Dear Prof. Cordain,

I am an orthopaedic surgeon specializing in hip and knee arthroplasty for the treatment of symptomatic arthritis. I am currently coming to the end of a clinical fellowship in Toronto and will be returning to the UK to take up a post as a consultant (attending) in a NHS hospital and I would be grateful if you could give me any information on the use of Paleo diet and evolutionary fitness principles in the treatment of my patients.
 
I first read about the Paleo diet on Art de Vaney’s website, then read Rob Wolff’s ‘The Paleo Solution’ and am now reading through your book ‘The Paleo Diet.’ I already give many of the patients I see dietary advice because very often they are overweight (in fact, more often than not) and have radiographically mild disease but considerable pain. It is an observation many surgeons have made anecdotally that patients who are of normal weight and are active seem to be able to tolerate far more severe disease (in terms of joint destruction observable on X-radiographs) than those who are overweight and sedentary. Many patients can be educated that weight loss may improve their symptoms and are willing to try but conventional diets are difficult to follow, so I advise them to follow Paleo principles because I think it is a much easier diet to follow consistently. However, I wonder if there is anything specific I should be advising that may help their symptoms. Also, exercise is important for joint function, symptom control and general health, but of course it is very difficult to exercise when one has a painful joint. Do you have any advice that I can pass on to them, or do you know of anyone doing clinical work in this field who I could get in contact with?

Many thanks for your time in reading this. Kind regards,

Julian Gilbody MSc, FRCS (Tr & Orth)
Lower limb arthroplasty fellow, Toronto Western Hospital

Dr. Cordain’s Response:

Hi Julian,

Thanks for your support of the Paleo diet. I believe that arthritis, particularly RA (rheumatoid arthritis) is driven by inflammation emanating from the gut. See our group’s paper “Modulation of immune function by dietary lectins in rheumatoid arthritis.” Hence, inflammation of the gut and inflammation of the joints (particularly in RA) appear to be linked by a number of dietary mechanisms we have proposed in this paper. Clearly arthritis can result from purely mechanical factors independent of the gut immune response. Nevertheless, arthritis of mechanical origin is also driven via systemic inflammation, and any environmental factor (pharmaceutical, dietary or otherwise) that reduces inflammation will also tend to reduce symptoms of arthritis (mechanical or otherwise). This therapeutic response in all arthritis patients who adopt the Paleo Diet may help to explain your anecdotal observations why contemporary Paleo diets are therapeutic for your arthritis patients. Keep up the good work, and keep me posted on any case studies you may encounter.

Regards,

Loren

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Hi Loren,

Here I go again with the question of the week. I love my job!

What do you think about carnitine found in high levels in red meat ( and in other products- other meats,  sports drinks, etc) and its potential association with the formation of coronary plaque?

I appreciate your response to my questions.  Feel free to answer when you have time.  No rush.

Thanks for your time and expertise. — Pam

Dr. Cordain’s Response:

Hi Pam,

Good to hear from you.  General practitioners such as yourself are responsible to your patients for giving them proper dietary advice, particularly whether or not they should avoid red meat to protect against heart disease.  The most recent commotion about red meat, carnitine and formation of coronary plaque (atherosclerosis) comes from the paper (1) listed below from Stanley Hazen’s group at the Cleveland Clinic.

My colleague, Chris Masterjohn, has done a superb job of critiquing this paper and it’s scientific shortcomings.  See his write-up here:

http://www.westonaprice.org/blogs/cmasterjohn/2013/04/10/does-carnitine-from-red-meat-contribute-to-heart-disease-through-intestinal-bacterial-metabolism-to-tmao/

I am in complete agreement with Chris’s conclusion that,  “The bottom line here is that the popular interpretation of this study as an indictment of red meat makes no sense”.  I have a few additional comments that corroborate Chris’s conclusion.

Although intriguing, Hazen’s model doesn’t fit well with the bigger picture of atherosclerosis etiology, particularly the two large meta analyses by Key’s group (2, 3) showing cardiovascular disease (CVD) mortality in vegans and vegetarians to be no better than the general population.  Vegans/vegetarian data from India actually show high mortality from CVD and an earlier disease progression/mortality (4).

