Archive for December, 2007
A newly published study, Structured exercise training programme versus hypocaloric hyperproteic diet in obese polycystic ovary syndrome patients with anovulatory infertility: a 24-week pilot study, in the journal Human Reproduction, finds either a structured exercise program (SET) or high-protein diet effective for obese women with PCOS.
The high-protein diet provided 35% of calories from protein and a calorie deficit of 800-calories per day. The structured exercise program (SET) was held at a facility to monitor exercise three times per week.
The researchers conducted a 24-week investigation into two different non-pharmacological interventions – exercise or diet – allowing study subjects to choose which they would prefer to follow for the course of the study. The researchers allowed patient choice so as to “improve compliance and effectiveness” rather than attempt to purely evaluate one or the other through randomization of the subjects.
Throughout the study, the women participating followed either the dietary protocol or engaged in the three-times-per-week exercise regiment at a facility that monitored them while they exercised. Each week the women also met for group education sessions to help them stay on track throughout the study.
At the end of the study, the researchers found both interventions led to statistically significant improvements – especially with regard to body weight, BMI, waist circumferance, waist-hip-ratio, insulin resistance indices and in serum SHBG, androstenedoine and DHEA-S levels. The last two were only changed from baseline in those who followed the high-protein diet.
The researchers noted that they “hypothesize in both cases insulin sensitivity improvement itself is the pivotal factor involved in the restoration of ovarian function.”
From the data itself, this appears to be a solid hypothesis. In women with PCOS who experienced a resumption of ovulation – they had significantly greater weight loss, reduction of their BMI, waist circumferance and waist-hip-ratio than those who did not ovulate.
For example, at 12-weeks, women who followed the high-protein diet and ovulated, they reduced their waist circumferance an average of 10.6cm compared to women who didn’t reducing theirs by just 2.8cm. Similar reduction in waist circumferance was noted in women following the exercise protocol – at 12 weeks those who ovulated had reduced their waist circumferance by an average of 11.7cm, where those who did not ovulate reduced theirs by just 2.8cm.
Critically important in this finding is that by 12-weeks a clinically significant improvement was noted, with no further changes at 24-weeks. This leaves open the question of whether the women in either group who did not respond favorably (ovulate) to their intervention by week 12 might have if they crossed-over to the other protocol for the remaining 12-weeks. I would think that if by 12-weeks one isn’t seeing the improvement desired, changing protocol may offer an option since the researchers noted that the two interventions seemed to work through different mechanisms – so if one doesn’t work for you, the other might.
The take home message on this one is clear – patient choice is important (in this study it led to a high rate of complicance with the intervention) since both interventions worked. If you are interested and committed to making a dietary modification to a higher-protein diet, try it….if you’re more the type to enjoy a structured exercise program, try it – this study demonstrated that both offered an effective non-pharmacological first-line intervention that was inexpensive and non-invasive for obese women with PCOS.
I’m still reading through the just released Nutrition Recommendations and Interventions for Diabetes – the 2008 position statement from the American Diabetes Association regarding dietary recommendations for those at risk for or diagnosed with diabetes.
While I finish reading the actual documents and write up what I think of the paper, here are links to what others are saying today:
Adam Campbell – Apparently Hell Just Froze Over
An article in dLife, written by Richard Feinman, PhD:
Here’s an idea to chew on: The carbs in your diet tell your body what to do with the fat you eat, so it’s the type and amount of carbohydrates that matter when it comes to your weight and health.
Virtually every bit of health information today includes the advice to avoid saturated fat — the so-called evil stuff that lurks in animal foods like steak and eggs. The basis for this recommendation is that research has shown a correlation between saturated fat intake and total cholesterol and LDL (“bad cholesterol”). The problem with these studies is that the effects are not large, there is wide variation among individuals and, in most of these studies, the predicted benefit in incidence of cardiovascular disease did not materialize. In addition, we now know much more about risk factors for cardiovascular disease (CVD) beyond LDL. No assessment of CVD risk can be made without considering HDL (“good cholesterol”), triglycerides, and the size of the LDL particle. Plenty of research shows that these markers can worsen when people reduce their intake of saturated fat and that they can improve by reducing the intake of carbohydrates.
