Dr. Tom Rifai

Excellent conversation on LinkedIn and I’m bringing to you here. My added comments to complement Professor Phillips from McMaster University are immediately below:

Have been teaching patients and coaching clients for 20+ years that protein adequacy is a crucial part of not just muscle, but bone health.

Adding to Prof. Stuart Phillips excellent piece and list of items, in addition to calcium and Vitamin D, maintaining a low renal acid load dietary pattern by having healthy intake of whole fruits and vegetables and moderating grains (adds to acid load), as well as care to avoid excess sodium🧂by on average keeping

The power of flexitarian nutrition, with being the gold standard version, recognized in the New England Journal of Medicine.

In our opinion at Reality Meets Science® opinion, a low saturated fat, low cholesterol and, by definition, high natural fiber, low CRRAHP (calorie rich, refined and highly processed) food/beverage and protein quantity and quality optimized flexitarian approach is the most likely of all longevity eating patterns to resonate with the largest fraction of the public. And surveys of the United States public has supported this.

is also the most ethnic agnostic and multicultural compatible, with the most capacity for ultra personalization, approach to eating - including our unique “5% fun zone” approach.

High risk foods are at the pinnacle our pyramid (see comments for Flex5 food pyramid) for two reasons that are totally compatible:

First, they’re (albeit a bit dangerously) delicious!

Second, they must be kept down to a significantly “dull roar” in order to make health and happiness compatible with each other.

After all, “the dose makes the poison” no single food choice, at any single point in time is, in end of itself, “mistake”. It’s all about how often and how much.

Longevity (blue) zones and the population with the lowest rates of heart disease ever seen modern history, the Bolivian Tsimané Both allow about 5% of their food intake to be of “comfort food” (CRRAHP) variety.

If you want to learn Flex5 nutrition, check out our online course: https://dpm.drtomrifai.com/nutrition

And check out my YouTube interview of one of the world two most prominent experts on the Bolivian Tsimané, Prof. Michael Gurven: https://youtu.be/CmL8e0QaJ30?si=U4kHoLMNznbvt2Be

I LOVE being a dad and family man! It’s my biggest WHY for staying healthy! Happy Father’s Day to all my “father brothers from other beautiful mothers”!

Interested in metformin for anti-aging/longevity? Check out my new YouTube video.
Reality Meets Science

Metformin for longevity? An expert MD’s perspectives on benefits vs risks + several related issues. A deeper dive discussion combining my personal and professional experience with Metformin, including associated be vitamin deficiency risk beyond vitamin B1...

Explore the Flex5 Food Pyramid! It’s designed to promote holistic health with a balanced, sustainable approach. 🌱

🥑 On top, indulge mindfully in the "5% Fun Zone" with treats savored in a moment of silence.
🥦 Layer below, find heart-healthy fats from nuts, seeds, and oils.
🐟 Opt for modest portions of protein from seafood, lean poultry, egg whites, and Greek yogurts.
🍞 Embrace beans, lentils, starchy vegetables, and 100% whole grains for quality carbohydrates, fiber, vitamins, and minerals.
🍏 The largest volume of food should be whole fruits and low-starch vegetables for the best blend of high-nutrient and low-calorie density.

This pyramid isn’t just about what to eat; it's about enjoying food in ways that nourish both body and spirit. Try integrating these principles for a week and feel the difference in your health and energy levels!

Thoughts on CGMs in people without diabetes (plus more!) in today’s “quick podcast“ (10 min) video. Please let me know if the video plays, since I’m sharing via iCloud link. If not, I can repost later embedding the video directly into the post

share.icloud.com 1 Video

🧠 Your Mind Matters!

Integrating mental wellness into your healthcare is crucial. The Flex5 Mind Matters key emphasizes 3 main aspects: Mindfulness, Mindset, and Mental Health. Here are just some examples from each:

Mindfulness - Engage in diaphragmatic breathing and practice being present. This enhances self-awareness and helps manage stress, which is pivotal for maintaining personal and patient health.

