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Eating Well with Arthritis

Submitted by Jessica Pashko

Edited by Marcia Bristow MS RDN CSSD CD

Maintaining an active lifestyle into older adulthood promotes happiness, longevity and wellbeing. As attractive as this may sound, approximately 15% of  people suffer from a type of arthritis which presents challenges to making exercise part of daily life.1 Increasing age, overuse injuries, and decreased muscle mass greatly increase the risk of developing arthritis.2 While rheumatoid arthritis is an autoimmune inflammatory disease affecting the joints, osteoarthritis develops gradually from repetitive, high-impact movement.2 Due to the wide range of symptoms, there are several options for pain relief.

Common methods for arthritis management and prevention include use of a few supplements and non-steroidal anti-inflammatory drugs (NSAIDS.)  Some popular supplements are gluocsamine (builds cartilage,) chrondroitin (adds fluid to joints and builds cartilage,) and methylsulfonylmethane (anti-inflammatory on muscles.) Yet, these supplements can be costly and need to be taken consistently for best results. Supplements that contain fish oil, such as omega-3 capsules, may interact with other athritis management methods, including: NSAIDs, ginkgo, and Vitamins C and E, affecting the intended use.1 Daily use of NSAIDs over a long period of time, or taking more than 6 tablets in a 24 hour peiod, can cause stomach discomfort. Luckily, research suggests that whole foods with anti-inflammatory properties can lessen arthritis symptoms, prevent worsening and may be a safer, more cost effective alternative to using supplements.1,2,3

Foods are referred to as “anti-inflammatory” when they contain antioxidants, such as omega-3 fatty acids, oleic acid and Vitamins A, C & E, since they block inflammatory pathways.1,2,3 Studies have found that consumption of omega-3-rich foods decreases joint tenderness and duration of morning stiffness, and vitamins A, C & E combined reduce the severity of rheumatic symptoms.1 Furthermore, a survey found that people with arthritis believed that diet positively impacted symptoms: pain, joint swelling, and reduction of physical fitness.3 In addition to improving symptoms, whole foods can be less expensive and more flavorful!

While there is always room for more research, both supplementation and whole foods remain options for managing arthritis. Ultimately, it comes down to cost effectiveness and ease of use when deciding which approach is best for you. However, with supplementation comes the risk of exceeding safe level of intake, which is why it is best to eat food first, then supplement. Fatty fish, walnuts and eggs are omega-3-rich foods to add to your diet. Substituting olive oil for other fats is yet another strategy for increasing oleic acid, which will boost the antioxidant content of meals. Making your plate a “rainbow” with brightly colored fruits and vegetables can provide Vitamins A, C & E, plus fiber and minerals. Next time at the grocery store, add more foods to your basket instead of supplements.

References:

  1. Rosenbaum, Cathy Creger, PharmD,M.B.A., R.Ph, O’Mathuna DP, PhD, Chavez, Mary,PharmD., F.A.A.C.P., Shields K, PharmD. Antioxidants and anti-inflammatory dietary supplements for osteoarthritis and rheumatoid arthritis. Altern Ther Health Med. 2010;16(2):32-40.
  2. Szychlinska MA, Castrogiovanni P, Trovato FM, Nsir H, Zarrouk M, Lo Furno D, Di Rosa M, Imbesi R, Musumeci G. Physical activity and Mediterranean diet based on olive tree phenolic compounds from two different geographical areas have protective effects on early osteoarthritis, muscle atrophy and hepatic steatosis. Eur J Clin Nutr. 2018;56(229):1-17. doi:10.1007/s00394-018-1632-2.
  3. Grygielska J, Kłak A, Raciborski F, Mańczak M. Nutrition and quality of life referring to physical abilities – a comparative analysis of a questionnaire study of patients with rheumatoid arthritis and osteoarthritis. J Rheumatol. 2017;5(55):222-229. doi:10.5114/reum.2017.71629.
  4. Felson D. Arthritis: What works. What doesn’t. Nutrition Action Healthletter. October 2017.

The Link Between Social Media & Eating Disorders

Submitted by Amy Sercel MS RD CD

Edited by Marcia Bristow MS RDN CSSD CD

Social media use has become more and more common over the past few years.  In 2015 it was estimated that 90% of adolescents between the ages of 18 and 29 were on social media.1 Social media is now considered to be the most widely-used method of information sharing, and many people are using various platforms to learn recipe ideas, get health tips, and stay motivated as they work towards fitness goals.2 Unfortunately, social media also provides many opportunities to spread misinformation under the guise of evidence-based recommendations, and promote unhealthy attitudes and behaviors.  While this can lead to a huge number of health consequences, some of the more insidious outcomes include negative body image and even the development of disordered eating.

Some studies have shown that people who spend more time on social media tend to experience more body dissatisfaction and body surveillance.3 This means that they are more likely to hold critical views of their bodies and weight statuses, and may be more likely to engage in body checking behaviors to sure they haven’t gained any weight.  Typical body checking behaviors include pinching parts of the body, looking in the mirror, or trying on the same piece of clothing to ensure the fit hasn’t changed.  People who use social media more often also tend to make more comparisons between their own and other peoples’ bodies (both on social media platforms and in person).  They are more likely to place a high value on thinness and be less satisfied with their own weight regardless of their health status.3 In one study of 960 female college students, researchers found that women were more likely to express concerns about their weight after using Facebook; women who spent the most time on the site were more likely to engage in body- and appearance comparison.4

The biggest predictor of negative body image and disordered eating behaviors appears to be “active” social media use, especially when this is centered on photos.  Studies suggest that people who spend more time viewing photos, posting status updates, and looking at “fitspiration” or “thinspiration” posts may be more likely to base their self-worth on their appearance.3,5 Specifically, people who spend more time posing for, selecting, editing, retouching, and sharing photos of themselves (selfies) were found to have lower body image and a stronger desire to lose weight.  It isn’t possible to say which factor here is the cause and which is the effect, since this particular study was not a randomized experiment.1 Unfortunately, most social media platforms are currently photo-based, meaning that navigating social media might be even more difficult for people predisposed to, struggling with, or recovering from disordered eating.

