Diet and nutrition

Dr Evangeline Mantzioris
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If you’re a red meat-eater, there’s a good chance you’re eating more of it than you should. At last count, Australians ate an average of 81 grams of red meat per day. The planetary health diet was developed by researchers to meet the nutritional needs of people around the world, while reducing food production’s environmental impact. It recommends reducing our red meat intake to around 14g a day. That’s around 100g of red meat a week. Australia’s dietary guidelines are more conservative and recommend limiting red meat intake to a maximum of 455g a week, or 65g a day, to reduce the additional cancer risk that comes from eating large quantities of red meat. So, what should you eat instead? And how can you ensure you’re getting enough protein, iron, zinc and vitamin B12?

Protein

Animal sources of protein provide essential amino acids, which the body uses to make muscle, tissue, hormones, neurotransmitters and the different cells and antibodies in our immune system. The planetary health diet offers a good blueprint for gaining enough protein from a variety of other animal sources. It recommends eating, on average:
  • 25g of chicken per day
  • 28g of fish per day day
  • 1.5 eggs per week
  • 200g of milk per day day
  • 50g of cheese per day.
In addition to the 14g of red meat in the planetary health diet, these foods would provide a total of 45g of protein per day, which is around 80% of our daily protein needs from animal sources. The remaining protein required (11g) is easily met with plant foods, including nuts, legumes, beans and wholegrains.

Iron

Iron is essential for many of the body’s functions, including transporting oxygen to the blood. Iron deficiency can lead to anaemia, a condition in which you feel tired and lethargic. Pre-menopausal women need around 18 milligrams a day, while men only need 8mg. Pre-menopausal women need more iron because of the blood they lose during menstruation. So, how can you get enough iron? Beef, of course, is a rich source of iron, containing 3.3mg for every 100g. The same amount of chicken breast contains 0.4mg, while the chicken thigh (the darker meat) contains slightly higher levels, at 0.9mg. Pork is similarly low in iron at 0.7mg. But kangaroo will provide you with 4.1mg of iron for every 100g. Yes, kangaroo is a red meat but it produces lower methane emissions and has one-third the levels of saturated fat than beef, making it a healthier and more environmentally friendly alternative. Plant protein sources are also high in iron: cooked kidney beans have 1.7mg and brown lentils have 2.37mg per 100g. If you wanted to cut your red meat intake from the 81g average to the recommended 14g per day while still getting the same amount of iron, you would need to consume the equivalent of either 50g of kangaroo, 100g of brown lentils or 150g of red kidney beans per day.

Zinc

Zinc is an essential mineral that helps the body function optimally. It affects everything from our ability to fight bugs, to our sense of smell and taste. Zinc requirements are higher for men (14mg a day) than women (8mg a day) due to zinc’s role in the production and development of sperm. Of all meat sources, beef provides the most zinc, at 8.2mg per 100g. Chicken breast provides just 0.68mg, while the chicken thigh has 2mg. In kangaroo meat, the levels of zinc are lower than beef, at 3.05mg. The richest source of zinc is oysters (48.3mg). Beans such lentils, red kidney beans and chickpeas all provide about 1.0mg per 100g. To meet the shortfall of zinc from reducing your red meat intake, you could eat 12 oysters a day, which is unlikely. Or you could eat a combination of foods such as 150g of red kidney beans, one serve (30g) of zinc-supplemented cereals like Weet-bix, three slices of wholegrain bread, and a handful of mixed nuts (30g).

Vitamin B12

Vitamin B12 is important for healthy blood and nerve function. It’s the nutrient of most concern for people cutting out meat products as it’s only found in animal sources. Requirements of vitamin B12 are the same for both women and men at 2.4 micrograms (mcg) a day. Beef and kangaroo provide 2.5mcg per 100g serve, while chicken and turkey provide about 0.6mcg. Dairy products also contain vitamin B12. One glass of milk would give you half your daily requirement requirement (1.24mcg) and one slice of cheese (20g) would provide one-fifth (0.4mcg). Vitamin B12 can be found in trace amounts in spinach and fermented foods, but these levels aren’t high enough to meet your nutritional needs. Mushrooms, however, have consistently higher levels, with shiitake mushrooms containing 5mcg per 100g. To meet the shortfall of vitamin B12 from reducing red meat intake, you would need to eat 75g kangaroo per day or have a glass of milk (200ml) plus a slice of cheese (20g). Alternatively, a handful of dried shiitake mushrooms in your salad or stir-fry would fulfil your requirements.

