Category Archives: Overweight and Obesity

July 24, 2012 · 2:00 AM

Sources of Calories in U.S. Diet Over Last Four Decades

Italian seaside totally unrelated to this post

Do you ever wonder how many of your total calories come from added sugars? Grains? Dairy products? Added fats?

Deriving your personal numbers would require detailed nutrient analysis, but if you’d like U.S. averages, see this cool infographic at Civil Eats.

It also shows how many calories are or were available for consumption per capita over time (without accounting for wastage in restaurants). It’s based on U.S. Department of Agriculture data.

A superficial glance suggests that U.S. per capita daily calorie consumption has increased by about 600 from the 1970s until now. But remember, these numbers don’t discount for restaurant wastage. Nor do I see an adjustment for children versus adults. I’ve seen other calculations of and extra daily 150 calories (women) to 300 calories (men). Even the lower numbers could explain our explosion of overweight and obesity.

Steve Parker, M.D.

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June 4, 2012 · 9:04 AM

What Everybody Ought to Know About Exercise’ Effect on Weight

  • Your genetics largely determines your response to an exercise program
  • Physical activity isn’t a great way to lose weight
  • School-based or other programs to increase childhood physical activity probably won’t reverse childhood obesity statistics
  • Disregarding weight loss, exercise has other worthwhile metabolic advantages
  • Highly advanced societies shouldn’t blame our overweight problem on decreased levels of physical activity

Skyler Tanner slaughters some sacred cows in his blog post June 4, 2012. I pulled these bullet points from his post. Click on his embedded links for details.

Steve Parker, M.D.

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May 30, 2012 · 6:20 PM

TV’s Biggest Loser Plan Improves Diabetes and Prediabetes

TV’s “The Biggest Loser” weight-loss program works great for overweight diabetics and pre diabetics, according to an article May 30, 2012, in MedPage Today.  Some quotes:

For example, one man with a hemoglobin A1c (HbA1c) of 9.1, a body mass index (BMI) of 51, and who needed six insulin injections a day as well as other multiple prescriptions was off all medication by week 3, said Robert Huizenga, MD, the medical advisor for the TV show.

In addition, the mean percentage of weight loss of the 35 contestants in the study was 3.7% at week 1, 14.3% at week 5, and 31.9% at week 24…

The exercise regimen for those appearing on “The Biggest Loser” comprised about 4 hours of daily exercise: 1 hour of intense resistance training, 1 hour of intense aerobics, and 2 hours of moderate aerobics.

Caloric intake was at least 70% of the estimated resting daily energy expenditure, Huizenga said.

At the end of the program, participants are told to exercise for 90 minutes a day for the rest of their lives. Huizenga said he is often told by those listening to him that a daily 90-minute exercise regimen is impossible because everyone has such busy lives.

“I have a job and I work out from 90 to 100 minutes per day,” he said. “It’s about setting priorities. Time is not the issue; priorities are the issue.”

Of the 35 participants in this study, 12 had prediabetes and six had diabetes.  This is a small pilot study, then.  I bet the results would be reproducible on a larger scale IF all conditions of the TV program are in place.  Of course, that’s not very realistic.  A chance to win $250,000 (USD) is strong motivation for lifestyle change.

Steve Parker, M.D.

PS: Although not mentioned in the article, these must have been type 2 diabetics, not type 1.

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May 2, 2012 · 2:00 AM

Does Cutting Out Sugary Drinks Help With Weight Loss?

Are you obese, love sugary drinks, and want to easily lose four pounds (1.8 kg) over the next six months? Simply cut a couple of sugary drinks out of your daily diet, replace them with water or diet soa, and you may lose the pounds.  Or so say University of North Carolina researchers.
Down 4 pounds in 6 months. I’ll take it!

In the U.S., our consumption of calories from sugar-sweetened beverages (SSBs) almost doubled between 1965 and 2002, now comprising 21% of our total calories.  (I’ve seen lower estimates, too, such as all added sugars accounting for 17% of total calories.)  Remember that our overweight and obesity rates started rising around 1970.  Any connection there?

