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Category Archives: Nutrition

Obesity, Smoking, Death and Medication Use

May 3, 2012 Dr. Pullen

Somehow I was not in the least surprised when I came across a Huffington Post article showing which states in the US have the highest rates of medication use. Why am I not surprised? Intuitively I suspected that these are the states with the highest rates of obesity and smoking. Look back to a prior post on how obesity has surpassed smoking as the leading preventable cause of death in America. Every one of the top 9 most medicated states is in the highest tier of rates of obesity. What medical conditions lead inexorably to the use of multiple medications? Think diabetes, hypertension and chronic pain. All of these conditions are directly related to obesity in many cases. Also think heart and lung diseases like asthma, COPD and coronary artery disease, all well documented to be related to both smoking and obesity. Here are the 9 “most medicated states” from the Huffington Post article with the CDC 2011 rate of obesity in parentheses. For interest I’ve also put the state’s rank in terms of smoking incidence from the CDC data.
State (Retail Rx per capita) Rate of obesity Smoking Rate (national rank)

West Virginia (18.4) >30% 25% (tie for 8^th highest)
Tennessee (16.9) >30% 25% (tie for 8^th highest)
Alabama (16.9) >30% 25% (tie for 8^th highest)
Kentucky (16.5) 30% 29% (alone w/top rate)
Arkansas (16.4) >30% 26% (6 way for 2^nd)
South Carolina (16.3) 25%-29% 24% (4-way tie for 12^th)
Mississippi (15.9) >30% 26% (6-way tie for 2^nd)
Iowa (15.3) 25%-29% 22% (3-way tie for 17^th)
Missouri (15) >30% 26% (6-way tie for 2^nd)

For reference there are nine states with 2009 rates of obesity > 30% of which 7 are here in the top 9 most medicated states. The national average rate of smoking is 21% and all 9 of the states with the highest rates of medication use are in the top 17 states for rates of smoking.

I cannot access the SDI data to see what the rates of obesity are in the states with the lowest incidence of obesity are but here are some other health related statistics and their relationship to a relative lower obesity rate.

1) Colorado is alone as the only state in the US with a 2009 rate of obesity at <20%. Why doesn’t Colorado rank at the very top for the lowest for death rates in adults? Possibly because of a smoking rate of 20% (tie for 28^th highest leaving it pretty good but with a death rate of 709/100,00 (11^th best).

2) The fifteen states with obesity rates from 20-25% (the best except for Colorado) are listed below in alphabetical order:

Death rate (rank) Smoking Rate (rank)

a) Alaska 742 (2oth) 24% (Tie for 12^thhighest)

b) California 660 (4^th) 15% (50^th highest, i.e. 2^nd lowest)

c) Connecticut 691 (8^TH) 18% (tie for 38^th highest)

d) Hawaii 590 (1^st) 16% (49^th, i.e. 3^rd lowest)

e) Idaho 723 (16^th) 18% (tie for 38^th highest)

f) Minnesota 675 (5^th) 17% (tie for 44^th highest)

g) Montana 786 (33^rd) 20% (tie for 29^th highest)

h) New Jersey 717 (14^th) 18% (tie for 38^th highest)

i) New York 676 (6^th) 19% (tie for 32^nd highest)

j) Oregon 748 (22^nd) 18% (tie for 38^th highest)

k) Rhode Island 749 (23^rd) 20% (tie for 28^th highest)

l) Utah 659 (3^rd) 11% (51^st highest, i.e. lowest)

m) Vermont: 721 (15^th) 18% (tie for 38^th highest)

n) Virginia 762 (25^th) 19% (tie for 32^th highest)

o) Wyoming 773 (29^th) 21% (tie for 21^st highest)

Looking at this data you may note that 4 of the 5 states with the lowest death rates are in the 15 states with the lowest rates of obesity, and that none of them are worse than the 44^th highest smoking rates. (only Arizona is missing, in the next 25%-29% obesity rate and at a tie for 21^st in rate of smoking) You may also note that the only two states in the top 15 for lower obesity rates ranking in the bottom half for death rates have smoking rates ranking at 21^st and 29^th.

Contrast this with the five states with the highest death rates:

West Virginia with >30% obesity and 25% smoking rate (tie for 8^th highest)
Mississippi with > 30% obesity and 26% smoking rate (tie for 2^nd highest)
Oklahoma with >30% obesity and 26% smoking rate (tie for 2^ndhighest)
Alabama with > 30% obesity and 25% smoking rates (tie for 8^th highest)
Louisiana with >30% obesity and 26% smoking rate (tie for 2^nd highest)

In contrast the states with the lowest death rates have the opposite statistics for obesity and smoking rates:

Hawaii with 20-24% obesity and 16% smoking rate (3^rd lowest).
Arizona is the exception in these states with 25-29% obesity and a smoking rate of 21% (right at the national average and ranking in a 6 way tie for 20^th highest in the U.S.
Utah with in the 20-20% obesity and the lowest smoking rate in the U.S. at 11%.
California with 20-24% obesity and 16% smoking, second only to Utah.
Minnesota with 20-24% obesity and in a tie for 4^th lowest smoking rates at 17%.

