I am starting to use Substack for blog posts. My Substack address is drjohngscott.substack.com. I will continue to post on this site also for the time being, but I will eventually switch over completely to Substack. Substack is more flexible (and also free!). Try it out.
FEB 11, 2026
New dietary guidelines were released in January by the USDA and Department of Health and Human Services titledDietary Guidelines for Americans 2025–2030. In this post I’m going to illustrate the clear deficiencies of the new guidelines by comparing them to two older versions of Dietary Guidelines for Americans. I will begin the description of each guideline with the visual diagram used to summarize the guideline.
Dietary Guidelines for Americans 1995. These guidelines introduced the image of the food pyramid. The pyramid suggests daily servings for each of the food groups. Serving size is defined in the full text of the guidelines. The most servings are at the base of thy pyramid (bread cereal rice and pasta group) and the least number of servings at the third level of the pyramid, which include dairy and proteins. Note that the very top of the pyramid, which includes fats, oils and sweets, does not include serving sizes but just advises to use sparingly.
Thanks for reading Dr John Scott’s Substack! Subscribe for free to receive new posts and support my work.
The full version of the guidelines is 40 pages long and includes the names of a 12 member expert advisory committee. This committee included many famous experts in nutrition, especially Marion Nestle.
By 2020 a lot more information was available about foods that increased or decreased the risk of chronic diseases such as diabetes, heart disease and stroke. The image was changed from a food pyramid to an image of a healthy eating plate. The generic image did not include serving sizes except suggesting no more that 1-2 servings a day for dairy products.
The guidelines included a My Plate Plan calculator that makes calorie recommendations and serving sizes based on age, gender, height, weight and average activity level. Try out the calculator using the above My Plate Plan link. It’s fun to see how many calories you should eat and how they should be distributed.
Note the proportions of food groups on the Healthy Plate image. Vegetables (not including potatoes and french fries) and fruits make up half of the daily calories. Whole grains and protein make up the other half at roughly 1/4 each. Healthy protein emphasizes fish, poultry, beans and nuts with advice to limit red meat and cheese.
The guidelines also recommend eliminating processed meats like bacon and cold cuts. Limited quantities of healthy oils (both olive oil and vegetable oils) were recommended for salad and for cooking. It recommended avoiding trans fats
The full text of the 2020-2025 guidelines is 140 pages long. As with the previous guideline it lists the names of a 20 member advisory committee. It also includes a detailed description of how the guidelines were developed. Here is a particularly relevant quote from that description:
“The Guidelines must be grounded in the body of scientific and medical knowledge available at that time, not in individual studies or individual expert opinion.”
The new image for the 2025-2030 is an upside down version of the 1995 food pyramid. Things you should eat the most of are at the top and things to eat the least of are at the bottom. This image says nothing about actual quantities of the foods recommended. It has red meat (including an image of a steak), cheese and poultry at the top and whole grains at the bottom. This is the complete reverse of the 1995 pyramid, which had whole grains at the base of the pyramid with meat and poultry and dairy limited at the top. It is also almost the reverse of the 2020 Healthy Eating Plate. The 2025-2030 inverted pyramid does at least have vegetables at the top, but fruits are somewhere in the middle.
The full version of the new guidelines consists of only nine pages. there is no listing of an advisory committee or any scientific reviewers. The only authors listed are Robert F. Kennedy Jr (Secretary of HHS) and Brooke Rollins (Secretary of Agriculture).
The 2025-2030 guidelines have a little good advice (eat mostly unprocessed foods and avoid added sugar ), and a great deal of very questionable advice. See below
Fats
The 2026 guidelines advise eating (or drinking) full fat dairy (all saturated fat), They advise that healthy fats include beef tallow and the fat in red meat (all saturated fats). Here is a quote from the 2025-2030 guidelines:
“Healthy fats are plentiful in many whole foods, such as meats, poultry, eggs, omega-3–rich seafood, nuts, seeds, full-fat, dairy, olives, and avocados. When cooking with or adding fats to meals, prioritize oils with essential fatty acids, such as olive oil. Other options can include butter or beef tallow.”
Note that meats, poultry and eggs are listed before nuts, seeds olives and avocados and full fat dairy is mentioned in the middle of those much healthier polyunsaturated fats.
Another interesting quote from the 2025-2030 guidelines:
“More high-quality research is needed to determine which types of dietary fats best support long-term health.”
This is absolutely not true. There is plenty of research showing polyunsaturated oils and fats lower the risk of cardiovascular disease. I suspect this statement is a veiled reference to Kennedy’s completely unsubstantiated idea that seed oils, which are polyunsaturated oils are bad for you. Seed oils are polyunsaturated oils and have been shown to lower the risk of cardiovascular disease. Even polyunsaturated fats should account for no more than 20-35% of daily calories.
The 2025-2030 guidelines do say that saturated fats should be limited to no more than 10% of total daily calories. This is the same as recommended in the 20020-2025 guidelines. It is not clear how you would do that by eating full fat dairy, using beef tallow for cooking, and eating red meat for protein. We know that eating too much saturated fat increases the risk of heart disease and stroke. The American Heart Association recommends limiting unsaturated fat to only 5-6% of total daily calories.
Protein
The 2026 guidelines suggest protein intake of 1.2 to 1.6 grams of protein per kilogram of body weight. This is the amount of protein recommended for very active people (i.e. long distance runners and weight lifters. People who are more sedentary need only 0.8 grams of protein per kilogram and moderately active people only need about 1 to 1.5 grams of protein per kilogram of body weight.
The average American eats about 20% more than the recommended amount of protein (see this link from BBC Science Focus). Not only do we eat more protein than we need, two thirds of that protein comes from animals (Department of Agriculture Food Surveys Research Group).
Alcohol
Previous versions of the Dietary Guidelines for Americans have recommended a maximum of 1 drink a day for women and 2 drinks a day for men. A change to 1 drink per day for both men and women was proposed for the 2020-2025 guidelines, but any change in this recommendation was actively opposed by the alcohol industry so the advice remained unchanged.
The best current science shows that there is no totally safe level of alcohol intake. Alcohol at any level increases the risk of cancers of the GI tract, high blood pressure, cardiomyopathy, sleep disturbance, and dementia. The more alcohol consumed, the bigger the risk. Another problem is that “drink” means different things to different people
The UK national health service uses a measure called a “unit” of alcohol. A unit is 10 ml (about 1/3 oz) of pure alcohol. That is the amount that most people can metabolize in 1 hour. The NHS recommendation is that no more than 14 units per week is a low (not zero) risk level of alcohol consumption. Here is a chart showing what 14 units of alcohol is in common alcoholic drinks:
A shot of spirits is 25 ml (.8 oz) of 80 proof alcohol, which is equal to 1 unit.
The 2025-2030 guidelines recommendations just say “Consume less alcohol for better overall health.” This guidance is not very helpful.
Bottom Line
The 2025-2030 Dietary Guidelines for Americans are poorly researched and contain much advice that is contrary to current nutritional science. I strongly recommend that you ignore them. The 2020-2025 Dietary Guidelines for Americans remain the most comprehensive and well researched nutritional advice and I would advise that everyone continue to use them.
Alcohol intake recommendations are not current in either guideline. Although there is no absolutely safe level of alcohol intake, the UK NHS alcohol guidelines using units of alcohol as the measure make the most sense.
We have all lately heard a lot about MAHA (Make America Healthy Again) from Robert F Kennedy Jr. Some of the things he is advocating probably would improve the health of Americans, but many would not only not improve health, but would make it worse. In this post I’m going to try to identify the good parts and debunk the rest.
Food Dyes
Kennedy wants to eliminate “synthetic” food dyes except for “natural” ones. Food dyes have no nutritional value and many have never been adequately tested in humans. That does not mean they are toxic or cause disease. The only food dye that has been shown to be possibly toxic to humans is red dye #3 also known as erythrosine. It has already been banned in food and cosmetics. For other food dyes we simply do not know how safe they are for human consumption. . The FDA has recently approved 3 plant based food dyes:
Galdieria extract blue, a blue color derived from the unicellular red algae Galdieria sulphuraria.
Butterfly pea flower extract, a blue color that can be used to achieve a range of shades including bright blues, intense purple, and natural greens. This dye is produced through the water extraction of the dried flower petals of the butterfly pea plant
Calcium phosphate, a white color approved for use in ready-to-eat chicken products, white candy melts, doughnut sugar, and sugar for coated candies.
We don’t know any more about the safety of long term use of these plant-based dyes in food than we know about synthetic dyes. Just because they are extracted from plants does not make them safer. The drug digoxin was originally extracted from the foxglove plant. Taking too much of that can kill you. The most conservative thing to do is to ban food dyes, period. That would take congressional action, which is most unlikely in the current congress.
There is no evidence, by the way, that any currently used food dyes cause cancer or other diseases. There is just very little evidence about whether they are safe or not.
Emulsifiers
Emulsifiers are added to foods to prevent separation of oil and water in foods. They also can increase shelf life. Some are natural products like guar gum and some are synthetic. Emulsifiers are not new and have been used for hundreds of years. There is some evidence that certain emulsifiers may adversely affect the gut microbiome. Most of this work has been done in mice, so it is not clear whether emulsifiers have the same effect in humans. Emulsifiers are used most extensively in processed and ultra-processed foods. Unprocessed foods do not contain emulsifiers. Once again, the jury is out on whether emulsifiers have adverse effects in humans, but they might have an effect on the gut microbiome and promote inflammation and they might not. Kennedy is opposed to all emulsifiers in food. This is not exactly a nuanced perspective, as is the case with all his recommendations and obsessions.
Other Food Additives
There are hundreds of substances added to foods. Here is a link to an FDA list of all substances added to foods that are approved by the FDA or are GRAS (generally recognized as safe): Substances Added to Food. This list is 80 pages long! I have to say that I agree with Kennedy on this one. Already, all of these additives have to be listed on the contents label. If there are more than three things on the contents label that you don’t recognize, leave it on the shelf!
Seed Oils
Kennedy (who is a lawyer, not a health expert, by the way) parrots many so called “natural” food advocates who say that seed oils have toxic by products and the wrong ration of omega 6 to omega 3 fatty acids. They maintain that seed oils cause inflammation and thus increase the risk of heart disease and other conditions like obesity and diabetes. The evidence does not support these claims.
What are seed oils anyway?
