Dr. Monica Aggarwal

Are we too clean? The role of our gut bugs.

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Our gut is like our second  brain. It is the first line of defense against so many toxins that we ingest. It has a significant role in our immune response. Our gut full of bugs. And all of the bugs have their own DNA. These bugs are called our microbiota and their DNA is our microbiome. We are full of bugs (90% bug!) and many argue that we are more bug than we are human! Having healthy gut flora is very important in keeping our bodies strong. We develop our gut flora from birth when we go through our mother’s vaginal canal. We then suck on our parents’ skin. We then crawl on the floor and suck on our toys. We are exposed to other people, our pets and our plants, all of which are covered in bacteria and nourish our gut. We go outside and are exposed to dirt with all of its valuable microbes. We eat the grass and lick things that our pets have licked and we obtain more bugs. This is good. Exposure to small numbers of pathogens will strengthen our immune system. Over time, however, our behaviors have changed, as explained by the “hygiene hypothesis.” As we have learned the importance of sanitation and its role in infection, we clean and sterilize most everything. We know that sanitation prevents the spread of germs and because of this knowledge, we have reduced the number of illnesses that have affected our children. With greater access to medical care, we take our children into doctors with many common ailments. Antibiotics are commonly prescribed by physicians.

But have we gone too far? Is it possible to be overly clean? What is the impact of our hand sanitizers and antibacterial soaps? What is the impact on our bodies of treating all of our illnesses with antibiotics? Are we over-treating illnesses, and could many of them be just watched while our bodies work them out? I know many physicians who feel infections are viral where antibiotics don’t work, but still, maybe because of pressure from patients, will prescribe antibiotics. Are we doing the right thing? With all of these changes in the modern era, we have also noted the onset of so much more allergy, autoimmune disease and inflammatory bowel disease.[i]  The larger families of ages past who lived in less sanitary conditions were not afflicted with these same illnesses. [ii] Perhaps, then we should get a little dirty and not worry about cleaning so much. Something to think about. I don’t use antibacterial soap. I don’t use hand santizers. I just use good ol’ fashioned soap.


[i] Blaser MJ Who are we? Indigenous microbes and the ecology of human diseases. EMBO 2006, Rep 7:956–960

 

[ii] Strachan DP. Hay fever, hygiene, and household size. BMJ; 1989; 299:1259– 1260.

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An Update on Soy

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This is an update on soy. Still lots of confusion and concern out there.

Bottom LINE: Soy products are okay. There is a significant concern regarding soy and its association with cancer that many people are afraid to it. The data does not pan out.

Consider: Asian countries drink soy milk, eat tofu and soy beans (edamame) abundantly and don’t have a higher incidence of breast cancer. Asian countries do NOT have more breast cancer and in fact have a lower incidence. The Western nations, in fact, are leading the pack.

The Details: Soy has received lots of press lately. There have been small animal studies that have linked high doses of soy protein isolate or isolated isoflavones to increased cancer risk. Soy is metabolized differently in humans from rodents so we can’t compare rodents and humans in this situation. Further, human studies on soy protein isolate have not shown any difference from other soy products. We have seen in study that soy products such as soy milk, soy beans and tofu are of benefit to our bodies. In the US, we use a lot of concentrated forms of soy in our supplements and energy bars: a different way to eat soy. While they have not been shown to be of harm, more studies on these highly concentrated/processed soy products are needed.

Soy is full of isoflavones which are natural estrogens. While are estrogens, they appear to have an anti-estrogen effect where they prevent the natural estrogens from binding to the receptors (a good thing). They also have anti-oxidant and anti-inflammatory effects. They stop the formation of estrogen in fat tissue (recall obese patients have more breast cancer than thing patients) and they bind to the estrogen proteins which is another way it prevents estrogen from binding to a receptor. Studies on Asian women who eat soy the most isoflavones (compared to the least abundant eaters) had a significantly less (29%) risk of developing breast cancers. US studies have not found any bad affects either of eating soy. Studies even on breast cancer survivors have shown no detriment. There is data to suggest soy eaters have less prostate and colon cancers.

SO: eat your soy! Enjoy it, often and much. It is a great source of fulfillment for those who are plant based and a nice alternative for all. Don’t be afraid of it. But eat it from natural sources like our Asian country counterparts: soy milk, tofu, edamame. Don’t take a supplement or powder. Stay away from genetically modified soy. Look for the non-GMO words. Organic will be non-GMO. Be natural!

Wu AH, Yu M, Tseng C-C, Pike MC Epidemiology of soy exposures and breast cancer risk, Br J Cancer. 2008 Jan 15; 98(1): 9–14.

