Archive for category: Health & Wellness

A Brief History of fat

Our relationship with fat and dietary cholesterol has just gotten more complicated. Or has it gotten easier? I guess it depends on how you look at it. What we once thought was an absolute truth now no longer seems to be true at all. It was supposedly well known science that dietary fat and cholesterol are dangerous and need to be avoided. We now know, however, that science tells us the opposite. Dietary fat and cholesterol are not inherently unhealthy. How could this be? Let’s take a look at the history of what brought us to this point.

The evidence that convinced nutritional and health experts that dietary fat and cholesterol were dangerous to our health consisted of three main areas.

1- Studies showed that feeding animals very high levels of dietary cholesterol increased plasma cholesterol and vascular plaque. This started back in 1843, when researchers analyzed atherosclerotic plaque and found it to contain cholesterol.(Am J Clin Nutr 1974;27:403-422). After that, studies in the early 1900s showed that rabbits who were fed cholesterol developed more atherosclerosis (Cardiovasc pathology 1999;8:177-178). Then other studies followed in a similar vein. However, it should be pointed out, that rabbits and other herbivores that were tested have never adapted to eating cholesterol in their diet. They have forever been herbivores and their bodies are not evolutionarily adapted to eating cholesterol. In addition, they were given extreme amounts of cholesterol. Therefore, the correlation to humans eating cholesterol and fat in food is questionable at best.

2- Clinical studies in humans showed that increased fat and cholesterol consumption raised total cholesterol levels. Unfortunately, total cholesterol is a poor marker for cardiovascular risk and has very little to do with the fat and cholesterol you eat. Studies that investigated changes in specific lipid subtypes in response to fat intake showed that LDL and HDL increased proportionally, thus keeping the HDL:LDL ratio the same, and likely NOT increasing the risk of cardiovascular disease. More recent studies have confirmed this by showing that dietary cholesterol intake had no effect on cardiovascular risk (biochem biophys acta 200, 1529, 310-320)

3- Epidemiological studies subsequently showed that increased dietary cholesterol and fat intake was associated with an increase in cardiovascular disease. This was the main area of research that captivated the public and experts alike.

Let’s look a little deeper into the epidemiological studies and how they came to influence nutritional guidelines. The big push for the low-fat craze came in the 1950’s when Ancel Keys embarked on his Seven Countries Study, which was essentially his quest to prove that dietary fat and cholesterol led to heart disease. His timing was ideal for having a maximal impact as heart disease was fresh on peoples’ minds. President Dwight Eisenhower had just had a heart attack in 1955, and the rates of heart disease in the US were rapidly rising as the nation’s number one cause of death.

Everyone was primed to find a scapegoat. Society wanted to find the one thing that causes heart disease, eliminate it, and the go back to feeling safe and protected. It is an overly simplistic way of thinking, but at the same time it is part of human nature to want to simplify things into an easily answered question. Dr. Keys believed that the countries that ate cholesterol and fat-containing foods had higher rates of coronary heart disease, and those that ate less had lower rates. Therefore, based on his logic, dietary fat and cholesterol caused heart disease, and suddenly society had their scapegoat. This line of thinking provides absolutely no proof, but that did not stop him from promoting it as such.

In 1968 the AHA recommended that all individuals should limit their dietary cholesterol and fat intake (Dr. Keys was on the board of this committee), and the American Government incorporated the same into the official dietary guidelines in 1977. Acta Cardiol 1999;54:155–158 JAMA 1961;175:389-391. Based on these guidelines, the medical profession preached the dogma that dietary fat and cholesterol were dangerous and by definition, a healthy diet was a low fat, low cholesterol diet. Food companies raced to the market with “healthy” low fat food, and a multi-million dollar food industry was born.

However, the problem lay with the details of Dr. Keys’ study. Most importantly, his study was purely observational. There was no control group, no randomization, and no controlling for variables. Therefore it did nothing to prove causation. It merely pointed out an observed coincidence. In addition, there have been numerous debates about whether he handpicked his countries to fit his hypothesis. It has been suggested that he started with 22 countries and only kept the ones that supported his hypothesis, discarding the rest. In addition, the main example of beneficial effects of low cholesterol intake correlating with low CHD risk was extrapolated from peasants from the Greek Island Crete. These individuals performed hard manual labor for the majority of their lives. Therefore they were much more active then the other populations studied. But he did not control for this variable of increased physical activity and its beneficial effect of reducing the risk of heart disease. In addition, Dr. Keys sampled their dietary patterns during lent. The majority of them were avoiding meat and cheeses, thus underestimating their true average consumption of saturated fat.

All that being said, however, those details matter less since the study as a whole was plain and simply bad science. The study did not prove anything, and it should be considered an interesting finding that required more investigation, not a cause and effect result around which governmental guidelines should be based. The study did not accurately control for other behaviors such as level of physical activity, sugar intake, vegetable intake etc. It is very plausible that the people who ate more saturated fat ate more burgers, so they also ate more French fries, more simple carbs (buns), and were not eating as many vegetables (ketchup was their vegetable), and maybe even had more milkshakes and soda. It is very shortsighted to say with certainty that the fat was the culprit, (thus one of my favorite sayings, “Don’t blame the butter for what the bun did.”). A well-designed scientific study would control for all that, including physical activity, smoking, stress management, etc. Dr. Keys’ study did not, but he stated his results with authority as if it had.

Interestingly, there was a dissenting voice during that time frame that got drowned out by Ancel Keys. A British physiologist, John Yudkin asserted that fat was not the main culprit, but rather sugar was the main cause of CHD and death. Like Keys, his data was observational and not conclusive. His theory, however, was shunned and was not adopted like Keys’. It is fascinating to read reports as to why this may have been. Keys is described as aggressive, charismatic and combative. Yudkin, on the other hand, is described as calm, reserved and quiet. Some, therefore, believe the past 50 years of misguided dietary guidelines all started because of differences in personalities. That may be an over-simplification, but it is a fascinating theory none-the-less.