You don’t have to be a medical researcher to recognize that this is a politically charged issue. The thing that is missing for the public is an impartial evaluation of all the data on saturated fat. My personal opinion is that there is much contradictory data and a recent review of the situation suggests that there is not sufficient evidence to make any recommendations.
There is a sense that, in the absence of definitive evidence, lowering saturated fat will at least do no harm. This is not right. The problem for people with diabetes is what happens when saturated fat is replaced with carbohydrate, and research has repeatedly shown that this may actually be harmful. Consider that, according to the Centers for Disease Control and Prevention, during the onset of the current epidemic of obesity and diabetes, almost all of the increase in calories in the American diet has been due to carbohydrate. The percent of total fat and saturated fat in our diet decreased. In men, the absolute amount of saturated fat consumed decreased by 14 percent!
One of the most striking reasons to doubt the across-the-board proscriptions against saturated fat is the report from the large scale Framingham study in the Journal of the American Medical Association, titled “Inverse association of dietary fat with development of ischemic stroke in men.” You read that right: The more saturated fat in the diet, the lower the incidence of stroke.
Perhaps the most compelling research was published in a 2004 issue of the American Journal of Clinical Nutrition by researchers from the Harvard School of Public Health. Their study showed that, in postmenopausal women with heart disease, a higher saturated fat intake was associated with less narrowing of the coronary artery and a reduced progression of disease. Even with similar levels of LDL cholesterol, women with lower saturated fat intake had much higher rates of disease progression. Higher saturated fat intake was also associated with higher HDL (the “good” cholesterol) and lower triglycerides.
If saturated fat isn’t the problem, what is?
In this study, in which greater saturated fat intake was associated with less progression of coronary atherosclerosis, carbohydrate intake was associated with a greater progression. Carbohydrate, through its effect on insulin, is the key player. Insulin not only sweeps up glucose from the blood but it also plays air traffic controller, making the call as to whether that glucose is turned into fat or is used for energy. Most importantly, insulin determines what happens to dietary fat — whether it gets stored or oxidized for fuel. In fact, the fat profile in the blood (cholesterol and triglycerides) is not strongly tied to diet.
A recent study by Jeff Volek at the University of Connecticut compared low-carbohydrate and low-fat diets. Even though the low-carbohydrate diet had three times as much saturated fat as the low-fat diet, levels of unhealthy fats in the blood were lower in the low-carbohydrate group. How is that possible? That is what metabolism does.
What is the best diet?
We don’t know the ideal diet composition. We do know that saturated fat, unlike trans-fat, is a normal part of body chemistry and extreme avoidance is not justified by current scientific data. Removing some saturated fat to reduce calories is good, but adding back carbs appears to be deleterious. It appears that healthy, carbohydrate restriction will trump the effects of any kind of fat. For a person with diabetes, blood glucose must be the first consideration. If you have relatively tight blood sugar control, the amount of saturated fat you eat may be a non-issue. You can do what we did before the diabetes-obesity epidemic: regulate your intake by your taste and your natural appetite. No one ever did want to eat a pound of bacon.
1. Food and Nutrition Board: Macronutrients. In: Dietary reference intake: National Academies Press; 2005, p.484.
2. JB German, CJ Dillard: Saturated fats: what dietary intake? Am J Clin Nutr 2004, 80:550-559.
3. MW Gillman, et al. : Inverse association of dietary fat with development of ischemic stroke in men. JAMA 1997, 278:2145-150.
4. D Mozaffarian, EB Rimm, DM Herrington: Dietary fats, carbohydrate, and progression of coronary atherosclerosis in postmenopausal women. Am J Clin Nutr 2004, 80:1175-1184.
5. JS Volek, et al. A hypocaloric, very low carbohydrate, ketogenic diet results in a greater reduction in the percent and absolute amount of plasma triglyceride saturated fatty acids compared to a low fat diet. NAASO, Boston, MA, October, 2006.
