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What is PCOS?

PCOS is a very common endocrine condition, especially for women of reproductive age. 

PCOS simply means polycystic ovarian syndrome, which can be further interpreted as,

Poly – many or multiple 

Cys – cysts

Tic – pertaining to 

Polycystic ovarian syndrome is a syndrome with many or multiple cysts in the ovaries. 

The prevalence of PCOS is between 5 to 15 % but it differs in each study. This disorder can be both morphological which means cyst formation in ovaries or biochemical which means hyperandrogenism. 

In other words, PCOS is a multifactorial disease which means there are many factors that lead to this condition. Some women can experience mild side effects whereas others can have severe PCOS symptoms. So symptoms also differ between individuals. 

In the menstrual cycle, there are two phases –

Follicular phase – menstruation to ovulation (days 1 to 14)

Luteal phase – ovulation to menstruation (days 14 to 28)

If this cycle is abnormal, then it is a sign of PCOS. 

Ovulation is a process that happens when the mature egg is released from the ovary for fertilization. If the egg isn’t fertilized, the body sends out the egg through menstruation. 

In some cases, hormonal imbalance happens which means the woman doesn’t make enough hormones needed for the ovulation process. So when ovulation does not happen, the ovary develops many small cysts (fluid-filled sacs). This cyst is responsible for the production of hormones called androgens and thus it leads to PCOS. 

 

How is PCOS diagnosed?

 

Recent diagnostic criteria according to Androgen excess society (AES) 2006 are,

  • Hyperandrogenism 
  • Oligo-ovulation / anovulation 
  • Polycystic ovaries 
  • Exclusion of other related diseases

If a person is suspected to have PCOS, a blood test, and pelvic ultrasound is the next step that should be taken for confirmation. 

Blood is taken to assess hormones, lipid levels, and glucose. 

Pelvic ultrasound is taken to scan the ovaries. 

After the diagnosis of PCOS, the person is prone to have diabetes and also has an increased risk of developing sleep apnea, hypertension, depression, and cardiac problems. 

 

What are the clinical features of PCOS?

 

  1. Reproductive Features – 

Hyperandrogenism 

Hirsutism 

Ovulatory and menstrual dysfunction 

Infertility 

Complications in pregnancy

Miscarriage

Pregnancy-induced diabetes (Gestational diabetes)

Pregnancy-induced hypertensive disorders 

Neonatal complications 

Increased endometrial hyperplasia   

 

  1. Metabolic features 

Insulin resistance 

Metabolic disorder 

Dyslipidemia 

Type- 2 diabetes 

Increased cardiovascular risk factors 

 

  1. Psychological features 

Anxiety 

Depression 

Poor self-esteem 

 

Risk factors of PCOS

 

  1. Genetic 

Monozygotic twins 

One of the main risk factors for PCOS is genetics, especially in monozygotic twins. Monozygotic twins are identical twins. If one twin gets PCOS, the other twin also gets PCOS due to the genetic component. 

A first-degree relative is an individual’s parents or siblings or child who has PCOS have a high risk of having PCOS themselves. 

 

  1. Obesity 

In obese individuals, PCOS is very common especially in pre-pubertal obesity (if the person is obese before the onset of obesity).

 

  1. Early onset of menarche 

A person who attains puberty before 12 years comes falls under this category. 

 

  1. Large or small for gestational age 

If a person is born with less weight or more weight along with size, they are likely to have PCOS. 

 

PCOS AND OTHER RELATED CONDITIONS 

 

  1. FERTILITY AND PREGNANCY COMPLICATIONS 

 

There are many studies where pregnant women with PCOS develop complications during delivery. There is an increased risk of women having gestational diabetes, gestational hypertension, pre-eclampsia, and cesarean section if she has PCOS. 

Miscarriage is also very common in women with PCOS. 

There is no evidence-based study for postpartum depression among women with PCOS. 

 

  1. OBESITY AND PCOS 

 

Obesity is the main cause of the development of PCOS. obesity increases insulin resistance which in turn results in hyperinsulinemia and this high insulin increases adipogenesis and decreases lipolysis. Obesity is responsible for hormonal imbalance which increases androgen levels. 

The primary therapy for PCOS during their reproductive age group is lifestyle modification. 

 

  1. METABOLIC SYNDROME AND PCOS 

 

Metabolic syndrome is a group of abnormalities in our body that include insulin resistance, dyslipidemia, and hypertension. 

Several studies show that the main cause of this metabolic syndrome is hyperandrogenism. 

In a study, first-degree relatives showed a higher prevalence of hypertension and hyperlipidemia in women with PCOS. 

 

  1. PSYCHOSOCIAL FEATURES AND PCOS 

 

Depression and anxiety are very common in women with PCOS.

There are also risk factors in women with PCOS such as eating disorders that lead to obesity, depression, anxiety, low self-esteem, and poor body image. 

 

  1. HYPERANDROGENISM 

 

Hyperandrogenism is the production of androgens which is a male sex hormone. In PCOS, excess production of androgens happens and this leads to symptoms like facial hair and acne. 

These high levels lead to altered gonadotropin levels. If these levels are high then the person can face issues with ovulation. These high levels will affect the ovulation process by stopping it from occurring.

 

TREATMENT 

 

The primary treatment for the management of PCOS is the dietary modification and physical activity. So lifestyle modification is a major therapy recommended. 

Dietary management 

Women with PCOS should definitely plan their PCOD diet chart. They should

  • Calculate macros based on body compositions. 
  • Have a balanced diet with all the macros (Carbohydrates, protein, and fats along with vegetables). 
  • Exercise. It is very important for proper cardiovascular function and increases energy expenditure. 

Having a balanced diet and doing physical activity consistently has an approach that deals with the fundamental problem of PCOS which will help to improve the patient from the long-term consequences including, type 2 diabetes and cardiovascular disease.

 

PHARMACOLOGICAL THERAPY IN PCOS 

 

The secondary treatment for PCOS is suggesting supplements. There are no specific supplements given for PCOS but for hormonal disturbances, supplements are suggested. 

The ORS (oral contraceptive pills) are generally recommended to improve hyperandrogenism and insulin resistance. 

Generally, medical therapy for PCOS is given to reduce the symptoms. 

In the reproductive age group, OCP is given for conception, and metformin is given for insulin resistance.  

Here are some common myths you come across when dealing with PCOS-

 

Myth- 1 – Doing seed cycling prevents PCOS 

Fact

Seed cycling is a naturopathy treatment that is given to women with PCOS. 

Seed cycling claims to optimize the hormones during the menstrual cycle and also relieves symptoms that are caused by hormonal imbalances. 

But there is no scientific evidence for seed cycling and PCOS. 

In seed cycling, the seeds that are asked to consume are flax seeds, sunflower seeds, sesame seeds, and pumpkin seeds. 

 

So we can consume these seeds as a good fat source but we cannot reverse PCOS. 

 

Myth- 2  – All women with PCOS are obese. 

Fact: 

Only around 50% of women with PCOS are obese. Thin women with PCOS do have other features of PCOS like excess facial hair, irregular menstrual cycles, and anovulation. On ultrasound, there will be a polycystic pattern. 

 

Myth- 3 – PCOS is not linked to diabetes. 

Fact: 

PCOS patients have insulin resistance and are at increased risk of developing Diabetes mellitus. However, the actual cause and the effect are still not known.

 

Myth- 4 – Women with PCOS should have a gluten-free diet 

Fact- 

Gluten is a protein found in wheat, Raje, and barley. A gluten-free diet is not recommended for women with PCOS unless she has celiac disease or gluten sensitivity. These are immune-related disorders in which the body responds abnormally to gluten, causing digestive symptoms such as diarrhea, bloating, nausea, etc. 

 

Myth- 5 reducing your weight can get rid of PCOS

Fact- 

By following a proper diet, and physical activity, you cannot completely overcome PCOS, you need to bring down the blood glucose level to the normal range, regulate your hormonal levels to improve your ovulation, and regulate the menstrual cycle to completely get rid of PCOS. 

 

Myth- 6 PCOS affects only women who are above 30 years 

Fact- 

PCOS does not show any age bias. The syndrome can easily affect adolescent age groups by showing irregular periods. Pubertal obesity is one of the causes of the occurrence of PCOS in adolescent age groups. 

 

Myth- 7 PCOS is only about irregular periods. 

Fact- 

Abnormal lipid levels, hyperglycemia, and metabolic syndrome are very common in women with PCOS. Even there are higher chances for endometrial cancer and breast cancer occurrence. So PCOS is not only irregular periods, there are so many risk factors that occur in PCOS. 

 

Myth- 8 – PCOS and PCOD are different

Fact- 

PCOS is also called PCOD. PCOS and PCOD are the same, they are concerned with ovaries. 

PCOS is a polycystic syndrome and PCOD is a disease condition. 

PCOS and PCOD are common metabolic disorders that are linked to hyperglycemia, hormonal imbalance, etc.

They both have similar symptoms and risk factors. Aetiology of both is the same. 

The only difference between PCOS and PCOD is the abbreviation. 

There is no scientific evidence for the differentiation of PCOD and PCOS. 

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Are you familiar with your macros and micros?

Our body requires sufficient nutrition for survival, as it also helps in body function and staying healthy in general. Food is the primary source of our daily nutrient requirements followed by supplements that help to boost the nutritional level of our body.

As seen in the previous article, food, nutrition and, nutrients are three different entities that are interrelated but not the same.

Food is the primary source of energy while nutrients are part of the food that nourishes us.

Then what does nutrition imply?

Nutrition represents the entire process by which we get our required energy and nutrients from food.

 

Once we understand this basic difference between food and nutrition, the next step is to know about our macros and micros.

