Popular Diets: How Does Your Favorite Meal Plan Measure Up?

This is the first in a series regarding obesity, weight, and the diet culture we live in today. Dieting is one of the most common behaviors in our society.  In fact, it is so prevalent that 45 million Americans "go on" a diet each year.  At any given time, 1 in 3 Americans is actively dieting.  Despite these astonishing numbers, obesity remains at its all time highest levels in the US with approximately 31.3% of all Americans meeting the criteria for obesity.  Interestingly, 25.6% of Americans are also physically inactive.  The "diet" industry is a money maker, with sales of weight management formulas/diets grossing over 297 billion.  It is no wonder there are literally 1000s of product claiming that they will provide the solution for overweight blues.  But do they really work?  Only 45% of American have faith in their chosen diet regimen.

There is an old saying that "the diet that works best, is the one that you follow", and to some degree this is true.  Studies looking at the role of macronutrients (carbohydrates, fat, and protein)  have found that all "diet " plans work equally effective (No statistical differences found), as long as the diet restricted caloric intake (which generally is a requirement of a diet).  In addition, it has been reported by National Institutes for Health that 75% of the population consumes a diet low in fruits, vegetables, and dairy.

As it has been established, many American recognize that the are overweight or obese and need to do something about it.  The burning question is where to put that time, effort, and often times money.  The purpose of this post is to examine a limited number of "diet" plans.  These plans were chosen by their popularity among my Facebook friends  that were kind enough to respond to my public query on their preferred diet.

 Full disclosure: I am not paid to endorse or critique any diet or plan.  The views expressed in this article are based on my professional experience as a Registered and Licensed Dietitian for more than 20 years.  I also recognize that some of the diet plans that I will discuss in this article may work for an individual or a group of people.  I am giving my opinions based upon current scientific, evidenced based research.  In addition, diets, even the most insane methods may be effective in the short term.  My evaluations are based upon losing weight and the successful maintenance of that weight loss of greater than 2 years.  

Before I start discussing the pros and cons of each diet plan, I would like to identify some "red flags" that I look for when evaluating diet plans.  

Do they limit or restrict "Food Groups"?  

Are certain foods "good" while others are "bad"?

Does the diet restrict calories to < 1200 calories per day?

Does the diet require you to purchase special supplements, products, or packages foods?

Is the diet supervised by an unlicensed nutrition provider (not a Registered Dietitian)?

Can it be continued indefinitely to lose or maintain weight loss?

Is the "diet" expensive or cost prohibitive?

Does the person advocating the diet/plan make a profit from you?

Conversely, there are some characteristics that are seen in effective weight management such as:

Allow all food groups.

Allows for treats/extras occasionally

Uses common foods that can easily be accessed at a regular grocery store.

Allows an individual to lose and maintain the weight for > 2 years.

Helps individuals with problem eating behaviors.

Incorporates lifestyle changes in addition to healthy eating, such as regular exercise, and stable and predictable sleeping patterns.

Is sustainable (meaning the weight does NOT come back)

The Keto/Paleo/Low Carb

I have grouped the diets together simply because they have more in common than different.  IF you want more specific information on the KETO diet, please refer to my previous blog post.

What is it?

In short, these diets eliminate or at least severely limit carbohydrates, fruits, and vegetables.  Most importantly, they limit caloric intake, which is most likely the reason for the weight loss.  This diet consists of lots of meats, fats, and cream.  This diet tends to have many "versions", some allowing carbs, some not, and even some touting a "plant based" keto.

Pros:

-It may provide short term weight loss.

-It may help control blood glucose and insulin release.

Cons:

-It may increase risks for heart disease and cancer.

-Not sustainable indefinitely.

-Not nutritionally complete.  Deficient in Vitamin C, B Vitamins, and fiber

-Many versions/Confusing

-Expensive

WHOLE 30

What is it?

The Whole 30 claims to be "life changing' by eliminating cravings, rebalancing hormones, curing digestive issues, and improving medical conditions.  However, no independent research has confirmed any of these claims (studies using scientific methodology).  Self reports indicate that 96% of users lose weight.   It may not be the most medically appropriate meal plan for individuals that are at high risk for cancer and heart disease.

Pros:

Short term-30 days

No calorie counting or exercise required

Cons:

Eliminates grains, dairy, sugar, legumes, and alcohol.

Must eat lots of meat.

Only highly organized and committed individuals will be successful.

Nutritionally incomplete.

Expensive

Weight Watchers:

What is it?

Weight Watchers was founded in 1963 on the American Diabetes Association's Exchange System.  It is a subscription based weight loss plan which includes access to various forms of media, , products, services, and technologies.  Weight watchers has been studied and found to be 2.6% more effective in weight loss than a control group.  It is the most widely used weight loss program in the world with more than 4.5 million subscribers.  In addition, it is consistent with American Institute for Cancer Research and American Heart Association guidelines.

Pros:

Offers support groups/weigh ins/accountability.

Uses "regular" foods/no supplements.

Teaches food counting/point system to track intake and exercise.

Weight loss is maintained better long term.

Available online, app, phone, and in person.

Cons:

Costs to join/Expensive

Weight loss is slower than other programs

20/30:

What is it?

The idea of the 20/30 is to lose 20 pounds in 30 days.  It consists of a very restrictive meal plan, making it difficult for some to be compliant.  In the beginning stages, dieters consume < 1000 calories/day and then slowly begin adding foods back.  One of the fundamentals of the program is to buy supplements to "enhance the nutritional value of the diet and promote weight loss'.  The supplements also tout "hormonal regulation".  Professional note:  No supplements have been evaluated or endorsed by the FDA.

Pros:

Rapid weight loss

Meal planning done for you

Cons:

Increased lean body mass loss with rapid weight loss

Doesn't deal with emotional eating/behavioral issues

Poor retention/poor compliance/not sustainable

Expensive

21 Day Fix:

What is it?

The 21 Day Fix is a diet plan that  partners with Beachbody workouts and Shakeology Shakes.  Chances are that you know someone that has sold or been on the 21 day fix.  It combines a personal touch by self employing coaches (can have varying levels of education) that sell exercise plans/videos and meal replacement shakes.  In addition, the plan offers pre portioned color coded food containers.  