It appears that states where citizens choose not to smoke and trend to be less obese have both lower rates of medication use and lower death rates. My guess is that the observation of lower death rates and lower rates of medication use are the result of lower rates of diabetes, hypertension, COPD, cardiovascular disease in these same states. Yes these other health markers also trend directly with obesity and smoking rates.

So what can you as an individual learn from this? Get fit, avoid obesity and don’t smoke. No surprises here.

One Nation – Under Pressure

May 1, 2012 Dr. Pullen

By Brooke Douglas, RD, CD

High blood pressure. The words don’t exactly strike fear into most American’s hearts. After all, it’s not painful, like cancer. It doesn’t sound deadly, like heart disease. But it’s literally a time bomb in our blood vessels that threatens our heart, brain and kidneys. Make no mistake – it’s a killer! So what makes our blood pressure rise? Too much salt, extra body weight and spending too much of your time sedentary. But wait! Don’t blame it all on the salt shaker. Only 7% of the excess salt in the average American’s diet comes from the salt shaker. The remaining 93% comes from all the processed and convenience foods we buy at the vending machine, at the local corner store, at the grocery store (for quick dinners) and at fast food and dine-in restaurants.

If your doctor has told you to cut back on your salt intake…you will have to do more than put the salt shaker away.

As for extra body weight (lose weight) and inactivity (begin a modest exercise program and spend less of your day sedentary), applying the following tips may help you on your quest to lower your blood pressure.

Here are some sodium-cutting tips you can try today:

Introduce additional flavor to your foods with herbs and spices like garlic, oregano, basil, pepper, thyme and sesame. These all add flavor without the extra sodium. If a recipe calls for salt, cut the amount called for in half and taste it before adding more.

Make healthy choices at the grocery store. Processed foods (anything in a box or bag) tend to be high in sodium because it helps preserve foods longer and increase flavor. Always read labels for the foods you buy, including the sodium content on the nutrition facts label and the ingredients list.

Remember that “low-fat” or “low-calorie” doesn’t mean healthy. These diet foods can also be higher in sodium because manufacturers hope that added sodium, a flavor-enhancer, will bring back the flavor that is missing since fat and other higher-calorie ingredients are removed. This is especially true for frozen dinners, which are often loaded with extra salt.

Choose low-, no- or reduced-sodium versions of your favorite soups, frozen meals, canned foods, and snacks. Even butter is available without added salt!

Choose fresh or frozen veggies over canned varieties, which often contain added salt to help increase shelf life. If you can’t find sodium-free varieties of canned vegetables, rinse the can’s contents in a colander under water before cooking to remove excess salt.

Olives, pickles and other items packed in brine are saturated in salt, as are many smoked and cured meats, like salami and bologna. Limit your intake of these high-sodium foods and be on the lookout for lower-sodium varieties.

Fast foods are high in more things than just fat. Many of these meals, sandwiches and fries contain more than your daily recommended intake of sodium in just one serving. When consulting restaurant websites to make healthy choices, pay attention to sodium levels as well. By keeping your portions in check (order a junior burger or small French fry instead of the big burgers and super fries) will help control your sodium (and caloric) intake.

Thanks much to Brooke for returning as our first-of-the-month guest contributor. She does a great job with nutrition advice, so if you are concerned about your or a loved one’s blood pressure give her a call. Did you know that your insurance might cover several visits with a Registered Dietitian? Let Brooke help you navigate the insurance maze to determine whether your insurance will pay for you to having some nutrition coaching with a Registered Dietitian. You can find her at Nutrition Authority.

The Grapefruit and Medication Dilemma

March 1, 2012 Dr. Pullen

Grapefruit has a flavor that is unique and refreshing. There is something about sitting down to a half grapefruit, carefully separating the segments, enjoying each one and then squeezing out the

juice to sip that just makes a breakfast seem civilized and elegant. One problem, often in apparent to the casual grapefruit lover, is that there is something else special about grapefruit. It contains a substance that is an irreversible competitive inhibitor of the CYP 3A4 intestinal isoenzyme that breaks down a wide variety of medications. You may think Dr. Pullen has lost it, getting this technical on this blog intended for patients not scientists. Bear with me; it is an interesting and possibly important story.

