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Cholesterol Games

3rd March 2019

Mahatma Gandhi. 

I was advised that the Mail on Sunday was gong to attack us for daring to question the cholesterol hypothesis as well as the benefits of statins.

Below is the email I received.

Sent: 28 February 2019 16:53
To: malcolmken
Subject: MOS/Right to reply

Dear Dr Kendrick – The Mail on Sunday plans to publish an article this weekend on growing concerns about claims you along with numerous other people have publicly made about statins, the use of cholesterol in cardiovascular disease, and the allegations that investigators to the medication are financially conflicted because of payments made to the organisations they work for, and thus the evidence they supply about the efficacy of these drugs, and their side effects, are in some way untrustworthy.

Over the past 30 years, more than 200,000 patients have been put through the most rigorous forms of clinical trials to make definitive proof the pills lower heart attack risk by around 50 percent, and a stroke by 30 per cent, and reduce the possibility of death -- from any cause.

In January, the editors-in-chief of 30 significant heart health medical journals -- each a leading cardiologist -- signed a joint open letter, warning:'Lives are at stake [because of the] wanton spread of health misinformation. It is high time that this stopped.'

A 2016 analysis from the London School of Hygiene and Tropical Medicine, which tracks outbreaks and public health concerns, found fake news about statins could have prompted 200,000 patients in Britain alone to give up the drug over a single six-month interval following an article you wrote for the BMJ that claimed, erroneously, that 20 per cent of statins patients quit the drug because of side effects.

They estimate that up for 2,000 heart attack and strokes could be a consequence of this. We would like to offer you the opportunity to respond to this and the following:

*In your latest book, A Statin Nation, you state:'People are being scammed. The best way to prevent heart disease… has nothing to do with lowering cholesterol.' This is despite clinical trial evidence to the contrary, and despite no evidence that there is a con, which might imply that those who assert that lowering cholesterol can help lower the risk of heart disease know that this is untrue and are deliberately misleading the public.

*It has been alleged that the possible consequences of claims you've made about statins and cholesterol, far outweigh that of the infamous MMR vaccine scandal with one researcher stating:'In terms of death and disability that could have been averted, this may be far worse.'

*In our article, one leading cardiologist states that the facts you and others frequently cite about cholesterol and statins sound convincing but that in reality'they contain a grain of truth, combined with speculation and opinion, making is very difficult for the people to know who to trust.'

*You often quote observational studies as evidence of your claims about statins and cholesterol in posts and in media appearances which contradict findings of definitive clinical trials, which you don't mention. This is misleading.

They will not allow anyone else see the information they hold. Including all of the data on side-effects. It is kept completely confidential.' Also:'A fact that must be emphasised is that the CTT won't let anyone else see the data they hold. Including all the data on adverse events [side-effects] and serious adverse events.' It's a version of similar claims you've made a lot of times through the years. However, the CTT have said numerous times that they did not originally request the information on all adverse events so did not have it. They also point out that the stated data must be requested from the individual research organisation which carries out the trials, and is not in their present to provide. They say you understand this, as they've told you this, so to repeat the claim amounts to a lie.

*Your posture on statins and the link between cholesterol and heart disease amounts to misinformation.

*There is not any proof you work in NHS clinic, or as a GP in private practice.

Many thanks,

_________________

I wondered whether or not I should bother to reply, as I knew that the article would have been written, and very little was likely to be altered -- no matter what I wrote. Indeed, I thought long and hard about responding to the allegation that there's absolutely no evidence you work in NHS practice, or as a GP in private practice.

This could have been a lie, so I wondered about letting them print it, then suing their backsides off after. I then thought I will spend the next ten years having people write that I am not a physician at all -- on the basis of a lie printed in the Daily Mail. So, I disavowed them of printing this guide lie. Maybe I should just have let them get on with it.

They were going to write this…

A 2016 analysis from the London School of Hygiene and Tropical Medicine, which tracks outbreaks and public health concerns, found fake news about statins may have prompted 200,000 patients in Britain alone to give up the drug over a single six-month period following an article you wrote for the BMJ which claimed, incorrectly, that 20 percent of statins patients stopped the medication due to side effects.

Frankly, I wish I had written that paper, but I did not. It was written by Aseem Malhotra. This, I hope, gives you some idea of the high level of fact checking going on at the Daily Mail. Surprisingly, there were hardly any swear words.

