February 2018 Issue

Paleo: Spotlight on the Paleo Diet
By Toby Amidor, MS, RD, CDN
Today's Dietitian
Vol. 20, No. 2, P. 14

The Paleo diet, also referred to as the "caveman" or "Stone Age" diet, stems from the eating patterns of our ancestors who lived during the Paleolithic era, a time period associated with the development of mankind's tool-making skills, ending around 12,000 years ago. During that time, the women gathered fruit, berries, and vegetables, while the men hunted for meat. In today's modern era, the diet involves mimicking the same eating habits and consuming fruits, vegetables, nuts, seeds, healthful oils (eg, walnut, olive, coconut, and avocado), meat, fish, shellfish, poultry, and eggs in hopes of leading to a more healthful and disease-free life. The diet also encourages consumption of cage-free eggs and grass-fed meats (lean meat is recommended). It prohibits eating grains, dairy, legumes, potatoes, refined sugar, and refined vegetable oils, because proponents claim these foods appeared only after the agricultural revolution and are associated with inflammation and therefore many chronic conditions including heart disease, cancer, and diabetes. Not only is the diet touted as a more healthful eating pattern but it's also promoted as beneficial for weight loss.

Statistics and Rankings
If you Google the term "Paleo diet," you'll get more than 22 million hits in a split second, showing an array of Paleo blogs, recipes, articles, and books on the diet. A 2013 survey of more than 500 RDs, conducted by Today's Dietitian and Pollock Communications, a public relations firm in New York City, showed that dietitians predicted the Paleo diet as the top diet trend for the upcoming year.1 At the start of 2017, the Paleo diet was still maintaining its popularity among dieters. An independent survey conducted by Google and Green Chef, an organic meal kit delivery service, found that based on anecdotal behavior of 1,045 customers, the Paleo diet appealed to 20% of participants.2 Furthermore, 25% of survey participants aged 18 to 34 said they were more likely to try the diet compared with 11% of respondents aged 55 and older.

Moreover, CrossFitters nationwide also follow the diet. Regardless of its popularity, however, the US News & World Report annual Best Overall Diets ranked Paleo as number 32 of 40 and gave it a score of 2.3 out of 5.3

To determine the diet rankings, US News & World Report selected a 25-person expert panel from the country's top dietitians, dietary consultants, and physicians specializing in diabetes, heart health, and weight loss. The panel included Lisa Sasson, MS, RDN, CDN, a clinical assistant professor and dietetic internship director in the department of nutrition and food studies at New York University; Jill Weisenberger, MS, RDN, CDE, CHWC, FAND, a nutrition and diabetes expert; and David L. Katz, MD, MPH, FACPM, FACP, FACLM, founding director of Yale University's Yale-Griffin Prevention Research Center, and founder of the True Health Initiative.4

Nutritional and Environmental Inadequacies
In light of Paleo's low ranking in US News & World Report, it stands to reason why most RDs don't advocate the diet—and for a variety of reasons. "The Paleo diet has a lot of good things going for it. It recommends excluding processed foods and refined sugars and emphasizes fruits, vegetables, nuts, seeds, and lean protein," says Heather Mangieri, MS, RDN, CSSD, LDN, a spokesperson for the Academy of Nutrition and Dietetics and author of Fueling Young Athletes. However, Mangieri says, "Any diet that suggests eliminating an entire food group can set you up for nutritional deficiencies, boredom, and an overfocus on food." Because the diet eliminates all dairy, meeting calcium and vitamin D requirements can be difficult. Mangieri has experienced this issue firsthand in her private practice. "Even though Paleo proponents claim they can meet their calcium needs from nondairy foods, I have yet to find a client that eats that many greens and is that thought out in their eating. Supplementation becomes a must to meet the needs for these nutrients."

Grains and legumes (or pulses) are other groups that are frowned upon in the diet. "The right grains in the right amount can actually curtail inflammation," says Bonnie Taub-Dix, MA, RD, CDN, creator of the blog Better Than Dieting and author of Read It Before You Eat It: Taking You From Label To Table. In addition, fiber-rich legumes, including beans, lentils, and peas, have been consistently linked with reduced risk of obesity and chronic disease. "Fiber-rich carbs can supply energy, fiber, a host of vitamins and minerals, and a soothing satisfaction that could keep us from eating less nutritionally dense choices," Taub-Dix says. With the rise in popularity of ancient grains such as amaranth, millet, oats, and teff, and pulses, such as chickpeas and lentils, there's much opportunity to access versatile, naturally delicious whole grains and legumes that our ancestors ate. "Carbohydrates have a bad reputation, justified by the company they often keep, such as rich sauces and butter, and the forms in which they may be served (eg, donuts and pastries)," Taub-Dix says, "but the right carbs can save us from degenerative diseases."

