All about Omega-3's and how to get enough from plants vs fish vs supplements

Have you seen the Game Changers?  I haven’t – but I’ve read enough reviews from well-regarded nutrition scientists to indicate that I don’t need to.  Nor does anyone need to become vegan for health and performance benefits.  Don’t get me wrong, I am all for plant-based ie. eating more vegetables, choosing wholegrains and moderating meat intake.  Just because I’m not vegan however, it doesn’t mean I have zero care for the environment, or mine or others’ health, well-being and performance.  In fact I care for these things greatly, and this is why I become frustrated by false and misleading nutrition messaging.

Plant-based nutrition is all the rage right now, and for good reason.  But this doesn’t mean the entire world needs to become completely plant-based  Everyone is entitled to make their own personal choices and decisions about the way they eat.  Many factors contribute to our food preferences, including ethical, religious, social, cultural, economical, environmental, psychological, physical and pure taste and enjoyment.  Regardless of a person’s approach, my priority when working with individuals is for them to get the most from the foods that they like and choose to eat.

Enough with the Game Changers and the virtues of plant-based eating - this is not at all what I wanted to focus on!  Although it’s highly relevant to a nutrient that I find many people don’t get enough of, regardless of nutrition preferences - omega-3 fatty acids.  The topic of omega-3’s also opens up a whole host of questions around the best sources, sustainability of our fish supply and the role of supplements, which I will address to the best of my current knowledge.

My interest of late in omega-3 intake has primarily been in relation to vegan-style eating and how adequate intake can be achieved on a consistent basis.   I work with many vegetarian and vegan clients who are active and training at a high level, and working hard to make their nutrition work for them.  I’m also involved in reviewing vegetarian and vegan meal plans for online health and wellness programs (TiffXO and Centr) so have a responsibility to consider where omega-3’s are coming from.  Plus on a personal note I have a child who has difficulty eating fish, hence my priority to investigate non-marine sources a little more thoroughly (said child is now having flaxseed meal sprinkled on his breakfast each morning, in conjunction with repeated offerings of fish…..btw we have well exceeded ‘10’ exposures and seemingly still have a long way to go!).

Historically vegetarians have often been recommended to take a supplement to ensure their omega-3 intake is adequate.  Fish eaters can just eat salmon and sardines, right!!  Ok, not always that simple, but fish and seafood are by far the richest source of bioavailable omega-3.  Omega-3 has been identified as being important for a range of body functions, including:

·       Brain health and function

·       Management of inflammatory conditions such as chronic pain and arthritis

·       Cardiovascular health

·       A potential reduction in the body’s inflammatory response to strenuous activity

·       Just to name a few….

 Types of omega-3

When it comes to omega-3, the most important varieties to consider are these three:

EPA eicosapentaenoic acid (long-chain fatty acid)

DHA docosapentaenoic acid (long-chain fatty acid)

ALA alpha-linolenic acid (a shorter chain omega-3 fat). 

Why are fish and seafood so rich in these fatty acids? DHA and EPA are synthesized by marine algae, which are eaten by phytoplankton, which are then consumed by fish and seafood and accumulate over time.

ALA is a short chain omega-3 found naturally in non-marine foods such as flaxseeds, chia seeds, hemp seeds and walnuts. The short chain omega-3’s must be converted to long chain omega-3’s to be best utilised by the body. The conversion rate to the more effective DHA and EPA is low (estimated at less than 15%) so you need to consume quite a lot of ALA from foods plant sources to get a similar amount obtained by eating fish or seafood.  It’s not impossible, but takes some careful planning.

 How much do we need?

The recommended dietary intake of long chain omega-3’s to prevent chronic disease has been estimated to be 430mg per day for women, and 610mg per day for men, so around 500mg/day on average, although there is no set standard and different organisations recommend anything from 250-500mg combined DHA/EPA per day.  Unfortunately not many of us are likely to consume this much omega-3 on a regular basis. There are more specific recommended omega-3 doses for health conditions such as some types of arthritis, requiring higher dose supplementation beyond the levels of intake able to be achieved via food alone (it’s important to speak to your health professional and dietitian if your needs are elevated due to a health condition).  There is no recommended level of omega-3 intake advised for athletes at present, however I was just yesterday reading some interesting research on omega-3s in the context of nutrition and concussion. There is also potential for the anti-inflammatory effect of omega-3’s to impact recovery and muscle/joint health, but unfortunately specific research on athletes is lacking.

Omega-6 to omega-3 ratio

The ratio of omega-6 to omega-3 fats is often discussed as a contributor to health – with many of us consuming far more omega-6 fats from various vegetable oils and not enough omega-3.  This imbalance can potentially lead to inflammation in the body, which can then be linked to chronic health conditions.  The best way to address this is to put some effort into increasing omega-3 intake, plus taking care not to overdo sources of omega-6 fats.

Sustainability of fish sources

The other question to consider is what may happen if everyone suddenly starts focusing on omega-3 intake by eating more fish.  The old saying ‘There’s plenty more fish in the sea’ may not apply in this case, particularly if we are focused on a small number of specific varieties.  I started looking into this further and came across some great work being done by the Australian Marine Conservation Society and their Good Fish Project .  They have developed resources including a Sustainable Seafood Guide and a listing of Sustainable Seafood Restaurants, which are very useful in helping to make sustainable fish and seafood choices at home and when eating out.

