Intuitive Eating-Review

I recently read Intuitive Eating by Evelyn Tribole, MS, RD; and Elyse Resch, MS, RD, FADA.  Since starting this blog, this has to be my favorite nutrition/diet book I have read so far.  The authors wrote the first edition in 1995 after becoming dissatisfied with the typical dietitian mentality: serving sizes, exchange system, calorie counting, and so on.  The book focuses on several areas, but as the name implies, learning to eat intuitively is the main premiss.  The practices in mindful eating are now being used in eating disorder clinics around the country.  However, anyone suffering from a life of chronic dieting or food worry will identify with the example patients the authors use to help present the program.  I should make a huge disclaimer here, much as ET and ER do in their book.  THIS IS NOT A DIET!!!  By following the practices of mindful eating, people who are overweight will probably lose weight, and people who struggle with chronic dieting will come to peace with food.

Factoids: 
1. The weight-loss industry is a $30+ billion a year business.  (Programs, Pills, Shakes, Bars, Surgery)
2.  90-95% of all diets fail.
3. Restricting food slows Metabolism.
4. 45% of adults feel guilty about eating foods they like.
5. The US is the most preoccupied country with regards to weight and health concerns, we are the most overweight, yet we take the least amount of satisfaction and pleasure from eating.

There are 3-4 main types of eating disorders recognized within the medical Community and are considered a mental disorder, not a physical disorder; even-though they wreak havoc on the body:

Anorexia nervosa: Restricting food to lose weight below 85% of what is considered ideal.  Often starts off with the simple quest to lose a little weight, but spirals out of control to where patients may only eat 1 apple or a few carrots each day.

Binge Eating Disorder: Consuming more than what is considered a normal amount within a 2hr time period.  Binges may consist of 2000-4000 calories. Typically follows a time of food restriction.  People are typically of normal weight, but may be overweight.

Bulimia Nervosa:  Similar to Binge Eating, but each binge is followed by purging.  Purging may be done through laxative use, vomiting, or exercise.  Sometimes people begin to purge even after normal size meals.  The act of vomiting after a large binge of say 2000 calories, will only rid the body of approximately 800-1000 calories.  Patients have been know to purge more than 20x per day.  Patients may be of normal weight, underweight, or overweight.  

Eating Disorder Not Otherwise Specified: When people do not meet all the criteria for one of the other eating disorders.  Ex: A woman with Anorexia Nervosa who still experiences menstruation even though at 5'5" she only weights 100lb = 80%ideal body weight.  This is also where people who are chronic dieters or yo-yo dieters would fall.  People who are preoccupied with thoughts of food, nutrition, and distorted body image.  Again, these patients may be a wide range of body sizes.  Surprisingly, almost 50% of the female population could fall into this category.  Think of how many women have gone on a diet, regained the weight and then some, gone on another diet...only to then regain more weight.  It's a vicious cycle, and one that has a very devastating impact on the psyche and body.

There are ten steps to becoming an Intuitive Eater, and the book does an excellent job of outlining each.

1. Reject the diet mentality.
2. Honor your hunger.
3. Make peace with food.
4. Challenge the food police.
5. Feel your fullness.
6. Discover the satisfaction factor.
7. Cope with emotions without the use of food.
8. Respect your body.
9. Exercise-feel the difference.
10. Honor your health-gentle nutrition.

The authors stress that intuitive eating is a process, unlike diets there is no linear thinking.  It is not starting at one weight with the sole intention of losing a certain amount of weight.  It is a journey.  Some days will be better than others, but each part of the journey should be see as a positive experience.  Almost each step towards becoming an intuitive eater encompasses the need to enjoy food, enjoy life, and love your body.  Think about weight watchers statement that it is not a diet.  Of course it is!  It does not teach a person to listen to their body, it teaches them to focus on points.  And what is a person to do when their points run out at the end of the day, and they are still hungry or at a party with lots of delicious food?  Quite the quandary.  My favorite statement in the book is "If you don't love it, don't eat it, and if you love it, savor it."  

If you or someone you know struggles with chronic dieting or poor body image, I highly recommend reading Intuitive Eating. While you may be able to practice the principles on your own, like any journey it's best to have support from a friend or family member.  It can be scary to let go of the diet mentality and food rules, but being able to sit at a meal knowing you can eat without worry is liberating.  

