Coffee: how much is too much?

Hmm coffee. There’s nothing I like more than my Kathmandu plunger of coffee in the morning. I’m probably like a lot of kiwis, and 54% of those in the US it turns out. Sixty five percent of whom claim they ‘need’ their coffee in the morning. Me? If I go happen to go without it, I feel mildly aggrieved that I wasn’t able to experience the pleasure of the first sip, which is preferable to the thumping headache others report experiencing if they miss it. It enhances my morning rather than controls it. Regardless of what camp you fall into, as New Zealander’s we are a proud coffee drinking nation, therefore it’s not surprising that one of the most commonly asked questions I get ‘am I drinking too much coffee*?’ And I have to say that’s like asking ‘how long is a piece of string?’ Like most things, we can’t look at caffeine consumption in isolation of other behavioural and physiological factors. We have to view it in context of the overall lifestyle for that person.

If this is you, take comfort in the fact that you are among friends. (Image stolen from Pinterest)

In fact, if you look at some of the media headlines which report consumption of coffee at a population level, it is all looking pretty good. It used to be frowned upon for its diuretic effect in the body, yet we now know that for habitual drinkers, around four cups per day does not cause dehydration.  Moderate consumption (of around 3-5 cups per day) places people at a lower risk for cardiovascular disease,  reduced risk of type 2 diabetes,  lower risk of cirrhosis, non alcoholic fatty liver disease and hepatitis C. I know what you’re thinking: order me a Frappuccino and make it a Grande.

Not so fast.

When we look at studies of coffee consumption in the academic literature, we have to view it with the same light that we do the studies which conclude that saturated fat is associated with heart disease, or that red meat increases risk of cancer: these studies are observational and take a snapshot look at the population  – therefore the same inherent limitations exist: there is no cause and effect, it is just an association – when you ask a population once about their coffee intake you seldom get a clear picture of what they are drinking. Perhaps it IS a triple shot short black straight up from the café downstairs, or it’s a ½ teaspoon Moccona made with trim milk and hot water. In addition, we don’t always know the other lifestyle factors that occur in conjunction with the coffee consumption. Perhaps those with the lowest health risk who drink coffee are also people who are also regularly active, their body weight is within a healthy range for them, they may lead less stressful lives. Whilst these can be statistically adjusted in the studies, I tend to agree with those who argue that it’s always difficult to adjust away the accumulated affects of a healthy lifestyle.

Importantly, what studies like these are reporting are population averages. For example, if we track two groups of people over time (either those that consume coffee and those that don’t), we might find that in the group that drinks coffee, the actual intakes vary from two cups of coffee to eight cups of coffee a day. We might find that those who drink coffee have better sleep patterns than those that don’t. We would average out the intake and conclude that perhaps four drinks of coffee per day enhances sleep. However, it is highly likely there will be differences in those that drink two cups of coffee per day compared to those that drink eight cups. We also don’t know whether those that drink coffee have habitually done so, or have recently taken it up. Nor are we sure that those who don’t drink it have decided not to due to issues related to obtaining enough sleep. Further, among the group that actually do drink coffee, what is it about the lifestyles of the people in the study that drive them to drink eight cups of coffee in a day? These questions aren’t able to be addressed in population-based research in a way that is meaningful for the individual. In real life, we don’t work with the ‘average’ person, and at the individual level the coffee intake is not the problem – it’s the symptom of underlying issues that need addressing.

So what are the downsides of too much coffee? Coffee, or caffeine rather, is a stimulant. It elevates cortisol production (a stress hormone) which increases the load on the hypothalamic pituitary adrenal (HPA) axis, the regulatory system that is responsible (among other things) for regulating our thyroid metabolism, digestion, immune system and stress and sex hormone production. If you consume two espressos per day and feel more or less on top of everything from day to day, then this elevation in cortisol from the caffeine is more likely to be transient and if anything, the stress may well be good (after all, we need a certain amount of stress to thrive in everyday life). However, if you consume those two espressos on top of disrupted sleep, a rather heavy workload, a high training load (for an athlete) and might also be going through some relationship difficulty, then the accumulation of stressors will lead to a chronic elevation of adrenaline and cortisol. Over time this can cause disruption of the HPA axis, resulting in fatigue, increased susceptibility to illness, weight gain, and reduced ability to cope with further stress. None of these are desirable and, in fact, are becoming more common as our lifestyles are becoming busier. This collection of symptoms is referred to as adrenal fatigue, and while not always acknowledged as such in the medical arena, there are many people suffering the effects of burn out due to a chronic stress overload.

