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Nutritional and Health Comparisons of Paleo Vegetarian and Mediterranean Diets © Loren Cordain, Ph.D. Professor Colorado State University Fort Collins, CO USA The Typical Contemporary “Paleo” Basis for Contemporary “Paleo” Diets: Ancestral Plio-Pleistocene Hominid Diets: The Known – An Omnivorous Diet Minimally Processed, Wild Plants and Animals

!Kung Woman displays 1Cordain et al. Am J Clin Nutr 2000;71:682-92 of her gathering: tamma melons, 2Cordain et al. Am J Clin Nutr 2005; 81:341-54. grewia berries, tortoise, The Average Hunter Gatherer’s

229 Historically Studied Hunter Gatherer Societies1 Plant Foods (, fruits, seeds, nuts, tubers, roots, other) 34- 46 % calories

Animal Foods (, fish, eggs, poultry, seafood, organ meats) 56- 64 % calories

1Cordain L et al. Plant-animal subsistence ratios and macronutrient energy estimations in worldwide hunter-gatherer diets. Am J Clin Nutr 2000;71:682-92 Humanity’s Evolutionary Food Plate

“My Plate” replaced the USDA Food Pyramid in June 2011 1Cordain L et al. Plant-animal subsistence ratios and macronutrient energy estimations in worldwide hunter-gatherer diets. Am J Clin Nutr 2000;71:682-92 These foods comprise (>70% energy) in typical Western Diets But were virtually unknown in Ancestral Human Diets , Cereals, Rice and Pasta Products Added

Refined Oils Refined Processed (except honey) Meats

2Cordain et al. Am J Clin Nutr 2005; 81:341-54. Foods Not Present in Pre-Agricultural Diets (All Processed Foods)

Pancakes Cereal Pizza

Cookies, doughnuts , Cakes Muffins, Roles Pies Chips, Crackers . Ubiquitous Food Mixtures: . (/starch + refined fat/oil + refined + salt + flavoring + dairy food) . So called “MONO-FOODS” Foods Not Present in Pre-Agricultural Diets (All Processed Foods)

Cereal

Candy Ice Cream

Potato Mixtures

Sandwiches . Ubiquitous Food Mixtures: Pretzels . (Grain/starch + refined fat/oil + refined sugar + salt + flavoring + dairy food) . So called “MONO-FOODS” of the Western Diet: Neolithic (10,000 to 5,500 yrs ago) Food Introductions

SUCROSE

FIRST SALT MINES

WINE AND BEER

FIRST DAIRYING EVIDENCE

WHEAT & BARLEY DOMESTICATED ~10,000 YRS AGO

SHEEP, GOATS, COWS DOMESTICATED

Years ago

9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000

10,000 Human present Generations 333 300 267 233 200 167 133 100 66 33 0 (30 yrs)

2Cordain et al. Am J Clin Nutr 2005; 81:341-54. Evolution of the Western Diet: Industrial Revolution (~200 yrs ago)

HFCS

HYDROGENATED OILS

REFINED VEGETABLE OILS

REFINED

FEEDLOT PRODUCED MEATS

SUCROSE

Year 2008 Human 1798 1828 1858 1888 1918 1948 1978 Generations 7 6 5 4 3 2 1 0 (30 yrs)

2Cordain et al. Am J Clin Nutr 2005; 81:341-54. Evolution of the Western Diet: Industrial Revolution Processed Foods – The 20th Century

1969: PRINGLES CHIPS 1952: SUGAR FROSTED FLAKES

1941: M&M’s 1932: CORN CHIPS 1928: RICE KRISPIES 1921: WONDERBREAD 1913: OREO COOKIE

1911: CRISCO 1906: KELLOGS CORN FLAKES 1902: PEPSI 1900: HERSHEY’S CHOCOLATE BAR

Year 2008 Human 1898 1908 1918 1928 1938 1948 1958 1968 1978 1988 1998 Generations 4 3 2 1 O (30 yrs) Refined sugars, grains, vegetable oils and dairy = 70.9% of energy in the U.S. food supply Meats, Fish 1.4 Eggs 15.7 18.6 Nuts, Seeds Refined 3.1 Sugars Refined 3.3 Fruits Vegetable Oils Grains Dairy

17.8 4.8 Vegetables 0.8 Miscellaneous 23.9 10.6 . Refined sugars, grains, vegetable oils and dairy represent Neolithic & Industrial era foods that were not present in traditional ancestral human diets . By default, their inclusion displaces minimally processed, wild plant and animal foods.