Shu, X. The Journal of the American Medical Association, Dec. 9, 2009; vol 302: pp 2437-2443.

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If I eat a vegan diet, what about my calcium intake?

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Calcium is very important in bone development. However, this is not the whole picture. There are many other vitamins such as vitamin D, K and A that are essential to bone development. It is unclear how much calcium we need in our diet. Guidelines recommend 1000mg of calcium per day. We often think about cow’s milk when we think about the main source of calcium. That conception needs to be changed.

Many of us are sensitive to the milk and have a “milk allergy” or “milk sensitivity.” We believe these dairy products trigger a leaky gut.[i] As dairy products enter the gut, the tight junctions break and the breakdown products of milk enter the bloodstream. Our immune system is activated and our bodies develop immune complexes that start attacking parts of the body. In some people, the joints are affected and they develop rheumatoid arthritis. In others, it is the pancreas islet cells that are attacked and they develop Type I diabetes. In others it is lupus, vitiligo (loss of pigment in the skin) or multiple sclerosis. This immune system activation triggers oxidative stress and inflammation. We know that chronic inflammation is a risk for heart disease and cancer. Inflammation is also a trigger for bone breakdown. Then suggesting that we humans drink more milk to decrease fracture risk is a “conceivable contradiction.” [ii]

There are many studies now that suggest a link between increased dairy and cardiovascular risk.[iii],[iv] In a follow-up to the these initial mouse studies, an extensive review was conducted to evaluate humans and milk intake, and one of the studies in the review evaluated people who drank more than three glasses of milk per day versus those who drank fewer than one glass per day. The research found a dose-dependent higher fracture and higher death rate in women who drank more milk.

In the 12-year Nurses’ Health Study, nurses who drank more than two glasses of milk per day had no fewer fractures than those nurses consuming less than one glass of milk per week.[v] Interestingly, in that same Nurses’ study, those who consumed greater amounts of calcium from dairy foods had higher fracture risk. That increased risk was not seen with calcium from non-dairy sources.[vi]

This is really important. In other corroborating research, a meta-analysis of multiple larger trials showed there was no decrease in hip fractures with calcium supplementation.[vii] This means that taking calcium supplements did not decrease rate of fractures. There may even have been a slightly higher fracture risk in people taking calcium supplements who didn’t get adequate vitamin D.

Let’s consider the occurrence of fractures around the world. In countries such as India, Japan and Peru, calcium intake is less than one-third of the daily recommended allowance (300mg per day), and the risk of fractures in those countries is extremely low. The countries with the highest fracture risks are actually those where people drank an abundance of milk, namely Norway, Sweden, Iceland, Denmark and the USA. These studies suggest that maybe drinking milk is not all it’s cracked up to be!

Calcium is definitely important in our diet but it is not the only part of the picture. Don’t get hung up on calcium. Eliminating animal protein has been shown to decrease the necessary calcium requirements. We need vitamins A, D, and K in order to make bones along with our calcium. Most green vegetables have calcium and vitamins A and K! Vitamin D, on the other hand, often requires supplementation because we don’t absorb enough natural sunlight, the source for vitamin D.

Calcium comes from many non-dairy sources, including broccoli, kale, collard greens, turnip greens, bok choy, almonds, sunflower seeds, tahini, dried beans and blackstrap molasses. Flax seeds and sesame seeds are two more great sources of calcium.[viii] Calcium in low-oxalate vegetables such as kale is readily absorbed, so they are viable options for calcium intake in a plant-based diet.[ix]


[i] Deopurkar R, Ghanim H, Friedman J, Abuaysheh S, Sia CL, Mohanty P, Viswanathan P, Chaudhuri A, Dandona P. Differential effects of cream, glucose, and orange juice on inflammation, endotoxin, and the expression of Toll-like receptor-4 and suppressor of cytokine signaling-3. Diabetes Care, May 2010; 33(5): 991-7

[ii] Michaëlsson K, Wolk A, Langenskiöld S, Basu S, Lemming EW, Melhus H, Byberg L

Milk intake and risk of mortality and fractures in women and men: cohort studies. BMJ 2014; 349: g6015.

