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

Ooooh!  I’m sure they’re shaking in their boots.

I ran across a patient in the emergency department a couple months ago who coincidentally happened to be taking over-the-counter HCG oral drops for help with weight loss.  She didn’t ask my opinion of it, so I didn’t give it.

Now the FDA has sent a stern warning letter to seven HCG diet marketers to cease and desist.  I started seeing ads for homeopathic oral HCG at least a year ago.  And the FDA is just now getting around to the letters?

The Science-Based Medicine blog can teach you about homeopathy.

Here’s a snippet from the first FDA link above:

Miller explains that HCG was first promoted for weight loss in the 1950s. “It faded in the 1970s, especially when it became apparent that there was a lack of evidence to support the use of HCG for weight loss,” she says.

The diet has become popular again and FDA and FTC are taking action on illegal HCG products. “You cannot sell products claiming to contain HCG as an OTC drug product. It’s illegal,” says Brad Pace, team leader and regulatory counsel at FDA’s Health Fraud and Consumer Outreach Branch. “If these companies don’t heed our warnings, they could face enforcement actions, legal penalties or criminal prosecution.” 

You think these HCG marketers didn’t know from the git-go that what they were doing was illegal?

I’d have thought the FDA already had enough poop to start enforcement actions.

But what do I know?

Steve Parker, M.D.

I confess a few transgressions.

1) I had a handful of peanuts coated lightly with sugar crystals.

2) About 10 grams of white chocolate.

3) A piece of frosted chocolate cake.  Hey, my wife insisted and I gotta keep her happy.  When the wife’s not happy, nobody’s happy.  (She’s not an unreasonable person.)

I did couple Core Performance workouts.

Weight at the end of week 2: 170 lb (77.3kg). 

That’s down 2.5 lb over the week (a bit over a kg).  I didn’t expect that.  I have consciously been restricting my calories a bit, knowing I’d have to weigh-in and report here.  And I want to fit into my suit pants again!  It’s my version of hari hachi bu.

As I noted at the start of this experiment, I’m going “off plan” around Christmas.  Wouldn’t be surprised if I gained a few pounds back.  A good strategy would be to get in three workouts in the next week.  Also, when I indulge my sweet tooth, perhaps I should skip a meal, instead of doing both a meal and dessert.  I’m not going to sweat it.  There’s always next year for  a fresh start.

I don’t miss bread.  I miss sweets.

If you’re serious about avoiding holiday weight-gain or a weight-loss stall, you need to commit to a specific plan before the holiday arrives.

I’m thinking lots about my Lord and Savior, Jesus Christ.  Merry Christmas to all my readers!

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.

I had one inadvertent transgression.  To go with chili, my wife made some cornbread from a box mix.  I ate a muffin before reading the label.  It’s cornbread; I figured it was made of corn. 

Wrong. 

Ingredients in order: bleached enriched wheat flour, sugar, corn, etc. 

Even flour’s not flour any more.  The flour had six or seven ingredients listed after it parenthetically: additives.  What they took out in processing, they’re partially replacing.

So far I’m having no trouble bypassing the ever-present cookies, bagels, cinnamon rolls, and blueberry muffins in the doctors’ lounge at the hospital.  My public commitment in this blog improves my will power.  (You can get a free blog from Wordpress.)

Over the last week I’ve had a few servings of beans and potatoes.  I’m eating mostly meat, chicken, fish, salads with fatty dressing, low-carb vegetables, berries, and an occasional glass of wine.  Blackberries are very afforable in Arizona right now.

I shoehorned a couple workouts into the week, 45 minutes each.

Weight Loss Progress Thus Far

Weight: 172.5 lb (78.4 kg) so down a half pound (0.2 kg) in first week.  Had hoped for more, but not too bad.  At least I didn’t gain!  Weight yesterday was actually 170 lb but higher today.

I may yet fit back into those suit pants.  But I have a long way to go.

Steve Parker, M.D.

Compared to a low-fat diet, a very-low-carb diet yielded better fat loss and improved adiponectin levels, according to researchers at the University of Cincinnati.  So what?

Adiponectin is a hormone-like protein secreted by fat cells. But the fatter you are, the less adiponectin you have in your bloodstream.  This hormone has several effects: 

• it’s anti-inflammatory
• high levels of one form of it (a high molecular weight oligomer) are linked to lower rates of diabetes
• low circulating levels are associatedwith athersclerosis (hardening of the arteries), high blood pressure, and impaired function of cells lining our arteries
• it sensitizes the liver and muscles to insulin, which helps keep blood sugars under control

In summary, it’s a good thing to have around.  Low levels are linked to illnesses.  Overweight and obesity tend to lower your levels of adiponectin.  If you’re overweight and have low levels of adiponectin, you should be healthier if you can raise your levels.  How do you do that?  Lose weight.

