Category Archives: Weight Loss

Lose Weight With Contrave, But Don’t Kill Yourself

Open wide!

Open wide!

The FDA recently approved a new weight-loss drug for the U.S. market. It’s marketed as Contrave, a combination of naltrexone and bupropion.

Neither of the components is new. Naltrexone’s been used to treat alcohol and narcotic addiction. Bupropion, e.g., Wellbutrin, is for depression and smoking cessation.

Contrave joins two other recent drugs for weight loss. Belviq and Qsymia were approved in 2012. I still haven’t run across anyone using those.

To qualify for the new formulation, you need a body mass index over 30, or over 27 plus one or more weight-related medical condition such as type 2 diabetes or high blood pressure.

If you haven’t lost over 5% of your initial body weight in the first 12 weeks of use, the FDA recommends stopping the drug.

Potential adverse effects include suicidal thoughts and seizures. More commonly, users may experience headache, nausea, constipation, diarrhea, dizziness, insomnia, and dry mouth. Constipation and diarrhea?!

Even with the drug, you still have to be on a reduced-calorie diet and exercise program.

Why not try the Low-Carb Mediterranean Diet or Paleobetic Diet first?

Steve Parker, M.D.

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Filed under Weight Loss

Low-Carb Beats Low-Fat Diet for Weight Loss Once Again

…according to an article at MedPageToday.

Many physicians have been reluctant to recommend low-carb diets out of fear that they increase cardiovascular risk. 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).

This Avocado Chicken soup is low-carb. Use the search box to find the recipe.

This Avocado Chicken soup is low-carb. Use the search box to find the recipe.

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.

Regular readers here know of my Low-Carb Mediterranean Diet for diabetes and prediabetes. My Advanced Mediterranean Diet for non-diabetics also offers a low-carb option in addition to traditional reduced-calorie portion-control eating.

Steve Parker, M.D.

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Filed under Carbohydrate, Mediterranean Diet, Weight Loss

New Study Suggests Low-Carb Diet Healthier Than Low-Fat in T2 Diabetes

This is an important report because most diet studies last much less than one year. Details are in the American Journal of Clinical Nutrition.

Study participants were 115 obese (BMI 35) type 2 diabetics with hemoglobin A1c averaging 7.3%. Average age was 58. So pretty typical patients, although perhaps better controlled than average.

They were randomized to follow for 52 weeks either a very low-carbohydrate or a high-carbohydrate “low-fat” diet. Both diets were designed to by hypocaloric, meaning that they provided fewer calories than the patients were eating at baseline, presumably with a goal of weight loss. The article abstract implies the diets overall each provided the same number of calories. They probably adjusted the calories for each patient individually. (I haven’t seen the full text of the article.) Participants were also enrolled in a serious exercise program: 60 minutes of aerobic and resistance training thrice weekly.

Kayaking is an aerobic exercise if done seriously

Kayaking is an aerobic exercise if done seriously

The very low-carb diet (LC diet) provided 14% of total calories as carbohydrate (under 50 grams/day). The high-carb diet (HC diet) provided 53% of total calories as carbohydrate and 30% of calories as fat. The typical Western diet has about 35% of calories from fat.

Both groups lost weight, about 10 kg (22 lb) on average. Hemoglobin A1c, a reflection of glucose control over the previous three months, dropped about 1% (absolute reduction) in both groups.

Compared to the HC diet group, the LC dieters were able to reduce more diabetes medications, lower their triglycerides more, and increase their HDL cholesterol (“good cholesterol”). These triglyceride and HDL changes would tend to protect against heart disease.


You can lose weight and improve blood sugar control with reduced-calorie diets—whether very low-carb or high-carb—combined with an exercise program. No surprise there.

I’m surprised that the low-carb group didn’t lose more weight. I suspect after two months of dieting, the low-carbers started drifting back to their usual diet which likely was similar to the high-carb diet. Numerous studies show superior weight loss with low-carb eating, but those studies are usually 12 weeks or less in duration.

