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Nutrition - Q&A

If you didn’t have the chance to participate in the webinar or want to review it here:
https://www.spondylitis.ca/the-latest/videos/forums-webinar-videos/2020-nutrition-chronic-inflammatory-diseases-webinar/

Topics:

Nightshades

What about nightshades?

Nightshades are a family with 2,700 species. Just like any family there are a few cousins that you want to keep your distance from (tobacco is a nightshade), but that doesn’t mean we need to abolish the whole clan.
Some people report a sensitivity to nightshades, particularly the alkaloid component of nightshades, but there is no scientific evidence that we should avoid nightshades entirely. It could be something to experiment with, but not as the first choice.
If you have other habits that you could improve on, habits that we know make a difference, that would be a better place to start. Are you reasonably active? Eating a well-balanced diet with limited amounts of highly processed food? Managing your stress? Getting enough sleep?
Most of us have at least one area that we could improve, and we will get more benefit there than adjusting a small detail like nightshades.

What are nightshades?

Nightshades are the common name for a family of plants, the scientific/Latin name is Solanaceae. This family includes eggplant, peppers, tomatoes and potatoes (but not sweet potatoes), spices made from peppers, such as cayenne and paprika as well as other shrubs, and flowers. There are 2,700 species in this family and some, like tobacco, can be poisonous to humans if consumed in high amounts.
https://www.unlockfood.ca/en/Articles/Arthritis/Arthritis-Five-Common-Myths-are-Busted.aspx
This article goes into the fascinating story of how Europeans came to include potatoes and tomatoes into their diets, and how they were initially treated with fear:

https://botanistinthekitchen.blog/2013/08/21/making-ratatouille-like-a-botanist/

Nutrient Absorption

For those of us with enteropathic arthritis, are there strategies to increase and/or improve absorption of nutrients?

The biggest strategy would be working with your health care team to ensure your Crohn’s or colitis is well managed. If your bowels are in good health, you will be able to absorb nutrients very well. If not, then your body may struggle with absorbing nutrients, simply because your bowels are inflamed. If you experience flare-ups, try keeping a food journal to figure out which foods trigger the flare up so you can adjust your diet to suit you.

Inflammation

Is there research surrounding foods contributing to or reducing inflammatory arthritis?

Overall diet patterns contribute to reducing inflammation. There is no one specific food, drink or supplement that will counteract chronic inflammation but we do know that eating wholesome foods and beverages rather than processed ones will add up to decreased inflammation over time, so consistency is important.
This means eating minimally processed whole grains, like brown rice, barley, oats, couscous, quinoa and whole grain breads and cereals; including vegetables of various colours at most meals and snacks; eating a variety of fruits each day; eating small amounts of unsalted nuts and seeds; eating legumes (dried bean, peas, and lentils) at least a couple of times per week; and drinking plenty of fluids each day.
This is why it is so important to make small changes that fit within your lifestyle rather than trying to do a complete overhaul of habits. You’re more likely to stick with the small changes as they become habits.
It is early days for diet and arthritis. We’ll be digging in more to the specifics of this on the website as time goes on. More information can be found in the articles written on an anti-inflammatory diet, and the Mediterranean diet.

https://www.spondylitis.ca/education/healthy-living-2020/nutrition/

What makes a food pro or anti inflammatory?

Our answers will evolve over time as we get more and better information. One way to think about food and inflammation is to talk about inflammatory mediators: the pro- or anti- inflammatory messengers. Depending on what you eat, your body is more likely to make one or the other.

We need pro-inflammatory messengers to help us fight infections and heal cuts. It’s the chronic inflammation that is damaging over time. Some foods, such as highly refined carbohydrates like sugary cereal, white bread and pastries, sugary drinks like sodas and fruit drinks, fried foods, and red meats increase the inflammatory messengers. Consistently eating these types of foods may accelerate the inflammatory process.|

Some foods, often the ones that tend to keep you healthy in other ways, can help decrease inflammatory messengers. These include foods like green leafy vegetables, nuts like walnuts and almonds, fatty fish like salmon and tuna, fruits like strawberries and blueberries and olive oil.
In particular, omega-3 fats can be beneficial as they help make anti-inflammatory messengers. These are the ones you get from salmon, walnuts, flaxseed, canola oil, tofu and sunflower seeds.

