Food Fortification: A Risky Experiment?

Posted by on March 23, 2012 81 comments

We’ve learned enough in the last two years to revisit the supplementation advice from our book, and toward that end I am starting a series on micronutrients.

I’ve recently been looking at some papers studying the effects of food fortification with micronutrients. These changes provide a sort of “natural experiment” which may provide insight into the benefits and risks of supplementation.

Fortification of Food

Grain products are the most important category of fortified foods. Industrially produced baked goods must generally use enriched flour, and Wikipedia (“Enriched Flour”) tells us what they’re enriched with:

According to the FDA, a pound of enriched flour must have the following quantities of nutrients to qualify: 2.9 milligrams of thiamin, 1.8 milligrams of riboflavin, 24 milligrams of niacin, 0.7 milligrams of folic acid, and 20 milligrams of iron.

This is an ironic choice of nutrients. While thiamin and riboflavin are harmless, niacin, folic acid, and iron are three micronutrients we recommend NOT supplementing in the book. Another nutrient we recommend NOT supplementing, vitamin A, is also a fortified nutrient, although not in flour.

Sales Cartoon #6021 by Andertoons

Perhaps not even for that!

A history of nutrient fortification over time can be found at this USDA site. Enrichment has a long history, but the amount of fortification has increased substantially since the 1960s. Enrichment mixtures were added to rice, cornmeal/grits, and margarine beginning in 1969, and to ready-to-eat cereals, flour, and semolina beginning in 1973. Inclusion of high levels of folic acid in all enriched foods became mandatory in 1998.

You may have noticed that when putting raw rice in water, a white powder comes off the rice. This is the enrichment mixture which contains folic acid. According to the American Rice Company (hat tip: Matthew Dalby),

The enrichment mixture is applied to rice as a coating. Therefore, it is recommended that rice not be rinsed before or after cooking and not be cooked in excessive amounts of water and then drained. The enrichment … would be lost.

This is useful information: We can remove the enrichment coating by rinsing rice before cooking. That may turn out to be a good idea!

The Contribution of Fortification to Nutrient Intake

Using USDA data for the four nutrients most likely to be harmful in excess, I made up a chart of the contribution of fortified nutrients to total nutrient intake among Americans. It looks like this:

You can see sharp rises in fortified niacin and folic acid in 1973, in iron in 1983, and again in folic acid in 1998. By 1998, folic acid in fortified foods constituted 44% of all dietary folate, and enrichment mixtures provided one-third of all iron and niacin. Fortified vitamin A provided about 10% of all dietary vitamin A from 1964 through 2000.

Folic Acid

Here is a chart of per capita daily intake of fortified folic acid plus natural food folate in the United States since 1950:

Folate intake from foods has always been around 300 mcg per day, and jumped sharply when folic acid intake became mandatory in 1998. The USDA estimates that intake of folate, including folic acid, jumped from 372 mcg per person per day in 1997 to 678 mcg in 1998, and has remained above 665 mcg ever since (source).

For those who eat a lot of wheat products, intake may be even higher. A pound of enriched white flour has 770 mcg folic acid along with its 1660 calories. If Americans were getting 372 mcg folate from food prior to folic acid fortification, then someone eating a pound of enriched wheat products per day would be getting about 1,142 mcg folate from all food sources.

It’s not uncommon to eat substantial amounts of enriched wheat. The typical American eats 474 g (1800 calories) carbohydrate per day. Most of that is from enriched grains. Those eating industrially produced breads, cookies, crackers, and breakfast cereals may have a very high folic acid intake.

Add in a multivitamin – most multivitamins have 400 mcg and prenatal vitamins have 800 mcg – and a sizable fraction of the population has a folate intake of 1,500 to 1,900 mcg per day, 1200 to 1600 of it as synthetic folic acid. This is well above the tolerable upper limit (UL) for folic acid of 1000 mcg (Wikipedia, “Folate”).