Although it would be unfair to say our country’s entire low-fat craze came from Ancel Keys, he certainly promoted his hypothesis with enthusiasm and a fervor that gained a tremendous amount of attention. The subsequent national recommendations started an entire industry of “low-fat” food products ranging from cookies and cakes, to meat alternatives and even “Healthy” hydrogenated vegetable oils to replace anything that had dietary fat and cholesterol. The word “fat” became one of the most loaded and charged words in our language. Think about it. Sugar is a term of affection. You can hear the waitress with her southern drawl, “Hey, sugar. What can I get you?” We frequently use “sweet” to mean nice, caring, kind. “She is so sweet.” Fat, on the other hand, is a word you have to whisper for fear someone will hear you. The word fat has become associated with ugly, unpleasant, or even worse, death.

Unfortunately, our dialect and misguided dogma make an implicit assumption that eating fat makes us become fat. If cholesterol and fat are in arterial plaques, then it must get there by eating cholesterol. That way of thinking, however, ignores the fascinating and complex physiology that occurs in our bodies when we ingest food. In fact, it turns out that our bodies convert sugar to fat. This causes us to gain weight and can lead to fatty plaques in our arteries. Sugar increases insulin levels, and insulin is a hormone that causes our bodies to store more fat. Low-fat, higher carbohydrate diets have consistently shown less weight loss than higher fat, low carbohydrate diets. It seems contradictory, but eating fat can actually help us burn fat! As an example, a ketogenic diet, which is up to 80% from fat and less than 20 grams of carbohydrates, is one of the best diets for fat loss. Our bodies preferentially burn fat despite eating a high percentage of calories from fat. After all, from an evolutionary standpoint, we have been eating animal fats for 200,000 years. Grains have only been introduced over the past 10,000 years, and refined sugar (stripped of any fiber or nutritional components) over the past 300 years, a mere blink of the eye in evolutionary terms.

A big question that was not addressed as much during the past 50 years has been what do we eat instead of the fat? Once the government recommended a low-fat and low-cholesterol diet, society as a whole was not as concerned with what we replaced the fats with, so long as we got rid of the fat. Therefore, the high sugar, high fructose, processed foods reigned unchecked and became the new “healthy” staple of the American diet. Eggs for breakfast were replaced by sugar cereals, bagels, muffins and the like. Whole milk was replaced by orange juice and fructose containing drinks. Meat and chicken were replaced by white bread and white flour noodles. Since that time, the incidence of obesity and diabetes has increased dramatically. In 1950, 12% of Americans were obese. In 1980 it increased a little to 15%, and then sky rocketed to 35% by 2000. At the same time, rates heart disease and other chronic illnesses have also continued to climb. Again, this does not prove that the low-fat craze was the cause, but it certainly shows that the low-fat shift did not achieve the intended results of improving our health. At best it failed to make us healthy. At worst, it was the direct cause of an explosion of obesity, diabetes, autoimmune disease, and other chronic diseases.

More than 50 years have passed since the low-fat craze began, and there are still no randomized controlled trials to support the hypothesis that dietary fat and cholesterol increase the risk for heart disease (Am j clin nutr. 2010;91:535-546). In fact, multiple epidemiological studies and meta-analysis have subsequently shown no correlation between dietary cholesterol intake and cardiovascular risk. The American College of Cardiology (ACC) finally reversed their ban on dietary cholesterol in 2014 saying, “There is insufficient evidence to determine whether lowering dietary cholesterol reduces LDL-C” (JACC 2014,63,2960-2984.). In 2015, the American government guidelines followed suit saying, “Available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol.” (http://www.health.gov/dietaryguidelines/science-report) Taking this one step further, new research now suggests much more clearly that John Yudkin had the more plausible hypothesis that sugar is the main culprit leading to obesity, diabetes and CHD. It is fascinating to think how things could have been different if the sugar hypothesis, rather than the fat hypothesis, was adopted in the 1960s.

There remains no doubt that real, from the earth vegetables in a variety of colors should make up the majority of every meal. However, nutritional science has entered a new frontier, and all that was known in the past has to be questioned. When it comes to fat and animal based foods, many of the previous experts and authority figures who followed the conventional dogma have now begun to rethink their positions. Additionally, the rise of social media has given a voice to dissenters and supporters of the low-fat hypothesis alike.

If you choose to not eat animal products based on a moral belief about the treatment of animals, then the science does not matter as much as that is a very personal decision and is a matter of principal. If you choose to not eat animals based on environmental sustainability, that likewise has little to do with the science of how it affects your body. Even here, the science can get murky, but I will stick to what I know best and focus on the effects on our bodies.

There is no high level evidence proving that we should avoid animal based foods. Nutritional science is complicated, with mostly observational and epidemiological studies as opposed to studies showing a causative proof. That being said, however, large meta-analysis of most dietary trials have shown that there is no direct relationship between fat intake and heart disease. Period.

I would suggest, however, that quality matters. One of the problems may be that the quality of our animal based foods have deteriorated as a result of mass production and the associated use of corn feed, antibiotics and hormones. Studies have shown higher nutrient and lower toxin content in grass-fed as opposed to grain-fed meat, wild as opposed to farmed fish, pasture-raised as opposed to pen-raised chicken and hens (Nutr J 2010;9:10; J Nutr, 2005;135(11),2639-2643; Environ Health Prospect 2005;113(5), 552-556). From an evolutionary perspective, our ancestors only ate grass fed meat. They only caught wild fish. They only ate eggs from hens freely grazing grass. Our bodies have evolved over thousands of years to eat this way. If we could get back to those basics, we would take a huge step towards restoring a healthier dietary pattern.

So what can we conclude from the research we have available, good, bad or otherwise?

