For someone of only 21 years, Sherry would be considered relatively sedentary. She walks to and from the bus stop and to and from classes at college, but that’s where it ends. She doesn’t participate in any sports or other physical fitness training, unless you count dancing at the clubs every second week or so. Sherri would like to be more active, but she just doesn’t seem to have the time between school and two part-time jobs. At 5 feet 5 inches and 135 pounds Sherri has a BMI of 22 – right in the middle of the healthy weight zone. At her routine medical, Sherri was stunned to learn that her body fat was 28 percent. As it turns out, Sherri has a small bone frame and is carrying excess body fat.

These two examples help to illustrate the limitations of using body weight as an indicator of health and fitness. Body weight is important, but it is best used in conjunction with other tools, and some common sense. There is no one “ideal” weight for all people of a particular height because a person’s healthiest weight depends on bone structure, muscle mass, body fat and general body build. So how can you determine what is a healthy weight for you? How do you know if you are overweight or obese?

Let’s begin our quest by defining the phrase “healthy body weight.”

A healthy body weight is a weight at which the body functions most efficiently and effectively, affording itself maximum protection against illness and disease.

A healthy body weight is more about function and well being than socially defined beauty standards. There are three tools that, when used together, will accurately determine whether or not your body weight is healthy for you. They include:

1. Body Mass Index (BMI) – takes into consideration height and weight.
2. Percent Body Fat – takes into consideration total fat stores.
3. Body Shape – takes into consideration distribution of body fat.

Body Mass Index (BMI)

The old standard for determining ideal body weights were height weight charts. You would simply plug your height, weight and frame size into a chart to see if you fell within the ideal or healthy range. While these charts were useful, they had limitations. Today, the most widely used tool to determine if a person is in a healthy weight range is the Body Mass Index (BMI). We can determine BMI by using an equation [weight (kg) (1 kg = 2.2 lbs) ÷ height (meters) 2 (1 meter = 39.4”)], or a BMI chart (see BMI chart below).

BMI is recommended for people ages 20 to 65, but is not been considered valid for some people. For example, A BMI of 18.5 to 24.9 is considered in the healthy weight range. Those with a BMI below 18.5 are considered underweight and at an increased health risk. A BMI of 25 to 29.9 is considered overweight. Obesity is generally defined as a BMI greater than 30; severe obesity greater than 35 and morbid or extreme obesity greater than 40. Research suggests that those with a BMI of 19 to 22 enjoy the greatest longevity. BMI does not factor in muscle mass, so very muscular people will have a high BMI, but could have a very low percentage body fat (thus, they appear “overweight” according to BMI, but are actually very lean). Jake is a perfect example of this. In addition, very short people (5 feet/ less than 1.5 meters tall) may have higher BMI than would be expected relative to their size. BMI is not useful for pregnant women or those over the age of 65. To find your BMI, plot your height and weight on the BMI chart.

Percent Body Fat

While BMI is a measure of body fatness, as you saw with both Jake and Sherry, it is best to get a second opinion. So, step number two is getting a reasonable measure of body fatness.

There are numerous ways to measure percent body fat, although the most common methods include hydrodensitometry (underwater weighing), DEXA (dual energy X-ray absorptiometry) and anthropometry (skinfold thickness measures).

Hydrodensitometry and DEXA are both based on a two-compartment model that simply divides the body in to fat and fat-free mass. Although underwater weighing has long been considered the laboratory “gold standard,” it is highly impractical for use among the general public. Many people find it difficult, cumbersome and uncomfortable, and others are afraid of total submersion or cannot expel all the air in their lungs. DEXA is a relatively new technology using a whole body scanner that has two low dose X-rays. It is safe and noninvasive with little burden to the individual, although a person must lie still throughout the procedure which takes 10 to 20 minutes. DEXA is highly accurate, but the equipment is costly and not widely available.

The most common method of measuring body fatness is using anthropometry. Hand-held skin calipers are used to measure skinfold thickness at various body locations (3 to 7 test sites are common). Then a calculation is used to derive a body fat percentage based on the sum of the numbers. Skinfold measurements are made by grasping the skin and underlying tissue, shaking it to exclude any muscle and pinching it between the jaws of the caliper. The caliper method is based upon the assumption that the thickness of the subcutaneous fat (fat located just under the skin) reflects the total body fat, and that the sites selected for measurement represent the average thickness of the subcutaneous fat. As this is not the case for everyone, the accuracy is not as high as hydrodensitometry and DEXA.