The Fisheries Research and Development Corporation have also developed an excellent app where you can find the status of Australian fish stocks to help determine sustainable fish and seafood choices (go to www.fish.gov.au for more info).

Vegetarian sources – can you get enough from food?

Back to my main reason for looking into omega-3 a little further - can vegetarians obtain adequate omega-3 from foods or is supplementation necessary?  Research indicates that on average, ALA intake for vegetarians in Australia is not sufficient to allow conversion to an adequate amount of DHA and EPA.

ALA can be found in plant based foods like nuts, seeds and oils however the volume of these required to ensure adequate DHA and EPA conversion is likely to be challenging from a practical and palatability point of view.  Even though the amount of ALA in these foods may be high, the low conversion rate means that significant volumes need to be consumed - we are talking tablespoon upon tablespoon of flaxseeds and chia seeds for example, which can become quite hard going, but not impossible if this is your preference.  The other option are micro-algae supplements to part-supplement food sources within a fish-free diet.

Supplements

There has been significant debate surrounding fish oil supplements and their effectiveness, and ideally the best way to obtain your omega-3’s is through food sources.  However there are certain situations where supplementation may be useful.  Some people worry about the mercury content of fish oil supplements (needlessly, as the processing and purification remove all mercury), however a greater concern in recent years has been around quality and effectiveness of over-the-counter products.  I won’t discuss that in more detail here, but it’s certainly something to consider.

 As previously mentioned, there are vegan-friendly omega-3 supplements derived from algal oil.  These contain predominantly DHA and absorption may be similar to that from fish and fish oil. 

Is high dose supplementation necessary?

Research has indicated that certain medical conditions may benefit from higher dose omega-3 supplementation, such as heart disease and some forms of arthritis.  There has been recent controversy however with regard to cardiovascular disease – previously there were indications to suggest taking 1000mg fish oil (DHA/EPA) for cardiovascular disease and higher doses for elevated triglycerides, however this has been questioned due to some recent studies.  Your individual situation and health are unique – speak to your GP and Accredited Dietitian for more personalised advice. 

Summary

If you eat fish and seafood, then choosing sustainable sources rich in omega-3 is likely your best way to achieve adequate omega-3 intake.  Non-marine sources also can provide omega-3, but the type of omega-3 is less effective, meaning you need to consume significant volumes regularly to achieve adequate intake.  

Rather than focusing only on fish, perhaps a combination of oily fish/seafood and plant-based sources is the way to go (with appropriate supplementation if required, based on individual needs)….especially with the shift towards more plant-based eating into the future.

However you do it, omega-3’s are important – speak with an Accredited Sports Dietitian if you want to talk it all through for your unique individual needs.

Furthe reading:

https://www.mja.com.au/journal/2013/199/4/omega-3-polyunsaturated-fatty-acids-and-vegetarian-diets

https://ods.od.nih.gov/factsheets/Omega3FattyAcids-HealthProfessional/

Nicoise Salad

Image by Bec Doyle Photography from the book Eat Right For Your Life

Nicoise salad is one of my favourites, light but protein-rich and great for an easy dinner on a hot night or a portable and filling lunch.  The dressing works well for other salads too.  This recipe is from my book Eat Right For Your Life.

Nicoise Salad

Serves 4

Ingredients:

500g/1 lb baby new potatoes, quartered

200g/7 oz green beans, topped and tailed

1 medium red (Spanish) onion, sliced thinly

150g/5 oz mixed lettuce leaves

250g/9 oz cherry tomatoes

400g/14 oz canned tuna in oil, drained, flaked

4 hard-boiled eggs, peeled and cut into quarters

½ cup/90g seeded black olives

3 anchovy fillets in oil, drained and cut in half lengthways

 Dressing

Combine ¼ cup/60ml of lemon juice with one crushed clove of garlic and 2tsp of Dijon mustard (add 60ml olive oil also if desired).

Method

1. Steam potatoes and beans until just tender, drain and allow to cool.

2. Combine onion, lettuce leaves and cherry tomatoes in a large bowl. Top with potatoes, beans, flaked tuna, eggs, olives and anchovies. Serve with dressing on the side.

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Five reasons why red meat is good for athletes

I remember my first sports nutrition lecture at university, where sports nutrition at the time was compared to what athletes may have been eating centuries ago.  Red meat was clearly on the menus of our athletic ancestors with ancient Greek marathon winners awarded cattle for their endeavours, and a hearty steak pre-race may not have been uncommon.  The science of nutrition has come a long way since then, and although steak may not be a pre-race meal of choice, the nutrition benefits of red meat for athletes continue to be recognised. 

Nutrition fads come and go, and the popularity of red meat has catapulted from one extreme to another.  Current dietary guidelines suggest a prudent intake of red meat, however not everyone follows these guidelines, with the recent jump onto the Paleo bandwagon keeping the grass-fed beef farmers in business.  Regardless of the style of eating, when it comes to sports nutrition, red meat is a winner.  We don't always talk about meat as a food on it's own, often you hear about the importance of nutrients like protein or specific minerals for athletes, but when we break it down, meat is amazingly rich in a range of nutrients.

Here are my top 5 reasons why red meat is good for athletes:

Number 5 - Healthy fats

Discussions around red meat and health usually focus on saturated fat content, or more recently cancer risk.  If you look closely at the fat composition of Australian beef and lamb you will find that they do in fact provide omega-3 fats.  Not as much omega-3 as fish, but meat isn't all 'bad' fat. If you are concerned about your body fat levels, you can reduce the calories of meat by choosing lean cuts or trimming fat from meat, or cooling casseroles after cooking and skimming fat from the top. 