Canola (rapeseed) oil
Corn oil
Cottonseed oil
Soybean oil
Sunflower oil
Safflower oil
Grapeseed oil
Rice Bran oil
All of these are polyunsaturated (as opposed to saturated oils like animal fats, palm oil and coconut oil , which are not good for you in more than moderate amounts). They are more refined than cold pressed oils and a chemical process is used in the refining process. These chemicals, including hexane are volatile and completely evaporate during the refining process. There are no toxic by products in refined seed oils.
Health effects of seed oils – The evidence
Seed oils contain linoleic acid which is an omega 6 fatty acid. Multiple studies show that linoleic acid intake decrease the risk of heart disease and decreases , not increases inflammation. The best way to use these or any oil as a beneficial part of a healthy diet is stir frying vegetables, oven roasting fish, or crafting homemade salad dressings.
The correct ration of omega 6 to omega 3 fatty acids is not clear. To get both eat omega 3 fatty acids which are found in high amounts in walnuts and fatty fish. A good summary of the evidence on the good health effects of seed oils can be found on this Massachusetts General website: Seed Oils: Facts and Myths.
Beef Tallow
Kennedy thinks that using beef tallow for frying is healthier than seed oils. While beef tallow does make for delicious french fries, it is 100% saturated fat. Saturated fat can be healthy as a small part of your total fat intake, but eating exclusively animal fat vs unsaturated fat markedly increases the risk of heart disease, obesity and diabetes. Multiple studies over the years have confirmed increased risk from eating exclusively or large quantities of saturated fats. Kennedy has a video of him frying a whole turkey in beef tallow while saying that this is cooking the MAHA way. Here is a link to that video. In my opinion this is the height of irresponsibility.
Water Fluoridation
Kennedy cites studies that show decreased IQ in children who are exposed to fluoridated water. I have a previous post about the safety of water fluoridation. See this link. The bottom line is that these studies were done in countries and locales that had very high natural fluoride levels. There was no effect in these studies on the very low fluoride levels that are used in water supplies to prevent cavities in children. Banning water fluoridation will lead to excess tooth decay in the most vulnerable children.
Limiting foods that can be purchased with SNAP benefits
SNAP stands for Supplemental Food Assistance Program. It used to be called the food stamp program. Benefits are applied to a card that can be used like a credit card to purchase food. As of now households whose gross income is 130% or less of the federal poverty and whose net income is below the federal poverty level are eligible for SNAP benefits. The amount is determined by the number of people in the household. The federal government pays all of the benefits and 50% the administrative costs. The state pays the other half of the administrative costs. The Big Beautiful Bill Act will make substantial cuts to the SNAP program. More about that later.
People can use their SNAP benefits to purchase food, but not alcohol or cigarettes. Texas and Louisiana have just passed laws that also prevent using SNAP benefits to purchase soft drinks or candy. Kennedy has praised these new state laws. While it is true that soft drinks and candy are not healthy foods, excluding these from SNAP benefits is just a way to make lawmakers feel virtuous about limiting the food choices poor people make. It is not going to improve their nutrition because like non-SNAP households foods households buy on SNAP benefits tend to be ultra-processed foods. Healthy unprocessed foods are more expensive and require time to prepare and cook as well as requiring working appliances and cooking equipment. Families at or below the poverty level, who are often renting sub-standard housing are unlikely be able to afford to purchase or to have the time, and equipment to prepare and cook unprocessed foods. Non-SNAP households don’t do much better. See this link from the USDA: Foods typically purchased by SNAP households .One more MAHA recommendation that will likely not improve health!
What makes this even worse are the cuts to the SNAP program in the Big Beautiful Bill Act. Here is a summary of the cuts and when they will kick in:
Shifting SNAP costs to states by:
Requiring states to pay a portion of SNAP benefits for the first time in program history, up to 15%, based on their payment error rates, beginning in October 2027. Final negotiations in the Senate resulted in a temporary implementation delay for up to two years for states with high error rates.
Increasing the state’s share of administrative costs from 50% to 75%.
Restricting future adjustments to the Thrifty Food Plan, which will include cuts to SNAP benefits as well as benefit levels for The Emergency Food Assistance Program (TEFAP), SUN Bucks/Summer EBT benefits, and the Nutrition Assistance Program block-grant to Puerto Rico.
Increasing the number of individuals subject to time limits on their SNAP benefits, including, for the first time ever, parents of school-aged children over 14 and older adults age 55 through age 64 by expanding work requirements and restricting waivers.
Adds a time limit on benefits for veterans, currently homeless individuals and former foster care youth.
Eliminating funding for the SNAP Nutrition Education program.
SNAP is (or was) the most effective hunger relief program in the U.S.
With no evidence whatever, the MAHA report calls current childhood vaccination schedules “overmedication.” It emphasizes exceedingly rare adverse effects of vaccines and promises to do “randomized trials” of current vaccine schedules. Randomized trials are routinely done before new vaccines are approved and repeating them will be inordinately expensive and delay vaccine approval. The result of this MAHA policy will mean that we will see serious childhood diseases again, some of which will result in hospitalization and some totally avoidable childhood deaths. We have already seen a resurgence of measles cases in 40 states. See my previous post about Vaccine risks in perspective.
Bottom Line
Kennedy has legitimate concerns about the unhealthy ultra-processed foods that most Americans eat. The concerns about food additives are also reasonable but overblown. These legitimate concerns are mixed in with conspiracy theories about toxic byproducts in seed oils, health benefits of beef tallow, and vaccines as a cause of autism. He completely ignores the fact that most poor people cannot afford to buy, prepare or cook healthy unprocessed foods. He is overall a danger to public health.
Inflammation is activation of the immune system in response to threat or injury to the body. Acute inflammation mobilizes the immune system to repair an injury or fight an infection. Once healing takes place the immune system goes back to baseline. Chronic inflammation, however, involves long term activation of the immune system caused by some ongoing stress to the body. More and more, researchers are beginning to show that chronic inflammation is the common pathway to many diseases. There are multiple causes of chronic inflammation. In this post I will write about the causes of chronic inflammation. I will also do a series of posts about the many diseases that chronic inflammation causes. These posts will be based on the structure of an excellent book: Inflamed – Deep Medicine and the Anatomy of Injustice. It is not easy to read because it is disturbing but I highly recommend it. I will also write about a test to measure chronic inflammation. I will write about things you can do to decrease chronic inflammation if you have it and how to prevent it if you don’t. There are many causes of chronic inflammation that have to do with the structure of our society. These are things an individual cannot control. These societal causes will take ongoing efforts by all of us to change some of the toxic structures of society.
The Process of Inflammation
The inflammatory process starts with damage or threat of damage to the body. That can be an infection, a wound, or perceived threat of such. The immune system mobilizes white blood cells called macrophages to the injured area or site of infection. The cells of the immune system also release a cascade of messenger molecules called cytokines that amplify inflammation. These include interleukin 1ß, interleukin- 6 and tumor necrosis factor -α. The liver also releases a protein called c-reactive protein. When the threat is neutralized the immune system helps the body start to heal by releasing anti-inflammatory cytokines including interleukin (IL)-1 receptor antagonist, IL-4, IL-10, IL-11, and IL-13.
In chronic inflammation the pro-inflammatory cytokines continue to predominate and the c-reactive protein continues to be elevated.
Causes of Chronic Inflammation
Causes an individual can do something about
Low levels of physical activity.
Having a BMI at or above 30 , especially when excess weight is deep within your belly (visceral fat). The best way to measure belly fat is to use a tape measure to measure your waist at the widest point. Increased belly fat is greater than 35 inches for women or greater than 40 inches for men
An imbalance of healthy and unhealthy bacteria in your intestine (dysbiosis). Dysbiosis can be caused by antibiotics and by eating foods low in soluble fiber.
Regularly eating foods that cause inflammation, especially highly processed foods, or foods high in sugar or salt
Inadequate sleep
Using tobacco products.
Regularly drinking too much alcohol
Periodontal disease (gum infection) and tooth decay
Perceived stress
Societal Causes
Experience of racism (structural or personal)
Poverty
Homelessness
Worry about debt
Work stress
Exposure to air pollution
Exposure to chemicals (pesticides and herbicides for farm workers, glyphosphate (RoundUp) for everyone, microplastics in our bloodstreams for everyone. Every day, we are surrounded by thousands of synthetic chemicals. They are in our food, clothes, tools, furniture, toys, cosmetics and medicines. We know the health effects of only a few of these).
All of the inflammatory cytokines can be measured but those are expensive tests. A simple inexpensive test that measures inflammation, both acute and chronic is high sensitivity CRP. It will also be high with an acute infection or injury, but will return to normal after the infection or injury have resolved. If it remains elevated when you are not sick or injured it is a sign of chronic inflammation. It may be worth asking your doctor to order this test if you have any of the individual or societal risk factors for chronic inflammation. A normal hs-CRP is less than 0.55 mg/dl in men and less than 1.0 mg/dl in women. If your hs-CRP is high in the absence of acute infection or injury, that can serve as motivation to make lifestyle changes to decrease your chronic inflammation and put you in a population that has less risk of developing any of the diseases associated with chronic inflammation.
Anti-inflammatory lifestyle
Exercise regularly. The CDC recommends 30 minutes of moderate exercise (walking briskly) for 30 minutes at least 5 days a week.
Eat mostly unprocessed or minimally processed foods and avoid sugary drinks or foods with added sugar or high fructose corn syrup. Also include foods with high soluble fiber such as beans, carrots, sweet potatoes, nuts, berries and most fruits (not fruit juice). Organic foods, while more expensive, have no residual pesticides or herbicides. If you eat meat buy grass fed beef, and pasture raised chicken and pork. Eat more plant-based foods than meat.
Avoid taking antibiotics as much as possible
Sleep. Average at least 8 hours a night
Floss your teeth daily, brush twice a day and see your dentist every 6 months
If you don’t smoke, don’t start and if you do smoke quit.
It is better not to drink alcohol at all, but if you do limit it to 1 drink a day or less.
Learn meditation or self hypnosis to manage stress. There are good books and videos, but an in person course is best if it is available.
Drink only filtered water and not bottled water in plastic bottles
Gas stoves cause significant indoor air pollution. If possible switch to an electric stove. Induction type burners actually heat more quickly than gas. If you have to use a gas stove, be sure to turn the ventilator fan on and open a window if possible.