This doesn’t mean that these individuals should avoid social media altogether.  If you find that using social media triggers body dissatisfaction or other negative thoughts, consider the following strategies to make your social media feed more body positive:

  • Follow people or organizations that promote size diversity and body positivity.  Studies have shown that people who have a greater appreciation for the differences between peoples’ appearances are less likely to experience negative body image after using social medial.5 If you need some inspiration, check out this link for some body positive influencers.
  • Practice media literacy; learn to recognize credible sources of information in comparison with half-truths or misleading statements.  If a post seems confusing or false, Google the information or ask someone who knows more about the topic to learn whether it is accurate.
  • Try to post fewer selfies, or spend less time retouching photos before you post them if you think this is an area that challenges you.   Consider sharing posts about your interests, landscape photography, books, or music instead of photos of yourself.
  • Limit your overall social media use.  Instead of messaging someone through Facebook or Instagram, call them on the phone or connect in person.

If you are concerned about the impact of your social media use on your food choices and body image or are concerned about a friend or family member, seek out a Registered Dietitian and a therapist to help you work through these challenges.

References:

  1.  Cohen R, Newton-John T, Slater A. “Selfie”-objectification: The role of selfies in self-objectification and disordered eating in young women. Comput Hum Behav. 2018;79:68-74. doi:10.1016/j.chb.2017.10.027
  2.  Haber S. Dietitians on Social Media: Making Connections for Better Health. Food Nutr Mag. May 2017. https://foodandnutrition.org/blogs/the-feed/dietitians-social-media-making-connections-better-health/. Accessed June 4, 2018.
  3.  Holland G, Tiggemann M. A systematic review of the impact of the use of social networking sites on body image and disordered eating outcomes. Body Image. 2016;17:100-110. doi:10.1016/j.bodyim.2016.02.008
  4.  Hungry for “likes”: Anxiety over Facebook photos linked to eating disorders. ScienceDaily. https://www.sciencedaily.com/releases/2014/03/140304102438.htm. Accessed May 10, 2018.
  5.  Burnette CB, Kwitowski MA, Mazzeo SE. “I don’t need people to tell me I’m pretty on social media:” A qualitative study of social media and body image in early adolescent girls. Body Image. 2017;23:114-125.

What is the Gut Microbiome, and Why is it So Important?

Submitted by Jessica Fischer

Edited by Marcia Bristow MS RDN CSSD CD

The microbiome has become a hot topic in the health and nutrition world. Our gut microbiome holds the largest number of microbes in the body. Microbes, or microbial cells, are the cells that break down undigested food in the large intestine, prime our immune system, secrete neurotransmitters that allow nerve cells to communicate with each other, and more.1,2

There is increasing evidence that links the health of our gut microbiome to multiple chronic diseases. In the case of heart disease, people who eat red meat often have bacteria in their gut that convert substances in meat to what eventually becomes Trimethylamine N-Oxide, a compound that speeds up artery clogging. This may explain why people who eat red meat have an increased risk for heart disease.3 Other studies have researched the link between mental health and the gut microbiome. One study found that people with depression had much fewer and less diverse microbes than those without depression. In a study with rats, those that received transplants of microbes from people with depression were more likely to show signs of anxiety than rats that did not.4,5 Though there is still more research to be done, there is a clear connection between the health of our gut microbiome and our own health.

You might be thinking, how do I keep my gut microbiome healthy? Probiotics are the good microbes that inhabit our gut. Having probiotic rich foods or taking a supplement of probiotics may add to the good microbes inhabiting your gut. Probiotic-rich foods include kombucha, yogurt, kimchi, sauerkraut, kefir, and many others.6 Here is a link if you want more information about sources of probiotic rich foods. The supplemental form of probiotics are difficult to keep alive, as they are live microbes, and require a specific environment to thrive.

Eating probiotic-rich foods is also recommended to increase the population of beneficial bacteria in your gut. Prebiotics are different types of dietary fiber that these probiotics like to eat. Consuming a variety of fruits, vegetables, and whole grains will provide prebiotics to the probiotics that reside in your gut, in turn, create a healthier and happier gut microbiome.

References

  1. The Human Microbiome, Diet, and Health. 2013. doi:10.17226/13522.
  2. Renz H. Faculty of 1000 evaluation for Structure, function and diversity of the healthy human microbiome. Nature. 2012. doi:10.3410/f.717952553.793489697.
  3. Tang WHW, Hazen SL. The Gut Microbiome and Its Role in Cardiovascular Diseases. Circulation. 2017;135(11):1008-1010. doi:10.1161/circulationaha.116.024251.
  4. Schardt D. Can a healthy microbiome prevent depression or cancer? Nutrition Action. https://www.nutritionaction.com/daily/what-to-eat/can-healthy-microbiome-prevent-depression-cancer/. Accessed February 19, 2018.
  5. Malan-Muller S, Valles-Colomer M, Raes J, Lowry CA, Seedat S, Hemmings SM. The Gut Microbiome and Mental Health: Implications for Anxiety- and Trauma-Related Disorders. OMICS: A Journal of Integrative Biology. 2018;22(2):90-107. doi:10.1089/omi.2017.0077.
  6. Schardt D. The best food to feed your microbiome as you get older. Nutrition Action. https://www.nutritionaction.com/daily/what-to-eat/the-best-food-to-feed-your-microbiome-as-you-get-older/. Accessed February 19, 2018.

How is Your Sleep Hygiene?

Submitted by Ashley Simons

Edited by Marcia Bristow MS RDN CSSD CD

Sleep is often taken for granted and undervalued. While it is recommended that adults receive 7-9 hours of sleep per night, only about 48% of adults actually achieve an amount of sleep that falls within that range.1 As for the remaining adults, 26% receive an average of 6-7 hours per night and the other 20% obtain 6 hours or less.1 This is a huge problem considering that sleep deprivation can be a stepping-stone to a variety of health issues including heart disease, hypertension, cerebrovascular disease, and obesity.1,2 Sleep hygiene refers to practices that enable people to achieve optimal sleep quality.3

Our sleep quality has diminished over time, coinciding with people working more and increased use of technology.1 Work, family, and other obligations can often take up most of our time, leaving sleep as more of a luxury rather than the necessity it is. Both the quantity and quality of sleep are important. Stress is often a contributor to poor sleep quality and can derive from a variety of circumstances, such as phone alerts in the middle of the night as well as uncompleted assignments or tasks.4 With adequate sleep we think more clearly and efficiently throughout the day. When sleep deprived, it is easier to make poor lifestyle choices, especially regarding food. A sleep-deprived brain may actually crave foods that are high-calorie and promote weight-gain.2

If you keep your brain deprived of its 7-9 hours, you could be putting yourself at risk for a variety of health complications.1,2 Some of the leading causes of death are related to heart health, which sleep directly impacts.1 People often rely on caffeine, which correlates to poor sleep.5 A study on college students demonstrated that those with poor sleep hygiene also drank caffeinated beverages regularly.5 Poor quality of sleep often leads to consumption caffeine – a cycle that can be difficult to break.5 Stimulants, like caffeine, can keep you alert day and night. Caffeine dependence and ongoing lack of sleep can be hazardous to your health.

