Living Well, a Holistic Approach Part 3
Dietary Considerations
Why Are We Talking About Diet?
The only thing I know that is definitely associated with longevity, based on credible experimental evidence, is caloric restriction. Everything else is largely anecdotal. Rats subjected – if that is the correct term – to a life of adequate but not excessive food intake lived longer than rats fed ad libitum. We assume that this observation translates to humans, but this is not proven. However, there is circumstantial evidence that it does, and that is found in various populations around the world who tend to live much longer. This is worth a short diversion.
The top ten places or countries for longevity vary with the source of the data, but everyone agrees that some populations live longer: Hong Kong, Japan, Costa Rica, Greek Islands, Singapore, Italy, Iceland, Sardinia, Monaco, Channel Islands (England). There is enormous genetic and economic diversity here, so it is difficult to attribute longevity solely to genetics, aside from the possibility of Iceland which has an inbred population. Wealth and ease of living do not play a role, except in the Channel Islands where the standard of living is high and health care is quite good. However, Sardinian shepherds and Greek islanders also are on the list, and they are not known for their wealth. The absence of stress is prominent in some of these places and may be important – who would not live longer in Sardinia, the Greek Islands, or Costa Rica - but the list also includes Japan, Hong Kong, and Singapore, not known as low stress societies.
A common factor is diet. If we speak about Japan, we refer to this as a Japanese diet. If we consider Italy, Sardinia, and Greek Islands we call it a Mediterranean diet. All of these people eat diets rich in fish, vegetables, fruits, soy, and low in added sugar, fat, and animal protein. They also exercise portion control, a euphemism for saying they do not overeat. The Okinawans even have a term for it which means to eat until you are 80% full and then stop. Many also have a style of living that requires them to walk to most of the places they go. Imagine that! We really are what we eat, and the food and advertising industries in this country have not done us a good service by touting steaks and animal protein, fast foods, sweetened desserts, and then pharmaceuticals to combat the resulting diabetes, heart disease, and obesity.
With all our wealth, creature comforts, and labor-saving devices, the United States ranks #46 out of 193 countries in the world for longevity – in tight competition with Cuba, Estonia, Panama, Albania, and Croatia. Data from the CDC show that the US has an obesity prevalence of 42%, the highest in the developed world. The annual medical cost associated with obesity in the US was about $173 billion in 2019 dollars. We also have a national problem with high blood pressure – 47% of us are hypertensive and many of us eat more than three grams of salt a day. There is a relationship here that we will pursue later.
It just feels intrinsically better to have the mind and body in efficient working order. The prospects of a healthy and functional longevity are a bonus that is only partly understood. The dietary focus here is for those in reasonable condition and wish to remain so. It is not designed as a major weight loss or a bodybuilding or endurance program, but all of this will occur to some degree as you proceed. Our program can be modified to include these concepts though in a more moderate format. Stay with me; you will see.
Diet is of importance in remaining mentally, psychologically, and physically efficient. Exercise alone will not do it. You have seen many people exercising, and perhaps becoming stronger, but you and they see no visible physical improvement because they are overweight. Your muscle tone may be good, but unless you can see some definition in those muscles, neither you nor anyone else will believe it. Muscle definition will appear when the fat overlaying the muscle is removed. You use diet to remove it. If you live in the developed world – no pun intended – probably you are overweight. It may be only ten pounds, but it is likely to be there.
Removing this weight will not be difficult. It will involve no special diets, nor the eating of kale and rhubarb. It is a matter of counting calories and staying below the number you need to sustain your level of activity. Given a balanced diet, you need a certain number of calories to maintain life – more than that, you gain weight; fewer than that, you lose weight. Call it the arithmetic diet. The body is very efficient: if there are too many nutrients coming in, it sets them aside for later in the form of fat and glycogen (starch). The well-known secret is a balanced diet and portion control.