Bottom Line
Chronic inflammation is the common pathway for many chronic diseases. There are many individual strategies that reduce or prevent chronic inflammation. Many of these strategies are not possible for people with socioeconomic problems. The stress black people experience from structural and individual racism, homelessness or inadequate housing, anxiety over debt, exposure to environmental synthetic chemicals, and exposure to air pollution are societal problems that we all have a responsibility to address.
My next post will deal with chronic inflammation and cardiovascular disease.
In my last post I wrote about energy balance and the complex control of appetite and metabolism. I also wrote about diets for weight loss and how well they work and how sustainable they are. In this post I’m going to write about what we can eat that is good for our individual health as well as for the health of the planet.
Traditional Cuisines
People across the world do not eat the same things. Nonetheless, all traditional cuisines (not including the ones that have been “westernized”) are associated with good health and low risk of cardiovascular disease and stroke. This even includes the traditional Inuit cuisine, which is very high in meat (seal and other marine mammals), fat and fish.
What all these traditional cuisines have in common is that they are high in unprocessed or minimally processed foods. Meat is not a large part of any of the traditional cuisines, with a few exceptions, but it is not absent in most traditional cuisines.
Healthy Plant-based Foods
There are no particular vegetables, fruits, nuts or berries that you have to have in your diet in order to have a healthy plant-based diet. The trick is to eat a variety of plant-based foods. If you want to have an entirely plant-based diet, that can be very healthy but no one plant protein includes all the essential amino acids. In order to get all the essential amino acids you must be sure to include legumes, lentils and nuts in your diet as well as leafy vegetables and potatoes.
Is a plant-based diet better for the environment than one that includes meat?
The answer to this question is complicated. Some people choose vegan diets because they don’t believe in killing animals for food. Growing vegetables, fruits and nuts results in killing lots of animals and insects however. Most vegetables, fruits and nuts are grown in monocultures. Monoculture attracts large numbers of animals and insects that eat those crops. Farmers use insecticides and rodent poison to kill insects, including beneficial insects, mice and rats. Farmers are allowed to shoot deer that are eating their crops. Even farmers who grow organic vegetables use things like BT and neem oil to kill insects. People who think no animals die when they eat a vegan diet are mistaken. Soybeans in particular are grown in large monocultures and the USDA has a hard time policing soy that is supposed to be organic, but is not.
The use of manufactured fertilizer is another problem. Synthetic fertilizers, especially the nitrogen component are made from natural gas (which is mostly methane). Phosphate and potassium have to be mined.
Many food crops are genetically modified for insect and herbicide resistance. Food and fiber plants that are resistant to glyphosphate (Roundup) have resulted in detectable glyphosphate levels in all animals including humans. Corn that has been genetically modified to include BT has been harmful to honey bees.
So the answer to whether a vegan diet is good for the planet depends on how those vegetables, fruits berries and nuts are grown. Growing your own or getting vegetables from known small farm sources can be very good for the environment. Truck farming in large monocultures is not so good for the planet.
Is eating meat healthy and is it bad for the planet?
The current way that most meat animals are raised is not only cruel to the animals, but bad for the environment. Most meat animals (at least in wealthy western countries) are raised in CAFO’s (Concentrated Animal Feeding Operations). There is an alternative way to raise meat animals that is not bad for the planet. I will write about that shortly, but first I want to show you some examples of CAFO’s. Most meat eaters buy meat in the grocery store, neatly packaged. Since most people do not live on farms anymore, we are separated from and do not witness the killing of the animals whose meat we eat. I’m about to show you some disturbing photographs of how animals are treated in CAFO’s. After that I will write about how it is possible to eat meat from animals who are treated well up until the day they are killed.
This is a typical photograph of how our meat chickens are raised. This is a broiler CAFO
This is caged CAFO egg production. These chicken live their whole lives in these cages
This is a CAFO beef cattle feed lot. These animals are fed grain to fatten them up before they are sent to the slaughterhouse.
This if a pig CAFO. The animals hardly have room to turn around.
If you buy meat in a grocery store and you don’t know the source of the meat, it likely comes from a CAFO like these. Another problem with animal feeding operations like these is that they are fed grain that could be used for human consumption. It takes 6 pounds of grain for every pound of meat for cattle. Chickens require a little less and pigs a little more.
Farmed fish are raised in CAFO’s also. Here are two images of salmon raised in pens. Many of them fail to thrive and die. The dead fish that have been autopsied show very high levels of stress hormones.
Other fish that are farmed in CAFO’s include tilapia, catfish and shrimp.
How to eat meat and fish ethically without harming the planet
The first thing we can do is to simply eat less meat. The US and Australia are the biggest meat eaters in the world, and every country that can afford it is also increasing the amount of meat they eat. This is simply not sustainable. Cattle from feed lots and chickens from CAFO’s add carbon to the atmosphere and make global warming worse. We need to follow journalist Michael Pollan’s succinct advice about diet: “Eat food (food is anything your grandmother would have recognized as food), mostly plants, not too much.”
Ungulates
Ungulates (cattle, sheep and goats) eat grass, which we can’t eat or digest, and turn it into meat, which we can eat. Although ungulates do burp some methane, they also store carbon from grass in their muscles. Eating grass fed beef (or lamb or goat) does not add new carbon to the atmosphere, especially if meat only makes up a small part of our diet. Grass fed beef and lamb can usually be found at farmer’s markets. Specialty grocery stores are beginning to carry grass fed beef and lamb, and it can also sometimes be found at health food stores.
Chickens
Pasture raised chickens eat plants, worms and insects for most of their diet. They are often supplemented with some organic feed. Again they are part of the carbon cycle and do not add new carbon to the atmosphere. Many of the stores that sell grass fed beef also sell pasture raised chickens. Beware of terms like “free range” and “natural”. Chickens can be called free range if the door to the chicken house is open for part of the day. Free range says nothing about the density of chickens in the chicken house. Once they are raised in high density they don’t go outside even though they technically can. Organic chicken is better than nothing because no antibiotics can be used and they have no added chemicals. Organic chickens can be raised at the same density as CAFO’s however.
Eggs
Cage free eggs means chickens are free to roam inside a building, but it does not mean they get to go outside. The density of the chickens can still be unacceptably high. Cage free is certainly better than CAFO caged egg production, but is still not ideal. Pasture raised egg production is best, but this is not a term that is regulated by the FDA. If the egg carton says pasture raised, look for a stamp that says “Certified Humane” and/or “Animal Welfare Approved.” These are third party organizations that certify that eggs come from pasture raised chickens.
Pigs
Pigs are not ungulates, so they do not eat grass, but they do eat plants, insects and nuts. This diet can be supplemented with silage and grain, but pigs will also eat table scraps, so like grass fed beef and lamb, pigs can turn something we normally throw away into nutritious meat. Pasture raised pigs get to behave like pigs, which includes rooting and digging as well as running. Their meat is therefore less fat and more nutritious. Pasture raised pork is a little harder to find than grass fed beef and pasture raised chickens. Farmers markets are probably the best source.
Cornucopia
There is an excellent non-profit organization called Cornucopia. They rank sources of both animals and plants for ethical standards. They have scorecards for beef chicken, eggs, dairy, yogurt, cereal and others. They also include where to obtain each type of food. Here is a link to their website: Cornucopia.org.
Fish
There is no question that eating fish is good for your health. although children and pregnant women need to be careful because some ocean fish has a substantial amount of mercury. The fish with the highest levels of mercury are shark, swordfish, fresh tuna marlin, king mackerel, tilefish from the Gulf of Mexico, and northern pike. These species should probably be avoided by children and pregnant women.
Some type of fish are farmed sustainably and others are not. Wild caught fish is usually better, but not always. The Monterey Bay Aquarium has a rating service that is based on science and what is known about fish stocks Their service is called Seafood Watch. The service has the following ratings:
BEST CHOICEBuy first. Green rated seafood is well managed and caught or farmed in an environmentally responsible manner. It poses a low environmental risk.
CERTIFIEDBuy the certified products listed on our website.
GOOD ALTERNATIVEBuy if a Best Choice option is not available. This seafood poses a moderate environmental risk.
AVOIDTake a pass on this red rated seafood for now because it poses a high risk to the environment. They’re overfished, lack strong management, or are caught or farmed in ways that harm other marine life or the environment
They also have a super green list of seafood no-brainers. The database includes almost all edible fish with ratings for each one. Here is a link to their website: Monterey Bay Aquarium Seafood Watch.
Bottom Line
Traditional cuisines, which include many types of foods and that have not been westernized are all healthy and decrease your risk of heart disease compared to the standard American Diet.
Whether you are a vegan, vegetarian or include meat in your diet, the sources of your food have the most to do with how healthy what you eat is for you and for the planet.
The current level of meat that western countries eat is not sustainable for the planet. Meat should not be the main part of your diet. If you are a meat eater you should eat grass fed beef and lamb, pastured chicken and eggs, pastured pork and sustainable fish – wild caught or farmed responsibly.
CAFO’s are cruel to animals and harmful to the environment. We should not include meat or fish from them in our food budgets. Meat from pasture raised animals costs substantially more than meat from CAFO’s. Since we should be eating less meat anyway the extra cost should be sustainable for most people.
We are inundated from social media and other sources about diets and how well they work. In this post I’m going to describe the current most popular diets and how safe and effective they are at producing weight loss. I’m also going to write about the physiology of appetite, what controls appetite, and the mechanisms involved in weight regain after dieting. I will also discuss the ways people have discovered to maintain their weight loss. I am not going to discuss medicines for weight loss or bariatric surgery in this post. Those are subjects for another day. I did do a previous post on GLP1 agonists for weight loss. If you are interested you can link to that post here.
Energy Balance
Neither humans nor any other animal can survive without food. Our bodies convert food into the energy we need to keep our bodies intact and to be able to move about. The measure of the available energy in food is calories. A calorie is the amount of heat energy required to raise 1 gram of water by 1 degree centigrade. This is a very small amount of energy, so the unit we usually use is 1000 calories or kilocalories. When you see the number of calories on a food label, it is always means kilocalories even though it says “calories” on the label.
If on average we eat more calories than we use, our bodies store the extra energy as fat and we gain weight. If on average we use more energy than we get from our food, our bodies use the stored energy from fat and we lose weight. If on average we eat as many calories as we use, our weight is stable. We are in energy balance. We can also gain weight by increasing our muscle mass, but in this post I’m going to write about weight gain and loss as changes in body fat. This is an immutable law. Diet claims that calories don’t matter for weight loss are simply wrong. Calories in versus calories out sounds simple, but energy balance in our bodies is not simple at all.