However, skinfold measurements are easy to do, inexpensive and convenient.

Once you have a good estimate of your percentage body fat, check your numbers against the table below.

What is Your Body Shape?

Once you have figured out your BMI, and have a general idea of your level of body fatness, there is one more important factor to consider. What is your body shape? The most common descriptors of body shape are the apple and the pear. If you carry the bulk of your weight above your hips (mainly in your abdomen), you have an apple shape. People who are apple shaped sometimes have a larger waist than hips. If you are an apple shape, when you gain weight, it tends to go directly to your stomach. This body shape is more common in men.

If you carry the bulk of your weight in your extremities (your hips, thighs and buttocks), you are said to have a pear shape. People who are pear shaped generally have larger hips than waist. This body shape is more common in women.

You can easily determine whether you have an apple or pear shape by calculating your waist to hip ratio. Simply take a measurement of your waist and hips, and divide the waist measurement by the hip measurement. A ratio of 0.80 or less for women, and 0.90 or less for men is considered a pear shape. Whether you are an apple or a pear doesn’t really matter, unless you are carrying excess weight. If you are overweight or obese, having an apple shape puts you at much higher risk for heart disease, type 2 diabetes, hypertension and several types of cancer. For those who naturally become apple shaped with weight gain, it is critically important that a healthy body weight be maintained.

There is another common way to determine whether or not you are carrying excess baggage. Simply do a waist measurement. A measurement of over 32 inches for a woman and 37 inches for a man suggests that you should try to avoid gaining any more weight. A measurement of 35 inches for women and 40 inches for men indicates that health improvements could be expected with weight loss. In other words, it indicates overweight.

The Final Word

If after going through all of this, you have determined that you are underweight or overweight, do a personal inventory of your food and beverage intake and physical activity. Be brutally honest with yourself. If you are underweight, a visit to your health care provider can rule out any underlying causes of underweight, such as thyroid or adrenal abnormalities, is warranted. When an underlying disorder has been ruled out, think about how you can increase your energy intake, and in some cases, decrease your energy output. You may need to eat larger portions, increase fat intake (preferably with such high fat whole plant foods as avocados, olives, nuts and seeds) and/or eat more often.

If you are overweight or more importantly “overfat,” then you need to consider how to decrease energy intake and increase energy output. This means eating fewer calories and exercising more. Eating fewer calories does not necessarily mean eating less food. Focus your diet on whole plant foods – vegetables, fruits, legumes and grains, with smaller portions of such high fat plant foods as avocados, nuts and seeds. Limit refined carbohydrate foods made with flour and sugar. Avoid deep-fried foods and salty snack foods. Increase physical activity to 60 minutes a day. Aim for a balance of cardiovascular, strength and flexibility exercises. Finally, get support if you need it. There are plenty of people who can help you – support groups, dietitians, nutritionists, personal trainers, and a host of health care providers. By getting your body weight under control, you will be doing a lot to improve your long-term health, and the vegetarian cause. Whenever vegetarians set an example of great health, they inspire those around them to do the same.

Body Mass Index (BMI)

Understanding Your BMI

BMI < 18.5: May indicate underweight
BMI 18.5-24.9: Healthy weight for most people.
BMI 25-29.9: Indicates overweight
BMI > 30: Indicates class 1 obesity
BMI > 35: Indicates class 2 or severe obesity
BMI > 40: Indicates extreme or morbid obesity

Percent Body Fat

The post Is Yours a Healthy Body Weight? appeared first on North American Vegetarian Society.

Role of the Intestine (“Gut”)

The gut is the main interface between “us” and the outside world. The intestinal lining (or gut wall) is a semi-permeable membrane, like a sieve, that allows small molecules (the products of digestion) to pass through, and blocks the larger molecules. These larger molecules then travel through our intestine and are eliminated. When functioning as intended, the gut wall prevents these molecules from stimulating food sensitivity reactions. Unfortunately, certain factors in our lifestyles can create and sustain unwanted holes in this barrier. Maintaining the health of the gut wall may play a role in minimizing food sensitivities and preventing the development of further reactions to foods.

A healthy and unbroken gut wall is essential to our well-being; it affords protection against numerous diseases and food sensitivities. The state of health of the gut wall is variable; it can be healthy most of the time but suffer during illness, for example. It is clear that many of the lifestyle choices we make can have an impact on this membrane and the many microorganisms that dwell there.

