Archive for September, 2005

Dietary Debate: Dogma, Opinion or Evidence

As difficult as it is to let go of old habits and engrained beliefs, it is something we must do if we are going to tackle the very real issue of obesity in the United States. For more than thirty years we have been entrenched in the belief that dietary fats are the enemy and that strict limitation is the key to health and weight management.

While it is easy to assume that the general population simply ignores the recommendations to their own detriment, it is much harder to ignore facts and hard data.

In recent months a number of scientific journals have published reviews, editorials and commentaries about carbohydrate restriction as a potential approach for the obese and those with Type II Diabetes. Each has a common thread – the dietary recommendations today lack sufficient scientific evidence to support them.

What? Could it be that the recommendations we have in place today are no more than a collection of misinterpreted data and opinions?

How about we look at one of the recent articles.

In the September issue of Endocrine Today, Samy McFarland, MD, MPH provides a guest editorial titled “Dietary recommendations for people with diabetes: Time to reduce the carbohydrate loads. Recommendations should take account of current evidence for carbohydrate restriction” (To read the article you will need to register. Registration is free.)

In it, he starts by building the case for alternative options based on cold hard data.

“According to the USDA Continuing Survey of Food Intakes by Individuals (CSFII), the absolute amount of fat as well as saturated fat consumed has significantly decreased during the obesity epidemic. From a public health perspective, this represents a failure of low-fat/high-carbohydrate strategies to curb the obesity epidemic or at least to negate the other contributing factors such as sedentary lifestyle.”

He then continues to explore the impact of traditional low-fat recommendations in those with diabetes, examining reports by his own group and others, including national data.

“…in a national survey by our group across several health care delivery systems, 3,678 records of diabetic patients were examined with only one-third of the patients achieving HbA1c of less than 7%.

“These data, from 2002, are consistent with data from the Third National Health and Nutrition Examination Survey (NHANES III, conducted 1988-1994) and NHANES 1999-2000. Collectively, these data show a consistent pattern of overwhelming obesity and poor control of glycemia and dyslipidemia in the diabetic population despite decades of low-fat recommendations.”

He believes this hard data points to the need explore alternative dietary approaches. High on the list of alternatives is carbohydrate restriction. His reasoning? “… the current evidence for its effectiveness.

First up in the current evidence – two large, long-term studies – the Nurses Health Study and the Health Professional Follow-Up Study. Both studies show that dietary carbohydrate intake (measured as glycemic load) is linked with the risk of type 2 diabetes and CVD. The use of glycemic load as a measure helps to determine the quality and quantity of the carbohydrate in the overall diet.

He continues with current prospective cohort studies which show worsening of glycemic control and dyslipidemia in diabetic patients with a high-carbohydrate diets, while showing how carbohydrate restriction may actually reverse these serious metabolic abnormalities.

He even brings to light the fact that these data were acknowledged during the development of the 2005 Dietary Guidelines for Americans, but were quickly dismissed on the basis of “concern that increased fat intake in ad libitum diets may promote weight gain.”

He continues with, “[t]his concern, however, has not been substantiated, and at least two studies show that low-carbohydrate diets are not associated with increase in dietary intake of proteins or fats presumably due to effect of these diets on satiety.”

Throughout the rest of the editorial, he explores each of the benefits noted in various studies – glycemic control, reduction of postprandial hyperglycemia, improvements in dyslipidemia, increased insulin sensitivity, and reduction in antidiabetic medication in diabetics.

Sadly, he felt he needed to state within his editorial that “Because of the somewhat contentious atmosphere surrounding this subject, I feel obligated to point out that I am not supported or affiliated in any way with any individual or entity that promotes a particular diet.”

Isn’t this about science – the evidence and hard data? While I wish he didn’t need to make such a statement, I understand his reasons. The current atmosphere around anyone advancing the scientific evidence that supports carbohydrate restriction today is indeed critical and filled with suspicion of influence from vested-interest parties; as if the science itself is not main driving force.

After his disclaimer, he states, “This editorial is intended to stimulate a scientific and scholarly debate that will lead to more effective dietary recommendations that take account of the current evidence for carbohydrate restriction. This will thereby provide more options to our patients and our society at large in the current struggle with the epidemic of obesity and diabetes, which is claiming thousands of lives daily and leaving many people disabled.”

