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.

“How do I get my children to not only eat, but also to eat foods that are good for them?”

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“How do I get my children to not only eat, but also to eat foods that are good for them?  Where is the line of encouraging children to eat without creating food issues down the line?” – JB

My first counseling position as a dietitian was at a pediatric practice and I continue to see many children here at Soolman Nutrition and Wellness LLC.  JB is not alone in her concerns, as many parents share the same questions stated above.  While every child and family dynamic is different, I do find that the following ideas tend to help.

Allow your child to help with food selection.  Take your child to the grocery store and let him pick out a new fruit or vegetable that he is curious about or finds interesting.  I remember not being a huge fan of carrots as a kid, but then one day I saw carrots in the supermarket with the green stems still attached, which made me think of one of my favorite cartoon characters, Bugs Bunny.  Suddenly, I wanted carrots!  If bringing your child to the supermarket is not appealing because of the potential for conflict over foods you do not want to buy, consider going to a farmers’ market instead where the non-produce temptations are less.  Having a garden that your child helps to maintain can be a great way to get him interested in vegetables.  Even an indoor planting system, such as the AeroGarden, can have a similar effect.

Involve your child in food preparation.  Your child can participate by performing tasks that range from pulling grapes off their stem, to slicing a pepper, to making a side dish, to preparing an entire meal, depending on his abilities and level of interest.

Give one alternative and that’s it.  If your child is a picky eater and does not want to eat what the rest of the family is having for dinner, offer one standby alternative, something that is easy for you to make and is relatively healthy, such as a turkey or peanut butter and jelly sandwich.  It is understandable that parents want to give their child what he wants, and the fear that he will not eat anything can also be stressful, but being a short-order cook usually leads to more stress and conflict in the long run.  Create an environment where the only options are Choice A or Choice B and your child will likely adapt.

Set ground rules ahead of time for trying new foods.  Children often fear trying new foods not because of the foods themselves, but because of what might happen if they say they like or dislike a new food.   Their rationale is often, “If I say I like this broccoli, are they going to make me eat more of it?  I don’t want more of it, so I had better say I don’t like it.”  Negotiate ground rules with your child ahead of time regarding how he will try new foods.  For example, how often will he be expected to try something new, how much must he sample, and what happens if he dislikes the food?  What if he likes it?  Just this week, I brokered a deal between a mom and her son that established the ground rules under which he will try new fruits, and they both walked out of here happy and excited.  Be nonchalant about the process and roll with whatever reaction your child has.  Remind your child that tastes do change over time and encourage him to keep an open mind to the possibility of retrying a disliked food again down the road.

Tap into your child’s motivation.  Many children have trouble appreciating that what they eat affects their health down the road, so instead draw a link between what your child eats and what currently motivates him.  If he wants to be a better soccer player, for example, talk about how eating can help him play better.  I find that nearly every child perks up if I ask him if he would like more energy.  That gets my foot in the door to talk about basic nutrition concepts.  The child does not care that what I am teaching him can reduce his risk of chronic disease decades in the future, but he is engaged and pays attention because what I am talking about will help him with what feels important to him right now.

Set a positive example.  In my experience, the families in which the parents eat one way while expecting their children to eat another way also tend to be the families with the most conflicts around food, and I do not believe this to be a coincidence.  Role modeling the eating behavior you desire for your child can have a very positive effect on his own eating.

Talk about balance and being mindful, not weight or dieting.  Eating disorders, disordered eating, exercise obsession, poor body image, low self-esteem, and associated issues often (but certainly not always) start with messages that children pick up at a young age.  How you behave and treat yourself rubs off, so be wary of going on diets, talking about diets, disparaging yourself, or discussing weight in front of your children.  Similarly, overly restricting children can lead to secret binges, as was the case with a recent patient of mine who snuck a bunch of 100-calorie snack packs and soda when his mom was not looking.  Labeling foods as “bad” can also be detrimental.  Children need to learn how to find balance while incorporating all sorts of foods.  Otherwise, think about what can happen when that child grows up and has the freedom to access previously-forbidden “bad” foods whenever he wishes.  Instead of all that, a much more positive message is to talk about listening to what makes our bodies feel good, honoring our preferences, and loving and accepting ourselves no matter what we look like.  Help your child to build a foundation of balanced eating that gives him the best shot at having a healthy relationship with food for the rest of his life.