Don’t forget about fibre

A recent study found fibre intakes of around 25 to 29g a day were linked to lower rates of many chronic diseases such as coronary heart disease, type 2 diabetes, stroke and bowel cancer. Yet most Australian adults currently have low dietary fibre levels of around 20g a day. By making some of the changes above and increasing your intake of meat alternatives such as legumes, you’ll also be boosting your levels of dietary fibre. Substituting 100g of lentils will give you an extra 5g of fibre per day. With some forward planning, it’s easy to swap red meat for other animal products and non-meat alternatives that are healthier and more environmentally sustainable.The Conversation Evangeline Mantzioris, Program Director of Nutrition and Food Sciences, University of South Australia This article is republished from The Conversation under a Creative Commons license. Read the original article.
Prof Clare Collins
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There are many reasons people go vegan, from wanting to be healthier, to reducing their environmental footprint, to concerns about animal welfare. No matter what the reason, many people find it difficult to meet the nutrient intake targets for specific vitamins and minerals while on a vegan diet. These include vitamin B12, iron, calcium, and iodine. Here’s how to make sure you’re getting enough of these vitamins and minerals while following a vegan diet.

1. Vitamin B12

Vitamin B12, or cobalamin, is essential for making red blood cells, DNA (your genetic code), fatty acids located in myelin (which insulate nerves), and some neurotransmitters needed for brain function. Vitamin B12 is stored in the liver, so a deficiency probably won’t happen in adults in the short term.
Symptoms of B12 deficiency
Symptoms of vitamin B12 deficiency include tiredness, lethargy, low exercise tolerance, light-headedness, rapid heart rate or palpitations, bruising and bleeding easily, weight loss, impotence, bowel or bladder changes, a sore tongue, and bleeding gums. Other symptoms related to the nervous system include a loss of sensation in the hands or feet, problems related to movement, brain changes ranging from memory loss to mood changes or dementia, visual disturbances, and impaired bowel and bladder control.
Testing for B12 deficiency
Your doctor may request a blood test to check your vitamin B12 status and determine whether indicators are in the healthy range.
Vegan food sources of B12
Vitamin B12 is abundant in animal foods including meat, milk and dairy products. For vegans, plant sources of vitamin B12 include some algae and plants exposed to bacterial action or contaminated by soil or insects. While traces of vitamin B12 analogues can be found in some mushrooms, nori or fermented soy beans, more reliable sources include vitamin B12-supplemented soy or nut “milks”, or meat substitutes. Check the nutrition information panel on the label for the the B12 content. Crystalline vitamin B12 added to these products can boost the B12’s absorption rate to a level similar to that from animal products.

2. Calcium

Calcium is needed to develop and maintain the skeleton bones, and is stored in the teeth and bones. It is also essential for heart, muscle and nerve function.
Testing for calcium deficiency
Low calcium intakes are associated with osteoporosis or “brittle bones” and a higher risk of bone fractures. A bone scan is used to measure bone density, with osteoporosis diagnosed when bone density is low. Both low calcium intakes and low vitamin D levels increase the risk of osteoporosis. Check your bone health using the Know Your Bones online quiz.
Vegan food sources of calcium
Although the richest sources of calcium are milk and milk-based foods, vegans can get calcium from tofu or bean curd, some fortified soy or nut beverages, nuts, seeds, legumes, and breakfast cereals. Calcium needs can be higher for vegans and vegetarians due to the relatively high oxalic acid content of foods such as spinach, rhubarb, beans, and the high phytic acid content of seeds, nuts, grains, some raw beans, and soy products. These specific acids can lower the calcium absorption from these foods by 10-50%. In a study of calcium intakes of 1,475 adults , vegans were below national recommendations and had lower calcium intakes compared with vegetarians, semi-vegetarians, pesco-vegetarians, and omnivores.