Plautus captures the entire concept: “Moderation in all things”. This also can be translated as “Know your limits in all things.” The latter translation implies a more active knowledge and involvement on your part, while the former reflects a way of living. Either will work but if you use moderation in all things, you probably will avoid inadvertently running up against your limit in something, with perhaps adverse consequences. I have yet to read or hear of a sustained life-style plan that does not amount to moderation. There are many diet and exercise plans for the athlete, or the person dedicated to some activity, (rock climbing, marathons, triathlons, etc.) but they are good only as long as one is focused on that activity and has built it into a life plan. Over time, especially in older age, one must adopt a style of living that can be sustained yet provide the necessary breadth and level of activity, mental and physical, that keeps one engaged in both life and living.
Calories
Diet goes hand in hand with exercise and mental discipline. You can develop good muscle tone, but if the muscles are covered in a layer of fat, you will never see it and seeing it is what stimulates you to continue. We are all somewhat narcissistic, after all. The concept is arithmetical and does not require eating or not eating various things. Just burn what you eat. Replacement, not storage. Think about calories needed versus calories ingested.
A nutritional Calorie is derived from physics which measures energy in calories. A nutritional calorie is actually a kilocalorie in physics and sometimes is written with a capital C. A Calorie describes how much energy is released when a given food is metabolized. The average adult needs about 2,000 Calories daily to live, but this varies with activity and decreases somewhat in older age. An older woman who is not physically active needs about 1,600 C; a man needs about 2,000-2,200 C. Develop your diet around that and you will maintain weight. Take in an extra 100 calories per day for a month and you will gain about a pound (It takes 3000-3500 Calories above the daily requirement to gain a pound of solid weight). Over the course of a year, you will gain twelve pounds. It is easy to take in an extra 100 Calories a day.
Here is a simple example: if you like vodka martinis, as I do, you should know that one ounce of 80 proof vodka has about 100 Calories. If you add one ounce of dry vermouth to it, that adds an additional 45 Calories. Since no one uses just one ounce of vodka in a martini, and no one puts a full ounce of dry vermouth in one either, your vodka martini at the end of the day probably contains 220 Calories (two ounces of vodka and about ½ ounce of dry vermouth.) Leave out the vermouth and you still have 200 Calories. You have just taken in one-tenth of your daily caloric requirement. With a second martini you are up to 400 Calories and well on the way to gaining weight slowly. You can either cut down the martinis or decrease the food – I leave that to you. Just remember that to burn an ounce of vodka requires about ½ hour of walking or 15 minutes of cycling. I have chosen not to give up the martini and walk instead.
One must pay attention to caloric intake in order to maintain or lose weight. The only way I know to do this is to count calories, at least until you develop a working knowledge – it should require about two weeks – and then think about what you are eating. A good source for information of this sort is www.calorieking.com.
As a check on progress or as a place to start and as a rough measure of your physical fitness, the body mass index (BMI) can be a useful guide. It is calculated by dividing your weight in kilograms by the square of your height in meters. It also can be calculated by going to one of many web sites that will allow you to put in your weight and height (in pounds and inches) and it will give you your BMI. Input “body mass index” into Google and in less than a second more sites than you can count will appear. Two useful sites are: www.webMD and www.hallsmd.com. Both contain calculators, explanations, and charts that will compare you to the adult population according to gender. I find the latter site somewhat better.
In general, a BMI of greater than 30 indicates obesity; from 25-30, overweight; 19-25, normal; below 19, underweight. The median BMI for men is about 25; that is, half of the male population is overweight. For women, the median BMI is slightly higher. A normal BMI correlates with longer life and a healthier life. This can be a bit misleading since muscle has a higher density (weighs more) than fat and a healthy, muscular man could register as overweight on the BMI calculator. Arnold Schwarzenegger and Sylvester Stallone probably would calculate to be overweight but probably never have carried any fat on them in their lives. But, since we are not they, the BMI remains a useful guide for us.
It is difficult to lose weight in older age. It may require a change in habits that have developed over many years and the will to make those changes declines. Sometimes it takes a catastrophic event, such as a heart attack, to bring about a change to a healthy diet and lifestyle. It is better to make those changes before your body demands it of you by sending a message.
