Before you start a Ketogenic Diet...

The history

The ketogenic diet has been around for about 100 years.  It was originally prescribed to treat refractory epilepsy in children.  Awareness of the diet grew through an education campaign initiated by Hollywood movie producer, Jim Abrahams, after the diet cured his son’s epilepsy (read the story here).

According to The Charlie Foundation, ketogenic therapies are being used for autism, Alzheimer’s, brain tumor/cancer, Lou Gerhig's disease, mitochondrial disorders, Parkinson's disease and traumatic brain injury.

 

What Is a Ketogenic Diet?

According to the National Academies, the Acceptable Macronutrient Distribution Range is 45-65% carbohydrate, 10-35% protein, and 20-35% fat.  In contrast, a ketogenic diet contains very little (5-10%) carbohydrate, adequate protein (0.8-1.0 g/kg body weight; 15-25%) and 70-85% fat.  Yes, that is a lot of fat.

 

How does a ketogenic Diet work?

The ketogenic diet mimics fasting.  In the absence of adequate carbohydrate, the liver is forced to burn fat to produce ketone bodies (e.g., acetoacetate, β-hydroxybutyrate).  After the adaptation period, the body (including the brain) is able to use ketones for energy instead of glucose.  Meanwhile, ketones suppress appetite and inhibit the breakdown of muscle mass.

The ketogenic diet is currently gaining traction in the ultra-endurance community.  When the body is able to burn ketones for fuel, there is no fear of running out of carbohydrate (e.g., glucose, glycogen) and “hitting the wall.”

Following a high-fat, low-carb diet may also be therapeutic for people with insulin resistance and/or type 2 diabetes.  According to this review article from the European Journal of Clinical Nutrition, "When dietary carbohydrate is restricted to a level below which it is not significantly converted to fat (a threshold that varies from person to person), signs and symptoms of insulin resistance improve or often disappear completely."

 

Ketosis vs. Ketoacidosis – Concentration Matters

The level of ketones is important to understand.  Any time we fast (e.g., overnight), the body naturally begins to make ketones. 

  • Prolonged fasting (i.e., weeks) will result in ketone levels around 5 to 7 mmol/L. 
  • For a healthy human body, following a ketogenic diet will result in a state of ketosis, where ketone levels stay between 0.5 and 3.0 mmol/L. 
  • In contrast, ketoacidosis is when ketone levels increase ten-fold to 10 to 20+ mmol/L, usually due to insulin insufficiency (e.g., type 1 diabetes).

 

Risk of Heart Disease

Some people worry that eating copious amounts of fat will increase their risk for developing heart disease.  The truth is, eating more fat may, or may not, increase your cholesterol. Read more here (link coming soon!).

Some studies show that a low-carbohydrate diet lowers atherogenicity, while others provide evidence for the opposite.  There is a genetic component that confounds most studies.  For example, folks who have a polymorphism in the PPAR gene may be less able to convert fat into ketones and, therefore, should not follow a ketogenic diet.

Additionally, high LDL cholesterol may not be as bad as we originally thought.  The "large, buoyant" variety of LDL is much less problematic than the “small, dense" type).  Read more here.

 

Contraindications

For a full list of contraindications, click here.

Written by Adair Lindsay with the assistance of Hannah Berkon

What to eat to optimize athletic performance

Fueling your body before, during, and after a workout is crucial for optimizing performance and building muscle. However, an athlete’s nutritional needs depend on the activity type, intensity, and duration.  Here is a quick guide to help you determine if, what, and when to eat to improve your athletic performance and recovery.

  • If aerobic activity (a.k.a. cardio) lasts less than 45 minutes, no pre- or post-exercise nutrition is usually needed.
  • If aerobic activity lasts more than 45 minutes, a pre-exercise snack, rich in carbohydrates, eaten 30 to 60 minutes before activity, can help prevent fatigue and improve performance.
    • The food groups found on the top half of MyPlate are richest in carbohydrates: fruits, grains, and dairy foods.
    • To reduce upset stomach during exercise, choose pre-exercise snacks that are easy to digest like low-fiber fruit (e.g. banana, not raspberries), chips, crackers, low-fat milk, and yogurt.
  • If exercise lasts 1 to 2.5 hours, including “stop and start” sports, mid-exercise snacks can improve performance and delay fatigue.
    • Athletes need 30 to 60 g of carbohydrate (120 to 240 calories) per hour during endurance activities.
    • To prevent indigestion, choose easily absorbed snacks like sports drinks, gels, gummies, and beans.
  • If the exercise includes muscle-strengthening activities, a post-exercise snack, rich in protein, eaten within 30 minutes after the activity, can help improve recovery.
    • To maximize muscle protein synthesis post-exercise, consume 0.25 to 0.3 g protein per kg body weight (0.114 to 0.136 g / lb).  For most people, this is about 15-25 g protein.
  • In general, muscles want 3 to 4 times more calories from carbohydrates than from protein.  The ideal carbohydrate to protein ratio is 4:1.
    • If a post-exercise snack contains 20 g protein, this means also eating 80 g from carbohydrate (e.g. 5 slices of bread or 5 cups of fruit).
    • Examples of 4:1 ratio foods include chocolate milk, turkey sandwich, or regular Clif bar.