Our intake of calories is controlled by our appetite and the control of appetite involves multiple hormones and neurotransmitters at multiple places in the brain and in the body. Control of appetite is very complex. I will write more about this later in this post.
Energy we use is of two types. A certain amount of energy is needed just to keep our bodies functioning. This is called the basal metabolic rate. It is also called resting energy expenditure (REE). It varies with weight. The average REE is 1 kilocalorie per hour per Kg (2.2 pounds) of body weight. That means that for a person who weighs 70 Kg (154 pounds) the REE would be 1680 kilocalories per 24 hours, just sitting on the couch. To calculate your own REE, divide your body weight in pounds by 2.2 and multiply that by 24. That will give you the number of calories you use in 24 hours just sitting on the couch during the day and sleeping at night. In general it is going to be in the neighborhood of 1500 to 2000 kilocalories per day.
The other type of energy we use is the energy required to move our bodies. These are called active calories. Active calories also based on body weight. For a 154 pound person, walking briskly burns 280 calories per hour. More vigorous activity burns more calories. Here is an extensive table from the Department of Health Services of Wisconsin that shows kilocalories burned for various activities at different body weights: CALORIES BURNED PER HOUR.
So what would it take for you to be in energy balance if you weigh 70 Kg (154 pounds) and do brisk walking for 30 minutes 5 days a week? Brisk walking uses 280 kilocalories per hour, so 140 kilocalories for each exercise session. That would be 700 kilocalories per week or an average of 100 kilocalories per day. Regular household activities burn about the same amount per hour as walking, so if you do household chores for 4 hours per day including weekends, that would be another 1,120 kilocalories per day. Your REE is 1680 kilocalories per day. You would be burning on average 100 active kilocalories per day for your walking and another 1,120 kilocalories a day for household chores for a total of 2900 kilocalories per day. That number will be a little higher if you weigh more that 154 pounds and a little less if you weigh less than 154 pounds. To be in energy balance you would need to eat no more than 2900 kilocalories per day. If you exercise more, you can eat more and stay in energy balance, but you would need to add a lot more exercise.
Fortunately, you don’t have to do all these calculations. In a normal weight person your body stays in energy balance automatically. Obviously, people who are overweight or obese either are not now, or at some point have not been in energy balance. It doesn’t take being out of energy balance much per day to cause significant weight gain. Lets suppose you take in 100 more calories per day than you use. It takes about 3500 extra kilocalories to gain a pound of fat. That would equal weight gain of fat at a rate of a pound every 35 days, or 10 pounds per year.
Being overweight or obese has serious health consequences that escalate with the degree of obesity. In order for overweight or obese people to avoid these consequences, they need to make a conscious effort to lose weight. That is where diets come in. Exercise is important too, but more for maintaining weight loss than losing weight. Of course exercise is good for you whether you lose weight or not.
Diets
I will write about the most extreme diets first, and then discuss the more moderate ones.
Keto (ketogenic) Diet
The brain is the second most active organ in the body after the liver. The brain normally uses glucose for energy but when glucose is not available and all the glycogen in the liver (which can be converted to glucose) is used up, the body starts to break down fat into something called ketones. The brain can use ketones for energy although it cannot use fat directly. The purpose of the ketogenic diet is to switch the whole body to the use of ketones for energy instead of glucose. This is accomplished by a high fat, very low carbohydrate and low protein diet. Protein has to be low because it can be broken down in the liver to form glucose. Carbohydrate is reduced to less than 50 grams per day which is less than the amount in a medium bagel. Protein is restricted to less than 1 gram per pound of body weight per day.
The ketogenic diet works because it decreases appetite, so despite eating calorie dense fat, total calories consumed are markedly decreased. It does lead to significant and fairly rapid weight loss. It is, however a markedly nutrient deficient diet. People who are on this diet must take supplemental multivitamins and minerals. Doing so keeps people from getting gross vitamin deficiency, but there is also a loss of micronutrients found in complex carbohydrates and it is unclear what the effects of this deficiency are. The ketogenic diet is very low in fiber, which alters the gut microbiome adversely. It decreases triglycerides and increases HDL, which are good, but it also increases LDL, which is bad. On the other hand, it decreases hypertension and has an anti-inflammatory effect. It is not clear whether the positive effects are outweighed by the LDL increase effects. So far, there is no evidence that ketogenic diets increase the risk of heart disease.
The main drawback of the ketogenic diet besides the nutritional deficiencies is that it is virtually impossible to stick to for more than a few weeks or months. Ketogenic diets do reduce insulin secretion since there is much less glucose for insulin to carry into the cells. The ketogenic diet may be useful in type 2 diabetics to reduce insulin resistance and decrease weight, particularly for diabetics in poor control. It is not a diet that can be maintained long term.
Very Low Calorie Diets
These diets restrict calories to 800 calories per day or less using proprietary liquid formulas that contain electrolytes and high protein to prevent muscle loss. VLCD diets lead to rapid and significant weight loss and are used primarily for people with severe obesity or medical complications of obesity. Such a diet should not be used without supervision of a physician. Again, like the ketogenic diet, VLCD diets should not be maintained long term.
Intermittent Fasting
Intermittent fasting is going without food for some period. Non-caloric drinks such as water or coffee are encouraged during fasting times. The simplest is restricted time eating. This involves skipping one or two meals per day and only eating during a restricted time. Whole day fasts can be once or twice a week or even every other day. One might think that a person would eat twice as many calories on a non-fasting day and so would not experience weight loss. This rarely happens. Intermittent fasting does reduce average calorie intake, and so people on any of the intermittent fasting regimens lose weight. People who start an intermittent fasting diet get very hungry at first on fasting days, but this hunger tends to decrease over time. It takes discipline to maintain intermittent fasting over a long period, but people who have the discipline to stick to the intermittent fasting regimen can stay on it long term. If the food they eat on non-fasting days is healthy (more on this later) then this can be a successful long term eating plan to maintain energy balance at a lower weight.
Paleo Diet
This is supposedly the type of diet that humans ate in the paleolithic period prior to agriculture when all humans were hunter gatherers. Of course people on the paleo diet do not become hunter gatherers. According to the Mayo Clinic a modern paleo diet includes fruits, vegetables, lean meats -especially game meats, fish, eggs, nuts and seeds. These are foods that in the past people could get by hunting and gathering. It doesn’t include foods that became more common when small-scale farming began about 10,000 years ago. These foods include grains, legumes and dairy products.
People on a version of the paleo diet do lose weight for exactly the same reason as weight loss on other diets. The average calorie intake on the paleo diet is substantially less than the standard American diet. It is not clear that excluding grains, legumes and dairy products is a good thing. Whole grains, legumes and dairy products supply high quality nutrients that may be missing in the paleo diet. The paleo diet is also more expensive and may be out of reach for lower income people. There are no long term studies of the health effects of the paleo diet.
Whole30 Diet
This is similar to the paleo diet but is recommended for 30 days. Foods to avoid are alcohol, sugar, dairy products and legumes and grains. There is a list of foods you can eat and all of these are unprocessed foods. The idea is that you reset your metabolism, and then you gradually add back the avoided foods and see how they make you feel. There is no evidence about the claimed long term good health effects of the Whole30 Diet. Like other diets that lead to fewer calories consumed, people do lose weight on this diet.
Plant based Diet
A plant based diet is exactly what it says. It is derived entirely from plants and eliminates all animal products including dairy products and eggs. The sources of protein are legumes, nuts, seeds, soy and lentils. Sources of fat are nuts, avocados, olive oil and vegetable oils. Plant based diets tend to focus on unprocessed foods. Unlike the other diets mentioned in this post, there is a lot of evidence that plant-based diets decrease the risk of developing diabetes (and also treat type 2 diabetes), decrease the risk of high blood pressure, heart disease and autoimmune diseases. Plant based diets have an anti-inflammatory effect, which probably is responsible for many of the benefits of plant based diets.
Unprocessed plant based food is more expensive than ultra processed foods and requires substantially more preparation time. People who live in poor neighborhoods often live in a “food desert” and unprocessed plant foods may not be available or be too expensive to buy. People who have low end jobs often have neither the time nor the equipment for food preparation. Although plant based diets have multiple health benefits, they are out of reach for a substantial part of the US population.
GOLO Diet
The GOLO diet is a proprietary diet plan you have to pay for. It is essentially a Mediterranean type diet that includes a supplement. The supplement has a lot of minerals and vitamins and there is no evidence that any supplement helps with weight loss. It is currently heavily advertised on television and social media. The research cited in all of these ads is research funded by the GOLO company. I will write about the benefits of the Mediterranean type diet next, but GOLO uses a standard dietary plan and a worthless supplement to make money. Don’t waste your money on this diet.
Mediterranean Diet
The original Mediterranean diet was the traditional diet of Crete, Greece and southern Italy in the 1960’s. Italians and Greeks no longer necessarily eat like this, but their original diet had lots of whole grains, vegetables and fish and used lots of olive oil. This type of diet has been studied more than any other and has very similar benefits to the plant-based diet. It reduces the risk of high blood pressure, diabetes, heart disease and autoimmune disorders. Here is the Mediterranean diet food pyramid from Wikipedia. It was developed by Oldways Trust, Harvard and the World Health Organization.
The things at the base of the pyramid are the things you eat the most and the things at the top of the pyramid you eat the least. Notice that red meat and butter are at the top of the pyramid. You don’t eliminate any class of food entirely in this diet, you just don’t eat the things at the top very often. Once again the diet includes mostly unprocessed foods and requires considerable food preparation.
The Standard American Diet (Also called the Western pattern diet)
It is no wonder that we have an epidemic of obesity! The standard American diet is almost the exact opposite of the Mediterranean diet and plant-based diets. It is very high calorie and high in ultra-processed foods. That is why all of the diets I described above cause weight loss. Almost anything is better than the standard American diet!
