He Said, She Said: Supplements

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He Said

As both a practitioner and a patient myself, I support the idea that everybody should have the freedom to pursue the healthcare path that feels right to the individual in question. The same freedom, I believe, should also extend to practitioners to be able to offer the modes of care that meet their own standards of ethical practice.

Approaches often evolve in response to new education and research. Earlier in my career, I worked at a medical center where selling supplements to patients is a significant part of their way of doing business. As I learned more about the science behind supplements and about the industry itself, I grew increasingly uncomfortable with this approach. Because of that background, you will not find any supplements or products of any kind for sale at Soolman Nutrition and Wellness LLC.

During our sessions, the topic of supplementation does occasionally arise, usually brought up by patients who have heard or read that a particular supplement regimen may help with whatever conditions are ailing them. However, we must remember that supplement manufacturers are allowed to make whatever health claims they would like – well-founded or otherwise – on the bottle just so long as they also have the standard disclaimer, “These statements have not been evaluated by the Food and Drug Administration (FDA). This product is not intended to diagnose, treat, cure, or prevent any disease.”

In other words, the claims made on the bottle may be wildly inaccurate and have absolutely no credible research to support them, but the FDA does not have the power to intervene. Generally speaking, regulation within the supplement industry is reactionary, not proactive. Not only can manufacturers say whatever they want about their products, but they also do not have to prove their products are safe before they go to market. The FDA only steps in when a problem arises, as it did in the 1990s when people died from the anti-obesity supplement commonly known as fen-phen.

Furthermore, the FDA does not regulate the contents of supplements themselves, and oftentimes actual products do not contain what is listed on the bottle. Back in 2008, for example, I attended a talk during which a dietitian presented an independent research study that found that the hardly any of the tested protein powders contained the amount of protein advertised on the label. John Oliver, in his funny yet factual breakdown of the Dr. Oz debacle and the supplement industry in general, reveals that one in three supplements contains no trace of the plant advertised on the bottle. “If one in three milk bottles didn’t contain milk,” he says, “you might think twice about pouring the white mystery liquid all over your cereal.”

Even information regarding legitimate substances, such as vitamins, is skewed. Vitamins get their distinction because a deficiency in any one of them can cause a specific disease. For example, vitamin C deficiency causes scurvy, which is one of the reasons why the British navy began providing limes for their sailors in the 1800s. During Europe’s Industrial Revolution, children no longer received the same sunlight exposure as they did in generations past and consequently developed rickets, an indicator of vitamin D deficiency.

However, just because an adequate amount of a vitamin will prevent a deficiency-related disease does not mean that a benefit exists to taking excessive amounts. The United States Department of Agriculture’s Dietary Reference Intakes include tolerable upper intake levels, defined as “the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population,” for most vitamins, yet we can easily – and unknowingly – exceed these upper limits through supplementation.

For all of these reasons, unless a patient’s situation suggests the contrary, I recommend doing our best to get our nutrients through food first and only bringing in supplements when necessary. If it does look like a supplement is warranted, I suggest my patient run it by his or her primary care physician.


She Said

The topic of supplementation often comes up in my nutrition counseling sessions with patients and their families. Since I am not a medical prescriber, I always refer patients to their primary care physician when it comes to questions about supplements. While I usually suggest that patients try to receive most of their nutrients from actual food sources rather than pills or powders, there is some promising research on specific supplements that may help those struggling with eating disorders (EDs).

As one would guess, those struggling with EDs are usually deficient in many different nutrients due to extreme restriction and/or purging or laxative abuse, and this can compromise every organ in the body. These nutrient deficiencies can lead to a number of medical issues for the individual, including (but not limited to) osteoporosis, anemia, and heart and kidney problems.

Many supplements have been studied in their relation to EDs. For example, zinc supplementation has been linked to improvement in appetite, taste perception, and mood as well as enhanced weight restoration and menstruation in anorexic girls and women. Supplementation with essential fatty acids, specifically EPA and DHA, has also been found to aid in weight restoration while decreasing preoccupation with and anxiety around food in those with anorexia. For those struggling with bulimia, supplementation with electrolytes such as potassium and magnesium is often prescribed due to the large amount of electrolytes that are lost through purging.