3. Iodine

Iodine is needed to make thyroxine, a thyroid hormone used in normal growth, regulation of metabolic rate, and development of the central nervous system. Iodine is concentrated in the thyroid gland.
Symptoms of iodine deficiency
Iodine deficiency can lead to the enlargement of the thyroid gland, a goitre, or hypothyroidism. Symptoms of hypothyroidism include lethargy, tiredness, muscular weakness, feeling cold, difficulty concentrating, poor memory, weight gain, depression, facial puffiness, hair loss, dry skin, constipation, and slower heartbeat. In women, iodine deficiency can increase risk of miscarriage and stillbirth, and congenital anomalies, including mental retardation and cretinism.
Testing for iodine deficiency
Your iodine status can be assessed by a range of tests, including thyroid hormones in your blood, the size of your thyroid gland, or the presence of a goitre. Talk to your doctor about these tests.
Vegan food sources of iodine
The iodine content of food depends on the iodine content of plants, which in turn depends on soil iodine content. When soil content is low, iodine may need to be supplemented. Major sources of iodine are seafood, dairy products, and eggs. For vegans, iodised salt, commercial bread made using iodised salt, fortified soy or nut milks (check the product label) and seaweed are important. Substances called goitrogens, which are found in brassica vegetables – including cabbage, broccoli and Brussels sprouts, sweet potato and maize – can interfere with the production of thyroid hormones.

4. Iron

Iron is needed to make haemoglobin in red blood cells, which carries oxygen around your body. Iron is also needed for the production of energy in your muscles, and for concentration and a healthy immune system.
Symptoms and testing for iron deficiency and anaemia
Not having enough iron leads to iron deficiency, and is associated with reduced work capacity, impaired brain function, lower immunity, and delayed development in infants. The first stage of iron deficiency is referred to as low iron stores and your doctor may refer you for a blood test to check your iron status.
Vegan food sources of iron
In Australia and New Zealand, the biggest contributors to iron intake are wholegrain cereals, meats, chicken, and fish. The amount of iron absorbed from food depends on a person’s iron status (with those who are iron-deficient absorbing more), as well as the iron content of the entire meal, and whether iron is haem (from animal foods) or non-haem iron from plant sources such as grains and vegetables. Although iron from plant sources is less able to enter the body, you can boost your absorption by adding lemon or lime juice (citric acid) or other vitamin C-rich vegetables and fruits, which convert non-haem iron to a form than is better absorbed. Take care with food components that inhibit absorption of both haem and non-haem iron, including calcium, zinc and phytates in legumes, rice and other grains, and polyphenols and vegetable proteins that can inhibit absorption of non-haem iron. Long-term vegans will also need to keep an eye on levels of vitamin D, omega-3 fat and protein. A good strategy is to check in with your GP periodically to review your health and well-being, and an accredited practising dietitian can check whether you’re getting all the nutrients you need.The Conversation This article is republished from The Conversation under a Creative Commons license. Read the original article.
A/Prof Ken Sikaris
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Vitamin B12 testing remains the most common vitamin investigation in clinical practice and is often included in the investigation of common problems such as anaemia and dementia. The assessment of Vitamin B12 status using blood tests is imperfect and although a variety of other tests can be used to improve assessment, this can lead to complexity and confusion. In this discussion I hope to share the insights from thousands of analyses and hundreds of clinician’s questions.

Sources of Vitamin B12

Vitamin B12 is a unique cobalt-containing molecule naturally synthesised by bacteria. Some animals, especially herbivores, absorb it from their intestinal microbiome, and build up a store. Other animals, particularly carnivores, can obtain B12 by eating animals that store B12, or animal-based products such as eggs and milk. Vegetarians consuming milk products and eggs may have low B12 levels, as the B12 content of milk is often low (1mg/L) and even lower if ultra-heat treated. Non-animal sources of B12 are extremely limited, with Nori seaweed containing small amounts and B12 levels in mushrooms and most other plant-based sources reflecting bacterial exposure (eg manure/compost).(1) Only strict vegetarians are considered at serious risk of dietary B12 deficiency, and even then only after some years. However, vegetarian and vegan diets are becoming increasingly popular. Similarly, breast-fed infants of vegan mothers, if not supplemented, may also be at risk of B12 deficiency.

How common is B12 deficiency?

Vitamin B12 deficiency is relatively common (4- 26%) but difficult to define accurately because of varying definitions.(2) It is more common in the elderly and significant deficiency is present in up to 23% of elderly Australian populations.(3) Iron deficiency is similarly common, especially in young women, and since low consumption of iron from meat sources correlates with lower B12 intake, B12 deficiency should always be considered when dietary iron deficiency exists. While pernicious anaemia is often considered as a cause of B12 deficiency, this autoimmune illness has a relatively low prevalence compared to B12 deficiency. In our experience, only 4% of our Intrinsic Factor antibody requests are positive which is a similar result to that described by others.(4) Higher prevalence has been reported when using the less specific parietal antibody test, but even then, less than 20% of B12 deficiency can be attributed to pernicious anaemia.(5) Less than one in eight patients with positive parietal cell antibodies have pernicious anaemia and this lack of specificity increases in the elderly when the test should be avoided.