We also need some omega-6 fat, it is essential. More importantly, we need to balance the omega-6 and omega-3. Most of us don’t get enough omega-3 to have a balance, which is why the public health message is to eat more omega-3.

This is why we encourage a well-balanced diet, the Mediterranean diet is one example, though there are many other ways to eat in a balanced way. Hence why you always hear us dietitians talking about balance, moderation, and variety.

Oils

What other oils should we cook with besides olive oil?

Canola oil is another great option.

Peanut oil and almond oil are pretty good, but they don’t have any omega 3s. Hemp seed oil is pretty good, except it does have fairly high omega-6 and we need more omega-3 and 6. Same with sunflower, wheat germ, grapeseed, and pumpkin seed oils. Sesame oil is moderate in omega-6 but lower in omega-3.

Short answer? Canola oil is the best alternative to olive oil.

What are your thoughts about coconut oil vs olive oil? Seems to be all the rage.

Coconut oil is low in omega-6’s and has no omega-3. This is because it is almost all saturated fat. So, it’s fine to have a bit (we are supposed to limit saturated fat, not avoid it completely) but use it only for flavour, not as your primary cooking oil.

Supplements


Are dietary supplements recommended?

You only need supplements if you aren’t eating enough of a particular nutrient. There are a couple of general recommendations though:
Women of child-bearing potential should have 400mcg (0.4mg) of folate a day.

Pregnant women should take a prenatal multivitamin with 16-20mg of iron and 400 mcg of folate in it each day.

Breastfed babies should get 400IU of vitamin D each day, 800IU October – April if living north of the 55th parallel (Edmonton).

It’s hard for all of us to get enough vitamin D since we make it when our skin is exposed to sunlight, but only the summer.

Even if you went outside stark naked in January, you’re not going to make any vitamin D. The further north you get, the stronger the vitamin D recommendation will be.

In addition, as we age, our body becomes less effective at making vitamin D. So, adults 50 and over should take 400IU of vitamin D day per day.

Otherwise, your health care team, including a dietitian, will be the best ones to ask.

Nutrient Specific

What foods would you recommend for someone with low B12 and limited red meat?

Vitamin B12 is present in animal foods. In fact, tuna and salmon have as much or more B12 than red meat. Milk, yogurt and cottage cheese all have some B12 in them, too. Check out unlockfood.ca for more sources: https://www.unlockfood.ca/en/Articles/Vitamins-and-Minerals/What-You-Need-to-Know-About-Vitamin-B12.aspx

The challenge comes for vegetarians, especially vegans. You can get B12 from nutritional yeast, but it varies depending on the source, and how long it has been on the shelf. For some people, the best bet is to take a supplement.

About bioavailability, you’re recommending milk over broccoli for the calcium?

Yes.  Now, that doesn’t mean that you need milk to get your calcium from food. Simply that milk, cheese, and yogurt are the easiest way to get enough calcium. Unlockfood.ca has a great resource outlining the calcium content of common food.
https://www.unlockfood.ca/en/Articles/Bone-Health/Food-Sources-of-Calcium.aspx

Do you recommend micronutrient testing?  Understanding that you should get multiple tests to confirm results before making nutrition or supplement decisions?

As a general rule, no. However, if you have signs and symptoms of a deficiency, have health conditions that increase your risk, or your diet is missing sources of particular nutrients, then testing may be warranted. Talk to your health care team, including a dietitian, if you are concerned.

Fads

Do you have any views about intermittent fasting?

As dietitians, we are far more concerned about what might happen in 5, 10, or 20 years than what you do today. Through temperament or training, we tend to take a long view of things.

There are 3 main types of intermittent fasting (IF) that have been studied the most: alternate date fasting, 5:2 (fasting 2 days per week) and daily time-restricted feeding (eating between 7am and 6pm, or 6am to 3pm, for example).

