Category Archives: Weight Regain

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.”

Comments

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

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Mediterranean and Low-Carb Diets Beat Low-Fat for Weight Loss Over Six Years

Israeli flag

Remember Shai et al’s 2008 DIRECT study that compared weight loss over two years on either a low-carb, low-fat, or Mediterranean diet?  I reviewed it at length in 2008.

The same Isreali researchers now report the results of an additional four years of follow-up.  Do you know of any other weight loss study over that length of time?  I don’t.

Of the 322 original study participants, 259 were available for follow-up for an additional four years.  Of these, 67% told researchers they had continued their originally assigned diet.

Over six years, the weight loss was as follows:

  • 0.6 kg (about a pound) in the low-fat group
  • 1.7 kg (almost 4 pounds) in the low-carb cohort
  • 3.1 kg (almost 7 pounds) in the Mediterranean group

The difference between the low-carb and Mediterranean groups was not statistically significant.

Almost all the original study participants (86%) were men, so it’s debatable whether these results apply to women.  I bet they do.  I assume most of the participants were Israeli, so you can also debate whether results apply to other nationalities or ethnicities.

Bottom Line

For long-term weight management, Mediterranean and low-carb diets appear to be more effective than traditional low-fat, calorie-restricted dieting.

Beth Mazur at her Weight Maven blog has some worthwhile comments about the study.

Incidentally, my Advanced Mediterranean Diet (2nd Edition) book features both a traditional Mediterranean diet and the world’s first low-carb Mediterranean diet.

Steve Parker, M.D.

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The Two Secrets to Prevention of Weight Regain

Researchers are constantly searching for safe, effective weight loss pills.  More helpful would be a pill that prevents weight regain.  Weight loss is relatively easier.

Regain of lost body fat is the most problematic area in the field of weight management.  Whoever solves this problem for good will win a Nobel Prize in Medicine.  Why do most diets ultimately fail over the long run?  Because people go back to their old habits.  Here are the two secrets to prevention of weight regain:

  1. Restrained eating
  2. Regular physical activity

“Successful losers” apply self-restraint on an almost daily basis, avoiding food they know will lead to weight regain.  They limit how much they eat.  They consciously choose not to return to their old eating habits, despite urges to the contrary.

The other glaring difference is that, compared to regainers, the successful losers are physically active.  Oftentimes, they exercised while losing weight, and almost always continue to exercise in the maintenance phase of their program.  This is true in at least eight out of 10 cases.  It’s clear that regular exercise isn’t always needed, but it dramatically increases your chances of long-term success.

Steve Parker, M.D.

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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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Exercise, Part 2: The Fountain of Youth and Other Metabolic Effects

Part 1 of the Exercise series focused on how regular physical activity prevented or postponed death. Onward now to other benefits.

Waist Management

Where does the fat go when you lose weight dieting? Chemical reactions convert it to energy, water, and carbon dioxide, which weigh less than the fat. Most of your energy supply is used to fuel basic life-maintaining physiologic processes at rest, referred to as resting or basal metabolism. Basal metabolic rate (BMR) is expressed as calories per kilogram of body weight per hour.

The major determinants of BMR are age, sex, and the body’s relative proportions of muscle and fat. Heredity plays a lesser role. Energy not used for basal metabolism is either stored as fat or converted by the muscles to physical activity. Most of us use about 70 percent of our energy supply for basal metabolism and 30 percent for physical activity. Those who exercise regularly and vigorously may expend 40–60 percent of their calorie intake doing physical activity. Excess energy not used in resting metabolism or physical activity is stored as fat.

Insulin, remember, is the main hormone converting that excess energy into fat; and carbohydrates are the major cause of insulin release by the pancreas.

To some extent, overweight and obesity result from an imbalance between energy intake (food) and expenditure (exercise and basal metabolism). Excessive carbohydrate consumption in particular drives the imbalance towards overweight, via insulin’s fat-storing properties.

In terms of losing weight, the most important metabolic effect of exercise is that it turns fat into weightless energy. We see that weekly on TV’s “Biggest Loser” show; participants exercise a huge amount. Please be aware that conditions set up for the show are totally unrealistic for the vast majority of people.

Physical activity alone as a weight-loss method isn’t very effective. But there are several other reasons to recommend exercise to those wishing to lose weight. Exercise counteracts the decrease in basal metabolic rate seen with calorie-restricted diets. In some folks, exercise temporarily reduces appetite (but others note the opposite effect). While caloric restriction during dieting can diminish your sense of energy and vitality, exercise typically does the opposite. Many dieters, especially those on low-calorie poorly designed diets, lose lean tissue (such as muscle and water) in addition to fat. This isn’t desirable over the long run. Exercise counteracts the tendency to lose muscle mass while nevertheless modestly facilitating fat loss.