For more information, check out the Position of the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine: Nutrition and Athletic Performance.

Written by Adair Lindsay with the assistance of Hannah Berkon

Low FODMAP diet: a new therapy for IBS

Suffering from chronic gas, bloating, diarrhea or constipation, people with IBS will try just about anything to feel better.  Many undergo elimination diets in attempt to ascertain which foods are causing symptoms, with common allergens (dairy, wheat, soy) as popular suspects. While needle-in-a-haystack elimination diets may help, there is a new, evidence-based diet protocol that better identifies IBS trigger foods and improves symptom control in three out of four people with IBS.  It is called the Low FODMAP diet.

What are FODMAPs?

FODMAP stands for Fermentable Oligo-saccharides, Di-saccharides, Mono-saccharides and Polyols (saccharide means sugar).  Unlike the long chains of sugar found in starchy potatoes and rice, FODMAPs are small in size.  These sugars, when poorly absorbed, draw water into the intestines through osmosis, resulting in diarrhea.  The unabsorbed sugars also feed colonic bacteria resulting in gas and bloating.  Think of FODMAPs as “fast food for the gut."

While FODMAP malabsorption and subsequent fermentation occurs in most people, individuals with IBS or other Functional Gastrointestinal Disorders (FGID) may have hypersensitivity to gas production.  Additionally, FODMAPs have a cumulative effect and each IBS sufferer has a difference tolerance level for each type of sugar – just because a food contains FODMAPs doesn’t mean it cannot be consumed in any amount.

According to FODMAP expert, Kate Scarlata, the Low FODMAP diet is an opportunity to investigate tolerance and manage symptoms.  The general idea is to remove all FODMAP-containing foods from the diet in a wash out period lasting 2 to 6 weeks.  Once symptoms are greatly improved, FODMAPs can be gently reintroduced to the diet, one at a time, in varying amounts, to determine what is tolerated.  In other words (and I really want to stress this), the FODMAP-free diet is a learning diet, not a long-term elimination diet.  Many of the foods that contain FODMAPs are healthy, delicious foods and should be added back to the diet as soon as tolerable amounts are identified.  Let’s meet the FODMAPs now.

In which foods are FODMAPs found?

  • Mono-saccharides are single units of sugar (“mono” means one) like glucose, fructose and galactose.  Most are readily absorbed from the intestinal lumen into the blood stream, except for fructose in excess of glucose, which is found in honey, some high fructose corn syrups, and certain fruits like apples, cherries, peaches and pears.
  • Di-saccharides are made up of two sugars stuck together (“di” means two). While most humans are able to breakdown the disaccharides sucrose and maltose, some individuals are unable to digest lactose, the sugar naturally found in milk and milk products.  Indeed, scientists have known about lactose intolerance, and the subsequent gas and diarrhea associated with it, for years. 
  • Oligo-saccharides, or oligos for short, are short chains of sugar typically 3-10 units long (“oligo” means few or scanty).  This includes fructans, fructo-oligosaccharides (FOS) and galacto-oligosaccharides (GOS).  Oligos are found in foods like wheat, rye, onions, garlic, and legumes such as beans and lentils.
  • Polyols stands for sugar alcohols such as sorbitol and mannitol.  Polyols are found in some fruits and vegetables and often added to processed foods as artificial sweeteners.

Where did the Low FODMAP diet originate?

The Low FODMAP diet was developed by researchers at Monash University in Melbourne, Australia.  While evidence that food triggers gastrointestinal symptoms had been around for many years (e.g. lactose intolerance, beans are gassy foods), advances in science and technology allowed these researchers to look at the evidence in a new, innovative way.  The team at Monash University combined gave “structure” to the knowledge and provided the first evidence that the Low FODMAP diet improves IBS symptoms.  They also created a fantastic app, which I highly recommend.  

The FODMAP App (by Monash University)

The app provides accurate information about foods that trigger IBS reactions in order to help IBS sufferers manage their symptoms.  My favorite part of the app is the food guide which uses a stoplight system to identify FODMAP foods: red means avoid, orange means caution, green is safe.