[iii] Sonestedt E, Wirfalt E, Wallstrom P, Gullberg B, Orho-Melander M, Hedblad B. Dairy products and its association with incidence of cardiovascular disease: the Malmo diet and cancer cohort. Eur J Epidemiol2011; 26: 609-18

[iv] Huth PJ, Park KM. Influence of dairy product and milk fat consumption on cardiovascular disease risk: a review of the evidence. Adv Nutr2012; 3: 266-85

[v] Feskanich D, Willett WC et al., Milk, dietary calcium, and bone fractures in women: a 12-year prospective study. Am J Pub Health; June 1997, Vol. 87. No. 6

[vi] Feskanich D, Williett WC et al. Milk, dietary calcium and bone fractures in women: a 12-year prospective study. AM J Pub Health, 1997; 87 (6): 992-7

[vii] Bischoff-Ferrari HA, Dawson-Hughes et al. Calcium intake and hip fracture risk in men and women: a meta analysis of prospective cohort studies and randomized control trials. Am J Clin Nutr, 2007; 86(6): 1780-90

[ix] Heaner RP, Weaver CM. Calcium absorption from kale. AJCN 1990; 51: 656-7

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What is in this food? Weight Watchers frozen dinner.

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What is in this food? I was at work the other day and I saw someone eating this meal. She was explaining to her friend that she was trying to eat right so that she could lose weight. But will this food make you “lose weight?” First, notice the outside label. It says “Smart ones” and “weight watchers”. It says “2x the fiber versus regular pasta” It says “vegetarian” and only “270 calories”–all enticing marketing ploys. So I went in for a closer look. First, let’s look at the ingredients. The first ingredient is “enriched” pasta (which means they added some vitamins to the pasta with questionable absorption in the body) and then sauce. Then, there is parmesan cheese, half and half (milk, cream), whey protein concentrate, cornstarch, olive oil, sugar, salt, lipolyzed cream, butterfat, xanthan gum, flavor, lactic acid, spice and reduced fat mozzarella cheese.

So, look at how many ingredients are in this thing. Then, look at how many types of cream, milk and oil that are in this product.  Think about how much processing is in this food. Remember, our body doesnt like all that processed foods. It is highly inflammatory. What do you think “flavor” is?  A good guide to what you should eat is to ask “would my grandmother recognize these ingredients?” Also, consider, how you make pasta at home. When I make it at home, I take pasta noodles, red sauce and vegetables. What do you think all that other stuff is needed for? Consider that if the food has more than 5 ingredients in it, you probably dont want to eat it. Also note that this food has 500mg of salt in it! So, in order to make it taste better, they have added loads of salt to it.  I asked the woman if she felt full after eating it because when I eat, I like to feel full. She said she never feels full after eating the meal but that this what was she was allowed to eat. I then asked her what happens when she gets home. She said she was so hungry that she often ends up snacking or eating a large dinner.

This is not a healthy product. It will not get you to lose weight and it creates an inflammatory environment for your body. If you want pasta, eat fresh pasta. Skip the cream. Skip the cheese. Add red sauce and vegetables and eat well. Yum.

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Without meat and eggs, no protein?

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People ask me all the time about how I get my protein without eggs, meat and cheese. I just had this question today in clinic. In America, we are fixated with our protein sources. There is plenty of protein in beans and lentils that I promise you. You do not need animal products to get energy. You will actually find that without the animal products, you will likely feel lighter. I find that it is sugars and processed foods that make most people low in energy. It creates the ups and downs in sugar levels that lead that to that post lunch drowsiness. I dont get that!

Meat and eggs have been shown to go into the gut where the gut produces TMAO. This is a substance that has been shown to increase plaque in the heart arteries and increase bad heart outcomes. http://www.nejm.org/doi/full/10.1056/NEJMoa1109400

Some of the best athletes in the world don’t eat meat, dairy or eggs. I am the strongest I have ever been without these things!

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Kale: A SUPERFOOD

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Kale has received a lot of press lately as the wonder vegetable, a super food. It really is an interesting vegetable. It has an abundance of vitamin A, potassium and magnesium. It also has iron, calcium and protein. It has an abundance of B vitamins, including folate which has a role in brain development. There is also fiber in kale which is good for bringing out cholesterol. It also has alpha linoleic acid (ALA) which is an omega 3 fatty acid and lutein which is good for macular degeneration.

I tried to eat kale at least three times per week. There are different types of kale: lacinato, green and red kale. Red and green kale are hard to get in the winter. People often say that they don’t like kale. Lacinato kale has a thick stem and if you just chop the kale, it will be rough to chew. So De-stem the kale. Then chop up the leaves. I usually massage in some hummus to soften it, leave them for an hour and then might sprinkle a few sesame seeds on it. So good. You can use the stems in a soup or broth.

Learn to eat all sorts of vegetables but not only one type. For instance, spinach is full of iron but doesn’t have calcium and may even leach calcium that you have just eaten. Turnip greens, mustard greens, bok choy and kale among others have lots of calcium. So vary it up, many different types of greens all of the time.

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What is Normal Cholesterol? What should we aim for?

