Advanced Mediterranean Diet

God, help us figure this out

A few months ago, several of the bloggers/writers I follow were involved in an online debate about two competing theories that attempt to explain the current epidemic of overweight and obesity.  The theories:

1. Carboydrate/Insulin (as argued by Gary Taubes)
2. Food Reward (as argued by Stephan Guyenet)

The whole dustup was about as interesting to me as debating how may angels can dance on the head of pin. 

Regular readers here know I’m an advocate of the Carboydrate/Insulin theory.  I cite it in Conquer Diabetes and Prediabetes: The Low-Carb Mediterranean Diet and The Advanced Mediterranean Diet: Lose Weight, Feel Better, Live Longer (2nd edition).  But the Food Reward theory also has validity.  They’re both right, to an extent.  They’re not mutually exclusive.  The Food Reward theory isn’t as well publiziced as Carbohydrate/Insulin.

Dr. Guyenet lays out a masterful defense of the Food Reward theory at his blog.  Mr. Taubes presents his side here, here, here, here, and here.  If you have a couple hours to wade through this, I guess I’d start with Taubes’ posts in the order I list them.  Finish with Guyenet. 

You’d think I’d be more interested in this.  I’m still not.

Moving from theory to real world practicality, I do see that limiting consumption of concentrated refined sugars and starches helps with loss of excess body fat and prevention of weight regain.  Not for everbody, but many.  Whether that’s mediated through lower insulin action or through lower food reward, I don’t care so much. 

Steve Parker, M.D.

h/t Dr. Emily Deans

Rapper Fat Joe is in a YouTube video talking about his 100-lb (45 kg) weight loss by eating low-carb.  He’s not doctor, but he knows a lot about preventing diabetes and heart disease.  He’s livin’ it.

Steve Parker, M.D.

h/t Tom Naughton

U.S. obesity rate over last 40 years

Beth Mazur over at Weight Maven has posted a lecture by Dr. Stephan Guyenet in which he outlines the changes in American diet over the last 100 years.  It’s only 16 minutes long.  You may  find an explanation for our excess weight problem. 

Steve Parker, M.D.

  Dr. Barry Sears (Ph.D., I think) recently wrote about a lecture he attended by a dietitian affiliated with “The Biggest Loser” TV show.  She revealed the keys to weight-loss success on the show.  Calorie restriction is a major feature, with the typical 300-pounder (136 kg) eating 1,750 calories a day.  On my Advanced Mediterranean Diet, 300-pounders get 2,300 calories (men) or 1,900 calories (women). 

Although not stressed by Dr. Sears, my impression is that contestants exercise a huge amount. 

Go to the link above and you’ll learn that all contestants are paid to participate.  In researching my Conquer Diabetes and Prediabetes book, I learned that the actual Biggest Loser wins $250,000 (USD).  Also, “The Biggest Loser” is an international phenomenon with multiple countries hosting their own versions, with different pay-off amounts.  A former winner, Ali Vincent, lives in my part of the world and still has some celebrity status.

This TV show demonstrates that the calories in/calories out theory of body weight still applies.  Including the fact that massive exercise can help significantly with weight loss.  In real-world situations, exercise probably contributes only a small degree to loss of excess weight.  The major take-home point of the show, for me, is that you can indeed make food and physical activity choices that determine your weight.

Most of us watch too much

I know losing 50 to 10o pounds of fat (25–45 kg) and keeping it off for a couple years is hard; most folks can’t do it.  Do you think you’d be more successful if I gave you $250,ooo for your success?

Steve Parker, M.D.

The (Cleveland) Plain Dealer reports the sad and disturbing case of an 8-year-old boy being removed from his family home and placed in foster care simply because government bureaucrats thought his mother didn’t do enough to reduce his weight. He weighed over 200 pounds (91+ kg).

I don’t have all the details of the case.  But this just seems wrong.  Very wrong. 

Kudos to the reporter, Rachel Dissell, for well-done article. 

Steve Parker, M.D.

Daily work-related energy expenditure over the last half-century in the U.S. has decreased by over 100 calories.  This may well explain the increase in body weights we’ve seen, according to a 2011 article in PLoS ONE.

I sorta hate to open this can o’ worms, but it’s important.  As a population, are we fat because we eat too much or because we burn too few calories in physical activity?  Or is it a combination?  The correct answer may help us learn how to reverse the trend.