Gerrior S, Bente I. 2002. Nutrient Content of the U.S. Food Supply, 1909-99: A Summary Report. U.S.D.A, Center for Policy and Promotion. Home Economics Research Report No. 55 Typical Foods Found in Contemporary Diets Based Upon Food Groups

Nuts/Seeds Fresh Veggies Fresh Fruits

Fish/Seafood Grass Produced Free Range Eggs Healthy Oils Meats The Typical The Typical Mediterranean Diet

Varies from The Paleo Diet In these key dietary elements:

. Bread, pasta, rice, whole grain and potatoes are daily dietary components . Beans and legumes are daily dietary components . Cheese and yogurt are daily dietary components . Highly salted foods (cheese and olives) are daily dietary components . is only consumed on a monthly basis The Typical Mediterranean Diet: Is it Healthful and does it reduce the risk for CVD and ?

YES, BUT WITH CAVEATS Are there even healthier alternative diets? . Observational meta analyses1 support that adherence to Mediterranean Diets reduce CVD and metabolic syndrome risk . Meta analyses of randomized controlled trials (RCT) are less supportive2 Abstract “Fifty-eight studies exploring the relation between MD and lipoprotein concentration, antioxidative capacity and inflammatory markers, hypertension, , , and metabolic syndrome, were identified and selected. These included 33 cross-sectional, 9 cohort, and 16 intervention studies. Most of the studies showed favorable effects of MD on CVD, although a certain degree of controversy remains in the respect of some issues, as obesity. Important methodological differences and limitations in the studies make difficult to compare results, thus further studies, particularly randomized clinical trials, are needed to finally substantiate the benefits of MD and to shed some lights on mechanisms.”

1Grosso G et al. Mediterranean diet and cardiovascular risk factors: a systematic review. Crit Rev Food Sci Nutr. 2014; 54(5):593-610. The Typical Mediterranean Diet: Is it Healthful and does it reduce the risk for ?

YES, BUT WITH CAVEATS Are there even healthier alternative diets?

. Meta analyses of randomized controlled trials (RCT) to reduce CVD risk are less supportive2

Abstract “MAIN RESULTS: We included 11 trials (15 papers) (52,044 participants randomised). Subgroup analyses revealed statistically significant greater reductions in total cholesterol in those trials describing the intervention as a Mediterranean diet (-0.23 mmol/L, 95% CI -0.27 to -0.2) compared with control (-0.06 mmol/L, 95% CI -0.13 to 0.01). Reductions in blood pressure were seen in three of five trials reporting this outcome. None of the trials reported adverse events. CONCLUSIONS: The limited evidence to date suggests some favourable effects on cardiovascular risk factors. More comprehensive interventions describing themselves as the Mediterranean diet may produce more beneficial effects on lipid levels than those interventions with fewer dietary components.” 2Rees K et al. 'Mediterranean' dietary pattern for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2013 Aug 12;8:CD009825. The Typical Mediterranean Diet: Is it Healthful and does it reduce the risk for obesity/overweight? YES, BUT WITH CAVEATS Are there even healthier alternative diets?

. Meta Analyses (both RCTs and observational studies) indicate that adherence to Mediterranean Diets are equivocal for control of obesity/overweight or more weight loss3. Abstract “We identified 21 epidemiological studies that explored the relationship between the Mediterranean diet and weight. These included seven cross-sectional, three cohort and 11 intervention studies. Of these, 13 studies reported that Mediterranean diet adherence was significantly related to less overweight/obesity or more . Eight studies found no evidence of this association.”

3Buckland G et al. Obesity and the Mediterranean diet: a systematic review of observational and intervention studies. Obes Rev. 2008 Nov;9(6):582-93. The Typical Mediterranean Diet: Is it Healthful and does it reduce the risk for glucose control ?