A number of my patients struggling with EDs are either vegetarians or vegans, which can result in nutrient deficiencies including calcium, iron, and vitamin B12. Calcium deficiency can lead to osteoporosis, which can be tested for by doing a DEXA bone scan. Iron and vitamin B12 deficiencies can be detected by blood tests. In some cases, supplementation with these nutrients might be suggested to aid in the prevention or management of medical conditions.

At the end of the day, I try to focus on food with my ED patients, as most nutrients are best absorbed from dietary sources. But in some severe cases, supplementation might be indicated if the individual is unable (or unwilling) to eat the foods necessary to attain these nutrients. Refeeding can be a very uncomfortable experience for those struggling with EDs. Most of my patients who are refeeding experience painful bloating, cramps, constipation, and delayed gastric emptying, which can make it feel nearly impossible to eat anything at all. In those situations, supplementation with certain nutrients might be indicated until the individual is able to start eating normally again.

If you are considering supplements for either your own or your child’s ED, please consult with your physician before trying anything on your own. Your physician will be able to assess any nutritional deficiencies through a number of diagnostic tests and then can guide you in the right direction.


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A friend and I recently got into an email exchange about how rapidly nutrition advice seems to shift and how this often leaves people confused, frustrated, and feeling paralyzed about what to do.

No doubt, guidelines do evolve in response to new research, and in fact the Dietary Guidelines for Americans are updated every five years.  The shifts, while perceived as quite fickle, are much more subtle than most people realize.  However, the reason we perceive nutrition advice to be oscillating like the ever-changing wind is not due to this evolution, but rather because of misinformation.

Take yesterday as an example.  Each day, Joanne and I receive a blast of nutrition-related articles.  For each topic, we are provided with the story geared towards the general public, such as an article in the New York Times or Boston Globe, as well as the research piece or journal article on which the story is based, such as a piece in the New England Journal of Medicine.

Yesterday’s topic read, “Fats and Oils That Can Improve Your Health.”  As soon as I began to read the story, something seemed fishy.  Ghee and coconut oil topped the list of supposedly-healthy fats.  Although alternative medicine touts both of these fats as having health benefits, the research up to this point has not supported these claims.  Therefore, I was surprised to see them headlining the list.  When I got to the bottom of the article, I discovered that sure enough the story was written by a “Holistic Health Counselor,” as opposed to a credentialed and licensed expert in the field.

Next, I read the position statement released by the Academy of Nutrition and Dietetics on which the above story was supposedly based.  The content of the two publications bore little resemblance to each other.  Regarding coconut oil, the Holistic Health Counselor wrote, “This versatile oil goes well with both sweet and savory dishes and boasts many health benefits.  Made up of medium-chain fatty acids, this oil is good for those trying to lose weight because the body can easily use this healthy fat for energy.  A large portion of the fatty acids found in coconut oil are made of lauric acid, which can serve as an antimicrobial, antiviral, and antibacterial, helping to combat viruses and boost the immune system.”  On the other hand, the position statement read, “New food products containing coconut oil and other palm oils (eg, milk, spreads, yogurt) are touting health benefits of MCTs [medium-chain triglycerides, or medium-chain fatty acids].  Given that 44% of coconut oil is 12:0 and 16% is 14:0, and these fatty acids are hypercholesterolemic, consumption of coconut products is not currently recommended.”  Do you see any relationship between these two passages at all?

Omitting a link to the Holistic Health Counselor’s story was a conscious decision on my part in order to avoid further dissemination of misleading information.   If I showed you the article though, you would discover that it is concise, organized into a list with bold headings, and features colorful and attractive photos as well as a head shot of the author.  Compare that to the text-heavy, chemistry-laden, pictureless, 18-page monstrosity that is the position statement.  The former will attract more readers and gain steam and wide circulation due to forwarding to friends, postings on Facebook, etc.  The latter is lost in the dust, only to be read by the likes of me.