The complex assortment of immune system cells interspersed along the gut wall provides a slew of surveillance and protection activities, monitoring every molecule that encounters it. A major role of these cells is distinguishing between friend and foe; they can either welcome a food particle or organism (bacteria) with open arms, or initiate an immune system (allergic) response to it. Our ability to keep out unwanted bacteria, destroy any that might get through the intestinal barrier, and decide which substances (such as food proteins) to tolerate depends upon the intestine’s state of health.

Friendly Flora

The gut is home to more than 400 species of one-celled organisms. Some of these are “friendly” types of bacteria, whereas others have the capacity to produce toxic substances, invade the intestinal wall, encourage allergic responses or promote disease. Our relationship with the friendly bacteria is one of symbiosis, or mutual benefit. The bacteria benefit because they have access to food and water that pass down the intestine. We benefit because these bacteria perform a myriad of functions for us: they destroy toxic substances, aid us in digestion, produce certain vitamins and help protect us from unfriendly organisms.

Normally, the amount of “unfriendly” organisms are kept in check by the “friendly” bacteria. However, if anything decreases the friendly flora, a higher percentage of unfriendly organisms – such as clostridium, hafnia, citrobacter and candida – seize the opportunity, move into the area that was vacated and multiply. The result is an abnormal overgrowth of harmful bacteria. As these aggressive organisms take over, they produce damaging substances that set off a chronic, low-grade, inflammatory reaction, injure the intestinal membrane and make it more permeable or “leaky.”

Our Intestinal Wall, “Leaky Gut” and Food Sensitivity

A healthy gut wall is an effective barrier against unwanted substances. When the wall is compromised, it starts to allow these substances to “leak” into the body. “Leaky gut” syndrome applies to an intestinal wall with increased permeability, allowing some harmful contents (that would normally be excluded) to pass through. Naturally, this can place a greater burden on our body’s detoxification and immune systems.

Certain conditions and substances can injure the intestinal wall or change its environment in a way that allows large molecules to leak through, possibly leading to food sensitivities. These include:

• inflammation (e.g., colitis, Crohn’s disease);
• injury to the intestinal wall from drugs, chemicals or radiation (e.g., chemotherapy, anti-inflammatory medications);
• injury to the friendly bacteria living in the intestine (e.g., by antibiotics; use of colloidal silver; high intakes of sugar and/or alcohol; antacids);
• stress;
• immaturity of the intestinal lining (in infants and young children).

Antibiotics deserve a special mention in regard to leaky gut. While antibiotics kill off the bacteria causing the infection, they also destroy the beneficial bacteria, setting off a chain reaction that permits more harmful bacteria to enter the gut lining and allow foreign proteins to leak into the bloodstream. Adverse reactions may ensue, such as allergic reactions in the skin. Of course, there are occasions where it may be absolutely necessary to take antibiotics. If you have to take them, take as directed, and take good care of yourself through proper diet and supplements.

Healing the Intestinal Wall

Here is the good news: our intestinal membrane has an immense capacity to regenerate and heal itself. If we wish to restore a “leaky gut” to health, it makes sense to avoid the substances that may destroy beneficial bacteria (listed above), to provide a nutritious diet and to take supplements that promote a healthy balance of bacteria.

Promoting Intestinal Health Via a Healthful Vegan Diet

Complex carbohydrates, minerals, vitamins, protein, essential fats and phytochemicals are needed to build, maintain and repair the many cells that line our intestinal wall. A balanced diet of whole plant foods will provide the many nutrients that we require. Of course, when food sensitivities arise, this may seem like an immense challenge because some of the foods that have been part of our diet are now prohibited. However, the range of foods available to us is massive. Additionally, a multivitamin-mineral supplement can help to “top up” your nutrient intake; this can be particularly important when your system has been depleted. As always, vegans need to find a reliable source of vitamin B12.

As a vegan, you already know that nutrient-dense whole foods (vegetables, fruits, whole grains and legumes) support health and reduce disease risk. As a person with food sensitivities, you may feel at a loss as to how to compensate for foods you need to eliminate. Read on for some tips to help you.

Vegetables: Fortunately, most vegetables are low on the food sensitivity scale. The most common type of vegetable-related food sensitivity – oral allergy syndrome – occurs most often in people allergic to pollen. If you have a reaction to a vegetable, avoid it, or eat it only in its cooked form, if tolerated. Since there are hundreds of vegetables available, eliminating one or several rarely poses a problem; simply keep up your variety by getting in several different types a day that you can tolerate. Be sure to eat plenty of leafy green vegetables.