Many medications are metabolized in the liver through a number of different enzyme mediated steps using what are called the cytochrome P450 (CYP 450) enzymes. There are several different variations of this enzyme, each with a alphanumeric moniker, like 3A4, 2D1 and so on. One of the most important is the 3A4 isoenzyme. It is located in the liver primarily, but also on what is called the brush border of the small intestinal cells. The brush border is where nutrients and medications are broken down into tiny molecules by various digestive enzymes to be absorbed into the blood that goes to the liver. The CYP 450 3A4 enzyme at this intestinal brush border functions to inactivate significant amounts of some medications before they can get absorbed into the bloodstream.

Grapefruit (and a few other uncommonly eaten fruits) contain high amounts of something called furanocoumarin derivatives, which irreversibly bind to the intestinal brush border CYP 3A4 isoenzymes, and prevent the breakdown of many medications. By irreversible I mean this binding prevents an enzyme from functioning until the brush border cell dies and is replaced by another cell with new enzymes, often a period of a few days. When a person who takes one of the medications normally metabolized by the CYP 3A4 isoenzyme eats grapefruit or drinks grapefruit juice a higher percentage of that medication is absorbed into the bloodstream and becomes bioavailable. In the case of some medications this can be significant, and lead to the potential for toxicity or a higher incidence of dose related side effects.

As consumers of medical care it is important to know whether any medications you are taking have a significant grapefruit interaction potential or not. Your pharmacist will often counsel you regarding this issue, and it is usually mentioned in the drug handout information at the pharmacy, but this is easy information to overlook. Here is a list of the medications I think is most relevant to patients (not intended to be complete):

Statins: Simvastatin, Atorvastatin (Lipitor) and lovastatin (Mevacor) use the 3A4 pathway, but pravastatin, rosuvastatin (Crestor) and pitavastatin (Livalo) do not. This may be significant especially at higher doses of these drugs with the potential for dose related myalgias.

Dihydropyridine Calcium Channel Blockers: Several of the CCBs including fleldipine, nifedipine, nicardipine (Cardene). In addition verapamil, an non dihydropyridine CCB uses this pathway.

Carbamazepine: An anticonvulsant with a fairly narrow therapeutic window.

Sertraline (Zoloft) an SSRI type of antidepressant

Methadone: an opioid used for pain control and in some cases at methadone clinics for heroin addicts.

Omeprazole: a proton pump inhibitor used for stomach acid related disorders like reflux esophagitis

Cyclosporine: An important immunosuppressant.

Many of the HIV medications: In the early days of HIV therapy, to contain costs of branded drugs some physicians had patients routinely take their HIV drugs with grapefruit juice to allow lower doses of the medications. (don’t try this at home with your medications)

Losartin (Cozaar): a blood pressure medication

Colchicine: a gout medication

In many cases this interaction is not clinically significant, but in some cases it may be. If you use eat grapefruit or grapefruit juice you should consider asking your pharmacist about any medications you use to see if there is a significant concern. If there is be aware that this is not just an issue if the grapefruit and the drug are ingested at the same time, but for several days after eating/drinking the grapefruit.

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Belly Fat Is Bad For Our Health

February 13, 2012 Dr. Pullen

Is I took my shower this morning and once again looked down at my post-middle age belly, I am reminded that belly fat is bad. This is not news. We have known for years that belly fat is not just a problem because it hangs over the belt and many of us dislike the way it looks, but because it is an indicator of intraabdominal fat that is a risk factor for atherosclerotic heart disease. Having a big derriere or big thighs seems to be less of a health concern.

Look at both the subcutaneous fat and the fat inside the abdominal cavity in this overweight patient at laparotomy.

My cadaver for dissection in medical school was an old man, who was quite thin and had very minimal visceral fat, and when I saw my first few general surgical abdominal cases I was impressed by the amount of fat in the epiploical fat in the omentum and around the mesentery of many patients. I somehow had thought that most of our belly fat was just between the skin and the abdominal cavity, i.e. subcutaneous fat. In obesity a part of out abdominal girth is made up of intraperitoneal (inside the abdominal cavity) fat.

A Nov. 2008 NEJM article reported on a very large study of biometric measurements and showed that the rates of death were clearly related to “abdominal adiposity.” The study showed that increasing abdominal circumference and an increased ratio of abdominal circumference to hip circumference were both significantly related for a higher death rate. This correlation held up even when controlled for BMI, a general measure of height for weight. In other words if you have more belly fat that is a bigger health risk factor than if you carry your weight in your thighs, buttocks or breasts. Those of us with belly fat as opposed to having a fat in other places have long been known to be at higher risk of heart attacks, and recent research suggests correlation of belly fat with diabetes, and possibly some cancers.