Pros:

Stipulates exercise program/plan

Includes all major food groups

Offers support via social media

Cons:

Coaches not licensed dietitians, may not know how to deal with behavioral aspects of weight management.

The Shakeology Shakes are expensive.

Very low in calories

Questionable sustainability-many continue to have "cheat days" and then start new "21 day fix".

Mediterranean Diet:

The Mediterranean was inspired by the eating plans in Greece and Italy.

The diet is high in olive oil, legumes, unrefined cereals, fruits, vegetables, fish, moderate cheese and wine.  In addition, it is low in saturated fat, high in monounsaturated fatty acids.  The diet emphasizes physical activity, encourages plant based diet, and is endorsed by American Heart Association and American Cancer Society.  

Pros: 

May reduce the risk of cardiovascular disease and overall cancer incidence, neurodegenerative disease, diabetes, and early death.

Reduced cost of living (No meat)

Reduced cost of healthcare.

Similar weight loss result as other diets

Can have moderate alcohol intake

Cons:

Limited saturated fats and animal products 

No meat

Remember, when evaluating a diet plan for yourself, determine if it is a good fit for you.  There are pros and cons of all meal plans, as outlined in this post.  Some of the cons may not be that big of deal breaker for you, while others may find the same option absolutely undoable.  If you like carbs, stick with a plan that carbs are plentiful.  Or if you have a strong family history of cardiac disease or cancer, take into consideration the meal plans that may further increase those risks.  One size does not fit all, nor does one diet.  I advocate a diet that uses readily available foods, tastes good, incorporates a healthy lifestyle and doesn't require the purchase of expensive and unnecessary supplements.  EATRIGHT!

The Unorthodox Dietitian

As a Registered Dietitian and (slow) marathon runner, I am always being asked by my friends, family, and even strangers, “What do YOU eat?”.  I decided to write this blog to discuss my current journey with food and nutrition and answer that mystical question, at least for today.

People that know me well would describe me as bit “particular” or maybe even picky with regards to my food at baseline.  I think the quote by Sally Albright in the firm Where Harry Met Sally best sums it up.  “I just like it how I like it”.

I have always been fascinated by the reasons people eat what they eat and find this to be central to nutritional status, our daily habits that become our lifestyle, and what will eventually determine our health outcomes.  Over the past 3 decades, I have surveyed groups and individuals in a variety of settings on this topic.  The driving factor in their choice (and mine) is that food must be tasty.  As a Registered Dietitian, I find nutrition quality to also be at the top of the list.  Other factors that are influential for me is my proximity to food (grocery stores, restaurants, etc..), my schedule and time availability.  Food sustainability and food waste are also significant factors in my choices.

During the period, which most of the world now refers to as “COVID” (anytime between March 2020 and March 2022), I decided to give up “traditional cooking”.  I had several reasons for doing so.  I had been married for 20 years, and recently divorced at the time. Newly single and an “empty nester, I was tired of grocery shopping, preparing and packing lunches, making dinners, and everything it entailed.  I had just moved to Boston and started a new position at Beth Israel Deaconess Medical Center during the middle of a pandemic, which was incredibly intense.  In addition, I was in a new city with new food options, and I wanted to try as many out as possible and explore my new city.   My new rule for cooking was to only use the microwave and toaster oven.  My beautiful oven and range stayed pristine and were honestly never used.    This blog post is dedicated to my period of >1 year of no cooking and what I learned.

I like to run early in the morning, and most days I was jogging through Coolidge Corner in Brookline before 5 am.  Besides a few delivery drivers and a couple that smoked pot on their stoop (for all my Texas friends, it’s legal in Massachusetts), I was the only one on the road. After my 6-mile run, I would enjoy a protein shake and some fruit or a yogurt parfait (made with high protein yogurt, cottage cheese, oatmeal, and fresh fruit) most days.  After a long run, my favorite go to was Bruegger’s bagels egg white on a plain bagel toasted. During my work week, I brought a Lean Cuisine Cheese Pizza to work literally everyday (even on Christmas Day!).  I have been eating them for lunch for over 4 years pre-pandemic.  I actually like the taste of the pizza.  Besides the taste, it has 370 calories and most importantly, it came in a box that could easily be transported in my backpack as I walked a mile to work.  In addition to my pizza, I would pack a yogurt (I prefer Ratio yogurt, for the creamy, rich texture and taste, and also because of the high protein content).  I also included seasonal fruit like fresh cherries in the summer and apples (that I hand-picked off the tree myself in New England) in the fall.  For dinner, I often had an egg white omelet with vegetable (made in the microwave), a yogurt parfait, or an Amy’s Black Bean and Rice Burrito, or I would enjoy some of my favorite offerings in Brookline, such as Fugakyu Sushi, Otto’s Margherita Pizza, or fresh fish or a lobster roll from Legal Seafood on occasion.   I learned to make butternut squash in the microwave (very tasty) and even made smores in the toaster oven. 

Interestingly, 28% of American adults live alone.  This is a record high and is also anticipated to increase.  I found that preparing food for one using the microwave was quite economical.  I also realized that eating out, when consumed for 2 dinners was more cost effective than the wasted ingredients I would have had if I cooked the meal myself, particularly when only cooking for one.  I also was able to prepare the meals for less than $10.00/day, which is less than the average American spends on food.

I learned to be creative.  My RD (Registered Dietitian friends) helped me out with “recipes” when I was craving a “For One Dessert”.  (Shout out to my colleague Litsa for the Smores idea!).  I learned to re-think meal paradigms and “the way it’s always been done”.  For example, I had traditional breakfast dishes for dinner (often).  I played with new ingredients (like feta cheese) on eggs and ate lots more raw fresh fruits and vegetables.  I threw  the traditional meal “rules” out the window and made decided to do meals my own way.

I’m often asked what I did with my “spare time”.   I learned to value my time more.  With the extra time that I saved from not cooking, I read lots more for pleasure, explored places in my new city like art exhibits, concerts, comedy shows, played in a softball game at Fenway, took lots of side trips to apple orchids and historical markers, explored other states, enjoyed nature, all while training and completing my seventh marathon.  I also found time to take a Creative Writing Course at Harvard University.  My life satisfaction became higher because I was doing more of what I wanted to do and less of what was expected.  I had time to inhale and exhale and had a great time.  Further, my grocery shopping was super quick and there was rarely any food waste.   The moral of the story is that it is possible to eat quick, healthy, and sustainable. 