He wraps up the editorial quite nicely with “It is also important to establish guidelines for carbohydrate restriction, especially emphasizing the use of mono- and polyunsaturated fats as a way to achieve caloric balance, since these have been inversely linked with CVD risk. I also believe that clinical trials need to be conducted using graded levels of carbohydrate restriction and fat intake, with special emphasis on unsaturated fats, to examine their effects on weight loss, glycemic control, insulin resistance and CVD. An open-minded analysis of such experiments is needed to resolve the present controversy about optimal dietary recommendations for patients with diabetes.”

Can you hear me saying “Yeah!”

For years I’ve been saying “we need to be strictly committed to the scientific evidence” to establish evidence-based recommendations.

When the 2005 Dietary Guidelines for Americans were released, I was highly critical of the lack of references to the data that was supposedly used to formulate the recommendations.

I’ve continued to advocate for more individualized approaches and options in the “toolbox” and will continue to do so in the future. We know there is no one dietary approach that works for everyone. It is high time the medical and scientific communities publically acknowledged such and started the process to develop clinical guidelines for the various approaches that are supported by evidence and hard data. Such guidelines would provide healthcare professionals with useful options and tools for their patients – each of whom is an individual in need of a “diet” that is best suited for their individual needs!

After you’ve had some time to read the above editorial, you might want to write to the Editor of Endocrine Today to express your appreciation for publishing what is, sadly, a highly contentious issue!

September 30, 2005 at 4:42 pm Leave a comment

Evidence, or Lack Thereof, and the Impact on Health Recommendations

Want to see a good example of disagreement within the scientific community? Not only disagreement, but a disagreement that is based soley on the interpretation and use of scientific evidence.

Eggs.

Here in the United States, one of the leading medical organizations, the American Heart Association (AHA), continues to recommend that everyone to limit their consumption of eggs due to the cholesterol contained within the yolk. In fact, the upper limit per day is maybe one egg and that’s IF total dietary cholesterol intake from all sources is within the AHA recommended upper limit of 300mg per day.

A large egg contains about 213mg of cholesterol, so one egg per day is probably unrealistic due to cholesterol in other foods that are part of the diet. The AHA even clarified this restriction on their website to ensure anyone thinking that an egg a day is okay would understand that is not the AHA position!

The recommendation remains even though various large, long-term population studies have resulted in mixed findings about egg consumption and health outcomes. Some studies do show an increased risk of heart disease while others clearly show no additional risk. None of these large studies look at a fundamental that really is key to understanding the role of eggs in the diet, and certainly necessary in making a general population recommendation – the overall nutrient-density in the diet of those eating or limiting eggs. Add to this the fact that many population studies start from a point of disadvantage for reliability – many are based on self-reported recall data. But I digress…

In other countries, the medical organizations that are comparable to our American Heart Association take a different view. Take the National Heart Foundation (NHF) in Australia. Not only do they make no recommendation to limit egg consumption in healthy individuals, they have given eggs the “National Heart Foundation Tick” (the equivalent of the AHA ‘heart-check’ logo in the United States).

In fact, the NHF website states the reason for the endorsement of eggs:
The Tick is all about quickly highlighting healthier choices for the general population. Sometimes Tick also needs to help dispel myths and remind people that nutritious foods like eggs, lean meat and poultry, plain unsalted nuts and avocadoes are an important part of healthy eating.

So, the NHF in Australia considers the AHA position to be one built on myths, not scientific evidence! They do make it clear that those with heart disease will need to work with their healthcare professional to assess whether including foods higher in cholesterol is appropriate, but for healthy individuals there is no restriction.

The Heart Foundation does not restrict consumption of eggs for the general population. For healthy people, the best guide is to include a wide variety of nutritious foods, including eggs. People at risk of or living with heart disease may still be able to eat eggs but they should discuss their intake of egg yolks with their doctor or Accredited Practising Dietitian.

Here is where the Australian NHF is doing a much better job in communicating with their population than the AHA is doing here in the United States. The NHF is using the evidence while the AHA continues with the “conventional wisdom” that holds that the recommendations developed for those with disease or at high risk for disease should be streamlined to the general population to reduce risk.