Generally, one is better off by losing weight slowly, a few pounds a month, since that can be done by a modest decrease in Calorie intake. Slow changes can be sustained easily. This is done by taking in a few hundred Calories less than needed for maintenance until the desired goal is reached. Time is unimportant. Choose modest goals that can be met in a reasonable time for you and your success will reinforce your effort.
Portion size is important. It refers to how much of a given food you eat. It is not necessarily the same as a serving size; that is a standard of measure, such as a cup, gram, ounce, tablespoon, etc. Most nutritional labels mention a serving size, one cup, for example, but you may pour out one and a half cups into a bowl. The calorie equivalents on the nutritional label only apply if your portion size is the same as the serving size described. Portion sizes sometimes get out of control in restaurants because customers have expectations about what they should receive for the price they pay, and the restaurant wants you to return and to tell your friends. So, an omelet -ignore the filling, that is another issue – might be made of three eggs in a restaurant and look wonderful…but that would not be a portion size at home. Keep portion sizes under control by eating part of a main course and take home the remainder or use appetizers as a main course.
A Balanced Diet
A diet should be balanced in terms of protein, fat, and carbohydrates; contain the necessary vitamins and minerals; and supported by an adequate water or fluid intake. The 2015-2020 Dietary Guideline for Americans recommends a Calorie proportion of 45-65% carbohydrates, 25-35% fat, and 10-30% protein. There are many studies on proportions of macronutrients and mortality and the percent of fat seems to be the only one of the three that affects mortality. Too little, less than 20% is deleterious (there are essential fatty acids that we must have) and too much, greater than 40%, definitely is. The numbers above are in general use and a balanced diet is built around them.
Usually there is no need to add various nutraceuticals, vitamins, or other supplements to a balanced diet. Restrictive diets that feature an emphasis on something new to eat or require you to take in too much of one type of food or eschew another, go in and out of popularity, largely depending upon advertising. They are of questionable scientific value. I suggest you avoid them. Radical changes in diet or intake usually do not last very long, as the body rebels psychologically against the insult and clamors to get back to normal.
A healthy and balanced diet contains fruits, whole grains, vegetables, fat-free or low-fat dairy products, seafood, and poultry. Meat is included, but, in my view, it should be a minor component. If you eat too much meat, it will crowd out the seafood and poultry and replace them with animal fat. Eggs, nuts, soy, and seeds complete the menu. The Mediterranean diet is similar but contains more fruit and seafood and less dairy. I prefer it because it relies less on meat.
Carbohydrates should be present in the diet largely as whole rather than refined grains. Half or more of the grains we eat should be whole grains. Food made from wheat, rye, rice, oats or other cereal grain are grain products. They include bread, pasta, tortillas, breakfast cereal, rice, etc. Carbohydrates are the main source of energy and, correspondingly, are the largest per cent of the diet – 45-65%. Important vitamins and minerals, primarily iron and B vitamins, reside in the husks of whole grains and, therefore, are better for you. An example of this is whole grain rice and refined “polished” rice. The former contains vitamin B1(thiamine) in the husks and it is missing in the polished rice. Many grains are refined for a finer texture and longer shelf life at the cost of losing important nutrients, although many nutrients now are added back during processing. But we are better off, and I think get more flavor, with whole grains. We have been oversold and tend to overconsume refined grains. Keep whole grain products in mind when you shop or plan meals.
Proteins are polymers of amino acids and, when ingested, are broken down into their component amino acids. These are absorbed through the intestine and distributed throughout the body to be used in the synthesis and repair of tissues and create new cells. If there are more amino acids than are needed, they are used as energy sources. If you exercise, your demand for protein may be higher since you are building muscle. If you are an older person who is not exercising, you will notice that your muscle mass is slowly diminishing – an unavoidable event in the older population. This is why exercise of any type is important after seventy, it helps maintain muscle mass and strength. Protein allows the body to strengthen muscle by providing the construction materials to do so. Your diet should include 10-30% protein, and toward the higher number if you are actively exercising.