So why does increased intra-abdominal fat, also called visceral fat, correlate with heart disease. Animal studies in mice show that increased visceral fat leads to higher rates of inflammation. There is considerable evidence that measures of low-grade inflammation, like highly sensitive C-reactive protein (h-CRP) are indicators of higher risk of coronary heart disease. A condition called metabolic syndrome is defined by having increased belly fat, an abdominal circumference of more than 40 inches (measure the smallest abdominal circumference, usually just above the umbilicus while standing at rest) along with borderline or high blood pressure, low HDL cholesterol and borderline or slightly high fasting blood sugar. Metabolic syndrome is felt to be a pre-diabetic condition and is a risk factor for the same types of cardiovascular conditions as diabetes.

Unfortunately we don’t really get to choose where we become obese. Don’t believe the headlines or web sites promising a secret fix to lose your belly fat, or any other particular fat you dislike. There is no believable evidence to support specific exercises to lose weight in specific areas. We can get stronger muscles in areas we exercise, but cannot specifically lose our belly fat, or any other fat by any means other than overall reduction of body fat, i.e. weight loss. Weight loss is not easy, and maintaining weight loss is arguably even harder than losing weight. I have patients who truthfully assure me that they have lost hundreds of pounds, they have just gained it all back and more. Still reduction of total body fat is the only way to reduce belly fat, so I know I need to keep up my exercise and my efforts to eat better to lose my belly fat. Wish me success in my ongoing fight to lose my belly fat.

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FDA Removes HCG Diet Products from Market for Weight Loss

December 6, 2011 Dr. Pullen

To long time readers this came as no surprise. The use of HCG for weight loss has probably been studied more than nearly any other weight loss fad or diet, and the evidence that it does not work is overwhelming. See my prior post:

HCG Diet: Nothing New– One More Fad Diet That Doesn’t Work published on this health blog on May 8, 2010.

Today the FDA released an announcement that it has sent warning letters to seven makers of HCG products to companies marketing these non-prescription products stating that they are both unproven and not safe. I believe that they are not only not proven to be effective, but that there is considerable evidence that they are not effective. All the recommended diets using HCG are combined with severe calorie restriction, and this low calorie diet, usually 500 calories daily, can be associated with gall stone formation, cardiac arrhythmias, and are simply not safe.

Unfortunately there are no magic tricks for losing weight. Eating less, exercising more, and doing these things for long periods of time are the best approach. It is clear that we simply do not understand everything about weight control. It is a very complex and incompletely understood dilemma, but one thing is clear. The HCG diet simply does not work and I’m glad to see the FDA wielding its clout to get it off the market.

The Gluten Free Marketplace Explodes

December 5, 2011 Dr. Pullen

The Gluten Free Marketplace Explodes

Gluten Enteropathy, or celiac disease (sometimes called celiac sprue), is a condition where the lining of the small bowel is damaged by antibodies to gluten found in wheat, rye, barley, malt and some other grains. When people who are gluten sensitive eat food containing gluten their small bowel becomes inflamed, the villi that contain enzymes to help digest foods to allow their absorption become atrophic and dysfunctional, and they lose weight, become ill and just feel terrible. For many years it was felt that gluten enteropathy was rare in the United States, and was primarily a European problem. As late as 1999 the teaching in U.S. medical schools was that only 1:10,000 Americans had gluten enteropathy. Beginning in the early 1990’s research began to show that the incidence was much higher, and it is now estimated that as many as 1:100 Americans has gluten sensitivity. This for unknown reasons seems to be a real increase in the last half century, and not be just a product of increased awareness and better testing.

Gluten sensitivity can be dramatic or subtle, and difficult to diagnose. A battery of blood tests often including Anti-tissue Transglutaminase Antibodies(Anti-tTG) IgA, Anti-tG IgG, Anti-Gliadin Antibodies, Anti-Endomysial andibodies, or other antibody tests if positive can suggest the diagnosis. A negative test has a higher predictive value at ruling out celiac disease than a positive test has at confirming the diagnosis (the tests are more highly sensitive than they are specific). To confirm the diagnosis requires a small bowel biopsy that is usually obtained by upper GI endoscopic exam.

Once diagnosed with celiac disease a person has to learn how to eat a gluten free diet in a society where wheat and other gluten containing food is nearly everywhere. Fortunately more and more prepared foodstuffs are being marketed all the time, and more recipes, support groups, and nutritional advice is available than ever before.