To add to this, caffeine is an adenosine antagonist, which means that it takes the place of adenosine on receptors in the brain and blocks its activity. Adenosine is responsible for producing a more relaxed state and preparing us to get ready to wind down. Caffeine blocks this and therefore the neurotransmitters responsible for invoking an alert state are allowed to continue on, making you feel less sleepy after taking it. Useful if looking for a second wind later on in the day. However, given that caffeine has a half life of around 6 hours (meaning it takes that long to metabolise), when consumed in large amounts later in the day it is going to impact on sleep, regardless of how convinced you are that this isn’t the case for you. While you might not have any trouble getting to sleep, certainly the quality of sleep is compromised. This lack of restorative sleep not only impacts physiologically (increasing insulin resistance), but increases cortisol levels and the likelihood of reaching for foods and stimulants to level out energy levels the following day.

So…are YOU drinking too much?  If it leaves you feeling relaxed and calm then it probably only makes you more awesome. If it leaves you feeling a bit jittery and wired, or you use it to get through the day, perhaps you need to evaluate whether that long black is contributing to your health or stealthily removing it. Only you can determine that.

*the only thing I can say with almost certainty is that coffee made from Jungle Beans (or its derivative Zee) is best avoided regardless of context.

How would you tackle this problem?

Do you have someone close to you who challenges your food decisions? For some it is like water off a ducks back. For others, particularly after years of the own battles they’ve had with food, to have someone else question something which they finally (finally!) believe is making them feel better can bring up the insecurities that were beginning to be put to rest. If it’s just to do you and what you eat, then perhaps it’s a matter of riding it out and letting the results speak for themselves. What happens, though, when the challenge comes from your partner and extends to differences in what you want to feed your children? Readers: we need your help.

A lovely client of mine is in exactly this predicament now. She is constantly battling with her husband with how they feed their energetic three year old daughter. He travels quite a bit for work, therefore leaving Jane largely responsible for Annie’s food intake. For the last year Jane has been following a whole food paleo style diet and feeling fantastic. Like most people she’s found it relatively easy to maintain. Unlike other diets she has followed in the past, she no longer feels the light yet slightly gnawing hunger across the course of the morning, or the drop in blood sugar around mid afternoon that is often experienced by people who are “good*” during the day. She feels much calmer than she has in the past and feels the food she’s eating is optimising her nutrient intake. Most importantly, after a long history of battling with her weight, body image and self esteem, she finally feels like she’s on her way to conquering the negative thoughts in her head that have told her for years that unless she is a perfect size 10, she is not worthy. Those thoughts that tell her she’s already a failure before she has even started on (yet another) calorie restricted plan are no longer lingering. It’s a sense of empowerment that finally she is able to control her food intake and that it doesn’t control her.

Naturally, given she is the major caregiver for their daughter, she has done a lot of reading around the best foods to feed Annie. Gone are the cocoa pops and Weetbix. These have been replaced by scrambled eggs and potato hash, fruit smoothies that include coconut milk and spinach, and pancakes made from banana, eggs and almond butter. Crustless sandwiches and roll ups have been replaced with kumara wedges and roast chicken drumsticks for lunch. Needless to say Annie loves it. Some slight resistance initially upon trying different foods, but after the ‘food lag’ she is happy to try lots of different foods and now even talks about preferring fruit and nut butter to single lunch box packets of potato chips… and therein lies the problem. Instead of being happy that their daughter is being nourished through whole food choices to optimise her growth and development, Jane’s husband is taking a stand against whole food and this ‘fad paleo diet.’ When he is home, he is frequently challenging her on the food choices available in the pantry and the seemingly deprivation approach to meals that Jane is serving up at home. When they eat out, the evening typically starts with an argument over where to eat. Not because Jane is any more particular over restaurant choice than her husband (as they both enjoy good food), but because he refuses to choose a restaurant as he doesn’t know what she’s “allowed to eat.” The already tense undertones of the evening are further exacerbated by the inevitable “is there anything you can eat on here?” and his insistence on choosing Annie menu options that resemble the standard western junk food diet.