Macros and micros are short forms of macronutrients and micronutrients. The nutrients in food are divided into macros and micros based on the amount required by the body.

 

In this article, we will talk in detail about macros, micros their functions, types and deficiency.

 

MACRONUTRIENTS

 

As the name implies macronutrients are required by our body in large quantities. These nutritive components are needed by our body to maintain energy and structure.

 

Our body cannot synthesize macronutrients and hence they must be obtained through diet. It is also crucial to note that a healthy diet never excludes or limits the intake of any macronutrient.

 

There are three main macronutrients and they are equally important for our body to function properly.

They are as follows:

Carbohydrates

Protein

Fat

 

CARBOHYDRATES

 

Carbohydrates or carbs are the body’s primary energy source. It is also involved in providing energy to the central nervous system i.e our brains. Carbohydrates are broken down by our body into glucose or sugar molecules, which act as an energy source. Carbon, hydrogen and oxygen are the three elements that make carbohydrates.

 

Around 60% of our calorie requirement per day should be fulfilled by carbohydrates. They are present in both healthy and unhealthy food. Therefore, it is important to make sure that our carbohydrate requirement is fulfilled by healthy food sources.

 

Carbohydrates are further classified as-

Starches

Fibre

Sugars

 

Starches are complex in nature and have intact fibres. On the other hand, Fibres are also complex carbohydrates and are mostly present in plant-based foods. These help in digestion

Of the three types, sugars are simple carbohydrates that can easily be broken down and absorbed by the body.

 

Some of the best sources of carbs include Rice, Wheat, Millets, Fruits, etc…

 

The most commonly asked question is about sugar cravings.

We often feel the urge to snack on sugary foods. But do we crave sugar or sweet-tasting food?

Here’s a simple test to find out.

Keep a bowl of sugar and try eating it fully.

Not able to finish the bowl?

 

Then you are not craving sugars but looking for hyper-palatable foods to comfort yourself.

 

PROTEIN

 

Protein intake is very important as it is required by all the cells in our body to function properly.

It plays a vital role in tissue structure, hormones, metabolism, and transport systems.

It is also involved with enzymes that regulate metabolism and balance the acid/base environment of the body.

 

Proteins are made of amino acids and are found throughout the body. They make up many enzymes, haemoglobin, and antibodies. Amino acids are the building blocks of protein which are classified as essential and non-essential.

 

The protein requirement for each individual will vary depending on their age, medical condition, health goal, etc… On average 25% of the calorie requirement must be fulfilled by the protein intake.

 

Some sources of protein are eggs, meat, poultry, legumes (sprouted), paneer, tofu, soy, fish, and seafood.

 

Now as we understand the importance of proteins, it is also crucial to address the common perception that eating too much protein might cause kidney problem

 

Eating the required amount of protein won’t cause any harm when consumed within the required limits.

You need to be cautious about protein intake only when kidney function is already affected.

 

FAT

Fats from food provide the body with energy and help in other functions like insulating organs and making up the cell membrane.

It is also involved in the absorption and transportation of fat-soluble vitamins. Other functions of the fat include brain and nerve function, and hormone balance.

 

About 15% of daily calories should be from fat intake. It should also be noted that the fat type and source are important to prevent adverse health effects.

 

Fat, in general, is classified into :

Saturated fat

Unsaturated fat – MUFA, PUFA, Omega 3, and Omega 6

Trans fat

 

Saturated fats are solid at room temperature due to their chemical structure. They tend to be high in cholesterol, hence consuming foods rich in saturated fats tends to cause more diseases.

On the other hand, unsaturated fat such as Monosaturated fat and Polysaturated fat is known as healthy fats. They help to control cholesterol at healthy levels.

It is always better to balance out saturated fats with other types of fats such as MUFA and PUFA.

Trans fat comes from industrial fat processing where saturated or unsaturated fats are processed by adding hydrogen ions to them.

Trans fats are also solid at room temperature.

The process of adding hydrogen ions is known as hydrogenation and they extend the shelf life of the product.

 

Good sources of fat include nuts and seeds, fatty fish, oil, butter, and ghee.

 

One of the most common thoughts that comes to our mind when we talk about fat is that it may increase our weight.

In reality, though fat contains more calories when compared to protein and carbohydrates it doesn’t mean that you will gain weight. Weight gain occurs only when there’s a calorie surplus. Fats in fact slow down digestion and help to make us feel satiety.

Excess calories from carbohydrates and protein can also be stored in our body as fat, increasing our overall weight.

 

Thus, the key to a healthy meal plan is having a balanced diet.

 

MICRONUTRIENTS

 

Micronutrients are required by our body in small quantities and but still, they cater to various important body functions.

Therefore, their deficiency can cause serious effects.

 

The term micronutrient encompasses both vitamins and minerals. It can also be classified as essential and non-essential micronutrients based on the ability of the body to produce them. It is estimated that around 30 vitamins and minerals cannot be synthesized by our body. And hence, they have to be made available through food intake or supplements.

 

VITAMINS:

 

In general, vitamins can be categorized as essential nutrients as most of them can’t be synthesized by our body and even if they are produced, the quantity is not sufficient.

 

Heat, acid or air can degrade vitamins as they are organic compounds produced by plants and animals.

 

It offers a wide range of health benefits such as boosting the immune system, aiding brain and nervous system functioning etc.

Based on solubility, vitamins are further classified as Fat-soluble and Water-soluble vitamins.

 

Fat-soluble vitamin

 

They are predominantly found in high-fat foods and are also better absorbed into the bloodstream when consumed with fat.

Fat-soluble vitamins include-

– Vitamin A

– Vitamin D

– Vitamin E

– Vitamin k

 

Water soluble Vitamins

 

Water soluble vitamins are cannot be easily stored by the body as they dissolve in water upon entering the body.

Since they are not stored in our bodies, we have to get them regularly through diet.

Water-soluble vitamins include-

– Vitamin B1 – Thiamine

– Vitamin B2 – Riboflavin

– Vitamin B3 – Niacin

– Vitamin B5 – pantothenic acid

– Vitamin B6 – pyridoxine

– Vitamin B7 – Biotin

– Vitamin B9 – Folate

– Vitamin B12 – cobalamin

– Vitamin C

 

The major food source of vitamins is fruits and vegetables.

 

MINERALS:

 

Minerals are inorganic compounds from the earth that are required for optimal body functions.

It helps in strengthening bones, preventing tooth decay, carrying oxygen, and supporting the immune system.

Minerals are classified based on the quantity required by the body as major minerals and trace minerals.

 

Major minerals:

– Magnesium

– calcium

– phosphorus

– sulfur

– sodium

– potassium

– chloride

 

Trace minerals:

– Iron

– Selenium

– Zinc

– Manganese

– Chromium

– Copper

– Iodine

– Fluoride

– Molybdenum

 

Sources: Fruits, vegetables, nuts, milk and dairy products, Fortified foods, egg yolk.

 

We can see from an overview of macronutrients and micronutrients that micronutrient deficiency is more common.

Let us see in detail the common micronutrient deficiency –

 

Vitamin D

Vitamin B12

Iron

Iodine

Calcium

 

VITAMIN D:

It is one of the important fat-soluble vitamins that is needed for maintaining serum calcium levels and for bone density.

 

Vitamin D must be obtained from the sun, but it is evident from research that we don’t get enough from the sun.

 

We can get vitamin D from food sources such as egg yolk, mushrooms, dairy products, and fortified dairy products. But they are not sufficient so it’s always better to consume a supplement.

 

Deficiency:

Deficiency of vitamin D mostly leads to low bone density and can also lead to osteoporosis in adults

 

What causes Vitamin D deficiency?

When we don’t get enough vitamin D from food or the sun, our body cannot convert vitamin D into its active form.

 

Who is at risk?

People with malabsorption syndrome ( Crohn’s disease )

People with chronic kidney disease (where kidney won’t be able to convert vitamin D)

People with hyperparathyroidism ( where the body’s calcium levels are controlled by too much thyroid hormone)

How to prevent it?

You can combat vitamin D deficiency by taking supplements

 

What is the best time to get vitamin D from the sun?

The best time to get vitamin D from the sun is morning 10:00 am to 3:00 pm.

It is said that ultraviolet rays are intense during this time and our body can more efficiently make vitamin D

UV rays from the sun are classified based on their wavelengths as UVA, UVB, and UVC. UVB rays are responsible for producing the active form of Vitamin D in our bodies.

Additionally, it only takes a small amount of UV rays for our bodies to produce vitamin D. Therefore, we don’t have to expose ourselves to the sun for a long period. Excessive UV exposure will only damage our skin.

 

 

 

VITAMIN B12:

 

Vitamin B12 also known as cobalamin is a water-soluble vitamin that can be stored in our liver and can be used in the later stage of life when we absorb less vitamin B12.

Source: fish, shellfish, dairy products, nutritional yeast

Function:

To form and maintain a healthy nervous system

Deficiency:

Leads to neurological problems – poor memory, dementia, psychosis

Megaloblastic anaemia / pernicious anaemia (reduction in healthy RBC)

Depression

Loss of appetite and weight loss

Who is at risk?

Since B12 is mostly obtained from animal sources, vegetarians and vegans are at risk for vitamin B12 deficiency.

Older persons (who cannot absorb enough B12 from food)

Malabsorption syndrome

Symptoms:

Tingling sensation in feet

Muscle weakness and numbness

Weakness and fatigue

Irregular heart rate

How to prevent it?

You can either choose to have vitamin B12 shots (injection) or can have supplements.

 

CALCIUM:

Calcium is the most abundant mineral found in our body and is associated with our bone health.

It is also linked with parathyroid hormone, vitamin D, and calcitonin.