People over seventy should eat a variety of nutrient-dense proteins from lean meat and poultry. The meat should be low in fat. Red meat is a protein-rich food and considered a nutrient-dense protein source. Additional protein sources include seafood, eggs, beans, nuts, and soy. There is a movement to use plant-based foods in place of meat. This is a good way to avoid the saturated fat and cholesterol present in meat. Many of these products taste good and are a desirable substitute, but these plant-based meat alternatives are complex mixtures of various foodstuffs, high in sodium, and contain oils, usually coconut, that are high in calories and contain saturated fat (see below).
Seafood is a good source of protein and also contains essential fatty acids that our bodies need. Omega-3 fatty acids have been touted much because these are unsaturated essential fatty acids that our bodies cannot make. The designation omega -3 refers to the position of the double bond three carbon atoms away from the terminal methyl group and holds no mystique beyond that. Although we need essential fatty acids in small quantities, we receive them in a balanced diet, and particularly from seafood. Salmon and trout are good sources, as are anchovies. The problem with the latter is that you have to eat anchovies, so I suggest you stay with trout and salmon. Omega-3-containing nutraceuticals have been touted for years as important dietary supplements. Thus far, no independent scientific study has supported this. Save your money and eat salmon instead…or even anchovies if you really like them.
Fats
While we are on the topic of dietary fats, it is worth exploring saturated Vs. unsaturated fats. There is much writing about them but how much do you really know? The essence is that saturated fats tend to be solid at room temperature and come from animal sources - think a well-marbled steak. Unsaturated fats usually are liquid at room temperature and are from plant sources - think canola cooking oil. Chemically, unsaturated fats have one (mono-) or more (poly-) double bonds in the fatty acid chain. When these double bonds are reduced (saturated) by the addition of hydrogen, they are converted to the usual single carbon-carbon bonds and this changes their physical properties.
The health benefits are found largely with unsaturated fats. Dietary studies have shown that foods rich in unsaturated fat decrease blood cholesterol and lower your risk of heart attacks and stroke. Good sources of unsaturated fats are fatty fish such as salmon and mackerel; seeds such as flaxseed; oils such as flaxseed, canola, soybean; unsalted nuts; green leafy vegetables; avocados; and legumes.
Olive oil, a staple of Mediterranean cooking, is a largely unsaturated fat. It is comprised 73% of oleic acid, a monounsaturated fat, about 11% polyunsaturated fat, and about 14% saturated fat. It is generally considered a healthy choice for cooking and, since it is mostly monounsaturated fat, it is more resistant to high heat.
Although olive oil is a good cooking oil, it also is more expensive than some vegetable oils, of which there are many. The most popular are canola and sunflower oils, and they have the lowest amounts of saturated fats, 6% and 9%, respectively. They are largely monounsaturated fats, 62% and 82%, respectively, and so have a high smoke point like olive oil and their caloric content is the same, about 120 C per teaspoon. So, the cooking choice is one of cost, vegetable oils, or preference for flavor, olive oil, especially extra-virgin, from the first cold pressing of the fruit.
A word about coconut oil. It also has been much talked about because it is used in plant-based meat products. It has the highest content of saturated fat, about 92%, and about the same calorie content as the above oils. It is not as healthy as the unsaturated oils.
Coconut oil with its saturated fat content provides a segue into trans fatty acids. This has nothing to do with gender, but rather an industrial process. Vegetable fatty acids that are unsaturated can be hydrogenated using a chemical process that puts the hydrogen atoms on both sides of the broken double bond. Enzymatic hydrogenation is specific to one side of the double bond and these are cis-fatty acids. The specificity of enzymes is a fascinating aspect of biochemistry that we shall not expand upon here. The trans process (also called partial chemical hydrogenation) causes liquid vegetable oils to become more solid, as they become progressively more saturated. This extends the shelf and cooking lives of the fat and gives foods cooked (deep fried) in them a desirable taste and texture. Have you ever eaten anything that was deep fried that was not good? Restaurants and fast food outlets use trans fats because the oil can be reused many times in commercial fryers. In our younger years, we all enjoyed various things cooked in commercial fryers. However, it gradually became clear, due to research done in the 1990s, that trans fats can raise LDL cholesterol and lower HDL cholesterol and this increases the risk of heart disease and stroke and a higher risk of developing type 2 diabetes. In response, the FDA instituted labelling regulations for trans-fat and consumption in the US has decreased considerably. Several countries Denmark and Switzerland, for example and some jurisdictions in the US, California, New York City, and others, have reduced or restricted the use of trans fats in food service establishments.
