Category Archives: Overweight

Low-Carb Diet Beats Low-Fat for Weight Loss While Improving Cardiovascular Risk Factors

…according to an article at MedPageToday.

Many physicians have been reluctant to recommend low-carb diets out of fear that they increase cardiovascular risk. How could that happen? By replacing carbohydrates with fats, especially saturated fats, leading to atherosclerosis. I don’t buy that theory (here’s why).

medical clearance, treadmill stress test

This treadmill stress test is looking for atherosclerotic heart disease, aka coronary artery disease and coronary heart disease

A recent study compared low-carb to low-fat dieting over 12 months and actually found better improvements in cardiovascular disease risk factors on the low-carb diet (max of 40 grams a day).

After 12 months, folks on a low-carbohydrate diet had lost 5.3 kg (11.7 lb), while those on a low-fat diet with similar caloric value had lost 1.8 kg (3.9 lb). Both groups showed lowering of LDL cholesterol, while the low-carbers had better improvements in HDL cholesterol and triglycerides.

DietDoctor Andreas Eenfeldt can add this study to his list of others that show better weight loss with low-carb diets compared to low-fat.

Steve Parker, M.D.

Americans Eat Too Much

The U.S. adult population in the 1970s ate an average of 2400 calories a day. By the 2000s, our calories were up to 2900.

Putting a face on the statistics

Putting a face on the statistics

What did average adult weight do as we increased daily calories by 500? It increased by 8.6 kg, from 72.2 to 80.6 kg. In U.S. units, that’s a 19 lb gain, from 159 to 178 lb.

Children increased their average intake by 350 cals/day over the same time frame.

If I recall correctly, I’ve seen other research suggesting the daily calorie consumption increase has been more like 150 to 350 per day (lower end for women, higher for men). I suspect these latter figures are more accurate.

Details are in the American Journal of Clinical Nutrition.

The study authors don’t say for sure why we’re eating more, but offhand mention an “obesogenic food environment.”  They don’t think decreased physical activity is the cause of our weight gain; we’re fatter because we eat too much.

Steve Parker, M.D.

h/t Ivor Goodbody

Pollution May Be Causing T2 Diabetes and Obesity

It sounds like Jerome Ruzzin is convinced that’s the case. I put some thought into it last August and was skeptical—still am, but I’m keeping an open mind. Mr. Ruzzin has a review article published in 2012 at BMC Public Health (“Public health concern behind the exposure to persistent organic pollutants and the risk of metabolic diseases”). Here’s his summary:

The global prevalence of metabolic diseases like obesity and type 2 diabetes, and its colossal economic and social costs represent a major public health issue for our societies. There is now solid evidence demonstrating the contribution of POPs [persistent organic pollutants], at environmental levels, to metabolic disorders. Thus, human exposure to POPs might have, for decades, been sufficient and enough to participate to the epidemics of obesity and type 2 diabetes. Based on recent studies, the fundaments of current risk assessment of POPs, like “concept of additive effects” or “dioxins and dl-PCBs induced similar biological effects through AhR”, appear unlikely to predict the risk of metabolic diseases. Furthermore, POP regulation in food products should be harmonized and re-evaluated to better protect consumers. Neglecting the novel and emerging knowledge about the link between POPs and metabolic diseases will have significant health impacts for the general population and the next generations.

Read the whole enchilada.

The cold-water fatty fish I so often recommend to my patients could be hurting them. They are major reservoirs of food-based POPs.

Steve Parker, M.D.

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

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

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.

The Mellberg Study: Paleo Diet and Obese Postmenopausal Women

Sweden's Flag. Most of the researchers involved with this study are in Sweden

Sweden’s Flag

Swedish researchers compared a Paleolithic-type diet against a lower-fat, higher-carb diet so often recommend in Nordic countries and in the U.S. Test subjects were obese but otherwise healthy older women. The study lasted two years. Dieters could eat as much as they wanted.

They found that the paleo-style dieters lost more weight, lost more abdominal fat, and lowered their trigyceride levels. When measured six months into the study, the paleo dieters had lost 6.5 kg (14 lb) of body fat compared to 2.6 (6 lb) kg in the other group.

Measured at two years out, the paleo dieters had lost 4.6 kg (10 lb) of body fat compared to 2.9 kg (6 lb) in the other group, but this difference wasn’t statistically significant.

The greatest weight loss was clocked at 12 months: Paleo dieters were down 8.7 (19 lb) kg compared to 4.4 kg (10 lb)  in the other group.

But this study was about more than weight loss. The investigators were also interested in cardiometabolic risk factors and overall body composition.

The Set-Up

I don’t know what the researchers told the women to get them interested. Weight loss versus healthier diet versus ?  This could have influenced the type of women who signed up, and their degree of commitment.