Dear Barney Calman,

Thank you for your email. I am not entirely certain how you would like me to respond to each of your points.

To begin with, I do work for the NHS as a GP, and if anyone wishes to claim that I don't -- then that would be direct libel. Feel free to check with trust, or look me up on the GMC website. But if anyone states that I'm not working in the NHS then I shall most certainly sue. And I will win, so I would suggest caution on this point.

As for other specific points.

*You often quote observational studies as evidence of your claims about statins and cholesterol in posts and in media appearances which contradict findings of authoritative clinical trials, which you do not mention. This is misleading.

Do I not mention that the studies I estimate are observational, or that I don't mention the findings of clinical trials that are authoritative? Which of them is a issue, and why?

I'd add that the proof of the link between smoking and lung cancer was based on observational studies. Does this mean that smoking doesn't cause lung cancer? Or is that not their argument. Whilst observational studies are not generally regarded as powerful as randomised clinical trials, they have worth. Equally, most epidemiologists would agree that, whilst observational studies (demonstrating association) can't prove causality (unless the hazard ratios are extremely large ) a lack of association does disprove causation. Thus, it can be fully valid to rely on observational studies where there is not any association, or the observation is in direct contradiction to the hypothesis.

*It's been alleged that the possible consequences of claims you've made about statins and cholesterol, far outweigh that of the notorious MMR vaccine scandal with a single researcher saying:'In terms of death and disability that might have been averted, this may be far worse.'

If I'm wrong, then this statement could, possibly be true, although it does represent a form of reprehensible bullying -- accusing someone of causing many thousands of deaths. This is an accusation that Rory Collins has made. He attacked the BMJ for publishing an article suggesting statins can have a high incidence of adverse effects. You may wish to observe the e-mail exchange between Rory Collins and Fiona Godlee on this site https://journals.bmj.com/sites/default/files/BMJ/statins/SP13_Emails_between_Rory_Collins_and_Fiona_Godlee.pdf

I would also like to point you to a study published in the BMJ open Kristensen ML, et al.. BMJ Open 2015;5:e007118. doi:10.1136/bmjopen-2014-007118

The main findings of the study -- not refuted by anyone were…

6 studies for primary prevention and 5 for secondary prevention with a follow-up between 2.0 and 6.1 years have been identified. Passing was postponed between −5 and 19 times in primary prevention trials and involving −10 and 27 times in secondary prevention trials.

What this study found was that if you took a statin for five decades, the increase in life expectancy could be (on average) 3.5 days. That is around 0.75 days per year of statin treatment. That is the important outcome. The figures quoted by Collins and Baigent and the Oxford CTT group are relative risk reductions, and these figures are entirely meaningless unless you understand the absolute risk. Equally, to state lives could be saved is meaningless. No-one's life can be saved. That's what matters. I covered a lot of this in my novel Doctoring Data, which I'd advise that you read, as it summarizes the ways that data are presented to seem as beneficial as possible.

*In our article, one leading cardiologist says the truth you and others frequently cite about cholesterol and statins sound convincing but that in reality'that they have a grain of truth, combined with speculation and opinion, which makes is very tough for the public to know who to trust.'

I cannot answer this, what exactly does a grain of truth mean? What is a grain of truth mixed with opinion and speculation? Specific and concrete examples would be required before I could offer any meaningful answer.

*In your latest book, A Statin Country, you say:'People are being scammed. The best way to avoid heart disease… has nothing to do with lowering cholesterol.' This is despite clinical trial evidence to the contrary, despite no evidence that there's a con, which would imply that individuals who claim that lowering cholesterol can help lower the risk of heart disease know this is false, and are deliberately misleading the public.

Yes, I feel that people are being scammed, and I think the public are being deliberately misled. That's the reason I called my first publication The Great Cholesterol Con. I'd point out that there was one major placebo controlled double blind statin study done. ALLHAT-LLT, which was financed by the National Institutes of Health in the US. The conclusions of the study, published in 2002, were that:

CONCLUSIONS:

Pravastatin didn't reduce either all-cause mortality or CHD significantly when compared with usual care in older participants with well-controlled hypertension and moderately elevated LDL-C.  https://www.ncbi.nlm.nih.gov/pubmed/12479764

All the industry funded studies were positive. This is a remarkable coincidence -- or something else.