In March 2022, I moved to Austin in order to be closer to my family and to pursue a professional passion of mine to provide healthcare to uninsured and underserved populations in Texas with Central Health.  I have added air-frying to my cooking methods because it is  easy, quick , and produces a superior finished product.  Occasionally, I do get out a pan to make tacos ("recipe" below), but continue to eat simply.

I always felt that I was expected to cook elaborate meals to be a good wife, mother, woman, and excel in my profession. In fact, the more elaborate, the better.  I have been a Registered Dietitian for more than 25 years, and when I meet new people, they often think that I plan meals for a living and must enjoy cooking.  I have never done professional meal planning in my entire career, unless you consider calculating someone’s tube feeding or parental nutrition as meal planning.  Further, discussing nutrition intakes, assessing the nutritional status of patients, and dealing with disordered eating has its place for me at work.  I fully admit that sometimes, it’s nice to let go of dealing with food during my personal time.  Some people may judge my choices or my reasons behind them, but I am grateful to live my authentic life and be grateful to celebrate the version of myself that I choose to be today. I learned that societal expectations are overrated.   Embrace the unorthodox! 😊

#eatrightleslie #LeanCuisinePizza #PremierProtein #RatioYogurt #AmysBurrtos #RegisteredDietitian #Boston #Brookline  #CoolidgeCorner #simpleeating #microwave #toasteroven #airfryer #LowCostMeals #CookingForOne #Austin

Full disclosure:  I have no associations to report to any of the food companies mentioned in this article.

Prices based on Walmart website published procing, May 2022 

                                                

My Unorthodox Favorite Meals

                                                                              Cost      Kcal       Sodium     Protein     Fat

Lean Cuisine Cheese Pizza                                        

Yoplait Ratio Yogurt                                                 

Cherries/Blueberries/Oranges/Strawberries            

TOTAL                                                                        $4.62    620        760           37              12

Amys Bean and Rice Burrito                                     

Sliced Cucumbers                                                       

TOTAL                                                                        $3.34     330         615          10              9                                                                     

 

Premier Protein                                                          

Shredded Wheat                                                        

TOTAL                                                                        $2.15      370        190          35              4.5

             

Ratio Yogurt                                                                 

Fat Free Cottage Cheese                                             

Instant Oatmeal                                                           

Fruit                                                                                                                                                             

TOTAL                                                                        $2.13    430        625         39               8

 

Egg White Omelet-Microwave

4 Egg Whites                                                               

Spinach                                                                        

Mushrooms                                                                 

Feta/Mozzarella Cheese                                             

Sliced cucumbers                                                       

Corn tortillas     (2)                                                     

TOTAL                                                                         $2.41    333          520          30              7 

Other Unorthodox Favorite Meals

Caprese Salad-no cooking

    Tomatoes   (1 cup)                                                                                                                       

    Fresh Basil  (5 leaves)

    Spinach/Arugula Mix (1-2 cuos)

    Olive oil/lemon Juice  (1-2 Tbsp)

    Fresh Mozzarella cheese

Combine in a bowl.  Serve immediately.

 Salmon Dinner-Fry and Fly

     Air- Fried Salmon (5 oz portion)

    Lemon Slice

Cook in air fryer until outside brown and crispy.  Serve with:

    Microwave Jasmine Rice (individual Serving)

    Frozen Microwavable Edamame (1 cup)

Fresh Cucumbers (1/2 Cup)

 Chicken and Sprouts-Fry and Fly

Air Fryer Chicken (3-5 ounce serving)

Air fryer Brussel Sprouts (basted with olive oil and low sodium soy sauce)

Cook until brown and serve with:

Watermelon

Texas Tacos -1 Pan Plan

    96% ground beef

    Low Sodium Taco seasoning

Brown ground meat and seasoning per directions.  Serve with:

    Corn tortillas

    Broccoli Slaw

    Strawberries

Toaster Smores

    1 graham cracker (4 squares broken into 2)

    2 small bars/pieces of a Hershey bar

    1 large marshmallow

  Toast on broil and top with remaining graham cracker half

 

Eating Right for Marathon Training

If training for a 26.2 mile marathon (by the way-ALL marathons are 26.2 miles) isn't enough to worry about, many runners question how to eat for such an endurance event.  Fueling your body to forge ahead through all of those miles can be complicated by a bad case of nerves, nutrient adequacy, and increased hunger cues.  The purpose of this post is to give you some evidenced based perspectives on fueling for the race, as well as, sharing some of my own personal pitfalls (and yes, I knew better!).

Full disclosure, I have ran 5 marathons since 2014, and countless half marathons, not to mention numerous 5 and 10 K races .  Although I have completed them all, I have never qualified for the coveted Boston Marathon or come close to placing in my age division.  However, as a registered dietitian, I know that proper nutrition enhances your training and performance.  The most common questions about sports nutrition for runners revolve around increased nutrient needs, preventing gastrointestinal (GI) distress, having adequate energy during training and the race, and running to eat.

Marathon Running and Nutrition Concerns:

Increased Nutrient Needs:

There are a few key nutrients that endurance athletes are often lacking, especially marathon runners.  Two of these nutrients are the minerals, iron and calcium.

Iron deficiency is very common in marathon runners and has been reported to be as frequent as 17% in males and up to 50% in females.  Iron is necessary to transport oxygen to the cells, which is vital to optimal training and racing.  Runners have increased iron losses through sweat, urine, the GI tract, haemolysis (foot strike and muscle contraction), and blood loss associated with injury. To exacerbate the situation, marathoners often practice more restrictive eating patterns combined with decreased absorption can leave runners iron deficient.  It is imperative to eat an iron rich diet and/or to supplement iron if you have been diagnosed with anemia or are in a high risk group for the development of iron deficiency.  Supplements are better absorbed when taken with iron rich foods which include beef liver, soybeans, clams, spinach, mussels, pork, eggs, sweet potatoes, enriched bread and grains, dried apricots, figs, and raisins.  Females are at higher risk of anemia secondary to monthly menses, but males can also become iron deficient as well.  Symptoms of anemia include pale gums, pale skin, lower than normal energy despite adequate rest, and restless leg syndrome.