The low-carb diet improved improved lipid levels that might reduce risk of future heart disease, and allowed reduction of diabetes drug use. Given that we don’t know the long-term side effects of many of our drugs, that’s good.

If I have a chance to review the full text of the paper, I’ll report back here.

Steve Parker, M.D.

Reference: Jeannie Tay, et al. Comparison of low- and high-carbohydrate diets for type 2 diabetes management: a randomized trial. First published July 29, 2015, doi: 10.3945/​ajcn.115.112581    Am J Clin Nutr


Filed under Carbohydrate, Heart Disease, Weight Loss

Book Review: The South Asian Health Solution

Indian woman cooking chapati

Indian woman cooking chapati

Here’s my review of The South Asian Health Solution: A culturally tailored guide to lose fat, increase energy, avoid disease by Ronesh Sinha, published in 2014.

♦   ♦   ♦

Dr. Sinha practices internal medicine in northern California (Silicon Valley) and has a large dose of South Asians in his clinic. “South Asia” usually encompasses India, Pakistan, Nepal, Bangladesh, Bhutan, Sri Lanka and Maldives. It is home to one fifth of the world’s population. This book pertains mostly to Indians, which is Dr. Sinha’s ethnicity. I live in the Pheonix, AZ, area and we have a fair number of Indian engineers and physicians.


Because Dr. Sinha says they have unique genetic and cultural issues that predispose them to type 2 diabetes, abdominal obesity, coronary artery disease, high blood pressure, and adverse cholesterol numbers. For example, compared to natives who stay in their home countries, South Asian immigrants to the West have 3–4 times higher prevalence of diabetes, he says. Dr Sinha has a program that he’s convinced will prevent or forestall these medical problems in South Asians.

Dr. Sinha says South Asians eat too many carbohydrates and are too sedentary. Especially those who have moved to the West (e.g., US, UK, Europe, Canada). He notes that the core of the typical South Asian diet is flat breads, lentils, rice, fried crispy snacks (with heart-poisoning trans fats), culminating in 150–200 daily grams of carbohydrate more than he sees in other ethnics in California. Western fast foods, sodas, and sweets compound the problem.

He says “most South Asians are skinny-fat,” meaning skinny legs and arms but with a fat belly from visceral fat. This is also called sarcopenic obesity. The usual “healthy” body mass index (BMI) numbers don’t apply to Asians. The World Health Organisation classifies Asians as underweight if BMI is 18.4 or less, healthy at BMI of 18.5 to 13, overweight at BMI 23.1 to 25, and obese if BMi is over 25. These numbers are lower than those used for non-Asian populations.

Another issue in his South Asian patient population is vitamin D deficiency related to their dark skin (hence, less vitamin D production) and too much time indoors. He says vitamin D deficiency promotes inflammation and insulin resistance. More on this below.

Some South Asians have a K121Q gene mutation that causes insulin resistance, which in turn can cause disease. And whether it’s genetic or not (but I think it is), he says South Asians tend to have higher Lp(a) [aka lipoprotein(a)], which causes early and aggressive coronary artery disease. They also tend to have small dense LDL, leading to a lower-than-expected total cholesterol level which may be deceptively low.

Sinha notes a strong vegetarian preference in Indians but spends almost no time discussing it. From the book, I can’t tell if Indian vegetarians are lacto-ovo-vegetarians, pescetarians, or vegans. The author is not a vegetarian.