Sugar Alcohols

In my most recent post I discussed sugar imposters.  AKA: sugar substitutes, or non-caloric sweeteners.  However, I left out one large group that deserves its own posting.  They are the sugar alcohols.  These products are made by hydrogenating carbohydrates.  This is different from the hydrogenation process used to turn liquid fats into solid fats such as margarine.  However, both process do require the addition of a hydrogen molecule, and the breaking of a double bond.  Sorry if this is making you reach far back into your high school chemistry years.  There are approximately 10+ sugar alcohols available for use as a food additive, the ones listed below in bold are the ones you will most frequently run into on a nutrition label.

• Erythritol: Discovered in 1848, it naturally occurs in some fruits and fermented foods.
• Glycerol: Typically used as a filler in baked goods as well as a thickener in viscous foods.
• HSH: Hydrogenated Starch Hydrosylate, used as a humectant in order to retain moisture in foods.
• Isomalt: Naturally found in beets, and used widely in sugar sculptures because it does not crystalize as quickly as sugar.
• Lactitol: Non active ingredient in many medications, but an active ingredient in some laxatives.
• Maltitol: Widely used in candy, chocolates, and chewing gum.
• Mannitol: Found in almost all plants, and occurs during fermentation.  Used in medications needed to affect the brain, as it is capable of crossing the blood/brain barrier.  Sometimes used as a filler in illegal drugs such as heroin and cocaine...
• Sorbitol: Used as a thickener in many food and cosmetic products.
• Xylitol: Most easily tolerated of all SAs.  May aid in increasing bone density, preventing ear/upper respiratory infections, as well as controlling yeast infections.

Unlike the other sugar substitutes, sugar alcohols are not as sweet as sugar.  Products that use other artificial sweeteners, often add SAs in order to mask the flavor of the other sweeteners.  Because they are poorly absorbed by the body, and typically contain between 1/8 to 1/2 the calories of sugar, SAs contribute very few calories to the diet.  This means they also cause only small changes in blood sugars which can make them appealing to people with Diabetes.  However, since they are poorly absorbed in the intestines, overconsumption of foods made with SAs may lead to gas, bloating, and diarrhea.  People who have undergone any form of gastric bypass surgery should be especially wary of these side effects.

Sugar alcohols do not brown, and are not suitable for baking when used alone.  This is why they are most often seen in candy products, chewing gum, and mouth wash.  These products are used world wide, and do not appear to cause cancer.  People with diabetes, especially those taking insulin do need to be aware that these products will increase their blood sugar.  There is some evidence that excess intake of sorbitol by people with diabetes may increase their chances for nerve/small blood vessel complications.

As with most things dealing with food, I say if you want to eat it, eat the real thing.  These sweeteners have their place, most notably in chewing gum and breath mints.  But if you notice that a large proportion of your pantry contains foods with these or other artificial sweeteners in them, it may be time to take a step back and reevaluate your diet.  As I mentioned in the previous post, artificial sweeteners contain no important nutrients, so just like sugar, they should be consumed minimally.

Sugar Impostors

I had a recent request to do a post on sugar substitutes.  While there is a lot of conflicting research and information on the subject, I'm going to try and give the basic facts without too much personal bias.

• Sucralose (Splenda): Discovered by European scientists looking for new ways to use sucrose (sugar).  One researcher was told to test the new compound and thought he was told to taste it, thereby discovering its sweet property.  It is 600X sweeter than table sugar, and is poorly absorbed in the intestinal tract, therefore it provides almost no calories to the diet.  While it tastes the most like sugar of any of the substitutes, the chemical process of creating it leaves it looking nothing like sugar.  Splenda is probably the most commonly recognized sugar substitute, and while it contains Sucralose, it also contains absorbable carbohydrates in the form of dextrose and maltodextrin.  1 cup of Splenda contains 96 calories from 32g of carbohydrate VS. 1 cup of sugar = 770 calories, 200g carb. While the FDA and Canada consider Sucralose safe for consumption (1.1mg/kg/day), new studies from Duke University show that it may reduce the level of good bacteria in the intestinal tract, which can in turn lead to an increase in body weight in rats. 