• Vegetables are the undisputed cornerstone of a healthy diet and should make up the majority of every meal. The debate over whether fats are “good” or “bad” should not overshadow the fact that all research points to the healthy power of fresh (preferably organic) vegetables. That is not synonymous with being vegetarian, but it holds true that veggies are king.
• Dietary cholesterol has been exonerated and no longer needs to be avoided. Eggs are the primary example. Since they are a widely available and affordable source of protein, choline, xanthophylls, vitamin K2, and other vital nutrients, we should now focus on eggs for their health benefits rather than avoiding them.
• Fat is not inherently unhealthy. All fat is not the same, and diets that have shown reduction in heart disease and strokes have had over 40% fat (Lyon heart study and PREDIMED study).
  1. Monounsaturated fats (avocado, nuts, olive oil etc.) are clearly beneficial to our health and help with reduction of chronic diseases.
  2. Trans-Fats (food made with hydrogenated oils like doughnuts, muffins, cookies, crackers etc.) are almost certainly associated with increased risk of CHD and cancer and should be avoided.
  3. Saturated fat is not as evil as initially thought. We may not have convincing evidence for its direct health benefits, but we also do not have any credible evidence for its health detriments. Therefore this one is “neutral,” and more controversial, but we can no longer say with certainty that it needs to be avoided. We can now start to explore its potential benefits and enjoyment.
  4. Polyunsaturated fats (mostly found in cooking oils such as soybean oil, corn oil, sunflower oil etc.) may not be as beneficial as initially thought. Risk of oil oxidation causing systemic inflammation may lead to potential deleterious health effects. Again, the science is mostly observational but certainly suggestive.
• Simple carbohydrates, sugars and processed grains are the most likely foods to cause obesity, diabetes and heart disease, and therefore should be minimized.

Practical tips:

Cooking oils are a vey common way we encounter fats in our diet. There are many choices, and it can be confusing to know which are “healthy” oils and which are less healthy. Here is a quick primer:

You want to pick a cooking oil that has :

• a higher amount of monounsaturated fatty acids (MUFAs)
• a high smoke point (the point at which heat starts to change the structure of the fat and can cause it to oxidize),
• it should be made with minimal processing and not be prone to toxin accumulation.
• Lower Omega 6 to Omega 3 ratio. Simplistically you can think of omega 3 fatty acids as “anti-inflammatory” and omega 6 as “potentially inflammatory.” As with most things, it is more complicated than this, but it still helps to have a convenient way of thinking.

Whatever you choose, choosing organic is best as it avoids GMOs and contaminants. Also, look for oils that are labeled as “cold pressed” or “expeller pressed” as this ensures that the oil retains more nutrients and has fewer chemical contaminants.

Best oils: Avocado oil, almond oil, olive oil (be careful with high cooking heat), canola oil (important to be organic)

Second line: Butter, Ghee, coconut oil or other medium chain triglyceride (MCT) oil

Avoid: Processed oils such as corn, cottonseed, sunflower and soy based products. Avoid any partially hydrogenated oil. In addition, grapeseed oil is prone to contamination and has a high proportion of omega 6, thus unfavorable altering your omega 6 to omega 3 ratio.

Whether you are in the “low-fat” or the “low-carb” camp, one thing is clear beyond reproach. Focusing on real foods, avoiding processed or refined foods, and avoiding added sugar is a great place to start to improve your health. Improve the quality of what you use to nourish your body, and your heath will improve. If that is the only change you make, then you are well on your way.

A recent study popularized in the mainstream media claims that a class of popular heartburn drugs called proton pump inhibitors (PPIs) such as Prilosec, Nexium, Protonix and others, may be linked to a higher risk of dementia. On the surface this sounds very concerning. But lets look a little deeper to see how concerned we really need to be.

A study in Germany followed over 73,000 people 75 years old or older between 2004 and 2011 and found that those subjects who took PPIs had a 44% increased risk of dementia compared with those who were not taking PPIs. This is in addition to a previous study showing a “20-50%” increased risk of kidney disease in PPI users compared to non-users. To put all this into context, 15 million Americans currently take PPIs accounting for a $10 billion industry. After reading the headlines, I could see how there could be 15 million people throwing away their PPI pill bottles. While that might not be a bad idea in many cases, it is likely not necessary just based on this study.

Remember, an association does not prove causation. These two studies do nothing to prove that PPIs cause dementia or kidney disease. People take PPIs because they have GERD or heartburn. Could it be something about the heartburn that is the cause of dementia or kidney disease rather than the medication? People with heartburn tend to be heavier, eat worse diets, exercise less, or do one of a myriad of other unhealthy habits. Based on these studies, we still do not know if it was the medication or the underlying habits that caused the dementia and kidney trouble. So if you take a PPI for heartburn, don’t stop just because of this study. But there may be other reasons that you should consider stopping anyway.

Lets look for a second at what PPIs do. They reduce the amount of acid that your stomach produces. GERD symptoms are presumed to be due to the presence of acid refluxing from the stomach into the esophagus. So if you can reduce the acid content, the reflux will not cause as much symptoms and will not cause harm to the esophageal mucosa (the lining of the esophagus). As with many instances in medicine, PPIs are a band aid that masks the symptoms, but they do not attempt to address the underlying cause. Even worse, for some it makes them feel as if they have a license to eat whatever they want since they no longer have to worry about suffering with reflux symptoms.

When these medications first came out, it was recommended that you not take them for more than 6-8 weeks. They were never meant for long-term use. They are very good at helping repair the esophagus from damage that has been done by acid (a condition called erosive esophagitis). But the assumption is that an attempt is being made to find and eliminate the cause of the reflux. Why would we continue to mask the symptoms, without trying to address the root cause and reduce the reflux?