There are several techniques to enhance sleep hygiene. Engaging in meditation practices such as abdominal breathing and guided imagery or establishing a daily exercise routine and healthy eating pattern can be useful in decreasing stress and increasing sleep quality.4 Decreasing or eliminating consumption of caffeinated beverages can substantially improve sleep quality.4,5 Sleep is essential and making time for it will help to improve your overall health.1,2

References:

  1. Covassin N, Singh P. Sleep duration and cardiovascular disease risk. Sleep Medicine Clinics. 2016;11(1):81-89.
  2. Greer SM, Goldstein AN, Walker MP. The impact of sleep deprivation on food desire in the human brain. Nature Communications. 2013;4.
  3. Buysse DJ. Sleep health: can we define it? Does it matter? Sleep. 2014;37(1):9-17.
  4. Royal K, Hunt S, Borst L, Gerard M. Sleep hygiene among veterinary medical students. J Education and Health Promotion. 2018;7(1)47.
  5. Lohsoonthorn V, Khidir H, Casillas G, Lertmaharit S, Tadesse MG, Pensuksan WC, Rattananupong T, Gelaye B, Williams MA. Sleep quality and sleep patters in relation to consumption of energy drinks, caffeinated beverages, and other stimulants among Thai college students. Sleep and Breathing. 2014;17(3):1017-1028.

Is It Ever Okay to Eat Added Sugar?

Submitted by Amy Sercel MS RD CD

Edited by Marcia Bristow MS RDN CSSD CD

Sugar is one of the most vilified nutrients, and not without reason.  Sugar provides calories and carbohydrates that can fuel your muscles and brain, but on its own sugar doesn’t contain any vitamins, minerals, or fiber.  When eaten in excess, it can contribute to weight gain and the development of Type 2 Diabetes and heart disease.  Because of this, the Dietary Guidelines for Americans recommends eating no more than 10% of your calories from added sugar.1 Some people take this even further, resorting to desperate measures like cleanse diets or avoiding all carbohydrates (since these are broken down into simple sugars during digestion).  Even if you try to keep a more balanced approach, you may find yourself worrying about the “sugars” line on the nutrition facts label, wondering if it’s ever okay to eat food that contains added sugar.

The answer is yes!  While it’s true that eating a lot of added sugar instead of nutrient-dense foods can harm your health, foods that contain sugar can fit into a balanced meal pattern. This is especially true if the sugar helps you eat other nutrient-dense foods.  For example, many people find plain yogurt too sour and prefer to get some protein and calcium from flavored yogurt that may be sweetened with sugar.  Sprinkling a little cinnamon and sugar over an apple is a great way to enjoy some fiber and vitamin C.  Using a salad dressing that contains a little sugar can help you enjoy a variety of fresh vegetables.

Sugar is also an important source of fuel for your body.  Your muscles and brain use glucose, a simple sugar, for energy.  Not having enough of this during the day can leave you feeling tired or shaky.  While your body breaks down all carbohydrate-rich foods (grains, beans, fruits, vegetables, and dairy products) into glucose, if you need a quick source of fuel you may be better off eating something that contains sugar alone.  This is especially true if you’re going into an intense athletic event.  Food is digested more slowly when it contains fiber, fat, and protein, and it’s best to avoid these nutrients before or during an athletic event to prevent stomach problems.  Instead, one of the following will give your muscles quick fuel during activity:2

  • Jelly beans
  • Gatorade
  • Crackers with jam
  • Dried fruit
  • Toast with honey
  • Yogurt with fruit
  • Low-fat granola bar

These types of snacks are also convenient to carry and can be eaten relatively quickly, so the won’t slow you down.

Completely avoiding sugar can also set you up for even stronger food cravings that may become harder and harder to resist.  In one study, people who were dieting to lose weight had more cravings than those who were just “monitoring” what they ate to maintain their weights.  The more they restricted their food choices, the more cravings they experienced.  On the other hand, those who didn’t restrict any particular foods reported fewer cravings.3 Other studies have shown that people who feel guilt after eating sweets, especially chocolate, feel less control over their food choices and have more difficulty maintaining their weight in the long term.4 This suggests that allowing yourself to enjoy a small amount of something sweet when you’re really craving it will be better in the long run, because you won’t have to manage as many cravings in the future.

Avoiding sugar takes its most extreme form as Orthorexia Nervosa (ON).  Although it isn’t officially recognized as an eating disorder, ON is considered a form of disordered eating in which someone is so fixated on eating “healthy” foods that it actually damages their overall health and wellness.5 Someone with ON may start out by avoiding added sugar but eventually move towards avoiding entire food groups they consider unhealthy or “impure.”6 Not everyone who is concerned about added sugar is destined to develop ON, but it is important to be aware of this possibility and remind yourself to be flexible in your food choices.  Sugar can have a place in a balanced meal pattern, especially when you are enjoying sweets as part of a celebration or social event.  This won’t lead to negative health consequences, but avoiding certain foods or feeling guilty after eating them could.

Instead of completely eliminating added sugar from your meal pattern, incorporate it in moderation.  Recognize that sugar can be valuable if it helps you

  • satisfy an occasional craving
  • enjoy nutritious foods
  • or get quick fuel during a strenuous workout.

When eating added sugar, eat consciously and savor the experience.  If you’re having trouble balancing sources of added sugar with other, nutrient-dense foods, make an appointment with a Registered Dietitian who can help you enjoy sugar in moderation while meeting your nutrient needs.