Functions:

Formation of bones and teeth

Linked with bone cell formation and destruction

Muscle contraction

Transmitting nerve impulses

Sources:

Green leafy vegetables

Nuts and seeds

Fish

Calcium-fortified foods

Symptoms:

Muscle aches

Numbness and tingling sensation in hands and feet

Low bone density (bones get fractured easily)

Confusions, memory loss

Who is at risk?

Malnutrition and malabsorption

Certain genetic factors

Women at the menopausal stage

Those who have less vitamin D levels

How to prevent it?

Add more calcium-rich foods to the diet

Take calcium supplements.

 

IRON:

Iron forms an essential part of proteins and enzymes. Thus, it takes part in many vital functions of the body such as aiding muscles to store and use oxygen.

Sources:

Dietary iron can be classified into heme and non-heme iron where heme iron comes from animal sources and non-heme iron comes from plant sources

 

Heme Iron:

Fish

Organ meats

Red meat

Non-heme Iron:

Raisins

Prunes

Pumpkin seeds, sesame seeds

Dark green leafy vegetables

Beans and legumes

 

Function:

Formation of red blood cells

Oxygen transport

Produces anaerobic energy

Makes up proteins and enzymes

 

Deficiency:

Iron deficiency is the most common worldwide

Iron deficiency anaemia is a condition in which our blood lacks healthy red blood cells.

 

Symptoms:

Brittle nails

Less immunity

Extreme fatigue

Weakness

Pale skin

Unusual cravings for the non-nutritive substance

Poor appetite

 

Who is at risk?

Women (due to blood loss during menstruation)

Vegans and vegetarians

People who have vitamin A deficiency can intensify iron deficiency

 

How to prevent it?

Include more iron-rich foods

To maximize iron absorption by including vitamin C-rich foods

Iron supplement

 

IODINE:

Iodine is an important mineral for normal thyroid function. In case of deficiency, it leads to enlargement of the thyroid gland and our body cannot make enough thyroid hormone.

 

Function:

Formation of thyroid hormones (T3 and T4)

Source:

Iodised salt

Eggs

Saltwater fish and seafood

 

Symptoms:

Swelling in neck

Unexpected Weight gain

Fatigue and weakness

Hair loss

Dry flaky skin

Impaired growth and development

 

How to prevent it?

Since the RDA for iodine is very less including iodized salt on a regular basis might help.

 

MICRONUTRIENTS THAT COMPLEMENT EACH OTHER:

 

In this section, we have listed a few micronutrients that work best when taken together.

 

Iron and vitamin C

Vitamin C enhances the absorption of iron from non-heme sources (plant sources) by our body.

 

Vitamin D and calcium

Vitamin D and calcium are important for bone strength and work together to protect our bones wherein vitamin d is important for calcium absorption in our body.

So even if we take enough calcium from foods it might not be used properly if we have vitamin D deficiency.

 

Vitamin K and calcium

Too much vitamin K can lead to deposits of calcium in our arteries.

New research findings show that vitamin K is a regulator of calcium and is important for calcium deposition in bones

 

Vitamin B12 and folate

Folic acid and B12 work closely in making RBC which in turn helps with the proper functioning of the body.

 

MICRONUTRIENTS THAT WORK OPPOSITE:

The following combination of micronutrients is not supposed to be taken together for the following reasons-

 

Zinc and copper

Too much zinc can lead to copper deficiency by reducing the absorption of copper in our intestines.

 

Zinc, calcium, and iron

Excessive Zinc and calcium will inhibit iron absorption. In turn, excessive iron and calcium can also reduce zinc absorption.

 

Now, let’s bust some myths revolving around macro and micronutrients.

 

Myth: Eliminate carbohydrates from your diet to lose weight.

 

Fact: Eliminating carbs might initially show you results since you will be losing your water weight and not your body fat. In the long run, this type of diet is not sustainable as carbohydrates are the primary source of energy for the body.

 

Myth: Are you vegan or vegetarian? Then you are not getting enough proteins.

 

Fact: It’s true that plant-based sources have incomplete proteins. But when you take a balanced diet, your body will get the nine essential amino acids, even if it’s a plant-based diet. Therefore, it’s not true that if you are vegan or vegetarian you don’t get enough proteins.

 

Myth: Your body doesn’t need fat

 

Fact: Many are skeptical about fat intake as it might lead to weight gain. But one must know the difference between good and bad fat. Good fats are required by the body to perform various vital functions, for example, our brain requires good fat sources for energy.

Myth: Vitamin overdose is not possible.

 

Fact: It’s possible to overdose on vitamins, especially when you are taking supplements as well as fortified foods or if you are taking supplements for a very long time. Hence, it’s essential to take supplements under the guidance of a nutritionist/physician and track your vitamin intake.

 

 

 

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Are you starting a diet? You can better understand nutrition by knowing these differences.

If you are someone looking for a nutritionist’s guidance and find yourself encountering terms you don’t understand, you have come to the right place.

 

The nutritionist might tell you many things in Greek and Latin and you might be confused. It is true that some of our clients feel the same way when we suggest they take supplements to combat deficiencies. When we explain to them that they aren’t allergic but intolerant, they seem to get a tad confused. It is also possible that some people have a misconception about processed foods. 

 

By understanding the most commonly used terminologies and their differences, you will be better able to understand what you eat and what your nutritionist recommends.

 

  • NUTRIENT VS FOOD 

 

Most of us confuse the terms nutrient and nutrition. The term nutrition encompasses the term nutrient. 

 

Nutrients – are substances that are required for the nourishment of organisms while 

Nutrition –  is the entire process by which organisms obtain energy and nutrients from food.

 

We might also think food and nutrients are the same.

 

Food is the source of energy that helps our body to function properly and stay alive.

 

Nutrients are a part of food, which are used and metabolized by our body cells to provide energy.

 

Example: Fruit is your food and the vitamins and minerals in it are the nutrients.

 

Recipe – Smoothie is the food, the carbs, vitamins, minerals, protein, and fat we get from the ingredients are the nutrients.


  •  ALLERGY VS INTOLERANCE

 

It is possible to experience adverse reactions after eating certain foods. 

 

These reactions can be categorized as immunologic (allergic) and non-immunologic (intolerance).

 

Many people mistake food intolerance for allergy as one of its symptoms is allergy-like reactions.

 

  Allergy: 

  • Allergies occur when the body’s immune system responds or overreacts to a particular type of protein. 
  • This protein is usually from foods, pollens, house dust, animal hair, or moulds and they are called allergens. 
  • During allergy, our body produces antibodies to defend substances that are usually harmless.

 

Intolerance:

 

Food intolerances arise if the body is unable to digest a certain food. This impairment may be due to a lack of digestive enzymes or a sensitivity to certain chemicals.

 

Food intolerance refers to the body’s inability to digest certain chemicals in food due to lack of enzymes or sensitivity to the chemical.

 

  • These are chemical reactions that occur that are not immune responses.
  • This often happens when we can’t properly digest particular food or its components. 
  • Food intolerances are uniquely individualized. 

 

Food allergy is more severe and fatal than food intolerances.

 

Example for allergy: Peanut allergy or shellfish allergy – A person who is allergic to peanut or shellfish, and eats one of these could even die without medical assistance. 

Symptoms: can start with rashes, hives, and itching and can develop into fatal symptoms like dilation of blood vessels, drop in blood pressure, etc. 

 

Example of food intolerance: It mostly occurs from enzyme deficiency. 

Many people can be lactose intolerant – they won’t have the enzyme lactase which is necessary to digest lactose, the main sugar in milk.

Symptoms: nausea, vomiting, diarrhea, headache, etc. 


  • PROCESSED VS ULTRA-PROCESSED

 

The newest trend buzzing around among people is “saying NO to processed food”.

But one must understand that food does not make it from the farm to the fork unprocessed.

Even the fruits that we eat require some processing before they reach our plates. 

Choosing minimally processed foods is probably a better option than ultra-processed foods.

 

Processing:  Processing is anything that alters the fundamental nature of agricultural produce, such as freezing, dicing, drying, etc.

  • The nutrients in these foods will still be intact. 

Example: The milk we drink daily requires processing such as pasteurization to extend its shelf life. 

 

Ultra processing: A technique that converts agricultural produce into an entirely different form is known as ultra processing. 

 

Highly processed foods, also known as ultra-processed foods, are relatively cheap, convenient, and tasty but contain a lot of refined carbohydrates, saturated fat, and salt. 

  • They could also be referred to as hyper-palatable foods. 

Example: Potato chips, bread, soft drinks, etc.

 

  • SUPPLEMENTS VS MEDICINE

 

DIETARY SUPPLEMENTS: A dietary supplement is a vitamin, mineral, herb, or nutrient that a person takes to treat or combat nutritional deficiencies, improve their overall well-being, or improve their overall wellness.

Dietary supplement labels may make certain health-related claims, but they are not intended to treat or cure any specific disease. Dietary supplements are generally safe to consume and cause no adverse reactions. 

 

MEDICINE: This is a preparation or substance used to treat a particular disease and ease symptoms. Several chemicals are mixed together in laboratories to produce medicines.

 

For example, fish oil that we consume to lower the cholesterol level is a supplement and the fever medication that we get only with a doctor’s prescription is medicine.

 

  • COD LIVER OIL VS FISH OIL 

 

COD LIVER OIL – as the name suggests, it’s derived from codfish livers.

The oils in these fish tend to build up in the liver, and they also contain high levels of vitamins A and D.

 

FISH OIL – Fish oil comes from the flesh of fatty fishes such as tuna, mackerel, and salmon. 

This results in higher concentrations of EPA and DHA.

Fish oil doesn’t contain Vitamin A or D.

