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Sports Nutrition Update from the American College of Sports Medicine

Staying on top of the latest sports nutrition information is a challenge. That’s why I attend the annual meeting of the American College of Sports Medicine (ACSM). ACSM is a professional organization for sports medicine doctors and health-care providers, sport dietitians, exercise physiologists and sport science researchers. More than 3,000 ACSM members gathered in Minneapolis (May 2018) to share their knowledge and latest research. The following summarizes a Sports Nutrition Update session presented by many leading exercise scientists from around the globe.

Fat vs. Carb

Gareth Wallis PhD, Univ. Birmingham, UK

Which will better enhance athletic performance: A high carbohydrate or a high fat sports diet? Despite growing interest in a high fat sports diet, research does not support it for athletes who exercise at high intensity. Rather, research supports consuming 3 to 4.5 grams carbohydrate per pound  (7-10 g carb/kg) body weight per day to be well fueled for hard training and competitive events.

Grains, fruits and veggies are obligatory if you want to exercise hard. Some athletes eat a high fat diet for training and then switch to carb-loading before a competitive event. Bad idea. The enzymes involved in metabolizing carbohydrate become less active, so the muscles are less able to access carbs for fuel when it is needed for winning sprints and surges.

Protein for Athletes

Nicholas Burd PhD, Univ Illinois and Trent Stellingwerff  PhD. Canadian Sport Institute

If you want to build muscle, when is the best time to eat protein: before, during or after you lift weights? It might not actually matter because resistance exercise stimulates a muscle-building effect that is most robust within the first 4 hours but lasts for 1 to 2 days. You need not carry a protein shake around the gym! More important is to pace your protein intake evenly throughout the day.

Resistance exercise is far more potent than a high protein diet for increasing strength and muscle gains. That said, most athletes could expect to see only a gain of about 2 pounds (1 kg) of muscle in 13 weeks. That’s not very much compared to what they really want to see.

Maximal anabolic (muscle-building) effects are seen with about 25 to 30 g protein per meal. More precisely: 0.75 g protein per pound of body weight per day, or 0.1 to 0.2 g protein per pound per meal in young men. More than that has little or no further benefit. However, these recommendations do change with age. If you are >50 years old, you should target an additional 10 grams of high quality protein (milk, egg, fish, soy) per meal. That’s just a little bit more: a glass of milk or 1.5 ounces of meat-fish-chicken.

Despite rumors, protein does not damage the kidneys nor cause a decline in kidney function. Even people with chronic kidney disease should consume the RDA for protein (0.8 g/kg). A high protein diet also does not cause bone loss. Bone is 40% to 50% protein (collagen).

Over-consuming protein is not only a waste of money but it also stresses the environment. As athletes, we need to take a holistic and whole-foods approach to our diets. Natural protein-rich foods, as opposed to processed supplements, are best (if compatible with your training schedule) because they offer a complex and complete matrix that is more effective than processed proteins. One example of the benefits of whole foods can be seen with eggs. A whole egg promotes 40% greater muscle protein synthesis in the 5 hours post-exercise as compared to eating just the egg white (van Vliet AJCN 2017). Nutrient interactions seem to facilitate a more robust response when compared to eating isolated protein.

Sport Supplements

Eric Rawson PhD RD, Messiah College

There is no one single sport supplement that works for all athletes. To better understand why, we need a more specific scientific approach to studying supplements based on age, sex, body size, training status, and genetics. That would help us give better advice to target groups of athletes, rather than simply make population-wide recommendations. Many athletes take multiple supplements, so research with “stacked” supplements would also be helpful. Here’s some of what we do know:

Creatine enables an athlete to lift harder in the training room—and build more muscle. But not everyone is a responder. For example, 3 of 11 subjects in a research study had a strong positive response, 5 had a slight response—and 3 did not respond at all (Syrotuik, Bell 2004). Why not? Maybe their daily diets impacted their baseline creatine levels?

Creatine is found in meat and other animal proteins.  When a meat-eating athlete goes on a meat-free lacto-ovo-vegetarian diet (milk, eggs, beans) for 26 days, his or her creatine levels will drop. (Lukaszuk, 2005). To normalize the level, athletes could take creatine monohydrate supplements (the most effective form of creatine).

Caffeine is a known energy-enhancing sport supplement. Your response to caffeine will depend on your genetics. Caffeine works best when you are starting to fatigue. Athletes can consume it in coffee, tea, soda, gels, gum, and pills, preferably consumed with carbs.

Sodium bicarbonate is used by some athletes to buffer the lactic acid that builds up during intense bursts of exercise. Research suggests peak response times can vary widely, from 40-165 minutes. (Jones 2016 ISSN). This variability makes it hard for exercise scientists to offer firm recommendations; hence, outcomes vary. Sub-elite athletes seem to respond better then elite athletes. Because sodium bicarbonate easily causes nausea and vomiting, a solution it to take it in gastro-resistant capsules.

Fluids and Hydration

Linsday Baker, R&D Principal Scientist, Gatorade Sports Science Institute, Pepsi Co.

When you sweat, you lose proportionately more water than sodium, hence sodium levels in the blood increase with dehydration. The amount of sodium you lose in sweat varies from a lot to a little, related to both sweating rate and how well you are acclimated to exercising in the heat, among other factors. A high concentration of sodium in your blood stimulates thirst.

Thirsty athletes have three ways they deal with replacing fluid losses: hit-or-miss ad lib drinking as desired; drinking to quench thirst; and drinking on a set schedule. The effectiveness of these strategies depends on the individual athletes, availability of fluids, the weather, and exercise intensity and duration. If you happen to have a lot of tattoos, take note: tattooed skin may sweat less and excrete saltier sweat.

