Is Dining Out Making Us Fat?

So easy to over-eat!

So easy to over-eat!

The U.S. trend of increasing overweight and obesity started about 1970. I wonder if eating away from home is related to the trend. I found a USDA report with pertinent data from 1977 to 1995. It also has interesting info on snacking and total calories consumed. Some quotes:

“We define home and away-from-home foods based on where the foods are obtained, not where they are eaten. Food at home consists of foods purchased at a retail store, such as a grocery store, a convenience store, or a supermarket. Food away from home consists of foods obtained at various places other than retail stores (mainly food-service establishments).”

***

“Over the past two decades, the number of meals consumed has remained fairly stable at 2.6 to 2.7 per day. However, snacking has increased, from less than once a day in 1987-88 to 1.6 times per day in 1995. The increased popularity in dining out is evident as the proportion of meals away from home increased from 16 percent in 1977-78 to 29 percent in 1995, and the proportion of snacks away from home rose from 17 percent in 1977-78 to 22 percent in 1995. Overall, eating occasions (meals and snacks) away from home increased by more than two-thirds over the past two decades, from 16 percent of all eating occasions in 1977-78 to 27 percent in 1995.”

***

“Average caloric intake declined from 1,876 calories per person per day in 1977-78 to 1,807 calories per person per day in 1987-88, then rose steadily to 2,043 calories per person per day in 1995.”

***

“These numbers suggest that, when eating out, people either eat more or eat higher-calorie foods or both.”

Parker here. I’m well aware that these data points don’t prove that increased eating-out, increased snacking,  and increased total calorie consumption have caused our overweight and obesity problem. But they sure make you wonder, don’t they? None of these factors was on a recent list of potential causes of obesity.

If accurate, the increased calories alone could be the cause. Fast-food and other restaurants do all they possibly can to satisfy your cravings and earn your repeat business.

If you struggle with overweight, why not cut down on snacking and eating meals away from home?

Steve Parker, M.D.

Update:

Here’s a pie chart I found with more current and detailed information from the U.S. government (h/t Yoni Freedhoff):

feb13_feature_guthrie_fig03

What’s a Cruet?

Our new cruet

Our new $8 cruet

If you’re trying to lose weight or keep from getting fat, salads are helpful. I recommend them in my Advanced Mediterranean Diet, Low-Carb Mediterranean Diet, Paleobetic Diet, and Ketogenic Mediterranean Diet.

My favorite salad dressings are vinaigrettes. They can be as simple as olive oil, vinegar, salt and pepper. The problem with most commercial vinaigrettes is the label says “_____ Vinaigrette with olive oil,” but the first listed ingredient is soybean oil (or some other industrial seed oil) and olive oil is somewhere down the line. My current favorite commercial salad dressing has water as the first ingredient!

Get around that by making your own. Here’s a recipe and a salad to try it on. Also, if you’re watching your carb consumption, the commercial dressings  may sneak in more than you want. Again, avoid that by making your own.

Cruet label

Cruet label

You can make a vinaigrette in a jar with a lid. Add the ingredients then shake to create an emulsion. Or do it in a bowl with a whisk. My wife found us a cruet at the supermarket that I was hoping would allow mixing, storing, and pouring all from the same attractive container. Unfortunately, it leaks when I shake it.

Steve Parker, M.D.

Obese Women Get Just One Hour of Vigorous Exercise PER YEAR

Steve Parker MD

Steve Parker and son Paul in a Boy Scout overnight backpacking trip on the Mogollon Rim in Arizona

Obese men in the U.S. don’t do much better at 3.6 hours. I exercise vigorously for about 50 hours a year, and many folks easily beat that. I exercise for longevity, weight management, better quality of life, and so I can keep up with the lads in my son’s Boy Scout troop.

hypoglycemia, woman, rock-climbing

Not the best exercise if you’re markedly obese

myfoxny.com has the story on exercise habits of obese women, based on a recent article in Mayo Clinic Proceedings. A quote:

What kind of lives are the most inactive people living? “I think they’re living the typical life. They drive their children to school, they sit at a desk all day long, they may play some video games and they go to sleep,” Archer said.

