drink may increase appetite by stimulating hunger hormones (Grehlin), altering sweet taste receptors and triggering dopamine responses in the brain
• Predispose us to want sweet, calorie dense foods and fluids 
• Observational (diet soft drink leads to weight gain) vs experimental studies (swap to diet soft drink leads to weight loss, but beware of funding source and bias)
• Link to weight gain possibly from above, possibly from pre-existing poor dietary habits. One study of over 300 overweight  participants - drink 710ml diet soft drink or water per day for a year. At the end of the study, the diet soda group had experienced an average weight loss of 6.21 kg compared to 2.5 kg     https://www.ncbi.nlm.nih.gov/pubmed/26708700
• Bias in the scientific literature - some studies (including this one) funded by the artificial sweetener industry have been found to have more favorable outcomes than non-industry studies, so we need to be careful when interpreting results.
• Observational studies have found a link between high intake diet soft drink and the development of kidney disease ? related to acid load on the kidneys from high phosphorus content.
• Gut microbiome: Artificial sweeteners alter the gut flora, leading to reduced blood sugar control. This may be one way diet soft drink increases the risk ofT2DM, but more research needed. https://www.ncbi.nlm.nih.gov/pubmed/27090230   https://www.ncbi.nlm.nih.gov/pubmed/25831243
• Be careful if you have low bone density - particularly with phosphorus containing drinks, so cola, and those with caffeine. PO4 interferes with Ca absorption. 

At the end of the day, diet soft drinks offer no nutritional benefit. The ingredients list is empty and doesn’t offer anything positive to our health. 

If you’re a regular drinker, set yourself a challenge. 21 days to change a habit. Set a target, recruit some friends, get a calendar going to mark off days and set yourself a challenge. Try our sparkling iced teas. Challenge to break the habit so you can enjoy sugar-free soft drink on occasion, but it’s not a must have each day. 

https://www.nature.com/articles/s41430-019-0407-z

Carbonated water and teeth

https://www.ada.org/en

Milk 

Cows milk full vs skim = change in ratios, no sugar added. Permeates ensure consistency in nutritional composition of milk.  

Soy - similar nutritional profile - has to be by food standards law, plant-based, sometimes sweetened

Almond - low protein, low kJ, low fat, low CHO, low Calcium. Some are sweetened, some calcium fortified.   

Rice milk - low is kJ, protein, high in natural sugars. Hypoallergenic. 

Coconut milk - low in carbs and kilojoules, but is significantly higher in saturated fat than other non-dairy alternatives, lacks protein and calcium (unless fortified).

Oat milk - same kJ as cows milk, half protein, low fat, higher CHO, equiv Ca,  beta-glucans (soluble fibre reduce chol reabsorption)

Comparison table: 

https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Milk-Allergy-Foods-and-Ingredients-to-Avoid.aspx

Heart Foundation guidelines 

https://www.heartfoundation.org.au/news/new-advice-from-the-heart-foundation-on-meat-dairy-and-eggs

SHOW NOTES

The positives 

• We love plants - lots of benefits to a diet rich in plants
• Generating conversation! 
• Controversy is sadly often necessary to create a ‘movement’ we see why they did this! (We can’t because we’re trained and regulated health professionals - and therefore the most trustworthy source of nutrition advice) 
• Removing stigma around veganism and vegetarianism  (although the terminology they use was interesting eg never said vegan but implied it) 
• They help clear up the stigma around soy - check episode 4 where we present the science in a less inflammatory way! 
• Farming and environmental concerns 

THE SCIENCE

Unfortunately good TV often equals bad science

Supporting science - controversial sources, grand extrapolations from small studies, and statements that are misleading.

