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When a Pharmacist Talks With a Registered Dietitian/Nutritionist….

Dr. Jessica Nouhavandi, PharmD, co-founder and co-CEO of Culver City-based Honeybee Health, asked me recently what it’s like to think like a registered dietitian/nutritionist, and a little about my approach to nutrition, food, and eating.  

When did you first start working as a registered dietician (RD)? 

I have been an RD since 1980, so I’m now 40 years in! I was in graduate school back then, working on my doctorate and working part-time as a “relief” dietitian, so I’d fill in on weekends and when they needed someone during the week. It was great because, as a relief, I’d be experiencing all the different hospital units: oncology, cardiac ICU, pediatrics, the works.  

What inspired you to become an RD? 

Nutrition science was my undergraduate degree. I always enjoyed learning how the body worked, and the more I learned about how truly complex it is, the more fascinated I became.  Plus, in a nutrition curriculum, you also learn about food science, not just nutrition. Food science focuses on food before you eat it. Nutrition is what happens once you put it into your mouth.  

How would you say your approach differs from other RDs? 

My approach has definitely evolved over the years, because I keep learning, but also because nutrition is such an evolving science. I came up in a health care setting where the patient was the focus, not the statistics. My kids and families aren’t often “typical,” or they wouldn’t be in our clinic. I always felt I had to dig a little deeper with my patients and their family lives, to see what might be contributing to the child’s nutrition issues. 

There is the “cut-and-dry” approach that focuses mostly on educating people about what to eat and what a balanced diet is. However, just focusing on education doesn’t cut it any longer. It’s about motivating people to make changes. The combination of education WITH motivation can have much more of an impact than education alone.

You have a strong background in pediatrics, including working with children with special needs. Could you please elaborate on your “meet them where they live” approach to working with these children and their caregivers on nutritional issues?

When it comes to changing diets and eating behaviors, you have to remember you’re treating the child AND the caregiver. Caregivers need to know they don’t have to make huge food and eating changes all at once. I also tell them how long they should expect things to take. For a child with autism who eats 5 foods, parents need to know that he may never eat the same way as everyone else, but if he can accept at least two or three foods in each group, that’s enough.  Even that may take a year, and the only thing they need to really do is be patient and be consistent. It’s about baby steps towards improving, not big leaps to perfection. It’s about helping meet the child’s nutrient needs and also helping the caregiver feel he/she is doing their best.

What other chronic illnesses can benefit from particular diets? Can you please elaborate on one example? 

Many kids with ADHD are on medication to help them focus at school and do their best academically. When medication is prescribed, it’s often quite helpful, but there are side effects, the most common being a poor appetite. For these kids, it’s so important to get a solid breakfast into them every day. It might be the only thing they eat until dinner, so it must do double duty if possible, with calories, protein, and micronutrients. Most importantly, I stress that, once it becomes routine, it’s much easier—it’s a learning process. 

You talk about myth-busting when it comes to nutrition. The spread of misinformation has been a big issue with COVID-19 as well. What changes would you like to see to the way health information is shared online? 

One very popular online thing is “immune boosters.” Foods and supplements may “support” the immune system, but only a vaccine will actually boost immunity. That’s what it’s designed to do.  All nutrients “support” immunity, but support is such a vague term that it’s almost meaningless.

There is so much “junk science” online that credible sources get diluted or even lost. Please, follow your doctor’s or medical professional’s advice. It’s easy to get sucked in by celebrities, sports players, or others with high profiles, who talk about what they do, but it’s a huge risk.  Hydroxychloroquine is a perfect example. People are desperate for a COVID-19 cure and this just won’t do it. And anything described as a “miracle” food or supplement should be passed by.  Period.  

Can you please “cut to the chase” and give us your top 5 pieces of advice for anyone struggling to live a healthier lifestyle during these tumultuous times?