They will not allow anyone else see the information they hold. Including all of the data on side-effects. It is kept completely secret.' Also:'A fact that needs to be emphasised is that the CTT will not allow anyone else see the data they hold. Including all the data on adverse events [side-effects] and serious adverse events.' It is a version of comparable claims you've made numerous times over the years. However, the CTT have stated many times that they didn't initially request the information on all adverse events so did not have it. They also point out that the said data have to be requested in the individual research organisation that carries out the trials, and is not in their present to provide. They say you know this, since they have told you this, so to replicate the claim amounts to a lie.

You could perhaps ask them to point you to some letter or any other form of communication that the CTT have had with me. I will inform you the answer, they have never communicated directly with me, at any time. Thus, for them to state they've told me anything is, to be fully accurate, a lie. They claim don't hold the information, yet they've managed to publish major newspapers on statin adverse effects? For instance, this one. Interpretation of the evidence for its efficacy and safety of statin treatment .

Which contains sections such as these

'The only serious adverse events which have been shown to be brought on by long-term statin treatment --i.e., adverse effects of the statin--are myopathy (defined as muscle pain or weakness along with large increases in blood levels of creatine kinase), new-onset diabetes mellitus, and, probably, haemorrhagic stroke. Typically, treatment of 10 000 patients for 5 years with an effective regimen (eg, atorvastatin 40 mg daily) would cause about 5 cases of myopathy (one of which might progress, if the statin treatment is not stopped, to the more severe condition of rhabdomyolysis), 50--100 new cases of diabetes, and 5--10 haemorrhagic strokes. However, any adverse impact of these side-effects on major vascular events has already been taken into consideration in the estimates of the absolute benefits. Statin therapy may cause symptomatic adverse events (eg, muscle pain or weakness) in up to about 50--100 patients (ie, 0·5--1·0% absolute harm) per 10 000 treated for five years.'

So, they've written a paper outlining all the issues of adverse effects and serious adverse effects -- and yet they do not have the data. So, how did they handle that?

*Your stance on statins and the link between cholesterol and heart disease amounts to misinformation.

Maybe you would like to read this paper (that I co-authored)'LDL-C doesn't cause cardiovascular disease: a comprehensive review of the current literature.' Https://www.tandfonline.com/doi/pdf/10.1080/17512433.2018.1519391?needAccess=true  that was THE most downloaded paper published by Taylor and Francis in the previous year.

Or this paper'Lack of an association or an inverse association between low-density-lipoprotein cholesterol and mortality in the elderly: a systematic review.' Released in the BMJ open in 2016

'High LDL-C is inversely associated with mortality in most people over 60 years. This finding is inconsistent with the cholesterol hypothesis (ie, that cholesterol, especially LDL-C, is inherently atherogenic). Since elderly people with high LDL-C live as long or longer than those with low LDL-C, our analysis offers reason to question the validity of the cholesterol hypothesis. Moreover, our study provides the rationale for a re-evaluation of guidelines recommending pharmacological reduction of LDL-C in the elderly as part of cardiovascular disease prevention strategies. '

All I see from your e-mail are ad-hominem strikes on me. I see no facts at all. 

Yours Truly

Dr.Malcolm Kendrick

I followed up with a section of this battle that Prof Sir Rory Collins had Fiona Godlee within the book of the Aseem Malhotra newspaper where Rory Collins demanded an apology and a retraction of the paper. The BMJ took this so seriously they held an independent review.

I wrote a second e-mail to Barney Calman

I would also point you to this paragraph

A 2016 analysis from the London School of Hygiene and Tropical Medicine, which tracks outbreaks and public health concerns, found fake news about statins may have prompted 200,000 patients in Britain alone to quit the drug over a single six-month interval following an article you wrote for the BMJ that claimed, erroneously, that 20 percent of statins patients quit the medication because of side effects.

I didn't write that report. It is advisable to check your facts a little more closely before placing any article out there.

