Archive for August, 2005

Sensational Headlines: Metabolic Syndrome and the ADA

In recent days a number of headlines have suggested that the American Diabetes Association (ADA), in a joint statement with the European Association for the Study of Diabetes (EASD), have stated that Metabolic Syndrome doesn’t exist.

Based on the headlines, I, too, was outraged at the suggestion that one of the leading organizations for diabetes would take such an erroneous position. But, as is often the case, the published review does not synch with the headlines. This is one reason why it is so important that we look at the actual primary sources rather than headlines reporting on the primary! In this instance, the media has sensationalized the published paper, leading to a gross misrepresentation of what the review actually says and why it was published.

Let’s take a look at the actual publication in Diabetes Care: The Metabolic Syndrome: Time for a Critical Appraisal

The review opens with the critical paragraph:

The term “metabolic syndrome” refers to a clustering of specific cardiovascular disease (CVD) risk factors whose underlying pathophysiology is thought to be related to insulin resistance. Since the term is widely used in research and clinical practice, we undertook an extensive review of the literature in relation to the syndrome’s definition, underlying pathogenesis, and association with CVD and to the goals and impact of treatment. While there is no question that certain CVD risk factors are prone to cluster, we found that the metabolic syndrome has been imprecisely defined, there is a lack of certainty regarding its pathogenesis, and there is considerable doubt regarding its value as a CVD risk marker. Our analysis indicates that too much critically important information is missing to warrant its designation as a “syndrome.” Until much needed research is completed, clinicians should evaluate and treat all CVD risk factors without regard to whether a patient meets the criteria for diagnosis of the “metabolic syndrome.”

Basically, the statement makes sense – we know from the evidence (which dates back to the 1980’s and continues through the present) of the existence of metabolic-type syndrome: a cluster of oft-related components – obesity, hypertention, dislypidemia and insulin resistence.

What is presently lacking, and what the paper highlights, is:

  • A solid, working definition that has consensus/agreement
  • A thoroughly-understood pathogenesis (that is what happens to someone with the syndrome)
  • An agreed upon treatment course for those diagnoised
  • A standard of care for those diagnosed
  • Effective strategies that can help prevent metabolic syndrome

And these are the core of the paper published – the lack of adequate evidence about what to do with a patient presenting with the components in the cluster of symptoms known as “metabolic syndrome.” Nowhere in this paper is there a denial that there is real medical problem in people with this cluster of symptoms.

In reviewing the paper published it comes to light that the ADA and EASD are concerned that without the critical scientific data, we’re missing critical information to guide the best treatment.

They call for additional research with specific attention directed toward:

  • A critical analysis of how the syndrome is defined. Are all risk factors equally important? Do some combinations (of two, three, or four factors) portend greater CVD risk than others?
  • A definition of the syndrome, in which variables have defined lower and upper cut points or that uses continuous variables in a multivariate score system (e.g., Framingham/UKPDS risk engine).
  • An evidence-based analysis assessing the rationale and value of adding (or replacing) other CVD risk factors (e.g., age, CRP, family history, a direct measure of insulin resistance) to the definition.
  • An assessment of CVD risk in subjects with combinations of intermediate phenotypes only (e.g., IFG/IGT, mildly elevated triglycerides, blood pressure 120–140 mmHg) and who have, or don’t have, insulin resistance or hyperinsulinemia.
  • An aggressive research agenda to identify the underlying cause(s) of the CVD risk factor clustering.

So, while the headlines blared at us that the ADA has suddenly taken to the idea that Metabolic Syndrome doesn’t exist – the actual publication shows that the ADA is concerned with a lack of definition, pathogenesis and treatment; and strongly states we must use an evidence-based approach to tackle these issues. I have to say I agree!

If you’re one of millions already diagnoised with Metabolic Syndrome, this paper does not sweep away your diagnosis or diminish the risks you’re facing. We know, based on the evidence to date, that the most effective way to reduce risks right now, in those with Metabolic Syndrome (that is with components of the cluster of symptoms) is – weight reduction, adequate nutrition, exercise and reduction of stress.

With regard to nutrition, we now also know through Level 1 evidence that carbohydrate restriction is the fastest drug-free method for addressing the “cholesterol” (e.g. HDL and triglyceride) and “insulin” issues seen in the vast majority of those with the condition.

August 31, 2005 at 4:15 pm 1 comment

Low-Carb: Two Studies – Different Findings

The media last week picked up the news that two studies investigating low-carb diets were completed and the results are in.

The first study from researchers at the University of Illinois found that diet composition rich in protein combined with exercise was more effective for weight loss than the USDA Food Guide Pyramid with both diets providing participants the same calories each day.