I just read a very interesting article in the N.Y Times by Keith O’Brien that nicely outlines the history of the emergence of gluten enteropathy in the U.S., and the market leadership by General Foods in bringing gluten free food products to market to capitalize on the growing market for gluten free products. You may enjoy reading:

Should We All Go Gluten Free?

By Keith O’Brien November 25, 2011.

My guess is that you know someone dealing with the need to eat gluten free. Fortunately as awareness grows and resources become more easily available providing a gluten free meal is less onerous than it was just a decade ago.

I am also learning more about various nutritional deficiencies that can accompany celiac disease. The malabsorptive condition seen in patients with celiac disease can lead to several well documented vitamin deficiencies that are uncommon otherwise. Deficiencies in almost all of the fat soluble vitamins and B vitamins are more common in celiac patients than in the general population. I recently saw a 17 year old girl in the office with known celiac disease who had been well controlled on a gluten free diet for several years. She was found to be both vitamin B12 and folic acid deficient when evaluated for anemia and fatigue.

As a medical community we have become more aware and educated about celiac disease in recent years, and it is good to see that the marketplace is stepping up to meet the demand for gluten free products and make existence easier for this significant minority of Americans with gluten sensitivity.

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Healthy Snacks: Sensible Snacking for 9 to 5’ers

December 1, 2011 Dr. Pullen

The clock ticks to 3 pm on a Monday, and your office’s vending machine calls out for you to sabotage your healthy habits with an oh-so-tempting Reese’s candy or a Doritos bag of chips – and what do you do? Even if you have no problem turning down fatty foods throughout the day, many people, while at work may have trouble winning the healthy food fight when surrounded by unhealthy options all week.

BRAKE FOR BREAKFAST – Even though mornings may leave you sprinting for the door, taking time to eat breakfast has been shown to decrease unhealthy snacking and overeating later in the day. If you try to get as much sleep as you can, therefore creating the habit of “I don’t have time to eat breakfast”, why not keep some healthy items in the office? Foods like oatmeal and walnuts, natural peanut butter on whole wheat toast, or low fat cottage cheese and fruit are easy to prepare and store. If you go to work hungry you may be surrounded by unhealthy options, which increases the chance you will eat those unhealthy options. On another note, if you are one to say “I’m never hungry in the mornings” – the only reason for this would be if you overate the evening before. It is in your own best interest to trust the research about the benefits of breaking your nighttime fast and beginning your day with ‘food fuel’ for your brain!

PLAN AHEAD – Preparation is the key to healthy workplace munching and integral to helping you make successful food choices for both mealtime and snack-time. You know you are going to be hungry, so plan for it. Instead of running to the fast-food outlet across the street or relying on the junk foods brought in by coworkers, make a plan to have healthy foods available for your meals and snacks. It is too easy to get into trouble when we wait to look for something to eat when we are already hungry.

If you think you are too busy to pack snacks daily, pack once, eat for five days. In other words, pack up a bag of snacks for the week to take to work with you on Monday. Most offices have a refrigerator and a toaster oven or microwave, so use them.

HEALTHY DESK DRAWER SNACK IDEAS

Whole wheat fig bars

Individual servings of fruit

Raw almonds, walnuts, peanuts – ¼ cup

Dried fruit and nuts – limit to ¼ cup each

Instant soup cups – low salt variety

Plain granola bars (no mix-ins/candy)

Fresh, crisp vegetables in a baggie

Natural peanut butter on WW crackers

Whole wheat crackers and hummus

Nonfat yogurt with ground flaxseed

High-protein, high-fiber snack bars

Apple and low-fat string cheese

Oatmeal in a baggie (not instant)

Hard boiled egg and fresh fruit

Whole grain pretzels

Healthy, homemade muffins

Baked potato and tortilla chips

Single-serving pouches of tuna

Snacking should be purposeful. Snack to avoid overeating at meals and to keep your metabolism working along with you during the day. Appropriate and strategic snacking can help bridge the hunger gap between meals and keep you better focused, more productive and help with health and weight goals.

Brooke Douglas is a registered dietitian who contributes an article to this health blog on the first of every month. Have you had a ‘Nutrition Checkup’? You know who your doctor is. But who is your Registered Dietitian (RD)? If you would like to meet with a registered dietitian and schedule your ‘nutrition check-up’, contact Brooke Douglas, RD by logging on to her website at www.NutritionAuthority.com or call Brooke at 253.227.8284.

Also see:

Healthy Fruits – Healthy Vegetables. Brooke Douglas Tells it All

How to Eat Healthy on Vacation

Inflammation and Diet: Inflammatory and Anti-inflammatory Foods

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Omega-6 Fatty Acids-Good Fat or Bad Fat?