References:

  1.  A Closer Look Inside Healthy Eating Patterns – 2015-2020 Dietary Guidelines – health.gov. https://health.gov/dietaryguidelines/2015/guidelines/chapter-1/a-closer-look-inside-healthy-eating-patterns/#callout-balance. Accessed June 11, 2018.
  2.  Archer E. In Defense of Sugar: A Critique of Diet-Centrism. Prog Cardiovasc Dis. May 2018. doi:10.1016/j.pcad.2018.04.007
  3.  Massey A, Hill AJ. Dieting and food craving. A descriptive, quasi-prospective study. Appetite. 2012;58(3):781-785. doi:10.1016/j.appet.2012.01.020
  4.  Kuijer RG, Boyce JA. Chocolate cake. Guilt or celebration? Associations with healthy eating attitudes, perceived behavioural control, intentions and weight-loss. Appetite. 2014;74:48-54. doi:10.1016/j.appet.2013.11.013
  5.  Orthorexia | National Eating Disorders Association. https://www.nationaleatingdisorders.org/learn/by-eating-disorder/other/orthorexia. Accessed June 7, 2018.
  6.  Dunn TM, Bratman S. On orthorexia nervosa: A review of the literature and proposed diagnostic criteria. Eat Behav. 2016;21:11-17. doi:10.1016/j.eatbeh.2015.12.006

Let’s Talk About Fats

Submitted by: Jessica Ball

Edited by: Marcia Bristow MS RDN CSSD CD

Fats have always been a controversial topic, even though everyone needs dietary fats to survive. Fat in our body is more than just stored calories; it is in the membranes of each of our cells. Even our nerves need fats to be healthy!1 There are two main types of fats in the foods that we eat: unsaturated and saturated fats. Each has a separate effect on how fat is utilized in our body.

Fat is carried through the bloodstream by two different types of cholesterol: high-density lipoproteins (HDLs) and low-density lipoproteins (LDLs). LDLs are messier in their delivery of fats. Their spilling contributes to fatty buildup and narrowing of your arteries, increasing your risk of heart disease.2 However, this excess fat from LDLs is cleaned up and brought to the liver by HDLs. This reduces the possibility of buildup in your arteries and chance of chronic illness.2

Unsaturated fats are typically liquid at room temperature and include olive and canola oil. Also, nuts, avocados and fish oils are nutrient-dense sources of unsaturated fats. Including these types of fat in your diet increases HDLs and lowers LDLs in your blood, which has been shown to reduce risk of heart disease.3.4 Saturated fats are easy to identify because they are typically solid at room temperature. Meat, dairy and other animal products contain saturated fats. However, not all saturated fats are found in animal products. For example, palm oil and coconut oil are plant sources of saturated fats. It is important to limit consumption of these kinds of fats because they may decrease HDLs and increase LDLs in your blood and ultimately contribute to heart disease.3

Coconut oil, a plant source, has 50% more saturated fat than butter.5 So what’s all the fuss about coconut oil if it has such a high amount of saturated fat? Some recent studies have found that coconut oil is less efficient to digest than other fats, so it might promote the rate at which you burn calories and contribute to fullness. This may slightly promote weight loss, but the majority of studies are done on animals so the effect on humans is unclear.Coconut oil may increase HDLs, like unsaturated fats, and also increase LDLs, similar to saturated fats.5

Here’s the bottom line: eat more of the high-quality unsaturated fats, such as nuts, seeds, oils, fish and avocados. Moderate your intake of coconut oil, full-fat dairy, unprocessed meats and other saturated fats.

References:

  1. Harvard Health Publishing. The truth about fats: the good, the bad, and the in-between – Harvard Health. Harvard Health Blog. https://www.health.harvard.edu/staying-healthy/the-truth-about-fats-bad-and-good. Accessed May 8, 2018.
  2. HDL (good), LDL (bad) cholesterol and triglycerides. American Heart Association. http://www.heart.org/HEARTORG/Conditions/Cholesterol/HDLLDLTriglycerides/HDL-Good-LDL-Bad-Cholesterol-and-Triglycerides_UCM_305561_Article.jsp. Accessed February 16, 2018.
  3. Willett WC. Dietary fats and coronary heart disease. J Intern Med 2012;272(1):13-24.
  4. Willett WC. The Mediterranean diet: science and practice. Public Health Nutr 2006;9(1a).
  5. Coconut oil – what’s behind the “health halo”. Today’s Dietitian. http://www.todaysdietitian.com/newarchives/1016p32.shtml. Accessed February 16, 2018.

Carbohydrate Back-Loading and the Importance of Evidence-Based Nutrition Recommendations

Submitted by Amy Sercel MS RD CD

Edited by Marcia Bristow MS RDN CSSD CD

In the world of nutrition news, the topic of carbohydrates is one of the most confusing and controversial you’ll find right now.  Depending on the source, the recommendations range from entirely avoiding all carbohydrates to limiting yourself to certain types but not others.  If you’re following the trends, you might have heard about carbohydrate back-loading for losing weight and preserving muscle mass.  In regards to this blog, I am reminded of a quote I once read, “Be careful what you read, you might die of a misprint someday!”  Regardless, here is the information on Carb Back-Loading.

Carbohydrate back-loading is detailed in a book by John Kiefer, a “training and nutrition consultant” whose qualifications include having “read over 40,000 medical research papers covering various facets of human biology.”1 In short, Kiefer advises to avoid eating any carbohydrates until immediately after an evening workout that focuses on resistance exercise.  After the workout, you should eat large quantities of carbohydrates, especially “junk” carbohydrates because they have a higher glycemic index and will be more readily absorbed into your muscles.1

Foods like white bread, potatoes, candy, and sugar-sweetened drinks are said to have a high glycemic index because they raise your blood sugar quickly after you eat them.  Foods with a low glycemic index contain a mix of carbohydrates, protein, fat, and fiber, and will cause your blood sugar to rise slowly and stay more even over time.  Kiefer actually says to avoid carbohydrates with a low glycemic index after a workout.  He says they will create a prolonged increase in blood sugar levels, which will prevent your body from releasing growth hormone while you sleep and therefore limit the amount of lean tissue building that would occur overnight.  On the other hand, he argues, the blood sugar crash that occurs after eating high glycemic index foods will ensure that your overnight growth hormone release will be normal.1 The problem with this theory is that blood sugar levels still remain high several hours after finishing a high glycemic index meal, and blood sugar may even return to normal more quickly after eating a meal that contains more fiber and protein, and thus has a lower glycemic index.2

Kiefer also claims that your cells are most insulin-sensitive in the morning, so when you eat carbohydrates at this time your body quickly stores them in both your muscle and fat cells.  He says that skipping breakfast and avoiding carbohydrates during the day will promote fat burning by preventing your body from storing calories in fat cells, and by allowing another hormone, cortisol, to stimulate fat breakdown. When you do eat during the day, he recommends continuing to avoid carbohydrates, instead focusing on lean meat and low-carbohydrate vegetables like asparagus, spinach, broccoli, cauliflower, cabbage, zucchini, and bell peppers.1