Weight Regain After Weight Loss
With any diet (other than the very low calorie diets) weight loss stabilizes after a while and then there is very frequently some weight regain. Why does this happen? During the evolution of the human species, obesity was very rare. Hunter gatherers, even the few modern ones that remain in remote parts of the world are not fat. In evolutionary terms, weight loss meant that there was not enough to eat, so metabolic strategies to conserve calories during times of starvation had high survival value. The result is that when we lose a significant amount of weight, the body thinks we are starving. Several things happen to conserve energy. The first thing is that the basal metabolic rate or resting energy expenditure (REE) decreases an average of 50 kilocalories per day, but people who are obese to start with and lose a significant amount of weight can have decreases of REE as much as 700 kilocalories per day. Another body adaptation to weight loss is that the muscles become more efficient and use less fuel. This means that the calories you burn per hour with exercise decreases as you lose weight.
Appetite
As I mentioned before, the control of appetite is complex. Almost all control of appetite is unconscious. Appetite can be consciously controlled only for a short time, just as we can consciously control our breathing for a short time, but most breathing is (fortunately) unconscious. The part of the brain that controls our appetite and food intake is the hypothalamus. The hypothalamus secretes some hormones on its own and controls other hormones and/or peptides that both increase and decrease appetite. One hormone that increases appetite is Ghrelin. It is secreted by the stomach, small intestine, pancreas and brain and has multiple effects. It increases appetite and food intake and promotes fat storage. Hormones that makes you feel full or satiated are Leptin and GLP1. Control of appetite is actually a lot more complicated than this. Below is a table taken from a review article about hormonal control of appetite. Here is a link to the full article. It is not for the faint hearted. Hormonal Regulators of Appetite
The table summarizes what we know about the hormones and peptides that increase appetite and stimulate feeding and those that make us feel full and inhibit feeding. As you can see, control of hunger and satiety is very complicated. All of this takes place outside of our conscious awareness.
Hunger
Hormone
Primary location of production
Receptors
Action
Hypothalamus
NPY
Medial arcuate nucleus (also widespread in CNS
Y1, Y5
Stimulating feeding and atagonizing satiety
AgRP
Medial arcuate nucleus
MC3R and MC4R antagonist
Stimulating feeding
Peripheral Peptides
Ghrelin
Stomach
GHS-R1a
Stimulating feeding by increasing NPY/AgRP and antagonizing Leptin effects
Satiety
Hypothalamus
POMC/a–MSH
Arcuate nucleus
NC3R and MC4R
Inhibiting feeding, stimulating basal metabolic rate and altering nutrient partitioning
CART
Arcuate nucleus
Inhibiting feeding
Peripheral peptides
Cholecystokinin
Duodenum, jejunum
CCK-A
Inhibiting feeding and stimulating gall bladder contraction, intestinal motility, and inhibition of gastric motility
PYY
Ileum, colon, rectum
Y2
Inhibiting feeding by inhibition of NPY and stimulation of POMC
Glucose-dependent insulin secretion, induction of beta cell proliferation, promotion of energy storage, enhancement of bone formation
Insulin
Pancreas
Insulin receptor
Inhibiting feeding
Leptin
Fat cells
Leptin receptor, Ob-Rb
Inhibiting NPY and AgRP and stimulating POMC and CART
Adiponectin
Fat cells
Adipo R1, R2
Inhibiting feeding
With significant weight loss (10% or more) the hormones that control appetite shift toward the hormones that make us hungry. Those includes Ghrelin, NPY and AGrP. The hormones that make us feel full, including leptin and others decrease.
The result of all this is that even if we are sure we are staying on the same foods, we are unconsciously eating more of them. The result is weight regain. The bad news is that 80% of people who lose weight on diets regain a substantial portion if not all of the weight they lost within 1-5 years. The good news is that 20% of people maintain most of the weight loss they achieved even after 5 years. How do those 20% of people who lost 10% or more of their body weight keep from regaining weight? We actually know a lot about how they do it.
National Weight Control Registry
Here is the introductory paragraph from the National Weight Control Registry website:
The National Weight Control Registry (NWCR), established in 1994 by Rena Wing, Ph.D. from Brown Medical School, and James O. Hill, Ph.D.from the University of Colorado, is the largest prospective investigation of long-term successful weight loss maintenance. Given the prevailing belief that few individuals succeed at long-term weight loss, the NWCR was developed to identify and investigate the characteristics of individuals who have succeeded at long-term weight loss. The NWCR is tracking over10,000 individuals who have lost significant amounts of weight and kept it off for long periods of time. Detailed questionnaires and annual follow-up surveys are used to examine the behavioral and psychological characteristics of weight maintainers, as well as the strategies they use to maintaining their weight losses.
The extensive research on the 10,000 people in the registry who have maintained weight loss show the following things that they do. This list is again from the registry website.
98% of Registry participants report that they modified their food intake in some way to lose weight.
94% increased their physical activity, with the most frequently reported form of activity being walking.
There is variety in how NWCR members keep the weight off. Most report continuing to maintain a low calorie, low fat diet and doing high levels of activity.
What all this research means is that it is possible to maintain weight loss despite the cascade of hormonal mechanisms that kick in to conserve calories when weight loss happens that work to get us back to the weight that we were. It is possible, but not easy. It takes continual effort, although people in the registry do report that it gets somewhat easier over time.
Bottom Line
All diets when adhered to result in weight loss
Some eating plans are sustainable and are not nutrient deficient. These include intermittent fasting, plant-based diets and the Mediterranean diet.
More extreme diets such as the Keto diet, VLCD diets and Paleo diet are not sustainable and have various nutrient deficiencies.
Substantial weight loss triggers hormonal changes in the body that conserve calories. These changes are responsible for the fact that weight loss plateaus on almost any diet and significant weight regain even often back to the original weight occurs in 80% of people who lose a substantial amount of weight.
It is possible to maintain weight loss over many years, but it is not easy. Findings from the National Weight Control Registry suggest the following strategies to maintain weight loss
Longevity is the newest health buzzword. There are an increasing number of so-called longevity experts. They say, just read my book and follow my instructions and you can live past 100 years. Some of these “experts” focus on health span. They say follow my instructions and you will stay healthy and die suddenly at an advanced age. As of 4/21/2024 there are 34 books on longevity listed on Amazon.
In this post I will do my best to distinguish the hype from the science with regard to living a long and healthy life.
Hype
Calorie restricted diets – Some people have extrapolated mouse and rat experiments that show that animals fed restricted calorie diets live a lot longer than animals fed a normal diet. There is not one shred of evidence that this works with humans, and is more likely to lead to diseases of malnourishment.
Nutrtional supplements – Recommendations range from vitamins, to protein powder, to collagen powder, to herbal preparations, to encapsulated fruits and vegetables. There is absolutely no evidence that any of these things or any other supplements including multivitamins work to extend your life. Anecdotal reports of feeling better on these supplements are almost certainly a placebo effect
Anti-aging medicines – reservetrol, metformin, rapamycin have all been shown to prolong life in some experimental animals. In humans Metformin and reservetrol decrease the ability to exercise and rapamycin suppresses the immune system. There is no evidence whatever that these compounds increase life or health span in humans.
Extensive lab tests – Other than lipid (cholesterol) tests, there is no evidence that otherwise healthy non-obese people benefit from any blood tests. More about screening tests later.
Imaging tests – One of the most popular longevity “experts” ,Dr. Peter Attia, recommends full body MRI scans for his patients. Imaging tests in people who have no symptoms are much more likely to lead to over diagnosis and unnecessary treatment than to find things that really need to be treated,
Very intense exercise regimens – The only thing very intense exercise regimens accomplish that moderate exercise regimens do not is that the intense regimens are more likely to cause injury.
Science
Genetics
Up until into the 80’s, lifestyle is the major contributor to healthy aging. There are some people, however who remain healthy well into their 90’s and a few to past 100. Genetics is the main contributor to these “super centenarians.” There is not a single or even a few aging genes. Super aging is caused by hundreds of genetic variants called SNP’s (single nucleotide polymorphisms). We cannot alter our genes (yet), so there are no lifestyle changes you can make in order to live to 100 if you don’t have the rare combination of all these genetic variants.
That is not to say that lifestyle is not important to healthy aging. In the US, the average person’s last birthday in good health is age 65! Lifestyle changes will almost certainly help you do better than that.
Exercise
Regular exercise decreases your risk of chronic disease and therefore increases your chance of living healthier longer. To accomplish the maximum health benefit the CDC recommends 150 minutes of moderate exercise per week. Brisk walking or cycling at a moderate pace on level ground would qualify. If you choose high intensity exercise like jogging or running or high intensity cycling, you only need to do 75 minutes a week according to the CDC. The CDC also recommends activity to strengthen your muscles two days a week. For a population of adults doing this exercise regimen the risk of death is decreased by 17%. This regimen decreases the risk of heart disease, diabetes, certain cancers and decreases the risk of hospitalization or death from infectious diseases like COVID, flu and pneumonia. This regimen also increases bone and muscle strength and thus decreases the risk of falls and fractures. This exercise regimen also helps maintain a healthy weight.
Any amount of walking or activity decreases risk somewhat. The CDC recommended regimen decreases risk the most.
Nutrition
Eat mostly unprocessed foods and avoid ultra-processed foods. The best way to identify ultra-processed foods is to look at the ingredients label. If there are more than four ingredients, and/or if there are some you don’t recognize, then put that food back on the shelf. It is best to keep nutrition advice simple. The most concise recommendation I know comes from author Michael Pollan. “Eat food (food is anything your grandmother would have recognized as food), not too much, mostly plants.” I can’t do much better than that. Most of the evidence about the beneficial effects of good nutrition come from studies of the Mediterranean style diet. The Mediterranean diet adheres to Michal Pollan’s advice. It has lots of fruits, vegetables, fish, olive oil and very little meat. Adherence to this type of diet showed a 46% increase in living healthfully until 70 or greater.
Social Connectedness
The CDC defines social connectedness as the degree to which people have and perceive a desired number, quality, and diversity of relationships that create a sense of belonging, and being cared for, valued, and supported. An analysis of multiple studies showed that high social connectedness as defined above decreases the risk of premature death by 50%! High social connectedness also decreases the risk of heart disease, stroke and dementia.
Social Determinants of Health
The main reason that the US average health span is 65 years is the tremendous inequity of resources in the US. People who live in substandard housing (or no housing at all) do not have the opportunity or resources to do all of the things above that tend to extend life. That is why life expectancy at birth is related to zip code more than any other factor. My feeling is that we should expend our resources working on improving health equity, which will increase both life and health span for everyone rather than focusing on helping wealthy people live to 100.
