Advanced Mediterranean Diet

U.S. Cancer Incidence and Cancer Death Rates Both Down

Thursday, November 27th, 2008

The National Institutes of Health reports the good news in the headline above, the first time since the annual reports were started in 1998.

Cancer rates could be reduced further by wider adoption of the traditional Mediterranean diet.

Earlier this year the U.S. Centers for Disease Control and Prevention reported lower rates of death for 11 of the top 15 causes of death, and an unprecedented prolongation of lifespan in the U.S.

Thank you, God.

Happy Thanksgiving!

Steve Parker, M.D.

Posted in Cancer | 1 Comment »

Prevention of Weight Regain

Thursday, November 20th, 2008

Clinical Diabetes recently published a review article, “Weight Regain Prevention,” summarizing effective strategies for prevention of weight regain after a successful weight-loss program. The article is not specifically for or about people with diabetes. You are probably aware that regain of lost weight is a huge problem.

The authors start with a review of various weight-loss strategies, including low-calorie diets, very low-calorie diets, commercial programs such as Weight Watchers, behavior modification therapy, meal replacements, weight-loss drugs, etc. I recall no mention of bariatric surgery.

To its credit, Weight Watchers is the only commercial program to report data from randomized controlled trials, the gold standard in clinical scientific studies of effectiveness. [Weight Watchers lost more weight than the self-help control group.]

By way of review, here is the typical pattern of a weight loss effort. Maximal weight loss occurs in the first six months, at least for people who are compliant and don’t drop out of the program after the first few weeks. After the initial six months, weight regain starts. By one or two years after start of the effort, most people - but not all - have regained all the lost weight, if not more.

The authors’ recommendations for prevention of weight regain are mostly based on well-designed, published, peer-reviewed, scientific studies. They identified characteristics of successful weight loss maintainers - what I call “successful losers.” The idea is that a person will enhance her odds of keeping the lost weight off by incorporating these habits into her lifestyle:

Maintain high levels of physical activity. Consider at least 60 minutes daily of moderate activity. Ouch!
Limit television to less that a few hours a day.
Eat a diet low in fat and calories. [I disagree with the accross-the-board low-fat recommendation.]
Maintain a consistent eating pattern throughout the week and year. Successful losers often report less variety, compared to other people, in all food groups except for fruits.
Eat breakfast routinely.
Control emotional eating.
Weigh frequently, whether daily or weekly.
Catch and address weight regain early, before it gets out of hand.
Consider sequential medications. E.g., sibutramine for months, then orlistat for months.
Individual and/or group follow-up support. Even follow-up by phone works.
Have realistic expectations. Most dieters only lose about half the weight they expected in the first place. The resulting sense of disappointment sabotages efforts to keep the weight off. Anticipate the universal tendency to regain lost weight.
Helpful diet patterns: eat more than five servings a day of fruits and vegetables, watch portion sizes, self-record food intake, plan meals, limit fast food.
“Exercise is central to weight loss maintenance.” And finally . . .
“Exercise is central to weight loss maintenance.”

Steve Parker, M.D.

Reference: Ulen, Christina, et al. Weight Regain Prevention. Clinical Diabetes, 26 (2008): 100-113. DOI: 10.2337/diaclin.26.3.100

Posted in Weight Regain | 1 Comment »

Cinnamon Does Not Improve Blood Levels of Sugar or Cholesterol

Sunday, November 16th, 2008

A few small scientific studies suggest that eating cinnamon will improve blood glucose and cholesterol levels. One of the studies involved rats. That’s all some people need to start using cinnamon as a medicinal. I’ve seen it used to treat or prevent diabetes.

A recent meta-analysis published in Diabetes Care examined five randomized, controlled clinical trials testing the cinnamon theory. “Randomized, controlled trials” are the gold standard in testing whether a drug or other treatment is effective. Even better is if the trial is “double-blind,” meaning neither the study subjects NOR investigators know during the study if the subject is getting the drug versus a placebo. “Randomized” means that all qualified study participants are randomly assigned either to placebo or the drug/treatment being tested.

W.L. Baker and colleagues found five well-designed studies in the literature involving 282 people who were given cinnamon - from one to six grams daily - for at least three months.

Their findings?

Cinnamon does not appear to improve [hemoglobin] A1c, fasting blood glucose, or cholesterol in patients with type 1 or 2 diabetes.

So enjoy cinnamon for the flavor but without expectations it will improve glucose or cholesterol levels.

Now, Drs. Roizen and Oz in their book, YOU - on a Diet, write that cinnamon helps with weight control in overweight people. If you know of clinical studies that support that claim, please share with us.

Steve Parker, M.D.

Reference: Baker, W.L., et al. Effect of cinnamon on glucose control and lipid parameters. Diabetes Care, 31 (2008): 41-43.