• Saccharin (Sweet 'N Low): Discovered in 1879 by researchers at Johns Hopkins University.  This product was created with the intention of using it as a sugar substitute for people with diabetes.  One of the chemists licked his hand at dinner and connected it to the compound he had been working with that day. It did not become widely used until the sugar rations during both World Wars.  Studies in the 1970s showed an increase in the incidence of bladder cancer in male rats.  However, the metabolism of this sweetener is different in rats than in humans; further studies have shown no CONSISTENT evidence that saccharin may cause bladder cancer in humans. In 2000 the US National Toxicology program removed it from its list of possible carcinogens.

• Aspartame (Equal, NutraSweet): Discovered in 1967 when James Schlatter accidentily licked his finger while working on an anti-ulcer drug.  Created by the combining of Aspartic acid and Phenylalanine.  Both are amino acids-or the building blocks of protein.  It is 200x sweeter than table sugar.  It still contributes 4 calories per gram, but so little is needed to sweeten a product that the calories ingested are negligible.  In 1980 the FDA worked with the Public Board of Inquiry and determined that Aspartame does not cause brain cancer.  Between this time and the mid 1990s both the US and the EU approved aspartame for use in dry goods and sweetened beverages.  People with PKU should not consume products with Aspartame as its metabolism will cause a buildup of phenylalanine in the blood.  Metabolism of aspartame also creates formaldehyde, however this happens with other "natural" foods as well.

• Acesulfame Potassium (Sunnet, Sweet One) Discovered in 1967 by Karl Clauss, once again the silly scientist licked his finger on accident.  It is created by the combining of acetoaceitc acid and potassium; forming a crystal.  It is 200X sweeter than table sugar and is heat stable, meaning it can be used in baked goods.  It has not been proven to cause cancer by the FDA...and has been approved for use in the US, EU, Australia, Canada, and many other countries.  People with renal failure should avoid this product due to the potassium.

• Stevia (Truvia, Purvia): While it is new to the United States, people in the EU, Canada, East Asia, and South America have been using it in its natural leaf form as well as in a liquid and crystal form for years.  Paraguay indians have been using this herb for centuries, and the Japanese have used it in everything from sugar free gum to pickled vegetables.  There was some controversy in the US in 1985-1987 as to whether it was mutagenic...apparently a study showed that it may alter the DNA of salmonella bacteria.  Extracts are 200-300x sweeter than table sugar VS the herbal leaves which are only 10-25x sweeter.  As of 2008 it became approved for use as a food additive in the US and is generally recognized as safe.  If you want to use an artificial sweetener, this is the one I would go with.  Make sure to experiment with it when baking, as it does not caramelize or brown the same way sugar does.

For more information on artificial sweeteners check out these websites:
Mayo Clinic
Baking with out sugar
Family Doctor

What do I think... Artificial sweeteners are just that, artificial.  Our body does not need them and just like sugar they do not add any vitamins, minerals, or antioxidants to our system.  They also do not make food taste good.  Often times, products that are made with sugar substitutes also have to add extra fat and other chemical compounds to make them taste decent.  Would you rather eat 4 mediocre cookies made with Splenda for 150 calories, or 2 really good cookies made with sugar for 150 calories?  I know which I would choose.  There are some studies coming out that show people who consume artificial sweeteners actually eat more.  They trick the body into thinking it is receiving calories, and when they are not there, it craves more.  There is also very little evidence to support its efficacy in weight loss.  Weather or not they cause cancer, headaches, or ADHD, I recommend people avoid these products and limit their intake of refined sugars.  When you eat a sweet treat, go for the real thing and truly enjoy it.

Nitrates and Nitrites

Like many American kids I grew up eating turkey or ham and cheese sandwiches.  And if I was lucky, mom occasionally bought me a Lunchables.  Which is funny looking back; even in grade school I didn't think they tasted that good.  It must have been the novelty of it...and their great marketing.  In college I continued to make deli meat sandwiches, mostly out of convenience and cost.  But over the past several years it dawned on me... I HATE deli meat (except for the occasional roast beef and very rarely salami).  This is probably a good thing since most deli meats are preserved with sodium-nitrate.  Nitrates are a naturally occurring nitrogen compound found in vegetables.  Leafy greens and root vegetables are especially high in them: cauliflower, collards, broccoli, spinach, potatoes, beets, turnips...  When plants die and decompose, they release these nitrates into the ground.  This is a good thing and part of the reason why smart farmers rotate crops.  Corn is notorious for depleting the nitrogen in soil, where as soy beans replenish it.  Veggie nitrates are natural.