Mindset - Adopt the SLIP technique: Stop, Look, Investigate, Plan. View challenges as opportunities for growth, not setbacks. Embrace a "5% Fun Zone” for a sustainable, personalized longevity lifestyle.

Mental Health - Address mental health proactively by acknowledging past traumas and stressors. This fosters a more empathetic, comprehensive practice.

Utilize these tools to empower yourself toward better mental and physical health outcomes.

The Endocrine Society recently came out with a pendulum swing changing recommendations re Vitamin D supplementation and testing from test and treat to a vitamin D blood level of over 30 ng/mL to don’t test and only give RDA vitamin D dose (600 IU) to “generally healthy“ US adults (though one can ask how many US adults are actually “generally healthy”?).

This was largely based on the results of the massive randomized controlled VITAL trial of over 25,000 individuals, representing a large swath of a “generally healthy” US population (though there were thousands with less than optimal insulin sensitivity, above optimal blood pressure, cholesterol, weight etc.), of testing 2000 IU of USP verified vitamin D3 daily versus placebo.

Notably the baseline blood levels of the VITAL participants weren’t particularly low (at 31 ng/mL, with 30+ generally considered the low end of optimal zone) leading many critics to say that the population was wrong (the certainly represented average Americans to be honest) and that the 2000 dose was inadequate, considering that the National Academy of Medicine suggests up to 4000 IU of vitamin D3 daily is safe.

Before I delve into detail, my bottom line suggestion, since most people cannot get to the doctor often enough to have their “25 hydroxyvitamin D” blood levels checked repeatedly and vitamin D dosing ultra personalized for a level of over 40 ng/mL, is to take at least 1000 IU of vitamin D3 daily as part of the multivitamin (like Centrum Silver which has 1000 dose in it and has been shown in randomized control trials to reduce the risk of cognitive decline, and possibly cancer mortality in men) or otherwise a USP verified vitamin D3 (such as nature made Costco‘s Kirkland brands). Note that I recommend centrum silver generally because it doesn’t contain iron, and there’s too many men, and a notable number of postmenopausal women, who have too much body iron, which can increase the risk of type 2 diabetes.

Though of course if you have had proven low body iron levels, such as a ferritin blood test less than 50, having iron in a multivitamin can be a good thing though typically not enough to do much other than maintain iron levels in a menstruating woman, for instance. My wife takes a chewable, high-quality bariatric surgery grade iron supplement one week per month, for instance, to make up for menstrual losses as well as cooking in a cast-iron skillet.

But back to the main topic… Certainly 2000 IU vitamin D3 daily is safe, as proven by VITAL and would be a better dose in the fall/winter months of October through March, particularly at latitude levels of Atlanta and north.

Now to delve into to more detailed thoughts as to where we are since VITAL and the semi controversial, hard pendulum swing in the opposite direction re vitamin D recommendations by The Endocrine Society:

I find myself in between the society and those still remaining in the vitamin D evangelist camp (I used to be there)..…I am comfortable generally recommending 1000–2000 IU of vitamin D3 daily without testing as covering most peoples’ needs to cover otherwise serious potential gap in vitamin D intake - with 1000 IU being for April-Sept spring/summer months and combined with recommendations for safe, “no burn“ sun exposure + counseling for year round metabolically healthy vitamin D fortified foods, such as 1% or less fat dairy milk, unsweetened organic soy milk (Silk tastes best IMO) - w/ 2000 IU for October - March, especially north of Atlanta.

But I agree re another massive RCT to compare VITAL’s empiric “treat without testing” arm vs the small but noble Target D trial approach of test and titrate (adjust) D3 dosing for a 25 hydroxyvitamin D blood level of >40ng/mL.

