Making it easy

Since a lot of the commentary has been about the importance of making it easier to adopt a plant based diet, I’m going to include a few tidbits.

Thrive Market is the Amazon of WFPB pantry goods.  Prices seem pretty good and free delivery for orders over $49. It doesn’t get much easier than that.

The Purple Carrot is a service that delivers ingredients and recipes to your home. A bit expensive, I think, but the convenience factor has to have a price.

For working with your kids, here are 7 Days of Kid Friendly Dinners from Dr. John McDougall’s site.

More to come and if you have any suggestions please pass them along!

So what’s holding YOU back?

I had an interesting discussion with one of my kids last night. This is the son that is most definitely not a plant based eater. He said that it was going to take a lot more than health benefits to get a lot of people to consider changing their diet from standard American diet (SAD) to a whole food plant based (WFPB) diet. He thought that things like cost and convenience were very important. As I’ve already posted on Twitter and Facebook this morning, an epidemiological study in Spain reports that those who spend more on their food generally have a healthier diet and weight. But this is not new information. A 2012 article in the American Journal of Preventive Medicine described “Obesogenic Neighborhoods” and make a clear link between zip code and obesity that was at least as prevalent as genetics. In follow up work, a 2015 article in the same journal was the kind of study that doctors and researchers love. The researchers looked at people who moved into poorer socioeconomic neighborhoods and found that people gained weight after doing so.

But I digress. Rather than cover the science, I thought today I would share more personal information. Here’s why I follow a WFPB diet.

  1. Health. No secret here, WFPB diet is the healthiest diet we know. While there may be some who “feel” that other diets have health benefits, there is little scientific data to support long term health for any pattern of eating other than WFPB. This is particularly true for those who suffer the “diseases of affluence” like cancer, obesity, hypertension, diabetes, vascular disease and all of the non-disease symptoms that are diet related (like abdominal pain and constipation).
  2. The Planet. There are not a lot of ways individuals can actually make a difference, but this is one. If you won’t do it for yourself, do it for your planet. If you are such a brainwashed dolt as to believe that Climate Change isn’t real, well, go somewhere else and put your head back in the sand. Don’t worry, it will all be fine, just like Fox News said it would be (or, open your eyes and your mind and do a little research, it’s not hard to find). Everyone else knows that emissions from cars is bad for the environment. It turns out, cows are worse. The impact of methane emissions from livestock is worse than the impact of car emissions. A couple of “factoids” taken from The Purple Carrot website:
    • each burger you don’t eat saves the impact equivalent of 320 miles of driving
    • If everyone in the USA ate not meat or cheese for one day a week for a year (52 times a year) we would save the impact of 91 billion miles of driving
    • Eating WFPB for four days a week is the carbon-savings equivalent of three months with no car for a family of four
    • It takes 1,811 more gallons of water to produce a pound of beef vs. a pound of vegetables.
  3. Because I’m mad about being deceived. Yes, this the “let’s stick it to the man” part of me that is likely a product of being raised in the 1960’s. But this has seen a huge resurgence with millennials in response to “Big Tobacco” and it’s pretty clear that “Big Food” doesn’t want to go the way of Tobacco. The Physicians Committee for Responsible Medicine (PCRM) has been at the forefront of trying to hold the government and “Big Food” responsible. They successfully sued the USDA and in October of 2000, the court ruled that the USDA violated federal law by withholding documents and hiding financial conflicts of interest. In 2011 PCRM again sued the USDA over the 2010 dietary guidelines and “food pyramid” the did not give good guidance to Americans on diet choices. In response, the USDA switched to the “Healthy Plate” model that they still use. PCRM has also petitioned the FTC, USDA, and national dairy organization to stop false and misleading ads about the health benefits of milk consumption, which led directly to a cessation of that promotion. Apparently the Center for Consumer Freedom objects to all of this activity by PCRM and led to this “report“. However, the Center for Consumer Freedom is “The Center for Consumer Freedom (CCF), formerly the Guest Choice Network, is an American non-profit entity founded by Richard Berman that lobbies on behalf of the fast food, meat, alcohol and tobacco industries.” This whole nutrition thing stinks of greed and profit through purposeful deception and ignorance. I’m grateful that I have the time, energy and education and interest to pursue this and I truly understand that most of you do not. All the more reason why it should not be so difficult to get the truth.