Jane finds that they are constantly arguing over what they feed Annie. He views paleo through the lens of the media. Cutting major food groups, overly restrictive, the higher saturated fat content leading to adverse health in later years are three such criticisms that come up when he googles ‘paleo is dangerous.’ Just as important, he believes Jane is setting up Annie for a future of dietary restriction and problems with food. Not unlike, he points out, what Jane has been battling since her teens. Not only is Jane influencing Annie’s future physical health, but she is intentionally damaging her psychological health by being overly obsessive about removing processed food.

Ouch

While you might think that Jane just needs to discuss with him the premise of a whole food philosophy to clear up a few misundersatndings, unfortunately there appears to be little that can be done to change his mind. Any source of information that she provides him to back up her decision to include full fat dairy products or remove bread is countered by dietary guideline recommendations to build a diet on healthy wholegrains. Any evidence she presents him is discredited because it doesn’t come from health authorities and nothing she has said can convince him otherwise.

Tricky.

What’s a person to do in this situation? There are two immediate issues here. The first one is the lack of belief from Jane’s husband that she has turned a corner with her own self esteem issues. Her enthusiasm for the paleo diet is being read by her husband as a continuation of her obsession with food and body image. While she genuinely feels that she is getting on top of this, his accusations are bringing back feelings of doubt and insecurities. Obviously those aren’t the words he is using, but because she is being accused of being obsessive around food, that is what she is hearing. Potentially a bigger problem is his accusations around how she is feeding their daughter. What strikes at the core of Jane’s being is the inherent distrust he appears to have in her ability to be a responsible caregiver for Annie. That’s not what he is saying, but there is no doubt in her mind that that is what he is thinking.

So I’m writing this post as a shout out to others who may have been in this situation to offer some words of wisdom. Jane’s husband won’t listen to her. Or me. The information has to come from someone he trusts and respects, and looks up to. Theres no one in their immediate circle that fits that bill at this stage. And while Jane could ‘just relax’ when her husband is at home, that’s not ideal either. So, short of that, how does Jane tackle this?

*you know what I mean by good eh? That 300 calorie per meal diet that just gets you through to lunch but makes you want to chew off your arm by 4pm. blame their mid-afternoon crash on lunch. For a lot of people it’s under eating at both meals even if they feel somewhat satisfied after breakfast.

Nigel’s diet… why so much meat?

Thanks to Nigel there was an explosion of interest in my blog post last week – and with it, a lot of questions around including certain foods in my recommendations. One I’d specifically like to address is the inclusion of animal protein (or red meat) in (what some viewed as) large amounts. Now for those who have been reading my blog for a while, this will be covering old ground as I know I’ve talked about elements of this previously. However Nigel’s documentary series has sparked much more interest in what to eat and, as the questions I got suggest, a lot of this information is new ground for many – so I’m happy to delve further into some of these issues and explain why I encourage the inclusion of red meat in the diet.

The first point to make here is that a whole-food/paleo diet (as I recommended Nigel eat) is not a meat heavy diet – it’s good to dispel that myth immediately. Sure, some doing ‘paleo’, include large amounts of meat at every meal at the expense of vegetables; however that is not what most people I know do. In fact, I eat more vegetables than some vegetarians I know. The inclusion of small amounts of meat or animal protein at each meal helps stabilise blood sugars and prevents overeating due to energy crashes. In addition, these foods contain complete proteins that are essential for the repair and rebuild of musculoskeletal tissue, they provide (amongst others) iron, zinc, iodine (fish) which are important for over 200 metabolic processes in the body important in brain, gut, liver and thyroid health, and deliver important antioxidants such as co-enzyme q 10 for heart health (and great skin!) Alongside these are the fat soluble vitamins (A, D, K) and essential fats (omega 3 fatty acids, monounsaturated fats and saturated fats) and cholesterol that form the backbone of many hormones and messenger enzymes that are responsible for delivering instructions throughout the body.