With this argument, Kiefer is overlooking a few essential points about the cortisol.  Cortisol is a stress hormone that’s released when the body needs energy.  It does trigger the breakdown of fat stores, but it also stimulates the breakdown of muscle to be used as energy.  Eating carbohydrates prevents muscle breakdown because the body uses those carbohydrates for energy first.  Kiefer also implies that muscle protein breakdown doesn’t happen unless cortisol is “constantly elevated like during chronic stress,”1 however, this is untrue.  Cortisol acts on all cells, and doesn’t distinguish between fat and muscle when converting stored fuel into usable energy.  Additionally, to ensure that there is plenty of fuel in the bloodstream cortisol actually increases your appetite, which would make it much more difficult to avoid eating during the first half of the day.3,4

Kiefer’s final major argument is that you should do resistance training at night because resistance training makes your muscle cells able to absorb carbohydrates without needing insulin.  Since your other cells are least insulin sensitive at night, waiting to eat carbohydrates until after a resistance workout would ensure that those carbohydrates are stored only in muscle.  While he does include protein-rich foods in the post-workout meal, he only highlights the importance of eating carbohydrates to replenish muscle glycogen stores to prepare for the next workout. Training earlier in the day wouldn’t have the same impact, because your cells would be more sensitive to insulin and you would end up storing carbohydrates in both your muscle and fat.1

In addition to the factual inaccuracies scattered throughout Kiefer’s argument, the entire theory of carbohydrate back-loading goes against most nutritional biochemistry knowledge.  To begin with, once the body has reached its capacity for carbohydrate storage in the muscles, liver, and kidneys, any additional carbohydrates eaten will be stored as fat no matter when those carbohydrates are eaten, or if they are high or low glycemic index foods.  This means that even after a tough resistance workout, people still need to be conscious of the amount of calories they take in to prevent those calories to be stored as fat.  Furthermore, insulin will still be released when you eat carbohydrate-rich foods after a workout.  It’s possible that your muscle cells would take in more of the carbohydrates than your fat cells at this time, but there is no way to simply “turn off” the storage of carbohydrates in fat.

At the same time, there are many studies that directly oppose the idea that you should eat all of your carbohydrates at night.  One study in particular showed that dietary-induced thermogenesis, or the number of calories burned by digesting food, was higher when the majority of food was eaten in the first half of the day, and people eating larger morning meals lost almost twice as much weight during the course of the study than those who ate larger evening meals.5 Another study suggests that people who eat a high-carbohydrate breakfast every day are more likely to maintain weight loss and less likely to experience food cravings throughout the day.6

Throughout the book Kiefer takes an aggressive tone that seems to imply that anyone who questions his plan simply doesn’t have enough discipline.  He tells condescending stories about people who have “incorrectly” followed his carbohydrate back-loading plan, belittling the efforts that they did make without offering any suggestions for how they could make the plan effective for their lifestyles.  It’s well known that the mindset of being either “on” or “off” of a diet actually has worse health outcomes than creating sustainable lifestyle changes that fit within a person’s preferences.  The type of dichotomous thinking that Kiefer encourages ultimately leads to more weight gain, less enjoyment of food and eating, and can even trigger an eating disorder in someone who is predisposed to developing one.7

All in all, carbohydrate back-loading is an interesting idea that is ultimately not backed up by nutrition science.  Instead of trying to follow a restrictive eating pattern developed by someone whose main credential is having read research studies, listen to the recommendations that are known to be true.  Focus on creating a balanced meal pattern that allows you to feel satisfied and enjoy the meals you’re eating while staying within your calorie and macronutrient needs.  That meal pattern will include:

  1. A variety of whole grains that provide carbohydrates to fuel your workouts, in addition to fiber and other vitamins and minerals
  2. Fruits and vegetables that are full of vitamins, minerals, and antioxidants
  3. Lean protein to help build and maintain your muscle mass
  4. Fish, nuts, avocados, olive oil, or other unsaturated fat as sources of healthy fat

Keep in mind, you can always seek out a Registered Dietitian to provide you with individualized recommendations tailored to your lifestyle to ensure that you’re meeting your unique needs as best as possible.  After all, just because a program or plan works for one person does not necessarily mean it will work for you.

References:

  1.  Kiefer J. Carb Back-Loading Manual for Total Body Fat Control. 1.0. John Kiefer; 2012.
  2.  Yalçın T, Al A, Rakıcıoğlu N. The effects of meal glycemic load on blood glucose levels of adults with different body mass indexes. Indian J Endocrinol Metab. 2017;21(1):71-75. doi:10.4103/2230-8210.195995
  3.  Christiansen JJ, Djurhuus CB, Gravholt CH, et al. Effects of Cortisol on Carbohydrate, Lipid, and Protein Metabolism: Studies of Acute Cortisol Withdrawal in Adrenocortical Failure. J Clin Endocrinol Metab. 2007;92(9):3553-3559. doi:10.1210/jc.2007-0445
  4.  All About Cortisol. Precision Nutrition. https://www.precisionnutrition.com/all-about-cortisol. Published March 2, 2009. Accessed May 14, 2018.
  5.  Raynor HA, Li F, Cardoso C. Daily pattern of energy distribution and weight loss. Physiol Behav. February 2018. doi:10.1016/j.physbeh.2018.02.036
  6.  Jakubowicz D, Froy O, Wainstein J, Boaz M. Meal timing and composition influence ghrelin levels, appetite scores and weight loss maintenance in overweight and obese adults. Steroids. 2012;77(4):323-331. doi:10.1016/j.steroids.2011.12.006
  7.  Palascha A, van Kleef E, van Trijp HCM. How does thinking in Black and White terms relate to eating behavior and weight regain? J Health Psychol. 2015;20(5):638-648. doi:10.1177/1359105315573440

Ice Cream with a (Health) Halo?

