Adding Extra Protein to the Diet

Earlier this week, I was interviewed by Heidi Godman of the Harvard Health Letter and the Harvard Health Blog about adding extra protein to the diet in a effort to lose weight.  This comes on the heels of a study published in the Journal of Nutrition Education and Behavior showing that middle-aged women commonly believe adding protein to the diet is a solid weight-loss choice. I would like to add a correction to one misquote - "unprocessed" and "unrefined" carbs should be replaced with "minimally processed."  Grains (aka. carbs or carbohydrates) in their completely unprocessed form are often difficult to digest and laborious to deal with in the kitchen. Opting for minimally processed to improve both of these factors is a good way to go. The full post is below and can also be found at Harvard Health Blog:

Photo credit: lisamasson.photoshelter.com

Extra protein is a decent dietary choice, but don’t overdo it

POSTED MAY 01, 2013, 3:14 PM

Heidi Godman, Executive Editor, Harvard Health Letter

Diet-wise, I was good yesterday. I had a scrambled egg with salsa for breakfast; spinach salad with grilled chicken for lunch; a handful of almonds for a snack; a small piece of salmon, broccoli, and brown rice for dinner; and fruit for dessert.

I say “good” because I like to limit my carbohydrates to one meal a day—dinner, in this case. It makes me feel better than having carbs throughout the day. I’m not following any particular diet, but just trying to eat in what I think is a healthy way. That means having more protein-based meals than carb-based meals. It turns out I’m not alone.

The International Food Information Council Foundation reports that 50% of consumers are interested in including more protein in their diets and 37% believe protein helps with weight loss. A study in the May/June 2013 issue of the Journal of Nutrition Education and Behavior found that 43% of women surveyed are using the practice of eating more protein to prevent weight gain, and this strategy was associated with weight loss.

But just because people are doing something doesn’t make it healthy. I asked Dr. Michelle Hauser, a clinical fellow in medicine at Harvard Medical School and a certified chef and nutrition educator, if it’s a good idea to eat extra protein and cut back on carbs.

“If you’re eating more protein but you have a good mix of fresh fruits, vegetables and whole grains to make up the rest of it, that’s fine,” Dr. Hauser told me. One of the advantages of eating more protein-rich foods is that people who do it also tend to eliminate overly processed carbohydrates, such as white breads and prepackaged foods like cookies and crackers. Such foods are rapidly digested and turned into blood sugar, and tend to be low in healthful nutrients.

But it isn’t necessary to eliminate all carbohydrates and focus only on protein. Such an eating strategy may have a short-term payoff for weight loss, but it may also come with some long-term risks.

Understanding protein

Protein is a critical part of our diet. We need it to build and repair cells, and make healthy muscles, organs, glands, and skin. Everyone needs a minimum amount each day. The Institute of Medicine recommends 0.8 grams of protein per kilogram of body weight. For someone who weighs 150 pounds, that means 54 grams of protein per day. Another guideline is to make sure at least 15% of your daily calories come from protein.

How might more protein and fewer carbs in the diet make a difference for weight loss or weight control? “Protein takes more energy for you to digest than refined carbohydrates, and also gives your body a feeling of satiety,” says Dr. Hauser. Low-carb diets have been shown to help some people lose weight.

But over the long term, too much protein and too few carbohydrates may not be the healthiest plan. This kind of eating pattern has been linked to an increased risk of developing osteoporosis. That’s because digesting protein releases acids into the bloodstream. The body neutralizes these acids with calcium—which can be pulled from bone if necessary. Eating too much protein also makes the kidneys work harder. In healthy people, this usually doesn’t pose a problem. But those with kidney disease or diabetes (which is associated with kidney disease) need to watch their daily protein intake so they don’t overload their kidneys.

Depriving yourself of carbohydrates can also affect the brain and muscles, which need glucose (the fuel that comes from digesting carbs) to function efficiently. The fiber delivered by some carbohydrate-rich foods help bowels move. And remember that healthy sources of carbohydrates, such as fruits, vegetables, and whole grains, come with a host of vitamins, minerals, and other nutrients.

Making wise protein choices

It’s okay to cut back on carbs and eat more protein, but make sure you’re also getting some carbs in your daily diet. “If you take any healthy diet, 40% to 60% of calories should come from minimally processed carbs,” says Dr. Hauser. For someone on a 2,000 calorie-a-day diet, 40% would be 800 calories or 200 grams of carbs. (Note to self: increase servings of carbohydrates.)

