Category Archives: Overweight and Obesity

January 21, 2010 · 2:00 AM

Medical Cost of Obesity, Yearly, Per Person: $1,723

The direct yearly medical cost of being obese in the U.S. is $1,723 per obese person, according to a just-released report in Obesity Reviews.  Being overweight is a relative bargain at $266.

These numbers translate into $114 billion yearly, or five to 10 percent of total healthcare spending.

Not included in the numbers are costs such as lost productivity due to obesity-related illness and replacement or repair of items that wear out or break due to excessive amounts of physical stress.  Not to mention pain and suffering.

Are you overweight or obese?  Find out with an online body mass index calculator. 

Want to do anything about it?  See my “Prepare for Weight Loss” series.

Steve Parker, M.D.

Reference:  Tsai, A.G., et al.  Direct Medical Cost of Obesity in the U.S.A.  Obesity Reviews, online January 6, 2009.  doi: 10.1111/j.1467-789x.2009.00708.x

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January 10, 2010 · 2:00 AM

Diabetes + Overweight and Obesity = Diabesity

Mark Hyman, M.D., blogged about diabesity at the Huffington Post December 24, 2009.  He defines diabesity as a problem with glucose regulation associated with overweight and obesity.  The glucose physiology problem ranges from metabolic syndrome to prediabetes to full-blown type 2 diabetes.

“Diabesity” has been in circulation for a few years, but hasn’t caught on yet. 

What interested me about his blog post was that he advocates the Mediterranean diet as both therapeutic and prophylactic.  To quote Dr. Hyman:

The optimal diet to prevent and treat diabesity includes:

  • Fruits
  • Vegetables
  • Nuts
  • Seeds
  • Beans
  • Whole grains
  • Healthy fats such as olive oil, nuts, avocados, and omega-3 fats
  • Modest amounts of lean animal protein including small wild fish such as salmon or sardines

This is commonly known as a Mediterranean diet.  It is a diet of whole, real, fresh food. It is a diet of food you have to prepare and cook from the raw materials of nature.  And it has broad-ranging benefits for your health.

Food for thought, no doubt. 

Steve Parker, M.D.

Reference:  Hyman, Mark.  The diabesity epidemic part III:  Treating the real causes instead of the symptoms.  The Huffington Post, December 24, 2009

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January 2, 2010 · 2:00 AM

Legumes and Cereal Grains: Any Role in Weight Management?

Researchers at the University of Wollongong (Australia) reviewed the scientific literature on the role for cereal grains and legumes in weight management.

In this context, “cereal” refers to “a grass such as wheat, oats, or corn, the starchy grains of which are used as food” (American Heritage Dictionary). 

Here’s their summary:

There is strong evidence that a diet high in whole grains is associated with lower body mass index, smaller waist circumference, and reduced risk of being overweight; that a diet high in whole grains and legumes can help reduce weight gain; and that significant weight loss is achievable with energy-controlled diets that are high in cereals and legumes. There is weak evidence that high intakes of refined grains may cause small increases in waist circumference in women. There is no evidence that low-carbohydrate diets that restrict cereal intakes offer long-term advantages for sustained weight loss. There is insufficient evidence to make clear conclusions about the protective effect of legumes on weight.  

I haven’t read the entire article, but invite you to do so.  I’m searching for clues as to which type of carbs to add after one finishes the Ketogenic Mediterranean Diet.

Steve Parker, M.D.

Reference:  Williams, P.G., et al.  Cereal grains, legumes, and weight management: a comprehensive review of the scientific evidence.  Nutrition Reviews, 66(2008): 171-82.

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December 28, 2009 · 2:00 AM

Mea Culpa: Average Holiday Weight Gain Not as High as I Thought

Travis Saunders at the Obesity Panacea blog notes that average weight gain in adults over the Thanksgiving (U.S.)–Christmas–New Years’ season seems to be on the order of 0.8 pounds or 0.37 kg. 

Data are from a 2000 article in the New England Journal of Medicine.  Researchers weighed 195 Americans throughout the year.  My quick search at PubMed.gov found no better or more recent studies.

I mention this because I had written somewhere that average holiday season weight gain is about five pounds (2.3 kg).  I stand corrected.

Steve Parker, M.D.

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December 9, 2009 · 2:00 AM

Book Review: Good Calories, Bad Calories

Here’s my  review of good Calories, Bad Calories: Challenging the Conventional Wisdom on Diet, Weight Control, and Disease, by Gary Taubes, 2007.  I give it five stars on Amazon.com’s five-star system (“I love it”).