Nancy Clark, MS, RD counsels both casual and competitive athletes at her office in Newton, MA (617-795-1875). Her best selling Sports Nutrition Guidebook and food guides for marathoners, cyclists and soccer players offer additional information. They are available at www.NancyClarkRD.com. For her popular online workshop, see www.NutritionSportsExerciseCEUs.com.


Does juicing really “detox” the body?

Anything that promises detoxification sounds a little questionable – like products that claim to “pull toxins out of your system” or “cleanse the liver.”  The body does have detoxification mechanisms that are working all the time, and both healthful eating and intermittent fasting can accelerate those processes. Several-day juice “fasts” are one way to tap into the benefits of intermittent fasting and enhance removal of toxins from the body, because the body enhances the removal of toxins when not digesting food and burning more fat for its energy needs. Our fat supply stores toxins, and when we lose body fat we release more toxic waste simultaneously. The body also needs adequate phytochemical and antioxidants for the liver to most effectively process fat-soluble toxins so they can be excreted via the urine.

Get into the catabolic phase

We’re always either in a fed state or a fasting state; you’ve likely read about the anabolic and catabolic phases of digestion in my books or articles that discuss toxic hunger. When we are eating, digesting, and absorbing nutrients from food, we are in the anabolic phase; think of it like filling your car’s tank with gas. That is followed by the catabolic phase, between meals, in which our energy needs are met by burning energy that we stored during the anabolic phase.

The catabolic phase is when most healing and self-repair happens, and there is evidence that prolonged time in this fasting (catabolic) state has significant health benefits. Also, these benefits don’t necessarily require an extended, several-day water fast, which is difficult for most people to commit to.

I always say, the longer you live in the catabolic phase, the longer you live. Here’s why: Being in a fasting state shifts the body’s cells away from growth, and instead toward a mode of maintenance and repair.1,2 This repair mode is associated with a reduction in insulin and insulin-like growth factor-1 (IGF-1) production; two hormones that play a huge role in health and longevity.3,4 These hormonal changes lead to reduced inflammation, improved insulin sensitivity and stress resistance, slower cell growth, improved immune function, and reduced oxidative stress.5,6  Fasting also stimulates autophagy, an important self-repair process. Autophagy removes damaged components from cells and tissues.7

Eating right is already detox; calorie restriction enhances the benefits

On a cellular level, many dietary phytochemicals – such as isothiocyanates derived from cruciferous vegetables, sulfur compounds from garlic and onions, and carotenoids from a variety of colorful produce – drive the production of enzymes that enable the excretion of carcinogens and other potentially harmful compounds. This detoxification system counteracts oxidative stress, inflammation, and DNA damage.8  Eating right, in itself, enables valuable detoxification mechanisms.

Caloric restriction adds to this, and has been the one intervention that extends life in a number of different species. Adding periodic calorie restriction to an already nutrient-rich diet could intensify the body’s ability to heal and repair by extending the amount of time in the fasting repair mode and reducing growth-related signals.4  It also can enhance the breakdown and excretion of fat-soluble toxins; lowering the body’s toxic load.

Intermittent fasting

Intermittent fasting or a juice detox could also be a warm-up to incorporating occasional water fasting. Back in 1995, in my book, Fasting and Eating For Health, I discussed my experience of how fasting improved health parameters in my patients. I also co-authored a series of case reports documenting remission of autoimmune diseases following supervised fasting.9  More recently, fasting has been shown to have dramatic regenerative effects on the immune system. Studies over the past few years in animals and humans have suggested that fasting signals the immune system to discard old and damaged cells and generate new cells by increasing hematopoietic stem cells. The reduction in IGF-1 signaling was a necessary factor in this immune boosting. 6,10

Intermittent fasting – usually by reducing calorie intake dramatically a few days per week – is a method for getting some of the benefits of longer-term fasting. Human studies on intermittent fasting suggest it improves insulin sensitivity and promotes weight loss.2,11,12

I recommend incorporating a juice detox into your life, with vegetable juices plus one salad per day for several days, to act as a method of intermittent fasting, to slow aging and prolong lifespan as an easier alternative to water fasting.  Water fasting has a rapidly decreasing effect at removing toxins, as nutrients necessary for the removal also decrease as the fast progresses. Also, juice fasting enables the participants to continue to work and is safer, compared to water fasting, as it prevents dehydration, loss of electrolytes and fainting. It is also compatible for people who must remain on medications, so almost anyone can participate.

Tips for juicing wisely

  • Figure out a timeline you’re comfortable with. You may want to try juicing one day a week, or you may want to try a week-long juice cleanse.
  • Juice should be mostly vegetables, not fruit. Apple juice with a little kale added doesn’t bring much benefit. The maximum amount of fruit in a vegetable juice should be one serving of a low-sugar fruit, such as green apple or berries. The rest should be nutrient-rich vegetables, leafy greens in particular. Lemon and lime juice can be added to flavor your juice without counting toward the fruit serving. Include cucumber, lettuce and celery juice, along with carrots, beets, and some leafy cruciferous greens such as cabbage, kale or bok choy.
  • Follow it up with a health-promoting diet. A few days of juicing can be a great way to reset your taste buds and jumpstart a new, healthful, nutrient-rich diet. However, there is no health benefit of trying to use a juice cleanse as temporary detox, just a break from an everyday junk food diet. This only works if you stick with a Nutritarian diet for the rest of your life, incorporating some juicing and caloric restriction episodically.
  • If you have a serious medical condition or are on any medication, consult a physician before starting a juice detox.

Originally printed on DrFuhrman.com. Reprinted with permission from Dr. Fuhrman.

Dr. Fuhrman is a board-certified family physician specializing in nutritional medicine. He is President of the Nutritional Research Foundation and the author of 6 NY Times bestselling books, including The End of Heart Disease. Visit him at DrFuhrman.com.