Fruits: Like vegetables, raw fruits may cause oral allergy syndrome. If you suffer from this, avoid the offending fruits and focus on the bounty of fruits you can tolerate. Don’t forget the more unusual types, and experiment with frozen (no sugar added) fruits if finding good fresh fruit is a problem. Some fruits, like strawberries and citrus fruits, are rather high on the food sensitivity scale. If you are allergic to a fruit, read labels carefully and be aware of possible cross-contamination at restaurants and markets.

Grains: By far the most common offending grain component is gluten, found in wheat, barley and a few other grains. About one person in every 133 is sensitive to gluten. A smaller percentage of people has a true wheat allergy (but can tolerate gluten found in other grains). Either way, the approach is similar: avoid the wheat or gluten and seek healthful, tasty grain substitutes. Fortunately, foods like bread, pasta and baked goods are now available wheat- and gluten-free, and many of them are vegan as well. Recipes for vegan, gluten-free baked goods can be found on the Web and in many books.

However, these specialty items should not comprise the bulk of your grain intake. Incorporating more intact whole grains, such as millet, amaranth, brown rice and quinoa, is important in any healthful vegan diet. These grains are unrefined and provide vitamins, trace minerals and phytonutrients that are often missing in flour-based pastas and baked goods. If you can’t have wheat, try eating more of these intact grains and you may find that you don’t even miss wheat bread and pasta. Intact grains are superb in pilafs (mix cooked grains with lentils or beans, diced sauteed vegetables, herbs and seeds); hot cereals (add nondairy milk, fresh and dried fruits and nuts); burgers (cook grains with extra water, add shredded vegetables and form into patties); and salads (toss with fresh greens and a zesty vinaigrette). Sprouting whole grains is yet another healthful way to enjoy them. If you are extremely sensitive to wheat or gluten, avoid bulk bins at the grocery store and order your grains from trusted companies that work to avoid cross-contamination.

Legumes: Legumes (nuts, seeds, beans, lentils, peas and soy products) are extremely health-supporting. Because the body reacts mainly to proteins in foods and legumes that are high in protein, it is the food group with the most associated food sensitivities. This is a shame because legumes are important in the vegan diet; they are a concentrated source of protein and fiber, and, depending on the type, many vitamins, minerals, antioxidants and essential fats.

The good news is that with a little creativity, those with a legume sensitivity can still enjoy foods in the legume family. If you are anaphylactic to one or more nuts, it makes sense to avoid all nuts unless you are absolutely certain that alternate nuts are safe and have not come into contact with other nuts. However, it is extremely rare to have allergies to all nuts, all seeds or all beans. Most people with nut allergies can still enjoy seeds, for example. Seeds provide similar nutrients and are excellent substitutes. It is best to consume a wide variety of seeds, including pumpkin, sunflower, flax, hemp and sesame (sesame is the most allergenic of the seeds). Seed butters are excellent nut butter substitutes and some are produced in allergen-free facilities (read labels).

Some allergists recommend the complete removal of all legumes from the diet, including beans, for those allergic to peanuts, for example. (Some maintain this recommendation even if it is known that beans and lentils have been tolerated well in the past.) Such advice can do more harm than good, because needlessly avoiding hundreds of healthful foods may compromise our health, making us even more prone to food sensitivities. If you have been told to avoid all legumes, find a health care provider who is understanding of your needs and will work with you to determine a nutritional plan that is the most beneficial to your health, while minimizing the risk of a reaction.

Soy sensitivity can be particularly challenging for vegans. It seems that just about every vegan specialty item is soy-based. Soy can also be hidden in food ingredients like gums and starches, thickeners and flavor enhancers, so those extremely sensitive have to be especially careful. Nutritionally speaking, there’s nothing in soy that you can’t get easily from other sources. A wide variety of tolerated beans, nuts, seeds and grains, as well as soy-free items like rice milk, almond milk (look for fortified types) are acceptable substitutes.

Supplements That May Help

Glutamine has been promoted as a supplement to help build, maintain and transport substances across our intestinal wall. A typical dosage is 250 to 500 mg taken three times a day. Glutamine is the most abundant amino acid in the bloodstream; our bodies can manufacture it and it is present in plenty of plant foods. Eating a whole-foods vegan diet, you’ll receive glutamine, plus plenty of other amino acids, minerals and vitamins, too. No conclusive studies have been done assessing the effectiveness of glutamine, but given the available anecdotal evidence and its relative safety, there may be some benefit in taking glutamine in its concentrated form.