How much does exercise contribute to most successful weight-loss efforts? Only about 10 percent on average. The other 90 percent is from food restriction.

Fountain of Youth

Regular exercise is a demonstrable “fountain of youth.” Peak aerobic power (or fitness) naturally diminishes by 50 percent between young adulthood and age 65. In other words, as age advances even a light physical task becomes fatiguing if it is sustained over time. By the age of 75 or 80, many of us depend on others for help with the ordinary tasks of daily living, such as housecleaning and grocery shopping. Regular exercise increases fitness (aerobic power) by 15–20 percent in middle-aged and older men and women, the equivalent of a 10–20 year reduction in biological age! This prolongation of self-sufficiency improves quality of life.

Heart Health

Exercise helps control multiple cardiac (heart attack) risk factors: obesity, high cholesterol, elevated blood pressure, high triglycerides, and diabetes. Regular aerobic activity tends to lower LDL cholesterol, the “bad cholesterol.” Jogging 10 or 12 miles per week, or the equivalent amount of other exercise, increases HDL cholesterol (“good cholesterol”) substantially. Exercise increases heart muscle efficiency and blood flow to the heart. For the person who has already had a heart attack, regular physical activity decreases the incidence of fatal recurrence by 20–30 percent and adds an extra two or three years of life, on average.

Effect on Diabetes

Eighty-five percent of type 2 diabetics are overweight or obese. It’s not just a random association. Obesity contributes heavily to most cases of type 2 diabetes, particularly in those predisposed by heredity. Insulin is the key that allows bloodstream sugar (glucose) into cells for utilization as energy, thus keeping blood sugar from reaching dangerously high levels. Overweight bodies produce plenty of insulin, often more than average. The problem in overweight diabetics is that the cells are no longer sensitive to insulin’s effect. Weight loss and exercise independently return insulin sensitivity towards normal. Many diabetics can improve their condition through sensible exercise and weight management.

Miscellaneous Benefits

In case you need more reasons to start or keep exercising, consider the following additional benefits: 1) enhanced immune function, 2) stronger bones, 3) preservation and improvement of flexibility, 4) lower blood pressure by 8–10 points, 5) diminished premenstrual bloating, breast tenderness, and mood changes, 6) reduced incidence of dementia, 7) less trouble with constipation, 7) better ability to handle stress, 8) less trouble with insomnia, 9) improved self-esteem, 10) enhanced sense of well-being, with less anxiety and depression, 11) higher perceived level of energy, and 12) prevention of weight regain.

People who lose fat weight but regain it cite lack of exercise as one explanation. One scientific study by S. Kayman and associates looked at people who dropped 20 percent or more of their total weight, and the role of exercise in maintaining that loss. Two years after the initial weight loss, 90 percent of the successful loss-maintainers reported exercising regularly. Of those who regained their weight, only 34 percent were exercising.

 Part 3 of this series gets into specific exercise recommendations.

Steve Parker, M.D.

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The Holy Grail: Prevention of Weight Regain

Losing excess weight is easier than keeping it off.

Neither is exactly a walk in the park.

Prevention of weight regain is the most problematic area in the field of weight management.  You may have heard that “diets don’t work,” but they do.  Many different weight loss programs work short-term, if “work” is defined as loss of five, 10, or more pounds while you adhere to the program for several weeks or months.  The problem is that the lost pounds usually return.

Why?  You get bored with the diet, or your willpower flags, or the diet simply stops working, or the transition from weight loss to maintenance is unclear, or you just feel too bad to go on, or you lose your commitment, or you take a job as a taste tester for Baskin-Robbins Ice Cream, or whatever. 

Most diets ultimately fail in the long run because people go back to their old habits. 

Read on for the secret to prevention of weight regain.  They apply to a majority of weight-loss methods, although many programs ignore this problem because the cure is a hard pill to swallow. 

Moving Ahead

For purposes of further discussion, I will assume that you have already lost excess weight down to your goal and now we must focus on staying thereabouts from here on out.  Finally down to your goal!  A grand accomplishment!  You’ve got a new wardrobe, or the old clothes fit again.  You have more energy and feel younger.  Maybe you cured or improved some health problems.  Perhaps you’re getting more attention from the opposite sex (ooh la la!). 

Our species’ scientific name is Homo sapiens.  It is from the Latin sapere, which means “to be wise.”  Wisdom is the ability to make correct judgments and decisions.  Undoubtedly, your success at weight loss required correct judgments and decisions.  You are not done yet.  You will need sustained wisdom to avoid weight regain.