Both groups consumed the same number of calories, but the first group substituted high-quality protein foods, such as meats, dairy, eggs, and nuts, for foods high in carbohydrates, such as breads, rice, cereal, pasta, and potatoes.

The really important difference was the fact that when combined wiht exercise, the “high protein” group lost fat while sparing lean body mass and the USDA Food Guide Pyramid group lost muscle – as much as 25% to 30% of their weight loss – with their fat.

But, in the protein-rich, high-exercise group, Layman noted a statistically significant effect. That group lost even more weight, and almost 100 percent of the weight loss was fat, Layman said. In the high-carbohydrate, high-exercise group, as much as 25 to 30 percent of the weight lost was muscle.

In addition to the muscle-sparing effects, those following the higher protein diet also experienced greater improvements in their triglyerides and had a more dramatic (statistically significant) effect on trunk fat (in the mid-section). The researchers credit an increase in leucine in the higher protein, low carb approach as contributing to these effects.

As lead researcher, Donald Layman noted, “The diet works because the extra protein reduces muscle loss while the low-carbohydrate component gives you low insulin, allowing you to burn fat. We believe a diet based on the food guide pyramid actually does not provide enough leucine for adults to maintain healthy muscles. The average American diet contains 4 or 5 grams of leucine, but to get the metabolic effects we’re seeing, you need 9 or 10 grams.”

To achieve that leucine level, the researcher recommended adding dairy, meat, and eggs, all high-quality proteins, to the diet. According to Layman, losing weight doesn’t have to mean relying on supplements to fill in nutritional gaps in your diet. “If you use a high-quality protein approach to your diet, you can actually improve the overall quality of your diet while losing weight,” he said.

Now the above study was a four month investigation. That’s considered “short-term” and researchers really prefer long-term data, which brings me to the second study in the media this week from down under.

Researchers from Otago University just completed a one-year study comparing conventional diets to Zone-type 40:30:30 diets to high protein, low-carb Atkins-tyle diets.

The new findings are a follow-up to the data released at six months where the researchers concluded that “In routine practice a reduced-carbohydrate, higher protein diet may be the most appropriate overall approach to reducing the risk of cardiovascular disease and type 2 diabetes.”

As reported in New Zealand’s Stuff, the researchers are now strongly advising against sticking to the restrictive diet for more than a year, because of its potentially harmful effects on the cardiovascular system and anti-oxidant levels.

Hmmm….I wonder, what changed their mind?

How about we go look at the data?

Oh, it’s not yet published. But it will – soon – really – in the International Journal of Obesity!

So, we have no data to look at.

We have only a news article at this time to try to assess a research study and data.

Ya know what I call this? Convenient.

But, I digress….what the article does tell us is that the Atkins-type diets lost the most weight but gained more quickly when they abandon the strict rules. As one of the researchers, Dr Kirsten McAuley said, the change after the first six months is “[m]ainly because it was too restrictive, we would certainly have concerns about high-fat diets.”

Throughout the article there is anecdotal experiences provided by some who followed the diets. Yet, there is no hard data offered. No data providing insight into cholesterol levels, bone density, weight loss, fat loss, muscle loss, glucose control – basically nothing considered hard data which is what we need here!

Based on what we do have available, it’s already clear that part of the “problem” was dieters abandoning the low carb diet for another approach.

If weight gain happened after a switch to a different approach, an approach many consider “healthy and better” – one must ask – WHY! Why did the dieters success reverse on a different approach?

No one seems to be asking that question – instead we find the researchers stating that the problem was the low-carb diet, when the facts available (published data) show the approach worked.

Until the data is published it is difficult to write more about this study. What I will do is await the publication in the International Journal of Obesity and then report back to you my readers what the data reveals! Until then, I see no reason to abandon controlled-carb diets – the weight of the evidence, even with this potential study showing a negative result, still weighs in favor of controlled-carb nutritional approaches!

August 27, 2005 at 2:45 pm 3 comments

The 20-Year Decline Leading to Diabetes

Researchers from Howard Hughes Medical Institute (HHMI) have found there exists a detectable decline in energy production by mitochondria in cells which seems to be a key problem leading to insulin resistance, and later to Type II diabetes. The researchers said that insulin resistance is detectable as early as 20 years before the symptoms of diabetes become evident.

The research, led by Gerald Shulman, may lead to better testing and prevention of Type II Diabetes in the future. Shulman and his colleagues found that the rate of insulin-stimulated energy production by mitochondria is significantly reduced in the muscles of lean, healthy young adults who have already developed insulin resistance and who are at increased risk of developing diabetes later in life.