U. of Cincinnati investigators wanted to know if a very-low-carb diet would increase adiponectin levels better than a common low-fat weight loss diet.  They randomized 81 obese women to follow either a low-fat diet (American Heart Association Step 1) or a very-low-carbohydrate diet based on the Atkins diet.  Women followed the diets for either four or six months.

Findings

Both groups lost weight, but the very-low-carb group lost more: 9.1 kg loss for very-low-carb vs 4.97  for the low-fat group.

The very-low-carb group lost more body fat: 5.45 kg vs 2.62 kg.  (Fat loss was determined by DEXA scan.)

Adiponectin increased in the VLC group but not the LF group.

Discussion

We can’t tell from this article if adiponectin results would be the same in men.  The authors didn’t mention.

In fairness, the authors cite another similar study that found equal degrees of weight loss and adiponectin increase in both low-fat and low-carb groups.  It was a year-long intervention and average weight loss was 13.5% for both groups, a greater degree of weight loss than in the study at hand, in which the very-low-carb group lost 10% of body weight and the low-fat group lost 5.4%.  So you can probably increase your leptin with a low-fat diet if you lose enough excess weight.

Would the Ketogenic Mediterranean Diet work just as well as the very-low carb diet used in this study?  I suspect so, but don’t have the $500,000 it would take to do the research.  Care to donate?

Steve Parker, M.D.

Reference:  Summer, Suzanne, et al.  Adiponectin changes in relation to the macronutrient composition of a weight-loss diet.  Obesity, 2011. doi: 10.1038/oby.2011.60

Intentional weight loss didn’t have any effect either way on risk of death, according to recent research out of Baltimore.  Surprising, huh?

Obesity tends to shorten lifespan, mostly due to higher rates of cancer and cardiovascular disease like heart attacks and strokes.  Doctors and dietitians recommend loss of excess weight all day long, figuring it will reduce the risk of obesity-related death and disease.  That’s not necessarily the case, however.  It’s called the “obesity paradox“: some types of overweight and obese patients actually seem to do better (e.g., live longer) if they’re above the so-called healthy body mass index of 18.5 to 24.9.  For instance: those with heart failure, coronary artery disease, and advanced kidney disease.

It’s never really been clear whether the average obese person (body mass index over 30) improves his longevity by losing some excess weight.  That’s what the study at hand is about.

Methodology

Baltimore-based investigators followed the health status of 585 overweight or obese older adults over the course of 12 years.  Half of them were randomized to an intentional weight loss intervention.  All of them had a high blood pressure diagnosis.  Average age was 66.  Average body mass index was 31.  Details of the weight-loss intervention are unclear, but it was probably along the lines of “eat less, exercise more.”

What Did They Find?

The weight-loss group lost and maintained an average of 4.4 kg (9.7 lb) over the 12 years of the study.  This is about 5% of initial body weight, the minimal amount thought to be helpful for improvement in weight-related medical problems.  Most of the weight loss was over the first three years.

The men assigned to the weight-loss program had about half the risk of dying over the course of the study, compared to the men not assigned to weight loss.  The authors don’t seem to put much stock in it, however, stating that “…no significant difference overall was found in all-cause mortality between older overweight and obese adults who were randomly assigned to an intentional weight-loss intervention and those who were not.” 

Comments

With regards to the men losing weight, we’re only talking about 100-150 test subjects, a relatively small number.  So I understand why the researchers didn’t make a big deal of the lower mortality: it may not be reproducible.

This same research group did a similar study of 318 arthritis patients and intentional weight loss, finding a 50% lower death rate over eight years.

The authors reviewed many similar studies done by other teams, noting increased death rates from weight loss in some studies, and lesser death rates in others. 

When the studies are all over the place like this, it usually means there’s no strong association either way.  Nearly all the pertinent studies were done on relatively healthy, middle-aged and older folks.  The most reliable thing you can say about the issue is that loss of excess fat weight doesn’t increase your odds of premature death. 

 Remember that patients with coronary heart disease, congestive heart failure, or advanced kidney disease tend to live longer if they’re overweight or at least mildly obese.  It’s the obesity paradox.  Will they live longer or die earlier if they go on a weight-loss program?  We don’t know.

We do know that intentional weight loss helps:

• prevent type 2 diabetes
• maintain reasonable blood pressures (avoiding high blood pressure)
• improves lower limb functional ability

Maybe that’s enough.

Steve Parker, M.D.

