If you have ever felt confused or even intimidated by how to start eating healthy, you are not alone. There are thousands of articles, books, and infinite resources of information on the topic—all of which can be overwhelming off the bat! However, the reality is: Healthy eating is simple, easy, and approachable. All you need to do is stay consistent with daily habits, make informed decisions, and manage your self-control.

New Dr. Olson‘s Review Notes appear at the end of the story.

Take the first steps towards this positive lifestyle change by implementing the following strategies to make eating healthy easier over time:

1. Throw out junk food

The first step to take on a healthy eating journey is to throw out all the junk food in your home. By doing this, you eradicate the temptation of giving in to a craving. Did you know that some studies have suggested that junk food alters the brain1 in obesity-prone animals and humans in a way that is similar to what occurs in addiction? Processed food is purposely manufactured that way to encourage you to keep buying it (think added sugar and salt)!

2. Be realistic and specific to your goals

Ask yourself what goals you personally want to accomplish. Is it reducing the consumption of red meat, learning how to count calories to lose a certain amount of weight, improving your current physical condition, or something else?

Be realistic about how you plan to make every goal a reality. Even accomplishing short-term goals are a milestone—don’t discredit them. Start small by replacing all your drinks with water as opposed to soda. Or begin eating vegetables with every meal for one week. Short-term goals act as the foundation for your long-term ones. Lifestyle changes don’t happen overnight. They take time and are never instantly gratified.

3. Prepare a grocery list ahead of time

Never go to the grocery store when you’re hungry or lacking a prepared list. Doing so makes you more prone to buying things impulsively and spending money on unhealthy items. Before you make your next trip, have a healthy food list ready in your pocket. Then stick to the corners and edges of the grocery store. That’s where the produce and raw proteins are sold. Everything else in middle aisles is mainly comprised of processed and canned foods and snacks usually with too much sugar or salt. Save yourself the temptation by completely avoiding this whole area.

Be sure to read the labels on the food before you buy. Nutrition labels provide information about calories, macronutrients (carbohydrates, protein, fats), and percent of daily values supplied per portion of the food. Changes to the labels in 2021 have made them easier to use.2 including preservatives and other additives (such as coloring dyes) in descending order of predominance. By reading the ingredient list, you can see whether or not something has been processed with chemicals as opposed to being prepared organically or sustainably.

4. Prep meals ahead of time

Meal prepping3 helps you establish and solidify what your diet plan will look like for the week. This removes the factor of feeling inclined to grab take-out during a work break or buying a meal on a whim. Moreover, meal prepping saves you time and money!

Dedicate a day to cooking an entire week’s worth of meals. You’ll never have to come home worrying about what to eat for dinner again or feel tight on time because there’s always a delicious and wholesome meal waiting for you in the fridge.

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To take meal prepping one step further, always pre-chop fruits and vegetables once they’re taken home from the grocery store and package them in containers.

5. Be mindful of how you prepare food

Just because a type of food is healthy, such as green beans or a piece of salmon, it does not mean it stays nutritional if prepared in an unhealthy way. Avoid frying your food in oil, deep-frying them, or heavily salting them. These elements add excess amounts of sodium and fat to your foods. These additions automatically counter the food’s nutritional value. Instead, sauté, bake, or grill meals using non-stick pans4 with a small amount of cooking spray.

Additionally, healthy meals don’t need to be bland and dreadful to eat. There are numerous spice combinations you can use on food that is even more delicious than salt and actually have beneficial properties. For example, ginger is a common spice in Asian cuisine that has been shown to have multiple bioactive activities including anti-inflammatory, anti-oxidant, and anti-nausea.5

6. Simplify your meal recipes

A recipe, like healthy eating, does not have to be complicated. The best basic rule to follow is to eat a plate comprised only of vegetables, whole grains, a healthy protein, and fruits—according to studies illustrated on a chart from Harvard’s School of Public Health6. For example, a meal that satisfies this recommendation is a plate of grilled chicken, steamed vegetables, whole grain rice, and a small fruit bowl, and a glass of water on the side.

7. Snack healthy throughout the day

To keep your appetite at bay and raise you up from moments of low energy, eat healthy snacks throughout the day. Unsalted nuts make great snacks7 that not only taste good but are also filling. 

If you’re a diabetic, snacking is especially beneficial since it helps to regulate your blood sugar level. Snacking also prevents large spikes in blood sugar levels from occurring which may reduce your likelihood of developing cardiovascular issues, obesity, and Type 2 diabetes in the long run.

Related Content:
How to Counter Emotional Eating with Mindfulness
Condiments: Calories We Forget to Count

8. Practice the healthy eating mindset

A healthy eating mindset is defined by being mindful of your eating habits and decisions. Focusing on the flavor and texture of the food you eat enhances your enjoyment of the meal. It also slows down eating which allows food cravings to pass and helps you eat less.8

Having a healthy mindset includes practicing self-control in the face of junk food and understanding why it’s better to make a healthy decision rather than an unhealthy one.

9. Satisfy your cravings with wholesome alternatives

Whenever you crave something salty or sweet, seek out healthy alternatives. For example, if you have the urge to eat a pack of cookies, opt for eating fruit instead. If you have savory cravings, a burger or any other greasy food may emotionally satisfy them. But don’t give in because filling up on those foods often ends up making you feel worse.

Dip carrot sticks or celery stalks in homemade chickpea spread to satisfy the craving and get a fiber bonus. Try olive spread smeared on whole-grain crackers to calm a craving for salty food. Be creative, but always choose fresh, whole foods over highly processed foods with added salt or sugar.

10. Exercise in conjunction with eating healthy

Last but not least, add exercise to a healthy diet habit to reap the full benefits of a wholesome lifestyle. Daily exercise may also help maintain your weight and reduce your chances of developing chronic diseases. It also boosts mood and improves your overall emotional and sense of physical well-being.9 Exercising also increases your self-awareness of how food affects you over time, which is another factor that impacts potential food choices.

The bottom line

Once you have the right strategies in mind to tackle healthy eating and take action to follow them, staying healthy will become easier over time. Don’t give up on trying to live a healthy lifestyle. If mistakes happen along the way, remember that it’s normal, and don’t be discouraged. What really matters at the end of the day is being intentional with this lifestyle change to improve your well-being and overall quality of life.

In conclusion, stay consistent with healthy eating habits and remember that a positive and dedicated attitude towards healthy living is just important as eating clean.

Related Content: Healthy Eating Tips for Nurses & Doctors Who Work Long Hours



  1. Max F Oginsky, Paulette B Goforth, Cameron W Nobile, et al.  Eating ‘Junk-Food’ Produces Rapid and Long-Lasting Increases in NAc CP-AMPA Receptors: Implications for Enhanced Cue-Induced Motivation and Food Addiction,
  2. Changes to the Nutrition Facts Label. Food, and Drug Administration, current 02/10/21 

  3. Meal Prep: A Helpful Healthy Eating Strategy. Harvard School of Public Health, The Nutrition Source.  https://www.hsph.harvard.edu/nutritionsource/2017/03/20/meal-prep-planning/

  4. Healthy cooking tips. Better Health Channel. https://www.betterhealth.vic.gov.au/health/healthyliving/healthy-cooking-tips 

  5. Qian-Qian MaoXiao-Yu XuShi-Yu CaoRen-You GanHarold Corke, et al.

    Bioactive Compounds and Bioactivities of Ginger ( Zingiber officinale Roscoe).  PubMed,  2019 May 30;8(6):185. https://pubmed.ncbi.nlm.nih.gov/31151279/

  6. Healthy Eating Plate, Harvard School of Public Health, The Nutrition Source. https://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate/

  7. Carettin AlasalvarJordi-Salas SalvadóEmilio Ros, et al.   Bioactives and health benefits of nuts and dried fruits.  PubMed, 2020 Jun 1;314:126192. https://pubmed.ncbi.nlm.nih.gov/31958750/
  8. Heidi Godman, Contributor.  11 Benefits of Mindful Eating, U.S. News, Health. 2019 Oct. https://health.usnews.com/wellness/food/articles/benefits-of-mindful-eating
  9. Eduardo Matta Mello Portugal, Thais CevadaRenato Sobral Monteiro-Junior, et al.

    Neuroscience of exercise: from neurobiology mechanisms to mental health.  Neuropsychobiology PubMed 2013;68(1):1-14.

Medical Reviewer Notes by Dr. Olson

First, congratulations to Trevor for being clean and sober. I work as a psychiatric consultant in a substance use disorder clinic and I know it isn’t always easy, but one of the things that helps with recovery is to replace old ways of trying to feel good with new ones that are healthier. I support all of his recommendations.

I would add one thing: keeping a food diary. I use the app “My Fitness Pal,” although there are many others. It really gives me some accountability and as I review my daily behavior, it impacts the food choices (e.g. a bedtime snack) and keeps me on track. It also allows for increasing your daily calorie allowance and that helps with motivation when I just don’t feel like going to the gym or taking my dog for a longer walk.

Normally, most of the nutrients we eat are absorbed through the walls of the small intestines. When this process is impaired, whether by infection, certain diseases such as cystic fibrosis (CF), chronic pancreatitis, celiac disease, and other GI diseases, or surgical resection of the pancreas or small bowel, the result is typically malabsorption of nutrients.

Failure to absorb nutrients, calories (from fat, protein, and carbohydrates), and vitamins and minerals leads to a host of symptoms, including:

      • weight loss or slow growth in children
      • bloating and abdominal discomfort
      • diarrhea
      • foul-smelling stools that float or stick to the toilet bowl

Malabsorption also leads to a variety of complications related to specific nutritional deficiencies, including:

      • osteoporosis
      • weakened immune system
      • fat-soluble vitamin (A, E, D, K) deficiencies
      • essential fatty acid deficiencies

When patients cannot absorb sufficient calories and nutrients from food, they struggle to gain or maintain weight. As a result, growth may falter in children leading them to become too thin. They may also fail to their genetic potential for height. It can even lead to a delay in pubertal development.

Persistent malabsorption in adults leads to chronic malnutrition. It can also accelerate the progression of various diseases and contribute to frailty in older patients. This weight loss and GI symptoms (diarrhea, abdominal discomfort) also decrease the quality of life for patients and their families.

This article explains how clinicians can incorporate medical nutrition to improve weight, height, and body mass index (BMI) in patients with cystic fibrosis who, if not treated, will experience the ill effects of chronic malabsorption. By helping patients enhance dietary fat absorption and ingest a healthy source of fat calories, clinicians can guide patients to meet and maintain nutritional and weight goals.

Related Content:  Your Genes and Food: The Science of Personalized Nutrition

Malabsorption in cystic fibrosis

CF is a progressive, genetic disease characterized by abnormalities in the transport of chloride and the flux of water across cell membranes. This leads to the mucous in various organs to become thick and sticky.

Although many think of CF as a pulmonary disease, it actually affects many other regions of the body, including the pancreas. The pancreas is the source of digestive enzymes that help break down food in the intestines. Malfunction of the pancreas in patients with CF leads to pancreatic insufficiency (PI).

About 85% of patients with CF have PI.1 It is caused by a build-up of mucus and fibrosis in the pancreas that halts the production and release of digestive enzymes and the needed bicarbonate fluid. These enzymes are essential for the body to digest and absorb food calories and nutrients, including dietary fatty acids and fat-soluble vitamins, that are essential for human health.

Malabsorption: an ongoing challenge in cystic fibrosis

Malabsorption is an ongoing challenge for patients with CF. Low weight, lack of height accretion, and unintentional weight loss cause numerous health concerns in these individuals. This is particularly consequential for children who are still growing, those patients preparing for a lung transplant, and pregnant women.

Patients who are able to achieve a higher BMI may have better outcomes and a slower rate of progression of their disease. In fact, a nutritional therapy plan that includes a higher energy and fat intake compared to generally healthy people of similar age and sex supports better pulmonary function and survival in these patients.2

It is vital that clinicians address the weight status in adults and weight and height patterns in children as a component of treatment.

ADD_THIS_TEXT A healthier weight helps patients more successfully manage their CF.3 Therefore, it is important that clinicians caring for them consider how to effectively optimize nutritional status and support the quality of life for patients and families.

Current treatment for pancreatic insufficiency  

Treatment of chronic malabsorption syndromes due to PI focuses on helping patients get the most out of the calories they consume.

Current approaches for nutrition care of patients with CF and PI include:

      • lifelong pancreatic enzyme replacement therapy (PERT)
      • increased food intake and calorie-dense/high-fat diet over a lifetime
      • nutritional supplements by mouth or feeding tube when indicated

Each of these treatments has its limitations.

  • Pancreatic enzyme replacement therapy (PERT)

PERT is the foundation of malabsorption treatment in CF and PI. It involves the use of oral medications that contain enzymes to replace what the pancreas is no longer able to produce or release. The enzymes replaced in PERT include:

      • proteases that will digest protein
      • amylases that digest carbohydrates 
      • lipases to digest fat

More complete digestion of these essential food components helps improve their absorption and prevents the symptoms of malabsorption.