Gadi Sagar temple on Gadisar Lake, Jaisalmer, Rajasthan, India

Gadi Sagar temple on Gadisar Lake, Jaisalmer, Rajasthan, India



So, South Asians, at least in the West, have a high-carb diet, are too sedentary, and have genetic tendencies to heart disease and diabetes. How do these factors cause disease? It’s all tied together with insulin resistance. Insulin is the main hormone that keeps our blood sugar from rising too high after we digest a meal. Insulin drives blood sugar into our body cells to be used as energy or stored as fat or glycogen. If our tissues have insulin resistance, blood sugar levels rise. As a compensatory effort, our pancreas excretes more insulin in to the blood stream than would normally be the case. Whether or not that eventually lowers blood sugar levels, the higher insulin levels themselves can cause toxicity. For example, higher insulin levels raise blood pressure, which damages the cells lining the insides of our arteries, leading to chronic inflammation and atherosclerosis (hardening of the arteries). Some of the arterial damage is mediated through small dense LDL cholesterols (aka type B LDL), which is promoted by high insulin levels (hyperinsulinemia). Insulin resistance also results in a defective and overactive immune system, which further promotes chronic inflammation. This inflammation is “…the root cause of almost every imaginable chronic disease…from heart attacks and strokes to Alzheimers Disease.”

Anyway, this is Dr. Sinha’s hypothesis, and there is some scientific evidence to support it. Sinha says that the concept of insulin resistance “weaves together virtually every chronic ailment currently afflicting South Asians.” That may be a bit hyperbolic: He carves out no exceptions for arthritis, asthma, eczema, migraines, glaucoma, macular degeneration, hearing loss, erectile dysfunction, hepatitis C, prostate enlargement, toenail fungus, or male-pattern baldness.

Dr. Sinha’s Grand Unification Theory of Disease Causation has some support among physicians and scientists, but is by no means universally accepted among them. As for myself, I think he’s over-simplifying (for his readership’s sake?) and getting a bit ahead of the science.

Most clinicians aren’t testing directly for insulin resistance. What are the indirect clues? Belly fat, low HDL cholesterol, high trigylcerides, high blood pressure, prediabetes, and type 2 diabetes. These are components of the metabolic syndrome. Not everybody with one or more of these factors has insulin resistance but many do.


If Sinha is correct, the South Asian Health Solution is a “low-insulin lifestyle” achieved through carbohydrate-reduced eating, exercise, and avoidance or resolution of belly fat. These help improve all components of the aforementioned metabolic syndrome. The backbone of the plan is carbohydrate restriction. For low-carb eating, avoid wheat bread and Indian flat breads (e.g., chapatis, naans, parathas, puris, phulkas), aloo (primarily potatoes and starchy vegetables), rice and other grains, beans, and sugar. Keep track of your net carbohydrates (he likes, which includes South Asian foods).

If you need to burn off body fat, limit carbs to 50–100 grams/day (digestible or net carbs, I assume). Aim for 100–150 grams/day to maintain health and weight loss.

You might be able to add “safe starches” later: white rice, potatoes. To replace your Indian flat breads, learn how to make them with substitutes for wheat flour: coconut flour or almond flour (no skins) or almond meal (skin included). Recipe on page 347. Rice alternatives are cauliflower “rice,” shredded cabbage, broccoli slaw, chopped broccoli, and chopped carrots.

He likes ghee, extra virgin olive oil, coconut oil, and butter. Avoid high omega-6 fatty acid consumption, as in vegetable oils. Of course, avoid trans fats. Good fats are saturated, monousaturated, and omega-3s.

He provides a few low-carb recipes, surprisingly without specific carb counts: chapatis, microwave bread, cauliflower pizza, coconut cauliflower rice, shredded cabbage sabji, gajar halwa (carrot pudding), and coconut ladoo.

Dr. Sinha doesn’t provide a comprehensive meal plan. He trusts his California South Asians to figure out how and what to eat. They’re smarter than average (he never says that, but that’s been my experience with South Asians in my world).

Dr. Sinha is also a huge proponent of exercise. He’ll tell you about squats, lunges, planks, burpees, yoga, and Tabata intervals. He agrees with me and Franziska Spritzler that “physical activity is the most effective fountain of youth available.”

Steve Parker, M.D., Conquer Diabetes and Prediabetes

Taking a rest from the fountain of youth


I skipped some of the chapters due to lack of time and interest: women’s issues (e.g., pregnancy, polycystic ovary syndrome, post-partum depression, osteoporosis), childhood, fatigue and stress management, and anti-aging.