Be wise about this especially: you can never again eat all you want, whenever you want, over sustained periods of time.  

Now that you have reached your goal weight, you must restrain yourself on a daily basis.  Think about it.  You became overweight because you didn’t watch what you ate and didn’t exercise enough.  You can’t go back to your old ways.  Reject this advice, and you have a 100 percent chance of regaining your lost weight. 

Have you heard of the Energy Balance Equation?

Calorie Intake minus Calories Burned

         =  Change in Body Fat

You have been able to lose fat weight because you ate less energy (calories) than your body required for metabolism and physical activity.  Your body remedied the energy deficit by converting fat into energy.  A pound of fat contains 3,500 calories of energy.  If you lost a pound per week, your body on average converted 500 calories of fat daily into energy (7 days x 500 calories = 3,500 calories = 1 pound of fat). 

Now that you are at your goal weight and want to stay there, you need to add 500 calories per day back into the equation.  Add the calories by eating more food, exercising less, or a combination of the two. But if you add back more than 500, you will regain weight.

The true measure of a successful weight management program is not simply how much weight is lost, but whether the lost weight stays lost over the long run.  What distinguishes weight losers who keep the weight off from those who gain it back?  Two factors, mostly:

          1.  Restrained eating
          2.  Regular physical activity
.

“Successful losers” apply self-restraint on an almost daily basis, avoiding food that they know will lead to weight regain.  They limit how much they eat.  They consciously choose not to return to their old eating habits, despite urges to the contrary.  The other glaring difference is that, compared to regainers, the successful losers remain physically active.  They exercised while losing weight, and continue to exercise in the maintenance phase of their program.  This is true in at least eight out of 10 cases.  It’s clear that regular exercise is not always needed, but it dramatically increases your chances of long-term success. 

In a nutshell, my maintenance phase prescription for you is: Keep exercising, and eat a little more.  Keep exercising, and eat a little more.

Go out of your way to be physically active for 30 to 45 minutes on at least four days per week, if not all days.  Walking is fine.  The more you exercise, the more you can eat without getting fat again. 

At the end of your weight-loss phase and the beginning of the maintenance phase, it is surprisingly easy to start overeating.  Forewarned is forearmed.  Avoid this landmine any way you can.  It helps to continue monitoring food consumption and exercise on your food diary while eating an additional 200–500 calories per day.  Continue weighing daily.  Keep exercising.  After a month or two of this regimen, you’ll have an intuitive sense of what and how much you should be eating without regaining weight.  Then stop the daily log routine. 

Another option for transition to the maintenance phase: if you have been exercising regularly but loathe it, you could stop exercising and stay on your current calorie level diet.  In other words, don’t start eating more.  See what happens with your weight.  Perhaps you could later eat an extra 100 to 200 daily calories without gaining weight.  Continue recording your daily intake and weight for a couple months.  

Weigh yourself daily during the first two months of your maintenance-of-weight-loss phase. After that, weigh weekly.  Daily weights will remind you how hard you worked to achieve your goal.  When you look now at a brownie, candy bar, or piece of pie, you ask yourself, “Do I really want to walk an extra hour or jog an extra three miles today to burn off those calories?” If so, enjoy. Otherwise, forego the unneeded calories. 

Be aware that you might regain five or 10 pounds of fat now and then.  You probably will.  It’s not the end of the world.  It’s human nature.  You’re not a failure; you’re human.  

But draw the line and get back on your old weight-loss program for one or two months.  Analyze and learn from the episode.  Why did it happen?  Slipping back into your old ways? Slacking off on exercise?  Too many special occasion feasts?  Allowing junk food back into the house?  Learn which food item is your nemesis—the food that consistently torpedoes your resolve to eat right.  For example, I have two—candy, and sweet baked goods such as cookies and muffins.  If I just look at them I add a pound.  Remember an old ad campaign for a potato chip: “Betcha can’t eat just one!”?  Well, I can’t eat just one cookie.  So I don’t get started.  I might eat one if it’s the last one available.  Or I satisfy my sweet craving with fresh fruit or a diet soda.  Just as a recovering alcoholic can’t drink any alcohol, perhaps you should totally abstain from…?  You know your own personal gastronomic Achilles heel.  Or heels.  Experiment with various strategies for vanquishing your nemesis. 

It’s OK to overindulge in food infrequently (10–12 times per year), on special occasions such as birthdays, wedding anniversaries, holidays.  But you must counteract the extra calories by cutting down intake or by exercising more, either before or after the feast.  No big deal.

Click to read additional ideas on prevention of weight regain.

Steve Parker, M.D.

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