Methodology

Authors of the study at hand estimated the amount of energy (calories) necessary to perform various jobs, then noted changes in numbers of people employed in those jobs over time.  In the early 196os, for example, nearly half of U.S. jobs required at least moderate intensity physical activity, compared to less than 20% demanding that degree of energy now.  The authors note the dramatic shift from manufacturing to service-type jobs over the last 50 years.  Service jobs, like mine, often entail a lot of sitting and standing around. 

They chose to ignore how much energy we expend in exercise, figuring what we do in a 40-hour work week overwhelms the 1-2 hours of  exercise we may do.

Researchers’ Findings and Conclusions

They found that work-related daily energy expenditure has decreased by over 100 calories over the last half-century, which (in the authors’ view) would account for a significant portion of the increased body weight we’ve seen.  Since physically demanding jobs are unlikely to see a resurgence, the authors advocate physically active lifestyles away from workplace. 

Discussion

Surveys indicate that only one in four of us fulfill the federal physical activity guidelines: 150 minutes a week of moderate intensity activity or 75 minutes a week of vigorous intensity activity.  When activity is actually measured with an accelerometer, only one in 20 achieve that lofty goal.  We over-estimate how much we exercise, and under-estimate how much we eat.

The researchers cite studies showing significantly increased average per capita calorie consumption in the U.S. over the last several decades.  Some experts estimate the caloric increase is in the range of 500 a day for adults; the authors here think that’s too high but don’t offer a specific alternative. Looking at one of their references (Hall et al), they must think the increase is closer to 200 calories a day, comparing 2005 to 1975.

Several studies suggest that average daily energy expenditure has not decreased in developed countries, at least from the 1980s to the present.   A strength of the current study at hand is that it spans about 50 years, up to 2008.

My sense is that both calorie consumption (too much) and physical activity (too little) contribute to our overweight problem that started 40 or 50 years ago.  Excessive consumption is the predominant factor.  To ”exercise off”  the calories in a Snickers candy bar, you’d have to jog for an hour.  If you’re watching your weight, you’ll have more success if you just skip the Snickers.

In case you couldn’t tell,  I still believe in the “calories in/calories out” model of overweight and obesity, aka “the energy balance equation.”  At the same time, I believe certain calories are more fattening than others: concentrated sugars and refined starches.

Steve Parker, M.D.

References:

Church, T., Thomas, D., Tudor-Locke, C., Katzmarzyk, P., Earnest, C., Rodarte, R., Martin, C., Blair, S., & Bouchard, C. (2011). Trends over 5 Decades in U.S. Occupation-Related Physical Activity and Their Associations with Obesity PLoS ONE, 6 (5) DOI: 10.1371/journal.pone.0019657
 

Swinburn, B., et al.  Increased food energy supply is more than sufficient to explain the U.S. epidemic of obesity.  American Journal of Clinical Nutrition, 2009 (90): 1,453-1,456.  

Hall, K.D., et al.  The progressive increase of food waste in America and its environmental impact.  PLoS ONE, 2009, 4(11): e7940.  doi: 10.1371/journal.pone.0007940

A comment left under my recent Diabetic Mediterranean Diet blog post on healthy weight ranges reminded me about the waist-hip ratio.

The risk of heart and vascular disease is more closely linked to distribution of excess fat than with degree of obesity as measured by overall weight or body mass index. Waist-hip ratio (WHR) is a measure of abdominal or central obesity, the type of fat distribution associated with coronary artery disease. A high ratio indicates the android body habitus. To determine your waist-hip ratio:

1. While standing, relax your stomach—don’t
     pull it in. Measure around your waist mid-
     way between the bottom of the rib cage and
     the top of your pelvis bone. Usually this is at
     the level of your belly button, or an inch
     higher. Don’t go above the rib cage. Keep the
     measuring tape horizontal to the ground and
     don’t compress your skin.
2. Then measure around your hips at the
     widest part of your buttocks. Keep the tape
     horizontal to the ground and don’t compress
     your skin.
3. Divide the waist by the hip measurement.
     The result is your waist-hip ratio.

For example, if your waist is 44 inches (112 cm) and hips are 48 inches (122 cm): 44 divided by 48 is 0.92, which is your waist-hip ratio.

Scientists haven’t yet determined the ideal WHR, but it is probably around 0.85 or less for women, and 0.95 or less for men. Ratios above 1.0 are clearly associated with risk of cardiovascular disease such as heart attacks. The higher the ratio, the higher the risk. Compared with body mass index, WHR is a much stronger predictor of coronary artery disease. Several of the other obesity-related illnesses are also correlated with WHR, but the relationship between WHR and cardiovascular disease is particularly strong.