Listen, we all know where this attack is coming from. The CTT and Professor Rory Collins and Baigent et al.. They attacked Aseem Malhotra and Professor Abramson, then the BMJ, for publishing articles by Aseem and Abramson suggesting statins caused adverse effects in approximately 20 percent of individuals. Collins strikes were acute, and the BMJ was require to hold an investigation, where Collins strikes on these papers were judged to be unfounded. The whole review can be seen here. https://www.bmj.com/content/bmj/349/bmj.g5176.full.pdf

I would strongly suggest that you read it in full. It is, in a restrained manner, damning of Rory Collins and the CTT.

Here are a couple of sections from that report

All-cause mortality --A recent editorial by Vinay Prasad in Annals of Internal Medicine illustrates a fundamental problem that has always concerned the panel. Prasad compared two meta-analyses of statins in primary prevention that differed in their statistical decisions by less than half a percentage point and reached opposite conclusions--namely that that"statins decrease... total mortality" or conversely that"data. . . Showed no decrease in mortality associated with therapy with statins." Unfortunately, patients and clinicians have to make decisions in the grey area between these two diametrically opposed conclusions. The panel supports Prasad's contention that"The Cholesterol Treatment Trialists' research has a robust set of de-identified individual-patient data, which can enhance our understanding, and those data should be made widely available.

The decisions of the BMJ report, which are carefully written are worth considering

The panel was unanimous in its decision that the two articles don't meet any of the standards for retraction. The error did not compromise the principal arguments being made in either of the articles. These arguments involve interpretations of available evidence and were deemed to be in the range of reasonable opinion among those who are debating the appropriate use of statins. In making this assessment, the panel isn't expressing an opinion regarding the merits of these arguments, as that work was beyond the scope of the panel.

The panel did have one last comment. It became clear to the panel that the fact that the trial data upon which this controversy is based are held by the researchers and not available for independent assessment by others might contribute to a number of the uncertainty about risks and benefits. Different investigators may come to different conclusions with the very same data. In actuality, a particularly germane example occurred recently in both experienced Cochrane groups were charged with evaluating a particular intervention and, despite being given the same instructions, data, and resources, didn't arrive in identical results or decisions. The panel strongly believes that the current debates on the appropriate use of statins would be raised and usefully informed by making accessible the individual patient level data that underpin the relevant studies

Yours truly

Dr Malcolm Kendrick

P.S. employed to work in the NHS as a physician -- which is a truth.

In other words, the attacks on Aseem Malhotra were completely unfounded, as were the attacks on the BMJ. The whole dilemma of all-cause mortality is complex and there is a need for debate. Rory Collins and his team hold the robust set of de-identified data and those data should be made widely available. That would be the data they claim to not have?

How can it be allowed that one group of investigators hold all the information from the statin trial (not, apparently the adverse effects data -- although they have written detailed papers on this issue) and refuse to share it with anybody else?

Anyway, this is probably enough for today. I just wanted to give you some idea of the strikes and battles that are gong on and to shine a little light on what happens. The Mail on Sunday have published a very long article attacking'statin deniers' with images of me Zoe and Aseem in the front. I think I look quite dashing. Not as dashing as Aseem who is a really handsome swine, and also young, and smart -- and courageous.

Nor am I as attractive as Zoe Harcombe. I wasn't very keen on the bit where they called me self-pitying. But I was quite pleased that they included some of the things that I sent.

Until next time, best wishes from the mass-murdering, statin denying, self-pitying Dr Kendrick.

What are the best fermented foods?

Spicy foods, such as kombucha, miso, tempeh, and sauerkraut, provide many different health benefits. Learn about these fermented foods and other people.

Nutrient density in keto and paleo diets

What is nutrient density?

In this post we will address the following:

  • Do nutritious foods comprise, by definition, essential (micro) nutrients?
  • What factors affect nutrient density?
  • What is nutrient bioavailability?
  • Inactive vs active type of micronutrients
  • Examples of nutrient dense foods and why they're healthy
  • What role does micronutrient dense food consume in fat loss?
  • Can processed foods be nutrient dense?
  • What are the consequences of nutrient poor diets?
  • Buying list for nutrient dense food
  • My favourite nutrient dense recipes

What is nutrient density?

You may think answering this question is simple: food that contains many nutrients is nutrient-dense, right? I mean, just look at the label.

Actually, there's much more to it.

If I'm being honest, the huge problem is that food labels lie. You do not get the nutrients you believe you're getting. What you have been told about what is nutritious and what isn't is mostly nonsense. That being said, how can we make sense of nutrient density?