I’ve taken a broad-brush approach to the many benefits of including animal protein in the diet, but one thing I want to point out is that it’s not the eye fillet steak and the boneless, skinless, (tasteless) chicken breast that I’m talking about – the meat that is closest to the bone is the most healthy meat. Yes it’s fattier – but that’s a good thing (see above re: essential fats). There is beginning to be a trend of nose-to-tail eating now, making many of the offcuts of meat that were often binned now available to be purchased and used at the fraction of the price of an eye fillet steak (if people are willing to try them!). In New Zealand we have predominantly grass fed meat, which means we are largely protected from meat that has been grain fed. Grain fed cattle produces meat with a higher fat content but its fatty acid profile is not ideal – higher in omega 6 fats and higher intramuscular triglycerides (pro-inflammatory). The grain affects the health of the cattle, with more risk of infection and harmful bacteria which have downstream consequences to the quality of the meat we find in our food supply. While in NZ cattle are ‘finished off’ with grain, after a Twitter conversation I had the other week I believe the health consequences of this for us are negligible – though am happy to stand corrected!

And then there’s the issue of meat and cancer. And meat and heart disease. And meat and [insert health condition here that suggests you are a medium-rare steak away from certain death]. The problem with the media snippets most people are exposed to is that the finer (read: important) details are overlooked in amongst the rush to print that meat is as bad for you as smoking. Well (gasp) it’s not. Firstly, any research that suggests meat is adversely linked to any of the aforementioned conditions is association, not causational. These research studies cannot determine cause and effect and are not designed to do so. Secondly, many of the large trials asked participants to report their retrospective meat intake over a 6-10 year period once, in a questionnaire format (many people I know struggle to tell me what they ate last week). Thirdly, the distinction between actual meat and that which is found in a hamburger (for example) or even a meat sandwich in some cases is not made. There is a vast difference in quality between a rump steak and a sizzler (not to mention the latter is only around 45 percent meat and isn’t legally allowed to be called a sausage). People seldom eat a hamburger without a bun (this was before the advent of an ‘oxygen’ burger from Burger Fuel) and lumping a person who eats burgers five times per week (and upsizing with the fries and Coke) in the same category as someone who dines on eye fillet at a Pete Evan’s paleo restaurant five nights a week is problematic. Of course, I’m speculating here as to the overall diet quality of participants – but that’s all I can do as these important details pertaining to other nutrients known to affect health (i.e. processed refined carbohydrates, industrial seed oils) aren’t known. Many other lifestyle factors that contribute to poor health (such as a low level of physical activity, smoking, higher alcohol intake) are also seen in those with the highest intake of red meat and in some instances there wasn’t a linear relationship between meat intake and health (or death….) with the death rate falling in between those with the lowest intake and those with the highest intake (when split into groups according to overall consumption patterns.) These details mean little however when it comes to health reporting in the media. Nothing sells like sensationalism, and if we can draw parallels between red meat consumption and smoking then you don’t even need consumers to read the article to guarantee you’d have made an impact. Again, this is my Women’s Weekly overview; for a far more eloquent and in-depth critique of this, go to Zoe Harcombe’s review or Jamie Scott’s blog post discussing this issue.