Averaged over all Americans, folic acid from fortified foods comprises 44% of all food-sourced folate, but for Americans taking a multivitamin folic acid becomes 65% of all folate and, for those taking a prenatal vitamin, 75%.

There are several potential health problems that could arise from excessive intake of folic acid, and I’ll explore a few in this series.

Iron and Niacin

Iron intake has risen by about 50% due to fortification:

Niacin intake has also risen about 50%:

These two nutrients have similar concerns:

  • An excess of each promotes infections. Niacin (in the NAD+ form) is the rate-limiting factor in bacterial metabolism. Iron is a critical mineral for oxygen handling and is needed by most infectious pathogens; in fact the immune response tries to lock up iron in ferritin during infections.
  • Both niacin and iron are involved in oxygen handling during metabolism and an excess of each can aggravate oxidative stress.

Vitamin A

Although fortification never increased vitamin A intake by more than 10%, it may serve as a marker for consumption of artificial sources of vitamin A from supplements. Moreover, total food intake of vitamin A was apparently affected by fortification; food intake of vitamin A rises in the 1960s when fortification was growing, and falls after 2000 when intake of fortified vitamin A decreased:

In the book we noted studies showing that people whose intake of vitamin A was above 10,000 IU/day tended to have higher mortality. This was most commonly observed in people taking multivitamins.

There was a period of enthusiasm for vitamin A supplementation between the 1960s and 2000. Multivitamins had more vitamin A in that period. After studies showed negative results, the vitamin A content of multivitamins was reduced.

It is possible that the source of problems may not be vitamin A per se, but degradation products of vitamin A. I’ve previously blogged about how vitamin A plus DHA (a fatty acid in fish oil) plus oxidative stress can produce highly toxic degradation products (see DHA and Angiogenesis: The Bottom Line, May 4, 2011; Omega-3s, Angiogenesis and Cancer: Part II, Apr 29, 2011; Omega-3 Fats, Angiogenesis, and Cancer: Part I, Apr 26, 2011).

Naturally occurring vitamin A in foods is located in lipid fractions and protected from oxidation by accompanying antioxidants (eg vitamin E) and oxidation-resistant lipids. Vitamin A from fortification is not so carefully protected. The Food and Agriculture Organization of the United Nations comments:

Foods which have been successfully fortified with vitamin A include margarine, fats and oils, milk, sugar, cereals, and instant noodles with spice mix. Moisture contents in excess of about 7-8% in a food are known to adversely affect the stability of vitamin A. Beyond the critical moisture content there is a rapid increase in water activity which permits various deteriorative reactions to occur. Repeated heating, as may be experienced with vegetable oils used for frying, is known to significantly degrade vitamin A. The hygroscopic nature of salt has prevented its use as a vehicle for vitamin A fortification in countries of high humidity. In trying overcome this problem, a new vitamin A fortificant, encapsulated to provide an additional moisture barrier, was evaluated with limited success. The cost of using highly protected fortificants can be prohibitive in many cases.

There aren’t many foods that don’t contain 7% water, or acquire it after fortification, so degradation is a real concern.

Vitamin A in multivitamins may also be exposed to degradation. The possibility of vitamin A degradation, especially in combination with DHA from fish oil and oxidative stress, is why I’m skeptical of the health merits of fermented cod liver oil.

Conclusion

I think exploring the effects of fortification will be an interesting topic.

We will consider whether fortification may play a role in various diseases that have become more common since 1970 or 1998, such as obesity, diabetes, and autism.

And we will consider what the health effects of food fortification may tell us about how to optimize micronutrient supplementation.

 

PaleoFX

Posted by on March 18, 2012 45 comments

PaleoFX was a terrific meeting. It’s not easy to stage such a large event. Kudos to Michelle and Keith Norris, Kevin Cottrell, and the 100 volunteers who worked so hard to make it a success. Jack Kruse in his keynote speech talked of “paying it forward,” and the volunteers and organizers certainly did that.