In a presentation at Berkeley in November, Gary Taubes included a quote from the 1967 International Conference on Obesity.
“Even a brief visit to Czechoslovakia would reveal that obesity is extremely common and that, as in other industrial countries, it is probably the most widespread form of malnutrition.”
This idea, the obesity is a form of malnutrition, isn’t new and there is increasing data pointing to nutrient deficiency as contrbuting to the growing prevalance of overweight and obesity around the world.
How can that be though? Don’t a number of studies point to our increasing calorie intake, along with a more sedentary lifestyle, as the cause of our growing waistlines?
While it is difficult to believe that one could be deficient for essential nutrients – vitamins, minerals, trace elements, essential fatty acids, and essential amino acids – while consuming so much food, let’s see what the published data tells us.
Back in Janaury I wrote about a study out of Sweden that found four-year-old children already insulin resistant and overweight. One statistically significant finding was that the heaviest children were those consuming the least amount of dietary fat; they were also found to be deficient in vitamin D, iron and omega-3 fatty acids. Yet they were classified as obese. How did they manage to eat too much yet fail to meet nutrient intake levels for health and well-being?
In 2000 a survey of workers at a fertilizer plant revealed that many were overweight and obese – concurrent with their intake of excess calories they were found to be deficient in vitamin A, thiamin (B1) and consumed a poor ratio of mineral salts. The researchers concluded “Hyper-energetic, disbalanced nutrition, and incorrect nutritional-behavioral model are factors that determine the prevalence of overweight and obesity among the workers examined.”
A study published last summer concluded that “Vitamin D insufficiency was associated with increased age, BMI, and SBP, and decreased HDL-C.”
Just this month, a stunning paper was published examining the presence of micronutriet deficiencies in women. The researcher, Dr. Aswaf “examine[d] the relationship between micronutrient deficiency and the prevalence of mothers’ overweight/obesity in Egypt using the 1997 Egyptian Integrated Household Survey. The ordered logit results show an overlap between micronutrient deficiency and the prevalence of mothers’ overweight/obesity in Egypt. The odds of being overweight/obese are 80.8% higher for micronutrient deficient mothers than for non-deficient mothers, keeping all other variables constant.”
Lastly, and by no means the end of the data we could look at, data published from the NHANES surveys tell us something really interesting – over the last few decades our intake of protein has remained stable, level, not increased; our intake of fats and oils has also remained stable; our intake of carbohydrate has increased – yet deficiency in critical nutrients is increasing amongst the population, with too many Americans failing to meet requirements for Vitamin E, C, A and D, selenium, magnesium and potassium.
With just these few studies, there appears to be a connection between micronutrient intake and excess weight – malnutrition parallel to an overweight or obese body state.
For some time now, I’ve written about how the dietary recommendations are flawed. They’re focused on macronutrient ratios – carbohydrate, protein and fat – with the assumption being that if you follow such an eating pattern, you’ll meet micronutrient requirements.
One small problem – even the menus published by the government and medical organizations to provide an example to the public of how to eat are nutritionally deficient for critical essential micronutrients. In fact, I’ve even posted side-by-side menus that showed the recommended diet compared to a controlled-carb diet was nutritionally inferior to the controlled-carb menu. In such comparisons, I use menus that are published by organizations rather than create them myself to reduce any chance for bias on my part.
So, I wasn’t surprised to learn about a new study that Cassandra Forsythe wrote about a couple of weeks ago.
Go ahead – go take a peek – it’s worth the read!
1. Each week buy a variety of fruits that keep well at room temperature and keep them in a bowl on the counter as the snack option for your children. Apples, pears, oranges and plums are all easy for even young children to grab as a snack. If your family doesn’t have nut allergies to worry about, small bags of nuts and seeds can also be placed in the fruit bowl for easy access too!
2. Place fruits, cut vegetables with small dressing cups, single serve string cheese and small 4-ounce yogurt cups on a shelf in the refrigerator that is low enough for your child to easily access.