So, that’s it. It’s why I am a WFPB eater. How about you?




Let’s Start to Talk About Protein


I’ve had two people recently ask me to talk a bit about protein. I’ll admit that asking a plant based physician taking a nutrition course to talk about protein is a bit like asking a Trekkie what their favorite Star Trek episode is. So rather than diving into this topic as I am usually want to do, I thought I’d toss out a couple of snippets and see what bounces back. If you read something that interests you, let me know and I’ll make it the topic of a future post.

  1. How much protein is needed? The flippant answer is YMMV (your milage may vary) because the RDA (recommended dietary allowance) is based upon your body weight. Thus, everyone’s “number” is a little different. But, practically speaking, the numbers are not that different. The RDA figure is based upon the EAR (estimated average requirement), previously called the Minimum Daily Requirement. The EAR is 0.5–0.6 grams of dietary protein per kg body weight per day. In order to account for variations in diet, activity levels, etc. the RDA is constructed to encompass the EAR + 2 standard deviations. In this way, the RDA encompasses the needs to over 95% of the population and only about 2% (on the low side only) won’t have their protein needs met by following the RDA. So, what is the RDA? The RDA for dietary protein is 0.80 grams of dietary protein per kg body weight per day. So, if you’re a 150 pound person (68 kg) your RDA of dietary protein is 55 grams. Expressed as the percent of total diet calories, protein should comprise 8-10% of total dietary calories.
  2. It is important to note that the RDA is NOT the recommended minimum. It is the recommended TOTAL amount of protein necessary to maintain good health.
  3. A plant based diet naturally provides 8-10% of calories as dietary protein. While it is possible to push total protein intake to higher levels without consuming animals, it is difficult and requires the use of plant protein supplements. Given the inherent problems with high protein intake (see #8, below) there is no reason to do so.
  4. Is there a way to mix some meats into a plant based diet and still stay around the 10% level of calories as protein? Not really. Since a plant based diet alone provides perfectly adequate amounts of protein any additional protein as meat will push the total protein amount up into unhealthy territory.
  5. Do plants need to be “combined” to provide adequate and complete protein. Short answer: no. Long answer: no. 🙂 There was some concern about this many years ago, but it is widely understood that anyone eating a varied whole grain plant based diet need not concern themselves with protein combinations.
  6. Is animal protein needed for any reason? Again, short answer is no. The longer answer is also no, but the interested reader should have some information on why there is such a widely held misconception that animal protein is better for you than plant protein. I would argue, in fact, that exactly the opposite is true. But back in the early days of protein science, it was observed that animal proteins were used “more efficiently” than plant based proteins. That is to say, when people and animals are fed animal protein, which closely resembles their own protein in composition, the enzymes to digest the animal protein, the absorption, and subsequent utilization of the protein is all more easily done. As a result of this observation, animal based protein was labelled as “high quality” protein and plant based protein was labelled as “low quality” protein. The seemingly obvious follow up to that observation is: does it make a difference? And the answer is yes, but not how you think it does.
  7. Diets high in “high quality” animal protein do stimulate faster body growth rate and production of more growth factors. In a previous post I reported that American’s were not only getting fatter, but also taller. Unfortunately, weight is increasing faster than height, so body mass index (BMI) is increasing as well. But, it turns out that increased growth rate and growth factor production also means more cancer, which is just as stimulated by the protein as normal cells. It’s why we’re seeing earlier and earlier menarche (age of beginning menstrual cycles) in our girls, which increases the lifetime exposure of mammary tissues to increasing amounts of estrogen, which results in increasing breast cancer rates. It also means more growth factors, like Insulin-like growth factor 1 (IGF-1), which was implicated in increased cancer rates.
  8. Last for today, increased total protein intake is associated with “diseases of affluence”. This includes cancer, heart disease, diabetes, kidney disease and similar long term illnesses. Higher protein intake is independently associated with elevated cholesterol levels. Animal proteins are, by necessity, associated with animal fats (i.e. saturated fats, the ones you’re not supposed to have). Thus a diet rich in animal protein must also be rich in fat. Lastly, a diet of animal proteins and fats is associated with elevated dietary acids, that leads to leaching of calcium from the bones and osteoporosis. It’s well established that countries with the highest meat and dairy consumption have, by far, the highest rates of osteoporosis.