We begin far back with the Paleo concept. Our ancestors evolved to eat diets that were nutritionally complete, meaning that they contained all the essential micronutrients they had to function. Only dietary fat and protein turned out to be essential, not carbohydrates.

Our ancestors did not always succeed in getting enough food or the right kind. When they didn't, this could lead to nutrient deficiencies that cause disease and eventually be lethal. Thanks to modern science we have a good idea about what is is essential and what isn't. However, although we're pretty confident in what is essential and what isn't, how much of every essential micronutrient we should have to be healthy is significantly less clear.

There are 16 essential minerals, 13 essential vitamins, 2 essential fatty acids and 20 amino acids; 9 are essential amino acids, 6 are conditionally-essential amino acids (because we do not always make enough ourselves) and are 5 non-essential amino acids (since we always make enough ourselves).

Nutrient dense foods will have both (a) abundant quantities of these micronutrients and (b) a broad range of them.

There is no one-food that has the perfect amounts of everything you need. However, the foods that make you super close! They are animal sourced foods. Which ones? And they are both keto and Paleo!

When considered separately and comparative to animal sourced foods, vegetables, nuts and fruit are not particularly nutrient dense. Indeed, they lack a complete assortment of micronutrients, especially amino acids, some minerals and vitamins as well the fatty acid DHA. Nevertheless, it's also true that they have a reasonable bit of micronutrients which can be a good addition to one's diet.

Nutritious foods contain, by definition, essential (micro)nutrients

We all need a certain amount of energy and micronutrients for our body to function. Without listing all of the nutrients, lets cover some important facts about nutrient density. Not all sorts of nutrients and mixtures will do.

Everybody will eventually become ill without vitamin B12, one of the essential B vitamins. The several micronutrients arose out of millions of years of development, where it was better for people to get their vitamin B12 from the environment (food) rather than make it themselves (internal mobile production).

Most of us need a certain amount of dietary fat and protein to function. Those are the essential macronutrients. It seems our brain had glucose so much that it was better for it if we produced it'on-demand' rather than through the diet. Indeed, there is no such thing as an essential dietary carbohydrate. Additional humans evolved as apex predators searching big fatty game, and even scavenging the fatty marrow by breaking open the bones of left-over kills from other animals. It's no surprise that this is part of why we evolved to be outstanding fat and ketone burners.

You need to eat enough protein to get those essential amino acids that help maintain your basic physiology. At least 0.8 g/kg of body weight per day is suggested to avoid dying slowly from muscle wasting [1]. You should eat quite a bit more. Try 1.5 g/kg of body weight per day from high quality animal protein as a good starting point.

The fat known as DHA (docosahexaenoic acid) is only found in animal sourced foods and is an essential fat. It is simple to obtain enough from fish, eggs and ruminants. Most importantly, do not eat seed oils as they'll overwhelm DHA's activity, so to speak. You don't have to make any attempt to get it in your diet because it's everywhere – in plant and animal foods. To guard against having too much AA  just avoid seed oils (again). Other kinds of fats aren't essential but they're good energy sources, for instance the monounsaturated fat from bacon and olives or the saturated fat from beef and avocados.

What factors affect nutrient density?

It goes beyond the scope of this article to cover all essential micronutrients, so we will concentrate on the ones that people usually do not get enough of.

A food thing is nutrient-dense if it can provide adequate essential nutrients when eaten in reasonable quantities. For example, vegetables contain the inactive form of vitamin A (beta-carotene). So you may need to eat ridiculously huge volumes of carrots to cover your vitamin A demand for example. Consequently, carrots aren't considered a dense source of vitamin A. It might displace too many other more nutrient foods that are complete.

By way of instance, 100 g of beef liver comprises sufficient retinol, the active form of vitamin A, to prolong a person's retinol needs over a few weeks [two ]!

Few people wish to navigate that. Nutrita developed a food search engine to steer you throw this maze.

There is, of course, no single food or recipe that contains ALL essential nutrients in perfect amounts (even though a rib-eye isn't far off…). Some foods are particularly rich in certain nutrients and there's a simple guideline to be sure you get a good deal of those in; make high-quality animal protein that the centerpiece of your meal. That having been said, there's more to it than that.