He forgot about TV.

Without a doubt, it’s hard to exercise if you’re markedly obese. Here’s how.

Read more: http://www.myfoxny.com/story/24774893/average-obese-woman-gets-just-1-hour-of-exercise-a-year-study#ixzz2u2MMctiW

Steve Parker, M.D.

QOTD: James Fell on Weight Loss and Cooking

If you want to lose weight you need to cook. Period.

James Fell

Meet the Newest T2 Diabetes Drug: Dapagliflozin (Farxiga)

We have 12 classes of drugs in our armamentarium for the war on diabetes. The latest class is SGLT2 inhibitors and the newest of these is dapagliflozin. I read the manufacturer’s U.S. package insert and updated my SGLT2 inhibitor post.

Your kidneys normally filter some blood glucose into the “urine” and then reabsorb nearly all of it back into the blood. SGLT2 inhibitors interfere with reabsorption, so glucose ends up in the urine.

If you’re thinking that might cause yeast infections, you’re right.

Fun Fact: Taking 10 mg/day of dapagliflozin leads to loss of blood glucose into the urinary tract to the tune of 70 grams a day.

That’s 280 calories down the drain. I suspect that cutting 70 grams of carbohydrate from your diet would have just as much effect on diabetes as do these drugs. Without the yeast infections.

This drug class’s mechanism of action doesn’t appeal to me intellectually.

Steve Parker, M.D.

Your Heart Works Fine on a Low-Carb Diet

Amber Wilcox-O’Hearn explains why.

Paleobetic diet, low-carb,paleo diet, Steve Parker MD, cabbage soup, diabetic diet

This cabbage soup only has 9 grams of digestible carbohydrate per 2-cup serving

Your heart beats 100,000 times a day, every day, without rest. You’d think it needs a reliable energy source, and you’d be right. One of Amber’s references (#4) reminds me that, “Fatty acids are the heart’s main source of fuel, although ketone bodies as well as lactate can serve as fuel for heart muscle. In fact, heart muscle consumes acetoacetate in preference to glucose.”

Steve Parker, M.D.

PS: Paleo-compliant Cabbage soup recipe

Does Dining Out Cause Obesity?

Home-cooked meal

Home-cooked meal

The U.S. trend of increasing overweight and obesity started about 1970. I wonder if eating away from home is related to the trend. I found a USDA report with pertinent data from 1977 to 1995. It also has interesting info on snacking and total calories consumed. Some quotes:

“We define home and away-from-home foods based on where the foods are obtained, not where they are eaten. Food at home consists of foods purchased at a retail store, such as a grocery store, a convenience store, or a supermarket. Food away from home consists of foods obtained at various places other than retail stores (mainly food-service establishments).”

***

“Over the past two decades, the number of meals consumed has remained fairly stable at 2.6 to 2.7 per day. However, snacking has increased, from less than once a day in 1987-88 to 1.6 times per day in 1995. The increased popularity in dining out is evident as the proportion of meals away from home increased from 16 percent in 1977-78 to 29 percent in 1995, and the proportion of snacks away from home rose from 17 percent in 1977-78 to 22 percent in 1995. Overall, eating occasions (meals and snacks) away from home increased by more than two-thirds over the past two decades, from 16 percent of all eating occasions in 1977-78 to 27 percent in 1995.”

***

“Average caloric intake declined from 1,876 calories per person per day in 1977-78 to 1,807 calories per person per day in 1987-88, then rose steadily to 2,043 calories per person per day in 1995.”

***

“These numbers suggest that, when eating out, people either eat more or eat higher-calorie foods or both.”