PERT is key to malabsorption treatment in CF and PI. It is effective in helping patients absorb about 85% of the dietary fat found in their food.4

That said, these patients are still not able to utilize about 10% to 15% of dietary fat, which results in a constant loss of calories, essential fatty acids, and fat-soluble vitamins.

  • Increased intake of high fat, calorie-dense foods

The increased food intake required to reach an adequate number of nutrient-rich calories for patients with PI is substantial. Clinicians recommend that patients with CF eat more food. However, it is actually quite difficult to overeat on a regular basis in order to compensate for malabsorption.

To eat beyond your appetite is harder than you may think. This is particularly true for children who are just learning about hunger and satiety.

  • Supplementation

Increased calorie and fat intake can be achieved through the use of general nutritional supplements such as shakes, drinks, and snack bars. These products provide more calories but do not address the problem of reduced nutrient absorption.

The other consideration with this approach is that it takes patients away from their regular eating routines of enjoying usual foods and family meals. The same is true when supplementation takes the form of bolus or overnight tube feeding regimens.

These options limit the patient’s control, flexibility, and enjoyment of eating.

Currently, about 40% of patients with CF across the U.S. are utilizing some form of oral supplementation. Another 10% require a gastrostomy for supplemental tube feeding.5

New medical nutrition therapy is now available

A new advanced nutrition therapy, Encala (from Envara Health) is a medical food composed of a structured lipid matrix and active ingredients of lysophosphatidylcholine (LPC), monoglycerides, and essential fatty acids. It is a taste-neutral mixable powder that provides highly absorbable fat calories and essential fatty acids. It helps the body absorb fat and fat-soluble vitamins.

As a plant-based, gluten, and dairy-free source of fat calories, Encala helps patients meet and maintain nutritional and weight goals. Further, it allows patients to fit into their family’s preferred dietary patterns by mixing Encala into their favorite foods and beverages throughout the day. This approach offers an improvement for most patients over the available conventional therapies described above.

What research tells us about Encala

A recently published, NIH-sponsored study examined 66 children with CF and persistent fat malabsorption.6 It found that Encala was a safe, well-tolerated, and effective treatment. It improved dietary fat absorption, weight gain, and fatty acid status as compared to a placebo-treated group in a 3-month double-blind, randomized, placebo-controlled trial (a gold standard for intervention research).This report was based on the full scale of study (110 children, over 12-month treatment). 8

Here is a summary of the findings:

  • Encala fat was well absorbed in the study subjects. All had CF and PI in which pancreatic-derived lipase (the enzyme needed to digest fat) and liver-derived bile acids (needed for fat absorption) are missing or greatly reduced. Improved fat absorption resulted in better clinical outcomes including improvements in
      • weight and height
      • nutritional laboratory measures
      • overall dietary fat absorption
  • The children and young adults, aged 5 to 19 years old, were able to mix Encala powder with their favorite foods and drinks during the day. They and their families embraced the treatment because it allowed flexibility and choice in the diet.
  • Encala treatment may be considered before the initiation of tube feeding in patients with malnutrition who need intervention. About 10% of the patients in the study already had feeding tubes, a treatment that is not undertaken lightly. Encala proved successful and well-accepted when it was incorporated into the tube feeding regime. Absorption was related to better clinical outcomes including improvements in weight, height, BMI, and nutritional lab values. With this experience and published results, Encala may now be routinely considered to help patients with oral supplementation and feeding tubes achieve their weight goals sooner. This will likely support the successful transition from tube feeding back to regular foods, thus decreasing the duration, burden, and costs of tube feeding therapy in patients with CF and PI.

What about other patients with malabsorption due to pancreatic insufficiency?

Even if you do not treat patients with CF and PI, this research demonstrates how effective Encala is in addressing the fat malabsorption problem in one of the most clinically challenging populations. While it is encouraging to see the success of Encala in patients with CF, there are potential benefits for other patient populations with conditions related to reduced pancreatic function, fat malabsorption, and poor nutritional status, including those with the following conditions: 

      • chronic pancreatitis and celiac disease, common non-CF diseases with a high risk for fat malabsorption
      • surgical pancreas removal for cancer and non-cancer conditions
      • rare conditions including Shwachman-Diamond, Johanson-Blizzard, Pearson marrow-pancreas syndromes
      • other GI-related conditions with inflammation or chronic infection

In addition, Encala is calorically dense and well absorbed. It may be considered for the nutritional support of patients with the following conditions:

      • inadequate food/calorie intake including the frail elderly who often do not feel like eating enough food
      • unintentional, disease-related weight loss, including those in treatment for
          • heart failure
          • renal failure
          • cancer

This new calorie-dense treatment is something that can be offered to maximize the benefits of the food our patients are ingesting.

The bottom line on medical nutrition therapy for malabsorption

Encala is a new medical nutrition therapy that serves both as a source of healthy, high-calorie fat as well as a facilitator of absorption of foods and snacks that are consumed with the product. The use of the intervention is simple, effective, and minimally disruptive to typical, preferred dietary patterns.

Encala can potentially have a positive, broad impact on the treatment of a range of conditions. We hope that Encala is the first of many innovative nutritional supplements that become available so that your patients with poor growth or unintentional weight loss can thrive again.


    1. Singh, VK, and Schwarzenberg, SJ. 2017. Pancreatic Insufficiency in Cystic Fibrosis. Journal of Cystic Fibrosis, Vol. 6, Suppl. 2, Nov., accessed via https://www.cysticfibrosisjournal.com/article/S1569-1993(17)30813-5/fulltext
    2. Physicians Committee for Responsible Medicine’s Guide to Clinicians. Accessed via https://nutritionguide.pcrm.org/nutritionguide/view/Nutrition_Guide_for_Clinicians/1342064/all/Cystic_Fibrosis
    3. Cystic Fibrosis Foundation. Healthy High-Calorie Eating. Accessed via https://www.cff.org/Life-With-CF/Daily-Life/Fitness-and-Nutrition/Nutrition/Getting-Your-Nutrients/Healthy-High-Calorie-Eating/
    4. Calvo-Lerma, J, Martínez-Barona, S, et al. 2017. Revista Española de Enfermedades Digestivas, versión impresa ISSN 1130-0108, Vol.109, No.10, Madrid, Oct., accessed via httpss://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082017001000003
    5. Cystic Fibrosis Foundation. 2019 Patient Registry Annual Data Report. Accessed via https://www.cff.org/Research/Researcher-Resources/Patient-Registry/2019-Patient-Registry-Annual-Data-Report.pdf
    6. Stallings, VA, Tindall, AM, et al. 2020. Improved residual fat malabsorption and growth in children with cystic fibrosis treated with a novel oral structured lipid supplement: A randomized controlled trial. PLOS ONE 15(9): e0239642. Accessed via https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0232685
    7. Misra, S. 2012. Randomized double-blind placebo control studies, the “Gold Standard” in intervention-based studies. Indian J Sex Transm Dis AIDS. Jul-Dec; 33(2): 131–134, accessed via https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3505292/
    8. Stallings VA, Schall JI, et al. Effect of Oral Lipid Matrix Supplement on Fat Absorption in Cystic Fibrosis: A Randomized Placebo-Controlled Trial. J Pediatric Gastroenterology and Nutrition. 2016; 63: 676-680.

    Financial disclosure: Dr. Stallings is the founder and a medical consultant to Envara Health, the company that makes Encala. She was the principal investigator on the NIH cystic fibrosis research study described in the article.

    Published 12/21/20. Updated 2/2/21.

In this article, I will talk about the new USDA Dietary Guidelines Report and key takeaways for parents and doctors. Including the following:

      • Important new recommendations for children under 2 years of age
      • How new landmark clinical trials on food allergy prevention support the new USDA Dietary guidelines report to recommend early allergen introduction to help prevent food allergies
      • New guidelines on added sugar for infants and children based on the strong link between added sugar intake and obesity
      • Recently published guidelines from leading allergy organizations, like the American Academy of Allergy, Asthma & Immunology (AAAAI), on early peanut and egg introduction

So, let’s dive into it.

What is the USDA Dietary Guidelines Report for Americans?

The United States Department of Agriculture (USDA) just published the new 2020-2025 Dietary Guidelines Report for Americans (DGA) Report. It is the ninth edition of the national nutrition and health guidelines. All of its recommendations are backed by evidence and research.

Millions of Americans already use the USDA guidelines to help them make decisions about nutrition and diet. This year is the first time that the guidelines include recommendations for the 0-2-year-old age group. That happened as a result of a congressional mandate to create guidelines for this age range. The reasoning behind this addition is as follows:

“The first 1,000 days of an infant and child’s life, beginning at conception and continuing through the second year of life, are crucial for ensuring optimal physical, social, and psychomotor growth and development and lifelong health.” – USDA

2020-2025 USDA Dietary Guidelines Report for Americans: What Families Need To Know

The 2020-2025 DGA report will help shape the choices of millions of American families on diet and nutrition matters. Here are the 5 things every family should take away from the new guidelines: 

1. No Added Sugar for Infants and Toddlers

The new guidelines state that parents should “avoid foods and beverages with added sugars during the first 2 years of life.” This is an effort to help reverse the rise in childhood obesity. The report notes that there are nearly 5 million American children suffering from obesity.

This recommendation is timely because, as the USDA Dietary Guidelines Report states that many 6-12-month-olds have already had some amount of added sugar in the foods that they eat.

2. Introduce Allergenic Foods to Every Baby

One of the key recommendations from the new report is to feed babies allergenic foods such as peanut and egg. This should be done as early as 4 months of age in order to prevent severe food allergies.

This is in light of new clinical trials, that demonstrate that introducing allergenic foods is safe and can help prevent up to 80% of food allergies.

This guidelines report applies to any infant, no matter their risk factors (even for babies with eczema). This emphasizes how important early introduction is to help parents prevent their baby from developing food allergies.

To learn how to introduce allergens to your baby including recipes, visit preventallergies.org.

“Introducing peanut and egg in an age appropriate form, in the first year of life (after age 4 months) may reduce the risk of food allergy to these foods.” USDA

3. Insufficient Evidence on Diet During Pregnancy for Food        Allergy Prevention

According to the Dietary Guidelines Report, there is

“Insufficient evidence is available to determine the relationship between peanuts, eggs, or wheat consumed during pregnancy and risk of food allergy in the child.”

This means there is not enough research to support that eating allergy-causing foods during pregnancy will help protect your baby from food allergies.

The key takeaway for families is that early allergen introduction is still the only guideline for preventing food allergies in children.

4. Breastfeeding is Still Encouraged

The USDA report found strong evidence that breastfeeding may reduce your child’s risk of the following compared to children who have not been breastfed:

          • overweight
          • obesity
          • type 1 diabetes 
          • asthma

Further, the USDA report found that the longer children are breastfed, the less their chance of developing those diseases and conditions. However, it is important to note that the “optimal duration of breastfeeding with respect to these outcomes is not well understood”.

5. Obesity is a Pressing Public Health Concern

The guidelines indicate that over 70% of Americans are overweight or obese. Again, there is a strong link shown between added sugar consumption in children under 2 and the likelihood of developing obesity or becoming overweight. Furthermore, high rates of obesity are not only public health concerns, but they also drive diet-related chronic diseases, such as “cardiovascular disease (CVD), type 2 diabetes, and some types of cancer”.

Leading Allergy Organizations Support the USDA Guidelines

Recently, the top allergy organizations in North America published guidance that recommends: “to prevent peanut and/or egg allergy, peanut and egg should be introduced around [4-] 6 months of life.”

The leading allergy organizations include the following:

      • American Academy of Allergy, Asthma, and Immunology (AAAAi) 
      • American College of Allergy, Asthma, and Immunology (ACAAI)
      • Canadian Society of Allergy and Clinical Immunology (CSACI)

They have all come to a consensus with the recommendation in order to address the dramatic rise in food allergies. This is because the disorder now “affect[s] as many as 8% of children in the United States and 7% in Canada.

This recommendation now joins the overwhelming support already expressed for the new USDA guidelines. In addition, food allergy prevention recommendations have been issued by the following organizations:

  • American Academy of Pediatrics (AAP)
  • National Institute of Allergy and Infectious Diseases (NIAID
  • National Institutes of Health (NIH)

New Research on Food Allergies: Prevention is Possible for Every Baby

As a Board-Certified Allergist, I’ve seen the rise in food allergies firsthand. That’s why it’s really exciting to see the new USDA dietary guidelines report includes a strong food allergy recommendation. It states clearly that infants starting at four months of age should be introduced to allergenic foods like peanuts and eggs. Based on multiple landmark clinical trials, we have evidence that doing so can actually help prevent the development of a food allergy.


Additional information on food allergies and nutrition:

Foods Allergies: What Causes Them? And, Can They Be Prevented?
Your Genes and Food: The Science of Personalized Nutrition


In addition, any baby can develop a food allergy. It’s not solely based on genetics. Unfortunately, I think a lot of families may not know that genetics is not the only factor. In fact, there are multiple other things involved. Over half of babies diagnosed with a food allergy today actually have no direct family members with a food allergy.