Another point worth considering are the well studied polymorphisms disrupting FMO3 activity in trimethylaminuria patients causing inefficient conversion of TMA to TMAO.  Hence in these patients tissue concentrations of TMAO are severely reduced.  Given this metabolic scenario, one would expect that any of the polymorphisms disrupting the FMO3 gene would be highly protective for CVD (if the Hazen hypothesis is correct).  No CVD epidemiologic evidence supports this evidence.  In fact, a recent study (5) shows that heterozygote genotypes (158Glu/Lys and 308Glu/Gly) increase the risk of stroke six times in hypertensives.

1. Koeth RA, Wang Z, Levison BS, Buffa JA, Org E, Sheehy BT, Britt EB, Fu X, Wu Y, Li L, Smith JD, Didonato JA, Chen J, Li H, Wu GD, Lewis JD, Warrier M, Brown JM, Krauss RM, Tang WH, Bushman FD, Lusis AJ, Hazen SL. Intestinal microbiota metabolism of l-carnitine, a nutrient in red meat, promotes atherosclerosis. Nat Med. 2013 May;19(5):576-85

2. Key TJ, Fraser GE, Thorogood M, Appleby PN, Beral V, Reeves G, Burr ML, Chang-Claude J, Frentzel-Beyme R, Kuzma JW, Mann J, McPherson K. Mortality in vegetarians and nonvegetarians: detailed findings from a collaborative analysis of 5 prospective studies. Am J Clin Nutr. 1999 Sep;70(3 Suppl):516S-524S.

3. Key TJ, Appleby PN, Spencer EA, Travis RC, Roddam AW, Allen NE. Mortality in British vegetarians: results from the European Prospective Investigation into Cancer and Nutrition (EPIC-Oxford).  Am J Clin Nutr. 2009 May;89(5):1613S-1619S

4. Kumar J, Garg G, Sundaramoorthy E, Prasad PV, Karthikeyan G, Ramakrishnan L, Ghosh S, Sengupta S. Vitamin B12 deficiency is associated with coronary artery disease in an Indian population. Clin Chem Lab Med. 2009;47(3):334-8.

5. Türkanoğlu Özçelik A, Can Demirdöğen B, Demirkaya S, Adalı O. Flavin containing monooxygenase 3 genetic polymorphisms Glu158Lys and Glu308Gly and their relation to ischemic stroke. Gene. 2013 Mar 17. pii: S0378-1119(13)00244-8. doi: 10.1016/j.gene.2013.03.010. [Epub ahead of print]

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The reason for writing to you is I read an interesting article by you about pre historical diet and grains ((The Evolutionary Discordance of Grains and Legumes in the Human Diet).

Background : I am not an academic. Until 3 years ago I lived in Asia and had a BMI of 24. On returning to the UK I have increased my body weight by about a kilo a month for 20 months. I am now doing something about it by changing my diet. My observation about my previous diet in Asia was that it contained only about 1 cup of rice per day, and no other grains; and no other processed foods with hidden grains or sugars.

It is my view based on common sense and a little reading, that grains are not natural to us. Yet, professional nutritionist friends insist that on the food pyramid we should be eating about 1/3 of our calorie intake through grains. I have contacted several academic nutritionists, and while in their academic articles they accept the pre-historical evidence that we did not eat grains, they all want to insist on the paradigm that we should be eating large amounts of grains.

Firstly, would you agree that grains are not natural in any more than marginal quantities, and have you any idea why nutritionists think we should be eating them in industrial quantities?

Thanks for your time,

Best Regards

Russell

Dr. Cordain’s Response:

Hi Russell,

Good to hear from you, and I wish you success as you adopt the Paleo diet to help  weight.  Indeed our Stone Age ancestors did not consume cereal grains, except infrequently as starvation foods.  As a species, human have no cereal grain requirement for proper nutrition, as we can obtain all required nutrients from meats, fish, seafood, poultry, fresh fruits, vegetables and nuts.  In fact  consumption of cereal grains  actually reduces the overall vitamin and mineral content of the diet because cereal grains on average are less nutrient dense for the 13 vitamins and minerals most lacking in the US diet when compared to fish, seafood, lean meat, fresh vegetables and fruits.  I have pointed this fact out in a paper I published in the American Journal of Clinical Nutrition in 2005 (1).  Further, cereal grains contain a variety of “antinutrients” which actually adversely affect health.  I have described these effects in a paper I wrote called “Cereal Grains: Humanity’s Double Edged Sword” (2).  You can download and read both of these papers at the links I have provided below:

(1)          Cordain L, Eaton SB, Sebastian A, Mann N, Lindeberg S, Watkins BA, O’Keefe JH, Brand-Miller J. Origins and evolution of the western diet: Health implications for the 21st century. Am J Clin Nutr 2005;81:341-54. http://thepaleodiet.com/published-research-about-the-paleo-diet/#2005

(2)          Cordain L, (1999). Cereal grains: humanity’s double edged sword. World Review of Nutrition and Dietetics, 84: 19-73. http://thepaleodiet.com/published-research-about-the-paleo-diet/#1999

Best wishes,

Loren Cordain, Ph.D., Professor

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My name is Carl. I’m an assistant gymnastics coach just down the street at the University of Denver. For personal health reasons, I tried a grain, sugar and dairy free diet a few years ago and was stunned by the results. Since that time I’ve waffled a bit but (mostly 85-15), for the most part, gone Paleo.

Recently, I’ve read Taubes, Sisson and your book, “The Paleo Diet for Athletes.” I’m preparing to mount an offensive against the conventional wisdom and challenge what we currently tell our athletes in an effort to bring them more towards the Paleo side. I feel a low GI diet will enhance performance and help our athletes keep their body comps to a healthy minimum, something of great importance in a sport which uses such high intensity, ballistic movements and demands aesthetic appeal.

With your books emphasis on endurance sports, I’m wondering about the applicability to a sport like gymnastics. I’d be very interested in hearing your thoughts and, perhaps, a list of resources of relevant research. I just recently came across an article about ketogenic diet and performance in Italian gymnasts which demonstrated no detriment to performance in the short term.

I look forward to hearing from you at your earliest convenience.

Highest regards,

Carl

Dr. Cordain’s Response:

Hi Carl,

Joe Friel and I considered doing a chapter on Paleo for strength athletes, but didn’t do so because the dietary principles were virtually identical to those we suggest for endurance athletes.  To date, I am unaware of any scientific or clinical trials of contemporary Paleo Diets involving any type of athletes that have been published in the scientific literature.  Many of the activities and exercises done in CrossFit gyms all over the U.S. and the world tend to be strength oriented.  Further, many  elite CrossFit athletes who compete yearly  at the national CrossFit games (sponsored by Reebok) are avid Paleo Dieters and attribute part of their successful performance to their diet.  I will post your question at my blog & see if we can get some input from CrossFit athletes.

Best wishes,

Loren Cordain, Ph.D., Professor

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Dr. Cordain,
I have just finished watching your appearance on Dr. Oz yesterday, and am interested in following up on your comment regarding the need for study groups looking into “Leaky Gut Syndrome”. I have recently been diagnosed with Hashimoto’s autoimmune disorder, after many years of undiagnosed symptoms, much testing, and many life style changing debilitating symptoms. I am currently under the care of a very knowledgeable, thorough nurse practitioner who specializes in functional and integrative medicine. Throughout all of the many doctors I have seen, she is the first to ever talk about “Leaky Gut” and the multitude of symptoms it can cause.

If you know anything about study groups being formed, or have any pieces of advice you would be willing to share with me, I would love to hear!

Thank you for your research and information!

-Martha

Dr. Cordain’s Response:

Hi Martha,

Many thanks for your kind words about my research.  We have completed a large (~100) case survey of autoimmune patients including a substantial group with Hashimoto’s and other thyroid.  We examined medical records of the patients pre-post adoption of a Paleo Diet, and were encouraged by the results, particularly in autoimmune thyroid patients and those with Crohn’s Disease or ulcerative colitis.

We believe that increased intestinal permeability (“a leaky gut”) may represent an environmental trigger for many autoimmune diseases in genetically predisposed individuals.  I have written about the mechanisms involved in the scientific literature (these papers are available as free PDF downloads at my website).  In my latest book, The Paleo Answer, I have devoted a number of chapters explaining how various foods compromise intestinal function and promote a leaky gut.  The Paleo Diet severely reduces or eliminates these foods (grains, dairy, legumes, potatoes) and describes how patients with autoimmune disease should proceed cautiously with other foods known to cause a leaky gut such as capsaicin (hot) chili peppers, some nightshades, alcohol, antacids, alfalfa sprouts and a few others I describe in my book.