Another key nutrient to monitor is calcium.  Calcium deficiency is a leading cause of stress fractures.  According to Orthopedics Today, the prevalence of stress fractures ranges from 2-20% in endurance athletes.   Calcium deficiency can manifest itself with muscle spasms, numbness in the extremities, depression, weak brittle nails, and those stop you in your tracks stress fractures.  Bone density is further complicated and dependent on your diet as a child and during adolescence.  Kids with poor calcium intakes are more likely to have chronic issues with stress fractures later in life.  Further, drinking soda, which are rich in phosphoric acid complicates this issue by competing with calcium for absorption.  When training for a marathon,  it is vital to ensure adequate calcium intake from food or supplements.  This can be ingested by consuming 2-3 servings of milk or Greek yogurt per day, or by taking supplements such as chocolate calcium chews or antacids. Also, of note, iron and calcium supplements should be taken at opposite times of the day to maximize absorption of both supplements.

Gastrointestinal Distress:
If you have ever visited a "port a potty" at a marathon, you already know that there is LOT of GI distress occurring!  As a dietitian, and formidable expert on the subject, you would think this problem would have never occurred to me...but it did.  I was working toward my third marathon at the time, the New Orleans marathon occurring in February before Mardi Gras.  Two of my friends were kind enough to travel with me.  Dolly and Jolly (their running names are a whole different story) had signed up for the half marathon and the 10 K respectively.  Jolly, the 10 K runner, had grown up visiting New Orleans and had spent much time.  As a first timer to the "Big Easy", Jolly assured me that she was going to show me a proper fun time.  While planning our trip, she suggested taking a real "Chef taught-New Orleans cooking class".  Although I am not much of a culinary master, I thought it sounded fun and would definitely add some authenticity to our trip.  I told her to pick out the chef and that I would get it booked. This chef, I believe if memory serves me correct, was name Chef Bond and was located across the river in Algiers in his house.  The brochure had stated that Chef Bond would meet us at the ferry, but we soon realized that was not the case.  After entering the address into the navigation, we walked through neighborhood streets through the brightly colored homes that were in close proximity to each other until we stumbled upon a older large man in a white chef's smock smoking a cigarette on his front porch.  We confirmed his name and we were somewhat surprised when he asked, "How did you find me?", as if he had hoped that wouldn't.  He announced that he wasn't "quite ready' for us and that we could sit on the porch with him.  Jolly, however said that she needed to use the bathroom and I quickly followed her in the house.  In traditional architectural design of the neighborhood, the house all had a front porch, with a front door that opened directly into the living room, from which the kitchen could easily be seen.  To the back of the kitchen were 2 doors, which were both closed.  Jolly and I each picked a door and opened them.  My door to the back end of the house was the bedroom.  It was a horrific dim lit mess with a bare mattress on the floor and clothing scattered everywhere.  I quickly closed the door.  Jolly had found the one and only bathroom for the home which was also untidy, but a bit better than the bedroom.

After our visit to the bathroom, we made our way to the kitchen, where a young woman was busy attending to pots and pans.  There was a small refrigerator with a see through door like you might expect in a convenience store holding some vegetables and butter.  We sat at a large table/work island.  As we waited, we noticed several prescription bottles around the kitchen, which were also intriguing (Jolly, also happens to be a doctor).  After noticing our gaze on the bottles, the woman began to explain that she had just been released from the hospital with a urinary tract infection two days prior,  At this point, we should have probably left, as she was in charge of cleaning and helping to prep.  But we had already paid for the class, which ended up just being the two of us (another sign that we should have left).  As we began preparing our first dish, "Shrimp Cocktail with Remoulade Sauce", it became evident that Chef Bond wasn't a fan of mine.  I wasn't mixing or folding properly, and as we moved to the next course, I was told to chop what seem like 2 pounds of parsley. After 5 minutes of intense chopping, I asked if I was done.  He replied, "Keep chopping Princess".

After each progressive course of rich seafood, he would ask me in a insulted tone why I wasn't finishing my food.  I tried to explain that I was running a marathon in less than 36 hours, although that wasn't the only reason for my limited appetite.  The sanitation in the kitchen area (and really the whole house) had been way less than optimal, but I was trying my best to "go with it" and not be so picky, as many of my friends will use that term to characterize me.  However, when the woman with the raging urinary tract infection came out of the bedroom holding a full red snapper, I realized that the sanitation situation had hit another level.  Although I helped prepare the dish, I did not eat the "bedroom snapper".  My friend Jolly did, likely because she is way more adventurous and more polite than me.  We rounded out the evening with some crab cakes and were on our way.  We laughed as we boarded the ferry back across the river and thought we had heard the last from Chef Bond....

Little did we know that less than 36 hours later, Chef Bond would come calling.  Jolly, Dolly, and I were to meet in the hotel Lobby at 6 am to head to our respective starting places.  Jolly was late.  We called her and she said that she was experiencing severe GI distress from Chef Bond.  I remember thinking how smart I had been to only eat small portions while were there and was grateful that I had been spared.  Jolly finally emerged and we lined up at our starting points.  The race began and I was very excited to get to see the Crescent City on foot.  At the beginning of the race, my route headed down the beautiful St. Charles Avenue.  I was enjoying the beautiful view of the historic homes and the crowds cheering us on when the GI distress hit.  I was on mile 3.  There were no "portable pottys" or "honey buckets" around.  I could imagine the residents, who were sitting out on their meticulous front porches, signing petitions to keep such vile toilets out of their beautiful neighborhood.  I searched with my eyes on both sides to the street, frantically looking for any sign of a toilet.  The pain was getting worse and I knew there was no way I could go on for 23 more miles.  Finally, the route had a hairpin turn in which we came back down St. Charles.  At the turn, there was a park with a playground.  I also noticed there were picnic tables, and a building adjacent to it, which I could hope was a bathroom.  I ran off course, through the park and opened the first door that I came to.  I could see a wide opened door with a toilet waiting.  I ran to the stall like a long lost friend.  As I passed through the corridor of the bathroom, I heard a man's voice yell and me to say that I was in the MEN's ROOM...unfortunately, I was already committed and the Chef Bond experience was about to meets it's final destination.  I left the Men's Room, much relieved and horrified the same.  But I learned a valuable lesson, one that I already knew.  That is DON'T EAT UNSUAL FOOD BEFORE A MARATHON.