YES, BUT WITH CAVEATS Traditional Greek Bread Are there even healthier alternative diets? YES

. Meta analyses indicate that adherence to Mediterranean diets is ineffective for glucose control4 . Paleo Diets are superior to Mediterranean diets for HbA1c4 Abstract METHODS: We conducted a systematic review and meta-analysis aiming to determine the effects of a Mediterranean diet compared to other dietary interventions on glycaemic control irrespective of weight loss. RESULTS: Eight studies met the inclusion criteria, seven examined blood glucose (n = 972), six examined fasting insulin (n = 1330) and three examined HbA1c (n = 487). None of the interventions were significantly better than the others in lowering glucose parameters. The Mediterranean diet reduced HbA1c significantly compared to usual care but not compared to the Palaeolithic diet. 4Carter P et al. A Mediterranean diet improves HbA1c but not fasting blood glucose compared to alternative dietary strategies: a network meta-analysis. J Hum Nutr Diet. 2013 Jun 22. doi: 10.1111/jhn.12138. The Typical Mediterranean Diet: Is it Healthful and does it reduce the risk for chronic disease? YES, BUT WITH CAVEATS Are there even healthier alternative diets? YES

. A RCT demonstrated the Paleo Diet to be superior to a Mediterranean diet for blood glucose concentrations and waist circumferences changes Traditional Italian Bread over 12 weeks5 Abstract “RESULTS: Over 12 weeks, there was a 26% decrease of AUC Glucose (0-120) (p = 0.0001) in the Palaeolithic group and a 7% decrease (p = 0.08) in the Consensus group. The larger (p = 0.001) improvement in the Palaeolithic group was independent (p = 0.0008) of change in waist circumference (-5.6 cm in the Palaeolithic group, -2.9 cm in the Consensus group; p = 0.03). There was a tendency for a larger decrease of AUC Insulin (0-120) in the Palaeolithic group, but because of the strong association between change in AUC Insulin (0- 120) and change in waist circumference (r = 0.64, p = 0.0003), this did not remain after multivariate analysis.” 5Lindeberg S et al. A Palaeolithic diet improves glucose tolerance more than a Mediterranean-like diet in individuals with ischaemic heart disease. Diabetologia. 2007 Sep;50(9):1795-807 The Typical Mediterranean Diet: Is it Healthful and does it reduce the risk for chronic disease?

YES, BUT WITH CAVEATS Are there even healthier alternative diets? YES

. A RCT demonstrated the Paleo Diet to be superior to a Mediterranean diet for satiety, and caloric intake over a 12 week intervention6 Traditional Crete Bread with Olive Oil

Abstract RESULTS: The Paleolithic group were as satiated as the Mediterranean group but consumed less energy per day (5.8 MJ/day vs. 7.6 MJ/day, Paleolithic vs. Mediterranean, p = 0.04). Consequently, the quotients of mean change in satiety during and mean consumed energy from food and drink were higher in the Paleolithic group (p = 0.03). Also, there was a strong trend for greater Satiety Quotient for energy in the Paleolithic group (p = 0.057). decreased by 31% in the Paleolithic group and by 18% in the Mediterranean group with a trend for greater relative decrease of leptin in the Paleolithic group. Relative changes in leptin and changes in weight and waist circumference correlated significantly in the Paleolithic group (p < 0.001) but not in the Mediterranean group. Changes in leptin receptor and free leptin index were not significant. 6Jönsson T et al. A paleolithic diet is more satiating per calorie than a Mediterranean-like diet in individuals with ischemic heart disease. Nutr Metab (Lond). 2010 Nov 30;7:85. Paleo vs. Mediterranean Diets: Underlying Mechanisms Is this Dish Paleo? . Both Paleo and Mediterranean Diets Mediterranean? or Both ? have demonstrated therapeutic effects upon metabolic disease symptoms and obesity/overweight . In limited direct comparisons of Paleo and Mediterranean diets, Paleo was generally superior5,6 . Why?

Paleo? Paleo?

Mediterranean?