  1. van Niekerk G, Hattingh SM, Engelbrecht AM. Enhanced Therapeutic Efficacy in Cancer Patients by Short-term Fasting: The Autophagy Connection. Front Oncol 2016, 6:242.
  2. Mattson MP, Longo VD, Harvie M. Impact of intermittent fasting on health and disease processes. Ageing Res Rev 2017, 39:46-58.
  3. Pan H, Finkel T. Key proteins and pathways that regulate lifespan. J Biol Chem 2017, 292:6452-6460.
  4. Solon-Biet SM, Mitchell SJ, de Cabo R, et al. Macronutrients and caloric intake in health and longevity. J Endocrinol 2015, 226:R17-28.
  5. Longo VD, Mattson MP. Fasting: molecular mechanisms and clinical applications. Cell Metab 2014, 19:181-192.
  6. Cheng CW, Adams GB, Perin L, et al. Prolonged Fasting Reduces IGF-1/PKA to Promote Hematopoietic-Stem-Cell-Based Regeneration and Reverse Immunosuppression. Cell Stem Cell 2014, 14:810-823.
  7. Mattson MP, Allison DB, Fontana L, et al. Meal frequency and timing in health and disease. Proc Natl Acad Sci U S A 2014, 111:16647-16653.
  8. Stefanson AL, Bakovic M. Dietary regulation of Keap1/Nrf2/ARE pathway: focus on plant-derived compounds and trace minerals. Nutrients 2014, 6:3777-3801.
  9. Fuhrman J, Sarter B, Calabro DJ. Brief case reports of medically supervised, water-only fasting associated with remission of autoimmune disease. Altern Ther Health Med 2002, 8:112, 110-111.
  10. Wu S. Fasting triggers stem cell regeneration of damaged, old immune system. In USC News2014 [http://news.usc.edu/63669/fasting-triggers-stem-cell-regeneration-of-damaged-old-immune-system/]
  11. Antoni R, Johnston KL, Collins AL, Robertson MD. Effects of intermittent fasting on glucose and lipid metabolism. Proc Nutr Soc 2017, 76:361-368.
  12. Tinsley GM, La Bounty PM. Effects of intermittent fasting on body composition and clinical health markers in humans. Nutr Rev 2015, 73:661-67
Bananas is good way for healthy carbs

Sports Nutrition: #ScienceNotOpinion

Performance starts with fueling, not training! The best way to fuel for top performance seems to be a debatable topic these days. To keep on top of the science regarding food, exercise & performance, I look to SCAN, the Sports & Cardiovascular Nutrition practice group of the Academy of Nutrition and Dietetics (AND). Here are some tidbits of  information from this year’s 35th annual meeting in Keystone CO, May 2018.

In your search for sports nutrition information, Leslie Bonci RD CSSD wants you to find #ScienceNotOpinionand #FactsOverFallacy. Here’s some of what science supports:

—Exercising in a fasted stated leads to muscle breakdown. Think twice before eating nothing before morning exercise.

—The keto diet does not enhance performance, but rather leads to a down-regulation of the enzymes needed by carbohydrates to fuel a surge or a winning sprint at an event.

—Whole30 and Intermittent Fasting are just two more fads to add to the list of unsuccessful diets. You never want to embark upon a diet you won’t maintain for the reset of your life. Otherwise, diet backlash (binge eating, weight gain) takes it toll. Learn how to eat smarter, not diet harder!

—Carb-phobia refuses to go away, despite the plethora of research supporting the performance benefits of a carb-based sports diet. #Don’tDreadTheBread.

  • Omega-3 fats (DHA, EPA) found in oily fish (salmon, tuna, mackerel) are related to brain health. Animal research (rats, mice) suggests giving intravenous DHA within an hour after brain or spinal cord injury contributes to better outcomes regarding recovery. Would the same help athletes? Could DHA help with reducing the damage done by brain injuries? According to Michael Lewis MD, athletes, war fighters and others at high risk for getting concussed should consider taking 3,000 mg. EPA + DHA per day as a protective strategy.Omega-3s can also help treat depression, and that might help reduce suicides. Among soldiers with adequate levels of omega-3, the suicide-rate was 62% lower than soldiers with low blood levels of DHA.
  • Should athletes take anti-oxidant supplements? Likely not, according to exercise physiologist Scott Powers PhD of the University of Florida in Gainesville. The body has a natural balance of pro-oxidants and anti-oxidants. An imbalance can lead to muscular fatigue and molecular damage. Anti-oxidant supplements can down-regulate the body’s natural production of anti-oxidants, and that can blunt the training response. Athletes can ingest a performance enhancing balance of anti-oxidants (including vitamins C & E, zinc, carotenoids, and polyphenols) via all sorts of colorful fruits and vegetable: blueberries, strawberries, tart cherry juice, grape juice, broccoli, spinach, carrots….
  • The Academy of Nutrition and Dietetics, along with the American College of Sports Medicine and Dietitians of Canada, have created guidelines on nutrition for athletes. But what about nutrition for fitness exercisers and weekend warriors? If that’s you, exercise physiologist Asker Jeukendrup, PhD, of www.mysportscience.com suggests you match your nutritional guidelines to your athletic goals. That is, are you exercising to lose weight? build muscle? finish an Ironman Triathlon? or just to invest in better health?

When it comes to fueling during extended exercise, Jeukendrup stated the recommendations are similar for both athletes and less fit people: For exercise that lasts from 60 to 90 minutes, you want to maintain high energy by consuming from 30 to 60 grams of carbohydrate (120 to 240 calories) per hour of exercise. If you are a weekend warrior who exercises hard for more than two hours, you want to target 60 to 90 grams carh (240 to 360 calories) per hour. You might have to start at the low end of the calorie range while you train your gut to tolerate that much fuel. (The gut is trainable!). You’ll discover that exercise is much more fun when you have high energy!

