Oldways has put together an article reviewing Mediterranean diet promotional efforts in each of the 50 United States. I’m honored that they focused on me in Arizona. The Oldways website is jam-packed full of practical info on how to move towards the healthy Mediterranean diet pattern.
Mediterranean Diet: State by State
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Low-Carb Diet Better Than Low-Cal for Fatty Liver
Loss of excess weight is a mainstay of therapy for nonalcoholic fatty liver disease. A very-low-carb diet works better than a reduced-calorie diet, according to a recent study in the American Journal of Clinical Nutrition.
Nonalcoholic fatty liver disease (NAFLD) occurs in 20 to 40% of the general population, with most cases occuring between the ages of 40 and 60. It’s an accumulation of triglycerides in the liver.
Nonalcoholic steatohepatitis (NASH) is a subset of NAFLD, perhaps 30% of those with NAFLD. Steatohepatitis involves an inflammatory component, progressing to cirrhosis in 3 to 26% of cases.
Researchers at the University of Texas Southwestern Medical Center assigned 18 obese subjects (average BMI 35) to either a very-low-carb diet (under 20 grams a day) or a low-calorie diet (1200 to 1500 calories a day) for two weeks. Liver fat was measured by magnetic resonance technology. The low-carb groups’ liver fat decreased by 55% compared to 28% in the other group. Weight loss was about the same for both groups (4.6 vs 4 kg).
Bottom Line
This small study needs to be replicated, ideally with a larger group of subjects studied over a longer period. Nevertheless, it appears that a very-low-carb diet may be one of the best dietary approaches to nonalcoholic fatty liver disease. And I bet it’s more sustainable than severe calorie restriction. The Ketogenic Mediterranean Diet, by the way, provides 20-30 grams of carb daily.
Refernce: Browning JD, Baker JA, Rogers T, Davis J, Satapati S, & Burgess SC (2011). Short-term weight loss and hepatic triglyceride reduction: evidence of a metabolic advantage with dietary carbohydrate restriction. The American journal of clinical nutrition, 93 (5), 1048-52 PMID: 21367948
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Dietary Oil Change Over the Last Century
Dr. Stephan Guyenet at Whole Health Source provides details about the large increase in U.S. consumption of industrial seed oils over the last hundred years. I’ve not studied the issue in detail, so I have no opinion about the health ramifications. But it’s interesting for sure. Dr. G is well worth reading.
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The History of Diabetic Diets
Diet has always generated passion, and passion in science is an infallible marker of lack of evidence.
That sentence is from a wonderful review of diabetic diet cycles over the last 150 years. It’s by L. Sawyer and E.A.M Gale, published in Diabetologia (2009, vol. 52, pages 1-7, DOI: 10.1007/s00125-008-1203-9). Anyone with a serious interest in diabetic diets will appreciate the funny and philosophical style of the authors.
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Book Review: Carbohydrates Can Kill
I recently read Carbohydrates Can Kill, by Robert K. Su, M.D., written in 2009. Per Amazon.com’s rating system, I give it four stars ( I like it).
♦ ♦ ♦
Many developed Western societies have a love affair with carbohydrates, particularly concentrated sugars and highly processed grains and starches. The U.S. is a good example. Our skyrocketing rates of overweight and obesity (68% of adults) are testament to that. Obesity is strongly linked to cancer, high blood pressure, heart attacks, diabetes, strokes, and premature death. It’s not too much of a stretch to blame carbohydrates for at least a portion of these diseases and others. Dr. Robert Su thoroughly reviews these connections in Carbohydrates Can Kill.
Blissfully unaware of his prediabetes
This book addresses overweight, adverse health effects of obesity, nutrition and digestion in detail, and numerous scientific studies supporting his ideas.
One of the most interesting things to me was Dr. Su’s personal medical story. At age 62, he found himself 40 pounds (18 kg) overweight, blood pressure 205/63, and having apparent reversible heart pains (angina) when stressed or exercising. The combination of salt restriction and exercise didn’t help. Reducing carbs to 60-70 g/day and continued exercise (walking and stair-climbing) did the trick, helping him lose 30 pounds and controlling angina and high blood pressure. I expected him at any time to reveal he had a heart attack, stroke, or heart bypass surgery, but he dodged those bullets. His problems at 62 were a wake-up call. He didn’t want to end up prematurely dead or disabled, a burden to his family and unable to spend quality time with them. So he undertook major lifestyle changes. Very inspirational.
In addition to a medical degree, Dr. Su has a degree in pharmacy. He knew he’d be put on multiple drugs if he went to a doctor for treatment of his symptoms. Like me, he’s wary of drug side effects and wanted to avoid them, opting for diet and exercise instead. He gambled and won. I’m sure at least a few others would not be so lucky.
Dr. Su cites evidence that high blood sugars cause inflammation, which can predispose to cancer. Diabetics do indeed have a higher risk of certain cancers, yet he didn’t mention that diabetics have a lower risk of prostate cancer.
Dr. Su is anti-alcohol. The studies are mixed on the overall health effects of alcohol, but the bulk of the studies link low-to-moderate consumption of alcohol with less cardiovascular disease and longer lifespan. Clearly, heavy drinking can be lethal.