Paleo? Paleo? The Typical Mediterranean Diet

Nutritional Components of The Mediterranean Diet which vary from The Paleo Diet:

. Higher total carbohydrate . Higher glycemic load . Not gluten free . Greater anti-nutrients . Lower total protein . Lower animal protein . Lower branch chain amino acids (, , ) . Lower absorbable iron content . Lower absorbable content . Lower B12 . Higher salt (NaCl) content The Typical Mediterranean Diet: Not so Healthfy Foods: Daily Bread & Grains

. Bread represents the highest single source of salt in the western diet7. . Bread and cereals (even whole grains) are high glycemic load carbohydrates8. . Bread and cereals are the sole dietary source of gluten . Bread and cereals are major contributors to dietary acid load9 . Bread and cereals may promote adverse health effects10

7Centers for Disease Control and Prevention (CDC). Vital signs: food categories contributing the most to sodium consumption – United States, 2007 – 2008, February 7, 2012. 8Foster-Powell K, Holt SH, Brand-Miller JC. International table of glycemic index and glycemic load values: 2002. Am J Clin Nutr. 2002 Jul;76(1):5-56. 9Sebastian A et al. Estimation of the net acid load of the diet of ancestral preagricultural Homo sapiens and their hominid ancestors. Am J Clin Nutr. 2002 Dec;76(6):1308-16. 10Cordain L, (1999). Cereal grains: humanity’s double edged sword. World Review of Nutrition and Dietetics, 84: 19-73. The Typical Mediterranean Diet: Not so Healthy Foods: Daily Cheese and Olives (High Salt) Common Salt content Mediterranean mg/100 g Cheeses cheese

Parmesan 4069 Gorgonzola 3447 Romano 3048 Feta 2835 Greek Olives and Feta Cheese Kasseri 2540 Asiago 2540 Provolone 2225 Fontina 2032 Mozzarella 1692

Olives Kalamata olives 3833 Green olives 3890

CDC Recommended Daily Bread, Cheese and Olives: High Sodium Intake = 2300 mg7,11 or 5750 mg salt Salt Foods

7Centers for Disease Control and Prevention (CDC). Vital signs: food categories contributing the most to sodium consumption – United States, 2007 – 2008, February 7, 2012. 11 http://www.cdc.gov/features/dssodium/ The Mediterranean Diet is less micro nutrient dense than the Paleo Diet

. Bread whole grains and dairy foods are less nutrient dense in the 13 nutrients most lacking in the US Diet compared to: . Fresh vegetables, fish, seafood, lean meats, and fruits2,11

2Cordain et al. Am J Clin Nutr 2005; 81:341-54 11Cordain L, The nutritional characteristics of a contemporary diet based upon Paleolithic food groups. J Am Neutraceut Assoc 2002; 5:15-24. Nutrient Density for Food Groups (100 kcal samples) Superscripts are rank scores (7=highest;1=lowest) for each nutrient

Whole Whole Lean Grains Milk Fruits Veggies Seafood Meats Nuts/seeds Vitamin B12 (μg) 0.004 0.585 0.004 0.004 7.427 0.636 0.004 Vitamin B3 (mg) 1.124 0.141 0.893 2.735 3.196 4.737 0.352 (mg) 903 1525 331 1576 2197 1514 802 Vitamin B2 (mg) 0.052 0.266 0.093 0.337 0.094 0.145 0.041 Vitamin B1 (mg) 0.125 0.061 0.113 0.267 0.082 0.186 0.124 Folate (μg) 10.34 8.12 25.06 208.37 10.83 3.81 11.05 (mg) 0.01 1.54 74.26 93.67 1.95 0.12 0.43 Iron (mg) 0.904 0.081 0.692 2.597 2.076 1.105 0.863 Vitamin B6 (mg) 0.093 0.071 0.205 0.427 0.194 0.326 0.082 (RE) 22 505 946 6877 324 11 23 Magnesium (mg) 32.64 21.92 24.63 54.57 36.16 18.01 35.85 (mg) 7.62 194.37 43.04 116.86 43.15 6.11 17.53 Zinc (mg) 0.674 0.623 0.251 1.045 7.67 1.96 0.62

13 Most Frequently Most 13 Frequently Deficient Micronutrients Sum Rank Score 42 43 47 82 66 51 39

2Cordain et al. Am J Clin Nutr 2005; 81:341-54 Food Group: Nutrient Density Ranking (nutrient/ energy)

Nutrient Density Rankings per Food Group . No. 1: Veggies (82) . No. 2: Seafood (66) . No. 3: Lean meats (51) . No. 4. Fruits (47) . No. 5. Whole Milk (43) . No. 6. Whole grains (42) . No. 7. Nuts/Seeds (39) Conclusion: Displacement of fish/seafood, meat, poultry and vegetables and by milk, dairy and grains reduces the overall dietary micronutrient density The Typical Vegetarian Diet The Typical Vegetarian Diet