3. Look for and stock up on “juice box” like flavored waters – they look just like a juice box, but are plain water with a fruit essence to add some flavor and contain no juice! Allow your child freely enjoy these as they desire. Small bottles of water are also available, but a bit more difficult for a child to open on their own – but they too are a good option!
4. Invest in a good stand-alone water dispenser and set it up in the kitchen. Encourage your child(ren) to have water when thirsty. These water dispensers are often less expensive in the long-term than bottled water and easier for a child to use than twisting off the cap on a bottle.
5. Provide milk or water as the beverage at meals. Use child size cups (four to six ounces) rather than larger cups – they’re easier for small hands and do not encourage “big gulp” expectations for beverages.
6. Each week introduce a new vegetable or a new recipe for a vegetable, just once! Make it a non-starchy vegetable. At the meal the new vegetable is offered, make sure everything else served they like and eat. Establish the expectation that they must try the new food and if they do not like it, they do not have to finish it. But they do need to try it. You may be amazed at how many new vegetables your child will like! As you find new vegetables they like – or old favorites using a new recipe – add them to your recipes and include in meals as the year continues.
7. Don’t buy packaged, processed snacks. Your family may whine and complain, but chips, cookies, puddings and the like simply don’t need to be in your kitchen. See items 1 and 2 above. Let your children know this doesn’t mean they’ll never again have a cookie or chips, but that they’re treats and since they’re treats, they’ll still have them occassionally – which means they do not need to be available all the time in the house!
8. Look for and choose options that are free of high-fructose corn syrup, added sugars and added starch. For example, applesauce does not need added sugar, yet most contain added sugar and some now contain added artifical sweetener. These additional sweeteners only make things that are naturally sweet even sweeter, raising the expectation of sweetness in foods – so choose unsweetened varieties where you can.
9. When you eat out, don’t order from the kids menu. Too often the items on the kids menu are nutritionally bankrupt and they’re also always the same five or six things. Instead, for smaller children – ask for a plate and let them enjoy what you’re eating too. For older children, encourage them to choose from the menu and ask for a container to portion out their meal when it arrives and package the rest to take home the leftovers – that way they’re not overwhelmed by the size of the portion they’re served and you’re encouraging them to try new things while enjoying a meal out with the family.
10. Stop eating in the car – make a new family rule this year that eating in the car is no longer an option. Not only will your car have less crumbs, sticky messes and dropped food to clean up, your children will learn that they won’t starve waiting a few minutes until they’re home (or where they’re arriving) to be able to relax and choose something good to eat.
A new report, Expert Committee Recommednations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report, issued by the American Academy of Pediatrics (AAP) this month, is designed to tackle the growing prevalence of childhood obesity in the United States.
Its recommendations should make any parent shudder – not only does the position of the AAP assume overweight and obesity in children is a problem of behavior, it assumes every child in the United States, with the exception of those classified as “underweight” by BMI, is in need of routine intervention and prevention to avoid overweight and obesity in adulthood.
I kid you not.
Every child in the United States, except those with a BMI classifed as “underweight,” will now be subject to a risk assessment and prevention measures at every doctor visit. The implication within the document is clear – parents simply cannot be trusted to know how to raise normal healthy weight children over the long-term, even when their child is a normal weight, thus routine, repeated messages must be delivered at each and every opportunity.
The new guidelines call for healthcare professionals to question and investigate all of your family behaviors and habits at home – everything from what you eat, when you eat, how often you watch television or use a computer, if you eat out, where and how often, and how much time is spent being sedentary versus being active is to be collected and noted in your childs medical chart.
Despite the fact your child is classified within a “healthy weight” you’ll be subject to your own scrutiny as a parent too – if you’re overweight or obese, your child will be flagged as “at risk” due to your weight, not their weight.