For all the anecdotes we have about people feeling great, we also have stories about long term consequences. Dietitians see many people who have high blood sugar or high LDL cholesterol who have skipped breakfast for years or decades. This makes it difficult to recommend intermittent fasting. The practicality of IF is also something to take into consideration, as you need to plan your days and events around eating or not eating.

A final word of warning, if you do decide to try IF, you’ll need to carefully design your menu. Because you have fewer meals, you may run the risk of having less variety in your diet, which increases the risk of having nutrient deficiencies.

What about the anti inflammatory paleo diet for spondyloarthritis and celiac?

As a general rule, the more restrictive a diet is, the less we recommend it. Recently, research is starting to show higher risk of heart disease in those who follow a paleo diet.

Because the paleo diet cuts out grain products (which are a source of resistant starch and fermentable carbohydrates, both of which contribute to gut microflora, meaning they feed the good bacteria in our guts), there can be big changes in the gut microflora if someone eats this way for a long time. Over time, this can have a detrimental impact on health because the amount of beneficial bacteria in the gut that come from eating whole grain products decreases.

It can also be difficult to stick to a paleo diet long term, so you need to consider what is practical for you.

For celiac disease, the important thing is to avoid gluten, not all grains. There are various other grains and alternatives that can be consumed on a gluten-free diet that offer nutrients for a balanced diet, like quinoa, buckwheat (despite the confusing name), corn, potato, rice, sorghum and other flours from chickpeas, lentils, peas, and almonds. You can find more specifics from Canadian Celiac Association at https://www.celiac.ca/living-gluten-free/diet-nutrition/.

You can also read more about the Paleo diet at: https://www.unlockfood.ca/en/Articles/Weight-Loss/Will-the-Paleo-Diet-Help-Me-Lose-Weight.aspx

Starch/Carbs

Thoughts on low/no starch diet?

Carbohydrates are sugars, starches, and fibre. There are very few foods that are high in fibre but low in starch, and plenty of foods that are high in sugar and low in starch. So, I would worry about not getting enough fibre – which we know is key to good bowel health and maintaining a healthy diversity in our gut microbiome.

We know that natural sugar found in fruit does not have detrimental effects on health. If you already have diabetes, and are struggling to maintain your blood sugar, you won’t want to eat large amounts of fruit at one sitting. But, we know that diets high in fruit (not juice, just whole fruit) are protective against developing diabetes.

When it comes to carbohydrates, we know the more complex ones (starch and fibre) are better for us than the simple ones (white sugar, white flour). So eating whole fruits, whole grains and reducing our intake of juices and white grain products will have an overall benefit to our health. Vegetables and fruit are also high in antioxidants, vitamins and minerals so they have lots to offer.

What are your thoughts on eliminating gluten as an inflammatory food?

If you have a gluten-related disorder like celiac disease, yes, you need to avoid gluten.

For people without celiac disease, wheat allergy or other gluten-related disorders, gluten is safe to eat.

Eliminating gluten shouldn’t be your first step – consider your overall activity, sleep, and diet first. If you do need to explore gluten as a trigger for your symptoms, you’ll need to be eating products containing gluten to ensure the testing is accurate.

My rheumatologist instructed me to avoid wheat and other grains……finding a RD to help with this is difficult…..can you advise?

Some rheumatologists and doctors say this. The first thing to know is that if there is any family history of celiac disease, get the blood test to screen BEFORE eliminating wheat. (You may have to pay for the test, it is $60 in Ontario). Testing for celiac disease requires a person to be eating gluten. 

Dietitians have a responsibility to provide medical nutrition therapy that is supported by research. At the very least, there needs to be research to support the possibility of a treatment to be beneficial. This is a good thing. It allows us to provide treatments that we know have a chance at working. And, it helps prevent us from becoming snake oil salespeople.

Right now, there just isn’t research to support avoiding wheat for inflammation control. Try speaking to a dietitian about helping you create habits and a generally healthy lifestyle, and doing a food and symptom journal to identify if there are any particular food or habit that is triggering your symptoms. 