Hope this gives you all a bit to ponder. As I said before, let me know and I’ll be glad to expand upon any or all!

Why Does My Belly Ache?

Gluten’s Bad Rap, FODMAPs, and Plant Based Eating

Let’s get this part out of the way first. There is a disease called celiac sprue, often known as just celiac, where people have an intense immune response (allergic reaction) to gluten. Gluten is a plant based protein found in barley, rye, and wheat. There is no doubt that this condition exists and that the consequences can be devastating.

There is no evidence that non-celiac gluten sensitivity exists. I thought about writing that sentence again, because it seems worth repeating and it flies in the face of conventional wisdom, where the entire country seems to be on a gluten restriction program. But non-celiac gluten sensitivity is a made up condition. It’s a cure without a disease. It’s a way to profit from ignorance where sales of gluten free products is expected to reach $15 billion this year. Yes, $15 billion. Not because it’s better for you, but because you don’t know better. Let’s explore.

A 22 year old otherwise very healthy young man came to see me because of intermittent abdominal pain. It seemed to occur predominantly after eating and was characterized by a diffuse abdominal ache, with  cramping, bloating, belching, and occasional urgent diarrhea. Many will recognize these symptoms because they either share them or know someone who does. This is classic functional abdominal pain, which also goes by the irritable bowel syndrome (IBS) label. There is no anatomic abnormality that has been identified with this syndrome. If you do an upper GI endoscopy it is normal. If you biopsy the small intestine there is no sign of celiac disease. If you do a colonoscopy, it will be normal. If you do a capsule endoscopy and look at all of the small intestine, it will look normal too. Lab tests: normal. X-ray tests: normal. Ultrasounds: normal. Normal, normal, normal. But there are very real symptoms and so people often begin to think they are crazy or that it’s all in their head. Physicians are not much better and usually of no help at all. How can they be when there is nothing to treat? There are, of course, pills to give (never forget that all drugs are poison, I learned that my first day of Pharmacology in medical school and it’s the most true thing I learned in 4 years), but they rarely help. Out of desperation, many try a gluten free diet and sometimes it helps. And suddenly, they have self-diagnosed as gluten sensitive.

The AboutIBS website estimates that 10–15% of all Americans have IBS. True? Who knows. I, and most physicians, would probably say it’s about right. I have seen an amazing number of patients with vague abdominal pain and no other findings and I’m sure they are just the tip of the iceberg, so to speak. The problem is so common that it attracts a fair amount of research and publications. An in 2011, in the American Journal of Gastroenterology, Dr. Peter Gibson from Australia published a paper that pointed a finger squarely at gluten as the culprit for a lot of people. It was a good paper and, most important, a double-randomized placebo controlled trial, almost the holy grail of medical studies. And the gluten free boom was born. Don’t get me wrong. This has been a great time for the poor people with real celiac sprue. The widespread availability of gluten free goods is a godsend for them and I’m happy they have better access to foods. But, as any physician will tell you, the number of patients with gut aches have not decreased, despite the boom market in gluten free products.

What industry fails to mention and went almost completely unreported, was Dr. Gibson is a pretty good scientist. He wasn’t completely satisfied with his results and he went back to the drawing board and designed a new study. A particularly elegant study where people who identified themselves as having non-celiac gluten sensitivity were divided into 3 groups and fed three different diets, high gluten, low gluten and gluten free. They didn’t know which diet they were eating and they kept journals of their symptoms. Then, two weeks later, they rotated diets. Two weeks later, they rotated again, until each group had eaten each diet. Then the results were tabulated. Anyone want to guess the results?

No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates.

