Advanced Mediterranean Diet

Therefore I tell you, do not worry about your life, what you will eat or drink; or about your body, what you will wear.  Is not life more important than food, and the body more important than clothes? 

Look at the birds of the air; they do not sow or reap or store away in barns, and yet our heavenly Father feeds them.  Are you not much more valuable than they? 

Who of you by worrying can add a single hour to his life?

                                 Matthew 6: 25-27  (New International Version)

Ever wonder how much U.S. cardiologists earn?  The answer is just a click away in my last post at the SELF/NutritionData Heart Health blog.

That post was inspired by my attempt to analyze an article in Circulation comparing ten-year outcomes of three treatments for coronary artery disease: medical therapy (drugs and healthy lifestyle), angioplasty, coronary artery bypass grafting.  I had been hoping for easy answers, then got bogged down in details such as the fact that drug-eluting stents - a significant advance - were not in use 10 years ago.

Cardiology’s hard.  Most of Medicine is . . . if you do it right.

Steve Parker, M.D.

To reduce coronary heart disease, we need to focus on reducing consumption of refined carbohydrates rather than fat and cholesterol, according to Dr. Frank Hu.

Dr. Hu is not a wild-eyed, bomb-throwing radical. He’s a Harvard professor of nutrition and epidemiology with both M.D. and Ph.D. degrees.  High-glycemic-index carbs in particular are the bad boys, he writes in an editorial published in the American Journal of Clinical Nutrition earlier this year.

Additional details are at my April 26, 2010, post at the Self/NutritionData Heart Health Blog.

Steve Parker, M.D.

When taken by properly selected patients, statin drugs prevent strokes.  The American Heart Association’s published stroke treatment guidelines specify which stroke patients benefit from statin usage.  Find the details at a  Self/NutritionData Heart Health Blog post I wrote in early September.

Steve Parker, M.D. 

My Heart Health blog post yesterday at Self/NutritionData.com is about the drastic reduction in use of trans fats by U.S. fast-food restaurants.  Click to find out why and how.  Also called partially hydrogenated vegetable oils, trans fats are linked to heart attacks.

Steve Parker, M.D.

The weight-loss drug sibutramine (Meridia) should be withdrawn from the U.S. market, suggests an editorialist in the September 2, 2010, New England Journal of Medicine.  Based on a clinical study in the same issue, it’s more accurate to conclude that sibutramine shouldn’t be prescribed for people who aren’t supposed to be taking it in the first place.

Sibutramine is sold in the U.S. as Meridia and has been available since 1997.  Judging from the patients I run across, it’s not a very popular drug.  Why not?  It’s expensive and most people don’t lose much weight.

The recent multi-continent SCOUT trial enrolled 9,800 male and female study subjects at least 55 years old (average age 63) who had either:

1. History of cardiovascular disease (here defined as coronary artery disease, stroke, or peripheral artery disease)
2. Type 2 diabetes plus one or more of the following: high blood pressure, adverse cholesterol levels, current smoking, or diabetic kidney disease.
3. Or both of the above (which ended up being 60% of the study population)`.

Here’s a problem from the get-go.  For years, Meridia’s manufacturer and the U.S. Food and Drug Administration have told doctors they shouldn’t use the drug in patients with history of cardiovascular disease.  It’s not the scary “black box warning,” but it’s clearly in the package insert of full prescribing information.

Half the subjects were randomized to sibutramine 10 mg/day and the other half to placebo.  All were instructed in diet and exercise aiming for a 600 calorie per day energy deficit.  They should lose about a pound a week if they followed the program.  Average follow-up was 3.4 years.

What Did the Researchers Find?

Forty percent of both drug and placebo users dropped out of the study, a very high rate.

As measured at one year, the sibutramine-users averaged a weight loss of 9.5 pounds (4.3 kg), the majority of which was in the first 6 weeks.  After the first year, they tended to regain a little weight, but kept most of it off.

Death rates were the same for sibutramine and placebo.

Sibutramine users with a history of cardiovascular disease had a 16% increase in non-fatal heart attack and stroke compared to placebo.  To “cause” one heart attack or stroke in a person with known cardiovascular disease, you would have to treat 52 such patients.

Folks in the “diabetes plus risk factor(s)” group who took sibutramine had no increased risk of heart attack or stroke.

So What?

Average weight loss with sibutramine isn’t much.  Nothing new there.  [Your mileage may vary.]

People with cardiovascular disease shouldn’t take sibutramine.  Nothing new there.

An FDA advisory panel reviews sibutramine in mid-September.  Are they likely to recommend withdrawal of the drug from the marketplace?  No.  They’ll remind doctors not to use it in patients with cardiovascular disease, and perhaps phrase that as a “black box warning.”

Steve Parker, M.D.

Reference:  James, W. Philip, et al.  Effect of sibutramine on cardiovascular outcomes in overweight and obese subjects.  New England Journal of Medicine, 363 (2010): 905-917.