  • An estimated 35 million Americans are older than 65. By 2030, 70 million Americans will exceed the age of 85. Unfortunately, as we age, we lose muscle strength. That loss is associated with frailty and falls. Because the daily diet of an estimated 25% to 40% of older people lacks adequate protein, muscle loss gets exacerbated.

Research suggests that older people, including athletes, should increase their protein intake to 1.4 g to 1.6 g/kg per day, and up to 40 grams after hard exercise. Exercise physiologist Robert Murray, PhD,(www.sportsscienceinsights.com) reports this could help boost the muscle-building response to exercise. If you are an older athlete who weighs 150 pounds (68 kg), this means. 95 to 110 gram protein per day. That’s about 25 grams, four times a day—much more than in a bowl of oatmeal or a handful of nuts!

  • The health risks of yoyo dieting are more harmful than the (short-lived) benefits of weight loss. Julie Duffy Dillon RD (host of the Love Food podcast) reminds us that weight cycling (yoyo dieting) contributes to malnutrition, muscle loss, reduced metabolic rate, and feelings of deprivation. The binge-eating that occurs upon “blowing the diet” is linked to fat gain, inflammation, elevated blood pressure, and insulin resistance—to say nothing about disordered eating. Dieting is the #1 predictor of who will develop an eating disorder.
  • According to sports dietitian Nanna Meyer PhD RD of the University of Colorado in Colorado Springs, climate change is here. It’s time for athletes to think more about how we can be good Food Citizens and take better care of the earth that we enjoy. This could be by eating locally grown foods, choosing more plant foods, buying sustainably farmed fish, using fewer plastic water bottles, eating less food in wrappers, and buying from local farmers. Eat with integrity and with respect for the planet!

Nancy Clark, MS, RD counsels both casual and competitive athletes at her office in Newton, MA (617-795-1875). Her best selling Sports Nutrition Guidebook and food guides for marathoners, cyclists and soccer players offer additional information. They are available at www.NancyClarkRD.com. For her popular online workshop, see www.NutritionSportsExerciseCEUs.com.


Sports Supplements: Buyer Beware?

Definition of Sports supplement: A food, food component, nutrient, or non-food compound that is purposefully ingested in addition to the habitually consumed diet with the aim of achieving a specific health and/or performance benefit.

The global sports nutrition supplement market (including sports foods, drinks and supplements) accounted for $28+ billion in 2016 and, with the help of rigorous advertising, is expected to almost double by 2022. How many of the products are moneymaking ploys marketed to uninformed athletes? Unfortunately, too many.

Due to the plethora of products that have infiltrated gyms, fitness centers and professional sports teams alike, I get questioned by fitness exercisers and aspiring Olympians: Which of these supplements are actually effective?? Hands down, the most effective way to enhance sports performance is via your day-to-day sports diet, coordinated with a consistent training program. Eating the right foods at the right times creates the essential foundation to your success as an athlete.

That said, specific sports supplements could make a minor contribution to small performance improvements for certain elite athletes. If you wonder if the grass is greener on the other side of your sports diet’s fence, here are some facts from the 2018 IOC Consensus Statement: Dietary Supplements and the High-Performance Athlete (1).

  • Supplement use varies across sports. It increases with the athletes’ training level and age, is higher in men than women and is strongly influenced by perceived cultural norms. (For example, “Everyone” on my team takes creatine, so I do, too.)
  • Before making any decisions regarding sports supplements, you want to get a nutritional assessment to be sure your diet supports your performance goals. No amount of supplements will compensate for a lousy diet. To find a local sports dietitian who is a Certified Specialist in Sports Dietetics (CSSD), use the referral network at www.SCANdpg.org.
  • Despite the ads you see for a zillion sports supplements, very few have strong proof of directly enhancing performance. These include caffeine, creatine, specific buffering agents, and nitrate. Period.
  • Very little research with supplements offers definitive evidence, in part because the research is rarely done with elite athletes under real life conditions. Real life includes 1) multi-day tournaments, competitions or events, 2) “stacking” supplements (such as mixing caffeine and nitrates) and 3) determining if an elite athlete responds the same way to a supplement as does a Division-3 collegiate athlete. Real life also includes your unique microbiome (the bacteria in your gut that influence your overall health and well-being). We do not yet know how much a microbiome, which varies 80% to 90% between individuals, influences the effectiveness of a sports supplement and contributes to different responses.

Supplements are used for many different reasons. Here’s a breakdown of supplements by categories.

  1. Supplements used to prevent/treat nutrient deficiency. Nutrients of concern for athletes include iron (to prevent anemia), calcium and vitamin D (for bone health), as well as iodine, folate and B-12 for specific sub-groups of athletes, including vegans and women who might become pregnant. The basic supplement question is: If you are deficient, what led to that deficiency and what dietary changes will you make to resolve the issue so that it doesn’t happen again?
  2. Supplements used to provide energy. Sports drinks, energy drinks, gels, electrolyte replacements, protein supplements, energy bars, and liquid meals are commonly used to help meet energy needs before, during and after exercise. They are a convenient, albeit more expensive alternative to common foods. They aren’t magical or superior to natural food. They are just easy to carry, standardized and eliminate decisions about which foods would offer, let’s say, the “recommended ratio” of carbs, protein and fat.
  3. Supplements that directly improve performance. Caffeine, creatine monohydrate, nitrate, sodium bicarbonate, and possibly beta-alanine are the very few performance enhancing supplements that have adequate support to suggest they may offer a marginal performance gain. If you choose to use them, be sure to test them thoroughly during hard training that mimics the competitive event. Choose a brand that is NSF Certified for Sport to minimize the risk of inadvertent doping due to contamination. Every year, athletes get suspended for failing a drug test after they unknowingly took a supplement with an illegal ingredient…
  4. Supplements that indirectly improve performance. Some supplements claim to enhance performance indirectly by supporting the athlete’s health and limiting illness. “Immune support” supplements that have moderate research to support their health claims include probiotics, vitamin D, and vitamin C. Supplements that lack strong support for their immune-enhancing claims include zinc, glutamine, Echinacea, vitamin E, and fish oil. Tart cherry juice and curcumin show promise

A supplement with strong evidence to indirectly improve performance by helping build muscle is creatine monohydrate. Questionable supplements without strong evidence for athletes include gelatin and HMB.