Note: For the sake of brevity, I referred to a child as “he,” as opposed to “he or she,” but in no way was that to imply that these suggestions are specific only to boys.  On the contrary, I find that these ideas work well for both boys and girls.

“What are the facts about sugar? How much is too much?”

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“What are the facts about sugar?  How much is too much?”

Last week, I solicited suggestions for blog topics from our Facebook followers.  AF wrote to me with the preceding question, which I have chosen to answer because many people are confused about sugar.

Back in 2009, the American Heart Association published their opinion that women should limit their daily intake of added sugar to 100 calories (25 grams) while men should limit their intake to 150 calories (37.5 grams). 

Let’s put these numbers in context.  One cup of Coke, not even a full can, contains 27 grams of sugar.  One tablespoon of chocolate chips contains eight grams.  We will find 20 grams of sugar in a half-cup serving of Ben & Jerry’s vanilla ice cream, while a single Oreo has 14 grams.

When we think about what we eat over the course of the day and all the sources of added sugar we ingest, both the obvious sources like the examples I cited as well as more subtle sources like marinara sauce and salad dressing, most of us reach the American Heart Association’s upper limits very, very quickly.

If you are currently having more daily sugar than their guidelines suggest, my advice is not to panic and suddenly restrict yourself in order to achieve their guidelines, but rather to make small changes over time to reduce your added sugar intake.

Also, recognize that differences of opinion exist regarding how much added sugar is too much and others are more liberal.  For example, the USDA’s dietary reference intakes say, “Limit [added sugar] to no more than 25% of total energy.”  For somebody who needs 2,000 daily calories, this means a maximum of 500 daily calories from sugar, or 125 grams.  For a female, this represents a five-fold difference compared to the American Heart Association’s guidelines.

So, do not stress too much about achieving the American Heart Association’s specific guidelines, but rather recognize the general principle that many of us can improve our health by reducing our intake of added sugar.

Also, I cannot stress enough that these guidelines are for added sugar, not naturally-occurring sources of sugar.  The lactose in milk and the fructose in fruit, for example, are not included.  So, one need not freak out that a medium apple contains approximately 19 grams of sugar, as this does not count towards the limits we have discussed.

The Saturated Fat Conspiracy

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We have seen articles and memes pop up in our Facebook news feed recently suggesting that saturated fat does not contribute to cardiovascular disease.  Some posts go so far as to accuse those responsible for our country’s dietary guidelines, which suggest limiting saturated fat to 7-10% of total calories, of corruption.

Guidelines do change over time in response to new research, which is why the dietary guidelines are updated every five years.  All of these social media posts got me wondering though, are we really behind the times?  Is there a whole bunch of data out there absolving saturated fat from its purported role in cardiovascular disease development and we in health care just don’t know it?  Are the people responsible for creating and updating our dietary guidelines actually corrupt and purposely ignoring data?

To answer these questions, I decided to take a look around the world to see what other countries have to say about saturated fat.

First going north to Canada, I learned that the Dietitians of Canada say, “Saturated fat should be limited to no more than 10 percent of your daily calorie intake.”

Hopping across the pond, I read that the British Nutrition Foundation advises, “Eat less saturated fat to keep your blood cholesterol down.”

You may have heard that Denmark instituted a tax on foods high in saturated fat and that this tax has since been repealed, but the repeal had nothing to do with a change in nutrition or physiology understanding, but rather because the tax by and large did not change eating habits.

My next stop was South Africa where the National Department of Health says, “You can prevent heart disease by living a healthy lifestyle: Eat a healthy diet.  Be sure to eat plenty of fruits and vegetables.  Eating foods low in saturated fat and cholesterol and high in fibre can help prevent high blood cholesterol.” 