 

However, cod liver oil often contains a lower concentration of omega 3’s when compared to omega 3 fish oil.


 

  •  SATURATED FAT VS TRANS FAT

 

SATURATED FATS: Saturated fat is solid at room temperature due to its chemical structure. 

Foods high in saturated fats tend to be high in cholesterol, hence consuming foods rich in saturated fats tends to cause more diseases. 

It has also been found that foods containing saturated fats are highly processed and contain more sugar and sodium which might have an effect on our body. 

Therefore, saturated fats should always be balanced with other types of fats such as MUFA and PUFA.

 

Example: butter, cream, cheese, coconut, etc.

 

TRANS FAT: Trans fat comes from industrial fat processing where saturated or unsaturated fats are processed by adding hydrogen ions to them. 

Trans fats are also solid at room temperature. 

The process of adding hydrogen ions is known as hydrogenation and they extend the shelf life of the product.

 

Example: margarine, shortenings, etc.

 

When we talk about nutrition, we often hear the following statements. We even hear some of these statements every day. But how true are they?

 

In this article, we will debunk 6 such statements:

 

  1. FLAX SEEDS ARE THE RICHEST SOURCE OF OMEGA-3 FATTY ACIDS. 

 

Our common perception is that flax seeds are rich in omega-3 fatty acids.

 

But in reality, they are a rich source of fiber, but not the best source of omega-3.

The omega-3 fatty acid found in flax seeds is ALA (Alpha-linolenic acid), which our bodies cannot convert to EPA/DHA.

 

Therefore, the most ideal choice is to consume EPA/DHA-containing foods such as fatty fish, salmon, tuna, etc.

 

  1. NOT EVERYONE NEEDS A GLUTEN-FREE DIET

 

Gluten is a type of protein found in wheat, maida, and rye which is responsible for the elasticity of these flours. 

 

So, WHO NEEDS A GLUTEN-FREE DIET? 

 

Individuals with celiac disease or individuals with gluten sensitivity or those who can’t tolerate even small amounts of the protein gluten should go gluten-free. 

 

If you are not gluten sensitive or have celiac disease, eliminating gluten from your diet can cause nutritional deficiencies. 

 

  1. EGGS ARE HEALTHY AND GOOD FOR CHOLESTEROL

 

Eggs are an economical and easily available source of high-quality protein which is a key source of many essential nutrients. 

 

Cholesterol is a waxy substance that is produced majorly in our body, forms an important part of our cells and is very important for the proper functioning of our body. 

While cholesterol is important for body functions, high amounts can lead to heart problems. 

But however not all cholesterol is bad, the cholesterol that comes from the foods you eat has a minimal impact because the body naturally regulates the amount of cholesterol that circulates in the blood.

 

WHAT HAPPENS IN AN EGG?

 

For many years now, we all have been thinking that egg yolk is full of saturated fat. But, the truth is that the major fat portion in eggs comes from MUFA and PUFA. 

Saturated fats when consumed along with MUFA and PUFA don’t show to have much effect on cholesterol.  

Also, if you are still not convinced and are skeptical about consuming whole eggs daily, remember that consuming saturated fats along with lots of ultra-processed foods/refined carbohydrates is unhealthy. 

Instead include eggs as a part of your healthy diet along with fruits, vegetables, and whole grains. 

 

  1. LATE-NIGHT EATING WILL MAKE YOU GAIN WEIGHT.

 

Many people think eating late at night will make them fat but the truth is it doesn’t. 

According to science, a calorie is a calorie taken regardless of the time. 

What causes weight gain is the type of food you eat and the number of calories you eat. 

Most studies suggest that nighttime eaters mostly make poor choices of food. 

Studies show that most people who eat late at night binge eat to keep them awake, for this they rely on hyper-palatable foods that are high in sugar and fats that have low satiety value and make them eat more. 

The second most important point is that the calories that go in from the hyper-palatable foods must be burned out, if not definitely it will make them gain weight. 

VERDICT – Eating late at night is not bad but the type of food we eat matters the most and the calories we eat must be within the limits. 

 

  1. IS IT OKAY TO SKIP YOUR BREAKFAST?

 

For most of our lives, breakfast has often been dubbed “BREAKING THE FAST” and is considered one of the most important meals of the day.

 

They say skipping breakfast might lead you to overeat later in the day.

 

But, this is not true.

 

Also, it may not cause you to eat less either. It definitely depends on the individual. 

 

If you are taking appropriate amounts of calories and nutrients throughout the day, skipping breakfast won’t make much difference. 

 

  1. A DETOX DIET IS IMPORTANT

 

A detox diet – is a more popular diet trend that claims to detox/ clean our body and eliminates harmful toxins from our body. 

A typical detox diet involves a period of fasting followed by a diet that includes only fruits, vegetables, fruit juices, and water. Sometimes it might also include herbs, teas, and enema. 

 

THE TRUTH – our body doesn’t need any detox program or diet, it’s naturally designed to detox itself. Our organs such as the liver, kidney, and lungs are detoxification machines that are naturally designed to get rid of the toxins from our body. 

That means maintaining a healthy diet is important in order to maintain the proper functioning of these organs. 

 

THE CON – The detox diets can also be dangerous since they include only a particular type of food group and avoid most of them and can cause nutritional deficiencies, electrolyte imbalances, and other problems.

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Supplement Series #4 – Collagen, is it worth your money?

What is Collagen?
Collagen is the most abundant protein in mammals forming about 25% of the total protein content in the body. It is an essential part of the connective tissues in the body. The main components of collagen are 3 non-essential amino acids namely, glycine, proline, and hydroxyproline. The different arrangements of these amino acids results in different varieties of collagen leading to different functions and site of incorporation.

What are the types of collagen?
A collagen molecule is formed by twisting together 3 long chains of amino acids to form a tight coil giving it a great tensile strength. Many of these long collagen chains join together to perform their specific function. The way these chains join at specific sites results in different types of collagen giving it specific characteristics and functions. More than 20 types of collagen have been identified so far. Some of the common types of collagen are:

IMost abundant collagen of the human body; present in scar tissue, the end product when tissue heals by repair; found in tendons, the endomysium of myofibrils, and the organic part of bone
IIArticular cartilage and hyaline cartilage
IIICollagen of granulation tissue; produced quickly by young fibroblasts before the tougher type I collagen is synthesized; reticular fiber
IVBasal lamina; eye lens
VMost interstitial tissue; associated with type I; associated with placenta

 
What are the functions of collagen?
Collagen in majorly secreted by fibroblast. It is sometimes referred to as the body’s scaffolding. The word collagen is derived from Greek and means “glue producer.” 
Collagen fibers support body tissues, it is a major component of the extracellular matrix that supports cells. Collagen and keratin give the skin its strength, waterproofing, and elasticity. Loss of collagen is a cause of wrinkles.
Connective tissue consists primarily of collagen. Collagen forms fibrils that provide the structure for fibrous tissue, such as ligaments, tendons, and skin. Collagen also is found in cartilage, bone, blood vessels, the cornea of the eye, intervertebral discs, muscles, and the gastrointestinal tract.
 
How can I get collagen naturally?
Since collagen is found in connective tissues, foods such as chicken skin, pork skin, beef and fish are great sources of collagen. Collagen obtained by this method is usually broken down to individual amino acids and are used up for formation of other proteins. There are not enough studies to show if collagen levels increase in humans upon consumption of these foods.
Another natural source of collagen is gelatin, a substance commonly used in cooking and derived from cooking collagen.
 
What are the types of Collagen Supplements available?
Collagen initially became famous as injectable solutions to help tighten skin and remove wrinkles. This fell out of trend as it didn’t last long and incited allergic reactions.
However, in recent years hydrolysed collagen supplements have flooded the market. Hydrolysed collagen are collagen threads broken into smaller peptides and chains to aid in easy absorption. Hydrolysed collagen is available majorly as powders. It’s also seen in the form of skin creams or tablets.
A thing to note here is that these supplements are generally marketed as Type-I Collagen or any of the 20 odd collagen types but it doesn’t make a difference which one you pick. While this is talking about the location from which the collagen was extracted, the hydrolysed collagen is already broken and used to form the different forms of collagen as required by the body.
 
Who would benefit from collagen supplementation and does it really work?
Although the body naturally produces collagen, the rate at which it is produced drops as we age. After a point, the rate at which collagen is produced is not enough to keep up with the body’s demand. Since collagen forms an essential part of the connective tissue, there are multiple benefits for taking collagen supplements.
SKIN HEALTH: Collagen production reduces as you age and this leads to dry and wrinkled skin. Studies have shown that supplementing collagen has improved skin elasticity and reduced dryness. The general conclusion is that collagen slows down skin ageing however more studies are needed to confirm the sole role of collagen in this process.
Joint Health: Ageing leads to deterioration and breakdown of joints. Studies have shown that collagen supplementation not only helps promote joint health but also helps alleviate joint pain.
Muscle Mass: Collagen is also a part of the muscle tissue and forms about 10% of muscle tissue. Multiple studies have shown that people taking collagen supplementation while exercising tend to put on more muscle mass and strength.
Heart Health: Collagen fibres line the inner walls of arteries and are shown to lead to weaker arterial walls. Studies have shown an improvement in arterial wall elasticity and reduction in stiffness when supplemented with collagen.
 
Are collagen supplements safe to take for vegans?
Collagen for manufacture of supplements is majorly obtained from animal sources such as bone broth and protein. However, a few vegan and vegetarian alternatives have started appearing online.