How To Follow the Food Allergy Prevention Guidelines Report At Home

You can do early and sustained allergen introduction at home by giving your baby allergenic foods such as peanut, egg, and milk. However, because you have to wait until your baby is developmentally ready to eat solids.

Further, the landmark clinical trials (LEAP, EAT, PETIT) suggest that it may actually be more beneficial to give babies allergens such as peanut, egg, and milk starting at 4 months of age. This can be really challenging for parents because many babies are not developmentally ready to eat solid food until at least 6 months of age. In some children, it is even later.

In addition, it can be a time-consuming process because you can’t just give these foods to your baby only once and expect to see the same results as in the studies. These same clinical studies show that you have to offer allergens on a consistent and regular basis in order to have the most benefit in terms of reducing your child’s risk of food allergies.

usda dietary guidelines promo photo for Ready Set Food

READY SET FOOD – Introduce Food Allergens To Your Baby. Recommended By 500+ Pediatricians And Allergists. *This is an affiliate link. That means we receive a small commission on each sale made through this link. It does not affect the price you pay. It does help support our work. (Photo provided by author)

Making early allergen introduction easy

I did try early allergen introduction with my son when he was a baby. It was challenging because I had to prepare all of the food. I also needed to pay attention to details such as how often I was giving the allergens. And, I had to make sure that all the food was getting into his mouth (and not everywhere else).

So I do understand that it can be a frustrating process. This is the main reason that my colleagues and I created a new product, Ready, Set, Food!*, to make it easier for parents to do early allergen introduction. We have eliminated the stress of food preparation by creating an evidence-based product that makes it easy for families to follow the new guidelines at home.

 Ready, Set, Food! is easy to use

The product is designed to be administered in two stages. The Stage 1 product consists of individual packets of the food allergen. The intended day of use is clearly labeled on each packet.

  • Packets for days 1-4 only contain organic cow’s milk.
  • Days 5-8 have organic cow’s milk and organic cooked egg white.
  • Days 9-11 (Maintenance) contain organic cow’s milk, organic cooked egg white, and organic peanut

You empty the packet into a bottle with at least 2 ounces of breast milk, formula, or water. You shake the bottle to mix just before feeding the baby. It can also be added to food. It’s that simple.

Stage 2 is the maintenance phase. Use for 6+ months is recommended by the company. They state that sustained exposure is important to minimize risk. The product is sold in cartons containing 15 packets that contain all three allergens. 

Note: this product is NOT intended for use by infants who have been diagnosed with food allergy. Further, if your has a sensitivity to the product, discontinue its use and contact your healthcare provider.

*This is an affiliate link. That means we earn a small commission on each sale made through this link. It does not add to your cost, but it does help support our work.

It shouldn’t be surprising to learn that doctors and healthcare providers are often frustrated when patients with eating and weight concerns don’t follow their advice. They caution and cajole, nudge, and lecture these patients about the importance of weight loss often to no avail. An unspoken question comes to mind, “Why do these people continue to sabotage themselves?”

Here are five possible reasons why patients ignore their doctors’ advice on weight loss and fitness.

1. Fear of failure and hopelessness

Most patients with eating and weight concerns are not new to the concept of diets and exercise. In fact, providers may not know that their patients have gained and lost 50, 75, or more than 100 pounds several times in their lives.1 These patients have been there and done that, and it hasn’t turned out as well as everyone had hoped.

For most of them, the deprivation they felt while dieting was stupefying, and the restraint they had to muster daily was insufferable until they finally ran out of self-control and self-discipline and gave into eating normal portions, sweets and treats, and foods that they enjoyed.2,3 While providers are trying to psych them on starting a new health regimen, they’re recalling the last time they let their gym membership lapse and the closet full of smaller-sized clothes they fear they’ll never squeeze into again.

2. Depression

Many patients with eating and weight concerns have neurotransmitter imbalances causing depression and anxiety.4 Maybe they started out with the happy genes, but more likely not. Even if they did, the weight stigma and fat prejudice that runs rampant in society, not only through the media but from surgeons to secretaries in medical offices, would have demoralized them and shattered their self-esteem.

Patients who misuse food when they have the blues or the blahs may not even know that they’re depressed. Those who have social anxiety may not realize that eating is their way of coping when out to dinner with friends or attending a work party. They don’t want to hurt their bodies. They only want to feel the way that others appear to feel—relaxed and normal—when they’re around people.

Related content: How to Help Your Partner Make Healthy Lifestyle Changes

3. Lack of life skills to attain and maintain health goals

Most of us weren’t raised with a full complement of the life skills needed to maintain a healthy lifestyle. For example:

        • effective self-care,
        • healthy relationships,
        • work and play balance,
        • emotional management,
        • goal achievement,
        • problem-solving, and
        • self-regulation.

Moreover, we don’t all start out on an equal playing field. Sadly, dysfunctional families too often produce children who are lacking in life skills and end up with a diminished quality of life in adulthood.

Expecting these patients to make healthy choices when they’ve never been taught how to delay gratification or tolerate frustration is a waste of time.

Hoping that they’ll call a friend when they’re upset rather than down a pint of Häagen-Dazs is misplaced optimism if they were raised in an insular family that mistrusted outsiders. Encouraging them to take a walk to unwind is wishful thinking if they feel they must be productive 24/7. We need effective life skills if we’re going to effectively take care of mind and body.

4. Mixed feelings about the weight loss advice

It may seem like a no-brainer to medical professionals that everyone would want to lose weight and be attractive. This is not always the case. Sexual abuse survivors often feel less vulnerable and safer with more meat on their bones. People who are more sexually active when they’re thinner sometimes fear that weight loss will compromise their marital fidelity.

Patients who’ve suffered emotional and physical abuse may insist that they want to date. However, they are afraid of relationships because of what has happened when they’ve let their guard down in the past. In other cases, holding onto excess weight may be a badge of suffering, a way to signify that life hasn’t been good to them. These are serious psychological dilemmas that won’t go away without clinical attention.

5. Rebellion – but not just against weight loss advice

One of the most common reasons for not following medical advice is unconscious rebellion. This is a characteristic of people who are confused about care versus control.5 If they had parents who were domineering, critical, and demanding (and parental dependence was encouraged), they, while wanting to follow providers’ advice, would resent being told what to do. They dislike being pressured, even to do what’s good for them. Further, they will avoid doing it out of misplaced spite.

Rebellion is a complex dynamic which most patients and providers are unaware of. Even though professionals try to care for them, these patients only feel and fear that they’re being controlled. No wonder what doctors say seems to go in one ear and out the other. It’s easy to see why this dynamic may seem like self-sabotage, but it’s much more unconscious and complicated.

The bottom line on why patients ignore doctors’ weight loss advice

Doctors and healthcare providers need not feel that without a graduate degree in psychology they can’t possibly do right by their patients who have eating and weight concerns. They do need to recognize that patients are not intentionally trying to remain unhealthy and hurt their bodies. And they must offer empathy and compassion for their minimal and inconsistent efforts.

If doctors are able to do these things, they will find themselves on the right track. In addition, providers would also benefit from encouraging patients to get support from eating disorders therapists so that no one has to wrestle with eating and weight concerns by themselves.


  1. Eric Stice, Kyle Burger, and Sonja Yokum, “Caloric Deprivation Increases Responsivity of Attention and Reward Brain Regions to Intake, Anticipated Intake, and Images of Palatable Foods,” abstract. NeuroImage (February 2013): vol. 67, 15: 322–330. https://doi.org/10.1016/j.neuroimage.2012.11.028. Accessed 12/20/20
  2. Paul S. Maclean, Audrey Bergouignan, Marc-Andre Cornier, Matthew R. Jackman, “Biology’s Response to Dieting: The Impetus for Weight Regain,” American Journal of Physiology: Regulatory, Integrative and Comparative Physiology (September 1, 2011): vol. 301, no. 3, R581-R600 DOI: 10.1152/ajpregu.00755.2010. Accessed 12/20/20. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3174765/
  3. A. G. Dulloo and J..P Montani, “Pathways from Dieting To Weight Regain, To Obesity and To the Metabolic Syndrome: An Overview,” abstract. Obesity Reviews (2015), 16: 1–6. doi: 10.1111/obr.12250, https://www.ncbi.nlm.nih.gov/pubmed/25614198. Accessed 12/20/20
  4. Karen R. Koenig and Paige O’Mahoney, Helping Patients Outsmart Overeating: Psychological Strategies for Doctors and Health Care Providers. (New York: Rowman & Littlefield, 2017), 36-7.
  5. Chelsea Fielder-Jenks, “Binge Eating Disorder and Anxiety,” Eating Disorder Hopehttps://www.eatingdisorderhope.com/information/binge-eating-disorder/binge-eating-disorder-and-anxiety. Accessed 12/22/20.

    First published 5/12/17. Updated and republished 12/25/20

Eating disorders are among the most dangerous and difficult to treat of all mental health disorders. Eating disorders do not discriminate. They can be found in both genders, all age groups, and across a wide variety of races and ethnic backgrounds. Eating disorders adversely impact the health and well-being of those affected. And, sometimes, eating disorders can become quite severe and, without aggressive medical treatment, can lead to death.[1]

This article will explore the key features of these often misunderstood disorders.

Our unhealthy relationship with food

Were you ever told you must clean up your plate?  Or eat your Brussel sprouts before you could have dessert? If so, you aren’t alone. Many of us grew up being harangued with some variation of these types of “eat your food or else” threats. However, they are just one of many contributing factors to American’s unhealthy relationship with food. Among others are:

      • Our belief that anything enjoyable is inherently wrong
      • Thinking that things that are good for us are not enjoyable
      • Eating and dieting are national obsessions
      • Obsession with thin beauty is reinforced by the media
      • Dietary recommendations are conflicting, contradictory, and constantly changing
      • Physicians and other health professionals may not recognize there is problem until it is quite advanced

The dichotomy between good food and bad food generates fear, anxiety, and guilt. We feel guilty about eating enjoyable foods, yet we use them to lift our moods, reward behavior, and celebrate milestones. 

This mentality leads to problems with eating disorders.

Different manifestations of unhealthy relationships with food

There are different manifestations of disordered eating, including:

      • Some individuals gorge themselves into obesity
      • Others eschew food altogether.
      • Yet others gorge on food and then purge.
      • And some rigidly obsess about what they eat.

Many of us may do these things to a lesser degree or intermittently. But in some individuals, these patterns take control of their lives. At this point, we say that they have developed a serious eating disorder.

Types of eating disorders

The three types of eating disorders most discussed and researched are Anorexia Nervosa, Bulimia Nervosa, and Binge Eating. [A detailed discussion of specific diagnostic criteria can be found here.[2]

  • Anorexia Nervosa 

Anorexia nervosa is characterized by weight loss (or lack of appropriate weight gain in growing children), difficulties maintaining the right body weight, and a distorted body image. 

  • Bulimia Nervosa

Bulimia nervosa is characterized by a cycle of bingeing, self-induced vomiting, and/or laxative abuse designed to undo the effects of binge eating.

  • Binge Eating Disorder

Binge eating disorder is the most common eating disorder. It is characterized by recurrent episodes of feeling out-of-control while quickly consuming large quantities of food. Binges are accompanied by feelings of guilt and shame. Purging and laxative abuse do not occur with this disorder.  

Other subtypes of eating disorders

These disorders are not formally recognized in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5.)

The pursuit of a healthy diet is considered laudable. But when fixation on eating a correct diet becomes the most critical part of one’s life, it is regarded as a disorder.

Muscle Dysphoric Disorder is sometimes referred to as “Bigorexia,” “Megarexia,” or “Reverse Anorexia.” It is not listed in DSM-5 as a separate diagnosis but rather as a subset of Body Dysmorphic Disorder.{3] While it shares several characteristics with anorexia, it is a desire to be bigger rather than smaller.

Diabulimia is not recognized as a formal diagnosis by the medical or psychiatric communities. However, it has been referred to as the world’s most dangerous eating disorder. It refers to an eating disorder in a person with diabetes, typically Type I Diabetes, wherein the person purposefully restricts insulin to lose weight.

How common are eating disorders?

The National Institute of Mental Health (NIMH) reports that binge eating disorder occurs in 1.2% of adults. The rate twice as high among females. Bulimia nervosa affects 0.3% of adults and is five times higher among females than males. The lifetime prevalence of anorexia nervosa in adults is 0.6%, and it occurs three times more among females than males. 

Many more individuals may experience the symptoms of an eating disorder but do not yet have a formal diagnosis. Also, many individuals struggle with body dissatisfaction and subthreshold disordered eating attitudes and behaviors.

Related content by the same author: Body Dysmorphic Disorder: Obsession with a Flaw Interferes with Life

What causes eating disorders?

A considerable amount of research has been done on the biological, psychological, developmental, and sociocultural risks associated with eating disorders. While the number of risk factors identified as contributing to the development of eating disorders has increased, evidence for the cause of eating disorders [5] has not been conclusive. 