Posted in Food, Drugs | 5 Comments »

What Does an Advanced Mediterranean Dieter Eat?

Thursday, November 13th, 2008

A number of people following my Advanced Mediterranean weight-loss plan have recently asked for a grocery shopping list they can take to the supermarket and local farmers’ market. It’s now available as a printable PDF.

There’s so much variety of food on the Advanced Mediterranean Diet that it was tricky to get it all on one page.

I’m reading so much about the health benefits of dark chocolate that I may add it to AMD 2.0!

The meat and poultry choices in particular offer a few surprises.

If the shopping list PDF doesn’t print well for you, please let me know by clicking here.

Steve Parker, M.D.

Posted in Food, Shameless Self-Promotion | 1 Comment »

Statin Reduces Heart Attacks, Strokes, and Death in Healthy Older Adults, But at What Cost?

Monday, November 10th, 2008

An article published today in the Los Angeles Times reported results of the JUPITER trial: Daily use of a specific statin drug in apparently healthy people reduced by 50% the chances of heart attack and stroke over two years. Furthermore, the odds of undergoing heart angioplasty or coronary artery bypass surgery were also reduced by 50%, and the odds of death by any cause were reduced by 20%.

The Jupiter trial enrolled men over 50 and women over 60 with normal cholesterol levels but elevated high-sensitivity C-reactive protein. The study was terminated after two years of follow-up. The study drug was rosuvastatin, manufactured by AstraZeneca and sold in the U.S. as Crestor at a cost of $3.45 per day (U.S.), according to the LA Times.

Do not assume that the drug’s beneficial effects demonstrated in JUPITER are a class effect applicable to all statin drugs such as Lipitor, Zocor, and Mevacor. If they are, let those drug manufacturers spend the time and money to prove it.

Critics of the study say that widespread similar use of statins in healthy middle-aged and older individuals would cost $9 billion a year in the U.S.

Who can wrap their brain around $9 billion a year? The recent U.S. Wall Street bail-out was $700 billion. The U.S. government just gave insurance company AIG another $40 billion. So $9 billion is chicken scratch, right?

Again according to the LA Times article, Dr. Mark Hlatky of Stanford University calculated the NNT - the number needed to treat - to prevent one heart attack, stroke or death over two years. That number is 120. In other words, to prevent one heart attack, stroke, or death over two years, 119 people have to take the drug daily for two years, with no benefit to them. At the outset of this preventive “treatment,” a given individual has less than a one percent chance of benefiting from treatment over the next two years.

At $3.45 per day, the drug costs $2,518 for two years. This doesn’t include the cost of physician visits and blood monitoring for toxicity. At the end of two years, what do you do? Your doctor is likely to recommend taking the drug indefinitely.

Does this sound like a good deal to you? Will you be that lucky one out of 120 to benefit? Can you think of better ways to spend your $2,518 over the next two years?

Would you consider other ways to prevent heart attack, stroke, and death, such as losing excess weight, quitting smoking, getting regular exercise, and switching to a traditional Mediterranean diet?

Popping a pill is easier, no doubt.

Let’s say you decided to spend your $2,518 on something other than Crestor. But your health insurance will pay for it. Would you take the pill then?

Remember, AstraZeneca isn’t going to give the drug away for free. They’ve spent millions on development and testing. Someone has to pay for it, whether it’s you, your health insurer, or your employer. If the latter two pay, won’t that be reflected in higher insurance premiums or lower paychecks?

Steve Parker, M.D.

Additional resources:

Ridker, Paul, et al. Rosuvastin to Prevent Vascular Events in Men and Women With Elevated C-Reactive Protein. New England Journal of Medicine, online November 9, 2008. DOI: 10.1056/NEJMoa0807646

Hlatky, Mark. Expanding the Orbit of Primary Prevention - Moving Beyond JUPITER. New England Journal of Medicine, online November 9, 2008. DOI: 10.1056/NEJMe0808320

O’Riordan, Michael. JUPITER hits New Orleans: Landmark study shows statins benefit healthy individuals with high CRP levels. HeartWire, November 9, 2008.

Szwarc, Sandy. In-depth skeptical analysis at Junkfood Science. Ms. Szwarc spent more effort analyzing the JUPITER study than 99.9% of Crestor-prescribing physicians ever will.

Posted in Cardiovascular Disease, Drugs | 4 Comments »

Benefits of a Food Journal

Friday, November 7th, 2008

Nearly every successful weight-loss effort involves conscious reduction of caloric intake.

Let’s assume you are 40 pounds (18.2 kg) overweight. To hold steady at that weight, you are eating a certain amount of calories, on average, on a daily basis. To lose weight, you have to eat fewer calories than your baseline level, whatever that is. Or you could start burning up more calories through physical activity while holding caloric intake steady. Many people combine caloric restriction with increased exercise. Whichever path is chosen, the result is conversion of excess fat into weightless energy.