  • Red indicates that a food is high in FODMAPs and should be avoided.  
  • Orange means the food is moderate in FODMAP and may be tolerated by some.  
  • Green indicates the food is low in FODMAPs and safe for consumption.

One fact that surprises most folks is that the level of ripeness can determine whether or not a food is safe.  For example, a green banana is low in FODMAP but, as the banana ripens, the starches turn into sugar making a ripe banana high in FODMAP and, thus, a "red light" food.  Check out the short video below for more information about the app.

The diagnosis of IBS should be made by a medical practitioner.  If you’ve read this far, it is likely you’ve already been diagnosed.  However, it is highly recommended that you employ the help of a medical professional before starting a Low FODMAP diet.  Your primary care physician can order tests to help you personalize the FODMAP diet by determining which FODMAPs are OK for you to consume.  Before making an appointment, you may want to familiarize yourself with these tests as not all health professionals are aware of these diagnostic options.

The FODMAP Breath Test

The FODMAP breath test identifies malabsorption of fructose, lactose, and sorbitol.  Each sugar is tested individually.  After swallowing a measured amount of sugar, the test measures the amount of gas in the breath.  If the sugars are poorly absorbed, the intestinal bacteria ferment the sugar to produce gases such as hydrogen and methane.  These gases are absorbed across the intestine, carried through the bloodstream to the lungs, and exhaled.  If your breath test for fructose, lactose and sorbitol are all negative, then you would only need to restrict the other FODMPs from your diet: fructans, GOS, and mannitol.  In addition to sugar malabsportion, the breath test also confirms proximal small intestinal bacterial overgrowth (SIBO).  Getting a breath test done prior to starting a low FODMAP diet and help reduce the number of foods you need to avoid.  Learn more about breath test here.

Again, I want to stress that that FODMAP diet is not a life-long diet.  There are many healthful foods that are excluded on a Low FODMAP diet.  The purpose of doing a Low FODMAP diet is to determine which FODMAPs you are most sensitive to and in which amounts so that you can ultimately incorporatate as many foods as possible in quantities that you tolerate.  The end goal is for each IBS sufferer to be satisfied with symptom management while eating the most healthy, varied diet possible.

Should I follow a Gluten Free diet?

There is currently a lot of confusion around gluten.  Due to increasing availability of gluten-free products as well as coverage in the media, more and more people are choosing to follow a "gluten-free" diet.  What amazes (and worries) me is that some folks adopt this diet without even knowing what gluten is!

 
 

What is gluten?

Gluten is the general name for the proteins, gliadin and glutenin, found in the cereal grains wheat, rye, barley and triticale.  The gluten protein makes bread dough elastic enough to rise, giving it that light and fluffy texture (read more here).

 
Image from  Grist.org

Image from Grist.org

 

Who should avoid gluten?

People who have celiac disease, an autoimmune disorder that affects approximately 1 in 100 people, must avoid gluten because ingestion of gluten leads to damage in the small intestine.  Left untreated, celiac disease can cause serious health problems such as vitamin and mineral deficiencies (such as anemia), early onset osteoporosis, infertility, and gastrointestinal cancers.  Read more about celiac disease at The Celiac Disease Foundation.  Until new treatments are approved (e.g. Lazarotide acetate), people diagnosed with celiac disease must follow a gluten-free diet to remain healthy.

What about the other 99%?

Although many people claim to feel better when they follow a gluten-free diet, the scientific community is still conflicted as to whether individuals without celiac disease might benefit from a gluten free diet.

Some doctors, like Dr. William Davis, believe that gluten is toxic for humankind and everyone should follow a gluten-free diet.  There is some evidence to support this.  For example, it is true that no one is able to completely digest gluten.  It is also true that fragments of undigested gluten peptides can make the intestines leak, attract immune cells into the intestine, and cause inflammation in the gut.

Zonulin and Its Regulation of Intestinal Barrier Function: The Biological Door to Inflammation, Autoimmunity, and Cancer.  Click here to access the study.

However, according to Dr. Alessio Fasano, the leading expert in gluten-related disorders, "we engage daily in a war with many dangerous bacteria but rarely do we lose this battle, which is an event that leads to infection.  We are also engaged in daily confrontation with gluten, but only a minority of us will lose this battle.  These are the genetically susceptible individuals who will develop gluten-related disorders."

Who are these genetically susceptible individuals?

In addition to celiac disease, there exist spectrum of non-celiac, gluten-related disorders, including well-known wheat allergy (think hives and difficulty breathing) and the more recently accepted non-celiac gluten sensitivity (NCGS) - which is a real condition!

How do I know if I have gluten sensitivity?