Steve Parker, M.D.

I have a stack of scientific articles I’ve been meaning to review in depth and blog about.  But I have to finally admit I don’t have the time.  Here they are.  Click through for details.

1. Long-term calorie restriction in humans appears highly effective in reducing atherosclerosis risk factors (lab tests) and actual carotid artery atherosclerosis. Only 18 study subjects, however.
2. A very-low-carbohydrate diet improved memory in older adults with mild cognitive impairment over six weeks.  Twenty-three subjects were randomized to either high-carb or very-low-carbohydrate diet.  The low-carbers improved verbal memory performance, lost weight, reduced fasting blood sugar and fasting insulin levels.  Ketone levels were positively correlated with memory performance.
3. A high-fat diet impairs cognitive function and heart energy metabolism in young men.  Sixteen test subjects.  Crossover study design with a five-day high-fat diet deriving 75% of energy from fat, compared to a low-fat diet deriving 23% of energy from fat.  High-fat diet led to impaired attention, speed, and mood.  I’m sure low-carb bloggers have been all over this.  At first blush, it appears they were testing during “induction flu” phase of very-low-carb eating, between days 2 to 7 of a new ketogenic diet.  It takes several weeks to adapt metabolism to running almost entirely on fat rather than standard carbohydrates.  Suspect results would have been different if given time to adapt.
4. Weight-loss with the laparoscopic gastric banding procedure has poor long-term outcome, according to Belgian surgeons reporting on 82 patients.  Four in 10 patients had major complications.  Nearly half of the 82 patients needed to have the bands removed, and six of every 10 required some kind of re-operation.
5. Trust me, you DON’T want age-related macular degeneration.  Women, reduce your risk of ARMD with a healthy lifestyle, including regular exercise, avoidance of smoking,  and by eating abundant plant foods (vegetables [including orange and dark leafy green ones], fruits, and whole grains) and limit foods high in fat, refined starches, sugar, alcohol, and oils.  At least according to these researchers. 
6. Leafy green vegetables and olive oil are linked to reduced heart disease (CHD) in Italian women.  Fruit consumption had no effect.  This is from a subset of the huge EPIC study, following 30,000 women over almost eight years.
7. The Mediterranean diet protects against metabolic syndrome, reducing risk by about a third according to a huge meta-analysis from Greek and Italian investigators.  It works best in Mediterranean countries. 
8. The Mediterranean diet was linked to slower rates of cognitive decline in Chicago residents over the course of almost eight years.  The comparison diet was the Healthy Eating Index-2005.  Of the 3,800 participants, about two-thirds were black.  A Manhattan population showed lower risk of dementia when eating Mediterranean-style.

There ya’ go.  This is better than letting the articles just sit in my briefcase for months on end, eventually to be thrown out.

Steve Parker, M.D.

In the past it was pretty easy to find tables of recommended healthy body weights.  Not so much anymore.  Most of the experts want you calculate your body mass index, recommending the healthy BMI range as 18.5 to 24.9.  I recently spent an hour putting together a healthy weight range based on BMIs.  Since I have many readers outside the U.S., I use both U.S. customary and metric numbers.

Metropolitan Life Insurance Company last published its ideal weight and height table in 1983.  The US Department of Agriculture abondoned its 1995 healthy weight table by the turn of the century recommending BMI calculation instead.  Of note is that the upper end of its weight ranges was a BMI of 25; the lower ends were all BMIs of 19. 

Body Mass Index (BMI) is your weight in kilograms divided by your height in meters squared (kg/m²).  A pound equals 454 kilograms. An inch equals 2.54 centimeters.  There are 100 centimeters in one meter. Thus, a 5-foot, 4-inch woman (1.63 meters) weighing 200 pounds (91 kilograms) has a BMI of 34.2.  Perhaps you’re starting to understand why this weight standard isn’t too popular yet.

 To learn your own BMI but skip the math, use an online calculator.

 To see if your BMI is in the healthy range of 18.5 to 24.9, find your height in the table below, then look to the healhy weight ranges to the right.  Measure your height without shoes and weight without clothes.