It isn’t that the scientists and researchers in the US don’t know that the evidence shows that there is a segment of the population that should limit cholesterol – this is well known within scientific circles, and is a segment of the population known as “responders” to cholesterol in the diet. From my understanding, those who are “responders” represent about 10% of the general population. Which leaves 90% of the population unaffected by dietary cholesterol intake.

Yet, the recommendations in the US are based on that small population of people instead of recommending testing to determine if one is a responder or not. In a recent Lean Plate Club column, Alice Lichtenstein, a professor of nutrition at Tuft’s University was quoted as saying, “Some people are responders, some people are not. If you’re not, then there’s no reason to be concerned, but the only way you can tell is by getting a blood cholesterol test.”

So you know, it isn’t a single test either, but atleast two tests done months apart, to measure the effect of including dietary cholesterol foods on your cholesterol levels.

But, rather than make recommendations toward healthy individuals and separate recommendations for those with disease or high risk, the current recommendations ignore the healthy and continue to recommend for the general population what is more appropriate for the sick in an effort to try to reduce the risk of those who are healthy.

The real question we need to ask and seek an answer to is this – have the recommendations, when actually followed by healthy individuals over a long-term period, worked to improve their long-term health AND reduced their risk of disease? To date there is no convincing evidence that a healthy individual, specifically one who is not a “responder,” should limit their intake of eggs or dietary cholesterol below 300mg per day.

What is much more important to the overall achievement of good health and well-being is the quality of the foods you eat and their nutrient-density and eggs meet that standard for healthy people!

September 28, 2005 at 4:00 pm Leave a comment

A look inside America on the Move

The press today is buzzing about the Partnership to Promote Healthy Eating and Active Living that has organized a national initiative, “America on the Move,” to encourage healthy eating and increased physical activity for individuals and groups of people interested in participating together.

Tomorrow, September 28th, is designated as the “Day of Action” to sign up and be entered into a drawing for a number of prizes.

Sounds good so far, doesn’t it?

Well, not so fast.

America on the Move is sponsored by Pepsico. That’s right, the makers of Pepsi, Frito-Lays Chips, Gatorade and Tropicana Juice among other things.

Couldn’t the organizers find any non-food industry sponsor, like say, a pedometer manufacturer – which would have been more appropriate?

Ah, but it gets better…the parent of America on the Move, the Partnership to Promote Healthy Eating and Active Living is sponsored by:

  • PepsiCo’s Smart Spot Products
  • Cargill
  • Masterfoods USA

As part of their organization, they have a conference and summit, and these are or were sponsored by:

Conference Sponsors
Summit on Promoting Healthy Eating and Active Living: Developing a Framework for Progress

  • Underwriters
    Kellogg Company
    Knoll Pharmaceutical Company
    Kraft Foods
    Masterfoods USA
    Novartis
    The Procter & Gamble Company
    The Robert Wood Johnson Foundation
    Roche Laboratories
  • Contributors
    American Diabetes Association
    Consumer Federation of America
    Sporting Goods Manufacturers Association

Summit Sponsors
An Economic Analysis of Eating and Physical Activity Behaviors: Exploring Effective Strategies to Combat Obesity

  • Major Donors
    The Coca-Cola Company
    Kraft Foods
    The Robert Wood Johnson Foundation
  • Other Contributors
    General Mills
    Kaiser Permanente
    Kellogg Company
    The Procter & Gamble Company

Are you starting to see a common thread here? The vast majority of the sponsors have a vested interest in you eating their products, many which are not exactly your best options for healthy eating!

While I applaude the idea to start a national initiative to encourage people to eat healthy and get more active, I remain suspicious of an organization that relies so heavily on food industry money. The conflict of interest is so glaring in this organization, that I have to wonder if its initative, America on the Move was started as a public relations effort by the food companies that are right now in the cross-hairs of the national debate on the obesity epidemic we’re facing.

I think what we need is a national organization that is founded, supported and financed exclusively by researchers, scientists and medical professionals and is dedicated to the science, without interference or influence from industry. Industry has too much at stake to be part of the debate – the temptation to sway the interpretation of the data too great.