♦   ♦   ♦

This brilliant book deserves much wider currency among physicians, dietitians, nutritionists, and obesity researchers.  The epidemic of overweight and obesity over the last 30 years should make us question the reigning theories of obesity treatment and prevention.  Taubes questioned those theories and pursued answers wherever the evidence led.  He shares in GCBC his eye-opening, even radical, well-reasoned findings. 

Ultimately, this tome is an indictment of the reigning scientific community and public nutrition policy-makers of the last four decades.  That explains why, twoyears after publication, this serious, scholarly work has not been reviewed by the New England Journal of Medicine, the Journal of the American Medical Association, the American Journal of Clinical Nutrition , and the Journal of the American Dietetic Association (as of August, 2009).

In Part 1, Taubes examines the scientific evidence for what he calls the fat-cholesterol hypothesis.  More commonly known as the diet-heart hypothesis, it’s the idea that dietary fat (especially saturated fat) and cholesterol clog heart arteries, causing heart attacks.  Taubes finds the evidence unconvincing.  He’s probably right.

Part 2, The Carbohydrate Hypothesis, revives and older theory from the mid-twentieth cenury that is elsewhere called the Cleave-Yudkin carbohydrate theory of dental and chronic systemic disease.  In the carbohydrate theory,  high intake of sugary foods, starches, and refined carbhohyrates leads first to dental disease (cavities, gum inflammation, periodontal disease) then, later, to obesity and type 2 diabetes, coronary heart disease, perhaps even cancer and Alzheimer’s Disease.  These are, collectively, the “diseases of civilization.”

Part 3 tackles obesity and weight regulation.  Taubes writes that “…fattening and obesity are caused by an imbalance—a dysequilibirium—in the hormonal regulation of adipose [fat] tissue and fat metabolism.”  Think of the transformation of a skinny 10-year-old girl into a voluptuous young woman.  It’s not over-eating that leads to curvaceous fat deposits, growth of mammary tissue, and increase in height; it’s hormonal changes beyond her control. 

The primary hormonal regulator of fat storage is insulin, per Taubes.  Elevated insulin levels lead to storage of food energy as fat.  Carbohydrates stimulate insulin secretion and make us fat. 

Although it’s a brilliant book, by no means do I agree with all Taubes’ conclusions.  For instance, if carbohydrates cause heart disease, why is glycemic index only very weakly associated with coronary heart disease in men?  It’s way too early to blame cancer and Alzheimers on carbohydrates.  Primitive cultures may not exhibit many of the diseases of civilization because their members die too young.  Taubes is clearly an advocate of low-carb eating.  Why didn’t he directly address the evidence that fruits, vegetables, and whole grains in the right amounts are healthy?

I have to give Taubes credit for thinking “outside the box.”  His search for answers included reviews of esoteric literature and interviews with scientists in the fields of genetics, athropology, public policy, physiologic psychology, and paleontology, to name a few.

Towards the end of the book, Taubes describes a Mediterranean-style or “prudent” diet that is popular these days.  After five years of research for his book, he says that whether a very low-carb meat diet is healthier than a prudent diet “… is still anybody’s guess.”  It’s hard for me to put aside numerous observational studies associating health benefits with legumes, fruits, vegetables, and wholegrains.  So my “guess” is that the Mediterranean-style diet is healthier.  Perhaps the answer is different for each individual.  Heck, maybe the answer is low-carb Mediterranean.  Both Taubes and I are prepared to accept either result when we have proof-positive data.    

Taubes doesn’t base his opinions on late-breaking scientific results.  Instead, his research findings mostly span from 1930 to 1980, especially 1940-1960.  Once the fat-cholesterol (diet-heart) hypothesis took root around 1960 and blossomed in the 1970s, these data were ignored by the entrenched academics and policy-makers of the day. 

To be fair, I’ve got to mention this is not light reading.  A majority of people never read another book after they graduate high school.  Of those who do, many (like me) will have to look up the definition of “tautology,” “solecism,” etc. 

I was taught in medical school years ago that “a calorie is a calorie is a calorie.”  Meaning: if you want to lose excess weight, it doesn’t matter if you cut calories from fat, protein, or carbohydrates.  I really wonder about that now.

Steve Parker, M.D 

Additional Reading

Bray, George A.  Viewpoint: Good Calories, Bad Calories by Gary Taubes.  Obesity Reviews, 9 (2008): 251-263.

Taubes, Gary.  Letter to Editor: Response to Dr. George Bray’s review of Good Calories, Bad Calories.  Obesity Reviews, 10 (2008): 96-98.

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December 7, 2009 · 2:00 AM

Are Fructose and High Fructose Corn Syrup Bad for Us?