The wisdom behind, “An apple a day keeps the doctor away” may be related to quercetin, a protective bioflavonoid that is present in the skin of apples. In theory, we may be able to make our gut less leaky and tighten up the tight junctions between cells by using 250 to 500 mg of quercetin two or three times per day. Formulations that contain mixed bioflavonoids including quercetin may be used as well. We also get quercetin from oranges, grapes, green beans and from other fruits and vegetables, but not as much as a concentrated supplement.

The mineral zinc is known to be important for the immune system to function effectively and to maintain the epithelium that lines the intestine. It makes sense to support our immune system by meeting recommended zinc intakes (the best vegan sources are beans, nuts, seeds and whole grains). Taking zinc supplements alone can throw off the balance of copper and other minerals, and excess zinc may even disturb immune system function. If you want to take zinc supplements, aim for one with about 15 mg of zinc, in a pill containing 1 to 2 mg copper as well. This can be part of a multivitamin-mineral supplement.

Omega-3 fatty acids reduce inflammation and may have direct influence on the gut wall. Get your omega-3s from flax seeds and oil, hemp seeds and oil, canola and soybean oils and walnuts. You can also take DHA supplements (several vegan varieties are available), 300 to 500 mg per day.

Probiotics are live microorganisms in cultured/fermented foods or supplements that promote good health by improving the balance of intestinal bacteria. Since the bacterial population in our gut can change depending on our food and lifestyle choices, we can help tip the balance in our favor by introducing “friendly” bacteria, or probiotics, via treated foods, pills, powders or liquids. Fermented and cultured foods have been used safely in human diets for many centuries and during the last decade, the health potential of probiotics has caught the attention of scientists worldwide.

Examples of foods that may be cultured or fermented include vegetables, grains, beans, fruits and tea. Cultured soy (soy yogurt) and miso are the most widely used among vegans in North America (unrefrigerated miso does not contain live bacteria). Companies are now formulating probiotic-containing foods, such as energy bars, cereals, juices and snacks. Currently there are no formal quality control measures for probiotics in foods, so it is important to buy from reputable manufacturers. (Note: People who are particularly sensitive to histamine and tyramine should avoid fermented and cultured foods that are high in these compounds, including cultured soy products and miso.)

The most frequently used bacteria in probiotics are those in the lactobacillus and bifidobacterium species (such as L. acidophilus, L. bulgaricus, L. casei, L. salivarius; and B. bifidum and B. lactis). Mixtures of these, in pill and powder form, are available at natural foods stores and at many pharmacies.

Though research is at an early stage, we are likely to see the development of standards for optimal doses and the content of live bacteria at the end of the shelf life of products. With the flurry of research on these topics, we are gaining more insight into specific actions of specific probiotics.

Probiotics Pointers

1. Take probiotics 15 to 30 minutes before a meal, so that digestive juices don’t interfere with their effectiveness.
2. Make sure that your probiotics are alive. The shelf life of probiotics supplements is generally a year; however, the number of active cells is likely to drop over time. To test the viability of your probiotics, try this experiment (this only works for mixtures containing L. acidophilus): Split about a half cup of soy milk between two small bowls. Into one bowl, place a heaping teaspoon of the probiotics and stir well. Leave both bowls on the counter overnight. The next day, lift and swirl the bowls. If the probiotics are live and active, the milk containing live bacteria should have curdled and bubbled. If the contents of both bowls look the same leave the bowls out for another 24 hours. If still no change, then your acidophilus is not live and should be returned to the store for a live batch.
3. Take your live probiotics daily for three to six weeks. Daily use for this period is likely to restore your bacterial balance.
4. Follow up with occasional or regular probiotics use. It is possible that some probiotics may stay in the intestine and establish a colony. However, the research shows they tend to pass through and need to be replenished on a regular basis.

Feeding Our Friendly Bacteria: Prebiotics

Prebiotics are food substances that pass undigested into the lower intestine and support our health by feeding and thereby encouraging a favorable balance of beneficial bacteria.

Think of prebiotics as food for probiotics. Prebiotics are specific types of soluble fiber and exist naturally in vegetables (asparagus, broccoli, garlic, Jerusalem artichokes, leeks, okra, onions, summer squash), fruits (bananas, apples, citrus fruits and many others), legumes (beans, peas, lentils), and grains (corn, barley, oats, wheat). Prebiotics can be purchased as supplements. The two most common types are fructooligosaccharides (FOS) and inulin. The recommended dose of prebiotic supplements is 5 grams per day.