Moving laterally to a country where lamb, which is quite high in saturated fat, is so pervasive in the food supply that even Burger King serves lamb burgers, the New Zealand Nutrition Foundation writes, “Saturated fat increases total cholesterol by increasing the ‘bad’ LDL cholesterol, so it should be eaten in the smallest amounts.  We should aim to reduce saturated fats in the foods we eat, and where fat is used, choose monounsaturated and polyunsaturated fats.”

Along with their dietary guidelines, Japan offers an excellent series of journal articles explaining the rationale for said guidelines.  In this paper, the authors acknowledge some of the flaws in saturated fat research, but ultimately offer similar advice to other countries, “In summary, saturated fat intake has been associated with increased incidence of myocardial infarction, obesity, and diabetes mellitus in a dose-dependent manner.  Thus, although it is not clear that increased intake of saturated fat is a cause of these diseases due to a lack of large scale intervention study, research suggests that a diet high in saturated fat may promote these diseases.”  In fact, the Japanese National Institute of Health and Nutrition’s guidelines of 4.5-7% of total calories from saturated fat for males and females age 18 and older is even stricter than what our own dietary guidelines suggest here in the United States.

So, it seems that if we are behind the times, unaware of critical data, or corrupt, then so is everybody else.

It could very well come to pass that in time we will refine our understanding of saturated fat’s role in cardiovascular disease development, and we can bet that future dietary guidelines will evolve in response.  In the meantime, when you see social media posts calling attention to a particular study or factoid, remember that there is going to be variation from study to study, which is why the research community, those responsible for creating our dietary guidelines, and practitioners, do not get too worked up about any one particular study.  The overall body of research is what matters.  For the time being, the world’s dietary guidelines are what they are regarding saturated fat because the overall body of research, while incomplete and imperfect, points in one particular direction.

He Said, She Said: School vs. Bagged Lunches

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When your child started school earlier this month, your family may have considered whether to buy the school lunch or provide food from home. Or did you automatically opt for one without giving much consideration to the other?

He Said

My first job as a dietitian was a research position that entailed traveling the country to collect and process data about the food served in elementary school cafeterias.

In one Chicago suburb, it was considered “uncool” to eat vegetables. Because students were more likely to use vegetables as ammunition for a food fight rather than for consumption, cafeteria supervisors intercepted students coming out of the lunch line and removed the vegetables from their trays before they sat down. I remember looking into a trash can and seeing thousands of peas that were served but never had a chance to be eaten.

In contrast, I visited a Tennessee hill town where they were dealing with the problem of students taking too many vegetables from the self-serve salad bar. I watched cashiers ring up students with one hand and pick off vegetables from their trays with the other hand in order to keep portion sizes in line with system guidelines.

One school I visited here in Massachusetts served soft pretzels as a main course. The school system dietitian explained to me that she wanted to make the lunches in her system healthier, but she was encountering harsh resistance from both parents and principals who cared more about the children eating – period – than they did about providing a healthier option that they feared the kids would reject.

Everywhere I went, I saw students discard or trade away food that their parents had provided from home. Just because you or the cafeteria staff gives your child something to eat does not guarantee that it will make it into his or her mouth, and a school lunch is not inherently more or less healthy than what is brought from home.

As you and your child decide what’s for lunch, consider not just your child’s preferences and health, but also the realities of the cafeteria dynamic. In order to get a glimpse of the latter, think about planning a visit to eat lunch with your child in the cafeteria. I saw parents eating with their children in every single school system that I visited.

She Said

Planning ahead is a great strategy for figuring out school lunch. First, I think it’s a good idea to suss out what your child’s school is serving. Most public and private schools have websites nowadays, so looking up the weekly/monthly cafeteria menu shouldn’t be too difficult. If, however, no website exists, talk to the school and they can give you a hard copy of the menu.