Ovo/Lacto Vegetarian . In the U.S. 3.2 % adults or 7.3 million people follow a Vegan vegetarian diet Vegetarian . Whereas, 0.5 % adults or one million Americans are vegans12 . The study12 indicated 53 % of all vegetarians ate their plant based diet to improve overall health

12Vegetarianism in American. Vegetarian Times Magazine, 2008. http://www.vegetariantimes.com/features/archive_of_editorial/667 Vegetarian/Vegan Diets: Do Not Reduce Mortality from All Causes . Key et al. (1999)13 conducted a large meta analysis comparing overall death rates between 27,808 vegetarians and 48,364 meat eaters. . “There were no significant differences between vegetarians and non- vegetarians in mortality from cerebrovascular disease, stomach cancer, colorectal cancer, lung cancer, breast cancer, prostate cancer or all other causes combined .”

or or or

. A more recent 2009 analysis (The EPIC-Oxford Study) 14, employing the largest sample of vegetarians (33,883) ever examined came up with virtually identical conclusions. . “Within the study mortality from circulatory diseases and all causes is not significantly different between vegetarians and meat eaters”. 13 Key TJ et al. Mortality in vegetarians and nonvegetarians: detailed findings from a collaborative analysis of 5 prospective studies. Am J Clin Nutr. 1999 Sep;70(3 Suppl):516S-524S. 14Key TJ et al. Mortality in British vegetarians: results from the European Prospective Investigation into Cancer and Nutrition (EPIC-Oxford). Am J Clin Nutr. 2009 May;89(5):1613S-1619S Complete Absence of Vegetarians or Vegans in in World Wide Hunter Gatherer Societies (n = 229)

50 45 Mode = (56-65%) Note: 42 45 No HG Median =(56-65%) 40 are vegetarian/vegan 35 35 35 30 30 58 % of all 23 25 societies 20 have > 56% 15 11 dependence 10 6 upon animal foods 5 0 2 Number of Societies (n) of Societies Number 0

0-5 6-15 16-25 26-35 36-45 46-55 56-65 66-75 76-85 86-100 % Dependence upon animal foods (fished + hunted)