References

  1. Lodish H, Berk A, Zipursky SL, et al. Molecular Cell Biology. 4th edition. New York: W. H. Freeman; 2000. Section 22.3, Collagen: The Fibrous Proteins of the Matrix. Available from: https://www.ncbi.nlm.nih.gov/books/NBK21582/
  2. High Yield Orthopaedics. JavadParviziMD, FRCS, Gregory K.Kim MD Associate Editor. https://doi.org/10.1016/B978-1-4160-0236-9.00064-X
  3. Zdzieblik D, Oesser S, Baumstark MW, Gollhofer A, König D. Collagen peptide supplementation in combination with resistance training improves body composition and increases muscle strength in elderly sarcopenic men: a randomised controlled trial. Br J Nutr. 2015;114(8):1237–1245. doi:10.1017/S0007114515002810
  4. Proksch, E., Schunck, M., Zague, V., Segger, D., Degwert, J., & Oesser, S. (2014). Oral Intake of Specific Bioactive Collagen Peptides Reduces Skin Wrinkles and Increases Dermal Matrix Synthesis. Skin Pharmacology and Physiology, 27(3), 113–119. doi: 10.1159/000355523
  5. Kumar, S., Sugihara, F., Suzuki, K., Inoue, N., & Venkateswarathirukumara, S. (2014). A double-blind, placebo-controlled, randomised, clinical study on the effectiveness of collagen peptide on osteoarthritis. Journal of the Science of Food and Agriculture, 95(4), 702–707. doi: 10.1002/jsfa.6752
  6. Sibilla, S., Godfrey, M., Brewer, S., Budh-Raja, A., & Genovese, L. (2015). An Overview of the Beneficial Effects of Hydrolysed Collagen as a Nutraceutical on Skin Properties: Scientific Background and Clinical Studies. The Open Nutraceuticals Journal, 8(1), 29–42. doi: 10.2174/1876396001508010029

 

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Supplements #3

Athletes are a group that use supplements for a myriad of reasons



We are back with our supplement series for the month! So far, we have covered protein and protein related supplements and commonly used vitamin and mineral supplements. While the former is still a never ending list, this article aims to cover more performance oriented supplements. Athletes use supplements for a variety of reasons:

    • To aid in faster recovery from training
    • General health benefits
    • For performance benefits
    • To treat illnesses
    • To compensate for a poor diet



Athletes are always on the lookout for something to boost their performance. This article will cover supplements whose efficacy is backed by science. These supplements have been extensively researched and have been found to benefit different types of sports. If you are an athlete, why not give this a read!

Nitrate:

What is Nitrate?
Nitrate is a molecule that plays an important role in the nitrogen cycle and also in cardiovascular health, blood pressure and exercise performance.

Where do you find nitrates and how does it actually work?
Dietary sources of nitrates include fruits, vegetables and processed meats (1). Vegetables such as beetroot, celery, spinach, rocket (argula) and lettuce are rich in nitrate. High amounts are also found in cabbage, kohlrabi,parsley and fennel (1). Dietary nitrate is converted to nitrite (by bacteria in the mouth and gastrointestinal tract) and further reduced to nitric oxide (1). This nitric oxide is what causes vasodilation (widening of the blood vessels) and results in decreased blood pressure. Nitric oxide also seems to play a role in calcium handling, glucose uptake, neurotransmission and muscle force production.

Why would athletes find supplementation beneficial then?
The content of nitrate found in green leafy vegetables and beetroot vary with soil conditions, time of year and even storage. Hence, like any other supplement, as the specific dose of nitrate is known, athletes would benefit from its usage. This is beneficial when performance is a goal. It has been shown that dietary nitrate supplementation lowered oxygen uptake during moderate to heavy intensity exercise in healthy participants (2). A recently published systematic review and meta-analysis concluded that dietary nitrate supplementation can positively impact endurance exercise capacity (3).

What about the dosage?
About 5-9 mmol of nitrate ingested 2-2.5 hours before an exercise session for about 1-28 days is effective (4,5).

Would only athletes benefit from nitrate?
Not only does dietary nitrate help in performance, since nitrate lowers blood pressure (6), it could potentially help in the general population as well. Not everyone needs to supplement with nitrate! Inclusion of good amounts of beetroot and green leafy vegetables into your daily diet is a great starting point!

Caffeine

What is caffeine and where is it found?
Caffeine is the most widely used psychoactive drug or stimulant. Yes! It is a drug! Like we all know, it is found in coffee beans, tea leaves and cocoa beans. Infact, as you would have all noticed caffeine is also added to energy drinks and soft drinks. However, the amount of caffeine in these sources vary. Caffeine is now available as pills, gels and even gums!

How does it act as a well known stimulant?
We all know that drinking a cup of coffee is the best wake me up drink! The stimulatory effects of caffeine are attributed to its effect on the central nervous system. Caffeine is a competitive inhibitor of adenosine which is responsible for relaxation. Caffeine thus binds to the adenosine receptors in the brain and stimulates the nervous system. (7)

Is caffeine a fat burner?
Caffeine does seem to increase metabolic rate and fat oxidation (8). However, as a standalone supplement it is not effective in reducing body weight. While it does boost fat metabolism marginally (9), the effects of caffeine are highly variable from person to person.

Why do athletes supplement with caffeine?
Caffeine has been shown to improve performance across a variety of sports. Endurance performance (7, 10) and team sports (11) performances have seen an improvement with caffeine supplementation. Infact, the position stand on caffeine from the International Society of Sports Nutrition (12) recognises its performance benefits on strength, sprint and power based sports as well. Acute ingestion has also been shown to increase pain tolerance and perceived effort (13).

What is the dosage and duration of caffeine supplementation?
The suggested dosage for caffeine supplementation ranges from 3-6 mg/kg body weight about 30-60 minutes before the onset of exercise (12).

Are there any side effects of caffeine consumption/supplementation?
Excessive caffeine consumption, greater than the recommended dosage could result in dependency, anxiety and gastrointestinal discomfort. Caffeine consumption in the evenings might interfere with sleep quality later at night as well.

Caffeine and nitrate are two supplements that have extensive research backing their efficacy. In fact, any supplement that you choose should be effective for the particular sport you are using it for! It is evident that caffeine works well across sports while nitrate might work best for an endurance based sport. With the supplement series, our aim is to ensure you all are educated and make an informed choice when it comes to nutritional supplements.

References

1) Hord N, Tang Y, Bryan N. Food sources of nitrates and nitrites: the physiologic context for potential health benefits. The American Journal of Clinical Nutrition. 2009;90(1):1-10.
2. Pawlak-Chaouch M, Boissière J, Gamelin F, Cuvelier G, Berthoin S, Aucouturier J. Effect of dietary nitrate supplementation on metabolic rate during rest and exercise in human: A systematic review and a meta-analysis. Nitric Oxide. 2016;53:65-76.
3) McMahon N, Leveritt M, Pavey T. The Effect of Dietary Nitrate Supplementation on Endurance Exercise Performance in Healthy Adults: A Systematic Review and Meta-Analysis. Sports Medicine. 2017;47(4):735-756.
4) Jones A. Dietary Nitrate Supplementation and Exercise Performance. Sports Medicine. 2014;44(S1):S35-45.
5) Naderi A, de Oliveira E, Ziegenfuss T, Willems M. Timing, Optimal Dose and Intake Duration of Dietary Supplements with Evidence-Based Use in Sports Nutrition. Journal of Exercise Nutrition & Biochemistry. 2016;20(4):1-12.
6) Siervo M, Lara J, Ogbonmwan I, Mathers J. Inorganic Nitrate and Beetroot Juice Supplementation Reduces Blood Pressure in Adults: A Systematic Review and Meta-Analysis. The Journal of Nutrition. 2013;143(6):818-826.
7)Graham T, Spriet L. Metabolic, catecholamine, and exercise performance responses to various doses of caffeine. Journal of Applied Physiology. 1995;78(3):867-874.
8)Acheson K, Zahorska-Markiewicz B, Pittet P, Anantharaman K, Jéquier E. Caffeine and coffee: their influence on metabolic rate and substrate utilization in normal weight and obese individuals. The American Journal of Clinical Nutrition. 1980;33(5):989-997.
9) Jeukendrup A, Randell R. Fat burners: nutrition supplements that increase fat metabolism. Obesity Reviews. 2011;12(10):841-851.
10) Pasman W, van Baak M, Jeukendrup A, de Haan A. The Effect of Different Dosages of Caffeine on Endurance Performance Time. International Journal of Sports Medicine. 1995;16(4):225-230.
11) Stuart G, Hopkins W, Cook C, Cairns S. Multiple Effects of Caffeine on Simulated High-Intensity Team-Sport Performance. Medicine & Science in Sports & Exercise. 2005;37(11):1998-2005.
12) Goldstein E, Ziegenfuss T, Kalman D, Kreider R, Campbell B, Wilborn C et al. International society of sports nutrition position stand: caffeine and performance. Journal of the International Society of Sports Nutrition. 2010;7(1):5.
13) Duncan M, Stanley M, Parkhouse N, Cook K, Smith M. Acute caffeine ingestion enhances strength performance and reduces perceived exertion and muscle pain perception during resistance exercise. European Journal of Sport Science. 2013;13(4):392-399.

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Supplement Series #2

We are back with our supplement series for the month! Incase you haven’t read our previous article, click here. This month we will be covering some supplements that are seen very commonly in households. Do you and your family take these supplements? If so, are they really necessary?