That’s the title of Dr. Gibson’s 2013 article in Gastroenterology. And I’m pretty sure you never heard of this paper at all. Because, if you had and you believed, as Dr. Gibson does, that gluten is not the issue, well, what happens to that $15 BILLION market for gluten free goods?

As the title above suggests, Dr. Gibson has hit on a better explanation for functional abdominal pain and it’s called FODMAPS. FODMAP stands for fermentable, oligo-, di-, monosaccharides, and polyols and with a name like that, even FODMAP seems easy. I have no doubt that for many people following a low FODMAP diet will ease some of their complaints. If you are interested and want to know more, Dr. Gibson’s own site is probably the best resource and includes explanations, video, diet recommendations and even phone apps to help people feel better. But I have two problems with the whole FODMAP thing.

First, the idea is classic reductionist western medical thinking. Briefly, this is the idea that if we keep reducing the whole gut to it’s individual parts and components, we’ll eventually find something that causes this functional gut disorder. This kind of thinking works with bacterial disease because, if you look hard enough, you can often find something that causes a wide range of symptoms. Think of Borrelia burgdorferi,  the forgotten cause of Lyme’s disease. The problem with this sort of thinking, however, is that the gut is a system and it requires a systems thinking approach. For instance, the Monash University site (where Dr. Gibson practices and does reasearch) has a list of high and low FODMAP foods. You’ll notice that there are a lot of fruits and vegetables that are not recommended on a low FODMAP diet. But a Google search of “low FODMAP cookies” yields 284,000 results, which would lead one to conclude that cookies are OK, but I should avoid asparagus, artichokes, onions, leeks, legumes, celery and sweet corn as well as apples, pears, mango, watermelon, nectarines, peaches and plums. Madness.

My second issue, which is really an extension of the first, is that functional gut problems and IBS are basically non-existent in people who follow a plant based diet. Unfortunately, there is little research here, but numerous anecdotal reports of people with symptoms becoming symptom free when adopting a vegan or plant-based diet. So, perhaps, there is more to it than the FODMAPs. Maybe, just maybe, it’s the whole package. It’s the fiber, the complex carbohydrates, the phytochemicals and the nutrients that work together, naturally and in concert, to make the gut function better.

So, what happened to my 22 year old patient? Well, time for truth, it wasn’t a patient. It was my son Andrew. And he’s now a plant based eater and only has pain when he eats cheese. Go figure.

Let’s Talk About Constipation

As a practicing General Surgeon in a rural community, my practice also involved a good bit of upper GI endoscopy and colonoscopy. As such, I have spent many years talking with patients about their GI complaints and one of the most common, by far, is constipation. In light of my current efforts to promote a plant based diet, I thought it might be time to have a few words about this common problem. It’s also an interesting study in where the medical practice in the US has gone so wrong.

I refer the interested readers to a new article, published in the Journal of the American Medical Association (JAMA) on January 12, 2016 entitled “Constipation, Advances in Diagnosis and Treatment“. The article was written by Arnold Wald, MD from the University of Wisconsin’s Gastroenterology Division. Dr. Wald was recommended as a “Best Doctor in America” for 2011, 2013, 2014 and 2015 (no mention of what happened in 2012). I’m not here to pick on Dr. Wald, who I’m sure is very learned and an excellent physician. I am here to pick on his article.

As background, you have to understand the role that JAMA plays in American medicine. There are basically two journals that most primary care doctors read. One is JAMA and the other is The New England Journal of Medicine. After that, it’s hit or miss depending upon the specialty and interest of the physician (i.e. Family Practice, Internal Medicine, Peds, etc.). So having a review article in JAMA, which is likely to have wide readership among primary care physicians, is a big deal. And, equally important, it’s a big deal to get the information right so these busy primary care docs know what to do when a patient presents complaining of constipation. In the section of the article headed Clinical Presentation and Assessment Dr. Wald is informing his readers what he recommends they do to assess patients with constipation. He says: “The clinical evaluation should include the duration of symptoms, frequency and consistency of stools, presence of excessive straining, feeling of incomplete evacuation, or use of manual maneuvers during defecation. Clinical evaluation should also focus on excluding organic causes and medications (box) and identifying the presence of “alarm” symptoms that suggest further workup is required for colon cancer (such as sudden change in bowel habits, blood mixed in the stool, unexpected weight loss, or a strong family history of colon cancer).” The (box) notation then goes on to a graphic that illustrates the other “common” causes of constipation that the clinician should consider. It includes: Mechanical, Neurologic Disease, Metabolic Disturbances, Medications (Partial List), and Miscellaneous causes.