Jack is a better speaker than writer, and I enjoyed the talk. He recounted a story of a woman he met as a surgical resident. She had an inoperable cancer; Jack closed the incision in the operating room, and she lived for another six months. She willed her wine collection to Jack, and each day before she died she took a single bottle from each case to the beach and wrote a letter to Jack explaining its provenance and what it meant to her. The package of letters came along with the wine after her death, and in a note she mentioned the story of the Old Man and the Starfish, and told Jack, “You are my starfish.” She advised him to withdraw from the rat race and enjoy life, as she had in her final six months. Jack didn’t pay much heed to that advice until 2006. Then, after reflection and perhaps some cold thermogenesis, he realized that he ought to “pay it forward” by working “transformational change.” At this point he pulled out what he said was a stick of dynamite and a lighter:

He said that the dynamite could work transformational change on the University of Texas, and it was our obligation to go out in the world and work transformational change by converting others to Paleo.

Luckily the fire marshal was not present, or PaleoFX might have come to a premature end.

The next day began with a talk by CJ Hunt, producer of the documentary “In Search of the Perfect Human Diet.” CJ has a great personal story: he had a heart attack at age 24, but now in his 50s looks like a young and athletic man. Here is the trailer:

CJ can’t market the movie widely until after film festivals, so if you’re interested, the place to buy is through his web site.

Robb Wolf was next, and talked about how he made Norcal into such a successful gym. Robb is an outstanding businessman and his advice for gym operators was excellent.

Cooking demos were next. Check out Nom Nom Paleo for some great pictures of food and people.

Next was a panel I served on, “Ancestral Wellness Through the Decades.” I was impressed with Skyler Tanner, who came well prepared. Melissa Hartwig, Emily Talley, Dr Shilpi Mehta, and Jack Kruse all had good things to say and we covered a lot of ground.

More panels and talks by Mark Sisson and Ron Rosedale followed. The “Whole Foods vs Supplements” panel with Chris Kresser, Amy Kubal, Diana Rodgers, Liz Wolf, Diane Sanfilippo, Dr Dan Kalish, and Joe Johnson was excellent.

After the day was over we had an author book signing and then the audio-visual team recorded interviews with presenters.

The audio-visual team was really, really good: I understand it was the team that produces Anthony Johnson’s The 21 Convention. One of the A/V guys stayed up all night Thursday night putting together a video from the first day’s action, and it was played first thing Friday and was really professionally done. Quite impressive. A DVD of the conference will go on sale in about 60 days, and I’m sure it will be outstanding.

We finally got back to our hotel at 11 pm, our only food having been some chipotle chicken for lunch. Chris Kresser, Dan Pardi, and I went to a Pappadeaux restaurant for some baked potatoes.

Friday, after the video, began with an open Q&A panel: “Ask the Paleo Experts.” The biggest fireworks came with a “safe starches” question, directly specifically to Jack Kruse and myself. Jack has been arguing that one shouldn’t eat any carbs in the winter – here is Jack on the subject of eating a banana in winter:

Only humans who fail to listen to evolutions rule book of engagement die. You can eat a banana in the winter and feel fine but Mother Nature says it’s impossible………therefore we ought not to do it. I will follow her lead over a diet book guru or the opinions of a bunch of people who let their thoughts subjugate their genes. Feelings and thoughts do not trump neural biochemistry …

Jack turned to me and said something like “I’d like Paul to explain why, if Neuropeptide Y is downregulated in cold weather, it can be safe to eat starches.” My answer was that we are warm-blooded mammals and maintain a constant body temperature so that our basic biochemistry, including the ability to digest and utilize glucose, works no matter what the outside temperature. Ron Rosedale, Nora Gedgaudas, and Emily Deans added to the discussion. Here’s a photo of half the panel, from Bryan Lambeth:

From the left are Emily Deans, David Pendergrass, Keith Norris, Lane Sebring, and myself. Offcamera were Jack Kruse, Ron Rosedale, Nora Gedgaudas, Dean Dwyer, and Dallas Hartwig.