Anecdotal experience, conflicts of interest

Gladiators 

• Whole premise of doc built on concept that gladiators didn’t eat meat…Their exact words were “gladiators were likely predominantly vegetarian”. True-ish. 80% ish plant based. Not vegetarian. Not vegan. Just like us.  
• We were misled from the start 
• They also implied that the gladiators were vegan for performance reasons, which again is misleading. Gladiators ate more of a plant based diet because of many reasons including access to animal products, availability, seasons and money! And because carbohydrates fuel the human body. Meat is expensive and many ancient civilisations only ate what they had access to.
• Gladiators weren’t overly lean - gladiators benefited from additional fat stores as food supplies were often scarce and this extra weight was protective when they went into battle/helped them stay alive. More fat = lasts longer in the arena. Different to many sports in today's day and age.
• 
   

Athletic performance

• You don’t have to eat animals to build muscle  
• So many other variables to consider when exploring athletic performance
• Nutritional advice should be tailored to the sport of choice, performance goals and outputs and individual variation 
• In one instance, they do cite actual peer-reviewed research, he narrates: “And when it comes to gaining strength and muscle mass, research comparing plant and animal protein has shown that as long as the proper amount of aminos acids are consumed the source is irrelevant.” https://www.ncbi.nlm.nih.gov/pubmed/15212753. What they fail to include is that the same study states that “as a group, vegetarians have lower mean muscle creatine concentrations than do omnivores, and this may affect supramaximal exercise performance.” (achieving higher than what is considered maxima) = prime example of cherry picking.
• Theory: Beetroot juice consumption increases bench press by 19%. Beetroot study - review of 9 studies with total of 120 subjects numbers -  The beetroot juice intervention led to significantly improved performance in four of the studies, while in another four no such effects were observed. In the show they quote a 19% increase in total strength for bench press, but this is referenced in the study cited not tested by it. Obviously we went and found the actual study. It was a cross over trial, 12 young men, lifting 60% of their 1RM (single rep max, the most they can lift). 3 sets until failure were performed and those reps were totalled. Those in the nitrate supplement group performed more reps. The weight equated to an 18.9% increase. “This study demonstrates that nitrate supplementation has the potential to improve resistance training performance and work output compared to a placebo.” The study was looking at a Nitric Oxide Enhancing Supplement, not just beetroot! Nitric oxide (NO) is generated from the nitrates in the beetroot. It’s a vasodilator so opens up blood vessels and improves flow in the short term. If you understand nutrition you’ll know that other foods contain nitrates, including beef, pork, chicken, liver, salmon, trout and tuna!
• Beware of supplements and performance enhancing drugs 

Experiments - endothelial function (cloudy blood) and erectile function 

• Neither are scientifically validated test. Looks good on screen. Convincing. But not scientifically meaningful.
• The ‘cloudy’ portion of blood in the test tube does not necessarily indicate there is an issue, more it shows there are triglycerides and fat transporters present called chylomicrons. This is a completely natural and necessary process, however the documentary portrays it to be negative to support their argument. 
• If there was sufficient EVOO or avocado in the vegan burrito, the blood sample would have looked the same. 2hrs post meal. They didn’t specify how much avocado they put in. And they didn’t have to because this wasn’t a study!  
• We know the fat was seen in their blood, but we don’t know if their endothelial function was impaired and/or their blood flow disturbed in any way due to their meal.
• The study that suppoerted their findings (n=11): “The high-fat meal consisted of 53.4 g fat (= 7.4 chicken breasts), 30.7 g protein, and 50 g carbohydrate, composed of 110 g rice, 100 g Korean barbecue, 20 g egg, 200 ml milk, 8 g oil, 25 g mayonnaise, 50 g vegetable.” The response shown, as stated in the paper’s title, was due to ‘oxidant stress’. Not the triglycerides 
• Another study n=10. The standardized high-fat meal consisted of whipping cream, liquid chocolate and non-fat dry milk and contained 65 g of fat, 25 g of carbohydrates.
• Supporting study funded by the Hass Avocado Board
• 
   
• We know that lean protein sources (e.g. poultry and fish) can improve endothelial function
• Neither of these “experiments” considered variables like sleep, muscle fatigue, stress, training, hydration, blood electrolyte levels, history of tobacco use, alcohol consumption, prior medical history, mental clarity, emotional state, genetic predispositions. n= 3 people. Not enough. 
• 
   

Clinically concerning hypertriglyceridaemia looks like this...