Can We Really Overcome Food Allergies or Intolerance?

Maybe. It depends upon the sensitivity, genetics and our health. If our intestinal membrane is in poor health, we may be able to nourish it back to health. With time, it may recover its ability to block the passage of proteins and other large molecules. A favorable balance of intestinal flora may be restored and our tendency to develop new food sensitivities may diminish.

A healthful vegan diet, providing all essential nutrients, will support the health of the gut (and the rest of the body). Furthermore, avoiding food and lifestyle components that compromise gut health (refined sugars, alcohol, stress, drugs, smoking) is important. Finally, supplements and other therapies show promise in gut healing. A main goal, of course, is to overcome your food sensitivities. But if you find that you are still responding to trigger foods, your efforts are not for naught! Keep focusing on good health, and over time, you might notice an enormous improvement.

How can you find out if you have a leaky gut and/or bacterial imbalance?
Several laboratories test for intestinal permeability and/or intestinal dysbiosis (imbalance). Contact Great Smokies Diagnostic Laboratory, 1-800-522-4762,www.gsdl.com, and Metammeetrix Clinical Laboratory, 800-221-4640,www.metametrix.com.

The post Food Sensitivities: What’s a Vegan Supposed to Do? appeared first on North American Vegetarian Society.

What kind of meat? Spam, canned corned beef, chicken, fish, crab, octopus, turkey tails, turkey necks, turkey hearts, pig’s feet, pig’s intestines, beef tongue or whatever meat is accessible. Imagine the beverages of choice being soda, fruit-flavored sugar-laden drinks and coffee with powdered creamer and sugar. Does this all sound a little far-fetched? One could only hope. Unfortunately, these foods are standard fare for people in Majuro, Marshall Islands. Diets of many other South Pacific islanders are strikingly similar. It would be difficult to design a diet that could more efficiently induce diabetes and other chronic diseases in any population. Not surprisingly, the rates of diabetes among the people of these islands are among the highest in the world.

In the Marshall Islands, an estimated 28 percent of individuals over 15 years of age have type 2 diabetes. For those over 35 years, the figures are closer to 50 percent. Not surprisingly, nearly 75 percent of women and over 50 percent of men are overweight and obese. About half the surgeries preformed on the island are amputations due to complications of diabetes. There are no facilities for renal dialysis.

Fifty years ago, diabetes was virtually unheard of in the Marshall Islands. People were slim and active and lived off the land. The diet consisted of such edible plants as coconut, breadfruit (a starchy fruit that grows on trees and is nutritionally similar to potatoes), taro, pandanas (a huge, extremely fibrous fruit with carotenoid-rich, juicy orange pulp) and leafy greens, in addition to fish and other seafood.

Today, with considerable overpopulation in Majuro, approximately 80 to 90 percent of all food calories are supplied by imported foods. The most costly imported foods are fresh fruits and vegetables and other perishables. By ship, they arrive every 28 days, and by air, every two weeks. In most of the outer islands, indigenous foods supply 50 to 75 percent of food calories. While health authorities promote local foods in urban centers, there are simply not enough local plants to supply food for the entire population on small, over-populated islands. Most people are poor and live in crowded households with very limited food budgets. Many Marshallese believe that getting enough to eat is the only real issue where food is concerned. They often do not buy into the idea that certain foods are more healthful than others. Local food is generally more expensive per calorie than imported food and less abundant, being dependent on the season and weather conditions.

What would it take to halt the diabetes epidemic in the Marshall Islands? There is little doubt that it would require a deep understanding of the culture, a respect and love for the people, significant insight into type 2 diabetes and a great deal of perseverance and determination. Enter Canvasback Missions and their founders, Jamie and Jacque Spence. Canvasback Missions is a unique non-profit organization that has been providing free medical, dental and eye care to the people of the Marshall Islands for more than 25 years. Jamie and Jacque Spence witnessed the unfolding of the diabetes epidemic. They were desperate to find a way to stop the devastation. After several years of efforts, they were awarded a research grant, and the Diabetes Wellness Project came to life. The goal of the program was simple – to reverse the diabetes epidemic through aggressive diet and lifestyle intervention. Canvasback enlisted key partners, such as the Marshall Islands Ministry of Health and Loma Linda University. A team of experts was assembled including Dr. John Kelly (president of the American College of Lifestyle Medicine) as co-principal investigator, Dr. Ralph Harris as medical director, and myself, Brenda Davis, as lead nutritionist and health educator. Dr. Harris and I were asked for a commitment of three weeks training in Guam and six months research in Majuro. In my case, the time stretched to eight months on the island, with ongoing trips back and forth of three to six weeks duration each time. My husband, Paul and son, Cory, joined me for the first five months.