What we need to do is to keep the acid in the stomach where it belongs and prevent it from going into the esophagus where it does not belong. After all, stomach acid is there for a reason. You need it to digest food, activate digestive enzymes in your small intestine, and help you absorb vitamins and nutrients (B12, calcium, magnesium). Reducing stomach acid it is not necessarily harmless. It has been linked to higher risk of infections (C. diff, pneumonia), vitamin deficiencies, and now dementia and kidney disease.

Sometimes the cause is a physical issue that needs aggressive medical care, such as a hiatal hernia (where part of the stomach slips into the chest), H. Pylori infection or a rare condition where the stomach aggressively overproduces acid. The majority of the time, however, simple lifestyle adjustments can help reduce reflux from the stomach to the esophagus. The following 6 steps are a must to help reduce the cause of reflux:

1-Not eating too late at night (a full stomach when you lie down is more likely to reflux)

2-Eating smaller meals

3-Avoiding alcohol, caffeine, fried foods and chocolate (these can relax the lower esophageal sphincter and allow the reflux to occur)

4-Don’t lie down within 2 hours of eating (gravity is your friend)

5- Stop smoking

6- Maintain an ideal body weight (especially reducing abdominal and visceral fat).

One other common cause that does not get enough attention is stress. Practicing stress management and relaxation techniques has been shown to reduce GERD symptoms. In addition, stress leads to obesity, poor nutritional choices, and increased risk of all 6 of the above GERD causes. Interestingly, magnesium supplementation has been shown to reduce GERD symptoms, and it has also been used to reduce stress reactions and anxiety. Could there be a causal relationship there? Possibly, and it certainly deserves some attention.

The most likely cause of GERD, however, is the food we eat. Not just the greasy food, chocolate etc., but actual food sensitivities. If our bodies cannot digest our food efficiently, it sits in our stomach longer and can cause reflux. Food intolerances are different for everyone, but the two most common are gluten and dairy. Others common intolerances are tomatoes or legumes. The best way to identify the culprit is to start with an elimination diet and then slowly introduce specific classes of food back into the diet. It is a slow, logistically challenging endeavor, but it is the best way to find the true cause of GERD. You can see why some prefer to simply write a prescription rather than go down the road of becoming a diet detective. It is so much easier. But you deserve to have someone spend the time to get to the bottom of your true causes rather than masking the symptoms with medications that have their own problems. Don’t trade a problem for another problem. Get to the root cause and eliminate it.

Lastly, and counter-intuitively, one cause of GERD could be too little stomach acid. That’s right! Too little. If you do not have enough stomach acid, digestion can be impaired, thus causing food to sit in your stomach longer. This increases the risk of reflux. One approach for treating GERD, therefore, can be GIVING acid (HCL) as a supplement. This is contrary to the pharmaceutical industry driven solutions, so is rarely discussed in mainstream medicine. In addition, the future will likely show a connection with the gut biome and small intestinal bacteria overgrowth. This again is taking shape outside of mainstream medicine. That doesn’t make it wrong, it just makes it harder to gain popular acceptance.

In conclusion, although a study can be presented in a dramatic headline, it may still be far from proving a true cause and effect relationship, as is the case with PPIs and dementia and kidney disease. Despite that, however, these studies are a welcome reminder that medications such as PPIs simply mask the symptoms of an underlying issue, and they may cause significant problems of their own. They do not address the root cause, and they cannot be assumed to be harmless. You deserve to prioritize your health, and have a thorough evaluation and detailed treatment plan aimed at the underlying cause of your heartburn.

At Boundless Health, we feel You deserve this level of attention and commitment. To find out more about how you can prioritize and take control of your health, please contact us today.

Bret Scher, MD FACC

info@myboundlesshealth.com

www.myboundlesshealth.com

858-799-0980

I saw a client last week who ignited the light bulb for this blog. He is a 55 year old man, 5ft 10in, 230 pounds, not very active but trying to improve his exercise. He has never really paid much attention to his nutrition and was a big snacker on chips, pretzels, cookies etc. With guidance from his physician he started to make positive changes in terms of his nutritional choices. But he was frustrated with his lack of weight loss. When he came to see us, one thing that struck me the most was that he was eating 4-5 handfuls of nuts (mostly peanuts) 4 times per day. That’s a lot of nuts! All of a sudden it made perfect sense why he wasn’t losing weight. Here are some thoughts on how to avoid this situation.

Nuts are a fantastic snack. They are:

1-packed with nutrients

2- they are filling,

3-they provide good fats, and

4-they are free of simple carbs and sugars that frequently plague our snack choices.

However simply saying “Snack on nuts” without more specific guidance is inadequate advice, and can frequently do more harm than good.

Nuts are calorie dense foods, they taste good, and are easy to eat while you are distracted doing other things. Therefore they are easy to over-consume. Overconsumption can lead to unrecognized calorie intake and weight gain. In addition, too many nuts can distort one’s omega 6: omega 3 ratio. More on this later. Thirdly, nuts contain phytic acid. Humans cannot adequately digest phytic acid (herbivores like cows and sheep can), and thus phytic acid can bind to iron and zinc in your gut leading to inadequate absorption and resulting mineral deficiencies.

Therefore it is important to specify a serving size of nuts to help prevent over consumption. A serving size usually equates to 1 oz. of nuts once or twice per day. But we do not all know what 1 oz. of nuts looks like, so we frequently say “a handful.” A 100 pound woman has a very different size handful than a 250 pound male. So it is also important to know quantity as well. For instance, 1 oz. is approximately 18 cashews (160kcal, 4g protein, 13g fat), 23 almonds (160kcal, 6g protein, 14g fat), 6 Brazil nuts (190 kcal, 4g protein, 19g fat), 10 macadamia nuts (200kcal, 2g protein, 22g fat), 45 pistachio nuts (160 kcal, 6g protein, 13g fat).