Be that as it may, I have run across a few people who can say, “I’ll just cut out soda pop and snack chips,” and they’re able to lose weight. These individuals are a distinct minority of “successful losers.” Most people end up replacing their soda pop and chip calories with other calories, and don’t lose weight.

The idea behind a food journal, also called a log or diary, is to record everything you eat - the type of food and the caloric content - for as long as you are watching your weight. How could this help?

You think twice before cheating on your diet.
You stay within your specified calorie restriction.
It can help you reach your consumption goals for specific nutrients.
You learn how many calories are in your food. If you have a teaspoon of sugar in your coffee but drink four cups daily, that sugar becomes significant.
If you decide to cheat and exceed you calorie limit, you know how many calories to avoid tomorrow to make up for it.
It can help you identify triggers for “emotional eating,” when food is a pacifier instead of necessary nutrition.
It helps you learn what is an appropriate amount of food to eat.
In short, the food journal improves compliance with the diet.

It’s well established that keeping track of your food intake increases your odds of successful weight loss. Most diets do work, if only temporarily. Compliance deteriorates over time, and that’s when the diet stops working. ‘Cause you’re not on it anymore!

Read more about food journals at CalorieLab or About.com. The article at About.com, by Shereen Jegtvig, is comprehensive and allows you to print her journal page forms.

One of the beautiful things about the Advanced Mediterranean Diet is that it is highly customizable. For example, you have four options for caloric intake, based on your age, sex, and activity level. Each calorie intake level is designed to help you approximate the traditional Mediterranean diet while losing excess weight.

Advanced Mediterranean Diet food journals, which I call Daily Logs, are now available free online here. They include space to record physical activity and miscellaneous comments. Print the PDFs on your printer holding standard (8.5 x 11-inch) printer paper. Each page holds logs for three days. These logs also work with the free DIY Mediterranean Diet (Do-It-Yourself).

Why the term “log” instead of journal or diary? Think of James T. Kirk dictating, “Captain’s log, stardate 754428 . . .” “Daring to go where no man has gone before . . .” Your successful weight-loss journey has been pioneered by others. Now it’s your turn.

Steve Parker, M.D.

Update March 6, 2009

NutritionData.com has added a free food diary called “My Tracking.”

Posted in Food, Weight Loss, Shameless Self-Promotion | Comments Off

Gastric Banding Versus Bypass: Which Is Better?

Tuesday, November 4th, 2008

Nonsurgical approaches to relieve morbid obesity, such as drug therapy, low-calorie diets, exercise, and behavior modification have been disappointing.

Bariatric surgery for morbid obesity, on the other hand, has been effective more often and to a greater degree. Hence, the ten-fold increase in bariatric procedures over the past decade.

The leading procedures these days are Roux-en-Y gastric bypass and laparascopic adjustable gastric banding. Banding is being promoted as safer and potentially reversible compared to the time-honored gastric bypass.

Doctors in the Department of Medicine at the University of California, San Francisco, recently reviewed the scientific literature that compares the two procedures. They found 14 comparative studies done between 2000 and 2007. The studies followed patients for at least one year after surgery, monitoring for complications, amount of weight loss, adverse events, quality of life, and effects on obesity-related medical conditions.

Findings

Loss of excess body weight (measured at one year) was greater for gastric bypass than for banding: average difference was 26%. In other words, bypass patients lost 26% more weight.
Bypass patients had greater resolution of obesity-related medical conditions: diabetes, high blood pressure, adverse cholesterol levels, and sleep apnea.
Length of hospitalization and operating room time were shorter for gastric banding.
Death rates were under 0.5% for both procedures.
Complications around the time of surgery were higher for bypass than for banding - 9% versus 5%.
Long-term need for additional related operations was lower after gastric bypass - 16% versus 24%.
Patient satisfaction was greater for gastric bypass.

Discussion From the Study Authors

Previous research has shown that weight loss improves both social functioning and quality of life. Carefully controlled studies have demonstrated between 25% and 60% reductions in all-cause, cardiovascular, and cancer mortality associated with significant weight loss.

There is a risk that commercial sponsorship of laparoscopic adjustable gastric banding may promote the use of these devices over Roux-en-Y gastric bypass, which has no commercial sponsor.

Until trials demonstrate the advantages of laparoscopic adjustable gastric banding in clearly defined subgroups of patients, Roux-en-Y gastric bypass should remain the bariatric procedure of choice in the United States.

My Comment

You can bet there will be heated debate about this study in the bariatric surgery community, with vigorous rebuttals from people heavily invested in the banding devices. Even if you have no dog in the fight, you can still disagree with these results. But have your facts ready.