With regard to the impact on cancer risk, it is the cured and processed meats that seem to be the main concern.  It is still wise to vary your protein foods and not eat red meat all of the time, but for most people you don't need to omit fresh meats. 

Number 4 -  Minerals

Beef and lamb are a great source of zinc and Vitamin B12, important for athletes.  Zinc is important for muscles and immune system, and may play a role in testosterone levels in males. 

Vitamin B12 is important for a range of body systems and may impact on immune function and energy levels.  Vitamin B12 is only found in animal products, and a small-medium size steak will provide your daily RDI.

Number 3 - Satiety

Do you usually find you are still hungry after a meal of steak and vegetables??  No, most likely not.  Red meat is filling due to the high protein content, and is broken down slowly in the digestive system so can keep you full for longer.  You don't need a huge serve either.  Protein in a meal can also lower the glycemic index, helping to keep blood glucose levels stable.  Red meat can help to manage hunger, as do other protein-rich foods, if you are an athlete trying to manage your weight or body fat levels.

Number 2 - Iron content

Iron is an essential nutrient for athletes.  Red meat contains haem iron, which is more easily absorbed than the non-haem iron found in plant sources. The easiest way to meet your dietary iron needs is to eat small serves of red meat regularly (x3-4 per week), plus include a range of other iron-rich foods.  Don't forget to add a food containing Vitamin C to your iron-rich meal for optimal iron absorption.

For more information about why iron important and a table of different foods and their iron contents, have a read of my article on the 2XU website, Iron Tough or Rusty.

Sports Dietitians Australia also have a great Fact Sheet Iron Depletion in Athletes.

Number 1 - Protein

Probably the best thing about red meat is the quality and amount of protein.  Red meat contains all the essential amino acids, making it high quality.  This includes leucine, the critical amino acid for stimulating muscle protein synthesis to promote muscle recovery and growth.  Meat is also protein-dense, so you only need a small serve for a big dose (lean beef contains approximately 30g protein per 100g, this can vary according to cut of meat).

For more information about protein and other foods that are great protein options, Back to Basics Protein - Foods That Contain the Most and Best Protein for Recovery and Training

If you choose not to eat meat for ethical reasons there are other foods such as dairy, eggs, nuts and seeds.  For athletes who follow a vegan style of eating it can be very difficult to meet needs for nutrients such as protein, iron, calcium and Vitamin B12.  It's not impossible, there are plenty of vegan athletes out there, but it takes significant time, effort and planning, as well as supplementation, to get nutrition intake spot on.

If you are an athlete who does eat red meat, then it's worth making a special effort to eat small amounts of fresh red meat regularly, in combination with other high quality protein sources,  for energy levels, recovery and performance.

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Best snacks for before exercise to perform at your best

Is fruit on its own the best pre-exercise snack?

Performance nutrition is a topic I am lucky enough to talk about pretty much every day.  I love talking about exercise and nutrition, and helping people get the best out of their training efforts, whether they workout at the local gym or train as an elite athlete.  I find a lot of people feel like they have their nutrition mostly under control, but don’t seem to be getting the best out of their training.   A lack of appropriate nutrition before and after training may be contributing to this, and may especially be a problem if you train in the late afternoon.  I see a lot of clients who head straight to training after work or school, but haven’t eaten for 4 or 5 hours since lunchtime.  By then, your body will have digested and absorbed many of the nutrients from lunch and there may not be much left to fuel your training session.  If you are trying to lose weight, it can still be useful to have some fuel on board to provide the energy to train harder and burn more kilojoules.   If you are working hard in the gym to put on weight, then you need energy to lift, pull and push.  If you are going into your session fatigued and low on fuel, you can’t expect to get the best results from your training (unless you have a planned strategy to complete some sessions lower on carbohydrate, but I will save that for another post).

 So what should you look for in a pre-exercise snack?

Protein

Protein is often the neglected nutrient when it comes to snacking, as many of our typical snacks are carbohydrate based (think fruit, biscuits, flour-based products).  Including protein in a snack means it will keep you full for longer, but can also help manage blood glucose levels, and is an essential nutrient for muscle growth and repair.  If you are doing a lighter cardio session then the protein is probably less important and you may be fine with a small carbohydrate snack (if anything), but for longer, heavier sessions there are benefits from including protein.

Carbohydrate

Low-glycemic index carbohydrate foods are those that are more slowly absorbed over time, resulting in more stable blood glucose levels and potential benefits for energy levels.  However many low GI foods are also high in fibre, and too much fibre pre-exercise can cause stomach upset for some people (especially runners).  Include carbohydrate in pre-exercise snacks, and choose low-GI if you tolerate it.  But the total amount of carbohydrate is potentially more important than the glycemic index, so it is a matter of working out which carbohydrate foods sit best for you before you train.

Healthy fats

It's important to include healthy fats in your diet if you are fit and active.  Fat can take a while to digest, so you may be better to add more of your healthy fats and oils to meals after exercise rather than before .  Avocado, nuts, seeds, olives, olive oil and fish all provide healthy fats.  