Another consideration is raw vs roasted. Many people prefer roasted for taste reasons, but studies have shown a significant decrease in nutrient availability once the nut is roasted. As with most foods, the less handling and processing the better. We definitely recommend the raw nuts whenever possible. If someone won’t eat the raw nuts because the taste, we suggest a combination of raw nuts and roasted nuts mixed together. To take it a step further, studies have shown that soaking raw nuts for 8hours increased nutrient bioavailability. It’s not the easiest thing to do, but it can help.

What types of nuts are best? Taste definitely plays a big role in determining what nuts we eat. But below are descriptions of some of the more nutrient dense nuts and they’re beneficial properties.

Walnuts- 1/4cup has 100% of the daily recommended amount of omega 3 FAs and have been associated with anti-inflammatory properties, “brain health,” among other benefits (Br J Nutr, 2012 May;107(9):1393-401).

Almonds– Rich in antioxidants including flavonoids and phenolic acids, and has been associated with mild LDL reductions.

Pistachios- high in lutein, beta carotene and Vitamin E. Pistachios have been shown to lower the amount of oxidized LDL (J Nutr 2010, Jun;140(6):1093-8)

Also consider pecans, cashews, Brazil nuts. Try to avoid simple peanuts as they are less nutrient dense.

And don’t forget the seeds– Pumpkin and sunflower seeds, which are also rich in vitamin E, magnesium, antioxidants and others.

I mentioned earlier how nuts can change the Omega 6 and omega 3 ratio. What is that about? This is an entire blog or two in itself. But here is my attempt at a quick summary (it gets a little technical, so I apologize in advance)

• Not all omega 3s are created equal. Most of the beneficial effects of omega 3 FAs are felt to be from DHA and EPA and not from other versions of omega 3s. DHA and EPA are the longer chain FAs found exclusively in seafood and marine algae. Alpha-linolenic acid (ALA) is a shorter chain omega 3 FA that is found in plant foods such as flax, hemp and pumpkin seeds as well as walnuts. ALA can be converted in the body to EPA and DHA but only at about 5% efficiency. In addition, this process depends on zinc, iron and pyridoxine. Non-fish eaters can therefore have a very difficult time maintaining adequate DHA and EPA levels, especially if they have co-existing nutrient deficiencies.
• Omega 6 fatty acids, such as linoleic acid (LA), are essential fatty acids meaning our body cannot produce them and we need to consume them. They are required for multiple functions including building cell membranes, helping in cell repair and other fatty acid functions. However, omega 6 FAs have also been implicated in many deleterious functions such as promoting inflammation, and can inhibit the conversion of n-3 ALA to DHA and EPA.
• The general assumption is that although we need omega 6 FAs for normal cell functions, we need to balance the amount of the more beneficial omega 3s with the potententially harmful (at higher doses) omega 6s.
• Research of hunter-gatherer societies has shown that the omega 6 to omega 3 ratio averages 1:1 up to a maximum of 3:1. In the traditional western diet, our ratio of omega 6 to omega 3 has ballooned to 20:1 predominately due to the excessive use of safflower oil, sunflower oil, corn oil and soybean oils as well as soy and grain fed livestock. It is estimated that our intake of omega-6 fatty acids is up to 20 times higher that “evolutionary norms.” The assumption is that since hunter-gatherer societies have fewer inflammatory diseases, it may be related to the lower ratio of the proinflammatory omega 6s compared to the anti-inflammatory omega 3s.
• The next natural question is, “So what? What does this mean for our health?” Observational evidence suggest increasing the proimflammatory omega 6s at the expense of anti-inflammatory omega 3s MAY be related to the increased prevalence of inflammatory diseases, i.e. heart disease, diabetes, cancer, auto-immune disease. For instance, why do traditional Japanese men and women have lower rates of inflammatory diseases despite higher rates of smoking and hypertension? Studies have shown, on average, their population’s omega 6 to omega 3 ratios is more in line with hunter-gatherer societies. There are other observational data to suggest a link, although no direct causative

The way I look at it, although there is no direct proven link, it is certainly plausible that higher omega 6 to omega 3 ratios promote inflammatory disease. However, more importantly, the key is that you correct the ratio by eating less vegetable oil, less cereal grains and less processed foods, and eating more omega 3 dense foods like fish and flax, and more grass fed livestock, pastured eggs etc. This has multiple other health benefits and we recommend it to most people anyway! I would go one step further and say if you are not a fish eater, we would suggest a high quality Omega 3 DHA/EPA supplement (high quality meaning one that gives you at least 400mg of DHA/EPA, and one that has a detailed distillation process to remove mercury, and other heavy metals and toxins).

In summary, we highly recommend healthy snack options that are low in simple carbs and sugars; snacks that provide beneficial nutrients, are easy to fit into our busy daily lives, and help us feel full. Nuts definitely fit all those requirements. But please make sure you limit your nut intake to 1 ounce once or twice daily.

In addition, we strongly suggest reducing the consumption of vegetable oils and processed carbs, and we encourage fresh (preferably wild) fish consumption and higher quality pastured and grass fed meat and eggs to promote adequate omega 3 levels and reduced omega 6 levels.

At Boundless Health, we are not just here to check off the boxes that we “did our job” and made the recommendations we are supposed to make. We are here to ensure that you get the information and guidance you need to safely incorporate our suggestions into your healthy lifestyle. Contact us today to learn more about our programs to help you achieve your health and wellness goals.

Health. Fitness. Life. Boundless Health

Intermittent Fasting- A Revolutionary Concept Making a Comeback

“Fasting?! Are you crazy?! I need to eat every 3-4 hours to keep from getting hungry and to regulate my blood sugar!”

For some people this statement may be true. However for many it may not actually be the case. The theory of frequent small meals has been popularized so much (even with a lack of scientific evidence) that many people feel it is an absolute must do. As with most things regarding your health, there are no absolutes and there is no one strategy that works for all of us.