Source: https://en.wikipedia.org/wiki/Hypertriglyceridemia

Source: https://www.elynsgroup.com/journal/article/milky-serum-in-hypertriglyceridemia-clinical-image

Source: https://www.semanticscholar.org/paper/Severe-hypertriglyceridemia-presenting-as-eruptive-Vangara-Klingbeil/b3148cd3bb48f43711a7a0ced40d446b1ef74618

Nutritional profile

• The show claims, animals eat plants, so we should bypass animals and eat plants too. To put it in context for you a cow has 4 stomachs (we have 1), can extract amino acids from plant based materials as a result of enzymes and bacteria that we as humans do not have. As humans our digestive tract is very different. We can not get the same nutrients from grass as cows do.
• Compared to animal sources, plant based sources are a poorer source of leucine - important for muscle growth 
• Vegans can get a complete profile of AA’s however they need to be eating a wide range of plant based protein sources.
• Estimated bioavaiability of protein in beef - 92%. Estimated bioavailbility of protein in kidney bean - 54%. Grams of protein does not equate to how much we as humans can absorb and access. 
• There’s a funny bit here where they reference a peanut butter sandwich as containing an equivalent amount of protein to 3 ounces of beef. To achieve the ~20g of protein that is in 3 ounces of beef, you would need to consume 2 slices bread plus 4 tablespoons peanut butter bringing the total to 510 calories (2100kJ), 20g protein, 34g fat, and 39g carbs. Beef - 213cal (894kJ), 20g pro, 13g fat, 0 CHO. So the peanut butter sandwich has yes the same protein, but more than double the calories, almost triple the fat, 40g vs 0g carbs
• “Even iceberg lettuce has more antioxidants than salmon or eggs.” - worse than comparing apples & pears…Just because they’re not ‘antioxidants’ doesn’t mean they’re not valuable nutrients! Eg omega-3 fatty acids in salmon and protein in eggs are so valuable!  How much protein or omega 3s are in iceberg lettuce?! Shall we compare it the other way?
• Go to episode 2 for tips on upgrading your salad 
• Wilks claims that cow’s milk can increase oestrogen and lower testosterone in men. The 2010 study he references, published in the journal Pediatrics International, was conducted using the milk of pregnant cows. The scientists pulled from a pool of 18 people (seven men, six children, and five women), and found that milk reduced testosterone secretions—not overall testosterone —temporarily. Seven men. Temporarily. https://www.ncbi.nlm.nih.gov/pubmed/19496976
• Focus on ADDING plants rather than REMOVING animal products.

OnCore Practical Plant-based tips 

Our upgrade your health tips (not 0-100!) 

1. It doesn't have to be all or nothing. 
2. Focus on adding plants rather than necessarily removing all animals. 
3. Add veggies, fruit, spices or acidic marinades (such as yogurt or vinegar-based marinades) to your meats - this may decrease hetereocyclic amines (linked to cancer development) formation by up to 99%
4. Start with meat free monday
5. Upgrade to one meal per day - plant-based lunches
6. Still eat REAL food - avoid fake cheese, fake-on, tofurkey. This takes planning and knowledge and perhaps tailored expert advice and guidance. 
7. It's relatively easy to meet your protein needs. It’s hard not to overdo the carbohydrate load. Tailored advice from a dietitian will help ensure you’re eating to match your goals. 
8. Watch a David Attenborough documentary instead - we think this gives a far more powerful, realistic perspective on how we could be better looking after our planet and health simultaneously 
9. Think about where you’re getting your health information - underlying biases, conflicts of interest, governing bodies or registrations? We are required to stay up to date and be safe and fair to public. 
10. Think about how you can ethically source your animal products (see below). 