Screening Tests
There are a few screening tests recommended by the US Preventive Care Task Force for healthy people. These tests are meant to find disease, especially cancer early so it can be more successfully treated and thus prolong healthy life. The absolute risk reduction of death for these tests is small, most around 1%, but that ends up saving a lot of people when you apply it to the whole US population. The recommended screening tests are listed below.
Mammograms for women beginning at age 50. Recommended every two years. Absolute risk reduction about 1%.
Pap Smears beginning at age 21 every 3 years through age 29 and then every 5 years from age 30 to 65. The absolute death risk reduction is .0009%, which means your would need to do pap smears on 11140 women to prevent one death from cervical cancer.
Colorectal cancer screening. There are three different tests: colonoscopy, the most invasive (recommended every 10 years), Cologuard (a stool sent to a lab in a box recommended every 3 years) and fecal immunochemical test (done on a stool sample and either tested at home or sent to lab recommended every year). All three tests reduce deaths from colon cancer with an absolute risk reduction of around 0.6%. Only colonoscopy can prevent some cancers by removing precancerous polyps.
Vaccines
There is no question that vaccines save lives by preventing some serious life threatening diseases, or making them less severe. Vaccines are especially important for infants and children, who are most at risk from the infectious diseases prevented by vaccines. Childhood vaccines prevent diptheria, whooping cough, tetanus, measles, mumps, rubella, polio, rotavirus (which causes severe diarrhea and dehydration in infants), hemophilus influenza (which caused joint infections and meningitis), hepatitis b, RSV (which causes severe respiratory illness), pneumonia caused by strep (the most common kind of bacterial pnuemonia), COVID (also for adults), meningitis, chicken pox, and HPV (the virus that causes cervical cancer in women).
Adults can get any of these vaccines, but also a vaccine to prevent shingles.
Bottom Line
Living in good health to past 100 depends on genetics, not lifestyle. Many things recommended by so called longevity experts do nothing to prolong life and may increase risk. There are a number of lifestyle changes including exercise, good nutrition, social connectedness, certain screening tests and vaccines that increase you chances of remaining healthy well into your eighties. The main cause of early death in the US is poverty, homelessness and systemic racism. Addressing these inequities is a lot more important than helping wealthy people try to live to 100.
Most people know these new effective weight loss drugs by their trade names: Ozempic, Wegovy and Mounjaro. Ozempic and Wegovy are different names for semaglutide. Mounjaro is the trade name for tirzepatide. All of these drugs are in the same class. They are called GL-P1 agonists. They mimic the action of a hormone called glucagon-like peptide. These drugs were developed to treat type 2 diabetes. They lower blood sugar by causing insulin release and also by delaying stomach emptying, which delivers less glucose to the bloodstream. The slowing of emptying from the stomach decreases appetite and causes an increased feeling of fullness. People on these drugs tend to reduce their calorie intake fairly markedly and that is how they work for weight loss.
Common Side Effects
The most common side effects of all these long acting medicines are nausea, vomiting, abdominal pain and diarrhea. These side effects usually disappear within a few weeks, and are less likely to happen if they are started at a low dose and increased gradually. Occasionally they are persistent. Some somewhat less common side effects include headache, fatigue, dizziness, constipation, heartburn, bloating, belching and flatulence (passing gas). People with diabetes can sometimes get low blood sugar. Again, most of these side effects usually go away within a week or two. Occasionally they can be persistent.
Rare Side Effects
These side effects are rare, but much more serious and can result in hospitalization. They include severe allergic reaction, acute pancreatitis, gall stones, acute kidney injury, suicidal thinking, and cancer of the thyroid.
Long Term Effects
The evidence so far is that stopping these medicines results in weight gain back to the original weight. That means that people are likely to have to stay on these medicines to maintain the weight loss. We know that the medicines are relatively safe when taken for two years, but we have no idea what long term side effects might be, or even if the medicines will continue to work past two years.
How well do they work?
The medicines are given by injection once a week and they work very well. These are the most effective medicines for weight loss that we have ever had, and there are some new ones in the pipeline that may even work better. As with any medicine, there are risks as I have documented above as well as benefits. You would not want to take one of these medicines unless the benefit exceeds the risk.
Who should take these medicines and who should not?
Obesity increases the risk of diabetes, heart disease and cancer, especially colorectal cancer. The best predictor of risk of disease from obesity is the waist circumference. Just take a tape measure and measure your waist at the level of the belly button. If you are female your risk of cancer starts to increase if your waist circumference is more than 31.5 inches. Your risk of cancer, especially colorectal cancer increases 5% for every inch above 31.5 inches. Above 35 inches the risk of diabetes, and cardiovascular disease starts to go up. For men the numbers are 37 inches for the risk of cancer going up and 40 inches for the risk of diabetes and cardiovascular disease.
The best treatment for obesity is prevention. That means eating unprocessed foods and regular exercise. If you are already overweight or especially if you are obese, it is very hard to lose weight and keep it off. Once you lose weight, your body thinks it is starving and all kinds of hormones and body changes kick in to try to get the weight back.
If your waist circumference is over 31.5 if your are female and 35 if you are male, then you are a candidate for one of these new weight loss medicines. For you the benefit likely outweighs the risk. If your waist circumference is less than those values, then the risk of taking these medicines is much higher than the potential benefit.
Cost
If your insurance does not cover medicines for weight loss the cost of these medicines may be prohibitive.
Wegovy costs $1,349.00 a month without insurance.
Ozempic costs $892.00 a month without insurance.
Muanjaro costs $1,300 a month without insurance.
Unfortunately many insurance plans do not cover weight loss medicines.
We have all been told for years that the main dietary risk factor for heart disease and stroke is how much saturated fat we eat. We have also been told that eating foods high in cholesterol also increases risk of heart disease and stroke. Evidence is accumulating that consumption of saturated fat increases risk of heart disease and stroke little if at all. Since your body makes cholesterol itself, eating cholesterol rich foods has almost no effect on serum cholesterol. Other aspects of diet have a much greater effect on increasing the risk of heart disease and stroke. In this post I will summarize the evidence and spend some time discussing things we eat and drink that do substantially increase the risk of heart disease, stroke and other chronic diseases.
The Seven Country Study
The most famous study that led to the saturated fat hypothesis was carried out by Ancel Keys. The study started in 1956 and was published in 1978. He looked at the dietary patterns of 7 different countries. The countries included Finland, Greece, US, Italy, Yugoslavia, Netherlands and Japan. He found that saturated fat intake was correlated with increased risk of heart attack and stroke. The country with the lowest saturated fat intake was Crete in Italy, which also had the lowest incidence of heart disease and stroke of the 7 countries. The diet of Crete is the basis for the famous Mediterranean Diet.
Diets of free living humans are notoriously difficult to measure. Keys did his best to accurately determine diet. He had a subset of his subjects in each country weigh their food for a number of days, which is considered the gold standard for dietary studies. The problem with any population study like this is that populations in different countries differ in lots of other ways besides diet. Also diets are complex, so some other factor or factors in diet could account for the low heart disease incidence in Crete. Another problem was that diet was measured in Crete during Lent, when most people did not eat meat. All Keys could really say was that saturated fat intake was associated with heart disease, but he could not say that saturated fat caused heart disease.
People who adhered to the Mediterranean Diet did reduce their population risk of heart disease, but there is a lot more to the Mediterranean Diet than reduced saturated fats. It also includes little added sugar, lots of vegetables and fruit and mostly unprocessed foods. It is not clear that reduction in saturated fat is responsible for the health benefits of the Mediterranean Diet.
The Framingham Study
The next big population study was the Framingham Study. A large group of people in Framingham Massachusetts was followed over many years with surveys about diet, activity, smoking and laboratory measurements of total cholesterol, LDL, HDL and triglyerides among other measurements. Heart attacks, strokes, death from either of these things and death from any cause were recorded in the study group. This was the first large study that implicated cigarette smoking as a cause of cardiovascular disease and cancer. It was also found that the higher the total cholesterol and especially the higher the LDL (low density lipoprotein) the higher the risk of cardiovascular disease. It was also one of the first studies that showed that the higher the blood pressure, the greater the risk of cardiovascular disease. This was a tremendously important and well done study.
The Diet-Heart Hypothesis
The diet-heart hypothesis is that saturated fat is the main dietary cause of cardiovascular disease. It has been very influential over 60 years and is still promoted by the American Heart Association and many cardiologists. Here is the train of thought. The 7 country study implicated saturated fat as associated with cardiovascular disease. It has been found through multiple studies that saturated fat intake raises LDL (so called bad cholesterol). The Framingham study showed that increased LDL was a major risk factor for cardiovascular disease. Since saturated fat raises LDL, therefore saturated fat must cause cardiovascular disease.
That makes perfect sense, so many randomized trials were carried out to nail down the diet-heart hypothesis. Unfortunately, as is often the case with beautiful theories, further randomized trials did not consistently show the expected increase in heart disease from eating saturated fat. The other part of the hypothesis was that eating polyunsaturated fats would decrease the population risk of heart disease. That was based on the observation that consuming polyunsaturated fats decreased LDL levels. Randomized trials have generally failed to consistently show that eating polyunsaturated fats reduces the risk of cardiovascular disease.
Reduced Risk of Cardiovascular Disease in US
Heart disease was epidemic in the US, peaking in the 60’s. Since then, the incidence of heart disease in the US and most other developed countries has decreased by 60%! Scientists debate the cause for this decline. Although saturated fat consumption decreased some, Americans still eat much more saturated fat than the 5% of fat recommended by the American Heart Association. So the fact that we eat somewhat less saturated fat does not explain the remarkable decline in heart disease over the last 60 years. What else changed?
Cigarette Smoking
In the 1940’s half of all Americans said they smoked cigarettes. Smoking began to decline in the US in the 60’s and today only 11.5% of Americans smoke tobacco! This has to be a major factor in the decline of cardiovascular disease (and lung cancer).