  • He likes high-sensitivity CRP testing.
  • His metabolic goals for South Asians are: 1) keep waist circumference under 35 inches (90 cm) in men, under 31 inches (80 cm) in women, 2) keep triglycerides under 100 mg/dl (1.13 mmol/l), 3) keep HDL cholesterol over 40 mg/dl (1.03 mmol/l) for men, and above 50 mg/dl (1.29 mmol/l) for women, 4) keep systolic blood pressure 120 or less, and diastolic pressure 80 or less, 5) keep fasting blood sugar under 100 mg/dl (5.6 mmol/l) and hemoglobin A1c under 5.7%, and 6) keep hs-CRP under 1.0 mg/dl.
  • He says HDL cholesterol helps reduce insulin resistance via apoprotein A-1 (apo A-1), which increases glucose uptake by cells.
  • He likes to follow the triglyceride/HDL ratio. If under 3, it means low risk of insulin resistance being present.
  • He likes to follow total cholesterol/HDL cholesterol ratio: ideal is under 3.5.
  • Statins are way over-used.
  • Ignore total cholesterol level by itself.
  • Stress control and sleep are important.
  • The author had some metabolic syndrome components: high triglycerides, low HDL cholesterol, and type B LDL (small, dense particles).
  • He dislikes the usual-recommended low-fat, low-cholesterol diet.
  • 4 tbsp (60 ml) of extra virgin olive oil daily seems to lower blood pressure.
  • Magnesium supplementation may lower blood pressure.
  • The liver stores about 100 grams of glycogen and muscles store 300–500 grams.
  • Vanaspati is a “cheap ghee substitute” made from vegetable oil and widely used in Indian restaurants and many Indian processed foods. Avoid it since it’s a source of trans fats.
  • Aloo sabji is a potato dish.
  • Traditional Indian herbs/spices include turmeric, cardamon, ginger, and cilantro.
  • Find an Indian medication guide at
  • Coconut milk is a traditional fat in India.
  • Curry, curry, curry.
  • http://www.pamforg/southasian.
  • Non-alcoholic steatohepatitis (NASH) is quite common in South Asians, seemingly linked to visceral (abdominal) obesity and insulin resistance related to carbohydrates.
  • The book has no specific focus on diabetes.


Overall, I like many of Dr. Sinha’s ideas. They seem to be supported by his experience with his own patients. I trust him. I bet many South Asians and non-Asians eating the Standard American Diet would see improved health by following his low-carb, physically active program.

Steve Parker, M.D.



Filed under Book Reviews, coronary heart disease, Heart Disease, India, Overweight and Obesity, Weight Loss

Prevent Weight Regain With the Mediterranean Diet

Italian seaside tangentially related to this post

Italian seaside tangentially related to this post

Investigators affiliated with universities in Italy and Greece wondered about the effect on obesity of two ketogenic “Mediterranean” diet spells interspersed with a traditional Mediterranean diet over the course of one year. They found significant weight loss, and perhaps more importantly, no regain of lost weight over the year, on average.

This scientific study is right up my alley. I was excited when I found it. Less excited after I read it.

The Set-Up

This was a retrospective review of medical records of patients of a private nutritional service in three fitness and weight control centers in Italy between 2006 and 2010. It’s unclear whether patients were paying for fitness/weight loss services. 327 patient records were examined. Of these, 89 obese participants met the inclusion and exclusion criteria and started the program; 68 completed it and were the ones analyzed. (That’s not at all a bad drop-out rate for a year-long study.)  The completers were 59 males and 12 females (I know, the numbers don’t add up, but that’s what they reported). Ages were between 25 and 65. Average weight was 101 kg (222 lb), average BMI 35.8, average age 49. All were Caucasian. No diabetics.