Sustainable produce 

https://sustainabletable.org.au/all-things-ethical-eating/ethical-meat-suppliers-directory/

https://www.sustainability.vic.gov.au/You-and-your-home/Live-sustainably/Sustainable-shopping/Food-shopping

https://www.wwf.org.au/what-we-do/food#gs.g3u330

https://kb.rspca.org.au/knowledge-base/how-can-i-shop-for-animal-welfare-friendly-food/

https://www.coles.com.au/corporate-responsibility/sustainability/responsible-sourcing

https://www.ethical.org.au/3.4.2/get-informed/issues/food-miles-buying-local/

https://www.sustainability.vic.gov.au/You-and-your-home/Live-sustainably/Sustainable-shopping

The Game Changers References:

The Gladiator Diet

https://archive.archaeology.org/0811/abstracts/gladiator.html

Beetroot

https://www.ncbi.nlm.nih.gov/pubmed/29311764

Nutrient Profiles 

https://www.ncbi.nlm.nih.gov/pubmed/23988511

https://pdfs.semanticscholar.org/0277/f4fd3e6205936e4d4c8e490abe9958607815.pdf

These are the studies cited with regards to vegetarian diets for athletes:

https://pdfs.semanticscholar.org/6358/c99b8b7047fd99f0867e148840829a125dd0.pdf

https://nutritionj.biomedcentral.com/articles/10.1186/1475-2891-12-86

https://www.ncbi.nlm.nih.gov/pubmed/26764320

Endothelial Function

https://www.ncbi.nlm.nih.gov/pubmed/11254924

https://www.researchgate.net/publication/12166386_Impaired_flow-mediated_vasoactivity_during_post-prandial_phase_in_young_healthy_men

https://www.ncbi.nlm.nih.gov/pubmed/23196671

https://www.ncbi.nlm.nih.gov/pubmed/10477529

https://www.ncbi.nlm.nih.gov/pubmed/20047267

https://www.ncbi.nlm.nih.gov/pubmed/24004888

https://www.ncbi.nlm.nih.gov/pubmed/19064532

https://www.ncbi.nlm.nih.gov/pubmed/15165919

https://www.ncbi.nlm.nih.gov/pubmed/24742818

https://www.ncbi.nlm.nih.gov/pubmed/22019438

https://www.ncbi.nlm.nih.gov/pubmed/11834139

https://www.ahajournals.org/doi/full/10.1161/01.cir.104.2.151

https://www.ncbi.nlm.nih.gov/pubmed/17916273

https://www.ncbi.nlm.nih.gov/pubmed/17609490

https://www.ncbi.nlm.nih.gov/pubmed/23848379

https://www.ncbi.nlm.nih.gov/pubmed/16027246

https://www.ncbi.nlm.nih.gov/pubmed/16365364

https://www.ncbi.nlm.nih.gov/pubmed/15547040

https://www.ncbi.nlm.nih.gov/pubmed/26024297

https://www.ncbi.nlm.nih.gov/pubmed/24706588

https://www.ncbi.nlm.nih.gov/pubmed/22091240

https://www.ncbi.nlm.nih.gov/pubmed/15190043

https://www.ncbi.nlm.nih.gov/pubmed/16198843

Antioxidants

https://www.ncbi.nlm.nih.gov/pubmed/30634559

https://nutritionj.biomedcentral.com/articles/10.1186/1475-2891-9-3

https://www.betterhealth.vic.gov.au/health/healthyliving/antioxidants

https://www.ncbi.nlm.nih.gov/pubmed/25637150

Plant Based Guide for Physicians

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4991921/

Heme Iron

https://www.ncbi.nlm.nih.gov/pubmed/23708150 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3583546/)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2954454/