Clinical issues

Unexplained anaemia and/or macrocytosis have traditionally been the indications used for suspicion of B12 deficiency. But there are other common reasons for anaemia such as iron deficiency and the anaemia of chronic disease. There are also other common reasons for macrocytosis including liver disease and alcoholism. Vitamin B12 levels are more likely to be low in a vegetarian (or vegan) than in a patient with anaemia or macrocytosis.(6) We also find that symptoms of confusion and dementia are just as likely to be associated with low B12 levels as anaemia. And while this may be partly associative due to the higher prevalence of B12 deficiency, it should be concerning because of the neurological sequelae of B12 deficiency that may arise prior to anaemia. Neurological symptoms of B12 deficiency include paraesthesia of the hands and feet, diminished perception of vibration and position, absence of reflexes, and unsteady gait and balance (ataxia). But the range of symptoms is broad and may include irritability, tiredness, and mild memory and cognitive impairment. Severe deficiency causes subacute combined degeneration of the spinal cord. In pregnancy, B12 deficiency is associated with some increase in the risk of neural tube defects and in childhood is associated with developmental delay and failure to thrive.

Why is testing so complicated?

Cobalamine is a precious vitamin that is captured and chaperoned around the body. Saliva contains a protein that will capture B12. In the stomach, intrinsic factor is produced to capture B12 released by digestion and transport it into the body. Within the bloodstream, there are two proteins that bind B12; haptocorrin and transcobalamin. These two proteins seem to have different functions with transcobalamin delivering B12 to the cells whereas haptocorrin correlates with storage. (This is similar to iron where transferrin transports iron to the cells and ferritin reflects storage.)

How to interpret B12 and HoloTC levels.

The amount of B12 attached to transcobalamin (ie holo-transcobalamin or HoloTC) therefore reflects the Vitamin B12 level available to cells. When there is a cellular deficiency of B12, the reactions dependent on B12 are obstructed and precursors such as homocysteine and methyl-malonic acid (MMA) build up and can be measured as indicators of functional B12 deficiency. HoloTC correlates better with homocysteine and MMA than the total B12 level of the blood. When total B12 levels are low or equivocal, it is appropriate to follow up with the more specific HoloTC test to help ascertain if there is a functional deficiency. Pregnant women often deplete their B12 stores during pregnancy, but they uncommonly have B12 deficiency evidenced by their normal HoloTC levels. Conversely, patients with some haematological malignancies may have high B12 stores (eg by tumours producing haptocorrin) but may not mobilise those stores evidenced by a low HoloTC and macrocytic anaemia.

Summary

Vitamin B12 deficiency is common and can be associated with neurological symptoms and haematological signs especially in vegetarians, and uncommonly in pernicious anaemia. HoloTC is more specific for clinical B12 deficiency than total B12 and that is why laboratories reflex test for HoloTC whenever the total B12 is low or equivocal.   General Practice Pathology is a new regular column each authored by an Australian expert pathologist on a topic of particular relevance and interest to practising GPs. The authors provide this editorial free of charge as part of an educational initiative developed and coordinated by Sonic Pathology.  

References

  1. Watanabe F, Yabuta Y, Bito T, Teng F. Vitamin B12-Containing Plant Food Sources for Vegetarians. Nutrients. 2014 May; 6(5): 1861-73.
  2. Moore E, Pasco J, Mander A, Sanders K, Carne R, Jenkins N, et al. The prevalence of vitamin B12 deficiency in a random sample from the Australian population. Journal of Investigational Biochemistry. 2014 Oct 2; 3(3): 95-100.
  3. Flood VM, Smith WT, Webb KL, Rochtchina E, Anderson VE, Mitchell P. Prevalence of low serum folate and vitamin B12 in an older Australian population. Aust N Z J Public Health. 2006 Feb; 30(1): 38-41.
  4. Aa A, Ah A, Ap S, Fh A, Pernicious anemia in patients with macrocytic anemia and low serum B12.  Pak J Med Sci. 2014 Nov-Dec; 30(6): 1218-22.
  5. Sun A, Chang JY, Wang YP, Cheng SJ, Chen HM, Chiang CP. Do all the patients with vitamin B12 deficiency have pernicious anemia? J Oral Pathol Med. 2016 Jan; 45(1): 23-7.
  6. Botros M, Lu ZX, McNeil AM, Sikaris KA. Clinical notes as indicators for Vitamin B12 levels via text data mining. Pathology. 2014; 46 Suppl 1: S84.
Megan Lee & Joanne Bradbury
Clinical Articles iconClinical Articles