Table of Healthy Weight Ranges Based On Body Mass Index: 18.5 to 24.9

       Height               Weight in lb        Weight in kg

5’0” or 152 cm             95 - 128             43.0 - 58.0

5’1” or 155 cm             98 - 132             44.4 - 59.8

5’2” or 157 cm           101 - 137            45.8 - 62.1

5’3” or 160 cm           105 - 141             47.6 - 63.9

5’4” or 163 cm           108 - 146             48.9 - 66.2

5’5” or 165 mc           111 - 150             50.3 - 68.0

5’6” or 168 cm           115 - 155             52.0 - 70.3

5’7” or 170 cm           118 - 160             53.5 - 72.5

5’8” or 173 cm           122 - 164             55.3 - 74.3

5’9” or 175 cm           125 - 169             51.7 - 76.6

5’10” or 178 cm         129 - 174             58.5 - 78.9

5’11” or 180 cm         133 - 179             60.3 - 81.8

6’0”  or 183 cm          137 - 184             62.1 - 83.4

6’1” or 185 cm           140 - 189              63.5 - 85.7

6’2” or 188 cm           144 - 195             65.3 - 88.4

6’3” or 191 cm           148 - 200             67.1 - 90.7

6’4” or 193 cm           152 - 205             68.9 - 92.9

BMIs between 25 and 29.9 designate “overweight” and accurately describe about 35 percent of the United States population.

A BMI of 30 or higher defines “obesity” and indicates high risk for poor health. About 30 percent of us are obese. At a BMI of 35 and above, incidence of death and disease increases sharply.

The BMI concept is helpful to researchers and obesity clinicians, but the number doesn’t mean much yet to the average person on the street and to many physicians. It should be used more widely. (I know, I know: it’s not perfect. Do you have a better, cheap, widely applicable standard?)  Know your BMI. If it’s under 25, any excess fat you carry is unlikely to affect your health and longevity; your efforts to lose weight would be purely cosmetic.

Steve Parker, M.D.

I just finished reading The Art and Science of Low Carbohydrate Living: An Expert Guide to Making the Life-Saving Benefits of Carbohydrate Restriction Sustainable and Enjoyable, by Stephen Phinney, M.D., Ph.D., and Jeff Volek, Ph.D. published this year.  I give it four stars per Amazon.com’s rating system (I like it).

♦    ♦    ♦

The authors medicalize overweight and obesity by naming the cause of most cases to be “carbohydrate intolerance,” along the lines of lactose intolerance and gluten intolerance.  Given the myriad illnesses and shortened lifespan associated with obesity, medicalizing it is reasonable.  Ask Gary Taubes why we get fat, and he’ll say it’s excessive consumption of carbohydrates, especially sugars and refined flours.  Ask Phinney and Volek, and they’ll say “carbohdyrate intolerance.”  For them, the “treatment” is avoidance of carbs.  I also referred to carbohydrate intolerance in my 2011 book, Conquer Diabetes and Prediabetes.

If a patient asks me why he’s fat, I guess I’d prefer to say “you have carbohydrate intolerance,” rather than “you eat too many carbs.”  It’s less confrontational and doesn’t blame the patient.

So how many of us in the U.S. have carbohydrate intolerance?  The authors estimate a hundred million or more - about a third of the total poplulation, or more, who could directly benefit from carbohydrate restriction.  I agree.

Before reading this book, I was convinced that carbohydrates are indeed major contributors to overweight and obesity, especially concentrated sugars and refined grains.  The authors cite much of the pertinent scientific/medical literature. 

Gary Taubes made the same case in his brilliant book, Good Calories, Bad Calories.  Dr. Robert Atkins argued the same in Dr. Atkins New Diet Revolution.  The problem is that many healthcare providers such as physicians and dietitians are biased against thosesources.  Physicians resist a non-physician such as Taubes giving them advice about the practice of medicine.  And most physicians over 45 still labor under the misconception that dietary cholesterol and total and saturated fat are major-league killers, so they’ve already dismissed Dr. Atkins and don’t have time to get caught up to date on the recent research.

Phinney and Volek have wisely targeted this work towards healthcare providers such as physicians, so it’s somewhat technical and clinical.  Both have Ph.D.s and Phinney is also an M.D.  The authors are respected researchers who thoroughly review the science behind low-carb eating.  They explain how high blood pressure, metabolic syndrome, type 2 diabetes, and other conditions are related to carb consumption.

I rate the book four stars instead of five only because it’s a little pricey at $29 (US).

Smart nutrition- and fitness-minded folks will also benefit from a reading.  For a more consumer-oriented book, I recommend the authors’ The New Atkins for a New You or Taubes’ Why We Get Fat.

Steve Parker, M.D.