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

Constipation-Is Number 2 your Number 1 Problem?

Let's face it-No one likes to talk about excretion patterns (or lack there of), especially constipation. As a dietitian, I have the "opportunity" to talk about poop, "Code Brown", or Number 2 often.  After all what goes in, must come out!  Unfortunately, constipation is a BIG problem in America, due to many factors, such as eating the "typical" American diet (low in fruits and vegetables), lack of physical activity, and lack of adequate fluid intake.   Constipation refers to inconsistent, infrequent, or hard to pass stool.  Other symptoms can include abdominal pain, bloating, and the feeling of that there is unpassed stool in the rectum. 

Chronic constipation can be problematic and be a real pain in the backside (literally).   It can result in hemorrhoids, anal fissure, fecal impaction, and even increased risk for colon cancer.

How often should I go Number 2?

Experts agree that there is a wide variance in "normal" bowel patterns.  Typically, normal frequency is considered from 2-3 times per week to 3-4 times per week in adults.  (Please note, individuals that have had bowel surgeries, gastric bypass, etc... will experience vastly different excretion patterns in most cases from their pre-surgery habits).  The most important thing to monitor is what is normal for you.  If you normally go Number 2 daily,  and then you notice that your bathroom time has decreased to 3 times per week, that would definitely indicate a change in normal bowel habits.

What can I do If I am constipated?

There a three things that I recommend to regulate your Number Two!

1) Make sure that you are eating plenty of fiber.  The recommended amount of fiber is 25-30 grams of fiber per day.  Fiber content is listed on our food labels of packaged foods under the "Carbohydrate" heading.  Some packaged foods, such as fiber rich cereal, bars, and canned legumes can actually have a significant amount of fiber.  Whole fruits and vegetables (with the skin) are rich sources of fiber.  Dried beans and peas are also excellent sources, with a 1/2 cup of beans containing 6-8 grams of fiber. 

A Word of Caution about Fiber:

If you have not been consuming much fiber, (let's say 10 grams per day), and suddenly increase your intake (to 30 grams the next day), then you are very likely to experience some not so pleasant side effects such as gas, foul smelling flatulence, loose stools, or as I like to call it, "Code Brown".  Instead, if you recognize that you need to increase your daily fiber intake, proceed slowly, adding 2-3 grams per day, to avoid the nasty side effects.

2) If you increase your fiber intake, then it is very important to increase your fluids.  I like to use the swimming pool slide analogy.  When I was a little girl, I used to go to a public swimming pool that had a small slide with two water spickets that were supposed to wet the slide.  However, the slide was old and the water spickets did not adequately wet the slide.  I would climb to the top of the slide, and about half way down, I would hit the dry area of the slide and literally get stuck midway on the slide.  This is exactly what happens in the bowel when someone eats a lot of fiber, without consuming adequate fluid.  The stool sticks in the bowel, resulting in abdominal pain and distention, which can be quite uncomfortable.

3) Make sure that you are being active.  This means that you are moving around throughout the day, engaging in physical activity, and reducing the time spent sitting.  The movement in the gastrointestinal tract, known as peristalsis, is more active when the whole body is active.  This is why physicians encourage their patients to sit up in bed as soon as possible, followed by getting to a chair, and then to walking the halls.  The movement facilitates peristalsis, increased blood flow, and reduced risk of constipation.

The Ounce of Prevention is Worth the Pound of Cure!

Number 2 can be managed by remembering 3 things:  Fiber, Fluid, and Activity! 

The Almond (Math) Problem

Recently, I was visiting with a client regarding her food diary.  Although my client had been keeping a food diary, it was incomplete, lacking serving sizes and macronutrient information.  As we began discussing her record keeping, I noticed that she had recorded "almonds" several times per day, over the course of the week in question.  I asked her to tell me exactly how many almonds was in each serving on her food record.  Her response was something like, "I'm not exactly sure, but probably a handful each time" (which was occurring 4-6 times day). 

So what is the BIG deal about eating almonds?  The package even says that they are "smart eating" and an "irresistible snack", and they are also whole and natural.  The package also highlights that they have no cholesterol, they are a good source of fiber, and contain no artificial ingredients.  It is true that most of the fatty acid content of almonds comes from monounsaturated fatty acids (~61% of the fat content) and polyunsaturated fatty acids (~25% of the fat content).  These are considered to be the "good" fats as compared to saturated fatty acids which are more prevalent in high fat animal products, such as whole milk, standard beef products, and chicken with skin.  These buzz words had been a selling point on her choice of "snack".

After some "investigating", it was clear that my client was eating more than the serving size of almond that we had discussed in her nutrition counseling session.  (Please note that portion sizes and serving sizes are inconsistent depending on which entity is being used).  For example, I had provided my client with serving sizes based on the Exchange System, developed by the American Diabetes Association and the Academy of Nutrition and Dietetics, which classifies foods into groups based solely on their calorie content.  In the Exchange System, 6 almonds is a serving of fat and contains 45 calories per serving.  On the label of her bag of almonds, a serving was defined as 24 nuts and contains 160 calories per serving.  Although my client could not exactly tell me how many almonds she was consuming per day, she could tell me that she was consuming one 12 ounce bag every week, as she was having to re-purchase them routinely in her weekly trip to the store. (This is the small bag up from the canister, but not the largest bag generally found at most grocery stores).

Here comes the "almond (math) problem"....If I look at the label on the almonds she is purchasing, it indicates that there are 12 servings in a bag, each containing 160 calories, with 130 calories derived from fat.  If she eats the entire bag in 1 week, the caloric cost of those almonds is 1920 calories per week (or 275 calories per day on average) of primarily fat. 