We all know eating “healthy” food is good for our physical health and can decrease our risk of developing diabetes, cancer, obesity and heart disease. What is not as well known is that eating healthy food is also good for our mental health and can decrease our risk of depression and anxiety. Mental health disorders are increasing at an alarming rate and therapies and medications cost $US2.5 trillion dollars a year globally. There is now evidence dietary changes can decrease the development of mental health issues and alleviate this growing burden. Australia’s clinical guidelines recommend addressing diet when treating depression. Recently there have been major advances addressing the influence certain foods have on psychological well-being. Increasing these nutrients could not only increase personal well-being but could also decrease the cost of mental health issues all around the world. 1. Complex carbohydrates One way to increase psychological well-being is by fuelling brain cells correctly through the carbohydrates in our food. Complex carbohydrates are sugars made up of large molecules contained within fibre and starch. They are found in fruit, vegetables, and wholegrains and are beneficial for brain health as they release glucose slowly into our system. This helps stabilise our mood. Simple carbohydrates found in sugary snacks and drinks create sugar highs and lows that rapidly increase and decrease feelings of happiness and produce a negative effect on our psychological well-being. We often use these types of sugary foods to comfort us when we’re feeling down. But this can create an addiction-like response in the brain, similar to illicit drugs that increase mood for the short term but have negative long-term effects. Increasing intake of complex carbohydrates and decreasing sugary drinks and snacks could be the first step in increased happiness and well-being. 2. Antioxidants Oxidation is a normal process our cells carry out to function. Oxidation produces energy for our body and brain. Unfortunately, this process also creates oxidative stress and more of this happens in the brain than any other part of the body. Chemicals that promote happiness in the brain such as dopamine and serotonin are reduced due to oxidation and this can contribute to a decrease in mental health. Antioxidants found in brightly coloured foods such as fruit and vegetables act as a defence against oxidative stress and inflammation in the brain and body. Antioxidants also repair oxidative damage and scavenge free radicals that cause cell damage in the brain. Eating more antioxidant-rich foods can increase the feel-good chemicals in our brain and heighten mood. Antioxidants can help restore the happy chemicals in the brain. www.shutterstock.com.au 3. Omega 3 Omega 3 are polyunsaturated fatty acids that are involved in the process of converting food into energy. They are important for the health of the brain and the communication of its feel-good chemicals dopamine, serotonin and norepinephrine. Omega 3 fatty acids are commonly found in oily fish, nuts, seeds, leafy vegetables, eggs, and in grass fed meats. Omega 3 has been found to increase brain functioning, can slow down the progression of dementia and may improve symptoms of depression. Omega 3 are essential nutrients that are not readily produced by the body and can only be found in the foods we eat, so it’s imperative we include more foods high in omega 3 in our everyday diet. 4. B vitamins B vitamins play a large role in the production of our brain’s happiness chemicals serotonin and dopamine and can be found in green vegetables, beans, bananas, and beetroot. High amounts of vitamins B6, B12, and folate in the diet have been known to protect against depression and too low amounts to increase the severity of symptoms. Vitamin B deficiency can result in a reduced production of happiness chemicals in our brain and can lead to the onset of low mood that could lead to mental health issues over a long period. Increasing B vitamins in our diet could increase the production of the feel good chemicals in our brain which promote happiness and well-being. 5. Prebiotics and probiotics The trillions of good and bad bacteria living in our tummies also influence our mood, behaviour and brain health. Chemical messengers produced in our stomach influence our emotions, appetite and our reactions to stressful situations. Prebiotics and probiotics found in yoghurt, cheese and fermented foods such as kombucha, sauerkraut and kimchi work on the same pathways in the brain as antidepressant medications and studies have found they might have similar effects. Prebiotics and Probiotics have been found to suppress immune reactions in the body, reduce inflammation in the brain, decrease depressed and anxious states and elevate happy emotions. Incorporating these foods into our diet will not only increase our physical health but will have beneficial effects on our mental health, including reducing our risk of disorders such as depression and anxiety.   Disclosure Statement Megan Lee receives funding from Southern Cross University and Santos Organics Joanne Bradbury receives funding from the Australian Traditional-Medicinal Society (ATMS), Santos Organics, and Metagenics to support academic research