As I mentioned above, most processed meats (deli meat, bacon, sausage, ham) are preserved with sodium nitrate.  Tap water is another sources of nitrates since farms often use nitrate containing fertilizers which run off and contaminate ground water aquifers.  Consuming excess nitrates found in processed meats has been shown to increase a child's chances for leukemia if they consume 12+ hotdogs in 1 month; they have also been linked to colon cancer in adults.  While most kids are not eating 12 hotdogs/month, they probably are eating hotdogs, deli meat, hamburgers, sausages, bacon and pepperoni pizza at least once per day at school.  To avoid these nitrates opt for nitrate free products such as those from Applegate farms and specific products by Hormel.  The American Meat Industry will tell you that nitrates are safe, however I'm not convinced.  But to be fair, here is a link to what they have to say.

No studies have shown a link between the nitrates in water and cancer.  However, there is a link between these nitrates and methemoglobinemia or "blue baby syndrome."  The nitrate is converted into a nitrite in the colon and is absorbed into the blood stream reacting with iron and hemoglobin in the fetal blood causing it to become methemoglobin.  Methemoglobin is unable to cary oxygen and this can result in breathing difficulties, low blood pressure, and developmental delays.  This is easily avoidable by either breastfeeding or using only filtered water to mix formula.

You may be wondering how I got on this topic?  Ryan and I made pasta bake the other night with Trader Joe's High Fiber pasta.  I compromised since Ryan wasn't in the mood for whole wheat.  The next day I looked at the ingredients and noticed that it contains Thiamine Mononitrate.  AAAHHH not a nitrate!!! Being the inquisitive RD that I am, I did a little research.  Thiamine Mononitrate (TM) is a synthetic form of the vitamin B1 or thiamine.  Thiamine is important in many different bodily functions and plays a roll in vision, hair/skin integrity, and the nervous system.  Processed grain products have been fortified with B vitamins for many years as a way to prevent dietary deficiency.  However, studies now show that TM does not actually prevent or reverse Thiamine deficiency; only natural sources do.  B vitamins are water soluble and when consumed in excess the body eliminates them in the urine.  However, TM is fat soluble and the body has difficulty removing it.  This can lead to accumulation in the liver and other fatty tissue.  The nitrates in TM may also accumulate in the kidneys.  This accumulation can cause problems such as kidney stones.  For healthy individuals I would recommend they try and avoid foods with TM in it.  People with liver or kidney disease should absolutely avoid this food additive.  To ensure adequate intake of Thiamine focus on consuming these foods: Pork, Tree Nuts (peanuts don't count), Sunflower and Sesame Seeds, and fish.

Iodine Deficiency

In the midst of moving I of course had to continue with my online graduate program.  Just after arriving here in MN I had a paper due discussing just about any topic of my choosing, but still relating to nutrition.  Being inspired by an article in Men's Health, I chose iodine deficiency.  Here I've included select portions from my paper.  Hope you learn something.... I sure did.

Approximately one-fourth of Americans suffers from hypertension, (blood pressure of 140/90mm Hg or greater) placing them at risk for coronary artery disease and stroke.  While medications such as Lasix are available and widely used, diet and lifestyle play a major role in the treatment of hypertension.  The DASH diet (Dietary Approaches to Stop Hypertension) has been promoted for many years, and is based upon the eating patterns of the Mediterranean population.  The diet is low in fat, cholesterol, and sodium; but promotes a high intake of fruits, vegetables, and whole grains.  This type of eating plan increases intake of potassium and calcium.  Both minerals appear to have antihypertensive properties.  Other lifestyle factors that influence blood pressure include body weight, physical fitness, and emotional/psychological stress.

Many Americans are becoming more aware of the complications associated with hypertension and have begun decreasing their use of table salt in an effort to cut out sodium.  However, is it possible that by cutting out salt, they are also cutting out an important nutrient, which may have cardiovascular benefits?  A recent Men’s Health Magazine article notes how the decline in table salt usage may be leading to an increase in iodine deficiency.  Salt was first iodized in 1924 in an effort to prevent mental retardation and goiter in the Midwest where these symptoms of iodine deficiency were quite common.  Today, people are switching to kosher and sea salt after watching famous Chef’s on TV use them.  Fast food restaurants, processed food companies often do not use iodized salt in their products.  Also, most Americans do not eat salt-water fish on a regular basis, further increasing the potential for iodine deficiency.  This is in direct conflict with Medeiros and Wildman who state that there is concern people in the United States may be over consuming iodine; thanks in part to the typically high sodium diets of Americans (pg 345).