High Blood Pressure
High blood pressure is a major risk factor for heart disease. The number of people with high blood pressure successfully controlled on medicine has more than doubled since 1960. This is clearly another major factor in the decline of cardiovascular disease
Trans Fats
The rise of trans fat consumption was an unintended consequence of the heart-diet hypothesis. Because animal fat (mostly saturated fat) was postulated to cause heart disease, the food industry started figuring out how to use vegetable oil to replace lard and butter, which were high in saturated fats. They needed something that would be solid, not liquid at room temperature. They discovered that if they partially hydrogenated vegetable oil, then it would be solid at room temperature and could substitute for lard and butter. They marketed these products as healthier because they were only partially saturated fats, not saturated fats. The medical establishment bought this story and recommended margarine as a substitute for butter and Crisco (the most successfully marketed shortening substitute) as healthier alternatives. I have been unable to find statistics on trans fat consumption in the US, but it was very large.
It turns out that consumption of trans fats markedly increased the risk of cardiovascular disease. For every 2% increase in the consumption of trans fats, heart disease increased by 23%. This is a shocking number! The consumption of trans fats certainly contributed to the epidemic of heart disease in the 50’s and 60’s. The FDA essentially banned the addition of trans fats to food in June of 1978. The elimination of trans fats is almost certainly another major factor in the decline of heart disease.
Interesterification
Since trans fats have been banned, food companies have come up with a new way to make vegetable oil solid and spreadable. It is called interesterification. It is complicated, but the simplest explanation is that it involves changing the arrangement of fatty acids on a glycerol backbone. These are fully hydrogenated fats, so are not trans fats. We know very little about how these new industrial fats affect human health, but the information we do have suggests that these new products may be just as bad for you as trans fats. You would do best to avoid them until we know more. More about how to do this later in this post.
Do we need to limit red meat consumption?
The main risk of consumption of any food is eating too much of it. It is total calorie intake that makes us fat, and being fat increases the risk of cardiovascular disease, diabetes and some cancers. Eating red meat by itself is very unlikely to increase your risk of heart disease as long as your total calorie intake is equal to the calories you burn up. So there is very little health risk to you in eating red meat, but there is a big risk to the environment. Cattle raising worldwide contributes about 16% of greenhouse gas emissions. Here is a link to a balanced discussion of greenhouse gas emissions from cattle raising: Livestock Don’t Contribute 14.5% of Global Greenhouse Gas Emissions.
The other thing to think about when consuming any meat product, including chicken is that almost all the meat you buy in the grocery store comes from giant factory farms, where animals are treated very inhumanely. That in itself is bad enough, but raising all those animals together increases risk of spreading disease to the people who eat them. Antibiotics are used in many factory farms to keep animals from getting sick. This contributes to the evolution of bacteria that are resistant to most antibiotics.
If you are not willing to give up eating meat entirely, try to find locally raised beef, pork and poultry. Farmer’s Markets are a good place to find meat from locally raised animals. It may be a little more expensive, but likely a lot safer.
What about eating fish?
If you are at high risk of cardiovascular disease or have cardiovascular disease then eating oily fish (salmon, sardines, anchovies, herring, mackerel, tuna, swordfish) twice a week reduces your risk of a heart attack by 50%. If you are at average risk, these fish don’t have unusual health benefits but if you like them, it’s fine to eat them. Because most of these fish contain some mercury they should probably be avoided by pregnant women and children. If you get canned tuna, get Pacific Island Tuna at Walmart. It is sustainably caught. Here is a link to an article from the Nature Conservancy about it: The Nature Conservancy. By the way taking fish oil is not nearly as good for you as eating fish.
Highly Processed Foods
There are convincing data that consumption of lots of highly processed foods leads to health concerns ranging from increased risk of obesity, high blood pressure, breast and colorectal cancer, to dying prematurely from all causes.These foods all also contain additives whose health effects have never been adequately tested. How do you recognize them? Just look at the label where the ingredients are listed. If there are more than two things you don’t recognize, put it back on the shelf. Here is an example of an ingredients list from a loaf of bread!
This is not bread you would want to eat! If you mostly stay out of the central aisles of the grocery store you will avoid most highly processed foods. Just be sure to look at the ingredients label before you buy anything.
It is all well and good for me to make these recommendations, but highly processed foods and factory farmed meat are cheap. People who are poor cannot afford to buy anything else. This is only one of the things that have led to the major health inequities that are present in this richest country in the world.
Foods that decrease risk of cardiovascular disease
Fiber
Increased dietary fiber has been shown to decrease risk of cardiovascular disease. This may well have to do with promoting a healthy microbiome in the intestine. Sources of fiber that promote growth of healthy gut bacteria are ones that contain inulin. The highest sources of inulin are leeks, asparagus, onions, wheat, garlic, chicory, oats, soybeans, and Jerusalem artichoke. Sourdough bread (no added sugar, honey, or high fructose corn syrup) is also a good source of fiber. Whole grains, fruits, nuts and vegetables are also good sources of fiber.
Fresh Fruits
Fresh fruits are a good source of fiber and also contain many beneficial nutrients including vitamins and antioxidants. Data from multiple studies show that eating fresh fruit daily reduces risk of cardiovascular disease.
Nuts
Eating a handful of nuts per day reduces your risk of heart disease by 20%. Peanuts are technically of legume, not a nut, but legumes reduce the risk of cardiovascular disease as well. Unsalted nuts are better for you than salted.
Whole grains
Whole grains are also a good source of fiber and other beneficial nutrients. Eating whole grains most days is associated with decreased obesity, diabetes and heart disease. Examples of whole grains are
Barley.
Bulgur, also called cracked wheat.
Farro.
Millet.
Quinoa.
Black rice.
Brown rice.
Red rice.
Wild rice.
Oatmeal.
Popcorn.
Whole-wheat flour.
Whole-grain breakfast cereals.
Whole-wheat bread, pasta or crackers.
Make sure to read the ingredients label for cereals and crackers. Don’t buy anything that has more than two ingredients you don’t recognize.
Fresh Vegetables
Fresh vegetables are also a good source of fiber. Sorry folks, but potato chips and french fries do not count as fresh vegetables! Once again eating fresh vegetables daily significantly lowers your risk of cardiovascular disease.
Bottom Line
Eating red meat and saturated fats does very little to increase your risk of heart disease, but it also does not reduce your risk. Raising livestock on factory farms causes significant harm to the environment and puts people at risk of infectious disease. Eating meat from locally raised animals is safer.
Eating high fiber foods, whole grains, nuts, fruits and vegetable does substantially reduce your risk of cardiovascular disease as well as cancer.
Eating highly processed foods, and this includes the new industrial fats made by interesterfication increases your risk of cardiovascular disease and cancer. The biggest risk of these is probably because they encourage people to eat more calories than they need and have almost certainly led to the epidemic of obesity.
The most concise recommendation for a healthy diet comes from author Michael Poulin: “Eat food (food is anything your grandmother would have recognized as food), mostly plants, not too much.”
Heartburn is defined as burning pain in the chest behind the breast bone and sometimes into the throat. It often occurs after eating or at night. Heartburn is caused by acid in the stomach (where it belongs) coming up into the esophagus (where it does not belong). Normally there is a one way valve that lets food go into the stomach, but keeps acid from coming back up into the esophagus. This valve is called the gastroesophageal sphincter. When that sphincter doesn’t work well, it allows acid from the stomach to come back up into the esophagus. The medical term for back up of acid from the stomach into the esophagus is gastroesophageal reflux disease often abbreviated as GERD. GERD has become increasingly common in western countries. One in five people in the US suffer from some form of GERD!
In this post I will talk about the causes of dysfunction of the gastroesophageal sphincter that lead to GERD and the symptoms of heartburn. I will focus first on foods and lifestyles that increase your population risk of GERD and also foods and lifestyle changes that reduce your population risk of GERD.
Finally, I will talk about medicines for GERD and the risks of side effects from these medicines.
Things that Increase the Population Risk of GERD
Smoking
Smoking cigarettes has been shown to decrease the pressure of the gastroesophageal sphincter. That means that anything that increases the abdominal pressure, such as coughing or bending over overcomes the weak sphincter and leads to GERD. The population of people who smoke has almost twice the risk of GERD of people who do not smoke.
Foods that relax the gastroesophageal sphincter
Decreased muscle tone in the gastroesophageal sphincter can lead to GERD. The following foods decrease the muscle tone of the gastroesophageal sphincter.
Fried (greasy) foods
High-fat meats
Butter and margarine
Mayonnaise
Creamy sauces
Salad dressings
Whole-milk dairy products
Chocolate
Peppermint
High salt intake
Obesity
Obesity increases intra-abdominal pressure, which can cause GERD even with a well functioning gastroesophageal sphincter. Obesity also increases the risk of developing a hiatal hernia. This is when part of the stomach comes up through the diaphragm in the same opening the esophagus goes through. Small hiatal hernias usually cause no symptoms, but large ones can lead to GERD.
Sedentary Lifestyle
Studies have shown that couch potatoes have a higher risk of GERD even if they are not over fat.
Medicines
The Mayo Clinic has a list of medicines that either can irritate the esophagus (causing heartburn) or can cause GERD. Here is the Mayo Clinic list:
Medications and dietary supplements that can irritate your esophagus and cause heartburn pain include:
Antibiotics, such as tetracycline and clindamycin
Bisphosphonates taken orally, such as alendronate (Fosamax), ibandronate (Boniva) and risedronate (Actonel, Atelvia)
Iron supplements
Quinidine
Pain relievers, such as ibuprofen (Advil, Motrin IB, others) and aspirin
Potassium supplements
Medications and dietary supplements that can increase acid reflux and worsen GERD include:
Anticholinergics, such as oxybutynin (Ditropan XL), prescribed for overactive bladder and irritable bowel syndrome
Calcium channel blockers, statins, angiotensin-converting enzyme (ACE) inhibitors and nitrates used for high blood pressure and heart disease
Narcotics (opioids), such as codeine, and those containing hydrocodone and acetaminophen (Norco, Vicodin, others)
Progesterone
Sedatives or tranquilizers, including benzodiazepines such as diazepam (Valium) and temazepam (Restoril)
Theophylline (Elixophyllin, Theochron)
Microbiome
It turns out that we have bacteria living in our mouth and esophagus as well as our colon (see my previous post on the microbiome: The Microbiome: How Our Own Bacteria Affect Our Lives). There is increasing evidence that when unhealthy bacteria (gram negative bacteria) replace healthy bacteria (gram positive bacteria) in the esophagus we are more likely to have GERD and a precancerous change called Barrett’s Esophagus. Unhealthy bacteria replacing healthy bacteria is called dysbiosis. It can be cause by eating too much fat, sugar, processed food and a low fiber diet.