While there are several diagnostic tests for celiac disease -- including elevated levels of tissue transglutaminase (tTG), the presence of genetic markers HLA-DQ2 or -DQ8 and, of course, the "gold standard" intestinal biopsy -- a biomarker for gluten sensitivity has not yet been found.  However, researchers at the Center for Celiac Research are working hard to identify one!  I am excited for this!  Once a biological marker is discovered, we will be able to measure levels in the body, making it much easier to figure out whether or not insidious symptoms like gas, bloating, muscle aches and brain fog are being caused by gluten!

What the heck is a FODMAP?

The tricky thing is that sometimes gastrointestinal (GI) distress is caused by the ingestion of FODMAPs.  FODMAP stands for Fermentable Oligo-saccharides, Di-saccharides, Mono-saccharides, and Polyols.  These sugars, when poorly absorbed, draw water into the intestines (diarrhea) and feed colonic bacteria (resulting in gas and bloating).  While glutenous foods are a type of FODMAP (i.e. they contain oligo-saccharides), there exist many other foods that may be contributing to GI discomfort if you are sensitive to FODMAPs.  This is a new area of research, but I do my best to explain it here (link coming soon!).

Which condition do I have?

The best way to determine if a gluten-free diet is appropriate for you is to see your doctor or registered dietitian nutritionist (RDN).  Before you change your diet, it is imperative to get tested to rule out celiac disease.  Once you stop eating gluten, your body no longer produces the biomarkers (i.e. tTG, villous atrophy) needed to diagnose the disease.  If your doctor is not up-to-date on the latest gluten-related research, recommend that he or she read the book Gluten Freedom by Dr. Alessio Fasano and/or the book released by The Mayo Clinic this past November called Mayo Clinic Going Gluten Free, which provides a checklist* for diagnosing non-celiac gluten sensitivity.

(*Checklist available in this New York Times article

My own beliefs align more closely with those of Dr. Fasano, that only genetically susceptible individuals need to follow a gluten-free diet.  Instead of silver bullets and one-size-fits-all approaches, it is my opinion that practicing personalized medicine - which considered genetics (fixed), microbiomics (modifiable) and environmental factors (culture) - is the best way to help clients achieve health.

Personalized Nutrition Counseling

Paleo, gluten-free, vegan?  With so many diets to choose from, how do you know what to eat?  Many of us listen to our friends and family for dietary advice.  But just because your best friend lost 10 pounds on the "Bulletproof diet" doesn't mean it will work for you, too.  When it comes to nutrition, there is no "one size fits all."

Although humans are 99.9 percent identical (Human Genome Project, completed 2003), it is the mysterious 0.1 percent of our DNA which determines "why some people are more susceptible to a particular illness or more likely to be healthy than their neighbor - or even another family member."

To reveal how your body responds responds to different foods and nutrients based on your individual genetic profile, Eating with Integrity offers an innovative, yet simple test created by Nutrigenomix.

 
Are you drinking too much coffee?
Having more than 1 cup per day if you have the “slow metabolizer” gene variation increases your risk of heart disease. Whereas, if you have the “fast metabolizer” gene, drinking several cups of coffee may actually be protective!
— Adair Lindsay, MS, RDN, LDN
 

In addition to our genome, the human microbiome also plays a role in health.  Recent research has shown that healthy, active, lean individuals have greater gut bacteria diversity.  On the other hand, a lack of variation in the microbiota is associated with health problems like diabetes, obesity, and gastrointestinal diseases.

 
This is only the beginning.
We have learned that the bacteria living in and on us are not invaders but are beneficial colonizers. The hope is that, as research progresses, we will learn how to care for our microscopic colonizers so that they, in turn, can care for our health.
— Joy Yang, as an NIH IRTA Fellow
 

Instead of just assessing your body's composition and lifecycle needs, a registered dietitian nutritionist (RDN) should also consider the state of your microbiome.  An RDN trained in functional medicine will always offer a personalized eating plan, full of delicious pre- and pro-biotic-rich foods, to improve your gut flora and your health.

Adair Lindsay, the Registered Dietitian Nutritionist at Eating with Integrity, offers the most personalized nutrition counseling available in the Washington, DC metro area.  Work with Adair to figure out which foods are best for your body.  Optimize your health by eating with integrity.

Welcome to Eating with Integrity!

Not all food is created equal. In addition to the many varieties of fruit, vegetables, grains, and legumes, there are a multitude of processed, food-like products that we regularly consume. With billions of choices lining the supermarket shelves, not to mention restaurant options, how does the average American decide what to purchase and eat? What makes a food nutritious and healthy? Is there a “perfect” diet and, if so, what is it?

This blog will strive to answers these questions (and many others) using a mixture of anecdotes, quotes, and facts. 

The important thing is not to stop questioning. Curiosity has its own reason for existing.
— Albert Einstein