Risk factors are first present in early adolescence, but eating disorders tend to emerge in late adolescence and early adulthood. Eating disorders do not present in the same way from one person to the next. However, research has found similarities in significant risks for developing eating disorders.

  • Risks for developing eating disorders

There are three variables that are commonly associated with eating disorders:

      • Perceived pressure to be thin
      • Internalizing a thin-ideal
      • Body dissatisfaction

In the last few years, research has shifted toward the genetics and neurobiology of eating disorders. Most researchers no longer believe that the cause is a matter of “will” or self-control.

  • Poor food choices

People routinely make poor choices, despite knowledge of negative consequences. Still, individuals with anorexia nervosa make bad food choices to the point of starvation.

One study found that individuals with anorexia engage a different part of their brain when making food choices compared to healthy subjects. The part of the brain identified is associated with habitual behaviors.[6]

Related Content:  5 Reasons Why Patients Ignore Doctors’ Weight Loss Advice

  • Genetics

Another report suggests a genetic model that considers environmental, nutritional, and genetic factors in eating disorders.[7] Evidence for a genetic link is supported by the fact that eating disorders occur more frequently when a close relative has an eating disorder or a mental health condition. 

  • Other risk factors:

      • Perfectionism
      • Body image dissatisfaction
      • Personal history of an anxiety disorder
      • Always following the rules
      • Weight stigma
      • History of dieting
      • Type 1 (insulin-dependent) diabetes
      • Teasing or bullying
      • Racial and ethnic minority groups 
      • Loneliness and isolation
      • Psychological trauma
      • Bullying
      • Weight stigma

Perfectionism is one of the most common risk factors for eating disorders. Eating disorder risks are higher in racial and ethnic communities, particularly for those undergoing rapid Westernization. Bullying leads to low self-esteem, isolation, and poor body image. 

Over 70% of people with eating disorders reported mental health issues.[8] The most common are anxiety disorders, followed by mood disorders, self-harm, and substance abuse. Perfectionism and negative emotions (anger, sadness, guilt, anxiety, and disappointment) are frequently associated with eating disorders.

Eating disorders in athletics

Both female and male athletes are at higher risk of developing an eating disorder compared to non-athletes [9] This is especially true for athletes participating in sports where leanness confers a competitive advantage.

Eating disorders are more prevalent in appearance-oriented athletic activities called “aesthetic sports“[10] (swimming, gymnastics, dance, and bodybuilding) than in ball sports. 

Early specialization in a sport appears to be a factor. Athletes tend to under-report their disordered eating. In combat sports like martial arts sports, athletes compete within weight classes. Disordered eating and pre-competition of rapid cutting of weight are everyday occurrences and predispose to eating disorders.

Diagnosis and treatment

Treatment begins with a good medical evaluation by a health care provider. Severe cases may require stabilization in a hospital experienced in the safe refeeding of severely malnourished individuals.[1]

Much of the psychiatric treatment of eating disorders focuses on psychotherapy with one of the following:

  • Cognitive Behavioral Therapy (CBT)

CBT is the leading evidence-based treatment for all eating disorder diagnoses in adults. It can also be adapted for adolescents. CBT is designed to produce changes in thinking. In eating disorders, it focuses on what is keeping the eating problem going. CBT includes homework exercises to complete between therapy sessions. Issues addressed include shape and weight, dietary rules, moods related to eating, perfectionism, and low self-esteem.

  • Family-Based Treatment (FBT)

FBT is the leading evidence-based treatment for eating disorders in adolescents and children. In FBT, parents play an active and positive role to help their child. 

  • Interpersonal therapy (IPT)

IPT is a time-limited, focused therapy developed for the treatment of depression that has been adapted for eating disorders. It recognizes the importance of current interpersonal relationships in the recovery process. 

  • Cognitive remediation therapy (CRT)

CRT was developed initially for patients with brain injuries. patients with eating disorders have deficits in their thinking. In particular, they have inflexible thinking. 

The Eating Disorder Assessment for DSM-5 (EDA-5) is a semi-structured interview meant to assist in assessing a feeding or eating disorder according to DSM-5 criteria. It is intended for use by clinicians who have some familiarity with the feeding and eating disorders. It is available electronically and in Spanish as well as other languages. The EDA-5 is available at no cost for use in clinical settings.

In those individuals with co-morbid mental conditions like anxiety and depression, anti-depressant medications are indicated.

Treatment outcomes

The best predictor of outcomes in treating eating disorders[11] is the degree of symptom reduction early in treatment. Other predictors of treatment success relate to

  • Body Mass Index (BMI)
  • fewer binge/purge episodes
  • higher motivation
  • lower depression
  • lower concerns about shape and weight
  • fewer comorbidities
  • better interpersonal functioning
  • fewer family problems

The bottom line 

Eating disorders are serious and, at times, life-threatening mental illnesses that require knowledge about the risk factors, causes, treatment options, and outcomes. 


    1. Mehler P. Medical Management of Severe Eating Disorders. The Doctor Weighs In, 2020 Dec 1. https://thedoctorweighsin.com/medical-management-severe-eating-disorders/ Accessed 12/10/20.
    2. National Eating Disorders Association. What Are Eating Disorders? https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia  Accessed 12/10/20
    3. Veale D. Body Dysmorphic Disorder. BMJ 2015350 doi: https://doi.org/10.1136/bmj.h2278 Published June18, 2015. ( Cite this as: BMJ 2015;350:h2278)  Accessed 12/10/20. Ed. note: this reference is behind a paywall.
    4. National Institute of Mental Health. Easting Disorders. https://www.nimh.nih.gov/health/statistics/eating-disorders.shtml Accessed 12.10/20
    5. Rikani AA, Choudhry Z, Choudhry A et al. A critique of the literature on etiology of eating disorders. . 2013 Oct; 20(4): 157–161. doi: 10.5214/ans.0972.7531.200409
    6. Foerde K, Steinglass J, Shohamy D, et al. Neural mechanisms supporting maladaptive food choices in anorexia nervosa. Nature Neuroscience (Advancce online publication), 2015 Oct 12. doi:10.1038/nn.4136. https://shohamylab.zuckermaninstitute.columbia.edu/sites/default/files/2017-02/karinsNNanorexia.pdf
    7. Himmerich H, Bentley J, Carol Kan et al. Genetic risk factors for eating disorders: an update and insights into pathophysiology. Therapeutic Advances in Psychopharmacology 2019 Feb 12. https://doi.org/10.1177/2045125318814734 https://journals.sagepub.com/doi/full/10.1177/2045125318814734
    8. Keski-Rahkonen A, Mustelin L. Epidemiology of eating disorders in Europe: prevalence, incidence, comorbidity, course, consequences, and risk factors, Current Opinion in Psychiatry: November 2016 – Volume 29 – Issue 6 – p 340-345 doi: 10.1097/YCO.0000000000000278 https://journals.lww.com/co-psychiatry/Abstract/2016/11000/Epidemiology_of_eating_disorders_in_Europe_.5.aspx
    9. Joy E, Kussman A, Nattiv A. 2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management, British J Sports Medicine, 2015, httpss://dx.doi.org/10.1136/bjsports-2015-095735 https://bjsm.bmj.com/content/50/3/154.short
    10. Thiemann P, Legenbauer T, Vocks S. et al. Eating Disorders and Their Putative Risk Factors Among Female German Professional Athletes 2015 March 31. https://doi.org/10.1002/erv.2360 https://onlinelibrary.wiley.com/doi/abs/10.1002/erv.2360
    11. Vall E, Wade T. Predictors of treatment outcome in individuals with eating disorders: A systematic review and meta‐analysis, International J of Eating Disorders, 2015 July 14, https://doi.org/10.1002/eat.22411. (behind a paywall). https://onlinelibrary.wiley.com/doi/abs/10.1002/eat.22411

Severe eating disorders are the only mental illnesses regularly accompanied by dangerous, life-threatening medical complications. Significant medical instability results from a number of abnormalities, such as progressive malnutrition, purging behaviors, and blood chemistry abnormalities.

In fact, the disorder can compromise virtually all of the body’s vital organs and systems.

There are a number of different eating disorders that lead to excessive weight loss and associated medical complications. The most common include:

In this article, I will focus on the medical complications of these disorders. I will also discuss how to manage because it is crucial to saving the lives of individuals suffering with a severe eating disorder. Further, it is key to helping patients achieve the medical stability and cognitive function necessary to engage fully in the recovery process.

Related content:
What You Need to Know About Eating Disorders
Eating Disorders: Risk Factors, Diagnosis, Treatment, and Outcomes

Medical complications of severe eating disorders

Common medical complications associated with severe eating disorders include the following [1,2]:

      • Gastrointestinal complications, including diarrhea, delayed gastric emptying (gastroparesis), constipation, abdominal pain, and swallowing difficulties) 
      • Liver function test abnormalities
      • Electrolyte abnormalities
      • Pseudo-Bartter’s syndrome (a complex of metabolic abnormalities related to purging)
      • Eye pain
      • Edema
      • Osteoporosis and osteopenia,
      • Superior mesenteric artery (SMA) syndrome
      • Cardiac dysfunction & arrhythmias
      • Muscle weakness
      • Traumatic falls

Medical complications of eating disorders can be treated effectively

The good news is that nearly all medical complications of eating disorders can completely resolve with safe nutritional rehabilitation and weight restoration. This is true regardless of how extensive they are.

Patients are resilient if they get the correct (and timely) treatment with a balance of informed medical and psychiatric care. This is especially critical for more chronic patients and patients of advanced age.

The bad news, however, is that eating disorders themselves are commonly undertreated. This means that a large number of patients receive only partial treatment for the complex medical and psychiatric concerns associated with these illnesses.

It is important to understand that severe eating disorders can be deadly. Anorexia nervosa, for example, is considered the deadliest of all mental illnesses with a mortality rate estimated to be ~10%. [3]  Further, AN patients carry an increased risk for suicide.

Many patients with severe eating disorders will require a high level of care

More than one-third of individuals suffering from eating disorders will require treatment at a higher level of care. This can range from 24-hour inpatient psychiatric care to comprehensive daytime behavioral programming. 

Most treatment programs offer some degree of minimum internal medicine and/or nursing support to manage medical issues of eating disorders. However, some patients may be so medically compromised by their illness that they require specialized medical, hospital-based stabilization prior to entering a residential eating disorder treatment program.

Determining what level of care a patient with an eating disorder needs can be challenging for reasons that include:

      • patient resistance,
      • secrecy shrouding eating disorder behaviors and symptoms,
      • the body’s ability to feign stability.

Determining the appropriate level of care needed

It is not uncommon for patients, families, and providers to begin with the least intensive intervention. However, starting a treatment plan with the appropriate level of care can have a significant impact on the patient’s health. It is also a factor that influences success in recovery and satisfaction with treatment.[4]

The American Psychiatric Association (APA) has outlined five levels of psychiatric care. They are divided between outpatient and inpatient treatments.

It is important to note, however, that this guidance fails to completely outline a crucial sixth level of care. This is the one that involves specialized medical treatment for individuals experiencing extreme medical instability that results from physical complications of malnutrition and purging. 

For this severe subset of patients, intervention should include medical stabilization in a specialized, hospital-based medical unit prior to beginning traditional behavioral eating disorder treatment.

Expert consensus suggests inpatient stabilization should occur when a BMI is <14 or when that patient’s weight is <70% of ideal body weight (IBW).

  • Weight specific recommendations to levels of care

In general, patients with AN or Avoidant/Restrictive Food Intake Disorder (ARFID) whose weight is:

      • below 70% IBW should first be treated in a specialized medical unit for the medical stabilization of those patients,
      • between 70 to 84% of IBW, are best served in an inpatient or residential treatment center,
      • between 85% to 95% of IBW, a partial hospitalization program (PHP) is generally appropriate.[5]

It is important to remember that no guideline is absolute when it comes to these complex illnesses. The frequency of purging behaviors and other physical or psychiatric symptoms must be considered alongside patient weight to ascertain the appropriate level of care that may be needed.

What is inpatient medical stabilization for eating disorders?

In general, initial medical stabilization in a hospital-based unit is recommended for eating disorder patients who are severely low weight, seriously medically compromised, or at risk for major complications from refeeding syndrome. The latter is a dangerous metabolic disturbance that can occur when nutritional rehabilitation is first initiated.

Patients with any/all of the following criteria may require medical treatment from experienced providers in a specialized medical hospital unit before entering a behavioral treatment program in a traditional eating disorder unit:

      • weight <70 percent of ideal body weight or BMI <14
      • unstable vital signs such as low or irregular heart rates or low blood pressure
      • cardiac disturbances such as abnormal heart rhythms or heart failure
      • loss of consciousness due to low blood pressure
      • acute kidney or liver failure and/or
      • critical electrolyte abnormalities such as low potassium or low phosphorous of extreme degrees.

What is the goal of medical stabilization of patients with severe eating disorders?