Nevertheless, many of us continue to be exposed to these fats through our diets. According to the American Heart Association, these fats are found in fried foods such as doughnuts; baked goods such as cakes, pie crusts, biscuits, frozen pizza, cookies, crackers; and stick margarines and other spreads. You can determine the amount of trans fat by reading the Nutrition Facts panel. Products can be listed as “0 grams of trans fat” if they contain less than 0.5 gram per serving. These fats sometimes are described as “partially hydrogenated oils” and this gets away from the trans word without removing the fat. So, read the labels when you buy food and, when eating out, ask what kind of oils are used for cooking. Many places, usually higher priced, will be using peanut oil or other high smoke point oils for the intense heat required in deep frying. Also, you could stop eating deep fried foods.
A final comment before we leave fats. There is much information about fats in the diet because they have been shown to have serious deleterious effects on our health: heart disease, stroke, diabetes, metabolic syndrome. Much of the internet information about all of this is of doubtful quality. Here are some reliable sources if you wish to pursue this.
American Heart Association: www.heart.org
Medical Encyclopedia: www.medlineplus.gov
Healthline: www.healthline.com
And
Protein as a nutrition source: www.hsph.harvard.edu
Dairy Products
Dairy products provide calcium, important for older adults to maintain bone strength and structure, protein, and vitamins B12, A, and D. In addition, there are certain minerals. They also can provide a fair amount of fat, so chose carefully. These products are made from milk and, in Western cultures, the milk comes from cows, goats, and sheep. The primary products made from milk are yogurt, cheese, ice cream, and butter. Except for the last two, which have more sugar and fat, the three other dairy products are considered nutrient-dense. That is, they provide a high level of nutrition for relatively few calories. The Dietary Guidelines for Americans recommends three eating patterns: Healthy U.S., Healthy Vegetarian, and Healthy Mediterranean. The first two include three low-fat or fat-free dairy servings per day while the Healthy Mediterranean includes two to two and a half servings for adults. (The Mediterranean diet just keeps popping up, doesn’t it? Could there be a message there?)
Humans have had a cautious relationship with milk and its primary sugar, lactose, for about as long as we have been around. Farmers made cheese thousands of years ago but lacked the enzyme lactase in the small intestine that allowed them to digest lactose. Prehistorically, we were all lactose intolerant as adults but also did not drink too much milk. Babies have the enzyme and can manage milk without difficulty but as they age, they lose the enzyme at variable rates and become lactose intolerant. Fortunately, during the cheese- or yogurt-making process, which has been around for millennia, some of the lactose is lost and adults can manage to digest these products.
Now, about 35% of the population with European ancestry have the lactase enzyme and are lactose tolerant. The same is true for some African and Middle Eastern populations. Apparently, about 8000 years ago in Anatolia (now largely Turkey), mutations in the genes at or near the lactase locus began to appear with some frequency and humans began to develop tolerance to lactose. It is not clear when these mutations began, but this is a very short time in evolution. There probably was some benefit to having this gene, since it allowed people to consume milk and its products without the diarrhea that occurred otherwise. Diarrhea in a poorly nourished population would have increased death rates and would have provided some positive selective pressure for the retention of the lactase enzyme.