Table sugar (sucrose) is a combination of glucose and fructose

Darya Pino earlier this month posted at her Summer Tomato blog a video regarding high fructose corn syrup.  The speaker in the video is pediatric endocrinologist Robert Lustig, M.D., of the University of California—San Francisco.
In the U.S. between 1970 and 1990, consumption of high fructose corn syrup increased over 1000%.  During those two decades, the incidence of overweight and obesity nearly doubled.  Many wonder if this is more than just coincidental. Most of this fructose is in soft drinks.  Soft drink consumption per person in 1942 was two servings per week.  In 2000, consumption was two servings per day.  Of course, these drinks typically have few nutrients other than sugars.
I wrote about fructose possibly being “the new trans fat” almost two years ago.

Dr. Lustig is convinced that high fructose corn syrup (HFCS) is a chronic toxin, at least in the amounts many of us eat, and the cause of our current epidemic of childhood and adult obesity and overweight.  Even if this idea is not new to you, you may be interested to hear the biochemistry and physiology behind his position.  If you didn’t enjoy college lectures or are not a food science geek, you probably won’t be able to sit through this 1.5-hour video. 

I enjoyed the heck out of it!  Made me feel like I was back in college again.  Few of my professors were as good as Dr. Lustig at lecturing. 

Here are a few of his other major points:

  • HFCS was invented in Japan in the 1960s, then introduced to U.S. markets in 1975
  • sucrose and fructose are both poisons
  • in the U.S. we eat 63 pounds (28.6 kg) of HFCS and 141 pounds (64.1 kg) of sugar per year [he didn’t define “sugar” in this context]
  • he praises Yudkins book, Pure, White, and Deadly [I’ve written about the Cleave-Yudkin carbohydrate theory of chronic disease]
  • the triglyceride/HDL ratio predicts heart disease much better than does LDL cholesterol
  • chronic high fructose intake causes the metabolic syndrome [does he think it’s the only cause?]
  • only the liver can metabolize fructose, in contrast to every other tissue and organ that can use glucose as an energy supply
  • high fructose consumption increases the risk of gout and high blood pressure
  • fructose interferes with production of our body’s production of nitrous oxide—a natural circulatory dilator—leading to higher blood pressures
  • fructose increases de novo lipogenesis—in other words, it creates body fat
  • fructose interferes with natural chemical messengers that tell your brain you’ve had enough food and it’s time to stop eating
  • high fructose intake reduces LDL particle size, potentially increasing the future risk of cardiovascular disease such as heart attacks [small, dense LDL cholesterol is more damaging to your arteries that large, fluffy LDL]

So What? 

You don’t need polititians to reduce your consumption of sugary soft drinks and high fructose corn syrup—do it yourself starting today.  Read food labels—HFCS is everywhere.  I’ve found it in sausage! 

The food industry greatly reduced use of trans fats in response to consumer concerns, before the polititians ever dabbled in it.  HFCS can go the same route.  Consumption of soft drinks, sports drinks, and other sugary beverages—the major sources of HFCS—is up to you.

Steve Parker, M.D.

PS: The Advanced Mediterranean Diet and Ketogenic Mediterranean Diet are naturally low in fructose.

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November 22, 2009 · 2:00 AM

Low-Carb Ketogenic Diet for Overweight Diabetic Men: A Pilot Study

A low-carb ketogenic diet in patients with type 2 diabetes was so effective that diabetes medications were reduced or discontinued in most patients, according to U.S. researchers.  The 2005 report recommends that similar dieters be under close medical supervision or capable of adjusting their own medication, because the diet lowers blood sugar  dramatically. 

Methodology

Twenty-eight overweight people with type 2 diabetes were placed on the study diet and followed for 16 weeks.  Seven people dropped out, so the analysis involved 21, of which 20 were men—the study was done at a Veterans Administration clinic.  Thirteen were caucasian, eight were black.  Average age was 56; average body mass index was 42.  The seven dropouts were unable to come to the scheduled meetings or couldn’t follow the diet.  No dropout complained of adverse effects of the diet.

Results

Participants were instructed on the Atkins Induction Phase diet, which daily includes:

  • under 20 g carbohydrate
  • one cup of low-carb vegetables
  • two cups of salad greens
  • four ounces of hard cheese
  • unlimited meat, poultry, fish, eggs, shellfish
  • a multivitamin

At the outset, diabetes medication dosages were reduced in this general fashion: insulin was halved, sulfonyureas were halved or discontinued.  If the participant were taking a diuretic (fluid pill), low doses were discontinued; high doses were halved.