The goals of medical stabilization are to improve and normalize the patient’s vital signs, cardiovascular system, and bowel function as well as restore levels of key electrolytes including phosphorus, potassium, magnesium, and calcium in a timely manner. Medical stabilization also involves nutritional rehabilitation to support weight restoration.

Most experts agree that careful caloric initiation is vital to medical stability and improved cognitive function. It is hallmarked by the ability to tolerate and complete the most basic activities of daily living. Inpatient medical units have the expertise and resources to deliver any form of nutrition required, including oral, enteral, or intravenous calories.

It is important that each of these goals is met in order for a patient with an eating disorder to be considered medically stable. Once the patient has achieved medical stability, he or she can continue in recovery by transitioning to a 24-hour psychiatric facility. It is important that the psychiatric facility has the ability to sustain medical progress while incorporating the following interventions:

      • intensive psychotherapy,
      • ongoing weight restoration,
      • other evidence-based recovery interventions.

Understanding the difference between medical and psychiatric treatment 

It is also important that providers, patients, and families understand the difference between inpatient psychiatric treatment and inpatient medical stabilization for the most severe eating disorders.

While an inpatient psychiatric facility offers round-the-clock behavioral treatment and likely some degree of medical support, an inpatient medical stabilization program requires a hospital-based telemetry unit.

Its full-time internal medicine physicians, nurses, dietitians, and skilled rehabilitation providers expertly treat any life-threatening medical complication of severe eating disorders. These medical teams collaborate with psychiatrists, psychologists, and behavioral health technicians to support behavioral recovery.

It is important for patients and families to understand that patients with serious complications due to eating disorders will be too weak, medically unstable, or cognitively impaired to engage in meaningful therapy during medical hospitalization.

Inpatient medical and inpatient psychiatric programs must work together to support survival and recovery in medically complex patients. Initially, however, there is no substitute for 24/7-available medical, dietary, and nursing expertise on a dedicated medical stabilization unit.

Avoiding refeeding syndrome

Increasing caloric intake quickly in individuals with severe anorexia nervosa or ARFID, without frequent monitoring of blood tests and electrolyte replenishment, can lead to refeeding syndrome. A dangerous shift in fluids and electrolytes within the body are characteristic of the disorder.

It occurs in a small subset of patients when calories are introduced quickly, lab tests are not checked frequently, and resultant abnormalities are not treated in a timely fashion. The lower the patient’s BMI, the greater the risk of refeeding complications.[6]  

  • Cardiac complications of refeeding

When the body is starved or severely malnourished, the heart muscle may atrophy. This causes diminished cardiac output. Further, the body begins to break down its own tissues—including fats and muscle—in an attempt to create the energy needed to maintain basic bodily functions. These changes can affect the body’s major electrolytes, including phosphorus, potassium, and magnesium.

  • A shift to carbohydrate metabolism

When food is reintroduced during the refeeding process, there is an abrupt shift from fat and muscle metabolism back to carbohydrate metabolism.  This increases the body’s uptake of phosphorus and other key electrolytes into newly developed cells. This leads to dangerously decreased levels of these electrolytes in the blood.

This sudden change in the balance of electrolytes causes the atrophied heart to work harder, which can cause irregular heartbeat, muscle damage, weakness, seizures, and even death. When the resultant blood chemistry abnormalities are not detected or are not addressed in less than a few hours, patients may be at risk for the refeeding syndrome characterized by the following:

        • cardiac failure, 
        • respiratory failure,
        • rhabdomyolysis (muscle death),
        • hemolysis (red blood cell rupture) and/or
        • seizures.

These life-threatening complications are preventable when refeeding is administered by eating disorder experts. However, many medical providers are not trained to identify or address refeeding syndrome in patients with extreme anorexia and ARFID. This unfortunate reality underscores the need for severely underweight patients to begin the refeeding process in a specialized inpatient medical setting capable of treating the most serious eating disorders.

Eating disorder patients with normal or high BMI

Assuming that patients with a “normal” or “higher” BMI are always stable enough to access lower levels of care may inadvertently cause harm. Some of these patients may present with a falsely elevated weight.

They can also be at risk for dangerous complications due to excessive purging behaviors followed by abrupt cessation or significant and rapid “weight disruption” that is marked weight loss over a short period of time.[6]

Thus, regardless of current weight, it is essential to consider the severity of purging behaviors and absolute weight loss when choosing an appropriate level of care.

Again, consider medical stabilization first for those showing severe weight disruption (more than 25% body weight loss in a short time period). Include as well those needing to safely “detox” from severe self-induced vomiting and laxative or diuretic abuse.

The bottom line on the management of severe eating disorders

Eating disorders at any stage are complex and can be life-threatening. Seeking treatment for a severe eating disorder can be overwhelming. This is especially true when life-threatening medical complications are present. However, helping providers, patients, and families understand which level of care provides adequate medical support to address these complications and restore medical stability is an important first step in the recovery journey.


1. Cost J, Krantz M, Mehler P. Cleveland Clinic Journal of Medicine, Medical complications of anorexia nervosa. (2020) 87 (6) 361-366; DOI: https://www.ccjm.org/content/87/6/361

2. Mehler, P. International Journal of Eating Disorders, Medical complications of bulimia nervosa, and their treatments. (2011) 44(2):95-104. DOI: https://doi.org/10.1002/eat.20825 

3. Berends, T, Boonstra N, van Velburg A. Current Opinions in Psychiatry, Relapse in anorexia nervosa: a systematic review and meta-analysis. (2018) 31(6): 445-455. Doi: 10.1097/YCO. https://pubmed.ncbi.nlm.nih.gov/30113325/

4. Cost J, Mehler P. Eating Disorders Review, Level of Care Considerations for Severe and Extreme Eating Disorders. (2019), Vol 30. https://eatingdisordersreview.com/level-of-care-considerations-for-severe-and-extreme-eating-disorders/ 

5. Mehler P, Crews C. Eating Disorders-The Journal of Treatment and Prevention, Refeeding the Patient With Anorexia Nervosa. (published online 2010) https://doi.org/10.1080/10640260127719

6 Garber, A. K.. Journal of Adolescent Health. Moving beyond “skinniness”: presentation weight is not sufficient to assess malnutrition in patients with restrictive eating disorders across a range of body weights. (2018), 63(6), 669-670. https://www.jahonline.org/article/S1054-139X(18)30425-7/fulltext

Getting regular exercise, eating right, and taking time to relax are all extremely important aspects of personal care. However, it can feel nearly impossible to successfully help your partner make healthy lifestyle changes.

You want your partner to make healthier choices because you love them. But the wrong choice of words may make them feel just the opposite. Asking your partner to work on their fitness or their mental health requires a delicate tone so that they aren’t left feeling insecure or unwanted.


Important resource: Resources to Help You Get Out (and Protect) the Vote


So how can you encourage your partner to take care of their mind and body without coming off as parental or pushy? It’s a tricky balance, but it can be done!

Here are 7 tips for creating a healthy relationship – inside and out.

1. Do it together

Everything is better when you do it together. Isn’t that the truth? When you’re with your favorite person somehow something as mundane as grocery shopping can seem like a little adventure. The same goes for working out!

One study found that friendly competition between exercise partners can increase the amount of time you spend working out.

Another study looked a the benefit of social support on weight loss and maintenance using standard behavioral treatment (SBT). One group of participants consisted of people trying to lose weight on their own. The other group was asked to do it in conjunction with 3 friends or family members.

Seventy-six percent of the solos finished the program. However, only 24% maintained their weight loss in full from months 4 to 10 of the study. On the other hand, 95% of individuals with social support completed treatment. Moreover, 66% maintained their weight loss in full.

This research highlights how motivational it can be to work out with another person. And you can be that person for your spouse.

2. Make healthy lifestyle changes fun

They say if you can make learning fun, you’re on the right track. Taking classes can be a great way to encourage your partner to make healthier choices.

One great way you can do this is by taking a class together. What is your spouse interested in? Water sports? Kickboxing? Spin? Perhaps group sports may be more to his liking/ There are myriad hiking, birding, swimming, and salsa groups that you could join. You might even consider taking a healthy cooking class together. Figure out what appeals to him, then do it together. What could be better than improving your health as a couple?

Doing novel and exciting activities together has been shown to contribute to healthy relationships. According to a study published in the Journal of Personality and Social Psychology, couples reported greater increases in relationship quality from before to after participating together in a novel and arousing vs. a more mundane and boring task. When these results were compared to a no-activity control, they found the effect was due to the novel-arousing task. The authors concluded that the “results bear on general issues of boredom and excitement in relationships”.

Participating in new and exciting activities that are also healthy can be a bonding experience that brings you closer to your partner while also improving your physical health.

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3. Be considerate and respectful

Can you imagine how you would feel if your spouse told you they were no longer attracted to you? No doubt it would make you feel hurt and maybe even ugly. This is the last impression you want to give your spouse when bringing up health and fitness topics!


Be considerate with your words. Whether you’re talking to a man or a woman, the subject of someone else’s weight should be handled with the utmost care.

4. Let them know the benefits of healthy lifestyle changes

Healthy habits truly contribute to a healthy relationship. Letting your partner know about the great benefits of eating right, drinking enough water, and getting in some daily exercise may motivate them to start making healthier decisions.

Your partner likely knows that exercise can contribute to weight loss and a firmer body. But do they know how it benefits their mental health? Research in The Primary Care Companion to The Journal of Clinical Psychiatry reveals that aerobic exercises such as walking or dancing have been proven to reduce anxiety and depression.

That same study goes on to say that getting 30-minutes of exercise each day can contribute has many benefits including the following:

  • an increased interest in sex
  • mood elevation
  • increased stamina and energy
  • increased mental alertness
  • improved cardiovascular fitness
  • reduction in cholesterol.

5. Take control in the kitchen

If you’re the main chef in the house then you’re in a great position to start bringing new, nutritious foods into the house.

Start slow. Introduce healthy dinners into your weekly meal rotation and see which one your partner likes.

Have a Meatless Monday, do healthy takes on comfort foods like cauliflower mac and cheese, baked “fried” chicken, or zucchini brownies.

A healthy relationship is about balance. Your partner is more likely to succeed with their health goals when they don’t feel restricted, so don’t be afraid to go out to a restaurant or have a bottle of wine every once and a while.

6. Don’t force healthy lifestyle changes 

Does your partner take the time to relax? Or is the stress of their job causing them to be miserable? Has your spouse gained weight? Are they making poor diet decisions that are negatively affecting their health?

These are all frustrating issues to deal with, but you aren’t going to get anywhere with your partner by nagging them.

Taking control of your health is a personal decision and lasting change can only happen when you’re truly ready to change. If you begin to fixate on changing your partner before they are ready to commit to their health it will start to cause problems in your relationship.

7. Be reasonable

Are your expectations too high? Your spouse isn’t automatically going to fall in love with kale just because it’s good for them. Nor will they always love the same workouts that you do. And that’s okay! Getting healthy is all about finding something that motivates us on a personal level.

Having tunnel vision about your spouse’s health will do more harm than good. Set reasonable expectations about your partner’s diet and exercise routine and remain balanced.

Celebrate small wins instead of criticizing missteps. The more complimentary you are about your partner’s progress, the more motivated they will be to continue making healthy habits.

The bottom line when it comes to healthy lifestyle changes and healthy relationships

To have a healthy relationship, you must develop healthy habits. It isn’t easy to get your partner to make healthy lifestyle changes, especially when it comes to diet and exercise. But don’t fret! By following these 7 tips, you’ll be able to encourage your partner to make better decisions and enjoy a happy relationship.

Chronic wounds aren’t typically something most people think about. If there is a break in the skin or deep tissue, nature takes over and our bodies begin the healing process.

However, for some adults, especially those who are older or managing health conditions, wound healing – particularly if the wound is chronic – is not as easy.

Chronic wounds are common 

Every year, more than 6 million people in the U.S. are affected by chronic wounds such as pressure injuries and foot ulcers[1]. Unlike acute wounds from a surgical incision or an injury, chronic wounds often occur in people with conditions like immobility or diabetes.

These types of wounds don’t necessarily show signs of healing within 30 days. If wounds don’t heal properly, they can lead to some very serious complications.

Because of the associated complications, chronic wounds put a significant financial strain on the health system. It’s estimated that $25 billion is spent annually in the U.S. to treat these wounds. This, plus the inconvenience and setbacks of people afflicted with chronic wounds makes it critical that healthcare providers help patients reduce the risk of wound complications.

Risks factors for chronic wounds

Some of the factors that put a person at higher risk for chronic wounds, include the following [2]:

  • older age
  • hypertension
  • poor nutrition
  • chronic lung disease
  • diabetes
  • obesity 

Self-care can make a difference in chronic wound care

I am a nutrition scientist and researcher at a global healthcare company that produces science-backed nutritional therapies. I’ve specialized in wound healing for more than two decades.

My passion is to empower patients and their caregivers with self-care strategies to support continued wound healing at home, as directed by a physician. By focusing on the following areas of wound care, healthcare providers can help patients and caretakers stay on top of their care plan in order to achieve the best outcomes possible.