November 1, 2011 Dr. Pullen

by Brooke Douglas RD

Omega-6 fatty acids are considered essential fatty acids: They are necessary for human health but the body can’t make them — you have to get them through food. Along with omega-3 fatty acids, omega-6 fatty acids play a crucial role in brain function as well as normal growth and development. Also known as polyunsaturated fatty acids (PUFAs), Omega 6 fats help stimulate skin and hair growth, maintain bone health, regulate metabolism, and maintain the reproductive system.

A healthy diet contains a balance of omega-3 and omega-6 fatty acids. Omega-3 fatty acids help reduce inflammation (very good- see The Anti-Aging Anti-inflammatory Diet), and some omega-6 fatty acids tend to promote inflammation (not good). Unfortunately, the typical American diet tends to contain 14 – 25 times more omega-6 fatty acids than omega-3 fatty acids.

The Mediterranean diet, on the other hand, has a healthier balance between omega-3 and omega-6 fatty acids. Many studies have shown that people who follow this diet are less likely to develop heart disease. The Mediterranean diet does not include much meat (which is high in omega-6 fatty acids and Omega 9 fatty acids) and emphasizes foods rich in omega-3 fatty acids, including whole grains, fresh fruits and vegetables, fish, olive oil, garlic, as well as moderate wine consumption.

However it is good to keep in mind that there are several different types of omega-6 fatty acids, and NOT ALL promote inflammation. Most omega-6 fatty acids in the diet come from vegetable oils as linoleic acid (LA). Be careful not to confuse this with alpha-linolenic acid (ALA), an omega-3 fatty acid. Linoleic acid (LA) is converted to gamma-linolenic acid (GLA) in the body (GLA is found in several plant-based oils including evening primrose oil (EPO), borage oil, and black currant seed oil.)

Gamma-linolenic acid (GLA) may reduce inflammation. Much of the GLA taken as a supplement is converted to a substance called DGLA that fights inflammation. Having enough of certain nutrients in the body (including magnesium, zinc, and vitamins C, B3, and B6) helps promote the conversion of GLA to DGLA.

For general health, there should be a balance between omega-6 and omega-3 fatty acids. The ratio should be in the range of 2:1 – 4:1, omega-6 to omega-3. The average diet provides plenty of omega-6 fatty acids, so supplements are definitely not necessary. Conversely supplementing with Omega-3 fatty acids is considered by most to be a wise decision.

You can find Brooke Douglas at Nutrition Authority for personal nutrition advice.

What Vitamins Should I Take?

October 20, 2011 Dr. Pullen

I’ve been asked “What vitamins should I take?” by many patients over the years. I’ve usually answered that a store brand multiple vitamin is a good choice for most people, but recent evidence suggests that maybe the best answer to the question is that most people who have a reasonably healthy diet are best taking no vitamins at all. I know that answering the question, “What vitamin should I take?” with the answer that most vitamin supplements may cause more harm than good is not likely to be the answer patients want to hear, but as more evidence becomes available it is more clear that we just cannot get the healthy nutrients of a balanced diet in a pill, and that attempts to do so may actually be detrimental to our health.

In the nearly 30 years I’ve been practicing medicine there has been one miracle vitamin/mineral/supplement after another in vogue, and almost none of them have stood the test of time. The only way to get the full benefit of nutritious foods is to eat them. Bummer. It’s so much easier to just buy vitamins or supplements and eat junk. Sorry but that just doesn’t give the benefits of a nutritious diet.

In the last couple of weeks two new studies show that there may be more harm that good from taking several vitamins. A large study published in the Archives of Internal Medicine where 38,000 women were followed for 17 years showed slightly higher death rates in women taking multiple vitamins than in women not taking them. Specifically taking multiple vitamins, vitamin B6, iron, copper, zinc and magnesium were all associated with statistically significantly higher death rates. Only calcium seemed to be associated with slightly lower death rates in this study of older women.

An NIH study released recently showed that Vitamin E is associated with higher rates of prostate cancer. Over the years Vitamin C, Vitamin E, beta carotene, saw palmetto, multiple antioxidant regimens, and nearly every vitamin with a letter or number has been in fashion for reduction of one health condition or another. One by one they have almost all been shown to be useless or worse.

Who else remembers the theory that the whole trick to avoiding atherosclerosis was to ingest the right ratio of saturated to polyunsaturated oils. I remember a resident physician in Boston when I was a student who urged everyone to drink corn oil every day so that we could eat all the meat we want because our ratios of fat consumption would be in balance and that would make eating animal fat OK. Most of us laughed at him, but that theory had lots of followers 30 years ago. Beta carotene and vitamin E as antioxidants have been clearly shown to be more harmful than good.