The initial plan was to recruit participants for the study, half of whom would be assigned to an intervention group and half to a control group. The research would include several groups (each with 30 to 60 people), with an aim of doing at least three interventions per year. The intervention participants would receive diet and lifestyle instruction over a six-month period, while the control group would receive the usual care. The intervention was to begin with a two-week intensive phase, in which participants would be provided with three meals a day, exercise sessions, health education, cooking classes and frequent blood sugar monitoring (four to five days a week). This would be followed by a month of twice weekly four-hour sessions, six weeks of once weekly four-hour sessions and three months of bi-monthly four-hour sessions. The four-hour schedule is shown in Table 1. All control group participants were guaranteed a place in the intervention group once their six-month control period was complete.

The Diabetes Wellness Project team, including Dr. Ralph Harris, Robert Chung, our program director, Norman Cruthers, our carpenter, Matt Choi, general assistant, myself and my family arrived in Majuro March 9, 2006. The first month or more was spent converting an extremely unsanitary TB clinic into a fully functioning diabetes wellness center complete with teaching kitchen, aerobics rooms, strength and cardio room, lecture room, laboratory, staff offices and washrooms.

The next step was to put of all the elements required for rigorous scientific research in place. This is a complicated task in a developing country with limited technology and a significant language barrier. English is a second language, spoken with various degrees of fluency by more educated Marshallese (the first language being Marshallese). Local personnel were recruited, interviewed, employed, motivated and mentored to become support staff. Computer systems were set up, and a massive screening of patients was initiated. Protocols were established for lab work. Research forms, handouts, recipes and lectures were developed. Relationships were established with Marshallese and American dignitaries, Ministry of Health personnel, community group leaders and store managers. Contact with our U.S. team members was limited by a very costly phone service and slow, unreliable Internet service.

The first intervention began in June 2006. Since that time, two additional interventions have taken place – one in September 2006 and the other in March 2007. The results of the intervention have been at times amazing and at times disappointing, but always informative.

As you may recall, during the first two intensive weeks of each program, participants are fed three meals a day. They are at the Wellness Center for either breakfast or lunch, and dinner. The alternate meal is sent with the participants in a cloth bag. Our main dietary goals are weight loss, blood sugar control and normalizing blood cholesterol, triglycerides, blood pressure and inflammatory measures. The ultimate objective is to reverse diabetes by overcoming insulin resistance and restoring insulin sensitivity. The most effective way of accomplishing this task is with a carefully designed vegan diet and exercise. The dietary parameters for the intensive phase are as follows:

• 100 percent vegan – no animal products
• Minimal refined carbohydrates – both sugars and starches
• Minimal ground grains (intact grains emphasized)
• Very high fiber (40 to 50+ grams per day)
• High viscous fiber (flax, oats, barley, beans, guar gum, psyllium)
• Moderate fat from healthful sources (20 to 25 percent fat)
• Low saturated fat (less than 7 percent of calories)
• Zero trans fatty acids
• Sufficient omega-3 fatty acids
• High phytochemicals and antioxidants
• Low dietary oxidants
• Low glycemic load
• Moderate sodium (less than 2,400 mg/day)

Following the two-week intensive phase, all dietary parameters remain the same, with one exception. Participants are permitted limited consumption of clean, boiled, steamed or grilled fish, if desired. Many participants choose to avoid fish for the entire duration of the study.

What do clinic meals consist of? Breakfast always includes beans and greens – a one-pot bean dish with whatever greens were available. We also served an intact whole grain cereal (often a barley/kamut blend) with nuts, seeds, ground flaxseed and soymilk, and a fruit salad laced with psyllium and guar gum (soluble fiber). Breads, muffins and other ground grain products are minimized. Lunch is generally “take-out” with a light green salad or raw vegetables, a heavy bean-based salad (sometimes including yams, corn or intact whole grains) and a piece of fruit (usually an apple or orange). Dinner includes a large green salad or a light soup and a bean or tofu and vegetable-based entree. Concentrated carbohydrates, such as potatoes and rice, are usually avoided at the evening meal.