Submitted by Amy Sercel MS RD CD

Edited by Marcia Bristow MS RDN CSSD CD

It’s not uncommon to have a craving for something sweet at the end of the day, and many people now satisfy that craving by turning to a low-calorie ice cream.  In 2017, Halo Top beat out household names like Breyers, Hood, Haagen Daas, and even Vermont’s own Ben and Jerry’s to become the number one selling brand of ice cream in grocery stores.1 Halo Top’s claim to fame is their low-sugar, low-calorie ice cream that contains between 280 and 360 calories and 20-24 grams of protein per pint.2

When you compare Halo Top’s nutrient content to that of other ice creams on the shelves, it’s easy to see why people gravitate towards this option.  A ½-cup serving of their vanilla bean contains 70 calories, 2 grams of fat, 6 grams of sugar, and 5 grams of protein.2 On the other hand, ½ cup of Ben and Jerry’s vanilla bean contains 250 calories, 16 grams of fat, 20 grams of sugar, and 4 grams of protein.3 Ben and Jerry’s is working on a low-calorie version of their own called Moo-phoria, but even that doesn’t compare to Halo Top.  A ½-cup serving of Moo-phoria Chocolate Milk & Cookies contains 140 calories, 4.5 grams of fat, 15 grams of sugar, and 3 grams of protein.4

Halo Top keeps their calorie and sugar content so low because their ice cream is primarily sweetened with erythritol, a low-calorie sugar alcohol.  Sugar alcohols are molecules that have a similar structure to regular sugar, so they still taste sweet but aren’t metabolized the same way sugar is.5 Some sugar alcohols, such as xylitol, have the reputation of causing digestive problems.  These sweeteners aren’t absorbed in your small intestine, so they continue on to your large intestine where they are broken down by your gut bacteria, which draws water into your intestine and causes diarrhea.  Unlike those sugar alcohols, most of the erythritol you eat is absorbed in your small intestine, entering your blood stream where it circulates for a while before you excrete it in your urine.6 This means you’re a lot less likely to get an upset stomach after eating it.

Erythritol is also lower in calories than other sugar alcohols.  While regular sugar contains 4 calories per gram and xylitol contains 2.4 calories per gram, one gram of erythritol contains only 0.24 calories.  Studies have also shown that it doesn’t raise blood sugar levels or increase insulin release, making it a potential alternative for people with diabetes who want something sweet.5,6 In one study, 20 subjects ate meals that contained table sugar and meals that contained erythritol.  Researchers found that erythritol didn’t affect the satiety hormones released after eating, and subjects’ blood sugars did not rise as much after eating the erythritol meal.  Additionally, the amount subjects ate at their next meal didn’t differ when they ate food with table sugar or erythritol.  This was a small study, so more research is needed to confirm these findings; however, they’re significant because previous research has found that people eat more later in the day after consuming other low-calorie and artificial sweeteners like aspartame.7

Taken together, all of this suggests that Halo Top could be a good alternative to other, higher-calorie sweets, especially if you’re working to lose weight, maintain weight loss, or monitor your blood sugar.  However, be careful not to get swept up in the glow of Halo Top’s health halo.  You might say a food has a health halo if it seems to have more nutritional value than it actually does because marketing highlights one particular nutrient it contains (low-calorie, high-protein, etc.) or a certain quality of the food (local, organic, etc.).8 When people see foods marketed this way, they tend to over-estimate the health benefits they provide and underestimate the calorie, fat, or sugar content.  Halo Top’s marketing draws on the health halo effect by putting the spotlight on its lower calorie and higher protein content, making people forget that it is a highly processed food that doesn’t contain any other nutrients, like vitamins, minerals, or antioxidants.

At the same time, Halo Top’s advertising heavily implies that it is the only dessert you can eat without feeling guilty about your food choices, while encouraging you to eat the entire (4 serving) pint in one sitting.  The idea that you should feel guilty for eating certain foods is counterproductive not only for your overall health, but also for weight maintenance or loss.  Feelings of guilt after eating “treats,” especially chocolate, are associated with higher amounts of dysfunctional eating, anxiety, depression, low self-esteem, and body dissatisfaction.  Additionally, people who associate chocolate with feelings of guilt tend to gain more weight and have less confidence about choosing and preparing healthy meals than people who have a neutral attitude towards chocolate.9

Halo Top may satisfy a sweet craving, and those 60 calories and 6 grams of protein per ½ cup serving may fit into a meal plan that meets your calorie needs, but could a better choice be made?  Absolutely.  A more balanced approach would be to choose a dessert with more nutritional value that doesn’t promote the idea that you’re doing something “wrong” by indulging in sweets.  Homemade silken mousse with a scoop of protein powder and ¼ cup of fresh raspberries, a baked apple stuffed with ¼ cup cooked quinoa and topped with ½ cup of Greek yogurt and 2 tablespoons chopped walnuts, or one of these oat bran banana muffins topped with 1 tablespoon of peanut butter would all provide similar calories and protein with more vitamins and minerals than a pint of Halo Top.  This way you can satisfy your craving, savor the experience, and get more nutritional value per serving.  Give it a try!

References:

  1.  Halo Top Is Now the Most Popular Pint of Ice Cream in America | Food & Wine. http://www.foodandwine.com/desserts/halo-top-most-popular-ice-cream-pint-in-us. Accessed March 26, 2018.
  2.  Dairy Flavors. HALO TOP. https://www.halotop.com/flavors/. Accessed March 26, 2018.
  3.  Vanilla Ice Cream | Ben & Jerry’s. https://www.benjerry.com. https://www.benjerry.com:443/flavors/vanilla-ice-cream. Accessed March 26, 2018.
  4.  Moo-phoria Light Ice Cream. https://www.benjerry.com. https://www.benjerry.com:443/flavors/moophoria. Accessed March 26, 2018.
  5.  Erythritol – Like Sugar Without The Calories. https://www.healthline.com/nutrition/erythritol. Accessed March 26, 2018.
  6.  What is erythritol? https://www.medicalnewstoday.com/articles/318392.php. Accessed March 26, 2018.
  7.  Overduin J, Collet T-H, Medic N, et al. Failure of sucrose replacement with the non-nutritive sweetener erythritol to alter GLP-1 or PYY release or test meal size in lean or obese people. Appetite. 2016;107:596-603. doi:10.1016/j.appet.2016.09.009
  8.  Tierney J. Health Halo Can Hide the Calories. The New York Times. https://www.nytimes.com/2008/12/02/science/02tier.html. Published December 1, 2008. Accessed April 9, 2018.
  9.  Kuijer RG, Boyce JA. Chocolate cake. Guilt or celebration? Associations with healthy eating attitudes, perceived behavioural control, intentions and weight-loss. Appetite. 2014;74:48-54. doi:10.1016/j.appet.2013.11.013

My Meal Kit Experiment

Submitted by Amy Sercel MS RD CD

Edited by Marcia Bristow MS RDN CSSD CD

Meal kits definitely take the guesswork out of cooking dinner.  Signing up for a subscription to a meal kit means that every week, you’ll receive a box with all the ingredients you’ll need to make 2-6 meals that serve 2-4 people.  There are lots of different meal kit services available.  After writing this blog, which breaks down the features of some (not all) popular meal kit options, I decided to try some of them out for myself.  Here are my impressions of each one.