Preventing GI DISTRESS

With that being said, common foods that can cause gastrointestinal distress include large servings of fruit and vegetables (extra fiber), greasy meats (burgers, sausages, cheesy dishes), fruit juices, caffeine containing products (such as excessive coffee), and some of the products marketed to endurance athletes like gels, bars, and gu like products.  It is important to note, that some people can eat all of these foods/products with no problem, while others can have significant issues.  Fiber, caffeine, and sugars cause differences in the peristalsis (or the movement in the GI tract) and changes in the osmolality in the gut, causing water to flush the large intestine which can trigger diarrhea.  Add a case of nerves to the mix and disaster can be around the corner.  The important thing to remember is to train like you are going to race.  If you have never tried a sports gel, race day is not the day to experiment.  And certainly, do not go to a New Orleans Cooking Class before a marathon!

Nutrition Adequacy:

Having a nutrient dense diet is important during normal circumstances, but it is imperative during marathon training.  Making sure that you are consuming a nutrient dense, varied foods from all of the food groups is imperative to perform and feel great while you are running.  As a general rule, choose fresh fruit and vegetables, while limiting package, processed foods, including fast foods and restaurant prepared meals.  Marathon running is not the time for restrictive eating or eliminating food groups.

Run to Eat or Eat to Run?

I often am asked by aspiring marathoners, if marathon runners can eat whatever they want.  Your diet should be inclusive of all foods, even a treat from time to time, but not running six miles and eating a whole pizza.  The calories simply do not equate.  I like to use the example of the Chocolate Molten Cake from Chili's.  This dessert contains 1170 calories.  That is equivalent to running 11+ miles, crossing the finish line and eating the cake!  Most people would agree that the effort to run 11 miles is far more than the Chocolate Molten Cake is worth.  It's very important to keep energy balance in check.  In addition, it is also normal for appetite to increase as the miles do.  Fill your body up with those vitamin and mineral rich foods, not the empty calorie, high fat sweets and desserts.  Your running will improve and so will your body composition.  No one sets out to gain body fat and/or weight when training for a marathon!

In addition, keeping a food diary can help you identify your pitfalls (excessive nocturnal eating), empty calorie snacking, etc..

Training and eating for a marathon requires some diligence, discipline, and consistency, but it can be one of the most fulfilling experiences imaginable.  With proper nutrition, marathon running can be enhanced and enjoyed.  Happy trails and healthy meals!  Hope to see you on the road!

LG

A special thanks to the Longview Loopers for inviting me to speak at their Saturday morning post run breakfast!

Bad to the Bone! Are you at risk for Calcium and Vitamin D Deficiency?

"I wish I knew now what I didn't know then."  These words have never rang more true to me.  A couple of months ago, I was in the midst of training for my fourth marathon (and before I go on, for my non running friends, all marathons are 26.2 miles, but no two marathons are alike.  The course vary, as does the weather, the runners energy level, and so on).  Typically, a runner trains for about 4 months in order to prepare for a full marathon.  I was about half way through this process.  I had been running aggressively with some extremely fast and decorated runners (you know who you are), and my goal was to get my marathon time down on order to possibly, maybe qualify for the Boston Marathon, which is the pinnacle for most runners.  I was on course for my goal, running hills, pace runs, pick ups, and long runs. I was up to the 18 mile point and had a successful long run despite the late heat and humidity in the fall, and the fact that I was getting less sleep than needed because my son was  playing his final senior season of football.  During that 18 mile run, I noticed that I had a pain in the back of my leg almost behind my Achilles tendon, maybe a bit higher.  I went home and started the RICE method (Rest, Ice, Compression, and Elevation), thinking that it must be Achilles tendonitis, which isn't uncommon in marathon runners.  I rested all of Saturday and Sunday (meaning that I didn't work out except for yoga) and returned to my training on Monday with a 7 mile run.  By Wednesday, my leg was highly aggravated and it hurt to walk.  So I took Thursday and Friday off and attempted to run my Saturday long run.  I made it a mile before I was in excruciating pain.  I had to turn around and hobble back to my car.  Disappointed and dismayed, I knew it was time to see the doctor.

Long story short, I found out that I had developed a stress fracture in my tibia, one of the larger bones in the lower leg.  This would be my second stress fracture in two years (the first was in my femur, the long bone in the thigh area) which I was diagnosed with after my second marathon.  What is significant about these fractures is that they were both in substantial bones that are atypical of stress fractures; smaller bones are much more susceptible to small stress fractures.  Besides learning that my goal of completing the marathon I had been training for was over, I also learned that I had a condition called osteopenia.  Osteopenia is diagnosed with a bone density test and is absolutely the least invasive medical test that I have ever experienced.  Osteopenia occurs when calcium has leached out of the bone or possibly there was never an adequate supply ther in the first place.  Calcium is best absorbed during childhood and adolescence when the bone is still growing and calcium absorption is at it's highest.

Unfortunately, I was not a registered dietitian (Or even a healthy eater) during my adolescence years and I replaced milk at school lunch early on with sodas possibly contributing to my osteopenia.  Sodas (it doesn't matter which ones) have an additive called phosphoric acid, which helps to maintain the "fizz" of the soda.  Phosphorus is an important mineral in the diet and needed for multitudes of biochemical pathways in the body, however, because of food additives found in sodas and even packaged bakery products, it is easy to consume more phosphorus than calcium consumed (Other food sources of phosphorus include edamame, mushrooms, potatoes, rice, cereals, milk, meats, beans, and eggs).  Ideally, calcium and phosphorus would be consumed at a 1:1 ratio.  It is estimated that the average American consumes a calcium to phosphorus more like 1:3 because of the vast variety of foods naturally containing phosphorus and the addition of phosphoric acid in processed foods to maintain extended freshness.  This unbalanced ratio creates an undesirable absorption scenario where less calcium is absorbed.  In addition, calcium is found in a lesser variety of foods, such as milk, yogurt, cottage cheese, salmon, and almonds.  As a teen, I did not drink milk, eat yogurt, cottage cheese, and rarely ate salmon, nor did I supplement calcium.