1Cordain L et al. Plant to animal subsistence ratios and macronutrient energy estimations in world wide hunter gatherer diets. Am J Clin Nutr, 2000, 71:682-92 Vegan/Vegetarian Diets: Poor Sources of Essential Nutrients . Plant foods are devoid of Vitamin B12 . A study of 95 vegetarians showed 77% of lacto/ovo and 93% of vegan subjects were B12 deficient when levels of both holotranscobalamin II and methylmalonic acid were employed15 . B12 deficiencies elevate plasma homocysteine . A meta analysis, 15 of 17 studies showed vegetarians had higher blood levels of homocysteine than omnivores16 . High homocysteine increases risk for CVD (meta analysis)17, dementia18, osteoporosis19, and infertility20 15Herrmann W et al.. Vitamin B-12 status, particularly holotranscobalamin II and methylmalonic acid concentrations, and hyperhomocysteinemia in vegetarians. Am J Clin Nutr. 2003 Jul;78(1):131-6. 16Obersby D et al. Plasma total homocysteine status of vegetarians compared with : a systematic review and meta-analysis. Br J Nutr. 2013 Mar 14;109(5):785-94 17Humphrey LL et al. Homocysteine level and coronary heart disease incidence: a systematic review and meta-analysis. Mayo Clin Proc. 2008 Nov;83(11):1203-12. 18Werder SF. Cobalamin deficiency, hyperhomocysteinemia, and dementia. Neuropsychiatr Dis Treat. 2010 May 6;6:159-95 19 Krivosíková et al. The association between high plasma homocysteine levels and lower bone mineral density in Slovak women: the impact of vegetarian diet. Eur J Nutr. 2010 Apr;49(3):147-53 20 Forges T et al. Impact of folate and homocysteine metabolism on human reproductive health. Hum Reprod Update. 2007 May-Jun;13(3):225-38. Vegan/Vegetarian Diets: Poor Sources of Essential Nutrients . Plant foods are devoid of long chain omega 3 fatty acids (22:6n3 - DHA, 20:5n3 - EPA) . Plant food sources of (18:3n3 – ALA are inefficiently converted in the body to DHA (< 1%)21 . Vegetarians and vegans are nearly universally deficient in DHA and EPA22 . Fe and Zn in whole grains and legumes are poorly absorbed in vivo because they are bound to phytate . Zn deficiencies are nearly universal in vegetarians23 and Fe deficiencies are common24 21Plourde M, Cunnane SC. Extremely limited synthesis of long chain polyunsaturates in adults: implications for their dietary essentiality and use as supplements. Appl Physiol Nutr Metab. 2007 Aug;32(4):619-34. 22Davis BC, Kris-Etherton PM. Achieving optimal essential fatty acid status in vegetarians: current knowledge and practical implications. Am J Clin Nutr. 2003 Sep;78(3 Suppl):640S-646S 23 Foster M et al. Effect of vegetarian diets on zinc status: a systematic review and meta-analysis of studies in humans. J Sci Food Agric. 2013 Aug 15;93(10):2362-71. 24Obeid R et al. The impact of on some haematological parameters. Eur J Haematol. 2002 Nov-Dec;69(5- 6):275-9 Vegan/Vegetarian Diets: Poor Sources of Essential Nutrients . Vegetarians and vegans frequently maintain iodine deficiencies25 and vegetarian diets induced iodine deficiencies in omnivores in as few as 5 days26 . Soybeans and soy products contain antinutrients which impair iodine uptake by the thyroid gland27, 28 . Soy consumption may be associated with hypo- Soybean products: , tempeh, thyroidism, goiter and auto- soy milk, soy sauce, miso immune thyroid disease28 25Krajcovicová-Kudlácková M, et al. Iodine deficiency in vegetarians and vegans. Ann Nutr Metab. 2003;47(5):183-5. 26Remer T, Neubert A, Manz F. Increased risk of iodine deficiency with vegetarian nutrition. Br J Nutr. 1999 Jan;81(1):45-9 27Tran L, wt al. Soy extracts suppressed iodine uptake and stimulated the production of autoimmunogen in rat thyrocytes. Exp Biol Med (Maywood). 2013 Jun;238(6):623-30. 28Doerge DR, Sheehan DM. Goitrogenic and estrogenic activity of soy isoflavones. Environ Health Perspect. 2002 Jun;110 Suppl 3:349-53. Vegan/Vegetarian Diets: Poor Sources of Essential Nutrients

Sunrise . The largest study of vegetarians At Tahoe (The Epic-Oxford Study), showed blood levels were highest in meat eaters and lowest in vegans and vegetarians29 . Nearly 8% of the vegans maintained clinical deficiencies of vitamin D29 . Whole grains contain antinutrients which suppress vitamin D metabolism10,31

29Crowe FL, et al. Plasma concentrations of 25-hydroxyvitamin D in meat eaters, fish eaters, vegetarians and vegans: results from the EPIC-Oxford study. Public Health Nutr. 2011 Feb;14(2):340-6. 10Cordain L, (1999). Cereal grains: humanity’s double edged sword. World Review of Nutrition and Dietetics, 84: 19-73. 31 Batchelor AJ, Compston JE: Reduced plasma half-life of radio-labelled 25-hydroxyvitamin D3 in subjects receiving a high fiber diet. Brit J Nutr 1983;49:213-16. Vegan/Vegetarian Diets: Concentrated Sources of Antinutrients

. Whole grains, particularly . Virtually all Legumes are gluten containing grains, concentrated sources of (Wheat, Rye and Barley) are antinutrients32, including: concentrated sources of . Saponins 31 antinutrients , including: . Lectins . Gluten . Phytate . Lectins (wheat germ . Alpha inhibitors agglutinin) . Polyphenols (tannins, . Phytate isoflavones) . Thaumatin like proteins . Protease Inhibitors . Alkyl resorcinols . Raffinose oligosaccharides . Alpha amylase inhibitors . Cyanogenetic glycosides . Tannins . Favism glycosides . Protease Inhibitors . Which may elicit multiple . Which may elicit multiple adverse health effects32 adverse health effects10

10Cordain L, (1999). Cereal grains: humanity’s double edged sword. World Review of Nutrition and Dietetics, 84: 19-73 32Cordain L. (2012). The Paleo Answer. John Wiley and Sons, New York, NY, pp. Thank You!