Some have speculated that cutting back on SSB consumption would lead to loss of some excess weight.  But it’s never really been tested until now.

By the way, your typical sugary carbonated beverage has 145 calories of pure carbohydrate, most often high fructose corn syrup.  That’s equivalent to 10 tsp (50 ml) of table sugar.  Soft drinks are liquid candy.

Methodology

UNC investigators recruited  about 300 overweight and obese folks (average BMI 36, average weight 100 kg (220 lb), 84% female, 54% black) who drank at least 280 calories daily of caloric beverages (sugar-sweetened beverages, juice, juice drinks, sweetened coffee and tea, sweetened milk, sports drinks, and alcohol).  In other words, they all drank at least two soft drinks or the equivalent daily.  Participants agreed to make a dietary substitution for six months.

The participants were randomly assigned to one of three study groups with a hundred participants per group. For the next six months…

  • Group WA substituted at least two of their SSBs daily with water (WA), any type as long as it was calorie-free.  Bottled water was provided.  This reduced sugary drink calories by 230/day.
  • Group DB substituted at least two of their SSBs daily with calorie-free diet beverages (DB).  Beverages were provided.  This reduced sugary drink calories by 230/day.
  • Group AC (attention controls) made no changes in baseline beverage consumption.  Investigators made a point not to talk to them about beverages.

All three groups had monthly group meetings.  WA and DB group meetings were focused on adherence to the beverage substitution guidelines.
The AC group meetings will involved a weigh-in and general weight loss information (e.g., read food labels, increase vegetable consumption, portion control, and increase physical exercise).

“All … groups had access to a group-specific …website, where they recorded the beverages (water and DB only) they consumed, reported their weekly weight, received feedback on progress, viewed tips, and linked to group-specific resources.”

Results

All three groups lost statistically significant amounts of weight, but there was no difference in amount of weight lost among the groups.  In other words, the folks who substituted water or diet beverages for  sweet drinks didn’t do any better than the AC (attentive control) group.

Average amounts of weight lost were in the range of 1.8 to 2.5% of total body weight.  For example, if you weigh 200 lb (91 kg) and lose 2% of your weight, that’s a 4-lb loss (1.8 kg).

Compared to the AC group, the WA group showed a statistically significant decrease in fasting blood sugar (down 3 mg/dl).  BTW, none of the participants were diabetic.

Sugar cane

Take-Home Points

Would the substituters have lost weight if they had simply cut out two sugary drinks a day, skipping the monthy meetings and website?  Don’t know.  But I bet that’s how the mainstream press will spin this.

If I were obese and had a sugary drink habit, I’d start substituting water.  Yesterday.

Substituting water for a couple sugary drinks a day could reduce risk of developing diabetes.

I was hoping to see a significantly greater weight loss in the water and diet drink substituters compared to the AC (Attention Control) group.  Presumably all of these AC folks would have stayed at their baseline weights if they hadn’t done any of this.  The substitution groups apparently didn’t receive the general weight-loss information given to the AC group.

One caveat: All groups had monthly meetings for six months.  What were the substitution groups  talking about other than adherence to the protocol?  Your guess is as good as mine since the researchers don’t say.  Perhaps something about those meetings led to the weight loss, not the act of substituting water or diet drinks for sugar.

So they lost an average of 4–5 lb (2 kg).  Big deal, right?  But remember this was just a six-month study.  Could that 4 lb turn into 12 lb (5.5 kg) over 18 months?  Maybe, but we don’t know.

Here’s the thing about averages.  Some of these people I’m sure lost closer to 5% of body weight, and some didn’t lose any, or gained.  Which group would you be in?  Only one way to find out.

Remember that many medical conditions linked to overweight and obesity improve with loss of just 5% of body weight.