Things that decrease population risk of GERD
Never smoking or quitting if you smoke
That’s pretty obvious. Enough said.
Maintaining normal body fat
BMI is not a very accurate measure of percent body fat. A better measure is waist to hip ratio. A healthy waist to hip ratio is .75 for women and .85 for men. A ratio of .85 or more for women and .90 or more for men is defined as obesity. It is a very easy measurement for you to do at home. Use a cloth tape measure and measure the circumference of your waist at the level of the belly button. Write that measurement down. Then measure the circumference of your hips at the widest part and write that measurement down. Use a calculator to divide the waist circumference by the hip circumference. If you fall into the over fat range, review my post The Psychology of Eating and How to Use It to Your Advantage.
Eat a high fiber diet low in fat, sugar and processed foods
Not only does this kind of diet increase the tone of the gastroesophageal sphincter, but it also leads to a healthy microbiome in the mouth and the esophagus, which further decreases the population risk of GERD and Barrett’s Esophagus. Here is a link to the Cleveland Clinic web page that lists 11 high fiber foods: 11 High Fiber Foods You Should be Eating.
Minimize the number of medicines you take
Certain prescription medicines may be necessary and unavoidable, but you can certainly minimize the over the counter medicines you take. Whenever your doctor recommends a prescription medicine, you should almost always ask if there are any non-medicine ways to treat the condition. There may not be, but you will never know if you don’t ask.
Medicines for GERD
Even if you do all the things to put yourself in a low risk population for GERD you still may suffer from GERD. Remember that risk is calculated for populations and has no meaning for an individual. You will either get GERD or you won’t. In other words individual risk is either zero percent or 100 percent.
If you do have GERD despite doing everything you can to put yourself in a lower risk population, you may need to take medicine to alleviate the symptoms and prevent precancerous changes of Barrett’s Esophagus.
H2 Blockers
These medicines block a histamine receptor called the histamine 2, abbreviated H2. They work by decreasing acid production in the stomach. These are the medicines with the least side effects including on the microbiome. They include:
Most people with GERD get symptom relief from these medicines. They used to be prescription only, but almost all of them are now available over the counter. A small percentage of people with GERD will not respond to H2 blockers.
Proton Pump Inhibitors (PPI’s)
PPI’s are the most potent inhibitors of production of stomach acid. PPI’s essentially block the production of all stomach acid. They include:
lansoprazole (Prevacid)
omeprazole (Prilosec)
pantoprazole (Protonix)
rabeprazole (AcipHex)
esomeprazole (Nexium).
Prevacid and Prilosec are available over the counter. The others are prescription only.
Remember that stomach acid is there for a reason. The hydrochloric acid in the stomach breaks down the food and the digestive enzymes split up the proteins. The acidic gastric juice also kills bacteria.
Because PPI’s are such potent inhibitors of stomach acid production, they increase the risk of certain intestinal infections, especially clostridium difficile infections. They also promote less healthy bacteria in the colon, even more so than antibiotics. Over the long term they can also cause osteoporosis (thinning of bones) and low magnesium levels.
Once started, they are difficult to stop. Stopping PPI’s causes a rebound production of stomach acid, much more than the normal amount. This leads to rebound symptoms of GERD. They have to be stopped gradually with H2 blockers used to slowly replace them. This regimen helps prevent rebound excess acid production.
Most people have no symptoms from short term use of PPI’s and some people have such severe GERD and/or Barrett’s esophagus that they must take PPI’s to get any relief. For this relatively small number of people, the benefit is much greater than the risk. People with symptoms of GERD should only use PPI’s as a last resort, when diet, lifestyle changes and H2 blockers fail to relieve symptoms.
Bottom Line
The symptom of heartburn is almost always due to stomach acid back-flowing into the esophagus where it does not belong. The medical term is GERD. Anything that tends to decrease the muscle tone of the valve between the esophagus and the stomach (gastroesophageal sphincter) increases the risk of GERD. Such things include smoking cigarettes, obesity, high sugar high fat foods with low fiber, certain medicines and a sedentary life style. Things that decrease the risk of GERD include not smoking, maintaining a normal body weight, eating a high fiber diet, regular exercise and minimizing taking over the counter medicines.
For people that have to take medicines for GERD symptoms, H2 blockers have fewer side effects and little effect on the microbiome. For the few people with GERD that don’t get relief from diet, lifestyle changes of H2 blockers, PPI’s may be necessary but have more severe short term and long term side effects including increased intestinal infections, promoting a less healthy microbiome and long term risk of osteoporosis and low magnesium levels.
Cholesterol is one of two fats in the bloodstream called lipids. Your liver makes almost all the cholesterol in your blood. Eating high cholesterol low saturated fat foods (such as eggs and shellfish) does not increase your blood cholesterol. The other fat is triglyceride. Almost all triglyceride comes from what we eat or is made in the liver from foods that have a lot of sugar or starchy carbohydrates. Fat does not dissolve in the blood, so these fats are carried in tiny droplets within a protein shell. These proteins are called lipoproteins. Any of these lipoproteins can be elevated without the others, so although many people may say, ”I have high cholesterol,” it is important to know what kind of ”high cholesterol” they have. In this post I will talk about the different kinds of hyperlipidemia (the medical term for high cholesterol), what kind of damage they can do, and how they can be treated both with medicines and diet.
Types of lipoproteins
There are four major classes of lipoproteins: chylomicrons, very low density lipoproteins (VLDL), low density lipoproteins (LDL) and high density lipoproteins (HDL).
Chylomicrons
Chylomicrons are the largest particles. They carry fat that you eat from the intestine to be used as fuel for the body or stored in fat cells. They are made mostly of triglycerides (90%), which is in the center of the particle with several different kinds of lipoproteins on the outside.
VLDL (very low density lipoproteins)
This is the next smallest class of particles. They contain about 50% triglycerides, 25% cholesterol and the rest a type of fat called phospholipids. They are made in the liver and carry triglycerides and cholesterol to the cells.
LDL (low density lipoproteins)
LDL particles carry more cholesterol than the others. They also deliver cholesterol to the cells. High levels of LDL particles are associated with an increased risk of heart disease. More about this later.
HDL (high density lipoproteins)
HDL particles have the most protein and the least amount of fat contained within them. That makes them more dense, hence the name, high density lipoproteins. The function of HDL particles is to carry cholesterol and triglycerides back from the cells to the liver. This decreases LDL in the cell walls of the arteries and helps prevent heart disease. Low levels of HDL are associated with increased risk of heart disease and high levels with decreased risk of heart disease. Paradoxically, very high levels of HDL actually increase the risk of heart disease.
Cholesterol
Cholesterol is essential to your body. Cell walls are made up of mostly cholesterol. Cholesterol is used to make many essential hormones in the body including estrogen, progesterone, androgen, cortisol and many others. Cholesterol moves in and out of cells to do it’s job. If LDL (and therefore cholesterol) is too high, it can accumulate in the walls of arteries at spots where there is inflammation. More about inflammation later. The immune system sends special cells called macrophages to ”eat” the offending LDL particles, but that causes more inflammation and more accumulation of cholesterol. This cholesterol buildup is called a ”plaque” and these can cause narrowing of the artery and can also cause blood clots to form which can completely block the artery. The result is a heart attack or stroke.
Triglycerides
Triglyceride levels are affected by what we eat. We absorb triglycerides directly from eating saturated fats but the liver also converts any unneeded calories to triglycerides that are then stored in fat cells. Very high triglyceride levels can cause pancreatitis (inflammation of the pancreas). It is likely that high triglycerides also increase the risk of heart disease and stroke, possibly by being deposited in the arterial walls like cholesterol. We are not sure at this point the exact mechanism that connects high triglyceride with cardiovascular disease
Inflammation
Inflammation in the artery walls starts the whole process of cholesterol buildup and plaque formation. In fact, one of the main reasons that statin drugs like atorvastatin (Lipitor) work is that they reduce inflammation in the walls of the arteries as well as lowering LDL (and thus cholesterol). It may well be that inflammation of the artery walls can cause plaque formation to begin even in people with normal LDL levels. We can get some idea how much chronic inflammation is going on in our bodies by having a blood test called high sensitivity C-reactive protein (CRP).
So what causes inflammation of the artery walls and is there anything we can do about it?
Inflammation is increased by our old friends: highly processed foods, sugar, high fructose corn syrup and a diet high in starchy carbohydrates. There is pretty good evidence to suggest that eating large amounts of saturated fats (essentially animal fats) also produces inflammation. Increased belly fat secretes a substance that causes chronic inflammation (See my previous post Why is the United States so fat and what to do about it for instructions about how to measure your belly fat). Finally, inflammation of the gums from plaque on your teeth leads to inflammation in arteries. Of course smoking cigarettes also increases inflammation in your arteries.
You can reduce inflammation in your arteries by stopping smoking if you are a smoker, eating unprocessed foods, especially fresh vegetables, fruits and berries, nuts and fatty fish. Taking good care of your teeth also helps. That means flossing daily and seeing the dentist for cleaning once every 6 months. Regular exercise such as walking at least five times a week also reduces inflammation. If your abdominal circumference is above normal, then losing weight will reduce inflammation. All of these things also tend to reduce LDL and triglycerides too, so you get double duty from these life style behaviors.
When you need to take medicine for hyperlipidemia
A significant portion of high LDL and/or triglycerides is genetic. You can make all the lifestyle changes I talk about above and still have high lipids. If that is the case, then you need to talk to your doctor about starting cholesterol medicine. That will likely be one of the class of drugs called statins. There are quite a few of these and they vary in potency, side effects and drug interactions. Almost everyone will be able to tolerate one of the statins without any significant side effects. There are a few people that have adverse reactions to all of the statins. There are some new non-statin medicines that look promising for decreasing LDL in those few patients who can’t tolerate statins. Your doctor will help you find the right medicine for you to help lower your LDL and/or triglycerides.
Bottom Line
All fats in the blood are carried by special proteins called lipoproteins. Cholesterol is carried mainly by LDL. In the presence of inflammation in the arteries, high levels of LDL lead to plaque formation in the arteries that can eventually lead to heart attack or stroke. High levels of triglycerides also increase the risk of heart disease. Lifestyle changes can reduce both inflammation and number of LDL particles and triglycerides, thus reducing population risk of cardiovascular disease. Sometimes lifestyle changes are not enough and cholesterol lowering medicines are needed.