September 27, 2005 at 5:55 pm 1 comment

One Billion Overweight Worldwide

Yesterday the World Health Organization warned that more than 1 billion people worldwide are overweight and that if the trend continues, the number will increase to 1.5 billion by 2015.

“The sheer magnitude of the overweight and obesity problem is staggering,” WHO Assistant Director-General of Non-communicable Diseases and Mental Health Catherine Le-Galès Camus said in the warning, issued ahead World Heart Day on 25 September.

Throught the above article, a number of statistics were presented and the rising rates of obesity were stated as being caused by a global shift in diet towards increased energy, fat, salt and sugar intake, and a trend towards decreased physical activity due to the sedentary nature of modern work and transportation, and increasing urbanisation.

More of the same “calories in calories out” explanation. Don’t get me wrong, calories do count in the weight gain-weight loss equation, but few are asking the harder question – why are we suddenly eating more calories as our requirement for calories is in decline with less activity? If you look at the data, the situation isn’t simply we’re moving less while eating the same. Not only are we moving less, we are eating more calories.

Throughout our evolutionary history, we’ve encountered situations of feast and famine and at no time in the past experienced such a dramatic surge in large segments of the population growing too large.

There have always been, and will always be, a small percentage of the population that are overweight or obese. There have been, and will always be a small percentage of the population that are underweight. These two facts are givens. The real issue is not these two ends of the spectrum populations.

The vast majority of humans, around the world, could be said to be part of the “middle population” – those who, until recently, always maintained a weight within a normal range in conditions other than famine.

Over the last thirty odd years, the focus of the medical and scientific communities and public policy makers has remained “calories in calories out” and “eat less and move more.” These are concepts even a child can understand and even though oft repeated, has done nothing to stop the rise of overweight and obesity in the United States or globally.

So, the question begs, is the message ignored or is the message wrong?

Many would contend that the message is simply being ignored. And on some level, I would agree – there are some who simply will not heed any warnings and will not alter eating habits which are leading to their weight gain. But to say that every person – 1 billion people now – are just ignoring the facts and doing nothing to change their overweight condition is ignoring the fact that the calorie theory might be wrong on some level.

Think about that for a moment. What is the likelihood that one billion people don’t understand “eat less calories and/or move more”?

Now, what is the likelihood that, given we’ve had thirty years of this message…if it really was the solution, if it really worked when followed….what is the likelihood we would still be seeing an alarming rise in the rates of overweight and obesity?

With that in mind, I contend that it is not simply the calories, but the type of calories that are far more important in the equation. We have data available from the last thirty years that consistently shows that it is a small minority who successfully are able to lose the weight and keep it off with the “eat less and/or move more” solution. Some will say that the majority who are unable to do so simply stopped following this workable approach and if they would just do it, they too would be successful in losing the weight and keeping it off.

To me, this is a very simple minded perspective that fails to ask why so many fail in their attempts to follow what should be an easy solution. Rather than ask if the problem is the solution, they’ll seek to blame the individual who has failed instead of working to find a solution that will work.

It’s a good thing that not everyone has tunnel vision about the issue. While still in the minority of those researching the causes and solutions of the obesity epidemic, a number of researchers are finding that it isn’t just the calories, but the quality of the calories; the form the calories are delivered in; and the overall quality of the nutrient load provided by the calories.

With one billion people already overweight globally, and that number continuing to grow daily, we need real solutions to reverse this trend. The solution is not a simple “calories in calorie out” equation, but much more complex than that.

In know for myself, simply eating less calories by following a calorie-restricted plan didn’t work well. It took a radical change in my diet, from one that was heavy with starches and carbohydrates to one that was rich with nutrients but much lower in carbohydrates to effectively enable weight loss and maintenance of that weight loss. While my diet today would be best described as “controlled carbohydrate,” it is still maligned by those making dietary recommendations because, even though it is heavy with vegetables, it lacks what is considered adequate intake of grains; even though it is nutritionally complete from just my food intake, it lacks what is considered a “balanced” variety of all the food groups.