1) Multivitamins: Multivitamins are supplements that usually contain a combination of vitamins and minerals and sometimes, other ingredients as well (1). While they’re available in several forms, the most commonly observed mode is through tablets or capsules. These supplements are easily available in  local pharmacies and even online platforms. Each essential vitamin and mineral have a preset requirement, known as the Recommended Dietary Allowance (RDA), which varies with age and gender. Most of the constituents in multivitamins are close to these recommended amounts. However, is it mandatory that everyone takes a multivitamin? Not necessarily. Those who are at risk of deficiencies and the dosage from the multivitamin supplement is sufficient to reverse it, benefit from its consumption. Even in these cases, purchasing the individual vitamin/mineral supplement might be better. Why does everyone consume them though? People consume multivitamins with an attempt to improve ‘health’. A good indicator of this is mortality, or the ability to live. A 2013 meta-analysis concluded that multivitamins had no significant effect on mortality risk (2). Further, there is insufficient evidence to conclude the role of multivitamins in preventing cancer and chronic diseases (3). In terms of health, multivitamins play a bleak role. Targeted supplementation seems to be more beneficial. Although, if you do plan on buying a multivitamin because the dosage does negate your deficiency, this link will provide tips on how to buy a good one (4) 
2) Vitamin D: Vitamin D is a fat soluble vitamin. The sources of vitamin D are primarily exposure to sunlight and foods such as egg yolks, fish like salmon and fortified foods. This particular vitamin is extremely important for calcium metabolism, which is in turn responsible for maintaining healthy bones and even nerve conduction. The RDA for vitamin D is 400-800 IU/day. However, a particular review reports that vitamin D deficiency in Indians range from 50-94% in healthy individuals (5). So, what causes the deficiency? Decreased exposure to sunlight and insufficient sources of vitamin D from the diet are the primary causes. So do you need to supplement with Vitamin D? If your blood tests indicate you have a deficiency or sub optimal levels, then yes. These supplements must be taken along with a fat source or meals. Our advice would be to go get yourself tested and then take a call!
3) Iron: Iron is a very essential mineral that enables your red blood cells to carry oxygen to your tissues. Iron is found in a wide variety of plant and animal sources such as green leafy vegetables, beans, lentils, nuts, seeds and meat. The iron from animal sources is more bioavailable (better absorbed) than those from plant sources. Vegetarians, worry not! Combining an iron source with vitamin C sources increases the bioavailability of iron. So keep that in mind! Do you need to supplement with iron? This again depends. Only if you are deficient, iron supplementation is necessary. Iron deficiency causes anemia, which seems to be seen primarily in premenopausal women who do not consume enough iron through their diet and also lose iron through menstruation (6). Iron deficiency anemia is just one type of anemia. We will be covering this in depth in our upcoming articles. Iron deficiency manifests through symptoms like fatigue, weakness, pale skin and shortness of breath. If you have been feeling very tired and exhausted, you might know where to look at. Get a blood test done to check your iron levels. To prevent yourself from a deficiency or sub optimal levels, ensure your diet has iron rich food!
(4) Fish oil:  Omega 3 fatty acids, eicosapentanoic acid (EPA) and docosahexanoic acid (DHA) are commonly referred to as fish oil. These are essential fatty acids, which means that your body cannot make them and must be obtained from diet. They’re found in fish and phytoplanktons. Our staple diets are rich in omega-6 fatty acids which are found in eggs, meat and oils. To balance the ratio between Omega-6 and Omega-3 in the body, consumption of fatty fish like salmon is encouraged. While you would have heard that seeds like flax and chia contain omega-3, they actually contain alpha-linolenic acid (ALA), which is a precursor to EPA and DHA. However, research suggests that ALA does not provide the same benefits as supplementing with EPA and DHA (7). However, the link between fish oil and cardiovascular disease is debatable. For those who do not consume fish (ie; vegetarians and vegans) supplementation of fish oil or microalgae (phytoplankton) might be beneficial.
This article covered commonly used household supplements. While this list is exhaustive, we will aim to cover more in the coming series and keep you informed.

References:

  1. National Institutes of Health. Multivitamin/mineral supplements.
  2. Macpherson, H,Pipingas,A, Pase, MP. Multivitamin-multimineral supplementation and mortality: a meta-analysis of randomized controlled trials. American Journal of Clinical Nutrition.2013;97(2):437-444.
  3. Huang HY, Caballero B, Chang S, Alberg AJ, Semba RD, Schneyer CR et al. The efficacy and safety of multivitamin and mineral supplement use to prevent cancer and chronic disease in adults: a systematic review for a National Institutes of Health state-of-the-science conference. Annals of Internal Medicine.2006;145(5):372-85.
  4. Examine. Do you need a multivitamin?
  5. P Aparna, S Muthathal,Nongkynrih, B,Gupta, SK.Vitamin D deficiency in India. Journal of Family Medicine and Primary Care.2018;7(2):324-330.
  6. Fernández-Gaxiola, AC, De-Regil, LM.Intermittent iron supplementation for reducing anaemia and its associated impairments in menstruating women. The Cochrane database of systematic reviews. 2011;10: CD009218.
  7. Wang C, Harris WS, Chung M, Lichtenstein AH, Balk EM, Kupelnick B et al. n-3 Fatty acids from fish or fish-oil supplements, but not alpha-linolenic acid, benefit cardiovascular disease outcomes in primary- and secondary-prevention studies: a systematic review. The American Journal of Clinical Nutrition. 2006;84(1):5-17.
  8. National Institues of Health. Omega-3 fatty Acids.
  9. Can I eat flax seeds instead of fish or fish oil for omega-3s?
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Supplement Series #1 – Proteins

With several people engaging in fitness and sports, the belief that supplements are the magical key to improvements in performance is making the rounds. Vitamin and mineral supplements are widely used by the general population, which we will address later. This article will cover supplements commonly used by fitness enthusiasts and athletes. Are you using supplements backed by evidence for its efficacy or are you just burning a hole in your wallet? You’ll find out now!

To begin with, what are supplements? Supplements are defined as “a concentrated source of nutrients or other substances with a nutritional or physiological effect.” (1). Like the name suggests, they are to be used to correct nutritional deficiencies or support specific physiological functions. To put it in simple terms, in the absence of food providing adequate nutrients, supplements can be used. That is, to supplement a diet. Supplements are commonly sold as pills, powders, tablets or capsules with a specific dose. The nomenclature of ‘supplements’ varies globally. While in Europe, they are termed as food supplements, in USA they are known as dietary supplements. The Food Safety and Security Act in India have also listed ingredients that a product should contain in order to be classified as a supplement. (2)


(1) Whey Protein: Whey is a milk protein and the water soluble part of milk. Whey protein by itself is marketed in three main forms. (3)

  • Whey isolate: Contains higher percentage of protein (~85-90% or more) since lactose and fat are removed.
  • Whey concentrate: Lower percentage of protein (~80% or more) compared to isolate since lactose and fat are not removed.
  • Whey hydrolysate: Partially pre digested to aid rapid absorption.

Why whey protein? Do we really know why it is this popular? Or are we just consuming it because everyone else is? Whey protein is rich in essential amino acids compared to its counterparts such as eggs, soy and meat. In specific, it is rich in branched chain amino acids (BCAA) which play an important role in muscle protein synthesis. In fact, whey protein has a biological value (BV) that is greater than the BV of an egg by 15%! (3). BV denotes how fast and how well our body can use the protein consumed. Apart from this, one scoop of whey protein gives anywhere between 20-25g of protein (or more based on the brand)! Convenient isn’t it? its property of rapid digestion, concentration of amino acids and convenience is what makes it popular.

How does whey fare when compared to other protein sources? A study by Tang et al. in 2009 (4) compared the effects of whey hydrolysate, casein (another milk protein) and soy protein isolate on mixed muscle protein synthesis (MPS). It was found that whey protein stimulated mixed MPS to a greater extent compared to soy and casein, both at rest and after exercise. However, soy stimulated mixed MPS greater than casein in both scenarios.

Do you have to consume whey? That depends! Like I mentioned before, whey protein provides 20-25g of high BV protein per scoop and if you are unable to meet your daily protein requirements through your diet, then go ahead. Vegetarians who find it difficult to incorporate complete protein sources into their diet or those involved in strength and endurance training who require higher levels of protein will find supplementing beneficial. You can still consume whey otherwise, simply because it is convenient and light on the stomach. In fact, whey can be added to oatmeal and smoothies to increase the protein content. At the end of the day, it is a matter of personal preference. Remember, it is a supplement.

(2) Casein : Casein is also a milk protein like whey and is a complete protein. The difference between whey and casein lies in their digestion. Contrary to whey which is rapidly digested, casein is a slow digesting milk protein. Casein, like any other protein can be used to meet daily protein requirements but whey seems to be the ideal post workout protein of choice.
However, casein releases amino acids at a much slower rate, so ideally it can be taken before bed, to aid in recovery.

(3) Branched Chain Amino Acids : Branched Chain Amino Acids or commonly known as BCAAs are a group of three amino acids Leucine, Isoleucine and Valine. They are also Essential Amino Acids which means they need to be obtained from the diet. Supplementing BCAAs are popular as it is thought to stimulate muscle protein synthesis (6). Contrary to this, a recent review concluded that BCAA supplementation alone cannot promote muscle protein synthesis (6).

Does BCAA consumption help in preventing fatigue? Serotonin regulates feelings of arousal, sleep and mood and is thought to be linked to central fatigue after vigorous exercise (7). The amino acid Tryptophan is a precursor to serotonin production. Post a bout of exercise, there is a decrease in BCAAs in the plasma and an increase in free tryptophan, thus increasing the free tryptophan/BCAA ratio. It is thought that supplementing with BCAA could balance this increase and delay fatigue (7). However, most studies provided a combination of BCAAs and carbohydrates during exercise (8). Although BCAAs are thought to reduce markers of muscle damage and soreness after strenuous exercise, its efficacy in doing so post high intensity exercise is questionable (9). Further, there is no direct positive link between BCAA supplementation and reducing markers of muscle damage.