Should the clinician note any abberant behavior – heaven forbid you allow your child, for example, a level of television time deemed excessive – you’ll be scolded to limit television time. Heck, even if nothing is found and all is well, you’ll still get the lecture about diet, exercise, limiting fast food and avoid sugary drinks….just in case….overweight and obesity is, afterall, a problem of behavior and you need constant reminder of that if you are to comply.
Where the guidelines sink to Brave New World levels is what is recommended for those children who have a BMI classed at or above the 85th percentile. There is to be no more sugar-coating the problem. Children with a BMI between the 85th and 94th percentile are overweight and children at or above the 95th percentile are obese.
In addition to the above assessments of risk, they’ll now be subject to routine bloodwork and you’ll be expected to do something about the “problem behaviors” now.
The first stage will be “Prevention Plus” through your doctors office. You’ll now be expected to visit the doctors office for monitoring more frequently and ensure your child eats 5+ servings of fruits and vegetables daily, ideally eliminate sweetened beverages from your child’s diet or limit to 1 per day, limit television time to less than 2-hours per day, make your child do physicial activity for 1+ hours per day, prepare meals at home, eat at the family table 5-6 times per week, have a “healthy” breakfast daily, and get the whole family on-board with the changes. You’ll have 3-to-6 months for the doctor’s office to see results, with visits scheduled to follow-up and monitor each month, and if no progress is noted, you and your child will be bumped to stage 2.
Stage 2 assumes you didn’t do enough on your own, so now you and your family will be expected to follow a “structured” planned menu, reduce television time to less than 1 hour per day, engage in planned “supervised” physical activities and record what you are doing to prove you’re complying with the recommendations and “achieving targeted behaviors”! If progress is not noted within three to six months, yup, you’ll be bumped to stage 3.
In stage 3 you’ll enjoy an intervention team (note sarcasm) that includes a behavior counselor (social worker, physcologist or other mental health provider), registered dietitian, exercise specialist and primary care provider, as well as weekly office visits to monitor progress in the “structured program in behavior modification” which will include, “at minimum“, food monitoring, short-term diet and physical activity goal setting and “contingency management.”
This “Comprehensive Multidisciplinary Intervention” now intensifies the urgency and seeks to maximize “behavior changes.” That’s because, if all this fails to result in progress and a reduction of BMI to the “healthy weight” category, they’re going to pull out the big guns and take your child to stage 4 – the “Tertiary Care Intervention,” which can include admission to a tertiary care facility for children as young as two, very low-calorie diets for children as yound as two, medications for children as yound as six, and/or bariatric surgery for children older than twelve.
Within the link above is the second document, Assessment of Childhood and Adolescent Overweight and Obesity, which details how to determine if a child is overweight or obese and reinforces the need for intervention, even in healthy, normal weight children. Noteworthy in this document is the explicit determination that BMI is the end-all-be-all measure of risk. While they note the BMI has flaws, and that the use of calipers to determine fatness is useful – “skinfold thicknesses are predictive of body fat in children and adolescents” – they continue on to dismiss its use and state “the expert committee does not recommend the routine clinical use of skinfold thickness measurements in teh assessment of childhood obesity.”
What this means is that if you have an athletic, muscular child, who happens to have a high BMI due to muscle, you’re going to be expected to do something about his/her weight to bring BMI to a “normal healthy” range.
Throughout the document the expert committee goes to great lengths to detail how to ask questions of parents and children, what to look for as problematic behaviors, and how to convince parents to modify those problematic behaviors.
A third document within the PDF package, Recommendations for Prevention of Childhood Obesity, we learn the justicification of the new guidelines in the opening sentences, “The majority of US youth are of healthy weight, but hte majority of US adults are overweight or obese. Therefore, a major health cahllenge for most American chidlren and adolescents is obesity prevention – today, and as they age into adulthood.”
Let’s not address what caused adults in this country to grow heavier, let’s just continue to assume it’s gluttony and sloth, lack of willpower, eating too damn much food, being lazy and more – those bad, bad, bad behaviors – and not allow our children to fall into the same trap and repeat, repeat, repeat to children they must eat a healthy diet and exercise daily!