A newspaper ad got the attention of 210 women in Sweden; 70 met the inclusion criteria, which included a body mass index 27 or higher and generally good health. Average age was 60. Average BMI was 33. Average weight was 87 kg (192 lb). Average waist circumference was 105 cm (41 inches). The women were randomized into one of two diet groups (N=35 in each): paleolithic-type diet (PD) or Nordic Nutrition Recommendations diet (NNR). There were no limits on total caloric consumption. (Were the women told to “work on weight loss”? I have no idea.)

We don’t know the ethnicity of these women.

Here’s their version of the paleo diet:

  • 30% of energy (calories) from protein
  • 40% of energy from fat
  • 30% of energy from carbohydrate
  • high intake of mono- and polyunsaturated fatty acids
  • based on lean meat, fish, eggs, vegetables, fruits, berries, and nuts
  • additional fat sources were avocado and oils (rapeseed [canola] and olive) used in dressings and food preparation
  • cereals (grains), dairy products, added salt and refined fats and sugar were excluded
  • no mention of legumes, potatoes, or tubers

The NNR diet:

  • 15% of energy from protein
  • 25-30% of energy from fat
  • 55-60% of energy from carbohydrate
  • emphasis on high-fiber products and low-fat dairy products

Over the 24 months of the study, each cohort had 12 group meetings with a dietitian for education and support, including “dietary effects on health, behavioral changes and group discussion.”

Various blood tests and body measurements were made at baseline and periodically. Body measurements were made every six months. Body composition was measured by dual energy x-ray absorptiometry. Diet intake was measured by self-reported periodic four-day food records.

Stockholm Palace

Stockholm Palace

Results

30% of participants (21) eventually dropped out by the end of the study and were lost to follow-up, leaving 27 in the PD group and 22 in the NNR cohort.

Food record analysis indicated the PD group indeed reduced their carb intake while increasing protein and fat over baseline. Baseline macronutrient energy percentages were about the same for both groups: 17% protein, 45% carb, 34% (I guess the percentages don’t add to 100 because of alcohol, which wads not mentioned at all in the article.) Two years out, the PD group’s energy sources were 22% protein, 34% carb, 40% fat. For the NNR group, the energy sources at two years were 17% protein, 43% carb, and 34% fat. As usual, dietary compliance was better at six months compared to 24 months. The PD group failed to reach target amounts of protein energy (30%) at six and 24 months; the NNR group didn’t reach their goal of carbohydrate energy (55-60%). The PD group ate more mono- and poly unsaturated fatty acids than the NNRs.

In contrast to the food record estimates of protein intake, the urine tests for protein indicated poor adherence to the recommended protein consumption in the PD group (30% of energy). Both groups ate the same amount of protein by this metric. (This is an issue mostly ignored by authors, who don’t say which method is usually more accurate.)

“Both groups had statistically significant weight loss during the whole study, with significantly greater weight loos in the PD group at all follow up time points except at 24 months.” Largest weight loss was measured at 12 month: 8.7 kg (19 lb) in the PD group versus 4.4 kg (10 lb) in the NNRs.

The PD group lost 6.5 kg (14 lb) of body fat by six months but the loss was only 4.6 kg (10 lb) measured at 24 months. Corresponding numbers for the NNR group were 2.6 and 2.9 kg (about 6 lb). So both groups decreased their total fat mass to a significant degree. The difference between the groups was significant (P<0.001) only at six months. The greatest weight loss was clocked at 12 months: PD dieters were down 8.7 kg (19 lb) compared to 4.4 kg (10 lb) in the NNRs. Both groups saw a significant decrease in waist circumference during the whole study, with a more pronounce decrease in the PD group at six months: 11 versus 6 cm (4.3 versus 2.4 inches).

Fasting blood sugars, fasting insulin levels, and tissue plasminogen activator activity didn’t change.

Both groups had improvements in blood pressure, heart rate, c-reactive protein, LDL cholesterol, PAI-1 activity, and total cholesterol. The PD group saw a greater drop in triglycerides (by 19% at two years, but levels were normal to start with at 108 mg/dl or 1.22 mmol/l).

Reported daily energy intake fell over time for both groups, without statistically significant differences between them.

paleo diet, Steve Parker MD, diabetic diet

Sweet potato chunks brushed with olive oil, salt, pepper, and rosemary. Ready for the oven.

Discussion

As measured at six months, the paleo dieters lost 10% of their initial body weight, compared to 5% in the NNR group. That’s worth something to many folks. However, the researchers didn’t find much, if any, difference in the groups in terms of cardiometabolic risk factors. They wonder if that reflects the baseline healthiness of these women. Would a sicker study population show more improvement on one of the diets?

I’m surprised the NNR group lost any weight at all. In my experience it’s hard for most folks to lose weight and keep it off while eating as much as they want, unless they’re eating very-low-carb. We’ve seen short-term weight loss with ad libitum paleo diets before (here for example, and here, and here). I bet the women signing up for this study were highly motivated to change. 