Bone growth is extremely interesting.  During adolescence, calcium is absorbed in the bone like a water into a dry sponge, but sometime in late teens to early 20s, that sponge becomes resistant to absorbing calcium and continues to decrease.  Complicating matters even more for females is pregnancy and lactation.  Calcium intake during pregnancy is vital for both mom and baby.  If mom is not consuming adequate dietary calcium, the calcium will be leached from mom's bones and teeth.  Prenatal vitamins generally contain 100% RDI for iron and minimal calcium.  This is because iron deficiency is the most prevalent acute deficiency during gestation.  Calcium is not added at the full RDI because it will inhibit the iron absorption.  The best alternative is to take the prenatal vitamin (or if you are not pregnant and take a multivitamin/multi-mineral supplement) at one end of the day and a calcium supplement at the opposite.  For example, I eat dairy products more often at breakfast, so I would take the calcium supplement in the morning and the iron containing supplement at bedtime to reduce and chance of interaction.

Vitamin D is also an important part of the equation to bone health.  Vitamin D controls calcium content in the blood, bones, and urine.  As an East Texan, I like to relate Calcium and Vitamin D to a pasture full of cattle.  Let's pretend that you were given 100 acres of land with 100 cows included , but no fence.  Would you expect the cows to remain on your 100 hundred acres?  Of course not.  The fence is needed to keep the cows in and to also deter others from freely stealing the cows off of the land.  In this made up scenario, the cows are representative of the calcium that should be stored in the bone and fence represents Vitamin D.  In this example, it would not matter how many cows were continually replaced, it would be an endless loss.  This is what happens when adequate calcium is either consumed from food or supplement, without adequate Vitamin D.

Vitamin D is even more elusive in foods than calcium.  Nutrition experts once thought Vitamin D deficiency was rare, however, current research has reveled that more than 3 million cases of Vitamin D deficiency is diagnosed each year, dramatically increasing in adolescence throughout the lifespan.  Although Vitamin D can be produced in the skin with exposure to sunlight, desk jobs, computerization, sunscreen, and limited exposure to outdoors have contributed to low Vitamin D levels. It is only found in fortified foods and beverages (fortified means it is added to a product and that it is not naturally found there).   The most common foods that are fortified with Vitamin D are generally dairy foods, which is both good and bad news.  The good news is that calcium and Vitamin D are found in the same foods.  The bad news is that calcium and Vitamin D are found in the same foods; therefore, if milk or dairy products are not consumed or tolerated, then potential deficiencies of calcium and vitamin D are likely to coexist, unless supplemented.  Vitamin D and calcium can be supplemented easily with traditional dietary supplements or newer versions, such as Viactiv calcium chews fortified with Vitamin D.  The Viactiv chews are often preferred to traditional supplements, as the chocolate or caramel chew is more palatable and delivers the same dose contained in the more traditional supplements.

Since being diagnosed with osteopenia, I have become more aware of my calcium and Vitamin D intake.  I currently eat a wide variety of foods, including yogurt, cottage cheese, and almonds.  In addition, I do supplement with calcium and Vitamin D, as recommended by my doctor after having serum levels checked.  Also, I am limiting my intake of foods and beverages containing phosphoric acid, including processed foods and sodas.  In addition, it is important to partake in strength training (weight lifting and/or using one's own body weight) to strengthen the bones and supporting muscles. 

I have had lots of well meaning non-running friends advise me to quit running, pointing out that running caused my stress fracture.  The fact is, however, challenging my running intensity and duration was not the only cause the stress fracture.  My stress fracture was actually predicated by my poor diet during those vulnerable years and would have eventually happened with or without the running.  I actually think by having the stress fracture, and then being diagnosed with osteopenia early may be a blessing as I became aware of a problem and now I can earnestly work to improve my bone health before it become osteoporotic.  I am currently back on the road, running slower, but more appreciative of every mile.  I can't wait for my next marathon!

Full disclosure:  Leslie Goudarzi is not affiliated with any product mentioned and does not receive any monetary benefit from such products.

Intermittent Fasting: Hype or Hoax?

Recently, I have had several of my clients and patients ask me about "Intermittent Fasting".  It seems to be popular in many dieting circles.  Hopefully, this blog post can answer some of you questions as well.

Intermittent fasting is one of the hottest topics among avid dieters at the "moment".  Intermittent fasting has been around for centuries, primarily practiced in various religions.  It wasn't until the early 1900's that some health benefits were observed among diabetic, obese, and epileptic patients (see previous post on Ketogenic Diets).  Basically, intermittent fasting  is a large term that encompasses an eating behavior where an individual eats very little on some days followed by "cheat" or "feast" days or very liberalized eating.  The question that I get the most is "Does this work?", meaning will I lose weight with this type of eating pattern.

As with all such questions, I like to examine the scientific literature on the subject.  A study published this May in the Journal of the American Medical Association: Internal Medicine examined if intermittent fasting was actually more effective in achieving weight loss than the traditional method of daily calorie restriction. 

Here is the recap:

100 study participants (86 women and 14 men) that were classified as obese (but without metabolic complications like Type 2 Diabetes or metabolic syndrome) were separated into 3 groups: those that were put on an "alternate day fast", (meaning that the participants rotated a day on and off of the fast and the feast days), those that followed a daily calorie restricted diet, and those that received no intervention (the followed their 'normal' diet).  The study lasted for a year and was divided into two 6 month phases.  The first phase emphasized weight loss while the second 6 months emphasized weight maintenance.  It is worth noting that the lead author of the study write a book advocating intermittent fasting.

Both the alternate fasting and the calorie restricted groups lost similar amounts of weight (6 % and 5.3% weight loss respectively).  There was slightly more dropouts in the alternate day fasting group than the calorie restricted group (13 versus 10 dropouts respectively).  The dropout rate is an important factor to consider, as it may be indicative that a plan was difficult to follow or simple produced poor adherence.

In the study, intermittent dieting was defined as consuming 25% of caloric needs on fasting days and 125% of calories on "feast" days.  The calorie restriction meant that the participants were allowed to consume 75% of estimated energy/calorie needs.  Mathematically, both groups consumed on average of 75% of estimated energy needs (meaning they ate 25% less calories than needed daily).