After the panel came my talk. It was my “fitness” talk and covered “Some Overlooked Factors in Fitness.” One of the topics I covered was body composition. After the talk I had a long chat with Jimmy Moore about how eating some carbs can improve body composition and facilitate weight loss. He said it was starting to make sense to him. Today he tweeted:

Wouldn’t it be funny if I actually started eating rice again? Stay tuned. @pauljaminet #safestarches

Who knows, maybe we’ll revive the PHD weight loss experiment Jimmy and I talked about last fall. Stay tuned!

While all these talks and panels were going on upstairs, there was a continuous string of Strength and Movement sessions on the first floor. I didn’t have enough time for those, but I did make time for a 15-minute mashing session from Kate Catlow of the Mindful Body Center. Great!

I spent most of Friday chatting to people. The great value of conferences like this is the opportunity to meet others in the Paleo community and to look for ways we can cooperate to achieve good things. I even got a head start on this: Nora Gedgaudas sat next to me in our flight into Austin. In her review of the conference, Emily Deans mentioned a few things under discussion:

I drove with Paul Jaminet in the car and we talked about his upcoming plans, Shou-Ching’s research, and his work with Aaron Blaisdell to help with publishing an Ancestral Health academic journal, all very exciting stuff.

Nothing is settled yet but there will probably be a few initiatives to report in coming months.

I think PaleoFX planted a few seeds that may grow into bigger things. Many thanks to the organizers and volunteers who made it all possible! I hope that a good time was had by all.

Around the Web; PaleoFX Edition

Posted by on March 10, 2012 40 comments

I’ll be speaking and sitting on two panels at the Paleo(fx) conference this week, Wednesday-Friday in Austin, Texas. The meeting has a great lineup of speakers and I’m looking forward to meeting a lot of interesting people there. If you’re there, be sure to introduce yourself!

[1] Music to Read By: Glen Campbell has Alzheimer’s, and is doing a farewell tour. His final concert will be June 30 in Bayfield, Wisconsin. Here is “Wichita Lineman”:

And “Rhinestone Cowboy”:

[2] Interesting posts this week:

My favorite post of the week: Emily Deans reports on the Pathogen Host Defense theory of depression. Depression is part of the immune response to infection: it is how the immune system gets us to rest and avoid other people so as to keep the infection from spreading. The supporting evidence: every genetic allele known to increase the incidence of depression, also increases immunity to infectious disease. Moral of the story: if you’re depressed, find and treat your infections.

Bix discusses the role of histamine in depression. Antihistamines relieve depression. Of course, they may also inhibit the immune system from fighting an infection.

Kamal Patel has a new website on pain management, paindatabase.com; he opens with an excellent discussion of nightshades. Peter Frost notes that redheads are more sensitive to pain.

Dr. Steve Parker reviews the classic study in which diabetic Australian aborigines were returned to their ancestral lifestyle.

Angelique Corthals presents an offbeat theory of multiple sclerosis. Another offbeat theory: Via Melissa McEwen, a paper argues that Crohn’s may result from bacteria which survive in refrigerators.

Chris Kresser discusses folic acid dangers, a topic I’ve recently done some thinking about.

Allan Balliet has a podcast interview with Dr Thomas Cowan, author of The Fourfold Path to Healing: Working with the Laws of Nutrition, Therapeutics, Movement and Meditation in the Art of Medicine.

Tony Federico was able to fix his cholesterol by adding carbs. CarbSane finds she sleeps better on 100g per day starches (PHD proportions) than she did on VLC. Cameron also had trouble on VLC.

Serum IL-6 levels predict mortality and disability. IL-6 is part of the immune response to many infections.

An 87-year-old billionaire aims to live to 125. He eats a lot of fruit and vegetable smoothies.

Parvovirus B19 is present in the thyroid glands of 90% of Hashimoto’s patients.

Stephan Guyenet got some nice exposure at Boing Boing, talking about how the cafeteria diet seduces rats. Matt Metzgar’s personal experiments are supportive of Stephan’s view.

Sean at PragueStepChild has a terrific post pointing out the flawed logic underlying a new “food reward in a pill” drug.