Another big pushback against the inclusion of meat is from an ethical and sustainability perspective. Now I’m not at all suggesting that people who choose not to consume animal products based on their moral standpoint should reconsider. This is a judgement call I have no business in commenting on. However for others, thankfully the availability of free range meat now accessible at relatively cheaper cost is increasing. Demand also affects supply, and the more we ask for free range meat and eggs, the more the price will be driven down (especially considering its not essential to be choosing eye fillet for every meal). Another argument against encouraging meat consumption is that it’s not sustainable for the environment, with more demand for meat increasing the fossil fuel used to produce it, the water usage required and an increase in the methane emissions (and the carbon footprint). If we put it into perspective, most of what we do has a carbon footprint. Grain-feeding cattle may (or may not) be more resource intensive (and have a larger footprint) given what is necessary to grow the grains to be fed to the cattle as opposed to raising cows on a grass field. And promoting a vegetarian diet based on this argument is flawed given the resources required to feed the world on vegetables.

Turn your heating off a put on a jersey instead.

So that’s my stance on including animal protein (and red meat) in the diet. There are many reasons why people choose not to include red meat in their diet – but if they are based on optimising nutrient intake, protection from later chronic illness, or from a sustainability perspective, then perhaps reconsidering it wouldn’t go amiss.

 

So…. how did Nigel Latta change his diet anyway?

ICYMI, Nigel Latta ended his six episode documentary series this week with a focus on sugar. Part of the fun, in amongst witnessing a two year old have their teeth removed and people in the kidney dialysis unit, was Nigel changing his diet to see what effects this would have on his health and wellbeing. Julianne Taylor, who did the research for the show, brought me in to help Nigel with that.

Interestingly, when first approached by Julianne, the plan was to put Nigel on a high sugar diet and see the effects it might have on his energy, his mood, and his metabolic outcomes (cholesterol, blood sugar, triglycerides and the like). I figured that would be an interesting experiment, particularly given that Nigel was pretty sure he had a good diet (smug, one might say). Other than the small issue of an afternoon crash, leading him to seek out something sweet to give him an energy boost, he thought it was all good. From what I knew of Nigel, he appeared pretty lean, he was fairly active, and he enjoyed vegetables and fruit. It’s fair to say that – on appearances – Nigel was your average kiwi guy. A bit shorter, maybe, but all in all a fairly average, run-of-the-mill male.

Then I got his diet to analyse. Hmm. This wasn’t the ‘healthy diet’ that I was expecting.. Here’s an example day of what I received (and it was on his ‘treat’ day – takeaways for dinner).

BREAKFAST
Banana
50g Muesli, toasted, sweetened with trim milk
Flat white with one sugar
1 Egg and 2 rashers of bacon on 2 slices of toast
LUNCH
Flat white with one sugar
CAFÉ: Serve of Quiche,Lorraine with a chicken salad roll
SNACK
CAFÉ: muesli slice
Flat white
DINNER
Diet coke
McDonalds Burger (McFeast)
McDonald’s large fries
McDonald’s Chocolate sundae

 

Far from being a low sugar diet, Nigel managed to get almost half of his carbohydrate energy from sugars, which included 54g of sucrose – this is the ‘proxy’ used to determine ‘added’ sugars. That’s 14 teaspoons, people. I don’t think that Nigel didn’t have a clue – I just think that people aren’t aware of where sugar is in food AND that the rise and fall of energy throughout the day (that is related to blood sugar) dictates food choice far more than what they think it does. And it’s easy to forget such things when reflecting on a ‘normal’ day.

On top of the diet, when the blood results came to me, I could see that this average kiwi bloke had fairly average results:

• Total cholesterol 5.3 mmol/L (<5.0 mmol/L)
• HDL cholesterol 1.08 mmol/L (>1.0 mmol/L)
• Triglycerides 2.4 mmol/L (<1.7 mmol/L)
• LDL cholesterol 3.1 mmol/L (<3.4 mmol/L)
• Chol/HDL 4.9 mmol/L  (<4.5 mmol/L)

As I discussed last week, the triglyceride level was higher than ideal and, when combined with a borderline HDL cholesterol reading, this is indicative of a greater number of VLDL cholesterol particles making up his LDL cholesterol reading – ie. elevating his risk of inflammation and artery and cell damage. Combined with the Chol/HDL ratio being high (indicative of a greater number of LDL particles) and Nigel’s tendency to store fat around his mid-section, we felt Nigel could do to improve his diet and his risk profile*.