Intermittent fasting goes directly against the theory of frequent small meals, yet it has very good evidence showing that it helps promote fat loss while maintaining lean body mass and athletic performance. It’s important to point out that this is not a specific diet, but rather a pattern of eating. It doesn’t change what you eat, it changes when you eat. The concept certainly makes sense. When our bodies are in a true fasting state, we begin to utilize fat as a fuel source, breaking it down into ketones for use for energy. However we only reach the fasting state when we have completely digested and absorbed our entire food intake, and our insulin levels are low enough that we switch from glucose metabolism to fat metabolism. That usually doesn’t happen until about 10 or 12 hours after our last meal. If you stopped eating at 8 PM and had breakfast at 6 AM; you only went 10 hours between meals and you never reached the fasting state and therefore never started to burn fat.

Intermittent fasting proposes that you have an eating window, for example from 12 PM to 7 PM, and then a fasting window for the remainder of the time. With this schedule, you have approximately 6 hours in the morning (starting around 5-7am, which is 10-12 hours after your last food intake) when your body is preferentially using fat as a fuel source and therefore improving fat loss. There are other variations to the schedule such as fasting for an entire day once or twice a week, or even 2-day fasts twice a month and every variation in between. However the most common and easiest to implement is the 6-8 hour eating window.

In addition to fat loss, intermittent fasting has shown improved longevity in mice and it’s thought to also apply to humans. It’s been reported to increase insulin sensitivity as well as reduce oxidative stress and to resist the processes of disease and aging. There is not yet solid scientific evidence to support this in humans, but theories abound and research is quickly being done.

In addition:

1-Intermittent fasting requires very little behavior change, just simply changing the timing of your meals and is therefore simple enough that people actually do it and powerful enough that it will actually make a difference

2- intermittent fasting takes away one extra thing to worry about. There is no thinking what’s for breakfast? There is no worrying about shopping for breakfast or preparing it.

3-Intermittent fasting provides the psychological benefit of realizing “I am in control of food and hunger, it is not in control me. “

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Intermittent fasting certainly makes sense from a physiological standpoint, and has been shown to work well for fat loss. However it is not without its potential drawbacks.

1-There is a significant psychological barrier when committing to not eating until lunch. Interestingly, it’s been said that “diets are easy in the contemplation, difficult in the execution. Intermittent fasting is just the opposite; it’s difficult in the contemplation but easy in the execution.” Most people report that once they get over the initial psychological barrier, it is very easy to keep to the schedule

2- You still need to get adequate calories and nutrients during the day. For some people this can be difficult to do in only a 7-hour window. Therefore it works best in people who can control their food intake during the day. People may have trouble maintaining an adequate caloric intake if they have to “grab whatever they can on the run” or those who are restricted to eating only during certain times. But if you can find the structure to eat whole, nutrient rich foods throughout that 7-hour window and get adequate caloric intake, then intermittent fasting can be huge success

In the end, is Intermittent fasting right for you? If your goal is fat loss, and you can control your food intake enough to consume adequate calories and nutrition in a 6-8 hour window during the day, and you don’t have legitimate issues with low blood sugar (as in patients on hypoglycemic medications), then it may be worth a try. Keep in mind, it does not have to be done every day. So if you have a big morning meeting, you are travelling, or you have a long endurance work out, you may want to skip that day (although some have reported excellent exercise performance when fasting for shorter workouts).

At Boundless Health, we are dedicated to finding the ideal approach to help you reach your goals. Intermittent fasting is one more tool we have to promote healthy fat loss. Remember, there is no one size fits all approach, so it is crucial to know all the various options that exist to find out what works best for you. Contact us today to learn more about how we can help you find your boundless.

Fitness. Health. Life. Boundless Health.

Can you believe that “we” as a medical community do not know with certainty what your goal blood pressure should be on medications? There was a time where blood pressure was treated to “100 plus your age,” so if you were 70 years old, your goal would be 170. Luckily those days are long gone, but for evidence-based guidelines, it is still murky what that goal should be. Of course I am quick to point out that the first line treatment for blood pressure has NOTHING TO DO WITH A PRESCRIPTION! Lifestyle choices with nutrition, exercise, daily activity, relaxation, sleep etc. are far more important and with no side effects. But I do have to admit that there are times when lifestyle cannot overcome the powers of genetics, and then medications are required.

Let’s look at the hypothesis of what an ideal blood pressure should be:

1: A normal blood pressure is 120/80 or less, and epidemiological studies show that those with blood pressures naturally in this range have lower incidence of cardiovascular complications and death in the long term. Therefore, for some it makes sense that we should target <120 /80 with medications

2: It is unknown if naturally having blood pressure <120/80 is different than artificially achieving it with medications. A prime example is that of HDL cholesterol. A high level of naturally occurring HDL is protective for cardiovascular disease in epidemiological studies. However, artificially raising HDL with medications not only lacks benefit, but also has actually been shown to increase the risk of stroke and death! Could the same be true with blood pressure? (No such “side effects” are seen with diet and exercise of course)

3: Blood vessels stiffen as we age and therefore we need a higher blood pressure to adequately perfuse our organs such as the brain and kidney. It is possible that lowering blood pressure too much in the elderly can lead to worsening cognitive function, renal insufficiency, or other complications.

Three fairly reasonable hypotheses, all without a clear answer.

If you read the New York Times, you would think this question is now finally answered and everybody should have a blood pressure less than 120/80. A number of press releases regarding the SPRINT trial have been published in non-scientific publications touting this study as “groundbreaking” and “completely reframing the way we treat hypertension.” Briefly the SPRINT trial was a trial that randomly assigned more than 9000 men and women over age 50 to one of two systolic blood pressure targets; less than 120 or less than 140. The study was stopped over a year early by the safety monitoring board because of a significant improvement in cardiovascular events and mortality in the lower target blood pressure group. Therefore there is no shortage of articles now proclaiming that <120/80 should be the target BP for everyone. This may end up being true, and that absolutely would revolutionize the way we treat blood pressure.