Although the weight loss percentages were very similar, the alternate day diet group had a increase in LDL cholesterol (the bad cholesterol) that the daily caloric restricted die group did not.  This may be indicative that it may not be the best choice for individuals at elevated risk for cardiovascular disease (increased LDL is a risk factor for the development of heart disease).  Remember, heart disease is the number one killer in America.  On in three Americans will die as a result of cardiovascular related conditions.

Other reasons that are concerning to me about the intermittent fasting group is the lack of behavioral change it requires.  In my practice, I have found that many of my clients have unhealthy relationships with food including general overeating with periods of starvation and binge eating. I think that the intermittent day fasting may actually enhance these negative interactions with food and does nothing to help change those behaviors.  Although the data suggests both groups had similar weight outcomes, having a healthy relationship with food psychologically is just as important.

Principles of moderation, including portion control, are important in developing healthy eating habits.  I think this can be best supported with consistent behavior as opposed to being on a varying daily calorie levels.

In addition, the sample size of 100 people is also small and more research should be conducted before coming to any "scientific" conclusion.  However, as a registered dietitian with over 20 years of experience, I would strongly caution in applying any one study with limited participants into one's own lifestyle.

The bottom line:  Don't look for an easy fix-it is simply not there.  Weight management is a highly complex problem that must be addressed in a multifaceted manner by trained professionals in obesity management and nutrition.  Enjoy food in moderation and practice calorie control, while enjoying a healthy dose of exercise.  Stay healthy and EAT RIGHT!

What About the Ketogenic Diet?

They say everything old is new again.  That is certainly true for the Ketogenic Diet. This high fat, adequate protein, extremely low carbohydrate diet, along with calorie restriction, was first developed in the 1920's at John Hopkins University to control seizures in pediatric patients.  Patients with epilepsy and seizure disorder would be admitted to the hospital for medical management of their acute seizure activity.  In the 1920's, there were few medications to control or subdue seizure activity.  Often, it became a waiting game of rest and observation.  Physicians and dietitians began to observe that once patients were admitted and were kept NPO (nothing to eat or drink to decrease risk of aspiration should another seizure occur), that the seizure activity greatly decreased or completely stopped, only to return once food intake was advanced. This phenomenon was hypothesized to be a result of the metabolic process known as ketosis and its relationship to the neurological anomalies causing the seizure.  Ketosis itself is the metabolic pathway used when fat is broken down  for energy as a result of inadequate carbohydrate intake.  However, it can be dangerous to be in ketosis for long periods of time due to potential acid-base imbalances and decreased growth in children, not to mention poor palpability and limited selection of foods; and therefore should only be initiated by a trained Neurologist and Registered Dietitian in ketogenic diets.  In the early years, kids on the ketogenic diet had difficulty (more than now) in maintaining/gaining weight and following growth parameters similar to peers of their age and gender.

My Personal Experience with Ketogenic Diets

When I worked at University Medical Center in Lubbock, I acted as the inpatient dietitian for the initiation of the Ketogenic Diet with Dr. Daniel Hurst, Pediatric Neurologist at Texas Tech Health Sciences Center.  Patients were carefully screened based on medical necessity (patients continuing to have many "breakthrough" seizures despite pharmaceutical management, experiencing developmental delays due to the side effects of the medication), anticipated compliance (parents MUST have the ability to say "NO" and mean it), and the overall  intellectual, social, and emotional ability of the family to adhere to the diet. For example, the child would not be allowed to have Halloween candy (not even one piece) or birthday cake.  For some parents, the emotional aspects of these choices were deal breakers.

The actual diet itself is very simple, but the devil is the details.  It meets the RDA for protein (but no more), a minimal amount of carbohydrate (the carbs in medications and even toothpaste must be accounted for), and the remainder of the calorie needs are met with fat.  At the strictest form, (during initiation), the patient would be kept NPO until they were positive for the appropriate amount of urine ketones (generally 2 days), on day 3 the diet would be initiated at 1/3 strength, and advanced daily until full strength.  The inpatient process generally lasted 5 days.  As the dietitian working with these children and their families, I would educate the families in addition to calculating every single calorie provided from food, medication, and yes, toothpaste.  I even personally measured (on a gram scale) and prepared each meal, as any slight deviation could cause the child to be out of ketosis and the whole hospitalization would have to be repeated, potentially costing thousands of dollars.  After successful initiation, the patient was then followed by the neurologist and the trained outpatient dietitian.   One of the most satisfying and rewarding moments that I have had professionally was observing a 3 year old little girl in which I had initiated the ketogenic diet.  When I first met her, she was extremely developmentally delayed due to her severe seizure disorder, having more that 30 seizures each day.  Between the seizures and medications, her little brain just didn't have the time to grasp the world around her, delaying her speech and gross motor development.  A year later, I saw the little girl who was now having seizures very rarely, walking and talking and had been able to greatly decrease her seizure medication regimen.  For me to date, that is one of the most amazing diet interventions that I have observed.

BUT... What about me?  I don't have a seizure disorder.. I just want to lose some weight...
As I stated before, the ketogenic diet is simple in the ratio...however, the implementation may have some downfalls, particularly if you don't have a medical reason to be so motivated (like eliminating seizures).  The diet allows very little carbohydrate.  This doesn't mean that carbohydrates are bad, it just means that they are limited on this particular diet.  The body (and taste buds) prefers carbohydrate, making it difficult for some adults to go "all in".  Let's say that someone goes on the ketogenic diet for 5 days, but then eats a slice of bread, 1/3 cup of pasta, or a serving of fruit, the biochemical pathway will revert out of ketosis, and would need to be re-initiated to obtain the result.  This process can be very taxing for the body and professionally I do not recommend "going in and out" of ketosis on a regular, planned basis.  Many individuals complain of some bothersome side effect during initiation and duration of the diet including headache, lack of energy, moodiness (usually "bad" moodiness), and discontent due to the limited selection of "allowed" foods. 