Adverse Effects

If some supplements are good, would more be better? No, supplements can cause harm. Too much iron can lead to iron overload. Too much caffeine increases anxiety. Supplements are linked to liver toxicity, heart problems and seizures. In the USA in 2015, dietary supplements contributed to about 23,000 emergency department visits. Manufacturers are not required to show safety or assure quality of a supplement. Athletes beware— and try eating better to perform better?

Nancy Clark, MS, RD, CSSD counsels both casual and competitive athletes at her office in Newton, MA (617-795-1875). Her best selling Sports Nutrition Guidebook and food guides for marathon-ers, cyclists and soccer players offer additional information. They are available at www.NancyClarkRD.com. For her popular online workshop, see www.NutritionSportsExerciseCEUs.com.


Maughan R, Burke L, Dvorak J et al. IOC Consensus Statement: Dietary Supplements and the High-Performance Athlete Intl J Sports Nutr Exerc Metab 2018, 28: 104-125.



Body Fat Promotes Heart Disease

Risk factors for heart disease – elevated LDL cholesterol, hypertension, elevated triglycerides, inflammation, and blood glucose – are all exacerbated by excess body fat, and overweight/obesity itself is considered a risk factor.1-3

Is it beneficial to be a little overweight?

However, there has been controversy about a potential “obesity paradox” in heart disease: the idea that some amount of excess weight either does not pose any risk or is even protective. Unfortunately, the studies that suggest there may be a protective effect of body fat are often the ones that get more news coverage; but this does a disservice to an already overweight and nutritionally misguided public, allowing them to believe that excess body fat won’t harm their health.

Is there really an obesity paradox? Or is it just that BMI is not a good measure of body fat?

Many of these studies have used body mass index (BMI), however BMI, which only takes into account height and weight, is not an accurate indicator of body fatness. BMI does not distinguish between fat mass and lean mass, nor does it take into account fat distribution (visceral fat vs. subcutaneous fat). Many people whose weights are within the “normal” BMI range are still carrying excess fat.

There has been no evidence providing a convincing explanation of how excess fat could possibly provide a cardiovascular advantage.  Plus, there are numerous medical conditions may cause unintentional weight loss, including depression, anxiety, autoimmune diseases, cancers, and digestive disorders. In the elderly especially, a low BMI may be an indicator of muscle loss and frailty rather than an indicator of a healthy low level of body fat. In short, people who are thinner are not necessarily healthier.

Relationship between body fat and heart disease: using better measures than BMI

A new study  is helping to clear this issue up,4 in a cohort of almost 300,000 people in the UK (age 40-69) who were followed for an average of 5 years. Their first analysis puts the optimal range of BMI for heart disease prevention at 22-23 kg/m2. It was a “J-shaped” association, meaning risk rose both above and below the 22-23 range. But the researchers went further. They used multiple measures of body fatness to get a more accurate picture: waist circumference, waist-to-hip ratio, waist-to-height ratio, and percent body fat.

Ultimately, what the researchers found was that using BMI produces different results than the other indicators. BMI was the only one that showed an increase in risk at the low end (<18.5 kg/m2). When they excluded smokers and participants with pre-existing diseases, the increase in risk associated with low BMI almost disappeared.  The more accurate measures of body fatness – body fat percentage, waist circumference, waist-to-hip-ratio, and waist-to-height ratio – showed a clear trend: more body fat, greater risk.4

More body fat, greater cardiovascular risk

The researchers concluded that the obesity paradox observation mainly occurs due to confounding effects of disease and other factors on BMI, and that the “public misconception of a potential ‘protective’ effect of fat on CVD risk should be challenged.”4

As discussed above, a low BMI is often an indicator of disease, rather than an indicator of a healthy weight resulting from healthful eating. The standard American diet (SAD) is fattening. If someone is eating the SAD and is not overweight, there is likely something wrong.

Lose weight permanently on a Nutritarian diet

The dramatic weight loss-promoting effect of the Nutritarian diet contributes to cardiovascular protection. A 2015 study published in the American Journal of Lifestyle Medicine analyzed and reported weight loss results provided by 75 obese patients who had switched to a Nutritiarian diet. The average weight loss was 55 pounds, and very importantly, they kept the weight off. None of these respondents had gained back the lost weight after three years.5

Reprinted with permission from Dr. Fuhrman.