Seth Roberts warns that supplement quality can vary widely.

Apparently Dr Steve Phinney thinks the best fat is a mix of butter, olive oil, and canola oil. I think it’s possible to do better.

The Daily Mail reports that passing weak electric currents through the brain can lift patients out of depression for up to six weeks.

Via Dave Asprey, an “M2A” (mouth to anus) capsule enables photography of the intestine. He’s got video. Dave also has a rapid fat loss protocol: a diet of coffee, butter, and supplements. I prefer our Food for a Fast.

Warning: Dr Clark says that coffee is bad for people with gluten sensitivity, due to cross-reactive antibodies.

Dr Mercola defends free speech, and objects to an FDA assertion that walnuts are drugs. Yahoo reports that the United States Department of Agriculture (USDA) is buying 7 million pounds of “pink slime” beef for the school lunch program.

I didn’t know this: “In healthy individuals, blood sugar rises to ~135 mg/dL after 15 minutes of vigorous exercise…. In Type 1 diabetics, the same intensity and duration of exercise produced blood sugars that exceeded 150 mg/dL in spite of continuous insulin infusion.” (from Sam Knox)

Via PaleoHacks, how a pig gets divided up into meats.

Matthew Green satirizes Paleo.

Finally, Apple came out with a new product last week, and Yoni Freedhoff has the marketing video:

[3] Cute animal:

Via Yves Smith.

[4] Meet Ray Audette: The author of NeanderThin: Eat Like a Caveman to Achieve a Lean, Strong, Healthy Body and one of the pioneers of Paleo:

[5] Not the weekly video: Dr. Mark Cucuzzella offers “The Principles of Natural Running”:

[6] Shou-Ching’s Photo Art:

[7] Weekly Video: Ever wondered what auroras look like from space?

Food for a Fast

Posted by on March 8, 2012 112 comments

Alfredo asked us to offer ideas for how to fast during Lent:

What to eat during fasting (other than cranberries & coconut oil) is on my mind. Looking for some variation in the fasting menu.

It’s a great question. We did have a post on one possible fasting food – Neo-Agutak: “Eskimo Ice Cream” – but never discussed alternatives or the reasons for eating particular foods during a fast.

Fasts don’t have to be food-free

Some people think a fast should involve no food at all. On the Neo-Agutak post, Don Matesz commented:

I would not say that I was fasting if I consumed more than 625 calories during any period of that “fast.”

But that’s not the position of the Catholic Church. During Lent, Ash Wednesday and Good Friday are fast days. The US bishops allow one full meal and up to two snacks:

The law of fasting requires a Catholic from the 18th Birthday (Canon 97) to the 59th Birthday (i.e. the beginning of the 60th year, a year which will be completed on the 60th birthday) to reduce the amount of food eaten from normal. The Church defines this as one meal a day, and two smaller meals which if added together would not exceed the main meal in quantity. Such fasting is obligatory on Ash Wednesday and Good Friday. The fast is broken by eating between meals and by drinks which could be considered food (milk shakes, but not milk).

Children, the elderly, and those whose health might be threatened are exempt from the requirement to fast.

So let’s consider a fast to be any period of reduced calorie consumption – not zero food.

Basic fasting: Electrolyte and fluid replacement

It is certainly a mistake to consume nothing at all during a fast.

People deprived of fluids and electrolytes die quickly. In a famous case cited in Wikipedia (“Starvation”), Drusus Caesar, son of Agrippina the Elder, was starved to death in 33 AD by the emperor Tiberius, and managed to stay alive for nine days only by chewing the stuffing of his bed. When Saint Maximilian Kolbe and nine others were starved in Auschwitz, seven of the ten died within two weeks.

When fluids are provided, however, survival can be much longer. Even in his 60s, Gandhi was able to go without food for 21 days. In the Irish hunger strikes of 1980-1981, no one who fasted less than 46 days died, and about half those who fasted between 46 and 73 days died.