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This is a good question. First, some definitions. Our lipid panel is broken into 4 parts: total cholesterol, triglycerides, HDL and LDL. Triglycerides are the most modifiable acutely with diet. these are responsibe to decreasing sugars and excess intake in our diets. We aim for a goal of <150 gm/dL for triglycerides. Recent data shows that people with lower triglycerides do better with long term mortality (i.e. they live longer). The HDL is the “health” cholesterol. A way to think about it is that it the cholesterol that takes plaque out of the heart. So the higher the better here. We aim for an HDL of >50 gm/dL in women and >40 gm/dL in men. The last  number is the LDL which is the “lethal” cholesterol. I always tell people to think about that as the cholesterol that gets put into the heart. Then the goal is to have low LDL, low triglycerides and high HDL.  The total cholesterol is just a sum of the whole. We dont know what number the LDL should be at. We know that >160 gm/dL is high. We also know that lower is better. We have studied statins use and bringing LDL to <70 gm/dL and those patients has improved mortality. When we are born are LDL is about 40-50 gm/dL.  We also know that young people at age 5-6 years already have fatty streaks (cholesterol lines) in the heart arteries. Autopsies of Vietnam and Korean war mortalities (average age 22 years) had plaque in their hearts.

Bottom Line

Lower is better. We will never drop it too low that we will not have enough. Our livers can make it. It is essential for cell wall production but an LDL of somewhere between 40-70 gm/dL is perfect. Remember, it starts in our very young. We have to eat well and have our kids eat well. There is no pass for our kids that “it is okay, they are little” Plaque builds at very young ages. Raise them as kids the way you want them to be as adults.

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My Gold: TURMERIC

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The studies on turmeric are amazing. A fascinating role for turmeric is in Alzheimer’s disease. The brain has cells called neurons that are responsible for connecting (synapsing) in order that thoughts we have manifest in actions. In Alzheimer’s disease, plaque forms between these cells decreasing the ability of these neurons to communicate. These communications are the key to cognition, memory and judgment and without them, we see the impairments that are evident in Alzheimer’s patients. In America, the rate of Alzheimer’s disease is almost 25 times of that seen in India. In animal studies, curcumin was found to bound to plaque and prevented it from clumping and decreasing communication! Curcumin is also an important antiviral and antiseptic. For centuries, people have put turmeric paste onto cuts to prevent bacterial infections. Use this often and much. It is bitter. Must grind black pepper with it to increase absorption.

Turmeric. I have a 1/2 teaspoon in my water 2-3 times per week and put it in all of my food. It is bitter so add a little lemon to the water. Or mix it in with your beans and lentils while you are cooking.

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What is the deal with soy? Good or bad for us?

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People asking about soy milk lately. Soy good or bad? Causes cancer or not? Soy is quite popular in the US. It comes if forms of whole soybeans (edamame), soymilk, soybean oil, tofu, tempeh, miso, and many vegetarian meat and dairy substitues. Soy has gotten bad press lately because soy products are made up of isoflavones. Isoflavones are phytoestrogens and it has been hypothesized that this extra estrogen would excessive; thus, increasing the risk of cancers, specifically breast cancers. Studies DO NOT support this. In fact, studies show that people who eat soy may have a decreased risk of cancer compared to those with no soy in their diets. There was a 2012 analysis of 9514 women from US and China. Those people who took in the most soy had a 25% less likelihood of developing recurrent cancer. There is data to suggest soy eaters have less prostate, colon and breast cancers. This may be in part due to the fact that those isoflavones are phytoestrogens but have an opposite effect than previously suspected. These phyoestrogens may actually block the effects of estrogens. Importantly though, soy has shown benefit in estrogen negative cancers as well.

There is also concern about male fertility. Studies show that soy does not have an adverse affect on male hormones (testosterone). Soy infant formulas will not affect the babies’ reproductive health. There is also a role in inflammation. Inflammation is the source of most chronic illnesses. One thousand Chinese women who ate more soy had less inflammation. Soy reduced hot flashes in menopause as well!

Bottom Line

It is okay and in fact good to eat soy!! But please remember whole soy products are the best; i.e. edamame, soymilk, tofu, miso. Remember, studies were not done on the processed soys: like soy protein isolates. Processed foods come with their issues and the soy protein isolates have some questionable health benefits. Also we need to consider the role of genetically modified soybeans. Try to eat non-GMO soy. But, Enjoy soy. Dont be afraid to have your kids drink it. It is all good! Now, dont overdo it because you think it will decrease your risk of cancer. Just eat it as a great protein and nutrient source as you desire but dont overdo it!

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