Reference: Shea MK, Nicklas BJ, Houston DK, Miller ME, Davis CC, Kitzman DW, Espeland MA, Appel LJ, & Kritchevsky SB (2011). The effect of intentional weight loss on all-cause mortality in older adults: results of a randomized controlled weight-loss trial. The American journal of clinical nutrition, 94 (3), 839-46 PMID: 21775558

The very-low-carb Spanish Ketogenic Mediterranean Diet cures metabolic syndrome, according to investigators at the University of Córdoba in Spain. 

The metabolic syndrome is a collection of clinical factors that are linked to high risk of developing type 2 diabetes and heart disease.  Individual components of the syndrome include elevated blood sugar, high trigylcerides, low HDL cholesterol, high blood pressure,  and abdominal fat accumulation.

Spanish researchers put 26 people with metabolic syndrome on the Spanish Ketogenic Mediterranean Diet for twelve weeks and monitored what happened.  At baseline, average age was 41 and average body mass index was 36.6.  Investigators didn’t say how many diabetics or prediabetics were included.  No participant was taking medication.

What’s the Spanish Ketogenic Mediterranean Diet?

Calories are unlimited, but dieters are encouraged to keep carbohydrate  consumption under 30 grams day.  They eat fish, lean meat, eggs, chicken, cheese, green vegetables and salad, at least 30 ml (2 tbsp) daily of virgin olive oil,  and 200-400 ml of red wine daily ( a cup or 8 fluid ounces  equals 240 ml).  On at least four days of the week, the primary protein food is fish.  On those four days, you don’t eat meat, chicken, eggs, or cheese.  On up to three days a week, you could eat non-fish protein foods but no fish on those days. 

How’s this different from my Ketogenic Mediterranean Diet?  The major differences are that mine includes one ounce (28 g) of nuts daily, less fish overall, and you can mix fish and non-fish protein foods every day.

Regular exercisers were excluded from participation, and my sense is that exercise during the diet trial was discouraged. 

What Were the Results?

Metabolic syndrome resolved in all participants.

Three of the original 26 participants were dropped from analysis because they weren’t compliant with the diet.  Another one was lost to follow-up.  Final analysis was based on the 22 who completed the study.

Eight of the 22 participants had adverse effects.  These were considered slight and mostly appeared and  disappeared during the first week.  Effects included weakness, headache, constipation, “sickness”, diarrhea, and insomnia. 

Average weight dropped from 106 kg (233 lb) to 92 kg (202 lb).

Body mass index fell from 36.6 to 32.

Average fasting blood sugar fell from 119 mg/dl (6.6 mmol/l) to 92 mg/dl (5.1 mmol/l).

Triglycerides fell from 225 mg/dl to 110 mg/dl.

Average systolic blood pressure fell from 142 mmHg to 124.

Average diastolic blood pressure fell from 89 to 76.

So What?

A majority of people labeled with metabolic sydrome continue in metabolic sydrome for years.  That’s because they don’t do anything effective to counteract it.  These researchers show that it can be cured in 12 weeks, at least temporarily, with the Spanish Ketogenic Mediterranean Diet.

Very-low-carb diets are especially good at lowering trigylcerides, lowering blood sugar, and raising HDL cholesterol.  Overweight dieters tend to lose more weight, and more quickly, than on other diets.  Very-low-carb diets, therefore, should be particularly effective as an approach to metabolic syndrome.  It’s quite possible that other very-low-carb diets, such as Atkins Induction Phase, would have performed just as well as the Spanish Ketogenic Mediterranean Diet.  In fact, most effective reduced-calorie weight-loss diets would tend to improve metabolic syndrome, even curing some cases, regardless of carb content. 

Most physicians recommend that people with metabolic syndrome either start or intensify an exercise program.  The program at hand worked without exercise.  I recommend regular exercise for postponing death and other reasons.

Will the dieters of this study still be cured of metabolic syndrome a year later?  Unlikely.  Most will go back to their old ways of eating, regaining the weight, and moving their blood sugars, triglycerides, and HDL cholesterols in the wrong direction.

Steve Parker, M.D.

Reference: Pérez-Guisado J, & Muñoz-Serrano A (2011). A Pilot Study of the Spanish Ketogenic Mediterranean Diet: An Effective Therapy for the Metabolic Syndrome. Journal of medicinal food PMID: 21612461

At my Diabetic Mediterranean Diet blog, I recently noted that regular physical activity prevented or postponed death.  Onward now to other benefits.

Waist Management

Where does the fat go when you lose weight dieting?  Chemical reactions convert it to energy, water, and carbon dioxide, which weigh less than the fat.  Most of your energy supply is used to fuel basic life-maintaining physiologic processes at rest, referred to as resting or basal metabolism.  Basal metabolic rate (BMR) is expressed as calories per kilogram of body weight per hour.