Legumes and potatoes are a debatable part of the paleo diet. Most versions exclude legumes. We don’t know if these women ate legumes and potatoes. Other than this oversight, the study paleo diet is reasonable.

The authors noted that the paleo diet group failed to reach their protein intake goal (30% of total calories), and suggested reasons “such as protein-rich foods being more expensive, social influences on women’s food choices or a lower food preference for protein-rich food among women.”

The results of this study may or may not apply to other population subgroups and non-Swedes.

The authors write:

In conclusion, a Palaeolithic-type diet during two years with ad libitum intake of macronutrients, including an increased intake of polyunsaturated fatty acids and monounsaturated fatty acids reduces fat mass and abdominal obesity with significantly better long-term effect on triglyceride levels vs an NNR diet. Adherence to the prescribed protein intake was poor in the PD group suggesting that other component of the PD diet are of greater importance.

Does this study have anything to do with diabetes? Not directly. But it suggests that if an overweight diabetic needs to lose excess body fat without strict calorie control, a lower-carb paleo-style diet may be more effective than a low-fat, higher-carb diet. I would have liked to have seen lower fasting blood sugar and insulin levels in the paleo dieters, but wishing doesn’t make it so.

Steve Parker, M.D.

PS: Carbsane Evelyn has taken a look at this study and blogged about it here and here. I’ve not read those yet, but will now.

Reference: Mellberg, C., et al (including M. Ryberg and T Olsson). Long-term effects of a Palaeolithic-type diet in obese postmenopausal women: a 2-year randomized trial. European Journal of Clinical Nutrition, advance online publication January 29, 2014. doi: 10.1038/ejcn.2013.290

What’s Pure, White, and Deadly?

Sugar, according to John Yudkin and Robert Lustig, among others. The Age has the details. A quote:

[Robert] Lustig is one of a growing number of scientists who don’t just believe sugar makes you fat and rots teeth. They’re convinced it’s the cause of several chronic and very common illnesses, including heart disease, cancer, Alzheimer’s and diabetes. It’s also addictive, since it interferes with our appetites and creates an irresistible urge to eat.

This year, Lustig’s message has gone mainstream; many of the New Year diet books focused not on fat or carbohydrates, but on cutting out sugar and the everyday foods (soups, fruit juices, bread) that contain high levels of sucrose. The anti-sugar camp is not celebrating yet, however. They know what happened to Yudkin and what a ruthless and unscrupulous adversary the sugar industry proved to be.

In 1822, we in the U.S. ate 6.2 pounds of sugar per person per year. By 1999, we were up to 108 pounds.

An occasional teaspoon of sugar probably won't hurt you

An occasional teaspoon of sugar probably won’t hurt you

The U.S. Department of Agriculture estimates that added sugars provide 17% of the total calories in the average American diet.  A typical carbonated soda contain the equivalent of 10 tsp (50 ml) of sugar.  The average U.S. adult eats 30 tsp  (150 ml) daily of added sweeteners and sugars.

On the other hand, Fanatic Cook Bix found a study linking higher sugar consumption with lower body weight, which you might think would protect against type 2 diabetes, heart disease, and some cancers.

Read the rest at The Age. It’s mostly about John Yudkin.

Steve Parker, M.D.

h/t Jamie Scott

Don’t Kid Yourself: Obesity Still Shortens Life Even If “Metabolically Healthy”

I'll eat my hat if this dude doesn't have metabolic syndrome

I’ll eat my hat if this dude doesn’t have metabolic syndrome

See details at MedPageToday.

Some folks can get away with smoking or drinking too much, but others can’t. They have hell to pay. There’s one sure-fire way to eliminate smoking-related disease risk.

Some studies suggest you can be healthy and long-lived while obese as long as you’re “metabolically healthy.” That is, if you have normal blood pressure, LDL cholesterol, triglycerides, blood sugar, and waist circumference. (You can be obese with a “normal” waist circumference, but it’s not easy.) A new meta-analysis finds the “metabolically healthy” label is a misnomer: you’re still at higher risk for death or cardiovascular events if you’re obese and free of metabolic syndrome features.

“Our results do not support this concept of ‘benign obesity’ and demonstrate that there is no ‘healthy’ pattern of obesity,” Kramer and colleagues wrote. “Even within the same category of metabolic status (healthy or unhealthy) we show that certain cardiovascular risk factors (blood pressure, waist circumference, low high-density lipoprotein cholesterol level, insulin resistance) progressively increase from normal weight to overweight to obese.”

Click for the scientific journal abstract.

This report does not directly address the “fat but fit” concept, whereby you can counteract some of the adverse health effects of obesity by being fit. By fit, I mean regularly exercising and achieving a decent level of capacity and tolerance for physical activity. Fat but fit still holds.

Steve Parker, M.D.

PS: For an opposing view of the study at hand, see comments by psychologist Deb Burgard. (h/t Beth Mazur)