Dr. Fuhrman is a board-certified family physician specializing in nutritional medicine. He is President of the Nutritional Research Foundation and the author of 6 NY Times bestselling books, including The End of Heart Disease.  Visit him at DrFuhrman.com


  1. Coelho M, Oliveira T, Fernandes R. Biochemistry of adipose tissue: an endocrine organ. Arch Med Sci 2013, 9:191-200.
  2. Tchernof A, Despres JP. Pathophysiology of human visceral obesity: an update. Physiol Rev 2013, 93:359-404.
  3. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association. Circulation 2017, 135:e146-e603.
  4. Iliodromiti S, Celis-Morales CA, Lyall DM, et al. The impact of confounding on the associations of different adiposity measures with the incidence of cardiovascular disease: a cohort study of 296 535 adults of white European descent. Eur Heart J 2018:ehy057-ehy057.
  5. Fuhrman J, Singer M. Improved Cardiovascular Parameter With a Nutrient-Dense, Plant-Rich Diet-Style: A Patient Survey With Illustrative Cases. Am J Lifestyle Med 2015.
fast food

Fast Food Genocide

In his latest book, Fast Food Genocide, Dr. Fuhrman details the shocking role diet has played in derailing the American dream for large segments of our population. He explains how these foods destroy not only our physical health, leading to cancer, diabetes, obesity, and heart disease — he also explores the previously overlooked association of diet’s influence on behavior, emotional health and intellect. The fast and processed food industries keep people hooked on their unhealthy, highly addictive products and that has led to a national health crisis. This tragic and far-reaching epidemic of inferior nutrition can be turned around, and Dr. Fuhrman offers hope, explaining the powerful way a Nutritarian Diet can solve what has become a national health crisis. It is an eye-opening book all of us need to read and share with our friends. Below, Dr. Fuhrman answers what motivated him to write this book and some of the questions surrounding it.

How Can Fast Food Be Genocide?

Genocide — the deliberate destruction of a population — is the most accurate way to describe fast food’s devastating effects on our society. Processed, nutrient-barren products are designed by the food industry to be highly addictive, cheap to produce, and highly profitable. These products do not contain the nutrients humans need to thrive, and in those using them as a primary food source, it has created an explosion of disease, much suffering and death. Fast food and processed foods also damage our genes, which we pass on to our children and grandchildren, and we are seeing dangerous increases in autism, learning disabilities, allergies, autoimmune disease and childhood cancer. This must be stopped.

Which Foods Are The Most Dangerous?

I define fast food in two ways: First, it is the food served at commercial chain restaurants, where processed meats, pizza, burgers, French fries, pretzels, soft drinks, and rich desserts are made in an assembly-line process, with commercial ingredients that are duplicated and dispersed all over the world. Second, it is any commercially-made convenience food that includes artificial ingredients, processed grains, sweeteners, salt, and oil, all with high-caloric concentration and minimal nutrient content. These foods have now become the majority of calories consumed in America.

Why Are These Foods So Damaging to Our Health?

A person who eats fast food, fried food and processed food has an increased risk of cancer, obesity, diabetes, autoimmune disease, depression, and mental illness. Even moderate use of fast food is dangerous. For example, one serving of commercial French fries per week is linked to an over 25 percent increase in risk of developing breast cancer. The World Health Organization has declared that processed meats are a class 1 carcinogen in humans, which places them in the same category as asbestos and cigarette smoking. Fake food produces cancer-promoting signals, damages blood vessel and builds plaque. The food is most often high in calories and fattening. Weight gain has its own dangerous consequences. Body fat produces pro-inflammatory signals, raises blood pressure, drives insulin resistance and secretes growth signals that promote cancer.

How Does Fast Food Contribute to Depression and Mental Illness?

The scope of the effects of fast food on the brain is not yet known, but based on what we know so far, we greatly underestimate these effects, especially the effects on the brains of children. A single episode of elevated blood sugar has been shown to have negative effects on attention and memory. Eating commercial baked goods and fast food is primary causative factor in mental illness and major depression, and brain imaging studies have suggested that elevated blood sugar impairs the brain’s ability to process emotion. For young children, fast food, candy and soda consumption are linked to behavior and attention problems, and depression and suicide in teens. Mental illness now affects one in five in America, and our poor diet is at the foundation of this epidemic.

Why Isn’t This Information More Widely Known?

Some reasons why we are ignoring the devastating health crisis that is right before our eyes is that; we believe food industry propaganda and easily misled by conflicting information; we develop a desire for become addicted to these toxic foods; and we believe in the heavily promoted dogma that modern medical care can save us from nutritional-induced tragedies.

Food companies have discovered how to feed the most people in the most efficient and cost-effective manner to maximize profits. While the marketing spin promotes moderate consumption as safe, and encouraged by social norms. Scientific studies demonstrate otherwise.

REGISTER for Dr. Fuhrman’s upcoming webinar on this topic, Fast Food Genocide: How Processed Food Are Killing Us and What We Can Do About It. Watch live or recorded! Register now >

Joel Fuhrman, M.D.Dr. Fuhrman is a board-certified family physician specializing in nutritional medicine. He is President of the Nutritional Research Foundation and the author of 6 NY Times bestselling books, including The End of Heart Disease.  Visit him at DrFuhrman.com

young attractive doctor and patient

Nutrition for Cancer

Prepare for Treatment

Did you know that by adjusting your nutrition you can feel better and stay stronger during cancer treatment? Both the cancer and the cancer treatment can affect your appetite, your ability to tolerate foods, and your body’s ability to utilize nutrients. By having a dietitian or nutritionist on your treatment team, you’ll be better prepared to cope with side effects and meet your nutrition needs during this difficult time.

Weight Management

young attractive doctor and patientSome cancer treatments can lead to weight loss while others can lead to weight gain. Weight loss may be due to a loss of appetite and/or an inability to tolerate food, while weight gain may be related to fluid retention, increased appetite and/or decreased physical activity. If cancer treatment is making it difficult for you to manage your weight, ask an dietitian or nutritionist to join your treatment team. You won’t regret it!

Complementary and Alternative Treatments

Many herbs and other supplements are marketed to people who are going through cancer treatment. Always talk to your oncologist before adding any herbs or supplements to your treatment regimen. Some herbs and supplements can cause harmful side effects and interfere with proven cancer treatments such as chemo and radiation.

For a detailed description of herbs and supplements and any evidence supporting their effectiveness and safety, visit nccam.nih.gov/health/atoz.htm. Your oncologist and a dietitian/nutritionist can help you sort through this information and make an informed decision about whether or not take any herbs or other supplements.