I suggest 3 arms to this proposed trial: two “empiric” (give vitamin D without testing) arms of RDA (600 IU) and one of 4000 IU, along with a third arm of test and titrate vitamin D3 dose to a 25 hydroxy vitamin D level of 40–60 (with baseline, mid trial and end of trial 25 hydroxyvitamin D levels tested in both of the empiric arms).

Why bump the empiric D3 dose to 4000 IU from the 2000 IU amount used in VITAL? This is considering the argument of inadequate dosing in VITAL by the “D evangelists” and that 4000 IU daily is the upper safe range for adults per Natl Academy of Medicine (formerly IOM).

But TargetD is too small a study (25K) to stand alone against the behemoth VITAL trial (a harrowing effort to say the least) which was a well over 30x larger population - that is unless TargetD’s final, peer reviewed and scrutinized published results are literally jaw dropping. We’ll see soon on that as preliminary, non-peer reviewed (therefore I’m not going to discuss here) results at a recent AHA meeting.

Otherwise, and even then to assure, we need another massive RCT at VITAL size with the aforementioned 3 arms:
1. RDA 600 IU
2. robust empiric dose (4000)
3. test and titrate/treat to ~50ng/mL (checking levels baseline, mid trial and end for the RDA and 4000 groups).

Note, 2000 empiric vs test/titrate to 40-60 was essentially the two approaches that the original 2008 Grassroots Health for Vitamin D CTA recommended. I remember it clearly. And I drank the Kool-Aid. Here’s grassroots health’s 2015 update to the original 2008 CTA for fair balance:https://www.grassrootshealth.net/wp-content/uploads/2017/12/scientists_call-to-daction_121817.pdf

That said, and as much as I respect many on the grassroots health advisory, I am not ready to believe that simply taking a US population from a level of around 30 to a level of 40–60 is going to reduce chronic disease by a massive “20-50% or more”. Numbers on the lower end of that range might be possible when those who are truly vitamin D deficient, especially those who have levels below 20 ng/mL, of which there are notable minority and at higher risk when covering for religious purposes, aggressively using sunblock, naturally darker pigmented skin, high-grade obesity, living in northern latitude throughout the year, osteoporosis/osteopenia… Though there are several factors that can drive bone loss unrelated to vitamin D including but not limited to smoking, salt intake, inadequate alkaline intake particularly in terms of whole fruits and vegetables etc.… to those living with psoriasis or in elder care facilities etc. So I’m certainly not against selective, and even erring on the side of caution semi liberal assessment of blood 25 hydroxy vitamin D levels.

I tested and titrated thousands to 40-60ng/mL, touting everything from “20-50% reduction” in cancers, MS, type 1 (and even 2) diabetes and heart disease - just like grassroots health call to action claimed…add prevention and treatment of psoriasis, where I did see cases improve - including one horrible case that got at least 50% better with intensive titration to 50 ng/mL (started at 10000 IU and maintained with 5000) over and above standard therapies.

I saw VITAL as D3’s holy grail - after all, it did just what grassroots health 2008 gave us as an alternative - ie simply Rx 2000 IU of D3 daily because “deficiency” in grassroots health’s thought leaders minds was “rampant” and evangelically conveyed as 30 ng/dL) levels.

Of course, re “generally healthy” - in the US not even 10% of our adult population would be considered truly metabolically healthy by the AHA simple 7 or Essential 8 guidelines. But pardon, I digress.

For me, as a “recovering vitamin D evangelist“, I was “sure” VITAL - an overly criticized trial as it was strong representation of a wide US population and - again - gave adequate quality 2000 IU of daily D3 to get from baseline of ~ 30 to grassroots health CTA goal of 40+ average, was going to silence the D3 skeptics.