Parker here. I’m well aware that these data points don’t prove that increased eating-out, increased snacking,  and increased total calorie consumption have caused our overweight and obesity problem. But they sure make you wonder, don’t they? None of these factors was on a recent list of potential causes of obesity.

If accurate, the increased calories alone could be the cause. Fast-food and other restaurants do all they possibly can to satisfy your cravings and earn your repeat business.

If you struggle with overweight, why not cut down on snacking and eating meals away from home?

Steve Parker, M.D.

Just What You Always Wanted: A Second SGLT2 Inhibitor (dapagliflozin or Farxiga)

Open wide!

Open wide!

Where do they get these names?!

The trade name in the U.S. is Farxiga. (How do you pronounce that?) In Europe and Australia they call it Forxiga. Go figure.

MedPageToday has the details. Here’s the FDA press release, which misspells dapagliflozin. Here’s the Australian package insert for full prescribing information. Here’s my summary of both drugs in the class at one of my other blogs.

We how have 12 classes of drugs for treating diabetes.

If you’re eating the typical high-carb diabetic diet—200 or 300 grams of carbohydrate daily—you quite likely can reduce your drug requirement by cutting back on the carbs.

Steve Parker, M.D.

 

Summary of ADA’s Standards of Medical Care in Diabetes – 2014

Wish I were here

Wish I were here

I just reviewed the new American Diabetes Association treatment guidelines and wanted to share some of my notes with you. You can read the original document free online. It has 620 references!

PERIODIC TESTS, TREATMENTS, AND GOALS

The American Diabetes Association (ADA) recommends the following items be done yearly (except as noted) in non-pregnant adults with diabetes. (Incidentally, I don’t necessarily agree with all ADA guidelines.)

  • Lipid profile (every two years if results are fine and stable)
  • Comprehensive foot exam
  • Screening test for distal symmetric polyneuropathy: pinprick, vibration, monofilament pressure sense, ankle reflexes
  • Serum creatinine and estimate of glomerular filtration rate
  • Test for albumin in the urine, such as measurement of albumin-to-creatinine ratio in a random spot urine specimen
  • Comprehensive eye exam by an ophthalmologist (if exam is normal, every two years is acceptable)
  • Hemoglobin A1c at least twice a year, but every three months if therapy has changed or glucose control is not at goal
  • Flu shots

Additionally, the 2014 ADA guidelines recommend:

  • Pneumococcal vaccination. Additionally, “A one time re-vaccination is recommended for individuals over 65 years of age who have been immunized over five years ago. previously immunized when they were <65 years of age if the vaccine was administered >5 years ago.” Also repeat the vaccination after five years for patients with nephrotic syndrome, chronic kidney disease, other immunocompromised states (poor ability to fight infection), or transplantation.
  • Hepatitis B vaccine for unvaccinated adults who are 19-59 years of age.
  • Weight loss for all overweight type 2 diabetic adults. How? By reducing energy intake (calories) while eating healthfully. “Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns.”
  • “Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation, remains a key strategy in achieving glycemic control.”
  • Limit alcohol to one (women) or two (men) drinks a day.
  • “In people with type 2 diabetes, a Mediterranean-style, MUFA-rich eating pattern may benefit glycemic control and cardiovascular disease risk factors and can therefore be recommended as an effective alternative to a lower-fat, higher-carbohydrate eating pattern.”
  • “As recommended for the general public, an increase in foods containing long-chain omega-3 fatty acids (from fatty fish) and omega-3 linolenic acid (ALA) is recommended for individuals with diabetes because of their beneficial effects on lipoproteins, prevention of heart disease, and associations with positive health outcomes in observational studies.”
  • “A variety of eating patterns (combinations of different  foods or food groups) are acceptable for the management of diabetes. Personal preference (e.g., tradition, culture, religion, health beliefs and goals, economics) and metabolic goals should be considered when recommending one eating pattern over another.”
  • During initial diabetic exam, screen for peripheral arterial disease (poor circulation). Strongly consider calculation of the ankle-brachial index for those over 50 years of age; consider it for younger patients if they have risk factors for poor circulation.
  • Restriction of dietary protein is no longer routinely recommended in people with diabetic kidney disease (nephropathy with albuminuria). Instead, the focus is on control of blood pressure and blood sugar to prevent progression.
  • Those at risk for diabetes, including prediabetics, should aim for a) moderate weight loss if overweight (about seven percent of body weight), b) exercise: 150 minutes per week of moderate-intensity aerobic activity.
  • “A variety of eating patterns have been shown to be effective in managing diabetes, including Mediterranean-style Dietary Approaches to Stop Hypertension (DASH)-style, plant-based (vegan or vegetarian), lower-fat, and lower-carbohydrate patterns.”