The 2015–2020 Dietary Guidelines for Americans continue to recognize the nutritional benefits of whole grains and recommend individuals make sure one-half of the grains they consume daily are whole grains. A 2016 meta-analysis of 45 cohort studies, published in The BMJ, looked at the relationship between whole grain consumption and the risk of various diseases including CVD and cancer.5 Researchers concluded that intake of whole grains is associated with a reduced risk of coronary heart disease, CVD, cancers, respiratory and infectious diseases, and diabetes. Furthermore, a 2017 study published in The American Journal of Clinical Nutrition found that when subjects consumed whole grains vs refined grains, inflammation was reduced.6

Despite the fact the Paleo diet eliminates food groups vital to health, Katz believes the eating pattern has some merit. "Every species on the planet does well on the diet which it natively adapted. And the idea that things would be different for our species is absurd. There is some modern science to show its benefits, but with limitations. Those limitations include what it is compared to (everything is better than the typical American diet), and how genuinely 'Paleo' it really is," adding that there's a big difference between what meat enthusiasts casually call "Paleo" and legitimate Stone Age Homo sapiens eating patterns, which by today's standards would make a huge negative impact on the environment. "To procure the wild plants and animals required for sustenance depends on a lot of space per person," Katz says. "I have done the math, and for the current human population to eat that way would require about 15 times the surface area of the planet. Eight billion Homo sapiens cannot be foragers, or substantially carnivorous, without decimating the planet."

Gabbi Berkow, MA, RD, CDN, CPT, is a Paleo advocate. She maintains the whole, unprocessed foods the diet recommends are low in calories, are high in nutrients, provide the fuel the body needs, and are the kinds of foods humans have evolved to easily digest. However, she doesn't agree with the blanket recommendations that everyone needs to eliminate dairy, grains (in particular, those containing gluten), and legumes, unless they have a medical condition that warrants it (eg, celiac disease or dairy allergy). In addition, Berkow says, "Dairy in particular is a good source of protein, calcium, and vitamin D, so cutting out dairy can make it harder to get enough of these nutrients."

Recommendations for RDs
When a client following the Paleo diet comes in for a visit to discuss weight loss or other health issues, it's important for dietitians to use the opportunity to build rapport and trust even if they're not 100% on board. "Paleo practitioners are dedicated and committed to their beliefs," Taub-Dix says, "so taking an approach that just presents the negatives could turn them off from listening to your words of wisdom. Try to present the rationale behind how the diet could be followed but perhaps enhanced."

The following are recommendations RDs can follow when counseling clients who are proponents of the Paleo diet:

• Show recognition. Acknowledge and praise the client's decision to consult a dietitian.

• Evaluate safety. Review the client's medical history, eating patterns, and other important data and determine whether there are any safety issues to discuss (eg, food-medication interactions or nutritional inadequacies that can be dangerous). If warranted, caution the client of any imminent dangers to his or her health.

• Determine adequacy. Examine the diet recommendations, paying attention to foods and food groups eliminated. Ensure clients have the necessary tools to maintain proper macronutrient and micronutrient intakes. This means focusing on appropriate portion sizes and preparation techniques for fish, poultry, beef, venison, eggs, and other animal proteins, along with fruit and vegetable consumption with each meal. If clients insist on avoiding dairy and grains, find alternative ways they can meet daily requirements for nutrients such as fiber, calcium, and vitamin D. Supplementation for some nutrients may be necessary.

• Focus on the positive. Mangieri recommends focusing on what needs to be included rather than excluded. Paleo living means transitioning to a diet high in fruits and vegetables; that higher volume of fruits and vegetables is necessary to meet your nutritional needs.

• Maintain a team effort. Assist clients in making the healthful, positive aspects of their chosen diet part of a sustained lifestyle change. Teach clients to modify recipes or food choices appropriately to achieve their desired goals. This may include supporting the addition of small amounts of whole grains, legumes, and dairy to maintain nutritional adequacy.

• Make it sustainable. Work with clients so they can maintain a healthful lifestyle long term. Discuss small changes to the diet that can help them achieve this goal.

— Toby Amidor, MS, RD, CDN, is founder of Toby Amidor Nutrition (http://tobyamidornutrition.com) and the author of the cookbooks The Greek Yogurt Kitchen: More Than 130 Delicious, Healthy Recipes for Every Meal of the Day and The Healthy Meal Prep Cookbook. She's a nutrition expert for FoodNetwork.com and a contributor to US News Eat + Run and MensFitness.com.

References
1. 14 top diet trends for 2014. Pollock Communications website. http://www.lpollockpr.com/blog/14-top-diet-trends-2014-2/. Published January 8, 2014. Accessed December 11, 2017.

2. Dietary fluidity: changing how you eat. The Cutting Board. March 1, 2017. https://blog.greenchef.com/2017/03/01/dietary-fluidity-changing-eat/. Accessed December 11, 2017.

3. Paleo diet: expert review. US News & World Report website. https://health.usnews.com/best-diet/paleo-diet/reviews. Accessed December 12, 2017.

4. Experts who reviewed the diets. US News & World Report website. https://health.usnews.com/best-diet/experts. Accessed December 12, 2017.

5. Aune D, Keum N, Giovannucci E, et al. Whole grain consumption and risk of cardiovascular disease, cancer, and all cause and cause specific mortality: systematic review and dose-response meta-analysis of prospective studies. BMJ. 2016;353:i2716.

6. Vanegas SM, Meydani M, Barnett JB, et al. Substituting whole grains for refined grains in a 6-wk randomized trial has a modest effect on gut microbiota and immune and inflammatory markers of healthy adults. Am J Clin Nutr. 2017;105(3):635-650.