The substituters cut out 230 calories a day of sugary drinks.  All other things being equal, they should have lost 12 lb (5.5 kg).  Problem is, all other things aren’t equal.  Numerous other factors are at play, such as activity levels, replacement of sugary drink calories with other calories, measurement errors, reporting errors, etc.

This was a female-heavy study.  Would this strategy work for men?  Even better in men?  We don’t know.  Why not try it yourself?

Steve Parker, M.D.

PS: I did a sugar-free and wheat-free experiment on myself earlier this year.  Lost some weight, too.

Reference: Tate, Deborah, et al.  Replacing caloric beverages with water or diet beverages for weight loss in adults: main results of the Choose Healthy Options Conscioulsly Everday (CHOICE) randomized clinical trial.  American Journal of Clinical Nutrition, February 1, 2012, Epub ahead of print.  doi: 10.3945/ajcn.111.026278

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March 26, 2012 · 2:00 AM

Is It More Important To Be Fit, Or Healthy Weight?

Men live longer if they maintain or improve their fitness level over time, according to research out of the Cooper Clinic in Dallas, Texas.  Part of that improved longevity stems from reduced risk of death from cardiovascular disease (e.g., heart attack and stroke). 

Compared with men who lose fitness with aging, those who maintained their fitness had a 30% lower risk of death; those who improved their fitness had a 40% lower risk of death.  Fitness was judged by performance on a maximal treadmill exercise stress test.

Body mass index over time didn’t have any effect on all-cause mortality but was linked to higher risk of cardiovascular death.  The researchers, however, figured that losses in fitness were the more likely explanation for higher cardiovascular deaths.  In other words, as men age, it’s more important to maintain or improve fitness than to lose excess body fat or avoid overweight.

Steve Parker, M.D.

Reference: Lee, Duck-chul, et al.  Long-term effects of changes in cardiorespiratory fitness and bodly mass index on all-cause and cardiovascular disease mortality in men.  Circulation, 124 (2011): 2,483-2,490

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January 7, 2012 · 3:24 AM

Food Reward versus Carbohydrate/Insulin Theory of Obesity

 

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’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. 

Any thoughts?

Steve Parker, M.D.

h/t Dr. Emily Deans

 

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October 9, 2011 · 2:18 AM

Does Diminished Work Activity Explain Our 50-Year Overweight Trend?

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

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

Methodology

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

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

Researchers’ Findings and Conclusions

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

Discussion

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

(If you want to emulate a Paleolithic lifestyle, you should probably shoot for an hour of exercise daily, not 20 minutes as above.)

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

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

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

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

Steve Parker, M.D.

References:

Church, T.S., et al.  Trends over 5 decades in U.S. occupation-related physical activity and their associations with obesity.  PLoS ONE, 2011, 6(5): e19657.  doi: 10.1371/journal.pone.0019657  

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

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

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September 9, 2011 · 2:00 AM

Low-Carb Diet Reduces Weight AND Increases Adiponectin

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.  Read on to find out why this matters.

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.

ResearchBlogging.orgIn 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, S., Brehm, B., Benoit, S., & D’Alessio, D. (2011). Adiponectin Changes in Relation to the Macronutrient Composition of a Weight-Loss Diet Obesity DOI: 10.1038/oby.2011.60

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July 21, 2011 · 2:00 AM

Spanish Ketogenic Mediterranean Diet Cures Metabolic Syndrome

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.

ResearchBlogging.orgVery-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

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July 18, 2011 · 2:17 AM

Waist-Hip Ratio: How to Determine, and What It Means

High WHR

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

The risk of heart and vascular disease is more closely linked to distribution of excess fat than with degree of obesity as measured by overall weight or body mass index. Waist-hip ratio (WHR) is a measure of abdominal or central obesity, the type of fat distribution associated with coronary artery disease. A high ratio indicates the android body habitus.  The Journal of the American College of Cardiology two months ago reported that heart patients (coronary artery disease) with “central obesity” had a greater risk of death.  A high WHR is one measure of central obesity.

To determine your waist-hip ratio:

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

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

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

Steve Parker, M.D.

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