However, as with most scientific evidence, the proof is in the pudding; and unfortunately we’ve yet to see the pudding come out of the fridge. There has been no release of any specific data, and as a result we should proceed with caution regarding how we view blood pressure management.

For instance, we know the targets were less than 120 or less than 140, but we don’t know what was actually achieved. In addition we know an average of 3 medications were needed in the goal less than 120 group. THREE MEDICATIONS!! Were patients living longer but not able to get off the couch without getting dizzy or falling over? This may be a bit of a dramatic example, but hopefully you get my point.

Furthermore, what type of lifestyle intervention or advice did they provide? As with treating cholesterol, the goal is not a lower blood pressure or lower cholesterol number. The goal is helping you live better, healthier and longer. Moving your body, exercising, making good nutritional choices, and managing your body’s sleep and stress response add dramatically to the overall goal and reduce the need for medications.

So as you can see, the SPRINT trial has the potential to turn upside down the way we approach and treat blood pressure. But we all have to remember that the first-line treatment for high blood pressure has nothing to do with your prescription pad and has everything to do with getting moving, exercising, maintaining an adequate body weight, and focusing on real whole foods and making proper nutritional choices. As for the target of pharmacotherapy, I eagerly anticipate the publication of the specifics of the SPRINT trial. But I caution all of us to resist drawing conclusions until all the evidence is revealed.

At boundless Health, we pride ourselves at critically examining health and medical scientific studies, and most importantly, realizing how those studies apply to you as an individual. Not as a population or a number, but as YOU. Contact us today to learn more.

Fitness. Health. Life. Boundless Health

Meditation: Now it’s for everyone

What do you think of when you hear the word MEDITATION? Monks in a remote mountain village, sworn to silence, sitting for hours trying to free their minds, trying to clear all thoughts and then levitating above the ground? Or do you think of Steve Jobs, one of the most creative and innovative humans ever to start a business?

What was once felt to be only for deeply pious individuals who dedicated their life to mindfulness, has now become mainstream and nearly a requirement for creativity, innovation and productivity. Steve Jobs was a devout practitioner of Zen mindful meditation. He saw the benefits of reduced stress, increased creativity and enhanced clarity in life. In his biography, Mr. Jobs is quoted as saying:

“If you just sit and observe, you will see how restless your mind is. If you try to calm it, it only makes it worse, but over time it does calm, and when it does, there’s room to hear more subtle things- that’s when your intuition starts to blossom and you start to see things more clearly and be in the present more. Your mind just slows down, and you see a tremendous expanse in the moment. You see so much more than you could see before.”

Sounds pretty good, doesn’t it? There is no question that having time to ourselves, slowing down our pace and our breathing, can work wonders to help us relax after a stressful day. But now there is evidence that meditation, or mindfulness, can do much more.

A recent study out of Harvard analyzed MRI images of participants before and after an 8-week meditation practice. They also analyzed MRIs on control subjects who did not participate in meditation. The treatment group averaged 27minutes each day of mindfulness exercises. Amazingly, the MRIs showed a significant increase in the hippocampus and other areas related to memory, self-awareness and compassion. There was decreased size in the amygdala, which is linked to anxiety and stress. None of these changes were seen in the control group. This was the first study to show in a prospective, randomized manner that less than 30 minutes of daily mindfulness practice can actually have direct effects on the brain size and composition.

They still didn’t levitate, but they did change their brains. Sounds pretty impressive to me.

In addition to actually changing your brain, mindfulness (defined by some as the “non-judgemental awareness of experiences in the present moment”) has been shown to reduce stress, relieve anxiety, reduce blood pressure, and improve overall well being. It doesn’t eliminate external stressors, of course, but it can dramatically alter how your body and mind react to them. Some would argue, what good is it if it only works when you are doing it or shortly thereafter? It is important to point out that meditation is like exercise. If you exercise one week, and then not again for 3 months, you will no longer have the beneficial effects of that one-week of exercising. But if you maintain your workouts 4 days per week, week in and week out, you will see dramatic short and long-term benefits. The same applies for mindful practice.

Plus, it isn’t very hard to do. Like anything it takes practice, and you actually do get “better” at it with time. Here is how to start:

• Sit in a quiet place with few distractions. Just be comfortable. You don’t need to sit cross-legged and hold your fingers in funny positions. You just need to be comfortable.
• Close your eyes and notice your thoughts. Don’t try to stop or control the thoughts, just observe them like a third party observer looking in from the outside.
• Yes, this may sound cliché, but a big part of mindfulness is focusing on your breath. Feel the breath as it comes in and out through your nose. As you focus on your breath, thoughts will come in to interrupt you, and that’s okay. Don’t judge your thoughts, don’t try to control them. Simply observe and acknowledge them, and then move your focus back to your breath.
• Become aware of how your body feels. The heaviness of your head, the feeling of your hands resting on your legs, your feet touching the ground, the air moving in and out of your nose as you focus on your breath.

And that’s it, the basics of being mindful. Be in the present, focus on your breathing, and allow the world to continue without reacting to it. Allow your thoughts to come and go without trying to control them or react to them. You can start with as little as 5 minutes, then progress to 10, 15 even 20 minutes.

I can’t promise that a regular mindfulness practice will make you as brilliant and creative as Steve Jobs. But I can promise you that it will help you think more clearly, feel more balanced, and help you unleash the true potential within yourself.

At Boundless Health, we are committed to helping you achieve your health and performance goals. We believe in evaluating every aspect of your life to help find the right approach for you, as an individual, to help you reach your goals. Does mindfulness or meditation fit into this approach for you? We would love to help you find out. Please contact us today to learn more.