Comfort food is perfectly understandable for the short term, but we’re in this for the long haul and we need to get back on track.  Here are some great ways to get started:

  • Protein matters! It comes in plant and animal forms, and unless you’re a vegan, get it from both animal and plant sources. Every meal, every day. 
  • MOVE! It’s absolutely safe to go outside and walk or be otherwise physically active. In fact, you should if you can as long as you wear a mask and keep your distance from others. If the benefits of physical activity were derived from a drug, it would be the most demanded drug ever. It’s not in pharmacies though, it’s in your shoes. Use them.
  • Best diet? Maybe it’s a screen diet. Cut it off at least an hour before bedtime and give yourself permission to do nothing. The world will spin without you and still be there in the morning. You’ll have missed nothing and improved your chance for better sleep.
  • Sleep is medicine, in my book, so for most people, no eating at least 2 hours before bedtime. You’ll have a better quality, deeper sleep when your digestive system isn’t working so hard breaking down food.  
  • Yes, fruit and vegetables are critically important, and there’s no substitute for them nutritionally. Frozen and canned are fine (canned beans should be in every pantry) and they last, but include fresh when you can, too. Summer fruit is unbeatable. Aim for at least 2 cups a day, total, but the more the better.

Anything else you’d like to add?

One thing people ask me about is if I’m a vegetarian or vegan. I’m neither. I eat everything and I don’t like wasting food. That said, people think you have to be strict about being vegan or vegetarian but you don’t. That’s a self-imposed thing, but being a “flexitarian” is perfectly fine.  Or just being an omnivore who sometimes eats vegan or vegetarian meals. It doesn’t have to be either/or. And I’m just glad dark chocolate fits all the above eating styles.

Dr. Jessica Nouhavandi, PharmD is the co-founder and co-CEO of Culver City-based Honeybee Health. Dr. Nouhavandi combines ethics, patient care and passion to create the ultimate patient experience. She earned her bachelor’s degree in bioethics and became a Doctor in Pharmacy from Western University of Health Sciences in 2011. Dr. Nouhavandi left her traditional retail pharmacy to start her own accredited online pharmacy, Honeybee Health, once she realized she could dramatically reduce medication costs for patients by cutting out industry middlemen such as insurance companies and pharmacy benefit managers. Honeybee Health now provides direct access to affordable, high-quality prescription medications to patients—without the need for insurance or coupons. You can read more about her and her company at www.honeybeehealth.com.

7 Nutrition Myths These Dietitians Are Busting

When people learn I’m a registered dietitian/nutritionist (RDN), they almost immediately start venting their frustrations about food issues. “Every day it’s another thing you can’t do or eat.  One day a food is good for you, the next day it’s bad for you.”  Since confused consumers make no changes, I always try to bust their myths and misinformation.

While consumers may be confused about food fads, RDNs are not.  They’re fed up with them.  They’re trained to spot hype, fads, and myths around a blind corner and it annoys them to no end. I asked some RDNs who have particularly good communications skills to tell me which popular nutrition fads really grind at them.  Here’s what they said:

Carbo-phobia!

Mindy Hermann, MBA, RDN, said straight up, “I wish people would stop thinking carbs are the devil.”  She’s had it with a near universal demonizing of these essential macros. 

Sure, most people eat too much added sugar, but she’s right that all carbs seem to be lumped together, whether it’s whole wheat bread or soda.  “Today it’s keto, yesterday it was Paleo, so many others before,” she said.  “I’m tired of all the iterations of high-protein, restricted carbs.”

Plant “Milk” Deserves No Halo

Nutritionally, plant-based diary alternatives just can’t hold a candle to the nutrition in real milk, according to Salge Blake, EdD, RDN, FADN, professor of nutrition at Boston University and the host of the hit health and wellness podcast, SpotOn! In addition to being a dynamite protein source, “Cow’s milk is chock full of vitamin D, calcium, and potassium, three nutrients that many Americans are falling short of in their diets.”  Dairy alternatives only have these nutrients if they’re added, and they often aren’t.  Unfortunately, says Salge Blake, “plant-based milks may also contain added sugars, adding calories and no additional nutrition to your glass.” 

Salge Blake also sees the affordability of real milk as a win-win.  “When it comes to your wallet, plant-based milks can be at least twice the price of cow’s milk.  For the nutrients and the money per gulp, you can’t beat low fat or skim dairy milk.”  If you’re allergic or vegan, soy is the closest alternative.  Be prepared to pay though.