Cardiovascular Disease

https://www.ncbi.nlm.nih.gov/pubmed/24871675

https://www.ncbi.nlm.nih.gov/pubmed/1973470

https://www.ncbi.nlm.nih.gov/pubmed/24606898

Cancer Risk

https://www.ncbi.nlm.nih.gov/pubmed/11519764

https://www.ncbi.nlm.nih.gov/pubmed/9786231

Human Evolution

https://blogs.scientificamerican.com/guest-blog/human-ancestors-were-nearly-all-vegetarians/

https://www.academia.edu/28523514/The_evolution_of_body_size_within_the_genus_Homo_new_empirical_data_and_theoretical_perspectives

https://www.ncbi.nlm.nih.gov/mesh?Db=mesh&Cmd=DetailsSearch&Term=%22Vitamin+B+12+Deficiency%22%5BMeSH+Terms%5D

https://www.ncbi.nlm.nih.gov/pubmed/10648266

Testosterone

https://www.ncbi.nlm.nih.gov/pubmed/10479226

https://www.ncbi.nlm.nih.gov/pubmed/2400756

https://www.ncbi.nlm.nih.gov/pubmed/10883675

Phytoestrogens

https://www.sciencedirect.com/book/9780123984562/polyphenols-in-human-health-and-disease

Oestrogen

https://www.ncbi.nlm.nih.gov/pubmed/11392381

https://www.ncbi.nlm.nih.gov/pubmed/17474873

https://www.ncbi.nlm.nih.gov/pubmed/19496976

Cortisol

https://www.ncbi.nlm.nih.gov/pubmed/3573976

Types of Intermittent Fasting

1. ADF - 25% energy reqs one day, nil restrictions on the next 
2. Complete alternate-day fasting (or total intermittent energy restriction) - no energy consumed on fast days
3. modified alternate-day fasting (or partial intermittent energy restriction) - up to 25% of daily energy needs on fasting days instead of complete fasting.
4. Most studies are in this method - mice and human 
5. In humans, Monks semi-fasted every other day with 1L milk + 500g fruit on fast day for 3 years
6. > Less time in monastery infirmary & lived longer (but not sig).
7. Periodic fasting 
   1. 5:2 (Michael Mosely) - not a whole lot of evidence yet, but more emerging
   2. The 2 Day Diet (Michelle Harvie) - 2 days 500-600Cal then eat & drink normal for rest of week
   3. 24hr fast
   4. Valter Longo– 5 day consecutive fast (800Cal/day) then normal for rest of month > evidence for protection against cancer.
   5. more extreme versions with several days or weeks of fasting. 
   6. During the fasting days, it may be allowed approximately 500 to 600 calories or about 25% of regular daily caloric intake instead of complete fasting.
8. Time-restricted feeding / TRE - eating only during a certain number of hours each day. Eg 16:8. This schedule is thought to leverage the circadian rhythm.
   1. Timing - earlier may be better. BF not most important meal of day but BF and lunch better for circadian rhythm and glucose tolerance the next day than lunch + dinner. 

Physiological benefits

http://oncorenutrition.com/to-fast-or-not-to-fast/

Coffee https://www.ncbi.nlm.nih.gov/pubmed/28177691

Practicalities / sustainability / contraindications 

http://oncorenutrition.com/the-fast-and-the-furious/

Guides: http://oncorenutrition.com/intermittent-fasting/

https://store.oncorenutrition.com/collections/all

Skin, hair, nails supplements

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509882/

• Many products on the market that claim to thicken our hair, improve the quality of out skin and strengthen nails.
• Many of these products come with fancy marketing and an expensive price tag!
• Are these supps all they;re cracked up to be? Here's what the research shows:

What do these supplements usually contain (individual products do very)?

• Hair, skin, and nail supplements commonly contain antioxidants (e.g. vitamins A, C, and E, and/or Coenzyme Q10).
• biotin & B- vitamins can be in there too!
• They can often contain the minerals manganese (helps your body utilize a number of vitamins and selenium (plays an important role in the health of the immune system by reducing oxidative stress), along with fatty acids (fish oil and/or flaxseed oil).
  
   
• Deficiencies of these nutrients is uncommon
• Over time, inadequate intake of vitamins A and E and biotin can affect our hair and skin, however this is rare!
• Sadly I’ve seen some really poor quality products (with very fancy marketing) that don’t even contain all of these ingredients.