If you and your child look at the menu and nothing looks appealing, the next step would be talking with your child about what he or she would like to bring for lunch. Letting your child help in planning and/or putting together lunch will greatly increase the odds that he or she will eat said lunch! Having your child accompany you to the grocery store to pick out lunch foods would be a smart idea as well.

Finally, a lot of my clients feel stuck around what to bring, feeling like sandwiches are the only option. Not true! One can piece together a totally healthy lunch without needing it to be “standard.” For example, hummus and pita, baby carrots, fruit, and milk can make a delicious piecemeal lunch. Another idea could be crackers and cheese, with cut-up peppers, fruit, and a beverage. Bringing leftovers from last night’s dinner, such as a pasta dish, would also work really well.

The bottom line: If your child can be involved in one or all steps in the school lunch process, success will be sure to follow.

Problems and Privileges

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Thank you to everybody who showed up for the Race Wellesley First 5K and 10K this weekend, including runners, supporters, volunteers, and sponsors!  I love events that bring the community together, and as such I was really happy to both be sponsoring and competing in the race.

I finished the 10K race in 10th place overall and in fourth place in my age group.  I missed out on a third-place medal by 0.9 seconds.  The guy who earned the bronze passed me with about a mile to go.  Rather than keep up with him, I elected to stay back.  My plan was to let him think I was out of gas, but then to take him by surprise and out-sprint him at the end.  The strategy almost worked, but I could not quite catch him at the line.  He ran a great race and definitely deserved the medal.

I have never won a placement medal in my life, so when the standings were announced and I realized that I missed out on one by a single second, I was frustrated and could not believe I let the opportunity slip away.  It is easy to look back on a six-mile course and develop a list of second-saving could-haves, would-haves, and should-haves.  I am sure the guy who beat me could say the exact same thing about his own performance, but the reality is that neither one of us gets a do-over.

This is all pretty out of character for me.  People who know me well know that I care much more about race time than I do placement.  The way I see it, time is a better reflection of my progress because I can compare myself to how I have done in similar races.  We are more in control of our own destiny with time, whereas placement heavily depends on elements that are out of our hands.  If the Kenyan national distance-running team shows up or stays home, for example, I am going to finish in a very different place in the standings regardless of how hard I run.

So, if I do not care that much about placement, why did I care in this race?  I am embarrassed to say it is because we were a sponsor.  There I was wearing my green Soolman Nutrition and Wellness LLC racing jersey, our logo printed on all of the racing bibs and centered on the race T-shirts, and our brochures stuffed into the gift bags that each runner received.  I imagined that in the eyes of everybody who was there, my race performance would make or break their opinion of me as a dietitian.

That is probably the silliest and most off-base notion you have read today.  Furthermore, it is not even in line with my opinion regarding how a practitioner’s life influences (or does not influence) patient care.  I temporarily got caught up in a belief system in which I normally do not include myself.

This morning, I went to supervision group.  That’s the term used for when a small group of dietitians gets together to discuss best practices, difficult cases, and other matters of patient care.  It turned into an emotional meeting or sorts, as people in the group shared some of their own personal struggles as well as their fears regarding what their patients might think if they found out about these issues.  Without disclosing details that might make their identities known, I will tell you that one of the dietitians mentioned a personal history of an eating disorder, another shared her struggles with a debilitating and incurable disease, and another disclosed that she will be undergoing radical surgery this winter and has been overeating due to her increased stress.

I only listened.  Had I contributed, I would have told them about my persistent back problems: the herniated disc, the four fractures that will never heal, and other associated issues.  I remember my physical therapist telling me earlier this summer that she does not get too worked up about MRI reports because almost every scan reveals some sort of structural issue, and by and large these issues are harmless.  She told me she only gets concerned when a report contains the word “severe.”  Then she looked at my report, looked back up at me, and gave me a half-smile.  “Severe” appeared in my report three times.