Stop Kicking The Canned Foods!

Shari Steinbach, MS, RDN, spent years working directly with consumers as a retail dietitian in supermarkets, is fed up with canned foods getting dissed when they offer so many advantages:

  • Sustainability: “90% of cans are recycled and they can be recycled indefinitely.” Linings are safe, with 90% containing none of the controversial BPA.
  • Convenience: They have a long shelf life and that helps prevent wasted food and wasted food dollars.
  • Nutrition: “You can cut 40% of the sodium in canned beans and veggies just by rinsing and draining them,” Steinbach says. Since 9 in 10 people don’t eat enough vegetables, “Canned beans and tomatoes count,” towards scoring enough of this critical food group, and are a, “convenient, nutritious way to balance your diet.”

Want her recipe for quick, veggie-loaded, chili using canned ingredients?  “Here’s a favorite simple chili recipe that I made this week”:

  1. Brown 1 pound of lean ground beef;
  2. Drain and add 2 cans of chili-seasoned beans and 2 cans of undrained diced tomatoes.
  3. Season to taste with cumin or chili powder. “Serve with a green salad and whole grain crackers. Enjoy!”

Don’t Panic If It’s Not Organic

That’s advice from Leslie Bonci, MS, RDN Owner of Active Eating Advice, who is fed up with food elitism.  I see her point.  I spent decades working with low-income families who will never be able to afford organic food.  They shouldn’t worry.  They can still put delicious, nutritious food on the table. 

“What do we even mean when we say clean?” Bonci says, because “clean eating” has no definition.  That leaves every definition up to whomever is spewing it and that’s a perfect recipe for consumer confusion, fear, and doubt.  Instead, Bonci favors creating “an enabled table where foods of all price points have a place.”

White Foods Are Bright Foods!

Liz Ward, MS, RDN, Author of Better is the New Perfect is bugged by all the attention given to putting “only the most colorful fruits and vegetables on your plate.”  Forget colors, she says.  “Instead of worrying about what types of produce are “best,” simply include the types you like, no matter how pale,” Ward advises.  Besides, white, brown, and tan produce, such as mushrooms, cauliflower, potatoes, and bananas, are just as worthy as their brighter counterparts,” are loaded with nutrition.

“And while we’re at it, can we stop shaming starchy vegetables, such as corn, potatoes and peas? They are packed with nutrition and starch is a form of energy.”  It’s true, these foods are hugely important to so many food cultures and have sustained people for thousands of years.  Empty calories they most certainly are not. 

One Diet DOESN’T For Everyone?  Seriously?

“The nutrition belief that I hope goes to its final resting place in 2020 is that a single diet plan, or way of eating, is right for everyone,” declares food anthropologist and nutrition communications consultant Robyn Flipse, MS, MA, RDN.  Looking ahead, Flipse feels personalized nutrition, not fad dieting, holds the most promise in the years ahead.  

Leah McGrath, MS, RDN, corporate dietitian for Ingles Supermarkets, couldn’t agree more.  “It seems like every year we have a new ‘hot’ diet,” she says.  “However, just like our fingerprints,  we should want to and  deserve to individualize our eating plans.” 

Flipse continued, “The one thing we’ve learned from the decades of fad diet trends we’ve endured is that none of them have delivered on what they promised because they have all overlooked our metabolic differences.”  They also tend to be extreme, which is probably why people burn out on them. 

Flipse admits that we still lack the scientific tools to allow us to tailor nutrition to each person’s needs.  Unfortunately, when consumer demand gets ahead of the science, charlatans see an opportunity to market all kinds of pseudo-scientific gimmicks.

Plant-Based Doesn’t Mean Plants-ONLY

This one is mine.  I’ve written about it before and everyone in 2019 seemed to be jumping on this bandwagon.  Thing is, there’s no universal definition of “plant-based!” 