Their research shows that a decreased ability to burn sugars and fats efficiently is an early and central part of the diabetes problem. This new data also suggest the basic defect lies within the mitochondria, which exist in almost every cell in the human body.

In the new studies, Shulman and colleagues discovered that the mitochondria in muscle cells respond poorly to insulin stimulation. Normal mitochondria react to insulin by boosting production of an energy-carrying molecule, ATP, by 90 percent. But the mitochondria from the insulin-resistant people they tested only boosted ATP production by 5 percent.

Among their findings was also evidence for a severe reduction in the amount of insulin stimulated phosphorus transport into the muscle cells of the insulin-resistant participants. This also points to a dramatic defect in insulin signaling and may explain the observed abnormalities in insulin-stimulated power production in the insulin-resistant study subjects, since phosphorus is a key element in the mitochondrion’s complex energy-production process, the oxidative-phosphorylation pathway.

This is some very important research. Not only does it demonstrate that warning signs are evident in the body very early before one actually becomes diabetic, it also indicates that insulin is a strong influence on the overall ability of cells to function properly well before outward signs of insulin resistence and diabetes are measurable.

Today the average American is eating excessive amounts of carbohydrate from very early in life. The human body simply does not need the very high level of carbohydrate we eat on average each day. The constant high level that is eaten is taking its toll slowly inside our cells, damaging our cells ability to effectively utilize the insulin and glucose.

Controlling carbohydrate intake to a level that effectively provides the energy and essential nutrients we do need without being excessive is really an important step to long-term overall health. Not only will controlling carbohydrate help maintain your weight, it also helps to keep your insulin levels stable – something that is key to limiting or avoiding insulin resistance.

We know from various studies that insulin resistance is present in virtually every Type II diabetic. We now know that insulin resistence slowly emerges, over time, as cells lose their ability to function properly. What you eat today truly will have an impact on your health 5, 10, 20-years down the road. The good thing is that it is never too late to modify your eating habits to be health promoting – that is eat a diet rich in essential nutrients, control your carbohydrates, eliminate the junk and include adequate protein and natural fats and oils.

August 25, 2005 at 2:15 pm Leave a comment

Calories Count – In More Ways than you Think

For a number of years now I’ve suggested that the conventional wisdom of calorie-restriction to lose weight is flawed – that it is very possible to eat too few calories and unwittingly sabatoge weight loss efforts; that many who struggle to lose weight are eating too few calories and undermining their metabolism in the process; and that the standard, one-size-fits-all recommendations to restrict calories to 1200-1600 calories per day for weight loss is too low for too many people.

Without hard data, I’ve relied on the idea that the Basal Metabolic Rate (BMR) in metabolism may be the trigger for a “conservation of energy” in the human body. That taking daily calories below the BMR triggers what many call “starvation mode” in the metabolism – that is, the body starts to use less energy as it prepares to survive what it perceives as a famine condition.

My recommendation has remained consistent over the years – one must try to determine their BMR and eat enough calories to meet that calorie requirement for basic function so the body will allow for loss of its stored energy – fat on the body. Interestingly, the BMR of most people is much higher than they realize and certainly higher than the often recommended calorie-restriction of 1200-1600 calories per day for weight loss.

For example, a 250-pound woman who is 5’5″ tall and 35 years old has a BMR of approximately 1880-calories per day. If she restricts her daily calories each day to 1400 or 1600-calories, she will set her metabolism up to perceive a famine since she is not eating enough calories to meet her body’s basic requirements to just function. Over the first few weeks she will lose weight, but she will also unwittingly be slowing her metabolism to perserve her stored energy – her fat stores – to survive the famine the body perceives with a calorie intake that fails to support basic function, which in turn causes the body to conserve energy, which slows or stops weight loss.

Recently hard data was published to support that such a metabolic slowdown exists and happens as one restricts calories.

In the Journal of Clinical Endocrinology and Metabolism, researchers published their findings in a study to investigate the effect of weight loss induced by caloric restriction on diurnal TSH concentrations and secretion in obese humans.

This was a “gold standard” study protocol – a rigorous clinical, prospective, crossover study that measured 24-hour plasma TSH concentrations at 10-min intervals along with the 24-hour TSH secretion rate. The results were fascinating!