Generally speaking, most people never read primary source articles.  They simply trust that the stories they read summarizing said articles do so with a high degree of accuracy.  Unfortunately, just like in the game of telephone, details and facts get lost or skewed with each iteration; the ultimate and initial messages conveyed often do not match.  The mismatch is what makes playing telephone fun and interesting, but in real life the consequences are negative.  A patient comes into my office having read the more popular article and understandably believes the content to be true, but then he or she hears me present the position statement’s stance.  “Have the guidelines already changed?” the patient asks.  “Who should I believe?  What am I supposed to do now?”  No wonder people feel stuck and confused.  Part of our work then becomes to undo this confusion so that the patient can move forward.

In a culture where we have limited time and attention spans, we get a great deal of our news through tweets, scrolling headlines at the bottom of the television, and sound bites.  Media members, fully aware of the small window they have to present an idea and under pressure to break a story first, sometimes sacrifice checking facts and preserving key messages.  The pressure to be first and to accumulate clicks, retweets, and Facebook likes is king while the responsibility to be accurate gets lost in the shuffle.

Somewhere along the line, somebody suggested to me that I should shorten my blogs.  People have neither the time nor attention span for my entries, and who besides my mom reads all the way through to the end?  Shortening my blogs, I am told, could increase our Facebook fans and Twitter followers, thereby making Soolman Nutrition and Wellness LLC more popular.  That could be true, but my position as a source of reliable information is one that I take seriously, and I am not about to sacrifice my credibility for some extra likes and retweets.  Despite today’s be-first-and-keep-it-short media culture, accuracy and completeness are still necessary in order to minimize confusion.


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Note: This post is a tangential companion piece to another piece I wrote, which you can read here.

Before I changed careers and became a dietitian, I put my math degree to use as an operations research analyst for the U.S. Department of Transportation.  I worked on many projects, one of which was helping to manage a mathematical model of the alternative fuels industry.  When I first joined the project, I wondered why – if energy sources other than gasoline existed – did we continue to primarily use gas for our cars?  Then I learned that all of these alternatives had serious downsides.  Fuel X would reduce tailpipe emissions, but cause massive pollution output at the plant where it was produced.  Fuel Y was so unstable that a simple fender bender could trigger an explosion.  Fuel Z was so expensive that it would price out many drivers.  I still remember one of my colleagues, who had been working in the field much longer than me, saying, “These alternative fuels are alternatives for a reason.”

Alternative medicine isn’t all that different.  If its unusual tests and approaches worked as well as its practitioners say they do, these tests and treatments would not be alternative, they would be mainstream.  I support an individual’s right to pursue the kind of healthcare that feels right to him or her, and I understand that not everybody wants to stick to the mainstream route.  In fact, I am glad there are people out there who question the mainstream, push the boundaries, and try new things, as that is often how progress is made.  My concern is just that alternative practitioners need to do a better job with transparency and disclosure.  In other words, they should be disclosing that a given approach is an unproven hypothesis, if that is indeed the case, not passing it off as a well-documented conclusion.

As an example, consider the plight of one of my best friends from high school, who wrote to me recently because an alternative nutritionist told her she should go gluten-free to help her rheumatoid arthritis (RA).  My friend says she has read on many websites that gluten causes RA.  I suspect that one day we will have a good understanding of the role, if any, that gluten plays in RA development and exacerbation.  That day, however, is not today.  For someone to put it on a website or recommend it to my friend as fact is just, well, in my opinion anyway, irresponsible, unethical, and unprofessional.

Sometimes people feel so poorly and get so desperate for an answer that they will listen to anybody who gives them one, independent of whether that answer is correct.  I do not mean that as a knock against any of the patients, but rather as criticism of practitioners who capitalize on desperate people making emotional decisions when they should instead hit the brakes and help said people make informed decisions.  If, for example, the nutritionist explained to my friend that the gluten-free diet is an experimental approach to dealing with RA and my friend – fully understanding the experimental nature of the approach as well as its potential pros and cons – decides to go ahead with it, then by all means.

These practitioners should disclose that some of their approaches and tests are not terribly accurate and are not widely accepted as valid, but they often do not.  Paradoxically, offering this disclosure would probably give them more credibility, not less.  Remember in school when a student posed a question that stumped the professor?  The professor who admitted “I don’t know” earned trust and respect, while the professor who made up an answer that was clearly BS looked bad even though that is the exact outcome he hoped to avoid by inventing an answer.