  • Ensure proper wound dressings and care

To ensure care is continued long after a hospitalization or clinic visit, clinicians should talk to their patients about the appropriate steps to clean their wound and keep a fresh dressing applied to it. This will help prevent germs from contacting the wound while absorbing fluid that drains from the site that could damage the skin surrounding it.

While the best methods for dressing will depend on the individual’s specific type of wound, there are general steps that patients and caregivers should become familiar with handling at home. These include,

      • cleaning the wound each time the dressing is changed,
      • applying a fresh dressing, and
      • possibly using a compression stocking or bandage to help improve blood circulation and promote healing[3].

Lastly, protecting the wound site is important. Patients should be coached to take steps to avoid any additional trauma to the wound. This can help reduce additional setbacks.

For example, if a person has a foot ulcer, it helps to make sure that any shoes or slippers are not aggravating the wound site. Further, directing patients to elevate the affected foot above heart level for 15 to 30 minutes a few times per day may help with swelling and improve blood flow.

  • Don’t underestimate the power of nutrition

Nutrition is often an overlooked part of wound care, however, it can support healing from the inside, out.

Our bodies are designed to heal skin and tissue damage, but only if they have the right tools to make it happen. Good nutrition is one of those critical tools.

For each stage of the healing process, specific nutrients are required. If a person isn’t getting enough of the right nutrients, the wound-healing process can be delayed.

The body needs additional calories as well as protein, amino acids, vitamins, and minerals to generate new tissue at the wound site.

Some of the specific nutrients to prioritize include the following:

        • arginine and glutamine, important amino acids during the wound healing process that provide building blocks for new tissue. 
        • Hydrolyzed collagen is necessary to stimulate the production of internal collagen at the wound site.
        • HMB (short for β-hydroxy-β-methyl-butyrate) helps slow muscle protein breakdown
        • Zinc supports immune function and skin integrity
        • Vitamins C, E, and B12 help strengthen the new skin and to help get more oxygen to the wound site.

It can sometimes be difficult for a patient to get enough of these key nutrients from diet alone, especially if they are malnourished or managing other health conditions.

Recovery during hospitalization or from illnesses can also take a toll on a patient’s appetite. It can also impact their ability to tolerate certain foods.

When a balanced diet is not enough, there’s a clinically-backed nutrition supplement that supports the wound-healing process by providing essential nutrients that have been shown to enhance collagen formation in as little as two weeks which healthcare providers can recommend.[4]

  • Counsel on the signs of infection

With chronic wounds, there’s no precise timetable for healing. Each patient is unique, and how quickly and efficiently a person’s body recovers from a chronic wound can depend on several factors, ranging from the type and size of the wound to their overall health and nutrition status.

In general, the larger the wound, the longer the recovery process will be. For these patients, enlisting a caregiver for support can be a helpful strategy to make the recovery process easier.

  • When to ask for help

Throughout healing, it’s essential that patients learn how to recognize the signs of a wound that is getting worse instead of better – and when it’s time to seek additional care. These can include,

      • increased levels of pain and discomfort
      • redness
      • pus, or discharge from the wound site, 
      • sensitivity 
      • swelling
      • a noticeable odor[5]

Remind patients and caregivers to call immediately if they experience any of these symptoms, to ensure the infection is caught and addressed early.

Related Content:  What You Need to Know About MRSA and What to Do About It

Support patients during the age of COVID

It’s difficult to predict what the coming months will bring as the COVID-19 pandemic continues. We must recognize that individuals with chronic wounds may feel particularly vulnerable while navigating the healthcare system with its heightened health and safety measures.

This presents healthcare providers with an opportunity to engage with these patients in new ways. From reviewing the best methods for at-home wound care to discussing lifestyle changes and recommending helpful nutrition supplements.

These are simple steps that can go a long way in offering patients and their caregivers the proactive means to take control of their health.

Expanding the channels of support to include telehealth and virtual platforms could also be a valuable way to provide reassurance and emphasize the appropriate steps for at-home care. It also helps avoid unnecessary visits to doctors’ offices, hospitals, or other care facilities for the time being, as appropriate.

Related content: Doximity’s New Telehealth Platform Makes it Easy to Connect

The bottom line

The best way to ensure effective self-care, monitor wound healing, and answer questions as they arise is by scheduling regular check-ins. This allows clinicians to maintain an accessible and open dialogue with patients and caregivers as they deal with a chronic wound.


[1] Sen CK, Gordillo GM, Roy S, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen. 2009;17(6):763-771. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1524-475X.2009.00543.x

[2] Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res. 2010;89(3):219-229.  https://journals.sagepub.com/doi/abs/10.1177/0022034509359125

[3] InformedHealth.org. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006. What are the treatment options for chronic wounds? 2006 Oct 17 [Updated 2018 Jun 14].  https://www.informedhealth.org/what-are-the-treatment-options-for-chronic-wounds.2706.en.html?part=behandlung-ko

[4] Williams JZ, et al. Ann Surg. 2002; 236:369-374.3 Jones, et all, Surgical Infections, 2014. https://journals.lww.com/annalsofsurgery/Abstract/2002/09000/Effect_of_a_Specialized_Amino_Acid_Mixture_on.13.aspx

Jones, et al., Surgical Infections, 2014;15(6):708-712.): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4268587/

[5] Frank C, Bayoumi I, Westendorp C. Approach to infected skin ulcers. Can Fam Physician. 2005;51(10):1352-1359https://www.cfp.ca/content/51/10/1352 


The consumption of non-dairy milk is on the rise. In fact, in the United States alone, sales of non-dairy milk grew 61% from 2012 to 2017.1

Americans now order soy milk lattes at cafés. They fill their cereal bowls with cashew milk. And they use coconut milk in their desserts.

Even Dunkin’ Donuts, a grab-and-go mainstream chain, offers almond milk for coffees and lattes. Further, cooking shows dedicate entire segments to showing viewers how to make your own non-dairy milk.

Meanwhile, the dairy industry is taking a huge hit. From 2017-2018, sales of cow’s milk dropped over $1 billion.1 How did non-dairy milk take over the long-heralded traditional cows milk? And what does this mean for our health?

The origin of non-dairy milk

Soy milk is the oldest non-dairy milk. It began gaining popularity in the 1990s when scientists began releasing numerous studies on the health benefits of soy. Soy consumption can decrease blood pressure, lower levels of “bad” LDL cholesterol, increase levels of “good” HDL cholesterol, and decrease the risk for heart disease.2,3

The FDA began allowing soy milk manufacturers to include these health claims on their packaging, and sales of soy milk skyrocketed.4

Silk became the top seller as it was the first to move soy milk into the refrigerator section, next to the cow’s milk.4

Move over, soy. There’s another number one

But now, even soy milk is no longer the most popular non-dairy milk. Soy milk sales hit a peak of $1.2 billion in 2008 when new studies started making consumers doubt the health benefits of soy.4

Phytoestrogens, the same component of soy that attracted consumers in the 90s, was now being associated with increased risk for cancer.5 Phytoestrogens can interfere with or mimic estrogen, and the studies showed that the phytoestrogens could bind to the estrogen receptor and stimulate cancer cell production.5 However, these studies were done with higher doses and on rats, who process estrogen differently from humans. Research shows that phytoestrogens are safe when consumed as soy or soy products.6

However, the damage had already been done. Almond Breeze, which had long lagged behind Silk, seized the opportunity. It started promoting its almond milk among the large Latinx population, who have higher rates of lactose intolerance, in Florida.7 Almond Breeze is owned by Blue Diamond Growers, a coalition of almond farmers in California, and it got the California almond industry to advertise and fund research into the health benefits of almonds.7 Within two years, even Silk released its own almond milk to try to compete, but by 2013, almond milk surpassed soy as the best-selling non-dairy milk.7

The current rhetoric about traditional cow’s milk

Instead of showing the health benefits of non-dairy milk, recent studies and media campaigns are showing the downsides of traditional milk. However,  many of them are flawed.

Some people argue that the saturated fat in traditional milk increases bad “LDL” cholesterol, but they overlook the low fat and nonfat options. Furthermore, the adverse health impacts of processed food, which dominates the American food industry, far outweigh milk in saturated fat.

A Harvard study claimed that drinking traditional milk does not prevent osteoporosis.8 However, it was comparing male and female health professionals who were drinking one glass of milk or less per week to those drinking two or more glasses per week.8

Other posts by this author: What the Organic Label on Foods Really Means

First, two or more glasses per week is a large range. Second, the USDA recommends people consume three servings of dairy daily. One glass of milk serves as one serving, so both groups in the study were likely not drinking enough milk to notice any benefits.

Studies show that a plant-based diet lowers the risk of obesity, heart disease, diabetes, and even certain cognitive disorders and cancers.9 This trend towards plant-based diets seems to have spilled over to milk, but one can follow a plant-based diet while still drinking milk by eating less meat and more vegetables, for example.

Are we paying the price by moving away from cow’s milk?

Americans’ transition away from traditional milk is taking a toll on our health. In fact, 42% of Americans do not meet the Recommended Daily Allowance (RDA) for calcium. Calcium is important for strong bones and teeth. It is also for many other bodily functions, such as

  • muscle movement
  • blood clotting
  • nerve signaling
  • maintaining blood pressure.10

The other detriment to Americans’ health has to do with vitamin D. 35% of American adults are vitamin D deficient.11 A whopping 47% of Black/African American infants and 56% of White infants are also vitamin D deficient.10

Vitamin D is crucial for bone development and strength. In the 1930s, the U.S. began fortifying cow’s milk with vitamin D to eradicate rickets, a vitamin D deficiency that results in soft bones. However, with the rise of non-dairy milk, many of which are not fortified with vitamin D, the number of cases of rickets is increasing dramatically.12

Many foods other than milk provide calcium but only small amounts. For example, the RDA of calcium for American adults is 1,000 mg. One cup of spinach, known as one of the vegetables with the most calcium, contains 250 mg of calcium. You would have to eat four cups of spinach daily to meet the RDA.

What about taking supplements?

There is a multitude of calcium and vitamin D supplement options. However, they may actually do more harm than good. The downsides to supplements include:

  • Supplements are expensive
  • They are not FDA regulated
  • There are health risks associated with overconsumption.13

From 1999-2014, there was an 18% increase in the number of people taking over 1,000 IU of vitamin D daily via supplements. This is a higher dose than the recommended 600-800 IU.13 There was also a 3% increase in the number of people taking toxic levels of vitamin D.13

Calcium and vitamin D supplements are useful for certain groups of people with specific health concerns, not the general public. Calcium supplements are useful for those at higher risk for osteoporosis, such as older women.

There are many lactose-free cow’s milks that are fortified with vitamin D. Among the non-dairy milks, soy milk is reliably fortified with vitamin D. Other than fortified milk, a few foods have vitamin D, such as

  • fatty fish,
  • fish liver oils
  • egg yolk.

Therefore, vitamin D supplements are useful for vegans and other people who avoid these vitamin D rich foods.

The rise in non-dairy milk has given those who are lactose intolerant, lactose sensitive, or vegan more, very attractive choices. However, these individuals must also be cognizant of their risks.

Read the nutrition facts label carefully because many non-dairy milks have added sugars. And, be sure to talk to your doctor before taking any supplements.

The bottom line on the consumption of non-dairy milk instead of cow’s milk

There is no robust evidence on the detriments of cow’s milk. Many Americans are suffering low calcium and/or vitamin D levels even though there is a centuries-old fix.

So the next time you are at a supermarket, why not try to look past the colorful non-dairy deceivers and give our good ol’ cow’s milk another chance.


  1. Kateman, B. 2019. Non-dairy milk alternatives are experiencing a ‘holy-cow!’ moment. Forbes.
  2. He, J., Wofford, M. Reynolds, K., Chen, J., Chen, C., Myers, L. Effect of dietary protein supplementation on blood pressure: a randomized controlled trial. Circulation. 124:589-595.
  3. Wofford, M. R., Reynolds, C. R. 2011. Effects of soy and milk supplementation on serum lipid levels: a randomized controlled trial. Circulation. 124:589-595.
  4. Berenstein, N. 2018. A brief history of soy milk, the future food of yesterday. Serious Eats.
  5. McMichael-Phillips, D. F., Harding, C., Morton, M., Roberts, S. A., Howell, A., Potten, C. S. 1998. Effects of soy-protein supplementation on epithelial proliferation in the histologically normal human breast. Am J Clin Nutr. 68.
  6. American Cancer Society, American Institute of Cancer Research. Soy, foods that fight cancer.
  7. Franklin-Wallis, O. 2019. White gold: the unstoppable rise of alternative milks. The Guardian.
  8. Feskanich, D., Willett, W. C., Stampfer. M. J., Colditz, G. A. 1997. Milk, dietary calcium, and bone fractures in women: a 12-year prospective study. Am J Public Health. 87(6):992-997.
  9. Medawar, E., Huhn, S., Villringer, A. Witte, V. 2019. The effects of plant-based diets on the body and the brain: a systematic review. Transl Psychiatry 9, 226.
  10. Hoy, K., Goldman, J. D. 2014. Calcium intake of the U.S. population. U.S. Department of Agriculture.
  11. Sizar, O., Khare, S., Goyal, A., Bansal, P. 2020. Vitamin D Deficiency. National Center for Biotechnology Information.
  12. Thacher, T. D., Fischer, P. R., Tebben, P. J., Singh, R. J., Cha, S. S., Maxson, J. A., et al. 2013. Increasing incidence of nutritional rickets: a population-based study in Olmsted County, Minnesota. Mayo Clinic proceedings. 88(2):176–183.