Italian researchers reviewed the medical/nutrition literature of the last three years and confirmed that the Mediterranean diet 1) reduces the risk of death, 2) reduces  heart disease illness and death, 3) cuts the risk of getting or dying from cancer, and 4) diminishes the odds of developing dementia, Parkinsons disease, stroke, and mild cognitive impairment.

These same investigators published a similar meta-analysis in 2008, looking at 12 studies.  Over the ensuing three years (as of June, 2010), seven new prospective cohort studies looked at the health benefits of the Mediterranean diet.  The report at hand is a combination of all 19 studies, covering over 2,000,000 participants followed for four to 20 years.  Nine of the 19 Mediterranean diet studies were done in Europe.

The newer studies, in particular, firmed up the diet’s protective effect against stroke, and added protection against mild cognitive impairment.

So What?

The Mediterranean diet: No other way of eating has so much scientific evidence that it’s healthy and worthy of adoption by the general population.  Not the DASH diet, not the “prudent diet,” not the American Heart Association diet, not vegetarian diets, not vegan diets, not raw-food diets, not Esselstyne’s diet, not Ornish’s diet, not Atkins diet, not Oprah’s latest diet, not the Standard American Diet, not the  . . . you name it. 

Not even the Low-Carb Mediterranean Diet.

Just as important, the research shows you don’t have to go full-bore Mediterranean to gain a health and longevity benefit.  Adopting  just a couple Mediterranean diet features yeilds a modest but sigificant gain.  For a list of Mediterranean diet components, visit Oldways or the Advanced Mediterranean Diet website. 

Steve Parker, M.D.

Reference:  Sofi F, Abbate R, Gensini GF, & Casini A (2010). Accruing evidence about benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis. The American journal of clinical nutrition PMID: 20810976

 For overweight and obese women, loss of between five and 10% of body weight significantly reduces urine leakage.  According to the research report in last month’s Obstetrics & Gynecology journal, weight loss should be the first approach to urine leakage in overweight and obese women.

The other word for urine leakage is incontinence: an involuntary loss of urine.  It’s a major problem that isn’t much talked about.  It’s not exactly dinner-party conversation material.  You can imagine its effect on quality of lifeIn the U.S., leakage of urine on at least a weekly basis is reported byone in 10 women and one in 20 men.  It’s more common at higher ages and in women.  Just looking at non-pregnant women, incontinence affects 7% of women aged 20-39, 17% of those aged 40-59, and 23% of women 60-79 years old.

The study at hand involved 338 overweight and obese women: average age 53 (minimum of 30), average body mass index 36, average weight 92 kg (202 lb).  For participation, they had to have at least 10 incontinence episodes per week.  On average, they reported 24 leakage episodes per week (10 stress incontinence, 14 urge incontinence).  All women were given a “self-help incontinence behavioral booklet with instructions for improving bladder control.”  They were randomized to two different weight-loss programs, but I won’t bore you with the details.  The diets were the standard reduced-calorie type.  One diet group had many more meetings than than the other.

The women kept diaries of leakage, and even collected urine soaked pads for weighing.

Results

Eight-five percent of the women completed the 18-month study.

By six months, 89 of the women has lost five to 10% of body weight; 84 lost over 10%.  As expected, when measured at 18 months, only 61 women were in the “five to 10% loss” category; 71 were in the “over 10%” group. 

Greater amounts of weigh loss were linked to fewer episodes of leakage.  Maximal improvement in leakage episodes were seen in the women who lost between five and 10% of body weight, with no additional benefit to greater degrees of weight loss, generally.

Women who lost 5-10% of their body weight were two to four times more likely to achieve at least a 70% redcution in total and urge incontinent episode frequency compared with women who gained weight at 6, 12, and 18 months.

Weight loss works better for stress incontinence than for urge incontinence.

Three of every four women who lost five to 10% of body weight said they were moderately or very satisfied with their improved bladder control.

Bottom Line

Weight loss is usually not a cure for incontinence, but a reasonable management option for overweight and obese women.  It’s going to take loss of five or 10% of body weight.  Other options  include drugs, surgery, Kegel exercises, and just living with it.

Five or 10% weight loss for a 200 pound woman is just 10 or 20 pounds.  That degree of weight loss is also linked to lower risk of diabetes and hypertension: even more reason go for it.  

Does it work for men?  Who knows?

Steve Parker, M.D.

Reference: Wing RR, Creasman JM, West DS, Richter HE, Myers D, Burgio KL, Franklin F, Gorin AA, Vittinghoff E, Macer J, Kusek JW, Subak LL, & Program to Reduce Incontinence by Diet and Exercise (2010). Improving urinary incontinence in overweight and obese women through modest weight loss. Obstetrics and gynecology, 116 (2 Pt 1), 284-92 PMID: 20664387