Best wishes, and I hope you achieve success with the Paleo Diet.

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Good luck with your project.  Here are my answers:

1.) What is the most potential danger following the Paleo diet?

There are no known adverse health effects of the diet in most people.  Pregnant women should not exceed 25 % of their calories from protein, as the liver is less able to detoxify protein during pregnancy.

2.)  There is no vitamin D consumed in the Paleolithic diet. You wrote in your article, “The Nutritional Characteristics of a Contemporary Diet Based Upon Paleolithic Food Groups,” that sunlight is the only way our ancestors got Vitamin D. Today, with all the new research, how do you suggest we get our Vitamin D?

I suggest taking between 2,000 to 4,000 IU of vitamin daily if you cannot obtain regular sun exposure.

3.)  Since there is no calorie counting in the Paleolithic diet, how can a person lose weight?

Refined sugars, refined grains, refined vegetable oils and dairy comprise 70 % of the calories in the US diet.  By reducing these foods and replacing with fresh fruits, vegetables, grass produced meats, fish and seafood, we can make our diets more nutritionally dense and increase the satiety value of our foods — both of which will help to promote weight loss, along with elimination of processed foods.

4.)  If there really is “no limit” on how much to eat, how do you approach a healthy balance of the allowed foods?

Real foods such as lean meats, fish, seafood and fruits and vegetables are self-limiting.  Your body gives your brain signals to stop eating with these foods when you are full,  whereas it is quite easy to overeat nutrient depleted processed foods made from refined sugars, grains and vegetable oils, etc.

5.)  If a person has never shown a hypersensitivity to milk, legumes or grains will they feel the benefits of the Paleo Diet?

Yes.  These foods contain a variety of antinutrients and nutritional qualities which may adversely affect health in a manner that is not always obvious to the consumer.

6.)  What is your opinion on the use supplements for vitamins and minerals?

Except for vitamin D and fish oil (if you don’t regularly eat fatty fish), most antioxidant vitamins and minerals actually increase mortality from all causes.  See my most recent book, The Paleo Answer, for further information.

7.)  Do you think there are enough resources for our entire country and world to sustain a strictly Paleo diet?  No.  But in the US and other countries, we are not suffering from diseases of under-consumption, but rather from diseases of overconsumption.  Hence, most middle class US citizens can afford to eat high quality foods such as fresh fruits, vegetables, grass produced meats and poultry, fish and seafood.

8.)  In your opinion, what is the main reason people choose not to go Paleo?  They are either unaware of the concept, or shy away from it because they have pre-conceived notions that it is “too restrictive”.  In fact, these are the same people who consume 70 % of their calories from only 4 foods (refined sugars, refined grains, refined vegetable oils and dairy).  When prospective Paleo dieters remove these 4 foods, they will suddenly find themselves eating a more varied and nutrient rich diet than they ever, as fresh fruits, vegetables, grass produced meats, and seafood become their staples.

9.)  The Paleo diet cuts out a lot of foods from the average human diet.  What do you think is the most important food for us to cut out of our diets? Sugar, dairy products, grains, legumes, unhealthy fats/oils, etc.? Or, is this question impossible answer since each of these foods affects our health differently?

As I pointed out in the previous question, these same 4 foods comprise 70 % or more of the calories in the typical Western diet.  I think you would be hard pressed to find a nutritionist anywhere who would not believe that we could improve our health by reducing our intake of refined sugars, refined grains, refined vegetable oils and processed foods made from a combination of these ingredients.  Remember that in addition to reducing or eliminating these nutrient poor foods, the Paleo Diet also encourages people to eat more fresh fruits, vegetables, fish, seafood and grass produced meats and poultry.

10.)  How has the Paleo diet personally effected (sic) your life?

It is most gratifying for me to see how people worldwide have improved their health and wellbeing and in achieving their personal fitness and health goals.

11.)  Is there anything you would like to add?

Give the diet two weeks and see how you feel.  Also, have your blood drawn before and after two weeks on the diet and show your results to your physician.

Loren Cordain, Ph.D., Professor

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