Is there one dietary approach that works for everyone? No

Is there one ratio of carbohydrates to fats to proteins that works for everyone? No

Is there one formula of how many servings each day of vegetables, fruits, meats, nuts & seeds, legumes and fats that will work for everyone? No

Given the fact that there is no one approach that is going to work, it is high time the medical establishment and public policy makers begin to open their minds to the fact that there are a number of ways to approach weight loss and management and stop recommending the single, low-fat, high carbohydrate approach as the solution for the obesity epidemic.

We have one billion people who need access to the information about the various dietary approaches that have been shown to work. We need a working “tool box” of solutions available to physicians and nutritionists to offer their patients instead of the continued “if you just eat less and exercise more” routine that is clearly not working!

September 24, 2005 at 2:34 am Leave a comment

Insulin: Fat Storage – Fat Use for Energy

Researchers at the University of California, San Diego (UCSD) School of Medicine have reported in RxPG News that chronically high levels of insulin, as is found in many people with obesity and Type II diabetes, may block specific hormones that trigger energy release into the body. In other words, high insulin levels inhibit the use of body fat for energy in the body.

The researchers found in their studies that high levels of insulin can block stress hormones known as catecholamines, which normally cause the release of cellular energy. Adrenaline is the best known example of a catecholamine. For normal metabolism to occur, the body needs a balanced input of insulin and catecholamines. One of the actions of insulin –, the main energy storage hormone, is to block activation of the protein kinase A (PKA) enzyme. After a meal, insulin levels go up, and the body stores energy primarily as triglycerides, or fat, in adipose tissue to be used later. When energy is needed, catecholamine triggers activation of PKA, and energy is released. But in people with Type II diabetes, the hormonal balance has been thrown off, because the body continues to produce and store more triglyceride instead of breaking down the fat as released energy.

The findings provide additional understanding to the cause and effect occurring when insulin levels are chronically too high. We know that as insulin levels go up and the body loses the ability to effectively use it, so it makes more, bringing insulin levels even higher as the body struggles with what is called insulin resistence. Insulin resistence is a pre-cursor to Type II diabetes.

Overweight and obesity is seen in the vast majority of those with insulin resistence and Type II diabetes due to the chronic storage of fat in the body.

“If insulin levels get too high for too long a time – which happens in many patients with type II diabetes –the normal catecholamine signal that triggers fat breakdown and energy release can be drowned out. This can lead to excessive energy storage in the adipocyte,” said Hupfeld, assistant professor of Medicine in the UCSD Division of Endocrinology and Metabolism and a co-author of the paper. “This may be one reason why chronic obesity and Type II diabetes are often seen together.”

In lay terms, one gets fatter as their ability to effectively use insulin diminishes and their body makes more insulin, thus storing more energy as fat, in an effort to compensate for the insulin resistence. It really is a vicious cycle.

Now while the article continues to say that this data underscores the goal to bring down insulin levels – which I agree with – it fails to fully explore options other than using medications known as insulin sensitizers.

Too often, the medical community is dependent on the thinking that “managing” the problem with drugs is the short and long-term solution. While such an approach may be an effective short-term aid to bring things under control, it fails to address the need to reverse and eliminate the underlying cause of the chronic high insulin – poor diet.

We know from dozens of research studies that reducing carbohydrate, especially refined carbohydrates and sugars, stabilizes insulin levels and reduces the effects of insulin resistence. This is due, in part, to the lower levels of insulin required with less carbohydrate being metabolized to glucose, which in turn stimulates insulin, which in turn (especially when insulin resistence is present) leads to energy storage as fat. So, reducing carbohydrate intake is one effective dietary approach that can improve insulin sensitivity.

There are a number of controlled carbohydrate approaches available – everything from very low carbohydrate diets (Atkins) to moderate controlled carbohydrate diets (Zone) with a number of plans between the two ends of the spectrum of carbohydrate restriction (South Beach). No matter what approach you choose, one thing is important – this is not a short-term, temporary fix. It is something that you will need to follow for the long-term so choosing a plan you can live with for the long-term is key.

September 22, 2005 at 1:55 pm 4 comments

When the Abnormal Becomes Routine

When the story of John Keitz, the 39-year-old Dundalk, Maryland man who weighed 625-pounds, ran in the Washington Post back in June, I decided not to include the story of his determination to lose weight in my blog until updates on his progress were encouraging. Sadly such an update will not be coming in the future – John Keitz died yesterday at 750-pounds.