Snacks for pre-exercise 

Below are some pre-exercise snack ideas that will help to keep your energy levels high, contain some protein but not too much fat.  The serving size that is best for you will vary according to your goals, the type of training you do, and individual needs. 

* Soup eg. chicken and vegetable or minestrone

* Chopped fresh fruit with natural yoghurt and chopped almonds         

* Quinoa tabouli with chickpeas

* Rye or corn based dry biscuits with low-fat cheese and sliced tomato

* Fruit smoothie, made with low-fat dairy or soy milk, yoghurt and fruit (most other milks are low in high quality protein eg. rice, oat, coconut, almond)

* Bean and rice salad

* Sushi handroll

* Greek yoghurt with berries

* Mountain bread with turkey and salad

* Tuna with rice and vegetables

 * Natural muesli with low-fat natural yoghurt

* Vegetable sticks and wholegrain crackers with hommus dip         

 * Home-made popcorn (mix in some almonds)

 * Fruit/grain toast spread with ricotta cheese

* Rice paper roll

* Corn Thin with smoked salmon, low-fat cream cheese and dill

* Trail mix - almond, walnuts, cashews and sun-dried apricots

* Chia pudding made with milk and topped with fruit

* Toast or wholegrain crackers with avocado and salmon

* Almond Butter Balls plus yoghurt with berries

 If you are unsure about the best type of snacks and amounts for your needs, talk to an Accredited Sports Dietitian who can help you plan your daily meals and snacks to meet your nutrition and training requirements.  To find a dietitian in your area, go to Sports Dietitians Australia.

If you are interested in learning more about nutrition for exercise, training and sport, please sign up for my free newsletter at the bottom of this page, and you can also follow me on Facebook and Twitter for more nutrition updates.

Saturated fat is back and ketones are the new carbs…if you follow LCHF

I felt as though the Low Carb High Fat (LCHF) movement was taking over my life last week.  Along with everyone else in the country who has an interest in nutrition, I watched ABC’s Catalyst last Thursday night.  I then backed this up with the Low-Carb Downunder seminar in Melbourne on Saturday, so I was up-to-my ears in ketones and carbohydrate talk. My brain actually feels a bit overloaded and is experiencing a slight tug-of-war between my entrenched knowledge that has been accumulating over many years and this ‘new’ input that is being promoted by everyone from doctors, to scientists, to athletes and celebrity chefs. 

I am writing this post to provide an insight to some of the information presented at the Low Carb Downunder seminar for those who did not attend and may be interested.  There will also be the unavoidable mentions of Catalyst and associates, as well as a few interpretations of my own relating to all things LCHF.  Apolgies in advance about the length of this post, and there will be Part 2 to come, just so much to think about!

I arrived at the seminar and was greeted at St Kilda Town Hall by an unusual crowd, some sporty types, some middle-aged overweight men and women, mostly older vs younger people and I think more potential ‘users’ than health professionals.  There were also not as many people as I expected, from reports of the last Low Carb Downunder seminar that sounded like standing room only.  I was the only dietitian there (I will get to my concerns about that later….)

So I managed to find a comfortable seat amongst the believers, without being blown away by any ketone-related bad breath.  First line of the introduction by Dr Rod Tayler, anaethetist, was ‘How good was Catalyst?’ to which there was an almighty cheer.  Oh no, I was starting to think that maybe I really shouldn’t be there, but once the cheering had subsided I got out from under my chair and composed myself because I really wanted to hear what all the fuss over LCHF is about.  Well, the introduction was like nothing I had seen before – slide after slide of recommended reading. Actually not recommended reading, recommended purchasing!  It was a book sale….right up front, no warming us into it.  Not just books – there were DVD’s (including Cereal Killers of course), sponsors products, even ketone measurers!  All very strange for a so-called professional conference.  But I stuck it out, and I am glad I did, because things did get more interesting.

First presenter was Jimmy Moore, who also started off with visuals of his programs and books for sale, but then did get into more substantial content.  Throughout the entire day I found myself intrigued and amazed one minute, then finding it very hard to take things seriously the next.  The thing that seemed to get me off-side was that most of the information presented was based on anecdotes, case studies or articles written by journalists who had interviewed someone who has tried LCHF.  There was not a lot of original research or content (except for A/Prof Ken Sikaris, whose great presentation I will discuss in a future post).

One thing that quite surprised me, that was also very obvious during the Catalyst program, was the non-extreme approach.  Of course there was thorough discussion of the ketogenic diet, where carbohydrate intakes approaching less than 20g/day are all the rage, but there was also recognition that carbohydrates (albeit vegetable-based) can still make a valuable contribution as part of a LCHF approach.  From my perspective, it seems that the LCHF approach is not as anti-carbohydrate as Paleo, and there could be the potential to sneak in some fruit or grains here or there without feeling like you have betrayed the low-car fellowship.  There were no ‘carbs are poison’ or ‘sugar is toxic’ signs anywhere, and carbohydrates were in fact spoken of, at times, in a favourable light, particularly for active people.  I repeatedly heard the phrases ‘there is no one-size fits all’ and ‘what works for you’.  There was also an emphasis on the types of people that LCHF could work for and there was not necessarily a directive that everyone should be eating this way.  For example, it was highlighted both on Catalyst and at the conference that LCHF works best for individuals whose bodies have trouble 'managing or tolerating' carbohydrate and a major focus was people who are overweight and/or have diabetes.