The real answer is not known but the fact remains that a lactose intolerant species underwent a recent genetic change that now allows a third of us to consume milk and its products without difficulty. This genetic trend may continue, but any selective pressure is now gone or minimized by good nutrition and better medicine. Moreover, we have developed inexpensive and effective ways to eliminate the consequences of lactose intolerance for the two-thirds of the population that still have it. Cultures of lactobacillus, and other aids, can be taken orally to replace the enzyme inside the intestine. We all now have gone from being evolutionarily lactose intolerant to either genetically or pharmaceutically lactose tolerant. What will that do to the persistence of the lactase gene in our population? I suspect nothing, since there is no pressure to keep or lose the gene. You will have to ask your great-great-grandchildren, but it is an interesting story.
There are many types of dairy products and they are a universe unto themselves. A good source for information about dairy products is www.usdairy.com. There is some advertising here, but it is a useful site.
There are a few things that should be mentioned about each of the groups. Milk itself contains many nutrients that are important to those of us over seventy. These include protein, calcium, phosphorous, and several essential B vitamins, along with vitamins A and D. However, whole milk also contains a lot of fat that you do not need, and I recommend low-fat or fat-free milk instead. These retain the benefits of milk without the fat content.
Then there is cheese. The hopelessness of this situation was ably expressed by Charles de Gaulle: “How can anyone govern a nation that has two hundred and forty-six different kinds of cheese?” There literally are hundreds of varieties of cheeses. A stroll past the cheese section of your supermarket will leave you with a dizzying array of adjectives: chewy, crunchy, soft, hard, creamy, bold, buttery… and the beat goes on. Add to that the fact that the source, cow, goat, or sheep makes a significant difference as well. However, fortunately, we are not concerned here about texture and taste, but their nutritional role in your diet.
The overall nutritional benefits of cheese are those of its parent, milk. It is a good food but is calorie-dense: you generally take in about 100 C/ounce. It also is high in fat, and much of that is saturated, and is high in salt as well. People who are overweight, hypertensive, diabetic, have cardiovascular disease, high cholesterol, or just want to limit their intact of fat and salt, should eat cheese only in moderate amounts. Softer cheeses usually have more fat per unit weight than hard cheeses. The amount of salt is less predictable.
The labels become important here. Most cheese is made from whole milk, hence the high fat content, but there are low-fat cheeses. These must contain three grams of fat or less per serving. A reduced-fat cheese has at least 25% less fat than regular, according to Healthline.
A word about “processed cheese.” It isn’t cheese. These are made with cheese but have other dairy and other non-dairy products and chemicals added to them. Hence the name: “pasteurized process cheese food.” They are much less healthy than real cheese. They also tend to have more salt than regular cheese. Speaking of salt…
Salt
Salt intake will confound the issue of weight loss or weight maintenance by keeping water in the body and may raise your blood pressure as well. One of the first drugs given to persons with high blood pressure is a diuretic – a drug to increase salt excretion through the kidney. Extra salt distributes throughout the body and holds water with it. It takes a few days for the kidney to reestablish salt balance and your weight will fluctuate. If you continue to eat too much salt, then the weight gain will be sustained. For every pint of water you retain by excess salt intake, you gain a pound. Your salt intake should be around 1500 milligrams (1.5 grams) a day. This is considerably less than is recommended by most commercial sources but is much healthier. If you look at the labels on cans and packages that tell how much salt is in one serving as a per cent of your daily salt requirement, you will note that the manufacturers consider about 2,500 milligrams to be a normal daily salt intake. Therefore, a serving that gives you only 5% of the daily requirement of salt, and does not sound too bad, actually is giving you about 8% of your requirement based upon a 1,500 milligrams salt diet. Most medical authorities use 1,500 milligrams as a preferred daily salt intake. Many in the US eat over three grams of salt a day. This usually means a diet heavy on snack foods, fast foods, and processed foods. Please don’t do this, it makes no sense, causes you to gain fat and water, and will shorten your life.
Persons with diseases that require attention to diet – hypertension, diabetes – should reduce or eliminate salt, sugar, and those foods rich in either. That diet then should be adjusted for the number of Calories needed. It is quite possible that you will decrease or reverse high blood pressure by cutting your salt intake back to 1500 mg. or less.
A last comment: You cannot out-exercise a bad diet.