Here’s the program:

  1. 20 days of a very-low-carb ketogenic diet, then
  2. 20 days of a low-carbohydrate non-ketogenic diet for stabilization, then
  3. 4 months of a normal caloric Mediterranean diet, then
  4. repeat #1 and #2, then
  5. 6 months of a normal caloric Mediterranean diet

In the ketogenic phases, which the authors referred to as KEMEPHY, participants followed a commercially available protocol called TISANOREICA. KEMEPHY is combination of four herbal extracts that is ill-defined (at least in this article), with the idea of ameliorating weakness and tiredness during ketosis. The investigators called this a ketogenic Mediterranean diet, although I saw little “Mediterranean” about it. They ate “beef & veal, poultry, fish, raw and cooked green vegetables without restriction, cold cuts (dried beef, carpaccio and cured ham), eggs and seasoned cheese (e.g., parmesan).” Coffee and tea were allowed. Items to avoid included alcohol, bread, pasta, rice, milk, and yogurt. “In addition to facilitate the adhesion to the nutritional regime, each subject was given a variety of specialty meals constituted principally of protein and fibers. “These meals (TISANOREICA) that are composed of a protein blend obtained from soya, peas, oats (equivalent to 18 g/portion) and virtually zero carbohydrate (but that mimic their taste) were included in the standard ration.” They took a multivitamin every morning. Prescribed carbohydrate was about 30 grams a day, with macronutrient distribution of 12% carb, 36 or 41% protein, and 51 0r 52% fat. It appears that prescribed daily calories averaged 976 (but how can that be prescribed when some food items are “unrestricted”?).

I found little explanation of period #2 mentioned above, the low-carb non-ketogenic diet. Prescribed macronutrients were 25 or 33% carb, 27 0r 31% protein, 41 or 44% fat, and about 91 g carbohydrate. Prescribed daily calories appear to have averaged 1111.

After the first and second active weight loss ketogenic phases, participants ate what sounds like a traditional Mediterranean diet. Average prescribed macronutrient distribution was 57% carbohydrate, 15 % protein, and 27% fat. Wine was allowed. It looks like 1800 calories a day were recommended.

Food consumption was measured via analysis of 3-day diaries, but you have to guess how often that was done because the authors don’t say. The results of the diary analyses are not reported.

What Did They Find?

Most of the weight loss occurred during the two ketogenic phases. Average weight loss in the first ketogenic period was 7.4 kg (16 lb), and another 5.2 kg (11 lb) in the second ketogenic period. Overall average weight loss for the entire year was 16.1 kg (35 lb).

Average systolic blood pressure over the year dropped a statistically significant 8 units over the year, from 125 to 116 mmHg.

Over the 12 months, they found stable and statistically significant drops in total cholesterol, LDL cholesterol (“bad cholesterol”), triglycerides, and blood sugar levels. No change in HDL cholesterol (“good cholesterol”).

Liver and kidney function tests didn’t change.

The authors didn’t give explanations for the drop-outs.

Although the group on average didn’t regain lost weight, eight participants regained most of it. The investigators write that “…the post dietary analysis showed that they were not compliant with nutritional guidelines given for the Mediterranean diet period. These subjects returned to their previous nutrition habits (“junk” food, high glycaemic index, etc.) with a mean “real” daily intake of 2470 Kcal rather than the prescribed 1800 Kcal.”


A key take-home point for me is that the traditional Mediterranean diet prevented the weight regain that we see with many, if not most, successful diets.

However, most formulas for calculating steady state caloric requirements would suggest these guys would burn more than the 1800 daily calories recommended to them during the “normal calorie” months. How hard did the dieters work to keep calories around 1800? We can only speculate.

Although the researchers describe the long periods of traditional Mediterranean diet as “normal caloric,” they don’t say how that calorie level was determined  and achieved in the real world. Trust me, you can get fat eating the Mediterranean diet if you eat too much.

I’ll be the first to admit a variety of weight loss diets work, at least short-term. The problem is that people go back to their old ways of eating regain much of the lost weight, typically starting six months after starting the program. It was smart for the investigators to place that second ketogenic phase just before the typical regain would have started!

There are so few women in this study that it would be impossible to generalize results to women. Why so few? Furthermore, weight loss and other results weren’t broken down for each sex.