Bioavailability is a essential concept. It's essentially a percentage score for how much of a nutrient you can absorb and utilize . 50% Let's explore several of the factors that determine bioavailability.

Active versus inactive form

Most vitamins and some fatty acids come in different forms. There is an active form, which is the one which the body needs. One example: β-carotene includes a conversion rate of 3.6 to 28. It follows that getting retinol from a carrot is 360% to 2,800percent less efficient than it's from beef liver. For this reason, it makes much more sense to cover the demand for this vitamin by ingesting the active form from animal-sourced foods.

Distribution

The term distribution refers to how much each amino acid, of which there are 20, is present in a food. There are nine essential amino acids, and your body requires a particular amount of each. What does that mean when deciding on your source of protein? That means that all protein resources aren't equal and that it is imperative to choose high-quality protein; high bioavailability of amino acids and their appropriate distribution. As a guideline, animal protein has a much higher bioavailability than plant protein. Eggs are the gold-standard as we can absorb almost all of an egg, 98 percent to be exact! Steak in contrast is about 81% bioavailable.

On a true, unsupplemented vegan diet you would not fulfill your basic amino acid requirements, however much you eat. The chief concern is methionine and glycine deficiencies. In adults these deficiencies are eventually life-threatening, but in babies, a vegetarian diet can be deadly within a year [3]. It is important for all people, but especially vegetarians and vegans, to consume considerably more (high quality) protein than the ordinary person presently does.

Anti-nutrients are very common in plant-based foods. They stick to minerals like iron and zinc and so make it harder for our digestive system to absorb it all [4]. Because of this, mineral values on many food labels (e.g. a pasta box) are over inflated.

Which foods are nutrient-dense?

The two prime examples of extremely nutrient-dense food are liver and eggs.

Let us start with eggs. As mentioned already, their protein is of the highest quality you can find. An egg has an ideal amino acid composition, and your body can use 98% of it to create proteins. Moreover, they provide pretty much all vitamins and minerals in acceptable amounts [5].

The only thing that eggs are low in, is vitamin C. Vitamin C is, however, abundant in most other foods, especially plants, so most people today get more than enough of this vitamin. Interestingly, if you stick to a low-carb or carnivorous diet, your vitamin C want decreases a lot. One reason is because the less sugar you eat, the more easily you are able to take up vitamin C from the gut since there's less sugar present to compete with it [6]. The other explanation is that if you eat very little sugar that your body is free to upregulate some of its own antioxidants and so relies less on dietary sources such as vitamin C. However, you can still easily obtain a great deal of vitamin C from plants on a keto diet remaining under 2% of carbs, for example from a little low-sugar fruit or a few plain old lemon juice.

Now to liver. First of all, liver is your number one source for retinol, the active form of vitamin A. Eat a slice of liver every few weeks, and you can dump any pseudo-vitamin A resources. It's also rich in pretty much all B vitamins, potassium, choline, and even vitamin C (when cooked and fresh lightly)! On a ketogenic diet, regular use of liver covers any worries you might have about maintaining the benefit from a diet rich in in vitamin C. If you desire or need to, you can count on animal sourced foods to avoid scurvy (a vitamin C deficiency)!

Apart from these two there are of course many more nutrient-dense foods:

Fatty fish, such as herring and mackerel are an excellent source of vitamin D and are abundant in the vital omega-3 fatty acids DHA and EPA (eicosapentaenoic acid) [7,8].

Avocados are a great source of potassium [9,10]. They are also excellent for a ketogenic diet since they are very high in fat and low in carbs. Vegetables are in general less nutrient-dense than animal-sourced food, because of the three reasons mentioned above: amino acid distribution, anti-nutrients and inactive forms. They also contain the inactive form (e.g. ALA) of certain essential micronutrients, like DHA. ALA is found in plants like flax seeds and DHA in animals like sardines.

This does not mean"don't eat vegetables". They do contain plenty of micronutrients and energy which could be healthy and taste great. However, they should never form the foundation of someone's food pyramid since, independently, they cannot fulfill the basic needs of human biology like animal sourced foods do. Then certain veggies, fruit and starches can find their place in your diet should you respond to them nicely (most people do).

As you can see, a well-formulated paleo or ketogenic diet that's based on animal sourced foods is mechanically very nutrient-dense.