In fact, when Dr Zeeshan Arain, a Melbourne based doctor who works in both general practice and sports, spoke about his experiences with LCHF and athletes, he openly discussed the potential detriment of inadequate carbohydrate for an athlete who is highly metabolically active. Young male athletes with a decent amount of muscle mass perhaps?  There is currently a lot of focus on athletes and LCHF, but again much of the ‘evidence’ is anecdotal.  Dr Trent Stellingwerf, regarded sports nutrition researcher from Canada https://twitter.com/TStellingwerff has recently been active on Twitter summarizing the published data on fat adaptation and ketogenic diets and performance and showed the majority of studies indicate no change or reduced performance with LCHF (see my Facebook page Lisa Middleton – Advanced Sports Dieititian for the shared post, thanks to Thinking Nutrition for sharing this also).  John Hawley and his team at RMIT, along with Louise Burke and other researchers have led the way in this area of sports nutrition, and it would have been great to get their perspective on Catalyst.  It was a shame that line-up of interviewees on Catalyst was basically the presenter list from the Low-Carb Downunder seminar earlier this year, no bias there at all.  How about a novel idea, get the world's best researchers together in the same room to present the evidence and sort it out and come to some type of consensus so we can all move on with our lives?

One thing that has frustrated me are the headlines about athletes who are using LCHF, without any description about when and how they are using it.  I think if we asked for more detail, it may become obvious that LCHF is often being used as a weight loss strategy in the off-season, when peak performance is not required.  In-season carbohydrate intake may be a different story.  I think the potential role of LCHF for weight loss is quite obvious…..if you cut out most of the carbohydrates and sugar from your weekly intake, you automatically reduce your total calorie intake, and how much fat can you really physically eat?  You eat less so you lose weight.  No problem with doing this in the short-term, with appropriate guidance from a dietitian to ensure you are doing it properly.  Another key message from the conference is that LCHF is not high protein, with the recommendation that protein intakes should be kept relatively low.

It was great to hear real athlete perspectives at the Low Carb Downunder seminar.  Tom McDonald, a player from Melbourne Football Club, spoke of his experience with LCHF, and one of his incentives to initially reduce carbohydrates was for his digestive system. He was not trying to lose weight, in fact he reported that he has always been underweight.  So he reduced his gluten and grain intake, but still maintains an estimated 100-200g carbohydrate per day, with much of this coming from sweet potato and bananas. Tom indicated his normal breakfast on training days would be bacon/sausage/eggs, occasionally with sweet potato and the night before games he would go for something like bolognaise sauce with cheese, vegetables and sweet potato.  So effectively he has reduced his wheat/gluten/processed carbohydrates but does not follow extremely low carbohydrate patterns.

Other anecdotal examples followed. Brian Rabinowitz, an experienced and successful triathlete and coach, who has been doing LCHF of late and says he has never trained better and can vouch for a number of the athletes he trains who are also flying with their training and performance, having changed from a gel-fuelled race to virtually water and oil.  Vicky Kuriel is a ‘LCHF dietitian’ who presented on the day (so there were in fact 2 dietitians at the conference!) and reported that her husband competes in ironman events with nothing more than water and nut butter, a significant change from his previous high-carb fuelling.  Apparently he is feeling and performing better than ever (he does eat carbs usually, ~150g/day although it varies day-to-day).

I know these personal accounts are not evidence-based science, but I find them quite powerful, especially when they come from credible sources.  That is another point, some of the outspoken experts on LCHF are very smart people….they are not just salespeople trying to boost their commission (although they may have a book or product on the side?).  I have spoken with many professional people who I know and trust who have great faith in the LCHF approach.

Saying that, I am certainly not sold on the concept of athletes becoming fat adapted by eating more fat, allowing fat to be more readily available as the main fuel to power elite performance.  Examples were presented of ultra-endurance athletes who train their bodies to burn fat as fuel and use ketones instead of carbs, but the thing with ultra-endurance is that it can be done at a steady-state pace.  If you need to put on a burst of speed to pass a competitor or at the finish line, carbohydrate will provide the rapid fuel to do this.  The question remains, that even though the bulk of science does not support the role of LCHF for performance, are there specific types of athletes, or individuals with a specific genetic make-up, who may benefit from the LCHF approach?

A great quote that I came across on Twitter from Professor Stuart Phillips, well-regarded sports nutrition researcher from Canada:

‘When it comes to LCHF and sport performance, I think it's important to remember that "Science is “the process of understanding the world through experimentation and observation,” whereas beliefs are “feelings that something is true.” Thus, the former represents an ideal of discovering truth that exists separate from the knower, whereas beliefs are internally held understandings filtered through one’s world view. By “unscientific belief,” something is held as generalizable fact without substantial scientific supporting evidence…" Brown et al. Adv. Nutr. 5: 563–565, 2014. So evidence trumps anecdotal experience and cognitive dissonance!’

Stuart Phillips PhD Twitter - @mackinprof

I can certainly understand why scientists and health professionals, including dietitians, are having a hard time accepting this LCHF theory, and perhaps why I was the only dietitian at the seminar.  If your entire academic and working life has revolved around evidence-based practice, LCHF doesn’t quite fit as the bulk of evidence just is not there.  Health professionals are trained not to base their practice on case studies or something that worked for your neighbor down the road.  But I don’t think you can ignore emerging trends or turn a blind eye to what people are out there doing, even if it doesn’t fit the evidence-based practice model.    