In addition to a finely tuned vegan or near-vegan diet, participants receive daily education about nutrition and health. PowerPoint presentations, practical workshops and shopping tours are all a regular part of the basic program. To help increase the access to affordable produce, participants are taught how to grow their own gardens in earth-boxes. Soil and gardening experts are brought in to conduct lectures and workshops.

Exercise is also an integral part of the program. During the intensive phase, participants take part in a one-hour daily exercise class, in addition to at least two walks – before breakfast and after dinner. Following the intensive phase, participants are encouraged to continue coming to the clinic for daily exercise and/or to increase walking times. The fitness programs include a balance of cardiovascular, strength and flexibility exercises.

Now, for the million dollar question – did it work? During the first two weeks of the program (when three meals a day were provided by the Wellness Center), the success was remarkable. Consistently, participants reported dramatic reductions or complete disappearance of pain in the legs, arms and joints. They no longer required massages at night to reduce leg pain so they could sleep. Walking became much easier. Many reported significant reductions in nightly trips to the bathroom. Most noticed tremendous changes in their bowel habits, with greater frequency and bulk of stools. One person reported severe constipation with bowel movements once every 10 to 14 days. Within a week of beginning the program, he was having normal daily bowel movements. Almost everyone reported increased energy. Weight loss averaged about five pounds per person.

Blood tests indicated impressive changes as well. Fasting blood sugars declined 50 to 75 mg/dL, cholesterol went down about 20 mg/dL and triglycerides dropped close to 40 mg/dL. It is important to note that these changes were seen even with a dramatic reduction in medication use. Close to 90 percent of the participants stopped taking oral hypoglycemic agents, cholesterol, blood pressure and other medications.

At 12 weeks, average weight loss was approximately 10 pounds per person. Blood sugars were still down about 30 points from the beginning of the intervention, and HbA1C was down an average of two points. HbA1C is a blood test that measures control of blood sugar over a three-month period. Optimal HbA1C is under 5 percent. HbA1C of 7 percent or more indicates poor blood sugar control and increased risk of complications due to diabetes. A two-point drop in HbA1C is extraordinary. Every 1 percent the HbA1C drops, the risk of health complications drops by 30 to 40 percent.

Changes seen after 12 weeks were more variable, with compliant participants making remarkable recoveries, while others slowly regressed. Those who experienced regression were participants who stopped coming to sessions. Unfortunately, most of these individuals did not resume taking medications. While these individuals generally improved their overall diet and lifestyle, without their meds, some ended up with lab values similar to baseline. Of course, this is still an improvement if lab values are the same without meds as they are with meds, but the advantages are difficult to quantify. In these cases, it would be preferable to have patients resume medications and enjoy significant improvements in lab values.
On the other hand, the stories of committed participants are truly inspiring. One of our most skeptical subjects, a health care worker, brought her fasting sugar from 187 to 108 and her HbA1C from 8.7 to 5.7. Some of our newly diagnosed diabetics brought their blood sugars below the cut off of 126 mg/dL and their HbA1Cs below the goal of under 6 percent. Several other participants saw drops in HbA1Cs of three points or more – from 9 or 10 percent to 6 or 7 percent. Although we had only a few participants on insulin, all of them had to discontinue its use. For many of our participants, these changes were nothing short of miraculous. In the Marshall Islands the view of diabetes has always been of a devastating disease with a very slippery slope. It is impossible to escape the experience of seeing family members, friends and neighbors lose their vision, their limbs and their lives. To witness recovery or healing from this dreaded disease was unheard of.

While participants face barriers to success, program staff works countless hours to help each individual overcome these barriers. Medical follow-up is expanding; social barriers are being investigated and more fully addressed; store managers are bringing a greater volume and selection of healthful foods; restaurant owners are adding “Diabetes Wellness Program Approved” options to their menus; exercise opportunities are expanding; lectures and handouts are being translated, and Marshallese staff are being trained.

Diabetes Wellness Program participants have overcome seemingly insurmountable mountains of Spam, donuts, ramen noodles and cola. They have managed to put together low-cost, healthful meals despite the high cost and poor quality of their produce. They have managed to do it with little education and marginal English skills. They have managed to do it with few gyms, no hiking trails and limited access to fitness facilities. These pioneers are providing a powerful example of health and healing for other Marshall Islanders. They are providing hope amid a deep sense of hopelessness.

Many people have asked me if this program could work here in America. My answer is simple: If there is hope in the Marshall Islands with the enormous barriers the people face, there is hope at home. We have no excuses.

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