OK, I know that most of you are not physicians, but I’m hoping, at this point, you don’t need to be to spot the huge gap here. What did our esteemed colleague Dr. Wald miss? Well, how about diet? How in the world can you expect to work up constipation if you don’t ask about the diet? According to Journal of Academy of Nutrition and Dietetics article in May 2012 the average fiber intake for someone living in the US was 15 grams. 15 grams! Even the lame guidelines recommend a minimum of 25 grams. As a plant based eater, my daily intake varies between 45 and 100 grams and I can assure you that it makes a serious impact on colon function.

Bottom line (so to speak): if you’re a physician, ask patients what they eat. If they have any GI problems (and so many do) think about recommending a plant based diet. The naturally occurring high fiber is excellent for IBS, constipation, diverticular disease and hemorrhoids. And if you are interested in taking an active role in your own health, consider being more plant based to get you back to “normal”.

Add-on bonus! The second most important thing that Dr. Wald forgot to advise physicians to ask is what position do you assume for defecation (i.e. going #2, pooping, etc.). There has been some very good research done on the effect of position on ease of passing stool. The bottom line here is it is super important to get your hips flexed (i.e. get your feet off the floor). A commercial Squatty Potty  will do the trick. If that’s too difficult or inconvenient, Doctors Takano and Sands from the colorectal division of the Cleveland Clinic recommend “The Thinker” position. Food for thought?the-thinker-by-rodin-1233081-639x852

Back from Cruise Land

Just got back into town last night after a 5 night cruise on Celebrity Cruise’s Eclipse. First of all, it was a wonderful, relaxing, and warm experience. Living, as I do, in the “frozen tundra” a wintertime escape to a place where it’s over 30°C is amazing. But this is a blog about plant based diets and not travel, so I’ll stick to the points.

It’s hard to travel as a plant based eater. Sometimes really hard. Airports, forget it. Airplanes, not a chance. The best you can hope for is a small bag of peanuts or pretzels. But small towns are generally not good either, especially if you have to eat out. And even bigger cities can be challenging. We ended up in Miami for night and discovered a place called Jar + Fork. If you’re in Miami and are looking for some plant based food, it’s not a bad place to start. Really more of a paleo restaurant, but any decent plant based eater will find a home in paleo land.

One would think, though, on a gigantic cruise ship (121,878 tons) that there might be a little plant based love to be had. And the answer, I’m sorry to report, is that there is not unless you love salads. And I, my friends and readers (if there are any!) am not a “salad vegan”. Not that I don’t enjoy a salad from time to time, especially if I don’t have to do the preparation, but it’s not my favorite, by any means. If you’re diligent and look really hard, there are the occasional plant based treats. There was an “Indian” section that frequently had a dal and, if you looked between the chicken, beef, and lamb curries, there might be a vegetable curry. There was an “Asian” section that had a vegetable noodle dish, but typically flavored it with egg and getting some without egg was difficult. And there was an unadvertised vegetarian menu for the main dining room, but most every dish was loaded with cheese. So a plant based eater on a major cruise line can, with care and patience, find food to eat, but you better be OK with eating a lot of salad. And why is that? Clearly because we plant based eaters are too few and too silent. But I don’t want to have to go through the next 40 years eating an afterthought from the omnivore world. I want a world of tasty dining options that don’t include meat and cheese. And tasty food is out there, it’s not that hard to make, and it can not only taste great, but not make you sick! I want that!

Rant portion: But holy hell, the meat, cheese and dairy on display for the omnivores was impressive. Impressive, too, was the breadth and girth of a very large number of the passengers. It’s one thing to know that obesity is a problem in the world, but go on a cruise ship and watch very fat people eat enormous quantities of crappy food and it’s nothing short of impressive (and a little disgusting).