  • The 24-h TSH secretion rate was significantly higher in obese women than in normal weight controls
  • Weight loss was accompanied by diminished TSH release (before weight loss, 43.4 ± 6.4 mU/liter·24 h; after weight loss, 34.4 ± 5.9 mU/liter·24 h; P = 0.02)
  • Circulating free T3 levels decreased after weight loss from 4.3 ± 0.19 to 3.8 ± 0.14 pmol/liter (P = 0.04)
  • Differences in 24-h TSH release correlated positively with the decline of circulating leptin (r2 = 0.62; P

Now I know some of you are scratching your head wondering – OK, what does that mean?

Well, the researchers stated it best in their conclusions: Elevated TSH secretion in obese women is significantly reduced by diet-induced weight loss. Among various physiological cues, leptin may be involved in this phenomenon. The decreases in TSH and free T3 may blunt energy expenditure in response to long-term calorie restriction, thereby frustrating weight loss attempts of obese individuals.

This data shows that there does exist a measurable slow down in the metabolism with calorie restriction. That slow down can significantly affect weight loss. That it is possible to restrict calories too much and affect the endocrine system in the body, making it adjust and slow the metabolic rate to conserve energy.

Now, researchers did not look at BMR in this study. What this study does confirm is the delicate balance the body has to survive – if you’re not providing enough “fuel” the body will slow itself down and conserve energy so it can survive with less calories.

While many staunchly defend the “calories in calories out” perspective, those who have experienced weight loss stalls and stops during calorie restriction can now feel a sense of vindication and begin to understand how to lose weight effectively without damaging your metabolism!

Your first step is to eat enough calories to support your basal metabolic rate.

As you lose weight, your metabolism slowly does require less calories because it does not have the same “bulk” to support, so you must adjust your calories downward SLOWLY as you lose weight, not from the start. Give your body what it requires for calories to meet basic function so it does not try to conserve energy from the start.

In the above example, the calorie requirement each day should be no less than 1900-calories each day until 10-pounds are shed. Then re-calculate the BMR and adjust calories – at 240, the BMR is now approximately 1839-calories, so the requirement is adjusted down to 1850-calories a day for the next 10-pounds of weight loss. This is approximate…the key here is to make sure you’re eating at or up to 10% above your BMR.

With each 10-pound loss, an adjustment of calories downward, of about 50-calories per day, helps the body maintain its basic function (blood flow, body temperature, heartbeat, etc.) and allow the loss of stored energy – fat – rather than starvation mode to conserve energy and slow or stop loss of stored energy. As one nears their goal weight, calorie intake is slightly adjusted up to the Active Metabolic Rate (AMR) to allow the body to have the calories it needs to support not only basic function, but also movement each day.

At goal, finding that balance where you no longer lose weight yet do not gain weight is not easy, but not impossible. It means taking the time to get it right and watching your weight to ensure you’re not gaining again. If you start to gain, tweak your calorie intake slightly and watch. You will find the right calorie load to maintain your weight and keep your metabolism happy too!

This approach is highly individual – as it should be – and breaks the conventional wisdom that if you just restrict your calorie intake long enough you’ll lose weight. Yes, you’ll lose weight, but at what cost to your long-term health? To you long-term ability to keep the weight off? To you emotional well being as you struggle to maintain a calorie intake that is too low?

August 24, 2005 at 4:21 pm 3 comments

Raising the Bar on Breakfast

When you read the newspaper, do you expect the articles and bylined columns to be news or cleverly disguised advertisements?

If you’re like me, you expect news or newsworthy information. Too often, in newspapers across the country, you’re likely to find items that read like advertisements for a number of products on the market with the newspaper seeming to promote your purchase of such items.

Case in point – in today’s Washington Post, Sally Squires’ Lean Plate Club column offers readers Passing the Bar On Nutrition – a review of the various breakfast bars available in the marketplace.

Breakfast bars made by Kellogg’s, Post, General Mills, Quaker, Kraft and other companies offer a fast-food option to those eating on the run in the morning. Found just down the grocery aisle from their cereal cousins, many are fortified with enough vitamins to rival a multivitamin. To make up for the missing milk, some bars also contain plenty of calcium.

This wasn’t merely a ‘just the facts’ approach to provide information to readers about the existence of such products and the pros and cons of such products – this article named which ones tasted good and made recommendations to readers of the column.

Unfortunately, the article didn’t simply state that the breakfast bars are nutritionally poor and just another junk food option you should pass on. Sally Squires actually recommended you eat more than one if the breakfast bar is your option since one may not last until lunch!

Plan on More Than One. The bars will help take the edge off your hunger, but they probably don’t have enough calories to hold you until lunch. So either eat more than one bar or have a bar as part of breakfast that includes milk or a cup of low-fat yogurt and some fruit.