So fluids and electrolytes extend the duration of a fast by about a factor of four. Since we want our fasts to be safe and health-improving, we should certainly take:

  • Water.
  • Sodium and chlorine. During a fast protein is converted to glucose and ketones, releasing nitrogen waste in the form of urea. Sodium and chloride are excreted along with the urea. Salt loss can be fairly rapid during a fast, equivalent to as much as a teaspoon of salt a day. A large amount of water is lost along with it.
  • Potassium. Potassium is the intracellular electrolyte, sodium the extracellular, and osmotic pressure must be balanced. So potassium will be lost along with water and sodium, and should be replenished with it.
  • Calcium and magnesium. These also serve electrolytic functions and it is desirable to maintain their concentrations.
  • Acids. These are beneficial for the digestive tract and metabolism, and also for solubilization of minerals. Citrate, for instance, helps prevent kidney and gallstones.

Vegetables are the best source of potassium; bone broth is a source of calcium and magnesium. The best acids are citrus juices, such as lemon juice, and vinegars, such as rice vinegar. Sea salt, or salty flavorings such as soy sauce or fish sauce, can provide sodium chloride. So the most basic food to take during a fast is a soup made of vegetables in bone broth, with salt and an acid added.

Here are some pictures. First, make up a bone broth by cooking bones in acidified water:

It’s best to use a ceramic or enameled pot to prevent leaching of metals from the pot.

When you’re ready to eat, put some scallions or celery and cilantro or basil in a bowl, and add hot broth:

Add salt, pepper, acid, and spices to taste.

Spinach and tomatoes are great vegetables for these broths, because they are rich in potassium. Here is a tomato soup:

Here’s a slightly fancier example. I think this had tomatoes, onions, peppers, carrots, and kohlrabi:

Served with parsley and scallions, rice vinegar, and sea salt:

Adding some food

So far we haven’t provided any calories to speak of. The next step in reducing the stress of the fast is to add some nutrition to the soup.

The stress of a fast is largely due to the absence of dietary carb and protein. The body has limited carb storage – glycogen is depleted early in a fast – and is loath to cannibalize lean tissue for protein. On the other hand, the body has abundant fat reserves. So

Two strategies may make sense in different circumstances:

  • A protein-sparing modified fast. Protein, which is convertible to glucose, is eaten to relieve the carb+protein deficit.
  • A ketogenic fast. Short-chain and medium-chain fatty acids, such as are found in coconut oil, are eaten to generate ketones. Ketones can partially substitute for glucose utilization.

What these have in common is that they reduce the carb+protein.

Probably 90% of people who fast should favor the protein-sparing approach. Those on ketogenic diets for neurological disorders should probably favor the ketogenic fasting approach.

An example of a food suitable for a ketogenic fast would be Neo-Agutak: “Eskimo Ice Cream” (Dec 5, 2010).

A suitable food on a protein-sparing modified fast would supply most calories as protein; carb and fat calories would be from nutrient-dense sources. Egg yolks, which are rich in phospholipids like choline, and potatoes are good examples of nutrient-dense fat and carb sources.

The easy way to implement this healthy fast: just add eggs, potatoes, and maybe some fish or shellfish (which tend to be protein-rich, and comply with the Catholic guidelines for Friday abstinence) to any of the soups shown above. Heat the soup in the microwave and there you have it: a healthy fast-day meal!

Conclusion

Those on weight loss diets will notice that by adding protein, carbs, and a few nourishing fats to our fast-day soup, we’re getting very close to our recommended diet for calorie-restricted weight loss diets: see Perfect Health Diet: Weight Loss Version (Feb 1, 2011).

There’s a good reason for that: both posts work from the same design principles. Both aim at the greatest possible nourishment on the fewest calories.

Would you like to lose weight? Consider making these nourishing soups a staple of your diet.

Even if you’re not fasting or trying to lose weight, consider making these soups a regular part of your daily meals. It’s very easy to make a broth on the weekend and warm it up and pour it over diced vegetables at mealtime. You might find them a very satisfying addition to your diet.