So what’s a person to do? Here are my suggestions:

First and most important try to eat a healthy diet. Avoid fad diets, eat more fruits and vegetables, less meat, and exercise more. Don’t think you can rely on vitamins, mineral supplements, or gimmicks to substitute for healthy eating. See previous posts on Anti-inflammatory Foods, Foods High in Fiber , and Anti-aging Diet.
Be skeptical of whatever vitamin or supplement craze is in fashion at any given time.
Don’t think that more is better regarding vitamins. It has long been known that high doses of vitamins A, E and B6 can be toxic. There is little evidence to support high doses of any of the other vitamins either.
Keep in mind special conditions where supplementation with specific vitamins is important. Examples of these include many causes of malabsorption like gastric bypass surgery, some medication use, and celiac disease.
Understand that this is a long term issue. Eating well this month is good, but eating well for a lifetime is the key.
Avoid vitamin regimens that have been clearly shown to do more harm than good. These would include:
1. Beta-carotene supplements
2. Vitamin E supplements in most people
3. Iron supplements in men and post menopausal women
4. High dose supplements with nearly every vitamin. Currently Vitamin D is in vogue, and currently most of the data looks positive. Time will tell whether this works out or not.
5. I’d avoid even a multiple vitamin daily at this time if you eat a reasonably healthy diet and have no specific reasons to take the vitamin.

For other related articles check out:

Psyllium Husk

Dr Pullen Lives the Mediterranean Diet

Healthy Fruits – Healthy Vegetables

Use the subscribe section on the right sidebar to get e-mail notification of each new post, and follow @DoctorPullen on Twitter to see both DrPullen.com posts and other thoughts and information I find interesting.

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Healthy Fruits – Healthy Vegetables:Brooke Douglas RD Tells All

October 1, 2011 Dr. Pullen

Brooke Douglas RD is back with her first of the month post, this time telling us about healthy fruits and healthy vegetables. Don’t miss a word.

Almost Everything You Ever Wanted to Know About Fruits and Vegetables

Research shows that people who eat even 2½ cups of fruits and vegetables a day have only half the cancer risk of those who eat less than one cup a day. Hundreds of studies show that increased fruit and vegetable consumption may also help prevent heart disease, stroke, hypertension, birth defects, cataracts, diabetes, obesity and other serious conditions.

Healthy Fruits and vegetables are nutritional powerhouses which:

Are excellent sources of vitamins and minerals and contain disease fighting fiber
Contain antioxidants and phytochemicals
Are virtually fat-free (exceptions: coconut, olives & avocado) and cholesterol-free
Are helpful in weight management, due to their high-fiber, high-water, and low-fat content

Vitamins and minerals: Are essential in maintaining the health of the brain, heart, bones, teeth and nerves; making/repairing red blood cells; regulating body’s balance of fluids; and in other vital functions.

Many healthy fruits and vegetables are particularly good sources of vitamins A, C, E and K, some B vitamins, and many important minerals needed for healthy bodies. Beta-carotene and related compounds called carotenoids are converted by the body to Vitamin A. Carotenoids are found in high concentrations in carrots and other orange and yellow vegetables and fruits such as winter squash and cantaloupes. Dark green, leafy vegetables, such as spinach, kale, broccoli, and other members of the cabbage family, also contain high concentrations of carotenoids.

Dark green vegetables are also excellent sources of folic acid (a B vitamin needed during pregnancy to reduce the risk of neural defects in the fetus), Vitamins E and K, and minerals such as calcium, magnesium, manganese, iron, and potassium. Many fruits are also a good source of minerals, such as chromium (grapes), iron (cherries), manganese (pineapple), and potassium (apricots, bananas, orange juice, peaches and prunes).

Citrus fruits are good sources of Vitamin C, as is the family of plants that includes tomatoes, red and green peppers, potatoes, and eggplant. Other good sources of Vitamin C include papayas, strawberries, kiwis, cantaloupe, and the cabbage family, including broccoli, cauliflower and Brussels sprouts.

While there is overlap in the vitamins/minerals supplied by fruits and vegetables, you need a wide variety of colorful healthy fruits and vegetables to fully benefit from the various nutrients they contain.

Antioxidants: Disease-fighting compounds found in many foods, especially healthy fruits and vegetables. Antioxidants neutralize free radicals (compounds that damage cells and lead to cardiovascular disease, cancer, cataracts, premature aging, and impaired immunity.) Antioxidants include vitamins A, C, and E; beta carotene, minerals (selenium, copper, zinc, and manganese) and some of the phytochemicals.