His story is one riddled with contradiction – by all accounts, he was a charismatic gentleman, though with time he grew fatalistic about his weight; a man with an over-sized personality and an over-sized body; a happy-go-lucky sort who simply gave up and resigned himself to a bedridden state for seven years as he grew larger and larger.

In June when the Washington Post ran his story, I was shocked by the photos and the state of disarray his life was in. In the seven years since he’d fallen one evening while making dinner, the fall that ultimately led him to bed, he’d gone from 500-pounds to 625-pounds. He decided it was time to get help and was admitted to a facility near Annapolis, Maryland – eager to lose the weight and become “functional” again.

He had a good start to his weight-loss as the high-profile story in June recounted. Somehow, though, things turned for the worse over the summer. He had stopped complying with his diet and was gaining weight again. He wound up being admitted in late August to another facility in Ohio for treatment – upon admittance he was up to 752-pounds. A month later he was dead.

One has to seriously ask, just how can this happen? How can one, living with obesity, go from (no doubt) a difficult existence due to what can only be considered extreme-morbid obesity at 500-pounds, to a bed-ridden 625-pounds, to someone who finally seeks treatment and actually gains more weight while being treated for obesity – reaching a remarkable 752-pounds in less than three months?

What the hell happened here?

How does someone actually eat an excess of 444,500 calories in about 90-days, day-in-day-out consistently, to gain 127 pounds while he is being treated in two facilities? That’s right, this man had to be eating 4,938 excess calories each day! What were they feeding him? Someone was responsible for providing him with food – he was bedridden and obviously not able to walk to the refrigerator and help himself to whatever was in there!

If you haven’t noticed, I am a bit shocked by this story. Here was a man, a severely obese man, who needed help; whose life had moved beyond routine existence as a morbidly obese man to an existence that can be only described as abnormal. The abnormal somehow became routine and acceptable in his life and the lives of those around him.

Call me opinionated if you must, but I think his story is one that serves as a warning to anyone who is obese and slowly watching their life morph into a reality they wouldn’t have considered normal in years past. Take this example of a 39-year-old John Keitz and realize such altered reality happens to real people slowly, over time. Don’t wait until you’re bedridden, don’t wait until you can no longer roll over in bed and are still gaining weight, don’t wait until years have passed in such a state….do something today. I’ve said it many times, you have the power to change you life – do what you must do and don’t allow yourself to become another tragic story!

September 21, 2005 at 2:55 pm 4 comments

Grabbing a Coffee on the Run

When I stop into one of the local coffee shops to grab a cup of joe, I don’t usually worry myself with the details about what it is made with. Then again, I typically order a coffee and add my own creamer and sometimes a bit of sugar, at most a teaspoon.

But what if you do order one of the specialty blends offered on the menu board? Say, a venti Starbucks Carmel Chocolate Frappuccino. Do you know what you’re getting?

Well, Starbucks has the nutrition facts on their website in an easy-to-use format – it’s also an eye-opener! That venti Carmel Chocolate Frappuccino, with whipped cream – a whopping 730-calories!

But here is the really *disgusting* bit of information: that cup of coffee has 117g of total carbohydrate, of which 97g are sugar! That’s right – more than 24-teaspoons, you read that right 24-teaspoons of sugar in the cup of coffee. Good grief!

People pay for this? Pay to have someone else make their cup of coffee with an unbelievable amount of sugar in it?

Honestly, would you order a plain cup of coffee and then proceed to add 24+ teaspoons of sugar yourself? Here’s a more alarming visual – that’s more than a 1/2 cup of added sugar!

Would you ever consider adding that much sugar to your coffee?

Grabbing a coffee on the run may be convenient, but it’s important to be aware of what you’re getting! Before you order blindly, ask to see the nutrition facts for the various offerings – if they’re not available, stick with ordering a regular cup of coffee and add your own creamer and sweetener. That way you’re not unwittingly sabatoging your diet or your health with insane amounts of added sugar!

September 20, 2005 at 6:15 pm 2 comments

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