Paleobetic diet, diabetic diet, low-carb, paleo diet, diabetes

This monitor looks like an antique

Some of my dietary recommendations conflict with ADA guidelines. For instance, I think carbohydrate restriction is very important. I expect the experts assembled by the ADA to compose the guidelines were well-intentioned, intelligent, and hard-working. They’re are supported by 620 scientific journal references. I appreciate the expert panel’s work. We’ve simply reached some different conclusions. By the same token, I’m sure the expert panel didn’t have unanimous agreement on all the final recommendations. I invite you to review the dietary guidelines yourself, discuss with your personal physician, then decide where you stand.

GENERAL TREATMENT GOALS

The ADA in 2014 suggests general therapeutic goals for adult non-pregnant diabetics:

  • Fasting blood glucoses: 70 to 130 mg/dl (3.9 to 7.2 mmol/l)
  • Peak glucoses one to two hours after start of meals: under 180 mg/dl (10 mmol/l)
  • Hemoglobin A1C: under 7%
  • Blood pressure: under 140 mmHg systolic and under 80 mmHg diastolic
  • LDL cholesterol: under 100 mg/dl (2.6 mmol/l). (In established cardiovascular dis-ease: <70 mg/dl or 1.8 mmol/l.)
  • HDL cholesterol: over 40 mg/dl (1.0 mmol/l) for men and over 50 mg/dl (1.3 mmol/l) for women
  • Triglycerides: under 150 mg/dl (1.7 mmol/l)

The 2013 guidelines of the American Association of Clinical Endocrinologists focus on hemoglobin A1c rather than blood sugars:

  • Hemoglobin A1c: 6.5% or less for otherwise healthy people who are also at low risk for hypoglycemia.
  • For those with one or more significant illnesses and at risk for hypoglycemia, hemoglobin A1c over 6.5% is fine.

In other words, the target is individualized. Hemoglobin A1c of 6.5% equates to blood sugars that average 140 mg/dl (7.8 mmol/l)—that’s fasting, after meals, whatever. Back in 2011, the AACE recommended blood sugar goals:

  • Fasting Blood Sugar: under110 mg/dl (6.11 mmol/l)
  • Two Hours After a Meal: under140 mg/dl (7.78 mmol/l)

The ADA reminds clinicians, and I’m sure the AACE guys agree, that diabetes control goals should be individualized, based on age and life expectancy of the patient, duration of diabetes, other diseases that are present, individual patient preferences, and whether the patient is able to easily recognize and deal with hypoglycemia. I agree completely. For instance, there’s not much reason to aim for blood sugars of 100 mg/dl (5.56 mmol/l) in a 79-year-old expected to die of lung cancer in four months. The goal is comfort and symptom relief, even if sugars are 220 mg/dl (12.2 mmol/l).

Steve Parker, M.D.

Recipe: Brian Burgers With Bacon Brussels Sprouts, Tomato, and Pistachios

diabetic diet, low-carb diet, paleobetic diet

Brian burger and bacon Brussels sprouts

Here’s another meal recipe from my stepson. This makes three servings. You’ll want to make the Bacon Brussels Sprouts to serve with other meals, so I’ve provided an additional nutritional analysis for those alone.