Do you need BCAAs? Honestly, no. If you are able to maximise your daily protein intake and meet them via complete proteins, supplementation with BCAA is not necessary. Complete proteins such as eggs, meat, dairy, whey protein, tofu and other soy products already have BCAAs. Maximise your protein through food/other supplements everyday and save some $$$ on the BCAA!


(4) Glutamine : L-glutamine is an amino acid that is found in protein rich foods like meat, eggs, dairy and tofu. Our body can make glutamine, but there are times when our requirements exceed how much our body produces. So, it is a conditionally essential amino acid. It is to be noted that it does become an essential amino acid only during critical illness or injuries (10).
If you are taking glutamine to build muscle or improve body composition, then hold on to your money. Studies have consistently shown that consuming glutamine does not affect body composition (11). In fact, glutamine does not augment rates of muscle protein synthesis in healthy individuals either! Studies have used doses up to 900 mg/kg lean mass and noticed no increase in lean mass or muscle protein synthesis (12). If you are perfectly healthy, with no serious injury or illness, then glutamine isn’t for you.

What about recovery? Glutamine is widely recommended for aiding recovery post training. A recent study did find that co-ingestion of glutamine and leucine (another amino acid) did in fact lead to faster recovery compared to a placebo. Muscle soreness did not differ between the two. (13). Besides strength recovery, it could help in reducing muscle soreness after strength exercise (14,15). Supplementation of glutamine around exercise does seem to enhance strength recovery and possibly reduce muscle soreness.


Like mentioned before, glutamine becomes an essential amino acid in the critically injured or sick individuals. Although exercise also acts as a stressor, immunosuppression observed after exhaustive exercise is not due to plasma glutamine (16). But, what glutamine could benefit is the intestine. Glutamine is thought to be more relevant than glucose as an energy substrate for the gut (17). Hence it could help in reducing exercise induced dysfunctions of the gut.

Thorough research is needed before starting supplement usage. First, it is imperative to understand if there is evidence for the efficacy of the supplement. Second, think about what the use of the supplement is and if it is applicable to your sport/physical activity. Finally, make sure you purchase your supplements directly from the manufacturer’s website. Make sure that the brand you buy is authentic and widely used. Supplements from third party websites could be adulterated/contaminated. The ‘informed sport’ icon on the product is one way to ensure that it is safe. With this in mind, always tell yourself that these are just supplements to a well balanced diet.

References:

 
(1) EFSA. Food supplements.
(2) Health Supplements and Nutraceuticals Emerging High Growth Sector in India
(3) Smithers, GW. Whey and whey protein- from ‘gutter to gold’. International Dairy Journal. 2004; 18(7): 695-704
(4)Tang, JE, Moore, DR, Kujbida, GW, Tarnopolsky, MA, Phillips, SM. Ingestion of whey hydrolysate, casein, or soy protein isolate: effects on mixed muscle protein synthesis at rest and following resistance exercise in young men. Journal of Applied Physiology. 2009;107(3): 987-992.
(5) Examine. Casein protein.
(6) Wolfe, RR. Branched-chain amino acids and muscle protein synthesis in humans: myth or reality? Journal of the International Society of Sports Nutrition. 2017; 14(1): 1-7.
(7) Blomstrand, E. Amino acids and central fatigue. Amino Acids. 2001;20 (1):25-34.
(8) Blomstrand, E. Role for Branched-Chain Amino Acids in reducing central fatigue. The Journal of Nutrition.2006;136(2):544S-547S.
(9)Fouré A, Bendahan D.Is Branched-Chain Amino Acids Supplementation an Efficient Nutritional Strategy to Alleviate Skeletal Muscle Damage? A Systematic Review. Nutrients.2017;9(10):
(10) Lacey,JM, Dr. PH, Wilmore, DW. Is glutamine a conditionally essential amino acid?Nutrition Reviews. 1990;48(8):297-309.
(11) Ramezani Ahmadi, A, Rayyani, E, Bahreini, M, Mansoori, A. The effect of glutamine supplementation on athletic performance, body composition, and immune function: A systematic review and a meta-analysis of clinical trials. Clinical Nutrition. 2018;1-16
(12) Candow, DG, Chilibeck, PD, Burke, DG, Davison,KS, Smith-Palmer,T. Effect of glutamine supplementation combined with resistance training in young adults. European Journal of Applied Physiology. 2001; 86(2):142-9.
(13)Waldron,M, Ralph C, Jeffries O, Tallent J, Theis N, Patterson SD. The effects of acute leucine or leucine-glutamine co-ingestion on recovery from eccentrically biased exercise. Amino Acids.2018;50(7):831-839.
(14) Street,B, Byrne,C, Eston, R. Glutamine Supplementation in Recovery From Eccentric Exercise Attenuates Strength Loss and Muscle Soreness. Journal of Exercise Science and Fitness. 2011;9(2):116-122.
(15) Legault, Z, Bagnall, N, Kimmerly, DS. The Influence of Oral L-Glutamine Supplementation on Muscle Strength Recovery and Soreness Following Unilateral Knee Extension Eccentric Exercise. International Journal of Sports Nutrition and Exercise Metabolism. 2015;25(5):417-426.
(16) Hiscock,N, Pedersen, BK. Exercise-induced immunodepression- plasma glutamine not the link. Journal of Applied Physiology.1985; 93(3): 813-822.
(17) Cruzat,V, Rogero, MM, Keane, KN, Curi, R Newsholme, P. Glutamine: Metabolism and Immune Function, Supplementation and Clinical Translation. Nutrients. 2018; 10(11):1-31.

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Ditch the All or Nothing Mentality!

Our society has solely been focussing on ‘weight loss’ for a long time now. With the increasing number of individuals buying into the trend of fad diets, it is alarming to see the lengths to which people are willing to go, in order to lose weight. Avoiding carbohydrates, following extremely restrictive diets just before a special occasion, fasting for days together… The list is endless! All this makes me question What is our relationship with food like? Do we look at it as something to nourish us or something that we fear?
This article aims to throw light on our relationship with food. Beyond diets and weight loss, there are several factors that need to be looked at. Scaremongering is very common in the fitness industry and has lead to many of us having a skewed relationship with food.
For instance, When someone is on a ‘diet’ or is looking to change their habits for the better, they automatically assume that the only approach to do so is to be restrictive. This leads to an extremely rigid mentality, which we call ‘dichotomous thinking’. Dichotomous thinking is defined as thinking in terms of binary oppositions such as “good or bad”, “black or white”, or “all or nothing” (1). How does this apply to nutrition? A classic example of this would be ‘clean eating’. ‘Clean eating’ is a trend that has been growing rampantly and involves consumption of whole foods with no inclusion of processed foods. Now, this may look harmless, but invariably this trend has assigned moral values to food. Whole foods are ‘good’ and processed food is ‘bad’. With scant disregard to energy balance, we have assumed that eating ‘clean food’ has the ability to elicit weight loss and has a higher moral value. In contrast, ‘junk food’ is looked upon as inherently ‘bad’ and ‘unclean’. This tends to create fear or anxiety around ‘bad’ foods in the long run. Dichotomous thinking is not only restricted to food, but also weight (acceptable vs unacceptable) and diets (on a diet vs off a diet) (2).
To start with, I’m going to clear one myth that never seems to die in this field. No single food can cause weight loss or weight gain. No single food is inherently ‘good’ or ‘bad’. Assigning moral values to food and weight is problematic. In fact, rigid dietary control is often characterized by dichotomous thinking. Further, those engaging in rigid dietary methods are more likely to report symptoms of eating disorders, mood disturbances, higher anxiety and excessive concern with body size/shape compared to those with flexible dietary strategies (3). This is definitely a cause for concern. In contrast to rigid and restrictive eating patterns, a more flexible approach seems to have a positive effect on behaviours (4).
So how do you change your mindset? While this takes time, if you do have anxiety issues around certain food, the first step would be to stop ‘dieting’. Approach a professional specialising in eating disorders/disordered eating. Your relationship with food is a lot more important than you think. Restrictive eating and dieting only does more damage than good in the long run. Understand that any food in isolation is neither harmful nor beneficial. Some foods happen to be more nutrient dense than their counterparts. This article does not mean to imply that you now have a freeway to load up on cakes and pastries, nor does it say you need to only eat salads. The purpose of this article is to make you aware that extreme restriction is problematic. Learning a more flexible approach, instead of assigning labels to food improves your relationship with food and leads to a healthier lifestyle, both mentally and physically.

References:

(1) Oshio, A. Development and validation of the Dichotomous Thinking Inventory. Social Behaviour and Personality. 2009; 37(6):729-741.
(2) Dove, ER, Byrne, SM, Bruce, NW. Effect of dichotomous thinking on the association of depression with BMI and weight change among obese females. Behaviour and Research Therapy.2009;47(6):529-534.
(3) Stewart, TM, Willaimson, DA, White, MA. Rigid vs. flexible dieting: association with eating disorder symptoms in nonobese women. Appetite. 2002;38(1):39-44.
(4) Smith, CF, Williamson, DA, Bray, GA, Ryan, DH.Flexible vs. Rigid Dieting Strategies: Relationship with Adverse Behavioral Outcomes. Appetite.1999;32(3):295-305.
(5) Palascha A, van Kleef,E, van Trijp, HC. How does thinking in Black and White terms relate to eating behavior and weight regain?Journal of Health Psychology. 2015;20:638-648.

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Fad Diets – Why they don’t work in the long run.