13.  Harvard Health Publishing. 2017. Taking too much vitamin D can cloud its benefits and create health risks.

Working out regularly and intensively is the key to a chiseled body and peak physical fitness. However, if you want to get into the best possible shape and avoid injuries, allowing your muscles some time to recover is essential. With the right approaches, you may be able to speed up muscle recovery after a workout and improve your overall fitness in no time.

4 Steps for Post-Workout Muscle Recovery

In this article, we discuss four tips to speed up and enhance the effects of your post-workout recovery. Whether you work out by yourself at home or at a gym – with or without a personal trainer – it is important to give yourself a few minutes afterward to recover. Your muscles need the time to rest and to adjust after intense training.

1. Drink Lots of Fluids and Hydrate

Any fitness enthusiast knows the importance of proper hydration prior, during, and following an intensive dose of physical activity. It is confirmed by science as well.

It is important to drink plenty of fluids during all those crucial times if you want to avoid getting dehydrated which is associated with muscle fatigue, reduced performance, and other complications. Proper hydration also reduces the risk of heat illness when exercising in warm weather.

Unfortunately, many gym-goers focus on drinking water before their routine and forget to do it afterward as well. Others have a bad habit of only drinking water when they feel thirsty, which is not recommended.

If you are a fan of sports drinks enhanced with electrolytes or any other kind of post-exercise recovery drinks, popping open a Gatorade may help you as well. Of note, a recent systematic review and meta-analysis found that chocolate milk (which contains protein, carbohydrates, fats, water, and electrolytes) may be a good post-workout recovery drink.

Nevertheless, keep that in mind that at the end of the day, there’s nothing more beneficial than plain H2O.

2. Get a Good Night’s Sleep

It’s no secret that getting plenty of rest is the key to both mental and physical health. But did you know that the lack of it can greatly hinder the course of your muscular recovery? And, it can reduce your overall athletic performance.

A 2018 systematic review of published studies suggest that sleep interventions, such as sleep extension, can play an important role in some aspects of athletes’ performance and recovery.

Therefore, getting seven to eight hours of shut-eye per night may be important when you want to avoid any training-related complications.

If your schedule allows for it, try to sneak in a few afternoon snoozes during the week as well. Waiting two hours after a workout and then taking a quick 20-minute power nap restores the muscles, but it also won’t inhibit your nocturnal slumber.

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3. Focus on Your Protein Intake

Protein is the number one muscle repairing nutrient that you should be sure to incorporate in your diet. Instead of adding supplements to your smoothies, focus on getting your daily intake of protein from whole foods such as eggs, Greek yogurt, cottage cheese, and lean cuts of meat. These versatile ingredients make great snacks or full meals that will help with your recovery.

It is also important to consume a snack that is rich in protein before bed so that your muscles repair over time. The essential amino acids that are metabolized from this macronutrient not only bulk up your brawn but also diminish the sensation of soreness you would otherwise get the next day.

By the way, don’t forget about your pre- and post-workout protein intake either. 


4. Plan Your Rest Days Accordingly

When it comes to rest days, the general rule is to maintain a healthy gap of 48 hours between workouts if you are a fan of more physically demanding routines. Of course, this is not a universal rule. Rather it is a guideline that you can abide by or tailor to suit your personal needs and preferences.

Never forget about stretching, especially during recovery days. In time, this habit will help with your muscle recovery and won’t be a burden any longer.

Depending on your age and skill level, you might require less time to rest or more. If you find yourself taking longer pauses, try to squeeze in a couple of active recovery days each week.

These consist of light exercises, such as yoga or tai chi so that you don’t lose track of your fitness goals. It will also help you relax and recharge your batteries at the same time.

However, if you feel an injury coming on, it is best to listen to your body and take some days off.

Cold baths: helpful or harmful?

Until recently, some trainers and other fitness experts recommended cold water immersion (CWI) to help recover from a workout. It was believed that it could help reduce muscle fatigue and soreness in the short-run. And, indeed, some early studies cited as suggesting a benefit include these:

  • Burke et al (2000) found that cold water immersion augmented strength gains after 5 days of training.
  • Ilhsan et al (2015) found that there were increased markers of mitochondrial biogenesis in muscle. This suggesting that perhaps there could be an increased capacity for energy production. [Note: our better understanding of the mTOR pathways today actually suggests this put cells into a anti-growth mode instead.] 

*However, a 2015 paper, titled “Post-exercise cold water immersion attenuates acute anabolic signaling and long-term adaptations in muscle to strength training” was published in the Journal of Physiology tells a different story. It described two separate studies done by the research team:

  • Study 1

Study 1was a randomized controlled trial of 24 physically active young men who volunteered to participate in a 12-week lower body strength training program. Half of the men performed cold water immersion within 10 minutes of the training session. The other half participated in active recovery (10 minutes on a stationary cycle at low intensity). The study found that both groups increased muscle mass accretion (measured by muscle biopsy) and strength but it was significantly greater in the active recovery compared with the CWI group.

  • Study 2

Study 2 was a randomized, cross-over study of 10 physically active young men who performed two bouts of single-leg strength exercise on separate days followed by either CWI or active recovery. Examination of muscle biopsies revealed that CWI “delayed and/or suppressed the activity of satellite cells and kinases in the mTOR pathway. mTOR is a key intracellular regulatory protein. The effect lasted for up to 2 days after strength exercise.

The authors concluded:

“The use of cold water immersion as a regular post-recovery strategy should be reconsidered.”

The Bottom Line When It Comes to Muscle Recovery

To naturally enhance your muscles’ recovery period do the following:

  • Stay well hydrated by drinking water frequently not just when you feel thirsty
  • Get a good night’s sleep and toss in some power naps after your workout
  • Mind what you eat and be sure to include plenty of protein
  • Be sure to include rest days tailored according to your personal needs and preferences
  • Stretch frequently, particularly on rest days. Also, consider adding in a light exercise like yoga or tai chi on those days as well

With the right approach, you will reach your fitness goals sooner than expected.


This story was first published on Aug 5, 2018. It has been medically reviewed and updated for republication on July 11, 2020.

*This is a key correction to the prior version of this story when it was republished on July 11, 2020. Article updated and republished Aug. 6, 2020.

Organic food sales in the United States rose from $11 billion in 2004 to $49 billion in 2018. This is triple the annual growth rate for all food sales.1

The organic trend

The demand for organic foods is so high that a 2017 Washington Post investigation found that millions of pounds of soybeans from Ukraine were sold into the U.S. as organic when they were actually conventionally grown.2 Organic foods are now not only found in niche stores like Whole Foods and farmers’ markets but even mainstream stores like Walmart and Costco that pride themselves on affordability and accessibility.

Walking through the aisles at any one of these stores, one sees green stickers that say “natural,” “humane,” “USDA Organic,” “CCOF Organic.” How did we end up with so many labels and what do they mean?

Connotations of “organic” food

The label, “Organic,” has many connotations and impacts everyone from farmers to grocery suppliers to consumers. For some, “Organic” is shorthand for “healthy.” It lures them like an aphrodisiac.

For others, “Organic” is synonymous with “expensive.” It sends cost-conscious consumers a message to steer clear and deters farmers from applying for certification.

Still, for others, “Organic” is a lifestyle and philosophy. To understand the true meaning of the “Organic” food label, we must first understand its origin.

The origin of “organic” foods

Post World War II, war-torn countries were experiencing dire food shortages. They were trying to figure out a way to make as much food as possible, as fast as possible.3 Thus, chemical companies came up with an insecticide called DDT.

The use of DDT dramatically boosted crop yields and spurred the popularity of synthetic pesticides and fertilizers.(3) However, it also prompted a counterculture movement promoting organic agriculture.

Sir Albert Howard’s An Agricultural Testament detailed sustainable farming and encouraged eating whole foods.(3) J.I. Rodale founded the research institute, Soil and Health Foundation.(3) Most notably, Rachel Carson published Silent Spring, which revealed the horrid environmental and health effects of pesticides.(3)

Defining “organic” food

In its infancy, the term, “Organic,” signified vague, big picture ideals like family health and environmental stewardship. The current definition of “Organic” still signifies these ideals but details specific criteria to meet these ideals.

In 2002, the USDA developed National Organic Standards (NOS).4 According to the NOS, “Organic” means that a food was not produced with some pesticides, synthetic fertilizers, genetic modification, bioengineering, or ionizing radiation and has been certified by a USDA-authorized inspector.(4)

Organic foods are actually not free of all pesticides.(4) Organic foods may contain traces of chemicals from wind and water drift. The National Organic Program created the National List of Allowed and Prohibited Substances. It allows some synthetic pesticides, such as insecticidal soap, and prohibits some natural substances, such as ash.(4)

Organic meat, poultry, and eggs do not have antibiotics or growth hormones.4 Labels like “Natural,” “Humane,” “Local,” and “Sustainable” or “Pesticide Free” and “No Spray” are not federally regulated.(4)

Understanding “organic” food labels

The three main organic labels are as follows:

      • 100% Organic
      • Organic
      • Made with Organic Ingredients

With any of the three labels, the organic ingredients must be indicated.

  • 100% organic

100% organic is the strictest, with all the ingredients in that food being organic.(4) These foods may include the “USDA Organic” stamp and/or a claim about being 100% organic.

  • Organic

The most common label, “Organic,” means that 95-100% of the ingredients in that food are organic.(4) Again, these foods may include the “USDA Organic” stamp and/or a claim about being organic. The 5% could be non-organic ingredients, such as baking soda, citric acid, and pectin.(4)

Take Nature’s Path Organic Heritage Flakes cereal, commonly found in Whole Foods. Ingredients include wheat flour, cane sugar, oat flour, spelt flour, barley flour, quinoa, sea salt, and honey. The only ingredient that is not organic is sea salt. Because 95-100% of the ingredients in the cereal are organic, the cereal is considered organic.

  • Made with organic Ingredients

Lastly, “Made with Organic Ingredients” means that at least 70% of the ingredients are organic.(4) These foods do not receive USDA Organic certification. They can only write “Made with Organic ingredients” and apply for state certifications, such as California Certified Organic Farms (CCOF).(4)

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Can You Have Your Carbs and Eat Healthy, Too?

Controversies around “organic” food

Even with these added criteria, the term, “Organic,” can still be vague and confusing. Animal welfare requirements, such as the definition of “outdoor space,” are ambiguous.(3) There are also many controversies surrounding the environmental, economic, and health benefits of organic foods.

  • Environmental controversies:

Organic farming protects wildlife, preserves soil using nitrogen-fixing plants, and conserves water.(4)

Organic farming prevents chemical runoff, however, composting still releases nitrates into groundwater. Organically treated soil absorbs more carbon from the air, helping to mitigate climate change. But the nitrates that composting releases contribute to the generation of greenhouse gases.5

The USDA imports organic foods from across the world.6 The immense fuel needed to transport these foods may undermine any environmental benefits gained from organic farming. (6)

  •  Economic controversies:

Organic foods are more expensive than conventional foods. On the flip side, there are hidden costs for the testing and regulating of pesticides that taxpayers are paying.(4) Because of this, the sticker price of conventional foods does not reflect its true cost.

However, getting certified as USDA Organic is still very expensive for farmers. Many farmers, especially those who sell food at local farmer’s markets, may practice organic farming. However, they may not have enough money to get certified.(3) Therefore, not having the “USDA Organic” stamp does not necessarily mean that the food is not organic.

Other posts by this author: The Rise of Non-dairy Milk – Are Cows Getting the Boot?

  • Health controversies

Organic foods have fewer pesticides and antibiotics. Studies have shown that antibiotics from food contribute to antibiotic resistance in humans.7

Exposure to pesticides can lead to ADHD, autism, lower cognitive ability, and cancer. But the level of pesticides on conventional foods falls within the safe limits set by federal regulations.8

A 2012 meta-study published in Annals of Internal Medicine found little health benefits from organic foods.9 The studies that show that organic foods have more nutrients, such as vitamins and minerals, have many problems, including the following:(8)

      • Firstly, the difference in the levels of the nutrients is so small that it is unlikely to have an impact on our overall nutrition.(8)
      • Secondly, there are many confounding variables. For example, a rare ten-year study comparing plots of organic and conventionally grown tomatoes found that the organic tomatoes had higher antioxidants. However, after Stanford researchers zoomed out and compared this study with studies on other crops, they found no pattern.10  This is because foods vary in their nutritional quality whether they are organic or not. It is nearly impossible to isolate the effects of organic farming on any given food or the effects of organic foods on an individual because there are so many confounding variables. In the tomato study, soil type, moisture level, tomato variety, and a host of other factors could have affected the final antioxidant level in the tomato.