But there are good carbs and bad carbs, as well as good proteins and bad proteins. Foods that deliver whole, unrefined carbs, like whole wheat, oats, quinoa, and the like, trump those made up of highly processed wheat or other grains. Lean meats, poultry, seafood, and plant sources of protein like beans and nuts are far more healthful than fatty meats and processed meats like sausage or deli meats.

The good-bad thing can be confusing, so Dr. Hauser suggests a few simple principles.

Pick the healthful trio. At each meal, include foods that deliver some fat, fiber, and protein. The fiber makes you feel full right away, the protein helps you stay full for longer, and the fat works with the hormones in your body to tell you to stop eating. Adding nuts to your diet is a good way to maintain weight because it has all three.

Avoid highly processed foods. The closer a food is to the way it started out, the longer it will take to digest, the gentler effect it will have on blood sugar, and the more nutrients it will contain.

Choose the most healthful sources of protein. Good protein-rich foods include fish, poultry, eggs, beans, legumes, nuts, tofu, and low-fat or non-fat dairy products.

Photo credit: mybodyhealth.net

These three strategies fit in with the Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets. The DASH diet includes 2 or fewer servings of protein per day, mostly poultry or fish. “The Mediterranean diet uses protein from fish as a centerpiece of a meal, and other meats as more of a component of a meal,” says Dr. Hauser.

I had to ask if it’s important to spread carbs throughout the day or if it’s okay to limit them to one meal, the way I do. “If it makes you feel better to eat carbs at one meal a day versus spreading them throughout the day, that’s fine. You can scatter the carbs as you see fit,” says Dr. Hauser.

So I learned that while I was “good” yesterday when it came to eating, I now know that I can be better.

Greens and Coumadin (aka. warfarin)

Photo credit:vegetable matter@blogspot.com

If I had a dollar for every time a patient told me (or I heard a doctor tell a patient) they "can't eat greens or salads because I take Coumadin," well, let's just say, I wouldn't have to keep this doctor thing up!  What's the matter with this?  Well, it's not true. [For those of you wondering what Coumadin (generic name, warfarin) is, a description follows.]

As a doctor who is focused on helping people eat better, you can imagine how crazy this drives me.  And, more importantly, how negative an impact this has on the health of millions of people.

Don't lose faith in your trusty medical providers if you've been told this along the way.  Avoiding greens used to be the standard teaching.  The thing about medical science is that it's constantly evolving and advancing.  As one of my professors said early on in medical school, "half of what I'm telling you will be proven wrong in the future - I just don't know which half."

What’s so special about greens?

Leafy greens are an important part of a healthy diet.  They're also an important part in cultural traditions throughout the world.  Greens add vitamin A, vitamin C, fiber, calcium, iron, potassium, B vitamins, other minerals, omega-3 fatty acids, many phytochemicals and phytonutrients  - and the cause of concern when it comes to Coumadin, but vitally important for health, vitamin K.  Vitamin K is necessary to keep bones strong, prevent heart disease and regulate bleeding and clotting.

Photo credit: www.wellbeingmag.com

Before I get carried away, I won’t assume everyone eats like a rabbit and knows what I mean when I say “greens.”  Greens are literally any green vegetable or herb. 

Some examples of greens

Examples of the hundreds (maybe thousands) out there are: kale, spinach, chard, watercress and other cress, lettuces, amaranth, celery, beet greens, turnip greens, collard greens, mustard greens, dandelion, cabbage, Brussels sprouts, broccoli, bok choy, rapini, endive, chicory, Jew’s mallow, Miner’s lettuce, cilantro, basil, parsley, sage, arugula, spring mix and other mixed baby greens, fiddlehead ferns, lovage, sorrel, sea kale, nori, chickweed, thyme, salsify, sea vegetables…I could go on and on!

Exposing the myth

Why did the "I can't eat greens" myth propagate so widely?  It's because greens DO interact with Coumadin.  I know this is confusing - stick with me.  

Coumadin is a blood thinner – called an "anti-coagulant" in medical terminology.  Millions of people take it to prevent blood clots that can cause death or serious injury due to stroke, blood clots in the lungs (called pulmonary emboli), leg pain and swelling, among other things.  People start taking it either temporarily, or permanently, depending on the reason it was started in the first place.  Some reasons people start taking Coumadin are that they have irregular heart rhythms, orthopedic surgeries (like hip replacement), artificial heart valves, previous blood clots in the legs or lungs, problems with the blood or diseases that cause increase risk of developing blood clots like lupus, factor V Leiden, polycythemia vera, just to name a few.  Cancers can also cause blood clots but are treated with a different type of anti-coagulant.