Green Chef – $26.98 for the first week, $71.94 – 98.94 for subsequent weeks of 3 meals for 2 people

Recipes Made:

  •        Spanish Egg ‘n’ Hash with Saffron-Porcini Spices, Potato, Carrots, and Arugula
  •        Tamari-Glazed Salmon with Wasabi Edamame, Rice and Pickled Ginger, and Bok Choy
  •        Italian Mushroom Bowl with Lentils, Tomatoes, Kale, Basil Pesto, and Parmesan Fricos

Green Chef was the first meal kit I tried, and it was certainly impressive.  The ingredients were familiar but prepared in ways that I had never tried before, so the recipes felt novel.  Even so, the cooking techniques required were not difficult.  None of the recipes took more than about 45 minutes to make and they were easy to follow.  Many of the vegetables were also sent pre-cut, which helped reduce the cooking time even more.

The three recipes were very filling, averaging about 600 calories per serving.  Additionally, some of the plastic containers used for packaging were re-useable, so it didn’t feel like the meal kit generated a lot of waste.

The most significant downside to Green Chef is the cost.  After the introductory rate, the omnivore plan is about $80 per week.  The vegetarian plan is the least expensive option at about $72 per week.  It’s also important to note that Green Chef does not allow you to choose the specific recipes you’ll receive each week, although you can change your dietary preferences to exclude a certain ingredient if you don’t like one of the recipes you’re scheduled to get that week.

Sun Basket – $33.94 for the first week, $71.94 for subsequent weeks of 3 meals for 2 people

Recipes Made:

  •        Salmon in Parchment with Shiitakes and Mango-Cucumber Salad
  •        Miso Ramen Bowls with Braised Tofu and Bok Choy
  •        Quinoa and Kale Fritters with Sweet Potato-Mushroom Hash

Sun Basket did not disappoint with the variety and flavor of their recipes.  The number of ingredients each recipe called for felt manageable, and every meal was delicious.  Pre-made spice blends, sauces, and marinades helped to add an interesting dimension to each meal.  Out of all the meal kits I tried, Sun Basket introduced me to the widest range of new flavors.  A third bonus of this service is that Sun Basket sends you the recipes for all of the week’s possible recipes, so you could potentially re-create them on your own if you feel inspired.

These recipes were also very satisfying, averaging about 550 calories per serving.  I easily shared one among three people and did not feel like I had under-eaten.  The meals were also relatively high in protein, ranging from 16-44 grams per serving.

Some of the recipes I made with Sun Basket were rather challenging.  The recipes required a lot of steps that were not always the easiest to follow.  One recipe in particular took almost two hours to finish.  For this reason, Sun Basket would probably be best for two people cooking together, or for someone who has more time to spend perfecting a meal.

Blue Apron – $24.94 for the first week, $59.94 for subsequent weeks of 3 meals for 2 people

Recipes Made:

  •        Spiced Cauliflower and Jasmine Rice with Poblano Pepper and Cilantro-Yogurt Sauce
  •        Crispy Buttermilk Catfish with Roasted Delicata Squash
  •         Spicy Poblano and Mushroom Quesadillas with Baby Romaine and Avocado Salad
  •         Penne Pasta and Beef Bolognese with Pecorino Cheese

Although I only ordered one box for my introductory week with Blue Apron, I arrived home to find that the meal kit service had mailed me three!  The customer service representative who answered my confused phone call was highly amused by the situation and told me that I could keep all three boxes for no additional charge.  I later received a handwritten card thanking me for being a Blue Apron customer.

These meals were all very straightforward, with the recipes broken down into simple steps that included photos to follow along with.  It took between 30 and 45 minutes to make these meals, and they were easy to complete by myself.

Similar to the other meal kit services, these meals averaged about 630 calories per serving.  Unfortunately, I didn’t feel that any of these recipes introduced me to any new spices, ingredients, or cooking techniques.  The recipes also seemed to be lacking in whole grains, which was reflected in their relatively low fiber content of 7-12 grams per serving.  I was also surprised by the number of times the recipes stated to “season with salt and pepper.”  This direction appeared between four and seven times in each of the recipes I was sent, and I would have preferred to see the recipes flavored with herbs or spices instead.

Plated – $31.85 for the first week, $71.70 for subsequent weeks of 3 meals for 2 people

Recipes Made:

  •        Roasted Vegetable Tikka with Toasted Naan, Sautéed Spinach, and Coconut Chutney
  •        Fish Tacos with Avocado Sauce and Crunchy Slaw
  •       Maple-Roasted Delicata Squash with Burrata and Quinoa-Arugula Salad

Of all the meal kit recipes I tried, the Roasted Vegetable Tikka ended up being my favorite because of the delicious blend of spices and the variety of vegetables it included.  I found that each recipe contained a pleasant balance of flavors and textures, and I appreciated the combination of raw and cooked vegetables in each meal.

Overall, the recipes were relatively easy to follow.  The directions were broken down into six steps, and each step was accompanied by a photo.  It took about an hour to finish cooking each meal.

The dinners Plated provided could easily have made leftovers or been divided among three people, averaging about 830 calories per serving.  This would be important to keep in mind if you are working to reduce your calorie intake.  Aside from this, the most significant downside of Plated is that the majority of the ingredients are sent in plastic bags.  These can be recycled at most grocery stores, however, it would be ideal if they could provide some reusable containers instead.

Purple Carrot – about $45 for the first week, $72 – 78 for subsequent weeks of 3 meals for 2 people

Recipes Made:

  •        Refried Butternut Tacos
  •        Fall Vegetable Hash
  •        Loaded Burritos

Purple Carrot is an entirely vegan meal kit service.  When I signed up, I immediately skipped the first week of delivery and didn’t get the introductory discount they offer, which would be important to keep in mind if you’d like to try this service.

Without knowing ahead of time, it would have been difficult to identify that these recipes were all vegan.  The recipes were unique and required me to use ingredients in ways I would never have considered before.  For example, the tacos were topped with roasted grapes, adding an element of sweetness that nicely complemented the butternut squash.  That recipe also led me to try plantains for the first time.