What can you do?

The term, “Organic,” was based on ideals of family health and environmental stewardship. However, all of the different organic labels and the controversies around the term, “Organic” may not be the ideal.

Growing and buying organic foods is expensive. Organic farming has environmental benefits.  But the environmental impacts of transporting them to market offset these benefits. Therefore, it may not be the answer to a sustainable global food system.(6)

There is little evidence about the health benefits of organic food.(9) In fact, organic foods are not always healthy. They can have just as much if not more salt, fat, and sugar. Unfortunately, this is a difference that consumers fixated on buying organic products could overlook.

Therefore, I urge you not to judge a food simply based on whether or not it is organic. I urge you to read the nutrition facts label on food. When possible, I urge you to speak to farmers to learn about organic agriculture in practice and to hear their side of the story.

Scientists are currently measuring the nutrient levels in various crops and breeding varieties that would yield a more nutritious product.11 This may eventually lead to federally regulated labels that would be more useful for identifying nutritious food.

Dabbling in organic foods

In the meantime, if you like the idea of organic foods but are not ready to buy all organic foods, you can pick and choose:

If you are interested in lowering pesticides in your food, choose organic for the following foods that have thinner skin and therefore, more pesticide residue.(8) These foods are called the Dirty Dozen, published each year by the Environmental Working Group (EWG)(8):

      • Strawberries
      • Kale
      • Spinach
      • Nectarines
      • Grapes
      • Apples
      • Cherries
      • Peaches
      • Tomatoes
      • Pears
      • Potatoes
      • Celery

If you are interested in promoting organic agriculture, choose organic for the following foods that take up more land(8):

      • Wheat
      • Corn
      • Grains
      • Beef
      • Dairy

If you are interested in fewer antibiotics and hormones and human-animal treatment, choose organic for animal-based products, such as(8):

      • Milk
      • Eggs
      • Cheese
      • Poultry

The bottom line if you’re thinking of buying organic foods

You need not feel compelled to buy organic. However, I urge you to read food labels and not only the organic ones. If anything, I hope the origin story, ambiguity, and controversies surrounding the term makes you a little more curious about your food.


  1. Organic Trade Association. 2017. Organic industry survey. https://ota.com/organic-market-overview/organic-industry-survey
  2. Whoriskey, P. 2017. The labels said ‘organic.’ But these massive imports of corn and soybeans weren’t. The Washington Post. https://www.washingtonpost.com/business/economy/the-labels-said-organic-but-these-massive-imports-of-corn-and-soybeans-werentc
  3. Raoul A. 2020. Organic farming. Encyclopaedia Britannica. https://www.britannica.com/topic/organic-farming
  4. USDA, Agricultural Marketing Service. National Organic Program. USDA oversight of organic products. https://www.ams.usda.gov/about-ams/programs-offices/national-organic-program
  5. Dahan, O., Babad, A., Lazarovitch, N., Russak E. E., Kurtzman, D. 2014. Nitrate leaching from intensive organic farms to groundwater. Hydrology and Earth System Sciences. 18:333-341. https://hess.copernicus.org/articles/18/333/2014/hess-18-333-2014.pdf
  6. USDA Agricultural Marketing Services. 2018. International Trade Partners. https://www.ams.usda.gov/services/organic-certification/international-trade
  7. Misiewicz, T., Shade, J. 2016. Organic food and farming as a tool to combat antibiotic resistance and protect public health. The Organic Center. https://www.organic-center.org/sites/default/files/project/2016/07/TOC_Report_AntibioticResistance_FINAL.pdf
  8. Harvard Health Publishing. 2015. Should you go organic? https://www.health.harvard.edu/staying-healthy/should-you-go-organic
  9. Smith-Spangler, C., Brandeau, M. L., Hunter, G. E., Bavinger, J. C., Pearson, M., Eschbach, P. J. et al. 2012. Are Organic Foods Safer or Healthier Than Conventional Alternatives? Annals of Internal Medicine 157(5): 348-366. https://www.acpjournals.org/doi/10.7326/0003-4819-157-5-201209040-00007
  10. Aubrey, A. 2008. Are organic tomatoes better? National Public Radio. https://www.npr.org/templates/story/story.php?storyId=90914182
  11. Aubrey, A., Charles, D. 2012. Why organic food may not be healthier for you. National Public Radio. https://www.npr.org/sections/thesalt/2012/09/04/160395259/why-organic-food-may-not-be-healthier-for-you

Lecithin is a very popular dietary supplement. But what do we know about its risks and benefits?

With regard to benefits, we know that lecithin supplements are heavily promoted as a panacea for:

  • Cardiovascular health
  • Liver and cell function
  • Fat transport and fat metabolism
  • Reproduction and child development
  • Physical performance and muscle function
  • Cell communication
  • Improvement in memory, learning, and reaction time
  • Relief of arthritis
  • Healthy hair and skin
  • Treatment for gallstones

I have always been suspicious of promotions that promise to cure all human ailments. So it doesn’t surprise me to find that a recent review of a number of scientific papers on PubMed reveals that the researchers still refer to hoped for lecithin benefits with terms like “may,” “might,” “theoretically could” and not with “does.” Further, most papers and credible health-related websites point out that there is a woeful lack of research about the efficacy of this particular dietary supplement.

So, I believe that, at this point in time, it is safe to say that none of the claims about lecithin have any credible evidence to back them up.

There are two possible but minor exceptions

    1. Lecithin is a natural emulsifier, so claims that it dissolves gallstones may be credible. However, I haven’t come across a good study documenting it. And, WebMD gives lecithin treatment of gallstones an unenthusiastic “recommendation” of possibly ineffective.
    2. A small study out of Tokyo recently found that high-dose (1200 mg/day) soy lecithin increased “vigor” in middle-aged women who presented with fatigue compared to a placebo. The study was funded by Kikkoman, a Japanese food producer that makes a variety of soy products, such as soy sauce and soy milk.

What is lecithin?

Lecithin is actually a mixture of different fatty substances called glycerophospholipids, including: 

      • phosphatidylcholine (often thought synonymous with lecithin)
      • phosphatidylethanolamine
      • phosphatidylinositol
      • phosphatidylserine
      • phosphatidic acid

Lecithin is found in egg yolk, meats, soy, seeds, such as sunflower and rapeseed, and some vegetables, such as corn. Soy is the source of most commercial lecithin, although sunflower lecithin is increasingly popular because of concerns about GMOs in soy and food allergy labeling regulations.

Is there really lecithin in your lecithin supplement?

You probably assume that when you take lecithin supplements, you are actually getting lecithin. However, as is the case with many nutritional supplements, commercial preparations vary widely in the amount the substance that is actually in their product.

Why such variability? Because the suppliers of supplements were exempted by Congress from adhering to any standards of manufacture, purity, or claims of benefits. How this came about is emblematic of our broken political system, but don’t get me going on this.

Only a fraction of commercial lecithin is made up of the real thing. So, what makes up the rest? The answer: fatty acids!

Not exactly the stuff to help in weight reduction, cardiovascular health, or good liver function. In fact, theoretically, they could work against all those potentially wonderful benefits.


Before we go any further, let me introduce a relatively new medical term: metabolomics. We are all familiar with the concept of genomics, meaning the study of the genome, or the total genetic content and its effect on health and disease.

Similarly, the sum total of chemicals, substrates, and metabolites in the body is called the metabolome. Metabolomics is the study of those substances in health and disease. The advantage of taking an all-inclusive approach is that it is unbiased.

The classical scientific approach is to study a specific gene or molecule, essentially ignoring everything else. This is akin to peeping through a keyhole. You see only what the hole allows you to see.

On the other hand, studying the whole genome or the whole metabolome gives a complete picture of everything that is involved in the process being studied.

For instance, for many years, only one or two genes were thought to be involved in the development of type 2 diabetes. Why? Because these were the only genes that “made sense” as targets for study. The advent of whole-genome studies demonstrated the involvement of dozens of genes in the disease. This was a complete surprise.

What’s the downside of lecithin supplements?

So, let’s return to the question at hand. If lecithin supplements don’t cause any harm, why not give it the benefit of the doubt? After all, a future study may prove its benefit.

In a paper published in Nature, Wang and his collaboratorsat the Cleveland Clinic studied the metabolic fate of lecithin. They used the metabolomic approach to look for circulating small molecules associated with coronary heart disease.

They screened blood from patients who had experienced a heart attack or stroke. Then they compared those results with the blood of people who had not had those serious cardiovascular events.

They found major differences in choline, betaine, and trimethylamine (TMA).It turns out that gut bacteria produce these metabolites from lecithin. And then they convert them to trimethylamine-N-oxide (TMAO).

This terminal metabolite, TMAO, is a known atherogenic substance.

That means it is involved in atherosclerotic plaque formation.

None of the metabolites appeared in the blood after the gut flora was wiped out with an antibiotic. Could it be that the gut flora in people with cardiovascular disease is different in some way from that of healthy people? We don’t know, but we do know that the physiological state of a person can determine the gut flora. For instance, the gut flora of obese people is markedly different from that of the non-obese.

Based on this study alone, we still can’t tell if these lecithin metabolites are causative factors, or whether they are just markers of the disease. This is because correlative studies can show only correlations, not cause and effect.

Lecithin is not the only culprit that leads to TMAO

Is lecithin the only culprit that produces TMAO? Red meat contains another triethylamine. This molecule, called L-Carnitine, is similar to choline and lecithin. Like them, it should be metabolized by the gut flora into MAO and then converted to TMAO in the circulation.

The same Cleveland Clinic group examined the production of TMAO by omnivores, vegans, and vegetarians following the ingestion of L-carnitine.

They found that the omnivorous humans had higher levels of circulating TMAO. The reason? Meat eaters have gut bacterial flora different than vegetarians and vegans.

It contains species that feast on triethylamines:

      • choline
      • lecithin
      • carnitine


Confirmation that the gut microbiome is key to the production of TMAO

Let’s look at an interesting study published in the prestigious New England Journal of Medicine by Tang and colleagues. It had two phases.

In the first phase, the investigators gave healthy participants a phosphatidylcholine challenge using a stable isotope-labeled form of the phospholipid. They then used mass spectrometry to monitor choline metabolites before and after the suppression of gut microbiota with broad-spectrum antibiotics.

They found that the phosphatidylcholine challenge increased all choline metabolites. Antibiotics suppressed the generation of TMAO metabolites. After the antibiotics were discontinued, they reappeared.

TMAO also found to correlate with cardiovascular events

In the second phase, the researchers examined the relationship between fasting plasma TMAO levels and incident cardiovascular events over a 3-year period. They studied more than 4,000 participants undergoing elective coronary angiography.

They found an independent, dose-dependent relationship between the metabolite and the risk of a cardiovascular event on the basis of the TMAO quartile. The highest quartile had 2.54 times the risk over the lowest quartile.

The bottom line when it comes to the risks and benefits of lecithin supplementation

Here is what we know about lecithin:

  • The phospholipid phosphatidylcholine (lecithin) is the major dietary source of choline, an essential nutrient that is part of the B-complex vitamin family. Choline has various metabolic roles, ranging from its critical involvement in lipid metabolism and cell-membrane structure to its role as a precursor for the synthesis of the neurotransmitter acetylcholine.
  • Red meat, processed meats, and egg yolk contain high levels of lecithin.
  • Gut flora metabolizes phosphatidylcholine (lecithin) into three metabolites that show up at high concentrations in people who have had a heart attack or a stroke. They are choline, betaine, and trimethylamine. We metabolize those bacterial metabolites into TMAO, a known atherogenic substance.
  • A large 4,000-patient study over 3 years showed a significant correlation between TMAO levels and cardiac events and stroke.

Causality vs correlation

One could argue that that the gold standard for demonstrating causality, namely a randomized, placebo-controlled study has not been done. Fair enough. But the accumulating evidence, both epidemiological and observational, and the detailed mechanistic studies provide a solid foundation for the clinical observation. This puts the onus of proof on the companies that make money off it and the “true believers” who fall for their unsubstantiated claims.

So, how does one make a decision about whether to take lecithin supplements?

Since the lecithin metabolite, TMAO, is a known atherogenic substance, I believe that until we better understand whether it actually causes atherosclerosis, the prudent approach would call for moderation.

That means limiting your intake of the foodstuffs that have high levels of lecithin.

Further, since there is no credible evidence supporting claims of health benefits, there is no reason to take high doses of lecithin in the form of nutritional supplements. If you do choose to take them, based on what we know now, you could be increasing your risk of a heart attack or stroke in exchange for no known benefit. It’s not a good trade-off, in my opinion.

First published – 01/25/2012. The author last updated it on 7/2/20 to include findings from the latest scientific studies.