What it DOESN’T mean is vegan.  Eating a plant-based diet doesn’t automatically guarantee your diet is balanced or healthful, either.  Living on soda and chips is a fully “plant-based”, vegan diet.  And it ain’t balanced.  A huge salad with 10 different veggies, some nuts, and crumbled feta or parmesan cheese or a couple of ounces of beef or salmon is not vegan – but it IS plant-based.  Flipse put it best, “I tell people if 50% or more of what they eat is plants, then they have a ‘plant-based’ diet.”

Organic: The Answer To Cancer Prevention?

If anyone tells you they have the definitive answer, they’re misleading you.

Growing foods conventionally usually – but not always – involves the use of some pesticides when there’s a need to control harmful bugs, plant viruses, fungi, etc. that damage either the whole plant or the edible portion of it.  These compounds are expensive, so farmers tend not to use them unless absolutely necessary, and then in the least amount possible for the needed benefit. 

Organic crops are thought to be grown without pesticides, but there are hundreds of pesticides approved for use on organic crops.  Most are organic ones, but in certain circumstances, as with a particularly difficult to control pest, USDA has rules in place to allow limited use of a few dozen synthetic pesticides is allowed, and the food produced can still be labeled “organic”. 

But Is Organic Food Healthier?

Twice the price,
but twice the benefit?

“Healthier” has no formal definition, but let’s say it means you have a lower risk of developing cancer, since that’s a highly desirable outcome by everyone.  Would eating organic food make you less likely to develop cancer?

This recent study wanted to find out.  It was a prospective study – meaning that it went on for years before results were determined.  As part of a large study involving 68,946 French participants, all volunteers “self-reported” the frequency of consumption of organic foods.  Responses about consumption were multiple choice and ranged from 1 (“most of the time”) to 7 (“never”), with an option for “I don’t know”.  Demographic information was also gathered, including about household income.  This was interesting, because the top household income bracket was US $3,100, hardly “upper income” even in 2009, when the study launched.

The Good News: Organic Eaters Had Less Cancer

More frequently eating organic foods was “associated” with lower your cancer risk.   Key word, “associated”.  It’s the bane of my existence because it is often interpreted as “cause-and-effect,” a very wrong assumption. 

Why?  This study was “observational”.  These types of studies aren’t designed to evaluate cause-and-effect.  They can only generate a hypothesis that clinical studies could then evaluate for more direct conclusions.  This study is incapable of making such conclusions.

Photo: www.inkmedia.eu

The not-so-good news: the benefit of eating organic was minimal, at best.  The risk of getting cancer went down only 0.6% — that’s 6/10ths of one percent, and only for the most frequent eaters of organic food.  Even then, the benefit may be less than reported. Read on… 

Limitations of the Study, A.K.A. the “Fine Print”

The authors responsibly called out a fairly lengthy list of limitations of this study, and why the results need to be seen with caution:

  1. The participants were volunteers who were “likely particularly health conscious individuals”, therefore limiting the application of the results to the general public.
  2. The questionnaire used asked about frequency of consumption but not quantity.    Also, possible misclassification of organic foods, “cannot be excluded.”
  3. Follow-up time was short – an average of only about 4½ years.  Cancer can take many years to develop and it’s unclear what the diets of these participants were prior to participation.
  4. Possible “residual confounding resulting from unmeasured factors or inaccuracy in the assessment of some covariates cannot be totally excluded.”  This means there is a lot they didn’t measure or that they couldn’t measure accurately. 
  5. They could not exclude the non-detection of some cancers. 

Cut-To-The-Chase-Nutrition Takeaways

  • Will eating organic food help prevent cancer? Not based on this study.
  • Organic food is expensive, and thus out of reach of many, even if they can find it.
  • Organic doesn’t mean pesticide-free. 
  • Focus on this: A mountain of research showing the health benefits (including cancer risk reduction) of eating plenty of fruits, vegetables, beans and whole grains, was done using conventional foods! 

Wanna Eat Healthy? Get Your Nitrates!

Think nitrates in your food and eating healthy don’t go together? What’s this gorgeous spinach salad have to do with nitrates? Read on, but let’s start at the beginning.