Kristy Richardson is a dietitian and exercise physiologist, specializing in sports nutrition and weight management, She is the founder of OC Nutrition and also works as a nutrition professor at Fullerton College.


American Cancer Society (2012). Nutrition for the Person with Cancer During Treatment: A Guide for Patients and Families. Retrieved November 4, 2013, http://www.cancer.org/acs/groups/cid/documents/webcontent/002903-pdf.pdf.


How To Gain Weight Healthfully

“No matter what I eat, I can’t seem to gain weight…”

“What about those weight gain powders … do they work?”

“How much more protein should I eat to help me bulk up?”

Although two-thirds of Americans are overweight or obese, a handful of skinny people—including many athletes—feel very frustrated by their seeming inability to gain weight. Their struggle to bulk up is on par with that of over-fat folks who work hard to lose weight. Add in rigorous training for a marathon, soccer team, or other sport, and scrawny athletes can feel at a disadvantage, fearing that no matter how much they eat, they’ll get even skinnier.

Clearly, genetics plays a powerful role in why some athletes have so much trouble not only gaining weight, but also maintaining any weight they manage to add. “Hard gainers” tend to be fidgety. They rarely sit, to say nothing of sit still. They are constantly puttering around, or when sitting, they are tapping their fingers, swinging their legs, twirling their hair, and shifting around in the chair. All of these activities burn calories that commonly end up in the midriff of calmer people who can sit motionless for hours.

If you are a hard gainer, you might have been told that consuming an extra 500 to 1,000 calories per day will lead to gaining 1 to 2 pounds per week. Unfortunately, Nature often confounds this mathematical approach. For example, in a weight gain study where the subjects were overfed by 1,000 calories per day for 100 days, some subjects gained only 9 pounds, whereas others gained 29 pounds (1).

How could that be? The answer likely relates to Non-Exercise Activity Thermogenesis (N.E.A.T.), the technical term for spontaneous movements that naturally occur in fidgety people. When you overfeed a fidgety person, they can become even more active, as if Nature wants them to burn off those calories.

Seven Tips to Gain Weight Healthfully

Fret not; even very lean people can gain some weight when they systematically enhance their diet. Although they cannot change their genetics and their tendency to fidget, they can boost their calorie intake. If you are a scrawny athlete, have a teenage eating-machine who wants to weigh more, or are trying to bulk up for football, here are some tips to help you gain weight healthfully.

1. Eat consistently. Do NOT skip meals; doing so means you’ll miss out on important calories needed to reach your goal. Every day, enjoy a breakfast, an early lunch, a later lunch, dinner, and a bedtime meal. This might mean breakfast at 7:00, lunch at 11:00, second lunch at 3:00, dinner at 7:00, and a protein-rich bedtime snack at 10:00.

2. Eat larger than normal portions. Instead of having one sandwich for lunch, have two. Enjoy a taller glass of milk, bigger bowl of cereal, and larger piece of fruit.

3. Select higher calorie foods. Read food labels to discover which wholesome foods offer more calories. For example, cranapple juice has more calories than orange juice (170 vs. 110 calories per 8 ounces); granola has more calories than Cheerios (500 vs. 100 calories per cup); corn more calories than green beans (140 vs. 40 calories per cup).

4. Drink lots of 100% fruit juice and low-fat (chocolate) milk. Instead of quenching your thirst with water, choose calorie-containing fluids. By having milk with each meal, you can easily add 300 to 600 wholesome calories a day. One high school soccer player gained 13 pounds over the summer by simply quenching his thirst with six glasses of cranapple juice instead of water (1,000 vs. 0 calories). He consumed the fluid he needed (juice is 98% water) and bonus of more carbohydrates to refuel his depleted muscles, plus a good dose of vitamin C to enhance healing.

5. Enjoy peanut butter, nuts, avocado, and olive oil. These foods are high in (health-promoting) fats. They’re a positive addition to your sports diet; they help knock down inflammation. Their high fat content means they’re calorie-dense. To boost good fats, add almonds to cereal & salads, spread extra peanut butter on the PB&J sandwich, dive into the guacamole with baked chips, and add extra olive oil dressing to your salads. That’s an easy extra 500+ calories/day.

6. Do strengthening exercise as well as some cardio. Weight lifting and push-ups stimulate muscle growth so that you bulk-up instead of fatten up. Plus, exercise stimulates your appetite and, sooner or later, you’ll want to eat more. Exercise also increases thirst, so you will want to drink extra juices and caloric fluids.

Take note: You will not build bigger muscles by eating extra protein. While you want to target a protein-rich food with 20-30 grams protein at each meal (and 10-15/snack), having more will not build bigger muscles. Resistance exercise builds muscles. To have the energy to do the muscle-building training, you need extra carbs. That’s where drinking more 100% fruit juice and chocolate milk offer benefits; you’ll be better-fueled & better able to lift heavier weights.

7. Don’t bother to buy expensive weight gain drinks. A hefty PB&J with a tall glass of chocolate milk adds about 1,000 calories for about $2.00. You would spend at least $10 get-ting those calories from Muscle Milk.

Conclusion: By following these tips, you should see progress, but honor your genetics. Most people do gain weight with age as they become less active, more mellow, and have more time to eat. Granted, that information doesn’t help you today, but it offers optimism (or a warning) for your future physique!

Nancy Clark, MS, RD, CSSD (Board Certified Specialist in Sports Dietetics) counsels both casual and competitive athletes at her office in Newton, MA (617-795-1875). Her best selling Sports Nutrition Guidebook and food guides for marathoners, cyclists and soccer players offer additional information. They are available at www.NancyClarkRD.com. For her popular online workshop, see www.NutritionSportsExerciseCEUs.com


1) Bouchard, C. 1990. Heredity and the path to overweight and obesity. Med Sci Sports Exerc 23(3):285-291.