How vitamin K interacts with Coumadin

Vitamin K, in addition to the things mentioned above, is used to make components (called "clotting factors") in the blood that help the blood to clot. These clotting factors are made in the liver. When we eat foods or take daily vitamins with vitamin K in them, we don’t just use up the vitamin K and get rid of it.  Our bodies recycle vitamin K! Once vitamin K is used, it’s turned into an inactive (not useful) form of vitamin K. For the liver to use the vitamin K again, it needs to be converted back to an active (useful) form of vitamin K. Coumadin prevents the body from recycling inactive vitamin K to active vitamin K.  This basically makes most of the vitamin K in our bodies invisible or useless. 

The trick with Coumadin is to block just the right amount of vitamin K – not too little and not too much.  This makes the blood less likely than usual to clot, but not impossible.  We need some vitamin K active to make some clotting factors because if we weren’t able to clot our blood at all, we would bleed to death. It's a delicate balance.  People born with diseases of the blood that make clotting difficult, like hemophilia, live precariously with this problem.  If 100 people took Coumadin for 1 year, 7 would have major bleeding and 1 person would die from bleeding. It's very complicated to keep Coumadin at the right level because many things besides vitamin K affect it. Regulating the level often takes medical professionals who focus specifically on caring for patients taking this medicine at a Coumadin clinic.  Some doctors that have close relationships with their patients and see them frequently, adjust the dose themselves, but this is getting less common because of the amount of work involved.

Interactions with Coumadin

Greens are just one of the many, many things that interact with Coumadin – almost every medication both prescription and over the counter, alcohol, grapefruit juice, cranberries, multivitamins (especially vitamins A, C, E and K), some spices and seasonings (fenugreek, anise, garlic, ginger, horseradish, licorice, turmeric), many herbal and nutritional supplements, liver, natto (a Japanese food item), omega-3’s and green tea just to name a few. As you can imagine, completely avoiding everything that interacts is going to make life very tough to live!  Many of these things are difficult or impossible to give up.  

How to live your life healthfully AND keep a safe Coumadin level

For things that would have negative consequences for your health if given up - like greens, sources of omega-3 fatty acids, losing weight, antibiotics and other lifesaving treatments - don't give them up.  Not giving them up means that you need to work closely with your physician or Coumadin clinic to regulate your level. For things that are in your normal daily routine, work with your providers to stabilize your Coumadin level WHILE YOU CONTINUE TO use/eat them.  Then, BE AWARE WHEN CHANGES OCCUR to your routine and understand that some of those changes will require close medical follow up to make sure that your Coumadin level doesn't get too high or low.

Example 1, let's say you eat a green salad three nights per week and have collard greens with your Sunday meal.  That's a lot of vitamin K, right? (It is, trust me on this.) But remember, if this is your ROUTINE, let your doctors know and they can adjust your Coumadin accordingly and get it to a stable level.  Then, you only need to be concerned about greens (or any other thing that affects Coumadin levels) if you make a significant change.  

Example 2 - Let's say, it's a hot summer and you start eating large salads for one meal every day.  You've just doubled your intake of greens, and along with them doubled your intake of vitamin K.  You will likely need a higher dose of Coumadin than you did before you made this change.    

Example 3 - Your doctor gets the level adjusted and all is well until the fall. Suddenly, you crave the warm comfort of soups and stews while the crisp, coolness of salads seem less appealing.  You cut out salads completely, but keep collards with your Sunday meal.  Well, now you are getting only about one-seventh the amount of greens (and vitamin K) each week that you got in the summer.  You will definitely need a reduced Coumadin dose or risk life threatening bleeding.  

Example 4 - Similarly, it you got pneumonia and had to take antibiotics, you would need your Coumadin dose adjusted while on antibiotics.  

Example 5 - If you hurt your shoulder and needed to take tylenol, again, adjustment would be needed.

For most of you reading this who don't take Coumadin (and many who are), you're thinking, "this is too complicated!" Well, it's true.  Coumadin is one of the most complicated medications you can take.  No matter what your life choices, your Coumadin level will likely need regular adjusting.  Many, many people are stuck with this archaic medication regimen.  For some lucky patients who meet very specific criteria, there are some substitute drugs that are not nearly as difficult to regulate.  Unfortunately, they're expensive and they're not right for everyone.  

Big Picture

Photo credit: www.healthwisehome.com

Constant things don't usually require big dose adjustments, changes to your lifestyle, foods and medications/supplements often do. The key is to create routines and stick with them.  Notify your doctor or Coumadin clinic of any changes to that routine.  By doing this, you can maintain a normal, healthy lifestyle - including eating a healthy diet rich in green vegetables!