But let’s face it, It’s easy to beat VITAL up with 20/20 hindsight. But it was it was not whatsoever an irrelevant study. 2000 IU in a massive population with an average level of 31 should’ve still caught enough people less than 30, considering that vitamin D levels are brought up by about 10 points for every 1000 IU given, to show remarkable cardiovascular or cancer benefits. And it did show results consistent with reduced death from cancer, though it didn’t reduce how often cancer occurred ( incidence of cancer)

So the maintenance of the previous test and treat guidelines would not be appropriate in the face of a massive RCT, with over 30x more subjects than TargetD, that was a far more accurate representative sample of the general population and who had D levels below 40, and given a vitamin D3 dose quite arguably adequate to increase vitamin D3 levels to over 40 in a “generally healthy“ population.

Nor does VITAL whatsoever make the case of dropping the recommended amount to the RDA, even if for the cancer mortality risk reduction signal alone. I believe that since D3 was so safe and VITAL, and we still have at least one massive RCT to go before making any massive changes, continuing to recommend him dosing of 1000–2000 IU daily as noted is reasonable, unless your doctors willing to repeatedly test 25 hydroxy vitamin D levels and adjust your vitamin D to your own personal physiology and changing times of the year.

For me, to be honest, I am skeptical that taking the same population as VITAL (“generally healthy“ with a baseline vitamin D blood level of 30-ish already) and increasing the empiric dose from 2000 to 4000 units will make a massive difference. But I’m not confident enough to deny it!

It should be studied, but since we already have the answer on 2000 units and so I would suggest for the next massive RCT that 4000 be against the RDA low dose and 3rd arm of “test n adjust D3 dose” to a 25 hydroxyvitamin D blood level of over 40ng/mL as aforementioned.

Until a study like that is done, I don’t believe that anyone has a definitive argument for or against any of these “reasonable approaches” (ie RDA vs 2000-4000 IU D3 empiric vs test n titrate to 40-60) - each one of which having strengths and weaknesses. Though I personally believe the weakest is to only empirically give the RDA, even to whatever fraction of our population is “generally healthy“ - let alone to the massive number with cardiometabolic risk or other prone to other vitamin D sensitive risks (certain cancers, psoriasis, multiple sclerosis etc.) where cheap USP vitamin D3 even at 2000 could be life quantity, or at least quality, saving in the so many that are not “generally healthy”.

But 4000 is what should be next tested for empiric daily dose in “VITAL D3” - btw, a name I just made up, since there are 3 arms proposed and would only be testing D3 - ie not omega 3 again (which the original VITAL did in addition to D3) - as omega-3 is now a different story and needing to be in its own RCT re atrial fibrillation induction.

And that, as the late Greek Paul Harvey would say, is “the rest of the story” - or at least the current state of it – on vitamin D3.

If you’d like this content please do click “like” o the post, “like” or “follow” and share this free information page with friends and family. It would be greatly appreciated!🙏🏽

Enjoying my time here in London for the Founders Longevity Forum, part of London Tech week, and great to see the fruits of labor of those like Dr. Graham MacGregor. Dr. MacGregor has been a leader in the UK salt reduction campaign, saving thousands of lives in the process.

I just went to a restaurant for lunch and the low salt culture is apparently to the point that when I asked for no salt added to my vegetables and fish they said “…we don’t add salt. That’s why we have salt 🧂 on the table”

Also walking into the grocery stores you can find items you would never find the United States like bran flakes that don’t have a ton of salt added to them. Typical for US brands to have over 200 mg of sodium per 30 g serving. Here it’s 30 mg.

Didn’t order anything there but even walked into McDonald’s to find that McDonald’s salads are still here AC well and still on the menu. They even have vegan sandwiches, one of which looks pretty stuffed with vegetables. Yes, it’s still McDonald’s but it’s definitely not the same as the US.

In fact, next time I walk by I may check whether they add salt to their fries or if you have to ask.

UK Salt Reduction Timeline - Action on Salt Salt Intakes in EnglandThe latest report from the National Diet and Nutrition Survey 2018/2019, revealed that estimated salt intakes in adults in England are currently 8.4g/day; 9.2g/day for mean and 7.6g/day for women. No statistically significant changes in salt intake were seen between 2014/15 an...