Dietitians are just like everybody else.  Patients often assume that we are perfectly healthy, have perfect relationships with food, and in general lead the healthiest of healthy lifestyles, but the truth is that we have our problems too.  Like a cancer patient who goes on to become an oncologist, why do you think so many of us chose to pursue a career in health and dietetics?

So, taking myself down from the pedestal that some people seem to put me on, but on which I do not belong, is actually a big relief.  I do not have to live up to extraordinary expectations and feel bad about myself when I fall short.  Instead, I can just enjoy what I have, what I can do, what I have accomplished, and what is ahead of me.

It is a privilege that I have been generally fortunate with my health and that the problems I do have are manageable.  It is a privilege that I can go to physical therapy and work towards getting stronger.  It is a privilege that you, your neighbors, and your friends allow me to help you towards your own goals.  It is a privilege that I got to race in a great community event along a beautiful course on a crisp late summer morning with my wife cheering for me.

And yes, it is absolutely a privilege that I was able to finish one second shy of winning a medal.

My Big Fat Revenge

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So, a couple of days ago, I caught wind of a new reality TV show on the Oxygen network called My Big Fat Revenge, a show that appeared to be a hybrid of The Biggest Loser and Punk’d.  Intrigued, I decided to check out the show’s website to learn more about it.  Apparently, the “docu-series” gives overweight women the “opportunity” to not only lose weight through Draconian measures, but also to get retribution against family members, former boyfriends, former classmates,  etc., who had shamed and made these women feel humiliated about their weight in the past.  To do this, the “fat shamers” are “set up on blind dates, auditions, and nightmare jobs to experience what they put their offenders through,” so that the transformed women can teach them a lesson and get an apology.

All I can say is “no.”  What a horrible idea for a show!  Instead of having the women embrace their bodies as-is and then confront their tormenters, this show is condoning the idea that getting thin is the best (and only suitable) revenge.  In fact, by focusing solely on losing the weight, the women are actually validating their attackers’ assertions that they should have been ashamed of their weight.  While the show does assert that fat-shaming is wrong, it essentially undermines this message by saying that unless you lose weight and look thin, you do not deserve respect.

As a television channel that is supposed to be providing inspiring and empowering programming for women, I find all of the above very depressing indeed.

Veggies

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I know that many people might not believe it, but sometimes I need to “sneak” vegetables into my diet.  Being a registered dietitian, I am sure this seems odd!  Sometimes I do find myself craving a big, crispy salad or string beans, but there are also many other times when I am not feeling like vegetables, no matter how healthy I know they are. We all know that veggies have so many wonderful vitamins and minerals and are important for overall health. So, what’s a dietitian to do when veggies do not seem so appealing?

Well, in times like these, I try to squeeze veggies into my meals and snacks as much as I can.  At breakfast, I will add spinach or broccoli to my omelet and have it with salsa.  For a post-workout snack, I have been making a green smoothie using baby spinach or kale, almond milk, yogurt, and banana.  It’s amazing how you cannot taste the spinach at all in the smoothie – it tastes just like a banana shake!  With dinner, I try to mix cooked veggies into at least one part of the meal.  If I am having mac and cheese, for example, I will mix in some frozen peas or broccoli florets.  If pizza is for dinner, I will add peppers and onions for toppings.  And of course, veggie-based soups, like zucchini bisque, are an easy way to increase one’s veggie quotient.

Many of my clients struggle with their vegetable intake, and I completely understand this.  However, it is easier to sneak these nutrient-packed superstars than you may think.  Get creative! 

Did I really post weight loss advice?

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Earlier this week, I posted a blog by Joan Salge Blake, a nutrition professor at Boston University, in which she discussed a research study that looked at the impact of calorie distribution on weight loss.  The researchers found that subjects who consumed a large breakfast and small dinner lost more weight than subjects who consumed the same number of calories, but flip flopped their breakfast and dinner intakes.