So, for six weeks (in between visits), Nigel followed my advice for a low sugar diet. Some of the highlights of the diet were:

• I got Nigel to focus on getting his carbohydrate from natural sources that were minimally processed, Include protein at each meal (eggs, meat, poultry, fish)
• Include natural sources of fat (butter, coconut oil, olive oil, nuts, nut oils) while steering clear of seed oils, margarines and the like. Importantly, don’t avoid fat. This is fairly easy to do when you remove most of the processed food from your diet.
• Include vegetables at all meals where possible, focusing on the really colourful ones to ensure he was getting more nutritional bang for his buck
• Snacks: focus on sources of protein and or fat that will help keep him satisfied and not cause swings in blood sugar that he experienced which leads him to the cake and biscuits at his local café for a 3pm sugar hit.
• Drink more water, and less coffee.
• That 19 out of the 21 meals had to be awesome. It killed me to say it but – that McDonald’s meal in the context of my recommendations was not going to be the death of him. But, let’s be clear: that’s NOT the treat meal – those other 19 meals? Treats.
• Preparation is key to any good diet, and prepackaging nuts, cheese portions, having fruit (that can be eaten with either the fat or protein options for a snack), and hard boiled eggs would help keep him satisfied when he got hungry, avoiding the need to buy food that might not be ideal.

A typical day in the life of Nigel after I spoke to him would be:

• 3 eggs scrambled in butter or coconut oil with some avocado, spinach and tomato, +/- a piece of fruit based on hunger
• Lunch at café would be a lamb/chicken salad – avoiding the dressing unless it was an olive oil/balsamic vinegar dressing, but getting added avocado and ensuring a good amount of protein. If at home, add pumpkin seeds, avocado and aforementioned olive oil as a dressing to a salad and, again, a good serve of protein to help keep him satisfied.
• If Nigel felt hungry in the afternoon, then snacks on cheese, nuts, hard boiled eggs and the like were recommended.
• Dinner choices included (again) plenty of vegetables, meat, poultry or fish cooked in either coconut oil, kumara either baked or roasted in olive oil, or legumes or lentils (as Nigel doesn’t have any issues with digesting these).

As you would see on the show, over the course of the filming, Nigel lost 3kg and his energy massively increased. His blood cholesterol readings also improved. On an email half way through Nigel said that the diet had such an effect on how he felt that ‘there was no going back.’ And on email this week he revealed he was 8kg down and his enthusiasm for the change in eating hadn’t altered six months on. Importantly he can’t believe the change in his energy levels.

So… Nigel really is your average kiwi bloke (a bit shorter, perhaps – but average). However there was no need for him to have an average diet OR average blood cholesterol results. Why be average when you can be awesome? With the improvements in his risk profile, the slippery slope into poor health that many average kiwis will experience over their lifetime due to diet has been halted. Nigel’s health has moved from ‘average’ to awesome and he is not complacent about what he eats. As a father, this will undoubtedly have a flow on effect to the younger members of the Latta family. It was great to be involved in that.

*There was, however, some dissention amongst the ranks at my reaction to Nigel’s initial blood results. Apparently I was too alarmist and I could cause the public to be alarmed at their own ‘slightly elevated triglyceride levels’ in the absence of other risk factors. I was a bit perplexed by the email, quite frankly. Not because triglyceride levels that are elevated are almost never elevated without the presence of other risk factors, and this was a television show that due to editing and time restrictions, cannot delve into all of the risk factors. I was perplexed that there was an issue to begin with. Sorry. If you have a diet not unlike Nigel’s diet, then you need to sit up and take notice. Nigel was not that overweight. He was fairly active and – to look at – relatively lean. However his diet was pretty terrible, his energy levels were compromised AND didn’t have an ideal blood profile. If my (or the show’s) emphasis on triglyceride levels caused the general population to be alarmed at their own triglyceride levels then…. be alarmed people. If it makes you think about the amount of sugar you are eating then that’s okay by me.