Vicky Kuriel is a dietitian who was disillusioned about dietetics, and stopped working in nutrition for a period of time due to her frustration about the lack of results for her clients with traditional methods.  She is proud to be a LCHF dietitian and provided compelling reports of client success in the areas of weight loss and reduction of gastrointestinal symptoms.  Vicky also emphasized that the key is to find the right mix of nutrition for your individual needs and to listen to your body, so again it is not all about the lowest carbohydrate intake possible for everybody.  Vicky’s final slide said this, ‘The truth is transient in nutrition’ and her message was that we need to be open to new ideas and science.

Of course during the seminar there were a number of digs at ‘those nosy’ dietitians, although the speaker, knowing that I was the only dietitian in attendance, did kindly indicate that I was not one of those he was speaking negatively about!

I had been prepared for dietitians to be criticised at this conference, and to be honest, some of the comments were spot on.  As a young dietitian working at my first professional sporting club I was known as the carbohydrate queen.  My studies had taught me that carbohydrate and athletic performance, in the majority of sports, go hand-in-hand and that was my message for athletes…..carbs, carbs and more carbs.  Of course I still recommend carbohydrate to athletes, but my approach these days is somewhat more balanced with greater emphasis on overall nutrient balance and individualized nutrition strategies.  Another example where dietitians have a lot of work to do is in the hospital food service.  Admittedly I have never worked in a hospital, other than my placement at uni nearly 20 years ago, and I don’t have full comprehension of budgetary and other contstraints that may exist, but surely something can be done to improve on the rubbish food that is currently provided in many hospital settings.  During a short stay at hospital with my young son a couple of weeks ago, I was absolutely appalled at the breakfast tray that he was presented with.  A sachet of puffed rice cereal, a piece of white bread with margarine and jam and a tub of apple juice.  Absolutely terrible, and this is what hospitals are dishing up to our sickest members of the community whose bodies are crying out for nutrients (I am happy to be challenged on this one, as I am sure dietitians have made efforts to improve food service, with likely limitations.....please say this is the case?????). 

There has been outcry from dietitians around the world about the potential risks of LCHF.  Not enough fibre, not enough calcium, too much fat, not enough wholegrains….the list goes on.  With plenty of vegetables, fruit, nuts and seeds, a well balanced LCHF diet provides great potential to eat lots of fibre.  Especially for those following LCHF who are not following a super-low carbohydrate ketogenic plan, there is scope to eat many high fibre foods.

I can see the potential issues with calcium and this would need to be addressed for any person choosing a LCHF way of eating.  For someone who does choose to eat in a LCHF style, it is important to know what you are doing and it would be advisable to seek professional advice from a dietitian who can help to ensure you are getting all of the nutrients you need. 

In terms of fat intake, concerns about too much or the wrong type have mostly been driven by the impact on health and cholesterol levels, but the evidence is mounting that LCHF eating does not have a negative impact on blood cholesterol profile for everybody, and I will go into more detail about this in my next Thoughts post.

Most dietitians are anti-diet of any type, and there are warranted concerns about LCHF's restrictive nature and the potential impact on psychological well-being and a person's relationship with food.  I was very pleased to hear Dr Arain mention this issue in his presentation and address body image and societal pressures to be a certain shape/size.  He also mentioned body dysmorphia and disordered eating, and this highlights the fact that many people who recommend LCHF are also aware of the sensitivities associated with food, and the potential psychological impact of restriction and 'diets'. Although some LCHF advocates are not as aware....

Dr Arain also mentioned another potential negative associated with LCHF eating - the development of commercial 'low-carb' products.  Similar to the proliferation of highly processed 'low-fat' products, these 'low-carb' products would not fit the 'real food' approach of LCHF but many people may use these frequently for convenience.

This leads on to probably the biggest problem that I see as a result of generalised LCHF guidelines - people don't do it properly.  The message that 'high-fat' is good could be interpreted as 'well, make that double bacon with my triple-decker cheeseburger then thanks'.  I can visualize this at take-away stores around the country, with this new message that saturated fat is a good guy.  Not that I think this is or was the intention of the low-carb, high-fat supporters, but this is the message that is coming across to the general public loud and clear.  And it creates the problem that people skip the low carb bit and just add in the fat, because fat is ‘good’.

The danger is that people choose selectively to include or omit the foods they wish.  A friend of mine who is a great GP put it perfectly ‘people just take the bits and pieces from different diets that they like’, which from my perspective creates a potential risk of even greater negative effects on their health.  Bacon is good, so must be good with everything, right??  Maybe on an extra piece of white toast, but is butter or margarine better with that?? 

Nutrition right now is confusing, but one thing that everyone does seem to agree on is that you need to find the best way of eating that works for you, based on real foods, that allows you to live and perform at your best.

In the next post I will give a summary of Associate Professor Ken Sikaris' presentation on the effect of LCHF on blood cholesterol profile, plus Ketogenic diets and Banting…. To make sure you keep up to date as new articles go up, 'Like' my Facebook page Lisa Middleton - Advanced Sports Dietitian and subscribe to my newsletter via the website home page.

This Thoughts post provides informational content only, and should not be substituted for individual nutrition prescription from a health professional.  For more specific nutrition guidance and recommendations tailored to your individual needs you should speak to an Accredited Practising Dietitian. 

Low-fat does not always mean high-sugar, but do we need low-fat anyway?