Elimination Diets

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“Two separate people told me I should try going gluten and dairy free to combat my arthritis and go off my medicine.  Perhaps that could be another topic: elimination diets to combat various diseases.”

In response to my request for blog topics, a friend of mine suggested the preceding idea.  My response inspired a tangential post to which you can find a link here as well as about two-thirds of the way down.

Before we get to elimination diets, let us first consider some of the various ways in which foods might have a negative impact on us: allergies, intolerances, and sensitivities.

Food allergies involve the immune system and the reactions are rapid and often acute.  Think of somebody who accidentally eats a peanut and has to use his EpiPen to keep his throat from closing.  Doctors can test for food allergies with a high degree of accuracy.

Food intolerances do not involve the immune system.   For example, consider somebody who lacks the lactase enzyme in his system necessary to digest lactose, and as a consequence he experiences symptoms like gas, bloating, and diarrhea in response to dairy ingestion.  We call this lactose intolerance, and doctors can test for it via a hydrogen breathalyzer test.

Food sensitivities differ from both allergies and intolerances.  Symptoms associated with food sensitivities tend to set in slowly, leave slowly, and are more subtle.  The range of associated symptoms is also quite wide, including headaches, fatigue, joint pain, bloating, and nasal congestion, just to name a few.

The current tests for food sensitivities are, to put it kindly, not great.  In fact, there is no immunological society in either the U.S. or Europe that considers today’s food sensitivity tests valid.  One of the problems with these tests is that they can simply reflect exposure to a food.  In other words, if you have eaten a given food recently, it is more likely to come up positive.  Even worse, the results can actually reflect tolerance (yes, tolerance) to the food in question.

The best way to determine food sensitivities is through an elimination diet, a procedure in which somebody cuts out various foods and then reintroduces them in systematic fashion in order to see how his symptoms change in response.  Elimination diets can be slow (think weeks, not days) and tedious, and they require a tremendous amount of discipline on the patient’s part.  Another issue to consider is that the patient is unblinded.  In other words, he knows when he is or is not eating a given food and this can influence the results.  If someone or something has led him to suspect that a given food is responsible for his symptoms, then he might imagine or exaggerate a reaction due to expectation.  It’s sort of a like a reverse placebo effect.  Additionally, other confounding factors exist too.  All sorts of variables exist in our life, so the onset or dissipation of a symptom cannot automatically be attributed to a change in diet.

While elimination diets can yield useful data, the challenges and downsides associated with them understandably leave people looking for alternative approaches [At this point, I went off on a tangent, which I extracted and posted here.], which brings us back to the food sensitivity tests that I mentioned a couple of paragraphs ago.  These test results should never be taken literally, but they can be used for the basis of an elimination diet.  For example, if the results indicate that Foods X, Y, and Z are problematic, one can eliminate and then reintroduce these three foods to determine which (if any) of them are indeed problems.

Also remember that cutting out foods can have consequences and should not be done casually.  I know cutting out gluten is kind of the in thing to do these days, but going gluten-free without a good reason for doing so it not such a great idea.  Gluten-free products are often lower in fiber, iron, and some of the B vitamins.  Of course it is possible to get these nutrients elsewhere, but a gluten-free individual has to pay that much more attention to the rest of his diet in order to avoid a deficiency.  Additionally, gluten-free products tend to be more expensive than their traditional counterparts, and potential social repercussions warrant consideration as well.  Unless somebody has cause for eliminating a food and has discussed it with his doctor and dietitian first, cutting it out is probably not the best idea.

Despite all of these potential downsides, elimination diets are currently our best option for determining food sensitivities.  If you are considering eliminating a food (or foods) due to a medical condition or symptom, talk with your doctor and dietitian first.  While elimination diets have their place, they are not always the appropriate first step.  Your doctor may wish to run other tests first.  For example, celiac disease can be more difficult to diagnose if somebody has already begun to reduce his gluten intake.  So, talk with your healthcare team first.  Your dietitian can help you to design the logistics of your elimination diet.  If you are going to put in the effort to do one, might as well make sure you implement it in such a way that will maximize your chances of gathering useful data.  Lastly, if and when you do start an elimination diet, keep an open mind to all possible outcomes and do not assume that a given food is going to be either benign or problematic.