Especially for those of us over 50 (and for me closer to 60 than 50 now), strength and flexibility are critical. My longevity lifestyle drugs are driven by food and physical activity (including strength, flexibility and cardio – what we combine to call FLEXIO training), supported by positive psychology, skills in leveraging my environments (food, social and physical) for success and of course the key of accountability - esp to my family and to YOU, this community!

But what seems to be most interesting to people these days is that I take metformin and have for the last 20 years. So if you want to discuss my perspective on metformin to enhance Flex5 lifestyle for longevity and anti-aging, click the LOVE❤️ button (that way I know you’ve been paying attention!) And please feel free to comment with decorum and share this post and page widely with friends and family🙏🏽

Thank you all for helping this page race past 9K followers! Would have never made it without each one of you. 🙏🤗🎉

Wall squats for blood pressure control! Practicing what I preach… As discussed in my most recent short IG, and deeper dive Facebook, video.

While study protocol and therefore theoretical goal is two minute wall squats with knees flexed to a 90° angle for two minutes, with two minute break and then repeat three more times, three days per week, start with whatever degree you can tolerate of knee flexion and whatever time you can tolerate until you build up.

Of course, always discuss with your healthcare provider. This is for educational purposes only!

This is BIG. In my opinion a huge step forward in evidence for therapeutic lifestyle changes to ward off dementia, Alzheimer’s in this case.

Immense gratitude to Dean Ornish, M.D. and his team of investigators as well as the patients involved in this study.

alzres.biomedcentral.com

Feeling deeply touched by Susan Gentner's endorsement. 🌟 She shed an incredible 200 lbs and found further encouragement in our Flex5 community. Susan's journey highlights that it's never too late to make life-changing health decisions.

🌿 At Flex5 it's about consistency over intensity of change. Whether you're ready for small or big steps to optimize the odds of healthy longevity, get leaner, make peace with food, or overcome daily health challenges - we are here for you.

👉 Want to embark on a transformational health journey like Susan? Connect with us for inspiration and support.

🙏 A heartfelt thank you to everyone in our community. Your stories and successes inspire and motivate us every day!

It’s “HOT TOPICS” Thursday!
Video on bottom lines re microbiome, low cal sweeteners, protein & fat shaming + more - coming this morning…stay tuned!

One of UPFs (ultra processed foods) or - more accurately - CRRAHP (calorie rich, refined and highly processed) foods most health risky aspects is added sodium. See original study here: https://www.ahajournals.org/doi/full/10.1161/HYPERTENSIONAHA.120.14800

WP story: https://www.washingtonpost.com/wellness/2024/06/03/low-sodium-foods-microbiome/

Take Charge with !

Stress less by mastering the 3 Levels of Control:
1️⃣ Control: Directly manage what you can.
2️⃣ Influence: Shape the outcomes within your reach.
3️⃣ Let Go: Accept what's beyond your grasp.

Focusing on what we can control or influence can dramatically boost our happiness and reduce stress. Embrace this powerful perspective for a life of less stress and more success. Give it a try—transform stress into strength! 💪

To learn more about integrating these insights and join the discussion here: https://www.facebook.com/watch/live/?ref=watch_permalink&v=366494412397955.

A smaller, but notable part of our opioid crisis. Every life matters.

See link for full story:https://www.cspinet.org/sites/default/files/2024-02/Contaminated%20Poppy%20Fact%20Sheet%20Stephen%20Hacala%20Poppy%20Seed%20Safety%20Act%20January%202024.pdf

Going Facebook aLIVE on fat shaming in just a moment. For those of you on LinkedIn, please feel free to support this post.

www.linkedin.com

Proud to be named a “Top Motivational Speaking Voice” by LinkedIn!

No, plain baked or boiled potatoes with skin are not “magic foods”. Nor should they be demonized.

Assessing food is simple with criteria:

Let’s use the potato 🥔 as an example:

1. Calorie density is low (less than 1 calorie per gram of food at 0.94). That means if one at 4 pounds of potatoes at around 1700 cal.