When we see 'low-fat' plastered over a food label, we often automatically assume that the fat has been replaced with sugar, salt, additives or something else that is worse for us than the actual fat that has been removed.  As a result, many people avoid low-fat products, but if you take a closer look you will find that not all foods with fat taken out have nasties added back in (although many do).  Some low-fat products are in fact higher in nutrients and lower in kilojoules than their full-fat relatives, but you need to read the labels carefully.  More importantly, do we even need to choose low-fat anyway or just stick to the full-fat versions?  I am asked this question all the time, and the answer is far from clear cut, so I thought I would write about it and try to clarify the best options for different individuals and circumstances . 

'Low-fat' can be a very deceiving label on a food.  Some foods are labelled low-fat when they are naturally low in fat to start with, so the food has not been altered in any way from it's natural state (eg. rice-based crackers).  Some foods can have the fat reduced, but nothing else is added to replace it (eg lean meats from which the fat has been trimmed).  Other foods named low-fat or "xx% fat free' have had fat removed, or are formulated to have a lower fat content, but to make the food palatable have a myriad of sugars added.  Sugar can be can be disguised within an ingredients list within a range of forms such as glucose, dextrose, fructose, corn syrup, fruit concentrate, brown rice syrup, honey, honey powder (!), maltodextrin, invert sugar, maltose, malt syrup and agave (which for some reason is often promoted as a healthy sweetener but is still high in sugar and super-high in fructose, reducing the glycemic index but big deal, it's still sugar).  Additives are also often plentiful in processed foods to maintain texture and shelf life.  An example of the types of foods that may be low in fat but higher in sugar and other additives include processed sweet and dry biscuits, fruit/muesli bars, breakfast cereals, flavoured milks and smoothies, sauces and dressings, ice-cream and flavoured yoghurts. 

Speaking of yoghurt, the dairy cabinet is one area of the supermarket that can be overwhelming when it comes to choice, and yoghurt is probably the main culprit when it comes to reducing fat content but adding sugar.  I don't read labels in the yoghurt aisle. I just try to keep it simple and stick to natural or Greek varieties, and most of the time avoid fruit flavoured yoghurts.  Whether sweetened with sugar or artificial sweetener (I am a little unsure to be honest which one is least preferable),  there is usually minimal fruit content and most of them don't even taste like real yoghurt.  Add your own fruit/nuts/seeds at home.

The next dairy option to consider is milk.  LOW-FAT MILK IS NOT HIGHER IN SUGAR THAN FULL-CREAM!  Back to my fridge for some nutrition comparisons, per 100ml:

                                       Full-cream milk                Reduced fat milk

Energy                          64 calories                       46 calories   

Protein                          3.4g                                  3.5g

Fat                                 3.4g                                  1.4g

Saturated fat                 2.3g                                  0.9g

Carbohydrate                4.8g                                  4.9g

Sugars                            4.8g                                  4.9g

Sodium                           44mg                                44mg

Calcium                          128mg                               132mg

Similarly with yoghurt, low-fat natural or Greek varieties DO NOT have more sugar than full fat. 

Milk and natural yoghurts do not contain extra sugar when the fat is removed, but do we really need to choose the low-fat versions anyway?  I am asked almost daily whether low-fat or full-fat milk is better and my answer always varies depending on who I am talking to.  I have both reduced fat (not skim) and full cream milk in my fridge. I give my two young growing boys full-cream milk.  You can offer low-fat milk once little ones reach 2 years of age, but my boys are bundles of energy and the additional calories are useful for them.  We also have low-fat milk, mostly for my husband who is a large consumer of milk as part of milkshakes and protein drinks.  The benefit of low-fat is the reduction in calorie intake with larger volumes.  Myself I vary it, going for full cream milk usually, but sometimes low-fat if I seem to be having a bigger dairy day.  My preferred dairy option is yoghurt, and again, sometimes I choose full-fat, but probably more often low-fat as I eat a fair bit of it.   So it comes down to the amount of dairy food you eat, as to whether or not you need low-fat dairy options, with consideration also of health and body composition goals.  Many people are concerned about saturated fat intake with regard to specific medical conditions and this is also an area for discussion based on individual circumstances.  A great article for an update on the debate over saturated vs. unsaturated fats from Harvard School of Public Health, 'Is butter really back?'.  It is long, but well worth a read http://www.hsph.harvard.edu/magazine-features/is-butter-really-back/ and outlines the positive aspects of unsaturated fats for good health rather than trying to solely reduce total or saturated fat.

It is interesting to also compare the carbohydrate and sugar contents of non-dairy milk options also.  Looking at the full fat varieties, soy milk generally has a slightly higher carbohydrate content than dairy milk (5-6g/100ml vs. 4.8g/100ml). Oat milk (>8g/100ml) and almond milk (4.8-9g/100ml) are generally higher in carbohydrate than dairy milk, and rice milk usually twice as high (10-13+g/100ml), depending on the brand....rice milk is a terrific base for protein powders for athletes!  Regular coconut milk is not that much lower in carbohydrate (4g/100ml) than dairy milk but significantly higher in fat (the brand I looked at was ~24% fat, so 6x the fat of regular milk) and almost 4x as many calories. *Note, these values were taken from a range of supermarket products, some milk varieties may be higher, or lower in carbohydrate (particularly unsweetened varieties).