We must do this, even if they’re a healthy weight now, because – by golly – look at the adults around them! Bad examples, bad behaviors, bad, bad, bad.
Within the document we find lots of suggestions about how to monitor, control and modify behaviors – everything from positive reinforcement to cognitive restructuring to self-assessment to decision support.
Then there is the Recommendations for Treatment of Child and Adolescent Overweight and Obesity document. In it we’re treated to the dogma to eat a “healthful” diet before getting to the real meat of the purpose – sections on food behaviors and then dietary intervention that includes the “use of balanced macronutrient/low-energy diets” for our children as a means to an end.
This is followed with reminding readers about the importance of physical exercise and the role of structured and unstructured activity each day and more on limiting television viewing and media usage.
Of course it, like the other documents, would not be complete without a full presentation of behavior approaches and techniques to use when a child is overweight or obese by BMI along with the drugs of choice and the option for bariatic surgery.
It also justifies the use of a staged behavior modification approach starting with prevention and reaching tertiary care if needed. Unlike the previous documents, it provides more detail by age. Those details make it clear that a child as young as six, when after six-to-twelve months of increasing intensity without sufficient progress, it may then “be appropriate for patient to receive evaluation in tertiary care center,” followed by flow-charts to make the decision-making process as to when to step-up intensity a no-brainer.
I really have no problem with the idea of helping parents help their child eat a good diet, I have no problem with encouraging children to be active and play actively each day.
What I do have a problem with is the wholesale implication that children who are overweight and obese are so because they have behaviors which must be modified through intense, staged interventions that have no solid evidence to support their use across the population!
Worsening this is that now, even healthy normal weight children, are to be subject to repeated, routine messages to make it clear they must maintain a BMI within normal or else they too can look forward to intense behavior modification intervention.
You may wonder if anyone has ever investigated how such an approach may affect children long-term?
The last document includes an interesting sentence, “The purpose of this article is to offer practical guidance to providers by providing recommendations, including those that LACK THE BEST POSSIBLE EVIDENCE.” (emphasis mine)
It also includes a section titled “Potential Psycological Complications of Behavior-Based Treatment” and states, “Only one study, a 10-year follow-up study of children who completed behavior interventions for obesity, reported on potential complications of treatment. Epstein et al found increased rates of psychiatric disorders such as depression, substance abuse, and eating disorders…” noting it was unclear if these were a result of comorbid conditions associated with obesity.
Amazingly, after staing only one study followed-up on children after behavior intervention, they pooh-pooh this by pointing to another study as supporting behavior intervention comes with little to no risk to children in the future – “Other trials showed improvements in children’s psychological functioning and did not find higher rates of eating disorders among children treated with a family-based, behavior, weight management intervention.”
I wondered what that study was all about since the clear message here is not to worry about damaging children with this type of intervention. The reference is to a study conducted by Faith et al – Effects of contingent television on physical activity and television viewing in obese children – published in Pediatrics in 2001.
How this expert committee sleeps at night, I don’t know!
This is a bait-and-switch citation in what’s now being put forth as the standard of care to imply these interventions aren’t going to have any long-term consequences to our children’s mental health and well-being.
The study referenced, unlike the one that followed up TEN YEARS later, was short-term for twelve weeks, investigating whether making television viewing contingent on a physical activity (pedaling a stationary bike in front of the television) would reduce television viewing time. It did. But it DID NOT investigate any phsycological impacts, nor did it follow up years later to see if there were any psycological impacts.
Nice try though – and anyone reading the document who does not follow the reference trail will never know. Given this type citation madness is included, in what is probably the most important factor – long-term outcome and potential consequences – one must question what else in the document also has this type of reference?
Folks, we have here a plan to now subject every child to intense and routine messages about body weight, BMI, eating, activity and their “behavior” – with no hard evidence it will provide the desired long-term results and the potential to seriously cause harm as our children grow-up in such an environment of intense scrutiny, monitoring and implication that BMI must remain within “normal” or else.
This expert committee has apparently lost all belief in “First Do No Harm.”