Based on her past and current behavior, let's pretend that my client eats one 12 ounce bag of almonds every week for the next calendar year.  That would be a total of 99,840 calories from almonds.  Just for the fun, I am going to apply the Wishnotsky (1958) model of 1 pound of fat = 3500 calories (which by the way has been recently deemed mathematically inaccurate and over simplified manner of estimating weight loss, but at risk of putting you sleep with mathematical formulas, I am going to use this method to illustrate my point). 

If my client consumes an extra 99, 840 calories from almonds in a year (from consuming one 12 ounce bag per week), the math would be calculated as follows:

99, 840 calories/year       = ~ 28 pounds expected weight GAIN/year
3500 calories/lb of fat

As I mentioned before, every pound of fat does not contain exactly 3500 calories and multiple regression analysis have shown this to be true, I am using this method to illustrate a point. 

My client certainly does NOT want to gain 28 pounds in a year from almonds.  And as she replied. "There not even that good!  I thought that I was making a healthy choice".  Generally, we think it is the "BIG" things in our diet that are causing our "BIG" butts and bellies, but more often than not, it is the "little" snacks and bites that we enjoy that are the culprits!  As I mentioned previously, almonds are a great source of monounsaturated fats, however, it is most important to watch the serving size and the calories respectively!  Happy Eating!

Iron Deficiency is the MOST Common Deficiency-Are YOU at Risk?

Iron deficiency is the most common deficiency in the United States and world-wide, with approximately 10% of Americans and 30% of the world's population exhibiting iron deficiency anemia.  Although anyone can be diagnosed with iron deficiency, certain populations are at a very high risk.

Heme in blood cells contain iron; and hemoglobin carries oxygen to our cells and helps excrete carbon dioxide.  When hemoglobin levels become decreased, deficiency symptoms began to present.

Symptoms of iron deficiency include fatigue (despite adequate sleep), poor temperature regulation, decreased appetite, and pale skin.  In populations with darker skin tones, clinical paleness can be observed in the gum tissue.  Side effects as a result of iron deficiency anemia include low attention span, difficulty concentrating,and low immune response resulting in opportunistic infections and illness.

1.  Women of Childbearing Age: 

Females that experience menses have increased blood losses each month, making them at higher risk for low serum iron levels, particularly if periods are extremely heavy or long in duration.

2.  Infants, Children, and Adolescents:

The common denominator in infants, children, and adolescent iron deficiency is an expanding blood supply due to high periods of growth.  Infancy is the most rapid period of growth demonstrated from birth to 1 year of age.  Ideally, a term infant should triple their birth weight by their first birthday. As adults, it would be most frightening if our weight tripled in a year!  It is recommended by the American Academy of Pediatrics that infants from 9-12 months be screened for iron deficiency, as it can cause growth and developmental issues, as well as, decreased immune system. Infants at the highest risk are those that are breast fed without the inclusion of iron fortified cereal or good sources of iron from age appropriate foods.

Growth in children continues at a steady rate, and the blood supply increases accordingly.  Children should be monitored to insure iron needs are adequately met.  Like infancy, adolescence represents another period of high growth and expanding blood supply.  In addition, females have the onset of menses, further increasing iron needs.

Interestingly, the USDA school Lunch and Breakfast Programs are in place to minimize iron deficiency in at risk populations.  Adequate iron intake has been shown to improve attention span, concentration, and learning ability.  This is why parents often receive a friendly reminder encouraging breakfast during standardized testing periods and low income school often offer free breakfast to all students.

3.  Pregnancy: 

During pregnancy, women also have another period of rapidly increasing blood supply.  Not only does this increase in blood volume affect the iron status of the expectant mother, it also affects the iron store of the growing fetus.  Babies born with low hemoglobin levels can have low APGAR score and difficulty breathing after birth.  Iron stores are best maintained during pregnancy by choosing a diet rich in iron and vitamin C, in addition to taking prescribed prenatal vitamins.

4.  Athletes:

Iron depletion is a relatively common occurrence among athletes, ranging between 30% and 50%, especially among female athletes and both male and female athletes who participate in endurance sports.  Because female athletes often do not consume proper amounts of dietary iron ( as a result of lower calorie consumption and/or reduction in meat in the diet), coupled with increased iron losses in sweat, gastrointestinal bleeding, muscle stress/trauma, and menstruation, health and optimal performance may be compromised.  Decreased exercise performance is related not only to anemia, and decreased aerobic capacity, but also to tissue iron depletion and diminished exercise endurance.

The Best Foods to Prevent Iron Deficiency:

Iron is found in a variety of foods including:
-Oysters
-Liver
-Lean red meats
-Iron fortified cereals
-Peanuts
-Almonds
-Barley

Consuming vitamin C rich foods in the presence of iron rich foods (particularly meat sources) will help increase the absorption of the iron.  An example of a meal might be to have a steak (great source of heme iron) with broccoli (excellent source of Vitamin C).

Calcium and antacids can reduce iron absorption and should be taken at opposite times to prevent decreased iron absorption.  If iron deficiency persists, iron supplementation should be considered.  Taking supplements with heme or animal sources of iron and vitamin C will also enhance iron absorption.

If you are in a high risk group, you should consider asking your health care provider to check your iron status at your annual exam.  Iron deficiency is easily prevented and treated and can have a great impact on your health, physical performance, and cognitive ability.

Now, go pump some iron!

For more information, please contact Leslie Goudarzi, MS, RD, LD, Wellness Dietitian at the Institute for Healthy Living, at 903-239-1551.