Those of you familiar with how we work might have been surprised to see me post an article that seemed to give weight loss advice.  Our treatment philosophy is in line with the reality that when people eat well and are physically active, weight tends to take care of itself.  On the other hand, when people make weight loss in and of itself too much of a priority, they are likely to take approaches that can be unsustainable, unhealthy, and sometimes dangerous.  Then they blame themselves and a supposed lack of willpower when the real problem was the approach.  Because I have held this stance for years, my decision to post what looks to be a weight loss advice article probably seems a bit contradictory.

But it really isn’t, and here’s why: Even though the blog does discuss weight loss, I see it as more about health than weight.  Professor Blake wrote, “Since the hormone ghrelin, which increases your appetite, was lower during the day in the breakfast group, these women also experienced higher levels of satiety, or that filling of fullness, throughout the day.  In addition, large breakfast eaters also had significantly lower levels of insulin, glucose, and fat in their blood, which may help lower the risk of diabetes and heart disease.”

In other words, the subject group that consumed the larger breakfast seemed to be healthier than the group that consumed more calories later in the day.  They had better blood markers, felt more satisfied, and were in a better position to make sound food choices later in the day.

And yes, they lost more weight than the other group too, but that only reinforces the point I made earlier: When we make lifestyle choices that make us healthier, weight usually takes care of itself.

He Said, She Said: Sports Drinks vs. Water

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The definition of “proper hydration” not only varies from person to person, but also depends on the circumstances. Given the abundance of fluid choices on the market, we certainly understand why people question what is best and how much to have.

He Said

As the duration of our exercise session increases, especially if we are working out in the heat, the more likely we are to benefit from more than just plain water. In addition to replenishing fluid, we need to replace the electrolytes lost in sweat and the carbohydrates we metabolize for energy. Juice usually does not cut it, as the sodium concentration is too low and the abundance of fructose can cause gastrointestinal distress. For many athletes, sports drinks are the answer.

Commercial products, such as Gatorade and PowerAde, are popular options as is coconut water. Most of these offer a balanced blend of sugars, which increases gastrointestinal tolerance and absorption rate. One drawback to coconut water, however, is low sodium content. Many athletes, especially those whose sweat leaves white salt marks on their clothing, may benefit by adding extra salt to their coconut water.

We can typically control what we drink during training and sports where we can keep our beverage of choice on the sidelines, but the same is not always true during endurance events. Fuel belts and fluid backpacks can help, but their weight and bulk can hinder performance. Sometimes we are at the mercy of whatever the race director gives us. In this case, find out in advance (Check the race’s website and/or contact the race director.) what will be provided and practice with it in your training. If you perform well with it, great; if not, use the time to formulate a Plan B. For example, station along the route friends who can hand you your beverage of choice as you pass by.

Remember that perhaps no area of nutrition is more individualized than sports nutrition, so experiment during your training to figure out what has you performing your best. To the fullest extent possible, avoid drinking anything during competition that you have not tolerated during practice.

She Said

Why do we need water? Well, the wet stuff is for more than just quenching your thirst; every system in the human body depends on it (and your body is made up of 60-75% water). You need water to regulate your body temperature, lubricate your joints, flush toxins from your body, protect body organs and tissues, and carry nutrients and oxygen to cells. So, clearly, we need water to live!

I’m sure many of you have heard the advice “drink eight 8-ounce glasses of water each day,” and while that figure is not too off-target, it’s not a hard and fast rule. The Institute of Medicine determined that an adequate fluid intake for women is about 2.2 liters (approximately 9 cups) of total beverages a day; for men, it’s about 3 liters, or 13 cups. To reach these amounts, you can include the water that naturally occurs in many fruits and vegetables, soups, and beverages other than water, as all fluids count toward this daily total.

Of course, the above figures are averages, not exact numbers. Adequate hydration varies from person to person. Some people simply need more fluids, while others need less. To assess hydration status, I often tell my patients to look at their urine, as it can be an excellent indicator of dehydration. If your urine is very light yellow, almost clear, you are adequately hydrated. Dark yellow? Then you most likely need to up your fluids. In the end, pay attention to your body’s thirst cues – your body has more wisdom than you think.