Study subjects returned every two weeks for diet counseling and medication adjustment (based on twice daily glucose readings and episodes of hypoglycemia).  Food cravings and/or good progress on weight goals triggered a 5-gram (per day) weekly increase in carbohydrate allowance.  In other words, if a participant’s weight loss goal was 20 pounds and he’d already lost 10, he could increase his daily carbs during the next week from 20 to 25 g.  Carbs could be increased weekly by five gram increments as long as weight loss progressed.  [This is typical Atkins.]   Food records were analyzed periodically.   

Results

  • hemoglobin A1c decreased from an average baseline of 7.5% down to 6.3% (a 1.2% absolute decrease and 16% relative drop)
  • the absolute hemoglobin A1c decrease was at least 1.0% in half of the participants
  • diabetic drugs were reduced in 10 patients, discontinued in seven, and unchanged in four
  • average body weight decreased by 6.6%, from 131 kg (288 lb) to 122 kg (268 lb)
  • triglycerides decreased 42%, while cholesterols (total, HDL, and LDL) didn’t change significantly
  • no change in blood pressures
  • average fasting glucose decreased by 17% (by week 16)
  • uric acid decreased by 10%
  • no serious adverse effects occurred
  • one hypoglycemic event involved EMS but was treated without transport
  • only 27 of 151 urine ketone measurements  were greater than trace

My Comments

The degree of improvement in hemoglobin A1c—our primary gauge of diabetes control—is equivalent to that seen with many diabetic medications.  I see many overweight diabetics on two or three drugs and a standard “diabetic diet,” and they’re still poorly controlled.  This diet could replace the expense and potential adverse effects of an additional drug.   

In August this year I blogged about a study comparing the Atkins diet with a traditional low-fat diet in overweight diabetic black women in the U.S.  As measured at three months, the Atkins diet proved superior for weight loss and glucose control.

This study at hand is small, but certainly points to the effectiveness of an Atkins-style very low-carb ketogenic diet in overweight men with type 2 diabetes.

Steve Parker, M.D.

Yancy, William, et al.  A low-carbohydrate, ketogenic diet to treat type 2 diabetes [in men].  Nutrition and Metabolism, 2:34 (2005).   doi: 10.1186/1743-7075-2-34

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November 20, 2009 · 2:00 AM

For Heart’s Sake, Should You Avoid Red Meat in a Low-Carb Diet?

Low carbohydrate diets tend to contain disproportionate amounts of fat from animal sources.  Red meat has long been vilified as a major source of saturated fat that some experts believe cause hardening-of-the-arteries (atherosclerosis) via elevations in LDL cholesterol.  Others disagree.  Poultry, fish ,and shellfish generally have lower amounts of saturated fat than red meat.  Would a low-carb diet with a predominance of poultry, fish, and shellfish lead to a more advantageous cholesterol profile?

A 2007 report from U.S. researchers found no lipid advantage to the poultry/fish/shellfish model.    In fact, despite high cholesterol and fat intakes, neither diet caused a significant change in total, HDL, or LDL cholesterol levels.  Triglycerides fell in both groups, but to a statistically significant degree only on the poultry/fish/shellfish group.

Fun Fact:  Did you know that four of every 10 women in the U.S. are trying to lose weight?  The figure for men is one in three.  

Methodology

Researchers in Minnesota and Iowa enrolled 18 subjects (6 males, 12 females) between the ages of 30 and 50 who wanted to lose weight.  Average body mass index was 31.7, which is mildly obese.  The were encouraged to eat an Atkins-style ketogenic diet with a maximum of 20 g carbs/day, providing 1,487 total daily calories, with 7% of calories from carbohydrate, 43% from protein, and 50% from fat.  This included two or three cups of salad greens and low-carb vegetables.  Three ounces of cheese daily was allowed.  Subjects were randomly assigned to eat either red meat or poultry/fish/shellfish.  Dietary intervention lasted 28 days.

[This is very similar to Atkins Induction Phase, although Atkins does not limit total calories.  The researchers did not say why they wanted to limit total calories.] 

Data were not used from six subjects for good reasons (see article).  So final data analysis included only 12 subjects.

Results

Both groups lost the same amount of weight: about 5.5 kg (12 pounds) over 28 days.

Average carbohydrate intake was about the same for both groups: 55 g/day.

Average total daily caloric intake was about the same for both groups: 1,380.

The poultry/fish/shellfish group ate 630 mg cholesterol daily, twice as much as the other group.  [Eggs and shrimp were popular.]

The difference in intake of saturated fat approached, but did not reach, statistical significance (32 g/day in the red meat group vs 25 g).