In 2009, the New England Journal of Medicine published a study by FM Sacks, "Weight Reducing Diets: Comparison of Weight Loss Diets with Different Macronutrient Compositions", which had several interesting findings. The purpose of the study was to compare 4 diets of differing macronutrient composition after 2 years.  The study had 811 participants that met the criteria for overweight or obese.  The participants were randomly assigned to a diet varying in carbohydrate, protein, and fat composition, but all diets created a 750 calorie deficit a day (regardless of the composition).  They all had to participate in 90 minutes of exercise per week as well.  Interestingly, all participants lost similar amounts of weight despite the macronutrient composition, indicating that the diet that works the best is the one your follow!  Behavior factors (attendance, contact, commitment, and engagement were more important than macronutrient metabolism as influencing weight loss.

BOTTOM LINE:

With reference to weight management, if you like breads and grains more than bacon and heavy cream, then follow a diet with a higher carbohydrate content.  The key is reducing the amount of total calories consumed and compliance to making behavior related changes.  On a health note, high fat diets have been associated with heart disease and increased cardiovascular risk.  Cardiac disease remains the number 1 killer of both men and women in the United States.

Thank you Alyssa Simpson for your question on Facebook.

Are You having a "Crappy" Day? Everything You NEVER Wanted to Know About Diarrhea

In my last post, I discussed ways to alleviate constipation.  So it only makes sense to follow up with a post on it's evil twin diarrhea, or CODE BROWN, as I like to call it.  (In hospital training, we learn that that there is a "code" for every almost every situation; CODE RED for fire, Code BLUE for respiratory arrest, etc...so it is only logical that when a patient has a massive amount of stool output, that should be a worthy of "CODE BROWN" status too-although hospitals don't really recognize that is a legitimate "code).

It seems when it comes to bowel movements, people find themselves in the "Goldilocks Phenomenon", where the bowel movement is either too hard (aka constipation) or it is too loose (aka diarrhea. 

Before looking at some of the common causes of diarrhea. it is important to review how the "Poop" factory works.  The gastrointestinal tract (GI tract) includes everything from the mouth to the anus.  Most of the food we eat (95%) is digested and absorbed by the time it leaves the small intestine.  What remains of the food once it has been digested and absorbed will continue traveling to the colon or the large intestine (these terms are used interchangeably). 

There are three important processes that occur in the large intestine:  1) the absorption of water (to help make the stool a nice, neat, brown package), 2) the absorptions of minerals and 3) the fermentation of fiber.  The colon is very specific to it's job description and really doesn't like when any other job is added.  In fact, when other constituents show up, the colon usually expresses it's unhappiness with the onset of "Code BROWN".

SO WHAT CAUSES CODE BROWN?

Diarrhea can have lots of contributing factors.  Therefore it is important to examine some of the most common culprits (when viruses or gastrointestinal illness have been ruled out).

One factor can be medications, including antibiotics. Antibiotics are useful to treat infectious diseases/conditions in the body, but also disrupt the "good" bacteria that is found in the intestines that helps to digest food and provides anti inflammatory properties. Individuals that are on prolonged antibiotic therapy (commonly seen in patients with Staphylococcal infections can be especially at risk for such issues, even allowing for opportunistic "bad" bacteria, like C. difficile to invade the intestine, resulting in the "Mother of Code Brown" situations.

Other medications that  contain sorbitol (a sugar alcohol the increases the osmolality of the intestines and causes excessive water to be shifted into the intestines) can cause diarrhea.  When possible, it helps to take medications not suspended in sorbitol.  Some sugar free gums can also provide a significant amount of sorbitol (for an avid gum chewer) and may also contribute to unwanted bowel behavior.

A contributing dietary factor to chronic diarrhea in some individuals is the sugar found in milk and milk products known as lactose.  In normal functioning GI tract, lactose is broken down by the enzyme lactase into glucose and galactose in the small intestine and then metabolized and used for energy.  Unfortunately, some people do not have the enzyme lactase (or have inadequate amounts of the enzyme) to break down lactose in the small intestine.  As mentioned earlier, the large intestine has the three major functions (absorb water, absorb minerals, and ferment fibers); note that there is nothing on the list about breaking down lactose.  When lactose reaches the large intestine, there is no system in place to digest or absorb it.  Therefore, the colon does what it can to rid itself of the lactose-it solicits as much water into the colon to flush the lactose out, causing gas, abdominal pain, and loose, watery stools.  Many times, lactose/milk intolerance is self diagnosed when adverse symptoms consistently occur after milk intake, and the food is completely avoided.  Avoidance of any food group can lead to nutrient imbalances and deficiencies.  There are many alternatives to regular lactose-containing cow's milk, such as Lactaid Milk (where the lactose is already broken down into galactose and glucose) or lactase enzymes are taken concurrently when consuming milk/milk products.

Occasionally, individuals may go from a highly refined diet to a diet that is high in fiber over a very short time, decreasing gastrointestinal transit time,  resulting in diarrhea.  Therefore, it is very important to increase fiber intake slowly in order to allow the gastrointestinal tract to adapt to the increased fiber intake.

WHAT TO DO IF THERE IS TOO MUCH NUMBER 2?

Regardless of the cause of diarrhea (including viruses and GI illness), the colon generally has something that need to "get rid of".  I imagine Ray Charles in the colon playing "Hit the Road Jack" as the bouncer swiftly escorts the offending agent out of the large intestine. 

Generally, slowing the process down with anti-motility agents only prolongs the time of gastrointestinal discomfort and a "crappy day".  Remember, there is an offending agent in colon. One of the most effective nutritional management strategies of diarrhea includes consuming more soluble forms of fiber.  I like to think of these as the types of fiber that visually absorb water.  For example, if  a bowl of cherrios and milk was left out all day (perhaps in the sink), the cherrios absorb a great deal of the milk and increase in size and reduce the fluid in the bowl.  Soluble fibers acts in a similar fashion when the colon has a high volume of watery stool.  The soluble fiber will soak up the watery stool, adding bulk to the stool, and slowing down the transit time, so that it may be excreted in a nice, neat, solid brown package.  Foods that are generally well tolerated and help resolve diarrhea, include breads, cereals, apples (not the skins), bananas, and rice.  It is also most important to drink lots of fluids when diarrhea is present to prevent and/or treat dehydration.

Have a HAPPY, not CRAPPY Day! @eatrightleslie