Maybe wheat will be one of those, maybe not. Perhaps like Sam, you’ll find that your primary triggers are stress and lack of sleep. But, keeping an open mind will allow you to find what works for you and will help you find dietitians who are eager to work with you.

For help finding a dietitian, try ‘Find a Dietitian’ on the Dietitians of Canada website as a starting point: https://members.dietitians.ca/DCMember/s/find-dietitian?language=en_US 

Some provinces have a free service to connect to a dietitian: 

What is a whole grain?

Grains have 3 parts – bran, germ, and endosperm. The germ is the part that would germinate into a new plant – the seed. The bran is the fibrous outer layer that protects the seed. And the endosperm is the starchy bit that gives the seed energy as it is growing until it has leaves to generate its own energy. 

A whole grain has all three parts. It could be an intact grain like a wheat berry, barley, or wild rice.  Or it could be ground to be used as an ingredient. This would include whole grain whole wheat among others.

Grain Parts
https://wholegrainscouncil.org/whole-grains-101/whats-whole-grain-refined-grain

Be aware though, there is a loophole with whole wheat. Whole wheat might not technically be a whole grain because food manufacturers are allowed to split the wheat into its three parts – bran, germ, and endosperm (starch) – then recombine it into whole wheat flour. They are also allowed to hold back some of the germ, which they often do. 

This is because the germ contains oils, which go bad first. That is why it is often recommended to store whole wheat in the freezer – so it takes way longer for those oils to go rancid. Now overall, it’s not a massive difference, and you’d get a lot more fibre and nutrients in whole wheat than refined wheat. But, if you can get whole grain whole wheat instead, it is even better.  Look for that wording on the ingredient list,’ whole grain whole wheat flour’.

Resources

Are there any books on nutrition that you recommend?  Getting into macronutrients, micronutrients, understanding peptides, etc?

‘Eat More Plants’ by Desiree Neilsen is a current favourite cookbook and has an excellent explanation of an anti-inflammatory diet in the beginning section of the book. Her website also has lots of great information: https://desireerd.com/

Some other books to check out include:
-The Intuitive Eating Workbook by Evelyn Tribole and Elyse Resch
–Body Kindness by Rebecca Scritchfield
-Anti-Diet by Christy Harrison
-Well Nourished by Andrea Lieberstein
-The Mindful Glow Cookbook by Abbey Sharp
-Nutrition for Dummies

Heart Issues



I am a heart patient. I have AS. But my triglycerides are high and I don’t know how to lower them. I am taking all the medicines to lower triglycerides. My diet consists of greens and white meat mostly. Little fats, I try taking healthy fats. But I am just tired of eating what options I have. Also the place I live we don’t get much variety of vegetables.

There are several strategies to try to lower triglycerides. Some will work better for some people than others, based on your current habits and genetics.

Triglycerides (TG) are the storage form of fat in the body. So after you eat, your TG rise. The more you eat at once, the higher it is likely to rise. This is why we recommend smaller, more frequent meals, rather than skipping meals. Eating roughly every 4-6 hours, based on your hunger and fullness levels, is a good place to start.

Healthy fats, especially omega-3 fats, are important for lowering TG. Try to eat cold-water fatty fish at least twice a week. This would include salmon, trout, and sardines. If you don’t or can’t eat fish, omega-3 supplements are an option, but talk to your medical team first because there are some cases where they are not recommended.

Ground flax and walnuts are a source of a version of omega-3, but not DHA or EPA and those are the fats that are specifically helpful for TG.

Alcohol is another factor with triglycerides. If you have high TG, it is best to limit your alcohol intake. Up to 1 drink a day for women and up to 2 per day for men might be okay, but for some people even that is too much and raises their TG.

Another important note, if you have diabetes, especially if your sugars are running high, that can increase your TG as well. Your body will try to protect itself from high blood sugar by converting some of that sugar into TG. This is why we recommend people with high TG also limit high sugar foods and drinks (pop, juice, candy, etc.).

Frozen and canned vegetables and fruits are also good options. Frozen items are harvested and frozen at their peak ripeness, so are nutrient-packed. Canned items may have extra salt on them, so putting the food into a colander and rinsing with water before eating will help decrease the salt content.