How nutrient-dense food helps with fat loss

We all have to cover our nutrient demands. We need a certain amount of energy to survive, but we also need essential micronutrients to operate.

One idea to explain why people are fat states that they consume nutrient-poor food that's also calorie-dense, thus keeping them hungry so that they can keep eating until micronutrient needs are met [11]. Same thing as above but with protein; you'll never feel complete if you do not get enough protein [12].

In various words, junk-food seems to be the opposite of nutrient dense, so nutrient poor. Indeed, it is simultaneously high in energy (fat or carbs), low in protein and low in micronutrients. It's got other issues too, such as trans-fats, sugars, refined starches and oxidized oils: the ideal recipe to make you fat and sick.

Junk-food generally scores very high on the insulin index of foods (how much insulin your meals causes you to release). Junk-food is nearly always low in nutrient density. This combination is the entire reverse of foods such as meat and low-starch vegetables. Together, the vegetables and meat can form a nutrient dense meal which does not stimulate insulin excessively.

So, is there any processed food that is nutrient-dense? There surely is, in a'technical loophole' sense. In today's world, you can fortify anything with nutrients that are essential to make up for nutrient loss from food processing. Bread, for example, is generally fortified with vitamin B12, iron and potassium to prevent nutrient deficiencies (in vegans, for example). This form, also found in supplements, is the inactive form (hydroxocobalamin) of vitamin B12. The active form is called methylcobalamin.

The problem is you can't simply add micronutrients to foods to make them nutrient-dense; that's unscientific, but that's what most food makers do. Just like you can't pop mutis to make up for a nutrient poor diet. Another reason to avoid fortified foods is that they certainly contain oxidized seed oils and mostly consist of refined carbs. Quality olive oil doesn't make that list, fortunately. Do yourself a big favor and get your nutrients from better resources than seed oils.

The list below is by no means complete as it goes beyond the scope of this report. However, these are the ones that most people tend to get short of, so make sure to get enough of those:

Amino acids

It's vital to eat enough high-quality protein, at least 1.5 g per Kg body weight. If you tried to do that with low-quality plant-based proteins you would have to eat such large quantities of food that it would not be physically possible. This is why targeted supplementation of essential amino acids is vital in vegans and vegetarians. If you're keto but on the plant-based spectrum then get your essential amino acids from eggs, dairy and bivalve crustaceans (a category of shellfish).

Vitamin B12

Most B vitamins are crucial for nerve function. Regrettably, nerve damage is difficult to reverse, so you need to avoid a lack of B vitamins. Most vitamin B deficiencies are rare. But one that does occur surprisingly often and more and more so as the plant-based movement develops, is vitamin B12 deficiency [14]. All animal foods contain sufficient quantities of vitamin B12, however, you still need to check your levels as inflammatory conditions and gut dysbiosis may lower your ability to absorb vitamin B12.

Magnesium

Most people don't get enough magnesium [15]. This mineral is particularly crucial when you're starting a low-carb diet (like keto or paleo) because you get rid of plenty of water initially and along with it significant minerals. Dark chocolate, avocados, almonds, macadamia nuts, and spinach are particularly rich in magnesium.

Choline

Choline is needed to create specific phospholipids that are a part of the plasma membrane. Plasma membranes surround every single cell in the body. Liver and eggs are both rich in choline.

Vitamin D

Vitamin D also referred to as the sunshine vitamin, is difficult to get through winter months, especially when you're dark skinned. Oily fish is your best source for vitamin D from food. Vitamin D also helps you to absorb certain other nutrients, such as magnesium and calcium [17].

Retinol has various functions in the body: your nerve cells, blood cells, skin, eyes, immune system, and bones all need this vitamin to function properly. An acute deficiency is rare, but it can be hard to get optimal amounts from foods that are fermented. Liver is undoubtedly the best source for retinol and also rich in so many different nutrients!

Potassium

Most vegetables and mushrooms are excellent sources for potassium, and liver, again, is also a good source, along with fish such as halibut. The only problem is that it becomes easily lost when you boil the vegetables in water. So be certain to either use the water for something else or find an alternative method to cook your vegetables. Frying them in a pan with butter is always a good idea.