Standing man with broken inner mechanism, bad health

Are you training your gut?

Athletes tend to do a good job of training their muscles, heart and lungs. But some of them (particularly endurance athletes and those in running sports) commonly fail to train their gut. As one marathoner reported, “I was so afraid of getting diarrhea during long training runs that I did not eat or drink anything beforehand. I really struggled after 14 miles…” A high school soccer player admitted, “I’m so afraid I’ll throw up if I run with food in my stomach.” He ate only a light lunch at 11:00 and then practiced on fumes at 3:30. No wonder he had a disappointing season.

An estimated 30-50% of endurance athletes (including up to 90% of distance runners) have experienced gastro-intestinal (GI) issues during and after hard exercise. They fear bloat, gas, nausea, stomach cramps/pain, side stitch, diarrhea, vomiting, and urge to defecate. These issues arise during long bouts of exercise because blood flow to the gut is reduced for an extended period of time. When combined with dehydration, elevated body temperature and high levels of stress hormones, normal intestinal function can abruptly end.

If you are an athlete with a finicky GI tract, restricting your diet before and during exercise will not solve the problem. You want to learn how to train your gut to accommodate performance enhancing carbs and water. That way, you can train better—hence compete better—without stressing about undesired pit stops.

Thankfully, the gut is trainable. Competitive eaters have proven this point. Google Nathans’ Hot Dog Eating Competition and watch the video of a champ who stuffed 72 hotdogs into his stomach in 10 minutes. Clearly, he had to train his gut to be able to complete that task.

Competitive eating is unlikely your goal, but you may want to be competitive in your sport. That means you need to fuel wisely in order to perform optimally. While some “keto-athletes” choose to train their bodies to rely on fat for fuel (fat is less likely to cause GI distress), training the gut is a far easier alternative for most of us.

The following tips can help you exercise with digestive peace.

  • Drink enough fluids. Dehydration triggers intestinal problems. Your goal is to drink enough to prevent 2% dehydration (sweat loss of 2 pounds per 100 pounds of body weight from pre- to post-exercise). If you are a “big guy” who sweats heavily, this can be a lot of fluid. For example, a 200-pound football player could easily lose 4 pounds (a half-gallon) of sweat in an hour of exercise. He needs to train his gut to handle fluid replacement during training. He could need as much as 12 to 16 ounces every 15 minutes during a two-hour practice.
  • Feeling “full” and “bloated” during exercise indicates fluids (and foods) have not emptied from the stomach. This commonly happens during really hard exercise, when reduced blood flow to the stomach delays stomach emptying. Hot weather and prolonged exercise in the heat can also reduce stomach emptying.
  • You want to dilute highly concentrated carbs (i.e., gels), so be sure to drink enough water during exercise (i.e. 16 oz. water per 100 calories gel).This will help speed up gastric emptying.
  • If you plan to eat a peanut butter on a bagel before you compete, you want to routinely eat that before important training sessions. This helps train your gut to accommodate fat (sustained energy) as well as carbs (quick energy).
  • Once carbohydrate (such as sport drink, gel, banana, or gummi bears) empties from the stomach, it enters the small intestine and is broken down into one of three simple sugars (glucose, fructose, galactose). These sugars need “taxi cabs” to get transported out of the intestine and into the blood stream.
  • Too many gels or chomps without enough transporters can lead to diarrhea. By training with your race-day carbs, you can increase the number of transporters.
  • If you typically eat a low-carb Paleo or keto-type diet and then on the day of, let’s say, a marathon, you decide to fuel with carb-rich gels and sports drinks, your body won’t have the capacity to optimally transport the sugar (carbs) out of your intestines and to your muscles. You could easily end up with diarrhea.
  • When planning what to eat during extended exercise, choose from a variety of carbs with a variety of sugars (i.e., sport drink, gum drops, and maple sugar candy). This helps prevent the glucose transporters from getting saturated. Too much of one kind of sport food can easily create GI problems.
  • “Real foods” such as banana, raisins and cereal, have been shown to be as effective as commercial sport foods. Your body processes “real food” every day and has developed a good supply of transporters to deal with the carbohydrate you commonly eat. By experimenting and learning what works best for your body, you can fuel without anxiety about undesired pit stops.
  • For exercise that lasts for up to two hours, research suggests about 60 grams (240 calories) of carb per hour can empty from the small intestine and get into the blood stream. Hence, that’s a good target. For longer, slower, events, the body can use 90 g (360 calories) carb per hour from multiple sources,as tolerated. Again, train your gut!

The bottom line  

  • Train with relatively large volumes of fluid to get your stomach used to that volume.
  • Routinely eat carbohydrate-based foods before training sessions to increase your body’s ability to absorb and use the carbs.
  • During training, practice your race-day fueling. Mimic what you might eat before the actual competitive event, and tweak it until you find the right balance.
  • If you are concerned about diarrhea, in addition to preventing dehydration, limit your fiber intake for a few days pre-event (fewer whole grains, fruits and veggies).
  • Reducing your intake of onions, garlic, broccoli, apples, and sorbitol might help reduce GI issues during exercise.
  • Meet with a sports dietitian to help you create a fueling plan that promotes intestinal peace and better performance.

Sports nutritionist Nancy Clark MS RD CSSD has a private practice in the Boston-area (Newton; 617-795-1875). She helps both fitness exercisers and competitive athletes create winning food plans. Her best-selling Sports Nutrition Guidebook, and food guides for marathoners, cyclists and soccer are available at nancyclarkrd.com. For online workshops:  www.NutritionSportsExerciseCEUs.com.