While taste testers basically agreed the breakfast bars were too sweet, Ms. Squires enlisted the opinion of an “expert” to encourage readers to eat them. Even so, eating a cereal bar in the morning “is better than eating nothing at all,” said registered dietitian Amy Jamieson-Petonic, a spokeswoman for the American Dietetic Association. “Study after study shows the benefit of breakfast.”

Yes, there is a benefit to eating breakfast…but quite frankly something that is nothing more than a candy bar in disguise is not breakfast. Ms. Jamieson-Petonic should have stated such and made a recommendation about the benefit of a wholesome breakfast. Instead, she offered nothing more than an endorsement to these various products that are unhealthy, made by companies that support the American Dietetic Association.

Even Ms. Squires idea of a breakfast is nutritionally bankrupt – just have the real thing: a bowl of cereal with low-fat milk and fruit, which can match or exceed the nutritional value of a cereal bar.

While such a breakfast may indeed be better than the breakfast bar, it remains inadequate and will most likely not keep your sated until lunch.

A better option:

Florentine omelete (2 eggs, 1/4 cup spinach, 1-ounce swiss cooked in olive oil)
1-ounce uncured Canadian Bacon
1/2 cup cut canteloupe with 1/3 cup blueberries

Now that’s a breakfast to get you started for the day!

August 23, 2005 at 2:10 pm Leave a comment

"You’re Obese"….What Next?

Imagine you’re in your doctor’s office having an annual physical and the doctor tells you that you’re obese and obesity may lead to heart disease, stroke, diabetes, gastroesophageal reflux and even might make it hard for you to find another partner should you outlive your spouse.

What do you do?

Well, for a woman in New Hampshire, her response was to file a complaint with the state Medical Board. She was offended that her doctor told her the truth! When her doctor learned she was upset, he wrote her a letter to apologize to her, but that wasn’t enough.

Now you’d think the Medical Board would tell this woman ‘hey, you are obese and the things the doctor said may happen because you’re obese are all evidence-based’ – but that’s not what happened. Instead, the medical board is pursuing this case with an investigation.

[T]he board asked the Attorney General’s Administrative Prosecution Unit to investigate and seek a resolution to the complaint. A settlement agreement was proposed that would have had Bennett (the doctor) attend a medical education course and acknowledge he made a mistake. He rejected the proposal.

“I’ve made many errors in my lifetime. Telling someone the truth is not one of them,” Bennett said.

A public hearing is likely to be scheduled by the board.

I don’t know about you, but to me this is a waste of resources and a waste of time. Doesn’t the Medical Board of New Hampshire have some real issues to investigate, like physician incompetence or dishonesty? Do they really have nothing else to do that this is something they actually have time to pursue?

Have we as a society become afraid of the truth so much that we’re willing to file complaints against doctors who tell us the truth, because the truth hurts our or someone else’s feelings?

August 22, 2005 at 3:46 pm Leave a comment

Low-Carb Lifestyle Piques Interest of Researchers

Researchers at SUNY Downstate want to know what real people following a low-carb diet do to maintain their lifestyle.

In an effort to reach those following a low or controlled-carb diet, the researchers have teamed up with an online support forum dedicated to the low-carb lifestyle – Active LowCarber Forums, to host an online survey of 27-questions that takes about 5-minutes to complete.

The questions are designed to give researchers insight into what real people eat on a low-carb diet in the real world. An approach, that until now, researchers investigating low-carb diets have not utilized as they’ve followed dieters in controlled settings. Reaching those in the “real world” is often cost prohibitive for researchers, but with the access provided by the internet, researchers can now interact with those following a low-carb lifestyle more easily.

With the unique setting of an online low-carb support forum, the researchers hope to reach the very population they’d like to understand better – the low-carb dieter losing weight and those who have lost weight and are maintaining their weight with a controlled-carb lifestyle. The survey is designed to allow users to answer questions and do so only once, so if you take the survey, you cannot take it again.

Dr. Richard Feinman will be leading the study and has designed questions related to eating habits, state of health, activity level and more. For those following a low-carb diet and lifestyle, this is an opportunity to help researchers understand the way of life you’re passionate about.

As the start page for the survey notes, [c]arbohydrate restriction continues to be of importance as a method for weight reduction and treatment for diseases such as diabetes and cardiovascular disease. Scientific studies, however, are largely restricted to an abstract, experimental setting and there is a lack of information as to what people really do on low carbohydrate diets and how they feel about them. This survey is designed to help provide this information. The purpose is neither to support nor to criticise any diet but only to provide information.

The survey is found online here: Nutritional Information from an Internet-based Support Group: What can we learn from the Active Low-Carber Forums?

August 18, 2005 at 2:00 pm 5 comments

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