Ingredients:

13 oz (370 g) ground beef, 85% lean

1/2 tbsp (7.5 ml) Tessemae’s All Natural Dressing-Marinade-Dip “Southwest Ranch,” or A1 Steak Sauce or balsamic vinaigrette or AMD vinaigrette (Brian recommends the Tessemae’s Dressing)

1.7 oz (50 g) onion, diced coarse or fine

1 garlic clove, diced

1/8 tsp (0.5 ml) paprika

1–2 pinches of salt (pinch = 1/16 tsp)

pepper to taste (a pinch or 2?)

1/4 tsp (1.2 ml) dried rosemary, crumbled or crushed

1/2 large egg, whisked to blend white and yolk

3 oz (85 g) lettuce

1 lb (450 g) Brussels sprouts (cut and discard bases if desired, probably doesn’t matter),   shredded

8 oz (225 g) bacon (6.5 regular (not thick) 8-inch strips), diced

3 tbsp (45 ml) water

1.5 large tomatoes, sliced

4.5 oz pistachio nuts

diabetic diet, paleobetic diet, low-carb diet

Prepping the bacon; use a sharp knife

Instructions:

First cook the bacon in a pan over medium–high heat until done. Don’t discard the grease.

Next do your Brussels sprouts prep (shredding). It will take a few minutes to shred it with a knife. Set those aside.

diabetic diet, paleobetic diet, low-carb diet

Brian slaving away. Thanks, dude!

Start on the burgers now. Place the ground beef in a bowl then add your chosen sauce or vinaigrette, onion, egg, garlic, paprika, rosemary, salt, and pepper. Mix thoroughly by hand. Divide the mess into three patties of equal size. Fry or grill over medium heat until done, about 10 minutes.

diabetic diet, paleobetic diet, low-carb diet

Steaming in progress

As soon as the burgers are plopped on the heat, start steaming the shredded sprouts thusly. Take a pan with a lid, add 3 tbsp (45 ml) of the bacon grease and the 3 tbsp of water, then heat that up for a minute or two over medium to high heat. Then throw in the shredded sprouts, salt and pepper to taste (probably unnecessary), and cover with a lid. Immediately reduce heat to medium and cook for 4–6 minutes. The sprouts will soften up as they cook. Gently shake the pot every minute while steaming to prevent contents from sticking to the pan. If necessary, remove the lid and stir while cooking, but this may increase your cooking time since you release hot steam whenever you remove the lid. When the sprouts are done, remove from heat and add the remaining bacon and bacon grease, then blend.

Bacon has been added and blended after the sprouts are cooked

Bacon has been added and blended in after the sprouts are cooked

Serve the burger on a bed of lettuce (1 0z). Enjoy tomato and pistachios on the side. Serving sizes are below.

Number of Servings: 3 (one burger patty, 1 oz (30 g) lettuce, 1 cup (240 ml) of sprouts, 1/2 tomato or a third of all the slices, 1.5 oz (40 g) pistachio nuts)

Nutritional Analysis per Serving:

58% fat

17% carbohydrate

25% protein

740 calories

32 g carbohydrate

12 g fiber

20 g digestible carbohydrate

827 mg sodium

1,802 mg potassium

Prominent features: Rich in fiber, protein, vitamin B6, B12, C, copper, iron, manganese, niacin, pantothenic acid, phosphorus, riboflavin, selenium, thiamine, and zinc.

Nutritional Analysis for Bacon Brussels Sprouts: (1 cup, no added salt):

47% fat

28% carbohydrate

26% protein

180 calories

14 g carbohydrate

6 g fiber

8 g digestible carbohydrate

530 mg sodium

709 mg potassium

Prominent features: mucho vitamin C.

diabetic diet, paleobetic diet, low-carb diet

Brian likes his burger wrapped in 2 oz of lettuce