“Sorry, I can’t eat cake I’m on a diet”
By definition, a “diet” is the sum of energy and nutrients obtained from foods and beverages consumed regularly by individuals. To put it in simple terms, it is what you eat and drink on a day to day basis. Somewhere along the way, the meaning shifted to something more specific. Something that people dread. You guessed it right – Weight loss.
As a generation, we are used to quick results. Everything from groceries to electronics can be bought with a click. Unintentionally (or not) we have begun to channel that into how our bodies respond to an external stimulus, such as food and exercise. We expect results within a short span of time and will go to great lengths to ensure that it happens! Ever completely cut off a food group or had just juices for a week to shed some weight? That is exactly what I’m talking about.
This is what we call a ‘fad diet’. It’s nothing but a trend that claims to guarantee rapid weight loss and have an upper hand over our perfectly normal balanced diet. Most of the claims around fad diets might seem appealing.
“Guaranteed weight loss in a week!”
“Helps in removing harmful toxins from your body”
“Carbohydrates are stored as fat. Switch to fat as your primary source of energy.”
Sounds familiar? Although these claims might seem appealing, the diet by itself is extremely restrictive. Every single nutrient has a role to play in our body and nothing in isolation is inherently bad. Any ‘diet’ that you choose to follow is completely based on individual preference. But, is it sustainable? Is it personalised to help achieve your goals? It is imperative that everyone is informed of the pros and cons of these diets and make an informed choice. For that reason, here is a compilation of the most popular diets:
(1) Ketogenic diet: Both carbohydrates and fat can be used as a source of energy by the body. The body relies on glucose (broken down from carbohydrates) when one consumes their normal diet (1). In the complete absence or reduced amount (<20g) of carbohydrates in the body, the body enters a state of ketosis, wherein it relies entirely on stored fat for energy. Signs of ketosis can be identified by increased ketone bodies in the blood, headaches and fatigue due to extremely low carbohydrate intake and bad breath. Breakdown of fat results in the rise of ketone bodies in the blood, which are used as an alternate source of fuel. The ketogenic diet involves consuming minimal to no carbohydrates (~5% from diet) and using fat (~75% from diet) as a source of energy. It encourages consumption of copious amounts of fat from sources like bacon, ghee,butter,nuts,cheese etc. Starch, grains, beans and legumes, fruit and starchy vegetables are avoided. The sources of fat usually consumed in a keto diet are low chain triglycerides (LCT’s). Off late, consumption of fat sources that contain Medium Chain Triglycerides (MCT’s) like coconut oil are observed. Although they do not contain concentrated amounts of MCT’s, it is suggested that MCT’s generate more ketone bodies and may be more beneficial to incorporate in a keto diet (1).
Pros: A ketogenic diet was developed for children diagnosed with epilepsy. It was said to be therapeutic as fats do not spike insulin. It works by stabilising various mechanisms related to synaptic functions and thus has an anti-seizure effect. So you know who it actually benefits (2). Although, consumption of high amounts of fats can induce better satiety (3), thus reducing food consumption in subsequent meals. This can potentially help in losing weight. In order to adapt a ketogenic diet to the current lifestyles and improve adherence, a cyclical keto diet came into the picture. This involves following a keto diet for 4-5 days and increase carb intake for 1-3 days. There is currently no evidence to support the validity of a cyclical ketogenic diet.
Cons: A ketogenic diet can be extremely restrictive. Cutting all sources of carbohydrates can lead to irritability, ‘brain fog’, mood swings, headache and even constipation, due to lack of fibre in the diet. Although it might result in weight loss (provided you’re in a caloric deficit), it may not be sustainable in the long run. I mean, how long are you going to stay away from a good slice of pizza? On a more serious note, the exclusion of whole grains, fruits and vegetables could lead to deficiencies of B vitamins, iron, zinc etc. Further, the long term effects of such a high fat diet haven’t been studied.

(2) Paleo Diet: The Paleolithic diet or paleo diet resembles what hunters or cavemen ate several years ago. This diet primarily revolves around what our ancestors had access to – Whole foods. And by that, I literally mean, whole foods only. Sounds easy? Not really. You see, cavemen didn’t cultivate their food. So what they ate was what they could find. So on this diet, the idea is to avoid anything that could be made in a factory. What this diet would comprise of would be meat, free range eggs, fruits, vegetables, nuts and seeds. In order to adapt it to the current scenario, consuming spices/condiments and olive/coconut oil are acceptable. It has been speculated that they did have access to grains. However, evidence for a paleo diet to be superior than a balanced diet is still in question (4).
Pros: Any food that is ‘processed’ such as aerated beverages, most dairy products, legumes/beans, vegetable oils and even grains are not to be consumed on this diet. Since you will be consuming an abundance of fruits and vegetables, there lies an advantage. The focus on whole foods does steer us away from a conventional diet primarily filled with calorie dense foods of low nutrient content. In fact, studies have shown that a paleo diet improves insulin sensitivity, blood pressure and cholesterol (5).
Cons: To start with, the diet is pretty restrictive. More than it, it also creates a list of ‘good food’ and ‘bad food’. That by itself creates a sense of fear of food and is problematic. Further, we can follow a perfectly wise diet even with the inclusion of dairy, starch and legumes. The exclusion of dairy might lead to a deficiency in calcium(4).
(3) Detox diet: A detox diet is used to eliminate toxins from the body and assist with weight loss. These are also commonly known as juice cleanses. However, it can also involve consuming vitamins, minerals, laxatives and other ‘cleansing foods’ (6). While most commercial detox diets do not specify the ‘toxins’ they claim to remove, it should be noted here that the dose of the said toxin determines its harmfulness (7). For example, even an essential mineral like Iodine when present in excess can lead to thyroid disorder. Does that mean iodine in isolation is a toxin?
Various organs in our body, and in specific the liver are involved in eliminating potential toxins from the body. Commercial detox diets lure the masses promising rapid weight loss, but there is no scientific evidence to support this claim.
Pros: Well. This is a tough one. In a recent review on detox diets (7), it was highlighted that some plant based foods like coriander, citric acid (found in citrus fruits) and malic acid (found in grapes) can help in removing toxic metals from the body. However, most of these studies were performed on animals and can’t be generalised to the human population. While these detox diets may be successful in inducing weight loss in the short term, they may not be sustainable in the long run.
Cons: Detox diets involve severe energy restriction and might lead to nutrient deficiencies. For example, by just drinking juices for a week, one may not meet their recommended protein intake! Further, detox dieters could potentially be over consuming supplements/laxatives (7). A variety of nutrients need to be consumed on a daily basis, which a detox diet may not be able to provide.
(4) GM diet: A diet that was initially created for the employee of General Motors (GM), the GM diet allows you to eat a certain combination of foods each day. For example, on day one you eat only fruit (except bananas). On day two, only vegetables. This pattern of consuming specific foods continues for a period of 7 days. Since fruits, vegetables and other items allowed in the diet are low calorie, it has been shown to induce weight loss. However, as much as it is popular, there isn’t any research to support the claims of this diet.
Pros: Although a GM diet does include some whole foods, it follows a restrictive and specific pattern.
Cons: We need a variety of nutrients on a daily basis. By consuming just fruits throughout the day, other nutrients such as protein, fat and several other micronutrients available in whole grains, fruits and vegetables are neglected. Moreover, tendency to feel hungry might be prevalent. The weight lost on a GM diet may be temporary. Since it isn’t something you can follow lifelong (fight me!), there lies a possibility of regaining the weight lost.
Do you sense a pattern with all these diets? All of these diets involve restricting either all your food or a specific food/food group. Do you think that’s sustainable and that you can follow it life long? Not really right? In an ideal scenario, for a diet to be sustainable, it needs to be personalised to suit you and your goals. There isn’t one specific diet that is applicable to everyone. As mentioned before, all nutrients play a specific role in your body. Completely cutting yourself off from one for the sake of losing weight does more harm than good. Always make an informed decision when it comes to your fitness goals. The shortcuts might seem tempting, but remember health is wealth.

References:

1) Walcyzk, T, Wick, JY. The ketogenic diet: making a comeback. The Consultant Pharmacist. 2017; 32(7), 388-396.
2) Rho, JM. How does the ketogenic diet induce anti-seizure effects? Neuroscience Letters. 2017; 637, 4-10
3) Paoli, A. Ketogenic diet for obesity: Friend or foe?. International Journal of Environmental Research and Public Health. 2014; 11(2),2092-1207.
4) Pitt, CE. Cutting through the Paleo hype: The evidence for the Paleolithic diet. Australian Family Physician. 2016; 45(1): 35-38.
5) Tarantino, G, Citro, V and Finelli, C. Hype or Reality: Should Patients with Metabolic Syndrome-related NAFLD be on the Hunter-Gatherer (Paleo) Diet to Decrease Morbidity?.Journal of Gastrointestinal and Liver disease. 2015; 24(3): 359-368.
6) Allen, J, Montalto, M, Lovejoy, J, Weber, W. Detoxification in naturopathic medicine: a survey. Journal of Alternative and Complementary Medicine. 2011;17(12):1175-1180.
7) Klein, AV, Hiat, H. Detox diets for toxin elimination and weight management: a critical review of the evidence. Journal of Human Nutrition and Dietetics. 2014; 28(6): 675-686.
8) Healthline. What is the Cyclical Ketogenic Diet? Everything you need to know.
9) Medical News Today. What are the signs of ketosis?
10) Harvard T.H. Chan School of Public Health. Diet Review: Ketogenic Diet for weight loss.
11) Masharani, U, Sherchan, P, Schloetter, M, Stratford, S, Xiao, A, Sebastian, A, Nolte Kennedy, M and Frassetto, L. Metabolic and physiologic effects from consuming a hunter-gatherer (Paleolithic)-type diet in type 2 diabetes. European Journal of Clinical Nutrition.2015; 69(8), 944-948.
12) Harvard T.H. Chan School of Public Health. Diet Review: Paleo diet for weight loss.
13) Precision Nutrition. The Paleo problem.

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