Iodine is most often associated with the thyroid.  Iodine deficiency results in hypothyroidism, goiter, and cretinism. Thyroid hormones are not only integral to a person’s metabolism, but they also play a role in cardiovascular health including blood pressure and cholesterol levels.    Several literature reviews have compiled studies, which bring to light the connection between iodine deficiency, hypothyroidism, and the increased risk for cardiovascular disease.  Stephen A. Hoption Cann notes that, in recent years the prevalence of iodine deficiency has increased in many countries that use iodized salt, and that even subclinical levels of iodine deficiency can cause thyroid dysfunction leading to an increased risk for CVD

Ayturk and colleges studied the connections between metabolic syndrome and increased thyroid volume and nodule prevalence in people living in a previously iodine deficient area.  The study took place in Ankara, Turkey between August 2007 and February 2009.  Until 1999, Turkey was considered a moderately iodine deficient area, when mandatory iodization of household salt was initiated.  The researchers set out to discover if metabolic syndrome (MetS) is in fact not only linked to diet and lifestyle, but also associated with functional and morphological alterations in the thyroid gland.  

As expected, BMI, waist circumference, blood pressure, fasting blood glucose, fasting insulin, LDL-C, triglycerides, and fat mass were much higher in the MetS group than the control group.  HDL-C was lower in the MetS group.  FT3 and FT4 were not significantly different between the MetS group and the control group.  However, TSH levels, occurrence of thyroid nodules, and thyroid volume, were significantly higher in the MetS group than the control group.  All subjects including those in the control group were found to have increased thyroid volumes and nodule formations when insulin resistance was present.  Three study participants were found to have thyroid cancer, compared to the control group where no cancers were discovered.

In their discussion of the study, the researchers acknowledge the possible relationship between the hypothalamus-pituitary-thyroid axis and the influence of adipose tissue and leptin secretion on the axis.  They concluded that as fat mass increase, so does the excretion of leptin.  Insulin resistance causes an increase secretion of insulin, thereby increasing leptin levels further.  The increase in leptin and fat mass both stimulate an increase in TSH levels and ultimately induce further adipogenesis.   TSH is also involved in the regulation of thyroid growth.  The study did show that participants with elevated TSH levels were at risk for increased thyroid size but not thyroid nodules.

Unfortunately the researchers may have missed on very important aspect to their study, the actual intake of iodine by participants.  While Turkey may have previously been iodine deficient, the study was done 8 years after iodized-salt was introduced in the country.  It would have been beneficial to test participant’s iodine levels, as well as take a diet recall to assess their iodine intake.  The researchers proved that MetS and enlarged thyroids are related, but they failed to make any connection to their relationship with iodine intake.  This makes the title of their study somewhat misleading.  The only limitation mentioned is in connection to the small sample size found with thyroid cancer.  Because the detection rate was only 2.7% it is not considered statistically significant, and was not a main focus of the study.  Further studies should be done in this field in order to determine which came first MetS, or the enlarged thyroid.  If hypothyroidism is indeed a contributor to MetS, further studies into its root cause should be also done.  This may bring to light further information on iodine deficiency and it’s link to MetS and heart disease.

Ayturk, S., Gursoy, A., Kut, A., Anil, C., Nar, A., Tutuncu, N.B. (2009). Metabolic syndrome and its components are associated with increased thyroid volume and nodule prevalence in a mild-to-moderate iodine-deficient area. European Journal of Endocrinology. 161:599-605.

Cappola, Anne R., Ladenson, Paul W.  (2003). Hypothyroidism and Atherosclerosis. Journal of Clinical Endocrinology & Metabolism. 88(6):2438-2444.

Hoption Cann, Stephen A. (2006). Hypothesis: Dietary Iodine Intake in the Etiology of Cardiovascular Disease.  Journal of the American College of Nutrition. 25(1):1-11.

Medeiros, D. M., Wildman R.E.C. Avanced Human Nutrition, Second Edition. Jones & Bartlett Learning. 2012. Pg 73.

Rehagen, T. (2011, October). Do You Need More Salt?.  Men’s Health. 136-140.