Bret Scher MD FACC

President, Boundless Health

bret@myboundlesshealth.com

“Walking is man’s best medicine”- Hippocrates (Greek physician 460 BC-377BC). How did he know that? For one, he didn’t have scientific studies to reach that conclusion (at least I assume he didn’t). He didn’t even have fitness trackers to monitor how many steps people took (how did they survive in such prehistoric times??) I guess it all came down to common sense. Even “back then” Hippocrates could understand the physical and psychological benefits from an activity as simple as walking. Today, we have the research to support his claims.

We also have information from one of the best and healthiest trends of the past decades–the flood of activity trackers and step counters that keep us moving and motivate us to get off the couch. As a society, we have gone through the running and marathon trend, the gym trend, and now the “JUST MOVE” trend. What I love about the “just move” trend is the simplicity of it. No driving to the gym, no finding a parking space, no changing clothes, and it doesn’t have to take 3 hours to do. Don’t get me wrong, the gym is a great place to exercise, be healthy, and develop strength and power. Running a marathon is a fantastic motivator and a very worthwhile goal. But when it comes to reaching the masses and improving health for an entire population, nothing works better than a free activity that requires only a pair of shoes. And on top of that, the roads and sidewalks are open 24/7/365, and side effects may include increased work productivity and better moods to name only two.

As is frequently the case, however, there exists a disconnect between what we know is good for us and what we actually end up doing. Why doesn’t everyone get out and walk? Why doesn’t everyone get the magic 10,000 steps every day? Motivation and free time are the most often sited factors. Plus, it appears as if part of society is determined to force us to walk less. Long work hours behind a computer screen, moving walkways, escalators, the culture of fighting for the closest parking space, all are societal “forces” that cause us to move as little as possible. Recently, however, there has been a flood of research showing that exercise and being active can help us live longer! No only can physical activity reduce your risk of diabetes, hypertension, depression, but it can reduce your risk of DEATH!

However, unlike prescription medications, exercise does not come with dosing instructions and overdose precautions. So what is the optimal level of exercise? Current guidelines suggest 150min per week of moderate intensity or 75 minutes of high intensity exercise. This recommendation came from a combination of outcome data, and an assumption of what people will actually do. As you will see, the best data supports more exercise for maximal mortality benefit. But what does the data say about “overdosing” on exercise, or the toxic/therapeutic index? Read on for more.

A recent large study (JAMA Internal Medicine April 6 2015) followed 661,000 Middle Aged adults over 14 years investigating their risk of death. The highest risk was in those who did not exercise. Even a “little amount” of exercise (less than the official guidelines but more than no exercise) reduced the risk of death by 20%. The benefit continued to increase linearly with increasing exercise duration until it plateaued at 450 min per week. The following table summarizes the results.

In the same journal, an Australian study followed 200,000 adults and concluded that vigorous and frequent exercise had an additional 13% death reduction over more moderate exercise. These are important findings because they suggest there is no “over dose” or “toxic limit” to exercise, which seems contrary to other studies that suggested “extreme” or “excessive” exercise can actually worsen cardiovascular and/or mortality risk.

Perhaps the best-publicized recent study on the subject of exercise benefits and risks has been the Copenhagen City Heart Study (JACC 2015;65:411-9). Again it was shown that “light” running even just once per week resulted in reduced mortality benefits, with the maximal benefit in those who jogged at a slow or average pace between 1-2.5 hours per week. However, contrary to the above studies, they also showed there was a U shaped curve, meaning running at faster paces >3 days per week did not have a mortality advantage over sedentary non-runners (there may have been other benefits, but death prevention was not one of them).

On the surface this seems contradictory to what has been conventional wisdom that when it comes to exercise “more is better.” Although it is far from definitive, some research does suggest that there is a maximal beneficial amount of exercise, beyond which there are diminishing health returns. For instance, it is now well documented that there appears to be a association between exercise and atrial fibrillation. Moderate intensity exercise is beneficial and REDUCES the lifetime risk of atrial fibrillation, but intense exercise more than 5 days per week can actually INCREASE the risk of atrial fibrillation (Heart 2014:100;1037-42). We are starting to see more of this as the first generation of Ironman Triathletes, ultra-marathon runners, and others endurance athletes are now reaching their 50s or older and are starting to show higher rates of atrial fibrillation than we would have otherwise expected.

So how do we sum this all up? It appears Hippocrates was right on when he said “Everything in excess is opposed to nature.” Once again, we see that we all need to exercise with a purpose. The key is defining that purpose and tailoring an individualized exercise program or philosophy to achieve that purpose.

If your goal is optimizing cardiovascular health and mortality, the most efficient goal should be 450 minutes per week of moderate cardiovascular exercise. That is clearly a difficult goal to reach for many of us. So it is crucial to remember that we still gain benefit from performing any amount of exercise even 20min of walking. And we get increasing health benefits for any amount of exercise up to 450 minutes per week. However, performing more than 450 minutes per week, or frequent higher intensity exercise, may blunt the mortality benefit and may increase the risk for atrial fibrillation. We often see that those who perform high intensity endurance exercise frequently do so for reasons other than just cardiovascular benefit. They love the challenge, the thrill of accomplishment, the competition, the structure, and the community just to name a few. By defining their purpose, we can design their exercise program accordingly.

Best Evidence Summary Table:

At Boundless Health, our expert team of cardiologists, health coaches and physical therapists help identify your specific goals, and we work with you to safely achieve those goals. If your goal is to compete in an Ironman Triathlon, or play 18 holes of golf without pain, or reduce your risk of diabetes and heart disease, we are here to help you accomplish your goal. We help you train hard, and we help you train smart. We make you sweat, but we also emphasize the importance of rest, nutrition and overall health. We apply the latest research and science to you as an individual, and customize a program just for you. And along the way, we will help you move better, feel better, and live a healthier and more purposeful life.

Please contact us today to learn how together, we can build your path to a healthy future.

Bret Scher, MD FACC

President, Boundless Health

TPI Fitness Level 2, NASM CPT FNS

bret@myboundlesshealth.com