Above all, it is important to remember that most foods with a low-fat claim are highly processed.  If you are eating mostly fresh foods in as close to their natural state as possible then you don't have to worry too much about labelling, or ingredients, or the numbers in the nutrition information panel.  By eating less-processed and including fresh vegetables, lean proteins, fish, dairy, nuts, seeds, fruits and wholegrains you are likely to automatically reduce your intake of fat and sugar.  Fat is not the bad guy.  Healthy fats are good for you and should be eaten daily.  Whether you choose low-fat varieties of foods may relate more to your overall energy and calorie needs than anything.  But the other thing to remember is that even though reducing fat intake may reduce calories, you may end up hungry and disappointed.  The full-fat alternative may leave you feeling fuller so you may in fact eat less overall, and feel more satisfied if you prefer the taste.  Also remember that full-fat yoghurt is still only ~4% fat, or 96% fat-free, it's not like you are eating half a cheesecake for breakfast! 

If you are an athlete you may not want to reduce your calories necessarily, but instead focus on optimal carbohydrate and protein intakes for training and performance, so low-fat varieties of certain products may be useful to manipulate macronutrient intake for fuelling, recovery or body composition goals. 

I feel like I am making things more complicated than they really are, but the best choices in nutrition are very individual based on a range of personal factors - lucky there are so many options out there to choose from, the challenge is choosing from these the best one for you. 

What I love about eating like a cavemen

Perhaps like you, I have been quite fascinated at the to-and-fro in the media between various individuals about the merits, or otherwise, of following a Paleo style of eating.  I love a bit of healthy debate, and I think everyone has a right to their opinion, but the thing that disappoints me most is the tone of recent discussions and the use of blatant or insinuated negativity directed towards individuals and their opinions.  Present your arguments, based on science and fact, but please don't ridicule others to promote your own opinions.  Credibility is built on honesty, transparency and results, not by personal attacks to try and make your opinions appear superior.  At least the fiery debate has put nutrition into the spotlight and inspired many of us to think about, and discuss, how, what and why we eat.

So what is 'Paleo' anyway?  I think there is plenty of confusion about Paleo, low-carb, gluten-free, clean eating, etc.  The Paleo approach promotes gluten-free, but is not completely carbohydrate free, and is based on the eating patterns of our caveman ancestors from Paleolithic times.

The brief in a nutshell:

Include - fresh meat, poultry, fish/seafood, eggs, nuts, seeds, vegetables, herbs, occasional fruit

Avoid - everything else, including dairy, grains (especially wheat apparently), legumes and all processed foods.

Things I love about Paleo:

- food in as close to natural state as possible

- high quality protein from meats, poultry, fish/seafood, eggs, nuts and seeds

- plenty of fresh seasonal vegetables 

- use of herbs and spices

- not much sugar

- no additives

- sustainability

Things I don't love about Paleo:

- avoiding dairy and grains completely, even minimally processed varieties

- not  much fruit 

- unlimited type and amount of fat

- potential expense

- preparation time

- not family friendly, inappropriate for children with regard to nutrient inadequacy and restrictive nature 

I seem to have  more positives on my list than negatives BUT the negatives are deal-breakers.  A positive relationship with food involves flexibility with choices, and the option to incorporate any type of food (obviously some more regularly than others).  It also is important to enjoy food without guilt, and I think this could be challenging with any style of eating that prescribes long-term rules and restrictions.  

How about 'partial-Paleo' or even 'lacto-graino-Paleo' as an alternative to full-on Paleo?  Just like there are various options for vegetarians (eg. lacto-ovo-vegetarian follow a vegetarian style of eating, and don't eat meat but include dairy and eggs), there could be different options for Paleo, which allow for our modern lifestyles, preferences, cooking options and nutrition needs?  Lacto-graino-Paleo could include some nutritious options within the dairy, grain and legume families.  Perhaps some A2 milk, some natural/Greek style yoghurt, a delicious tasty cheese, and some nutrient-packed oats or rye products.  Or even sometimes, shockingly, enjoying delicious fresh-baked white bread or a crunchy and gooey chocolate brownie! 

I am certainly not endorsing a Paleo style of eating, or any other specific style of eating,  across the board, because everyone is different and different things work for different people.  I do believe that it is everyone's individual choice as to what, how and why you eat and how you live your life in general.  Food serves a purpose in keeping your body energised and healthy, but is also a big part of our lives to be shared, appreciated and enjoyed.  Many of our most wonderful food memories involve foods that would not be considered to be 'healthy'.  I can still smell the home-made sausage rolls, an infrequent but much loved and anticipated lunch order from the local general store next to my old primary school.  Or Mum giving my brothers and I a few coins (no doubt silver ones, that we often pooled together for maximum value) to spend at the supermarket on snacks to take into the movies.  We weren't in the fresh produce section that is for sure.  Who would want to deny children these experiences and memories?  Being a dietitian I am obviously interested in health and eating well, but I also love to enjoy special food occasions.

If you like the idea of Paleo, or any other particular style of eating, make sure it is right for YOU.  Think about how it fits your lifestyle, the demands, pressures and costs involved, whether there is good nutrient balance for your particular health needs, potential for nutrient inadequacies and if it really makes you feel good.....you may have to make some modifications to come up with something that suits your unique needs.  Above all, work towards eating choices that you can live with long-term and that allow you to eat well, widely and without ongoing deprivation or guilt.