Finally, physical activity is really important for TG control. For some people this is the main driver of their TG level. Both aerobic activity (that raises your heart and breathing rate) and strength training count.

Sugar

Does diet pop count towards the ‘added sugar’ problem you were talking about earlier?

Diet pop does not have sugar, so it avoids some of the problems of added sugar. For example, for people with diabetes, it won’t raise your blood sugar.  And, it can help with the transition off regular pop if someone is trying to cut back. 

However, diet pop can contribute to weight gain as your taste buds get used to sweet tastes and you crave sweet, high calorie foods.  

They can also make you feel hungry, because consuming anything starts the process of digestion, meaning the chemical and neurological processes get going.  This can result in your brain being told you’re hungry, much like the smell of fresh baking can stimulate appetite, even if you just finished eating a meal. The other thing that can happen is insulin levels rise.  Normally, this helps get the sugar from food into our cells for energy, but when there is no sugar there, the cells tell our brains to go find energy, as they falsely think they are ‘hungry’.   

Diet pop is also often highly acidic, which can damage the enamel of your teeth. 

If you’re trying to cut back on pop intake, there are a couple of strategies you can try: if you crave the caffeine component of pop, try drinking plain coffee or tea.  If you crave the carbonation, try any of the sparkling or soda waters on the market these days – flavoured or plain.  And, if you crave flavour, try adding frozen raspberries, cucumber, or mint to plain water

Eating disorder

What advice would you have for someone with a history of ED who has ankylosing spondylitis? For those of us with this kind of history, removing certain foods or food groups can be highly triggering.

110% You are absolutely right! And even for those of us who don’t have a diagnosable eating disorder past, we still have to contend with living in a diet culture that makes intuitive eating weird and difficult. Removing certain foods or food groups for the sole reason that someone told you to will always be triggering, I think.

But if you notice that you feel more energetic when you eat in ways that are more balanced, using minimally processed ingredients, it becomes only natural to eat foods that are helpful more often.

But even that can be triggering to contemplate.

To come at this from a different perspective… Most people would say that eating less candy is a healthy choice. But for someone with a history of an eating disorder, a decision to eat less of any food can cause that voice to return, even if you thought it long buried.

It is one of the many reasons why we don’t advocate avoiding any food or food group entirely. We also try to promote an additive perspective, as in, let’s add veggies or nuts or beans. Rather than talking about what to take away.

We try to balance giving useful information about healthy eating with knowing that, statistically speaking, at least a quarter of the people listening or reading have some level of eating disorder past or present. It is part of why we try to encourage a focus on foods to add (besides the fact that it is just more fun to think that way). And why we love talking about mindful and intuitive eating. But at the same time, it can be useful to classify foods to eat more often and foods to eat less often. It is a challenge and one that we are constantly trying to improve our skills around and we thank you for giving us the opportunity to address this tension directly.

Eating Patterns



Is it better to consume meat during the day rather than night?

It might be more comfortable to do so, but only because meat is more complex for our digestive system and takes longer to break down. Once we eat something, our digestive process starts, so it can be hard to fall asleep when your digestive system is still active. To simplify digestion of the three macronutrients: we break carbohydrates down the easiest while protein and fat need to go through multiple steps to reach their end products. So, eating meat or fat closer to bedtime means we have less time to break them down before the end of the day, and our digestive processes need to keep going.

Mediterranean Diet

If following a Mediterranean diet, how many times per week should chicken be consumed?

There are no hard and fast rules. It is one of the reasons why the Mediterranean diet is so versatile but also what makes it frustrating at times.

If we just look at suppers, there are 7 per week. So let’s break it down:

  • 2 or 3 times we have fish
  • 2 times we have meatless dishes using beans are our protein
  • Once a week is red meat – beef or pork
  • Which leaves 1 or 2 for chicken or turkey

As we said, there are no hard and fast rules, not even the example above. However, examples are useful, so we hope that helps.



Thanks to Samantha Holmgren & Audrey Boyer who have taken the time to answer your questions from our March 31st Nutrition Webinar. We’ve divided the questions by topics below.