The major determinants of BMR are age, sex, and the body’s relative proportions of muscle and fat.  Heredity plays a lesser role.  Energy not used for basal metabolism is either stored as fat or converted by the muscles to physical activity.  Most of us use about 70 percent of our energy supply for basal metabolism and 30 percent for physical activity.  Those who exercise regularly and vigorously may expend 40–60 percent of their calorie intake doing physical activity.  Excess energy not used in resting metabolism or physical activity is stored as fat.

Insulin, remember, is the main hormone converting that excess energy into fat; and carbohydrates are the major cause of insulin release by the pancreas.

To some extent, overweight and obesity result from an imbalance between energy intake (food) and expenditure (exercise and basal metabolism).  Excessive carbohydrate consumption in particular drives the imbalance towards overweight, via insulin’s fat-storing properties.

In terms of losing weight, the most important metabolic effect of exercise is that it turns fat into weightless energy.  We see that weekly on TV’s “Biggest Loser” show; participants exercise a huge amount.  Please be aware that conditions set up for the show are totally unrealistic for the vast majority of people.

Physical activity alone as a weight-loss method isn’t very effective.  But there are several other reasons to recommend exercise to those wishing to lose weight.  Exercise counteracts the decrease in basal metabolic rate seen with calorie-restricted diets.  In some folks, exercise temporarily reduces appetite (but others note the opposite effect).  While caloric restriction during dieting can diminish your sense of energy and vitality, exercise typically does the opposite.  Many dieters, especially those on low-calorie poorly designed diets, lose lean tissue (such as muscle and water) in addition to fat.  This isn’t desirable over the long run.  Exercise counteracts the tendency to lose muscle mass while nevertheless modestly facilitating fat loss.

How much does exercise contribute to most successful weight-loss efforts?  Only about 10 percent on average. The other 90 percent is from food restriction.

Fountain of Youth

Regular exercise is a demonstrable “fountain of youth.”  Peak aerobic power (or fitness) naturally diminishes by 50 percent between young adulthood and age 65.  In other words, as age advances even a light physical task becomes fatiguing if it is sustained over time.  By the age of 75 or 80, many of us depend on others for help with the ordinary tasks of daily living, such as housecleaning and grocery shopping.  Regular exercise increases fitness (aerobic power) by 15–20 percent in middle-aged and older men and women, the equivalent of a 10–20 year reduction in biological age!  This prolongation of self-sufficiency improves quality of life.

Heart Health

Exercise helps control multiple cardiac (heart attack) risk factors: obesity, high cholesterol, elevated blood pressure, high triglycerides, and diabetes.  Regular aerobic activity tends to lower LDL cholesterol, the “bad cholesterol.”  Jogging 10 or 12 miles per week, or the equivalent amount of other exercise, increases HDL cholesterol (“good cholesterol”) substantially.  Exercise increases heart muscle efficiency and blood flow to the heart.  For the person who has already had a heart attack, regular physical activity decreases the incidence of fatal recurrence by 20–30 percent and adds an extra two or three years of life, on average.

Effect on Diabetes

Eighty-five percent of type 2 diabetics are overweight or obese.  It’s not just a random association.  Obesity contributes heavily to most cases of type 2 diabetes, particularly in those predisposed by heredity.  Insulin is the key that allows bloodstream sugar (glucose) into cells for utilization as energy, thus keeping blood sugar from reaching dangerously high levels.  Overweight bodies produce plenty of insulin, often more than average.  The problem in overweight diabetics is that the cells are no longer sensitive to insulin’s effect.  Weight loss and exercise independently return insulin sensitivity towards normal.  Many diabetics can improve their condition through sensible exercise and weight management.

Miscellaneous Benefits

In case you need more reasons to start or keep exercising, consider the following additional benefits: 1) enhanced immune function, 2) stronger bones, 3) preservation and improvement of flexibility, 4) lower blood pressure by 8–10 points, 5) diminished premenstrual bloating, breast tenderness, and mood changes, 6) reduced incidence of dementia, 7) less trouble with constipation, 7) better ability to handle stress, less trouble with insomnia, 9) improved self-esteem, 10) enhanced sense of well-being, with less anxiety and depression, 11) higher perceived level of energy, and 12) prevention of weight regain.

People who lose fat weight but regain it cite lack of exercise as one explanation.  One scientific study by S. Kayman and associates looked at people who dropped 20 percent or more of their total weight, and the role of exercise in maintaining that loss.  Two years after the initial weight loss, 90 percent of the successful loss-maintainers reported exercising regularly.  Of those who regained their weight, only 34 percent were exercising.

Stay tuned for my specific exercise recommendations.

Steve Parker, M.D.