Fad Diets, Fiber, and Food Order: How to Counsel Patients
This transcript has been edited for clarity. Matthew F. Watto, MD: Welcome back to The Curbsiders. I’m Dr Matthew Frank Watto, here with my great friend and America’s primary care physician — probably the...
This transcript has been edited for clarity. Matthew F. Watto, MD: Welcome back to The Curbsiders .
I’m Dr Matthew Frank Watto, here with my great friend and America’s primary care physician — probably the primary care physician — and nutrition enthusiast, Dr Paul Nelson Williams. Paul N. Williams, MD: I do think nutrition is good!
Watto: What kind of diet are you following these days? Or are there any diets you would like to talk about? Williams: I’d rather answer the latter question than the former.
I eat a plant-based diet, but I am the least healthy vegetarian ever, as we talk about in the episode. I eat a plant-based diet without much in the way of vegetables. But this isn’t about me, Matt.
Watto: Well, you’re an innovator, Paul. Williams: I’ll innovate my way into a heart attack by 55. But we’re talking today about our episode with Dr Joan Blake, who spoke with us about the various nutrition topics that are hot right now and what the potential relative benefits and downsides are to all the diets you might be hearing about on social media or even from your own patients.
One of the big diets that we talked about and that we keep hearing about is this ketogenic diet. The ketogenic diet is very high in fats and very low in carbohydrates. It was initially developed for refractory epilepsy and is actually fairly effective for that, but it has now been repurposed for weight loss.
It’s an appealing diet because you do get really quick initial weight loss and even some glycemic and blood pressure control, initially. But over time, the concerns are that there might be some long-term consequences. I know, Matt, you’ve been hot on the topic of these lean mass hyper-responders for years now, where you see cholesterols in the 400s and 500s and low-density lipoprotein (LDL) cholesterols in the 200s and 300s.
I think we all worry about the long-term effects of this diet. I just don’t think the body is designed to eat in quite this way, even though the initial results are probably very satisfying. But the long-term outcomes probably can’t be good from a cardiovascular standpoint.
I think that’s one of our major concerns with it. Watto: And it’s just so hard to follow in the long term. Between that, the lack of long-term cardiovascular safety data, and frankly all the other available information we have that says when you’re eating a lot of animal fat over time the health outcomes look bad, I try not to recommend it for people.
But I think when some patients say they’re going low-carb, what they really mean is they’re just cutting out some of the refined or ultraprocessed carbs, which most healthy diets call for. Speaking of healthy diets, both the Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets are low in processed foods.
I think a lot of people think the Mediterranean diet is just red wine and chocolate. That’s not actually it. It’s a plant-forward diet.
You’re eating lean meats and fish. It also includes olive oil, which is a monounsaturated fat. So that one is good, and it still allows you to eat a wide variety of foods.
The DASH diet is another diet that’s healthy. It was even included in a previous hypertension guideline. It’s high in plants, vegetables, and fruits, and low in salt, which helps with high blood pressure.
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I think that’s one of the levers that all these longevity people are just ignoring — the fact that high blood pressure is very poorly managed overall, and it’s one of those things that’s just so important to manage in the long term over the decades. So, Paul, what about the paleo diet?
How do we like that one? Williams: Well listen, I’m not here to judge, Matt. However, the paleo diet — inasmuch as I understand it — is kind of a next-door neighbor to the keto diet in that it is very meat forward.
It excludes grains, dairy, and processed foods. I guess the idea is to eat like the cavemen did because they were notoriously healthy, despite having a lifespan of about 30 years. All jokes aside, I can imagine that there probably is initial weight loss with it, but based on its exclusions, it does really increase the risk for micronutrient deficiencies.
It is possible to achieve scurvy with this diet, beyond some of the more common micronutrient deficiencies. In any diet where you’re asked to completely eliminate a food group, you run the risk for micronutrient deficiency. Based on the distribution of fats to carbs and other macros with this diet, it just does seem less healthy compared with other options that we may have to help with both weight loss and better cardiometabolic outcomes.
Watto: My approach to diet is an empathic one. I will work with patients, help them investigate what diet is right for them, and try to use objective data to achieve that. Do they like how they look?
Do they like how they feel? How’s their blood pressure? What do their blood markers look like?
If everything looks good, it’s hard to argue with a specific diet. And if there is a gap in a diet, you can try to proactively monitor for that nutrient deficiency. If you’re encountering something like a vitamin B 12 deficiency, that’s a case where you can recommend a vitamin or supplement.
Speaking of gaps in a diet, Paul: fiber. How much did Dr Blake tell us Americans get? 10-15 grams of fiber a day?
Williams: An absurdly low amount, yeah. Watto: In general, I think an easy number to remember is 30 grams of fiber. That is what most men and women should be getting per day.
Maybe a little less for women, a little more for men. But most people are not doing that. Online, there’s been this trend of “fibermaxxing,” where people are just going from 0 to 60 in 2 seconds on fiber.
That is not recommended because your bacteria in your gut love fiber. In the long term, it’s a good strategy to increase your intake, but you want to do it slowly. If you’re at 15 grams a day now, maybe go to 20 grams a day and see how you feel.
Then you can go up to 25 or 30 grams. I would recommend a whole-food first approach, not just adding 30 grams of a fiber supplement to what you’re already eating. Williams: Agreed.
I’ll admit, I have grown to love psyllium gummies. But on the other hand, if you can get it through natural foods, that is probably a much healthier approach. Watto: Fiber, especially soluble fiber, can help lower your risk for cardiovascular disease, all-cause mortality, and colorectal cancer and it can help lower blood pressure and cholesterol.
It is kind of a “super macro” that we should be paying attention to. And I think it’s a marker of a quality diet, because if you’re getting a lot of fiber without supplementation, that means you’re eating a good amount of plants and whole foods. Okay, Paul, our last topic that I want to get to quickly: food order.
Does it matter? What do you think? Williams: I’ve never done anything quickly, Matt.
But yeah, it does matter. The food order we’re talking about is different than what you’d get at your traditional Italian restaurant. The recommended order in which you eat your food is salad or vegetables first, then protein, and finish off with carbs.
So unlike what happens at your Italian restaurant, eating bread first is actually probably not the best way to do it in terms of a healthful diet. What we’re hoping to achieve with this food order is feelings of satiety and glucose control. If you eat vegetables first, you slow down gastric emptying, you fill up a little bit faster, and you don’t have these glucose spikes that can happen if you’re just loading up with carbs at the start of the meal.
Being intentional about the order of your food can actually impact your health in positive ways. Watto: Researchers have conducted crossover trials where people are given the same meals in a different food order, and the data show that participants eat less and the blood sugar excursion is reduced .
Nowadays a lot of people have continuous glucose monitors, and they can test this for themselves. At one meal, eat your pasta and bread first. Then next time, eat your salad and meatballs first, and see what happens.
You probably will notice a difference in your blood sugar. Click here if you’d like to hear the full conversation with Dr Blake.
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