What does the science say?

• For those with no deficiencies, there's no good evidence that supplements can make a difference to our hair skin and nails.
• I’m not aware of any robust data suggesting that any supplements can improve the inevitable age-related hair loss, skin elasticity or nail weakening.
  
   

What if you are one of those people who have nutritional deficiencies?

• Most people get enough of the nutrients mentioned above through the diet, but in rare cases, a chronic disease and/or medical problem may cause a nutritional deficiencies, which as a result affect your hair, nails, or skin.
• If you’re experiencing hair, skin or nail issues for no clear reason, talk with your doctor and request a blood test . 
  
   
• Supplements can often contain heavy metals and other ingredients that aren’t necessarily health promoting. We always recommend food first!

Our recommendations:

In summary: While nutrition plays a key role in many skin issues, consuming pills specifically to target these without making any other changes to your diet or lifestyle is likely counterintuitive - eat a healthy, balanced diet and save your pennies!

Vitamin A and skin

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4428712/

https://www.ncbi.nlm.nih.gov/pubmed/17515510

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699641/

Transdermal absorption

MUST be fat soluble! Lipophilic. All water sol vitamins won’t be well absorbed.

MUST be small

Vit D - sublingal vit D spray, not yet transdermal

https://www.nature.com/articles/s41430-019-0503-0

Magnesium - poorly absorbed. Requires sweat glands/hair follicles

Dead cells of the upper skin layer do not contain functional magnesium transporters, which have not yet been identified in detail, magnesium absorption may be possible only at the small area of sweat glands and hair follicles.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5579607/

B12

Suitable alternative to oral or intramuscular injections at restoring serum B12 levels

The bioavailability of sublingual vitamin B12 appears to be equivalent to oral vitamin B12

https://www.ncbi.nlm.nih.gov/pubmed/30632091

https://www.ncbi.nlm.nih.gov/pubmed/29499976

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1884303/

 

Omega 3 fats

How does this impact our skin?

• DHA = structural component of skin and keeps our cell membranes healthy. When the cell membrane is healthy, this means healthy skin - yay!
• EPA has many benefits
• Reduces signs of premature aging.
• May reduce the risk of acne formation.
• Skin hydration.
• Can prevent Hyperkeratosis - thickening of skin
  
   
• Omega-3s can protect skin from the UV rays emitted from the sun.
• EPA in particular can help your body retain skin collagen after sun exposure

CORRECTION

• Saturated fat content of coconut oil approx 80-90%
• Saturated fat of extra virgin olive oil approx 15% 

Alkaline diet

http://oncorenutrition.com/dont-be-basic/

Eggs and cholesterol

Let's take it back, what is cholesterol?

• Cholesterol is a fat-like substance that is produced by our bodies and also found in food.
• Our bodies need cholesterol to function properly. e.g, cholesterol is used to build cell walls and hormone production.
• About three quarters of cholesterol in the body is produced by your liver and the rest comes from the foods we consume.
• Cholesterol is carried in the blood by lipoprotein as Lauren discussed last week. The main types of lipoproteins are high-density lipoprotein (HDL) and low-density lipoprotein (LDL). Obviously we want more of the good stuff (HDL) and less of the bad stuff (LDL)

Where’s the research at?

• Research has shown that dietary cholesterol does not significantly impact cholesterol levels in your body.
• Data from population studies showed a limited association between dietary cholesterol and heart disease in the general population.
• Healthy foods that contain cholesterol (e.g. eggs, fish, shellfish, yoghurt) can be protective against heart disease and high cholesterol.

Eggs specifically?

• The cholesterol found in eggs has little effect on your blood cholesterol levels.
• Cholesterol levels influenced by saturated and trans fats.
• Choose healthy sides to accompany you eggs, e.g. a slice of wholegrain rather than white bread and limit your intake of bacon.
• If bacon is your side of choice to accompany your eggs, the bacon will likely have more of an impact on you blood cholesterol than the eggs! We encourage you to try some vegetable based sides, e.g. spinach, tomato, avocado, mushrooms or beans!