The recipes were broken down into six manageable steps and were fun to cook.  I really enjoyed the combinations of ingredients they put together, especially because the result was that I tried many new vegetables that I wouldn’t usually have cooked with.  This meal kit would be an excellent introduction to vegan cooking for someone who is typically a meat-eater.  As an added bonus, almost all of the containers Purple Carrot sends are re-useable, so this meal kit feels less wasteful than some of the others.

These meals could easily serve more than two people, averaging about 800 calories per serving.  It was surprising to see that the recipes’ protein content ranged from 8 – 39 grams per serving.  I had expected that a vegan meal kit service would make an effort to provide high-protein meals each night rather than allowing such a wide discrepancy.

Hello Fresh – About $20 for the first week, $59.94 for subsequent weeks of 3 meals for 2 people

Recipes Made:

  •        Shepherd’s Pie with Mushrooms, Peas, and Roasted Carrots
  •        Bell Pepper and Black Bean Quesadillas with an Arugula and Heirloom Tomato Salad
  •        Butternut Squash Agnolotti with Kale in a Sage Brown Butter Sauce

Hello Fresh’s recipes were fun to make, taking about 45 minutes each.  The recipes were not complicated, and it was easy to follow the six-step directions.  Overall, the meals I made with Hello Fresh felt like familiar comfort foods, and it would probably be impossible not to find something you like in their recipe database.

This meal kit service advertises that their recipes are approved by a Registered Dietitian, and this is reflected in the meals’ nutrient facts.  The recipes average about 600 calories per serving and contain a variety of vegetables.  Hello Fresh would be a great choice for someone looking for quick, delicious dinners.  I was a little disappointed that the recipes didn’t include a wider variety of herbs, spices, or unusual ingredients, as it felt like the recipes sent by the meal kit were very similar to the types of dinners I would prepare on my own.

Final Impressions

My meal kit experiment was a lot of fun.  Meal kits definitely make dinner preparation a lot easier by reducing the amount of time you will spend planning meals, shopping for ingredients, and actually cooking.  For the most part, the recipes are all broken down into simple steps, which can really help increase your confidence if you don’t always feel comfortable cooking new things.  Best of all, meal kits offer a low-risk opportunity to try unfamiliar foods.

Each meal kit service offers its own variety of positives and drawbacks, and the service that works for one person may not be ideal for someone else.  If you’d like to try a meal kit, think about the amount you’re willing to spend each week and the types of recipes you want to make.  If you’re having trouble making up your mind, pick a few you’d like to try and make up your mind after you’ve sampled some.  Just make sure you skip one meal kit on the weeks that you’re getting the other one delivered.  If you’re not sure about keeping the meal kit, it’s also a good idea to skip the next few weeks after you order the introductory box.  You can always go back and “un-skip” them later, but this way you will have time to cancel the service before you’re locked-in and charged for the next week’s box.

Stomach Growling? Blame Ghrelin

Submitted by: Amy Sercel MS RD CD

Edited by: Marcia Bristow MS RDN CSSD CD

It’s an unfortunate fact that, when it comes to losing weight, many people end up re-gaining the weight they lost and sometimes more.  This trend is common with crash diets where people temporarily restrict certain food groups and/or carefully control calorie intake.  This dietary trend often leads to resuming old eating habits once the diet is “done”.  However, even people who make gradual dietary changes and incorporate more activity into their lifestyles may be unable to maintain weight loss.  One study found that only about 1 in 6 people who were overweight or obese were able to maintain a 10% weight loss for over a year.1 This difficulty maintaining weight loss could be related to a hormone called ghrelin.

Ghrelin is a hormone produced by the stomach when food has not been eaten for a period of time. Ghrelin is then sent to your brain to stimulate your appetite.  High ghrelin levels also promote the storage of energy as fat tissue.  After eating, ghrelin levels decrease the hunger signal and a sense of fullness or satiety results.  When someone purposefully eats less to promote weight loss, ghrelin levels go up throughout the day and aren’t as impacted by eating.2 One particular study found that ghrelin levels increased by 24% after people dieted for six months, and other studies suggest that ghrelin continues to increase as diets go on.3 This phenomenon was once critical for the survival of our hunter/gatherer ancestors, since it signaled the need to find food when it wasn’t readily available, and helped humans store calories to draw upon in a time of famine.  Now that food is plentiful, ghrelin may be more problematic than helpful.

Researchers have been looking for eating patterns that might help prevent this increase in ghrelin to make long-term weight loss sustainable for more people.  One study measured ghrelin levels and food cravings in people following meal patterns designed to facilitate weight loss.  One group ate three low carbohydrate, high protein meals each day, and the other group ate a high carbohydrate breakfast and low carbohydrate, high protein lunch and dinner.  The two groups ate the same number of calories each day.  Researchers found that people experienced fewer food cravings and had lower ghrelin levels when they ate a high carbohydrate breakfast.  The low carbohydrate breakfast group lost slightly more weight during the course of the study, but regained more than half of the weight they lost within four months after the study ended.  On the other hand, the high carbohydrate breakfast group continued to lose weight after the study ended, losing an average of 45 pounds over 8 months.2

Getting enough sleep, choosing a balanced meal pattern, and engaging in regular physical activity can all help keep ghrelin levels low.  Studies suggest that lack of sleep promotes ghrelin production, leading to hunger and cravings throughout the day.  Increased muscle mass and regular protein intake have also been associated with lower ghrelin levels.3

People working to lose weight should meet with a Registered Dietitian, who will provide support and recommendations tailored to their unique lifestyle.  A dietitian will calculate the number of calories someone needs to eat in a day and collaboratively develop a meal plan that will facilitate weight loss while the person to meets their calorie and nutrient needs.  Through this collaboration, the dietitian will discover times of the day when their client might feel more hungry or crave certain foods and develop strategies to help them prevent hunger, distract themselves from the craving, and achieve their weight loss goals.

References:

  1.  Montesi L, El Ghoch M, Brodosi L, Calugi S, Marchesini G, Dalle Grave R. Long-term weight loss maintenance for obesity: a multidisciplinary approach. Diabetes Metab Syndr Obes Targets Ther. 2016;9:37-46. doi:10.2147/DMSO.S89836
  2.  Jakubowicz D, Froy O, Wainstein J, Boaz M. Meal timing and composition influence ghrelin levels, appetite scores and weight loss maintenance in overweight and obese adults. Steroids. 2012;77(4):323-331. doi:10.1016/j.steroids.2011.12.006
  3.  Ghrelin: The “Hunger Hormone” Explained. https://www.healthline.com/nutrition/ghrelin. Accessed January 29, 2018.