Four pounds of potato chips? More like 10,000 calories! And unless you go for no-salt added, over 10,000mg of sodium.

Even a realistic half pound (227g) bag of potato chips and you’re way over 1000 mg of sodium.

2. Glucose, cholesterol and healthy microbiome controlling fiber level is very good at > 2 grams per 100 cal. That means at 2000 calories you’d be eating over 40g of natural, intact fiber.

FDA considers high fiber at 1.4g of fiber for every 100 calories.

3. Virtually no saturated fat and no cholesterol.

4. Blood pressure controlling potassium is excellent at >500mg, and since it’s largely potassium citrate, that means healthy bone strength enhancing alkaline residues.

So don’t put a plain baked or boiled potato 🥔 with skin in the same category as potato chips or the fatty n salty cheese, butter or full fat sour cream often added. Try low or fat free Greek yogurt instead of sour cream and otherwise be mindful of the amount or number of toppings you’re going to add.

That’s where Reality Meets Science® re spuds

See comments for supporting information.

Eating more potatoes may reduce risk for mortality, researchers find A greater weekly intake of potatoes reduced the risk for all-cause mortality as well as mortality from CVD, ischemic heart disease and acute myocardial infarction, a Norwegian-based cohort study showed.Potatoes have previously been tied to lower mortality in people with diabetes, particularly when c...

I'm truly humbled by your kind words and inspired by your journeys toward healthier lives. A big shout-out to Dennis J. Carr for such warm feedback—it means the world to me! 🙏

Your experiences fuel my passion for sharing knowledge about the impact of diet and lifestyle on our health. It's not just about what we eat, but understanding how our choices interact with our bodies. Every story you share teaches and motivates not only me but also our entire community.

Whether it's mastering the balance between lifestyle and medication, making peace with food, or any aspect of healthy lifestyle transformation - your testimonials keep us all going. Thank you for being such an active part of our journey towards and IN health and wellbeing!

Let’s keep learning and growing together. If you haven't yet, share your story or a special win in the comments below—I can't wait to hear more about your progress!

Sigh…first, this is not “new“ news. It’s reinforcing and supportive of the fact that there are already over double digit number of randomized control trials showing reduced cardiovascular risk when replacing sodium chloride partially with potassium chloride.

Secondly, the author was clearly not paying attention as the intervention was not “getting rid” of a home salt shaker, but replacing the salt that was in the home salt shaker with one that cuts sodium based salt by about 1/3 replacing most of it with potassium based salt.

Last but not least, the link to an example of a product that was similar to the one used in the study was a sub-optimal choice, in my opinion.

This is because it replaced 75% of sodium with potassium salt. The study was about a 30% level. And while I could somewhat appreciate the “executive decision” the article author recommend a product with over potassium potency of the study, as noted in the article interview of one of the cardiologist, we don’t necessarily want to encourage large amount of supplemental potassium as, on rare occasion people with renal insufficiency looking to laudably control their blood pressure with a partial potassium salt sodium substitute could drive up their blood potassium to risky levels.

Of course, the real way to reduce that risk is to emphasize that even with partial sodium salt substitutes, we should still recommend using modest amounts. Otherwise pallets won’t adjust to less overwhelmingly salted food flavors.

To strike the right balance, my preferred product to recommend to patients and health coaching clients, as well as what we use in the Rifai household, is Morton Lite Salt (I’ve no relationship to the company): https://www.walmart.com/ip/Morton-Salt-Lite-Salt-11-oz-Canister/10318920

Morton cuts sodium by 50%, has great flavor and is supplemented with iodine.

Reality Meets Science®

Link to full article: https://www.prevention.com/health/a46931515/salt-substitutes-reduce-high-blood-pressure-risk-study/

Link to original study: https://www.jacc.org/doi/10.1016/j.jacc.2023.12.013