Neither diet caused a significant change in total, HDL, or LDL cholesterol levels.  Triglycerides fell in both groups, but to a statistically significant degree only on the poultry/fish/shellfish group.

Urine ketones at or above 5 mg/dl were detected on 75% of all dipstick tests.

My Comments

I’m skeptical about the accuracy of the calorie counts.  Most people eating Atkins-style take in about 1,800 cals/day.  The preponderance of females, however, may explain the unusually low average caloric intake.  They didn’t follow their carb restriction very closely, did they?  These were free-living subjects not locked in a metabolic ward.

The researchers note that the allowance of cheese in both groups may have sabotaged their efforts for a clear delineation of higher versus lower saturated fat groups. 

HDL cholesterol usually rises significantly on low-carb diets.  Lack of that here may just be a statistical aberration.

This is such a small study that it’s impossible to draw firm conclusions.  Nevertheless, if someone is losing weight on a low-carb diet, it may not matter much from a lipid viewpoint whether they eat a predominance of meat or a predominance of poultry, fish, and shellfish.  The study at hand cannot address the long-term consequences of such a choice.

Steve Parker, M.D.

Reference:  Cassady, Bridget, et al.  Effects of low carbohydrate diets high in red meats or poultry, fish and shellfish on plasma lipids and weight loss.  Nutrition & Metabolism, 4:23   doi: 10.1186/1743-7075-4-23   Published October 31, 2007

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November 16, 2009 · 11:02 AM

Olive Oil in Mediterranean Diet Linked to Lower Body Weight

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The source of virgin olive oil

The University of Navarra in Spain reported recently that a diet rich in virgin olive oil reduces body weight, especially in those genetically inclined to gain weight.  Over one thousand research particpants were placed on a  Mediterranean diet and monitored by lead researcher, Ph.D. candidate Cristina Razquin:

This consisted of a high intake of fruit and vegetables and of non-refined cereals and fish, and the use of virgin olive oil as the main source of fatty food. Moreover, a high intake of legumes and nuts is recommended.

We’ll have more details when the research is published in a peer-reviewed scientific journal.  Olive oil is a type of fat.  This finding of lower body weight on an olive 0il-rich Mediterranean diet run counter to the generally accepted idea that dietary fat causes body fat.  Lower body weight is linked to lower risk of diabetes.

Steve Parker, M.D.

Reference:  A diet rich in virgin olive oil reduces body weight, according to research by the University of Navarra.  Press release, August 3, 2009.

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November 15, 2009 · 2:00 AM

Low-Carb Diet Helps Obese Swedes With Diabetes

Swedish boyObese people with type 2 diabetes following a 20% carbohydrate diet demonstrated sustained improvement in weight and blood glucose control, according to two Swedish physicians.  These doctors also have research experience with traditional low-fat diets in overweight diabetics, having demonstrated that a 20% carbohydrate diet was superior to a low-fat/55–60% carb diet in obese diabetes patients over six months.

What Was the Intervention?

Proportions of carbohydrates, fat, and protein were 20%, 50%, and 30% respectively.  Total daily carbs were 80–90 g. 

Recommended carbs were vegetables and salads. 

Rather than ordinary bread, crisp/hard bread was recommended (3.5 to 8 g carb per slice).  Starchy breads, pasta, potatoes, rice, and breakfast cereals were excluded. 

They were instructed to walk 30 minutes daily, take a multivitamin with extra calcium daily, and to not eat between meals. 

At the outset, diabetic medications were reduced by 25–30% to avoid low blood sugars.   

Results

The doctors followed 23 patients over the course of  44 months.  Average initial body weight was 101 kg (222 pounds).  After 44 months, average body weight fell to 93 kg (205 pounds).  Hemoglobin A1c, a measure of diabetes control,  fell from 8% to 6.8%. 

My Comments

In these pages over the last few months, we’ve seen the effectiveness of low-carb diets in people with type 2 diabetes in widespread populations: Japanese, U.S. blacks and caucasions, and, now, Swedes. 

The standard Western diet derives 55–60% of its energy from carbohydrates.  If you’ve been following this blog, we’ve looked at diets containing 40%, 30%, 20%, and 10% carbs.  Have you noticed the trend? 

Reducing the percentage of carbohydrates in the diet improves diabetic control and loss of excess weight.  And the more you reduce carbs, the greater the degree of diabetic control and weight loss.   

Steve Parker, M.D.

Reference:  Nielsen, Jörgen and Joensson, Eva.  Low-carbohydrate diet in type 2 diabetes: stable improvement of body weight and glycemic control during 44 months follow-up.  Nutrition & Metabolism, 5:14   doi:10.1186/1743-7075-5-14

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