The omega-3 fat DHA is essential, and you only find it in fish, eggs, and meat. The plant-derived omega-3 fatty acid alpha-linolenic acid (ALA) has an abysmal conversion speed, which means you won't have the ability to get enough essential omega-3 fatty acids from chia seeds, flax seeds or even walnuts [18].

Nutrita makes it easy to see which foods are nutrient-dense and also respect another healthy eating principles. This listing is just supposed to give you a basic idea of nutrient dense foods you might enjoy. A couple of them may seem unappetizing, but you'd be surprised....

  • Chicken eggs
  • quail eggs

  • liver and other organ meats:
    • kidney
    • brain (excellent source of omega-3 fats! )
    • heart
    • tongue
    • feet, ears, tail...
    • testes

  • All Types of meat (grass-fed preferred):
    • poultry
    • pork
    • beef
    • lamb
    • game...

  • bone marrow (as a side with steak or to make bone broth)

  • All Types of fish and fish
    • salmon
    • mackerel
    • herring
    • sardines
    • halibut
    • codfish (also cod liver)
    • prawns
    • shrimps
    • mussels
    • lobster
    • squid

  • all kinds of frozen or fresh vegetables (vegetables that grow above the earth are preferred)
    • spinach, salad, kale, and other leafy greens
    • peppers,
    • tomatoes
    • zucchini
    • eggplant

  • all kinds of mushrooms

  • fresh herbs
    • basil
    • parsley
    • mint
    • dill
    • rosemary
    • thyme
    • sage

  • nuts
    • walnuts
    • macadamias
    • pili nuts
    • pecans
    • cashews (not too many)
    • pistachios

  • berries
    • blueberries
    • raspberries
    • blackberries
    • berries (botanically a nut)

My Favourite nutrient-dense recipes

A nutrient-dense diet doesn't have to be complicated. Quite the the opposite. When you merely combine seafood, fish or meat with a side of veggies, it will be hard not to create a nutrient-dense meal!

Because animal foods are the densest sources of essential nutrients, I have the perfect recipes that showcase both!

Keto Paleo Bombay Meatballs

How can Nutrita's food search engine score the ingredients in this recipe?

  • Ground beef (15% fat) has a Keto score of 9/10 and Nutrient density score of 6/10
  • Onion (red) includes a Keto score of 5/10 and Nutrient density score of 6/10
  • Coconut lotion includes a Keto score of 9/10 and Nutrient density score of 1/10
  • Coconut oil has a Keto score of 10/10 and Nutrient density score of 0/10

Average Keto score = 9/10 into 10/10

How can Nutrita's food search engine score the ingredients in this recipe?

  • Lemon juice includes a Keto rating of 6/10

Typical Keto score = 8

Typical Nutrient density = 8/10 to 9/10

Any diet which primarily consists of animal sourced food is full of essential nutrients. Plants are usually much less nutrient-dense relative to animal sourced foods, but they can continue to be healthy, mutually beneficial additions to a person's diet. If your diet looks more like a steak with a salad and eggs than it does pizzas and smoothies, you are doing it right.

Eat seafood, fish, eggs or meat every day. And if you want to, include vegetables as you like. Or fresh herbs, they add a lot of flavor to your dish. Nuts are also a good options but seeds less so, given they are more difficult to digest and aren't so nutrient rich. Fruit, especially low-sugar fruit makes for a excellent dessert. So go for berries rather than bananas.

As long as you're avoiding foods that contain added sugar, flour and seed oils, and you are not shying away from animal protein, your diet is probably pretty nutrient dense!

Raphael Sirtoli is your co-founder of Nutrita, a site helping individuals grasp cutting-edge nutrition science. Nutrita is also a mobile app that helps individuals follow well-formulated low-carb diets in addition to reach their health and performance goals. His day job however is neuroscience research in the Behavioraln' Molecular Lab where he studies the metabolic effects of antipsychotics in rodent models of schizophrenia. His understanding of metabolism, nutrition and clinical medicine forms the foundation upon which Nutrita derives its evolving knowledge. He loves open scientific debate, Crossfit, football, hiking, psychedelic medication, cold water immersion and cooking for loved ones.

Twitter is https://twitter.com/Nutrita_app and Facebook https://www.facebook.com/groups/nutritaapp/.

The post Nutrient density in keto and paleo diets appeared initially on The Nourished Caveman.

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