You’re not going vegan but you want to eat better and you’ll start with baby steps, like I talked about in my previous post.  OK, and here are some popular intentions:

  • Try and eat more leafy green stuff.
  • Definitely cut the hot dogs, ham, bacon, the deli stuff, and “processed” meat, even if it’s lean.  Everyone knows that stuff is “bad” because it has nitrates, right?

Swapping out hot dogs and ham for spinach and beets (the new “in” veggie for 2019, as I mentioned here) would at least cut back on the nitrates, right?  Wrong. 

Where the Real Nitrates Are

Indeed, a bunch of healthy, nutrient-rich veggies like beets, spinach, celery, even iceberg lettuce and broccoli, have more nitrates than that hot dog you snuck in for lunch last week.  Check out this chart from a 2012 report of the nitrate content in foods.  Amounts are in “parts per million” (ppm):

This image has an empty alt attribute; its file name is mushrooms-417101_1280-2.jpg
More nitrates than a hot dog — & it’s healthy food!
  • Beets: 2797 ppm
  • Spinach: 2333 ppm
  • Celery: 1496
  • Mushrooms: 590 ppm
  • Broccoli: 394 ppm
  • Strawberries: 173 ppm
  • Cured sausage (hot dog), cooked: 32 ppm

Are Nitrates in Fruits and Veggies a Problem?

No, and not in other foods either, according to Melissa Joy Dobbins MS, RDN, CDE and known as The Guilt-Free® RD.   “This is a great example of how misinformation can create a “fear factor” when it comes to food. I think most people who are concerned about nitrates/nitrites would be surprised to learn that the majority of these nutrients in our diet are not from cured meats, but from plant foods, namely a variety of vegetables.”

Dobbins’ statement is evidence-based and reflects the conclusion of this 2015 meta-analysis of many studies on dietary nitrates, nitrites, and nitrosamines, which found nitrates associated with a decreased risk of gastric cancer.  The slight increased risk associated with increased nitrite intake was considered weak, and tended to come from weak or poorly-designed studies, which muddied their findings.  Even then, spinach still has more nitrites than cured sausage.

Nitrates & Their Cousins: Nitrites and Nitrosamines

Here are the basics you need to know about these:

  • Nitrates are naturally present in lots of different foods. 
  • Nitrites are also naturally present in foods but most are formed when bacteria in your saliva convert nitrates to nitrites. 
  • Nitrosamines are not naturally present in food but can form in food through several pathways.  Cooking at a high temperature, such as frying cured meat, or when an acid (like stomach acid) is present.  If there’s any concern, it’s with the formation of nitrosamines.  Even then, conversion from nitrite to nitrosamine can be inhibited or stopped by the addition of compounds like ascorbic acid, or “vitamin C”.  Seriously – check the ingredient label of many cured foods like hot dogs and you’ll find “ascorbic acid” is often present. 

“Nitrate-Free” Cured Meat?

There are cured meats labeled “no added nitrates.”  What they add instead is celery powder.  As you’ll see from the table above, celery is loaded with natural nitrate.  There’s no evidence that there’s any difference between the nitrate in celery powder and the nitrate added to “nitrated” cured meat. 

Celery: Fine wherever you find it

Nitrates: The Boil-Down

It’s ironic to know that someone eating a spinach salad is probably getting 10 times more nitrates than the person eating the ham sandwich, but Dobbins noted, “Does that mean we should be afraid of eating vegetables? No. It means we should look at the overall nutrients a food provides and try to consume more nutrient-rich foods and fewer empty-calorie foods.”

It may be that the folks who eat lots of cured meat may also have a less-healthy lifestyle overall.  They may be less likely to engage in regular physical activity, and less likely to eat a lot of veggies and fruits, and may drink more soda or eat more junk snacks.

Cut-To-The-Chase-Advice

Eat all the spinach, beets, mushrooms, celery and broccoli you can fit into your diet.  As for cured meat, I like Dobbins’ approach. Nitrates may not be an issue but balance still is, so don’t go crazy at a cold-cut buffet.  If you like cured meats, make them leaner cuts, like ham, instead of sausage.  And have that ham with lots of veggies – even high-nitrate ones like spinach and broccoli.  A meal loaded with nitrates can, and should, still be healthy.