Phytochemicals: From plants, “plant chemicals” are recognized as powerful disease-fighting compounds. Fruits and vegetables contain thousands of different phytochemical compounds. Categorized as carotenoids, flavenoids (compounds that give flavor/colors to fruit/veg), and other compounds, such as allicin, indoles, lycopenes, lutein, and phenols. Scientists studying phytochemicals are finding an impressive range of health benefits.

Color & Examples	Phytochemical Examples	Potential Benefits
Red: apples, cherries, strawberries, watermelon, beets, red peppers, radicchio, tomatoes	Lycopene, anthocyanins	Maintain memory function, heart health urinary tract health; reduce blood pressure, fight infections, and reduce risk of some cancers
Orange/yellow: apricots, mangos, oranges, peaches, pineapple, cantaloupe, carrots, corn, winter squash	Carotenoids, bioflavonoids	Maintain health of heart, eyes, and immune system, slow aging, and reduce risk of some cancers
Green: leafy greens, asparagus, broccoli, green beans, peas, spinach, honeydew, kiwi, avocados	Lutein, indoles, carotenoids	Improve vision, strengthen bones and teeth, and reduce risk of some cancers
Blue/purple: blueberries, blackberries, purple grapes, plums, eggplant, purple cabbage	Anthocyanins, phenolics, resveratrol	Facilitate healthier aging, enhance memory function, urinary tract health and cardiovascular health and reduce risk of some cancers
White/tan/brown: onions, garlic, cauliflower, turnips, mushrooms, potatoes, bananas, pears, dates	Allicin, quercetin, sulphoraphane	Improve heart health, maintain healthy cholesterol levels, and reduce risk of some cancers

Not all foods listed above, even within the same group, have the same health benefits. Foods with the same phytochemicals may contain different concentrations of the phytochemicals, and the compounds may be absorbed differently. Even different varieties of foods within the same category (such as different varieties of apples or lettuce) may contain widely varying concentrations and kinds of phytochemicals. However, those darker in color usually contain higher concentrations. So think “more color and more variety” in making your selections!

What is considered one serving of fruit?

• 1 medium whole fruit (apple, banana) • ½ cup of fresh, frozen or canned fruit
• 6 oz. (¾ cup) 100% fruit juice • ¼ cup of dried fruit

What is considered one serving of vegetables?

• 1 cup of raw, leafy vegetables • ½ cup cut up fresh, frozen or canned vegetables
• 6 oz. (¾ cup) 100% vegetable juice • ½ cup cooked beans, peas, or lentils

How Can I Get More…Healthy Fruits and Vegetables in My Diet?

At home:

• Top your hot or cold cereal with fresh fruit.
• Enjoy a glass of 100% real fruit or vegetable juice with breakfast.
• Make smoothies with fresh or frozen fruits and juices for a great breakfast or lunch choice.
• Choose hundred percent fruit and vegetable juices as delicious alternatives to soft drinks.
• At dinner, include salad/raw veggies; use low-fat or non-fat dressing to reduce fat and calories.
• Steamed vegetables are always a good side dish.
• Add vegetables to your favorite entrees, like tacos, lasagna, casseroles, and pasta dishes.
• Add pureed vegetables to sauces to fortify them.
• Try more vegetarian meals, like tofu, rice or pasta with vegetables, and Asian stir-fry dishes.
• For dessert, bake sweet potatoes, apples, peaches, pears, or bananas, or make fruit cobblers.
• Discover some of the many cookbooks that specialize in fruits and vegetable recipes.
• For a snack or when you’re on the go:
• Choose fruits and vegetables that can be eaten out of hand, like apple wedges, baby carrots, broccoli spears, or cherry tomatoes, grapes, bananas, and seasonal items like peaches and plums.
• In place of candy, choose dried fruit (easily packs in a bag/take on the road or eat at office.

When dining out:

• Order a dinner salad to begin your meal.
• Request an extra serving of vegetables as a side dish.
• Order meals that include vegetables or fruits as a major component. To keep fat and calories in check, request vegetables steamed without the addition of butter, oil or cream sauce.
• Ask for extra lettuce and tomato (or other vegetables) on sandwiches and burgers.
• Choose healthful desserts; fresh fruit, sherbet, sorbet, or angel food cake topped with fruit.
• Choose dishes on the nutrition charts of Healthy Dining Finder that have more servings of fruits/vegetables.

You can read more by Brooke on this health blog just look under the nutrition category. I especially like her post on intuitive eating and eat five a day. Also check out her site at Nutrition Authority.

What do you think? - Leave a comment!

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Healthy Fruits – Healthy Vegetables:Brooke Douglas RD Tells All