What is important to note is a small number of people are sensitive to eating dietary cholesterol that is naturally found in food. Therefore when they eat cholesterol rich foods, their LDL (not so good) cholesterol levels may increase.

Recommendation: 7 eggs per week.

Which foods will increase blood cholesterol?
The research suggests that processed foods which are high in saturated or trans fats will increase our blood cholesterol levels.

I was reading a large study in The American Journal of Clinical Nutrition, which followed over 300,000 people for 4–10 years. The subjects modified the type of fats consumed. Those who reduced their saturated fat intake by ~5% and selected polyunsaturated fats had lower rates of coronary illness or coronary related deaths.

Moral of the story: with a baseline healthy diet eggs are an excellent source of healthy fats and protein!

Pick your drink

G+T = up to 3 slices bread (short glass ~715kJ, 250ml tonic = 840kJ) = 14% daily energy needs.(7 = 100%)

Gin and soda = 1 slice bread (415kJ)

Cider = up to 4 slice bread

Cocktail - up to 5 slice bread

Dry wine, champagne, spirit = 1 slice bread

Beer = 2.5 slice bread

Better options

• Spirit + soda
• Champagne
• Dry wine

You know the drill

• Stay hydrated - 1 for 1
• Get a long glass if it’s soda, short glass if it’s soft drink
• Line your stomach → About 20 percent of the alcohol consumed is absorbed in the stomach, and about 80 percent is absorbed in the small intestine

Bone Broths

Bone broth? Do we need it?

• These days, bone broths are being hailed as a new curall regarding gut health, skin, immune system and joint relief.
• There are many testimonials to support this soups benefits— e.g. as wrinkle removers, gut bacteria boosters, bone builders and immune enhancers
• Unfortunately, the science doesn’t quite back it up!
• What is interesting is bone broth is something we have always had in my culture, my Omi makes the most delicious chicken soup and all these years we thought nothing of it (other than how delicious it was)!

What is bone broth?

• Usually made with chicken stock or beef stock, but can be made with pork and fish. The soup bases made by simmering the bones with added spices and vegetables, often for as long as two days.
• Bone broth is a fairly good source of protein and often contains ~ 6-12 grams a cup.

Where’s the evidence at?

Claims with some support:

Small studies which have found benefits on consuming chicken broth:

• Chicken soup & mucous secretion. There is research to suggest that consuming hot chicken soup can help to loosen and clear secretions - study from 1978 and we have spoken about this in previous prodcats.
• Chicken soup & inflammation. Laboratory studies that found chicken soup inhibits the activity of neutrophils (white blood cells). However, this evidence is not overly strong

Both small studies but some evidence nonetheless

Claims with no support:

• Bone broths & joint pain. Arthritis can occur as a result of collagen loss. Whilst bone broth contains collagen, dietary collagen isn't necessarily absorbed and directed straight into your joints.
• Bone broths & skin firming/elasticity. Claim also based on collagen, which forms a layer of tissue to support our skin. Just as dietary collagen isn't transported directly to the joints, it isn't taken necessarily directed to our skin either.
• Bone broths & digestion. Bone broths contain gelatin, which has claims to support and improve digestion. Again another claim with little evidence
• Bone broths & bones. Whilst the soup is made from bone, this doesn't mean it will build bone or strengthen the bones in our bodies. The animals bones in the soup release very little calcium into the broth, despite being simmered for many hours/days

Of note

• All bone broths are made differently - no consistency with products, therefore very difficult to test.

The bottomline: If you enjoy it, drink it or use it as a base for your soups, there is absolutely no harm. However it is not the cure-all it’s claimed to be! Save you $$ from the health food stores.

https://www.health.harvard.edu/healthy-eating/whats-the-scoop-on-bone-soup