I suspect the results of this study will be used for marketing KEMEPHY and TISANOREICA. For all I know, that’s why the study was done. We’re trusting the investigators to have done a fair job choosing which patient charts to analyze retrospectively. They could have cherry-picked only the good ones. Some of the funding was from universities, some was from Gianluca Mech SpA (what’s that?).

How much of the success of this protocol is due to the herbal extracts and TISANOREICA? I have no idea.

The authors made no mention of the fact the average fasting glucose at baseline was 103 mg/dl (5.7 mmol/l). That’s elevated into the prediabetic range. So probably half of these folks had prediabetes. After the one-year program, average fasting glucose was normal at 95 mg/dl (5.3 mmol/l).

The improved lipids, blood sugars, and lower blood pressure may have simply reflected successful weight loss and therefore could have been achieved  by a variety of diets.

The authors attribute their success to the weight-losing metabolic effects of the ketogenic diet (particularly the relatively high protein content), combined with the traditional Mediterranean diet preventing weight regain.

The authors write:

The Mediterranean diet is associated with a longer life span, lower rates of coronary heart disease, hypercholesterolemia, hypertension, diabetes and obesity. But it is difficult to isolate the “healthy” constituents of the Mediterranean diet, since it is not a single entity and varies between regions and countries. All things considered there is no “one size fits all” dietary recommendation and for this reason we have tried to merge the benefits of these two approaches: the long term “all-life” Mediterranean diet coupled with brief periods of a metabolism enhancing ketogenic diet.

I’ve attempted a similar merger with my Low-Carb Mediterranean Diet. Click here for an outline. Another stab at it was the Spanish Ketogenic Mediterranean Diet. And here’s my version of a Ketogenic Mediterranean Diet.

Steve Parker, M.D.

Reference: Paoli, Antonio, et al. Long Term Successful Weight Loss with a Combination Biphasic Ketogenic Mediterranean Diet and Mediterranean Diet Maintenance Protocol. Nutrients, 5 (2013): 5205-5217. doi: 10.3390/nu5125205


Filed under ketogenic diet, Mediterranean Diet, Prediabetes, Weight Loss, Weight Regain

David and Goliath: Dr. Briffa Versus National Health Service on Low-Carb Diets

The United Kingdom’s National Health Service last year published guidelines favoring low-fat weight-loss diets over low-carb ones. Dr. John Briffa objects:

See here for a comprehensive review of 23 studies which demonstrates superior results achieved by low-carb diets with regard to weight loss and disease markers. To my mind, dietician Sian Porter and the NHS Choices website have done a bad job of communicating the facts and summarising the evidence. I wish to formally complain about the inaccuracies in this article and its (to me) clear bias and lack of balance.

Read the whole enchilada (plus this update).

Steve Parker, M.D.


Filed under Weight Loss

Diabetes Drug Now Sold As Weight-Loss Aid

It’s liraglutide, which has been available to treat diabetes in the U.S. since 2009. It’s sold as Victoza. Click for my brief review of the drug class for diabetics. The weight-loss preparation will be sold in the U.S. as Saxenda and it’s a higher dose than is used for just diabetes.

Click for the CBS News report on Saxenda. A snippet:

One clinical trial that involved patients without diabetes found that patients taking Saxenda had an average weight loss of 4.5 percent after one year. Of the people treated with the drug, 62 percent lost at least 5 percent of their body weight. Meanwhile, only 34 percent of those given an inactive placebo had the same result.

Another clinical trial that included patients with type 2 diabetes found that patients had an average weight loss of almost 4 percent after one year. Of those given Saxenda, 49 percent lost at least 5 percent of their body weight, compared to 16 percent of those who were given a placebo treatment.

Click for the FDA’s press release.

Oh, by the way. You have to inject it daily under the skin (subcutaneous). And if you were hoping for a shortcut to weight loss, this ain’t it. You’re still supposed to follow a reduced-calorie diet and exercise regularly.

I’d try the  Low-Carb Mediterranean Diet first if I had diabetes.

Steve Parker, M.D.

PS: Full prescribing information.


Filed under Weight Loss