Like all books, CCK isn’t perfect. First, it could have used better editing to eliminate grammatical errors and wordiness. Next, I suspect Dr. Su is getting a little ahead of the science when he states that “….most diseases, if not all, are directly or indirectly caused by too much blood sugar.” If carbohydrates are so deadly (mediated via high blood sugar), why do the Kitavan’s of Melanesia have such low rates of heart attack, stroke, overweight, and diabetes, despite a diet deriving 69% of total calories from carbohydrates? (Calories from carbohydrates in the U.S. are about 50% of the total.) Granted, Kitavan’s carbs are mostly unrefined. Could the Kitavans be genetically protected from carb toxicity?
So, what do we do if carboydrates are so dangerous? Dr. Su recommends limiting carb consumption to a maximum of 100 grams a day. (By way of reference, average U.S. carb consumption is 250 grams a day.) Simple sugars and highly processed grains and starches should be avoided. Additionally, he recommends a yearly glucose tolerance test to determine fasting blood sugar, then blood sugar readings every 15-20 minutes after an unspecified meal for two or three hours. I wonder if a single hemoglobin A1c blood test would suffice. I agree with Dr. Su that fasting blood sugars should be under 110 mg/dl (6.1 mmol/l)—if not lower—and all blood sugars after meals under 150 mg/dl (8.3 mmol/l).
Dr. Su is a tireless advocate for carbohydrate-restricted eating. Visit his website: carbohydratescankill.com. If his diet and exercise ideas were widely adopted in the U.S., we’d be a healthier country. This book is a worthy read for anyone with overweight, obesity, diabetes, prediabetes, or otherwise enamored of concentrated sugars and highly processed grains and other starches. Note that one of every three U.S. adults has prediabetes, including half of all those over 65, and most of them are unaware.
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Quote of the Day
Science-based surgery (usually)Regarding complementary and alternative medicine:
The sciences give a mostly coherent understanding of the world. Mostly coherent. [They do] give an understanding of the possible, the probable, the improbable and the impossible. Most of the sciences, unlike parts of medical science, are not concerned with the impossible. There is not complementary and alternative physics, or chemistry, or biochemistry, or engineering. These disciplines compare their ideas against reality, and, if the ideas are found wanting, abandoned. Perpetual motion is not considered seriously by any academic physicist; if perpetual motion were an alternative medicine it would be offered at a Center by a Harvard Professor of Medicine.
—Dr. Mark Crislip, infectious disease specialist, at Science-Based Medicine, April 8, 2011
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Exercise, Part 9: Realistic Goals If You’re New to Exercise
FITNESS
Sustained physical activity requires that your heart pump blood to the lungs and to the exercising muscles. The muscles extract oxygen, sugar, and other nutrients for use in chemical reactions that enable the muscle to keep moving (contracting). To say that someone is physically fit simply means that the heart easily pumps a large volume of blood and the muscles extract and use nutrients very efficiently. The heart, after all, is just a hollow muscle that pumps blood. If you stimulate your heart muscle through exercise, it will become more powerful and able to pump more blood. Regular sessions of physical activity increase the metabolic efficiency and power of your other muscles, too. There are various degrees of fitness, with professional and Olympic athletes at the extreme upper end.
GETTING STARTED
I’ve had otherwise healthy overweight patients so “out of shape” that walking 20 yards to the mailbox was a real chore. They were tired and panting when they got to the mailbox and had to rest a bit before returning to the house. These folks are habitually sedentary and dramatically overweight. But you need not feel too sorry for them. After starting and maintaining an exercise program, these unfit people achieve the greatest degree of improvement in fitness level. They make more progress, and faster, than those who begin with a greater level of fitness.
The way to achieve aerobic fitness is to regularly challenge your large muscles to perform sustained physical activity. “Regularly” means at least four days a week, if not daily. Left alone, your muscles don’t want to do much other than just get you through your day comfortably, without effort or aching or cramps. You must challenge them to do more, work a bit harder, tolerate a little aching. You’ll know you’re challenging them during exercise when you perceive that mild to moderate effort is required to keep the activity going. You should be mildly short of breath, perhaps even perspiring lightly, yet still able to converse. “Sustained” physical activity means at least 30 minutes in a day. Most people find it a better use of their time to exercise for 30 minutes continuously rather than break it up into five or 10 minutes here and there.
Discontinuous activity (e.g., 10 minutes thrice daily) probably is just as good. If you think about it, there are many easy ways to increase your discontinuous physical activity. Consider taking the stairs instead of the elevator, parking far from the supermarket or workplace doors, walking the golf course instead of riding a cart.
(The exercise model above is “old school,” which isn’t necessarily good or bad. Some newer scientific studies suggest that you can achieve comparable levels of fitness with much less time exercising, if you do it intensely. An example is high-intensity interval training (HIIT). That’s worth a blog post or two by itself. I also leave strength training—also an important aspect of fitness—for another day.)
If you’re starting out in poor shape, you won’t be able to do 30 minutes of any exercise without adverse effects. Don’t even try. The worst thing you could do at this point is injure yourself or have such a horrible experience that you give up entirely. Thirty minutes of daily activity is your goal to achieve over the next four to 12 months. Moderate to high levels of fitness will take you six to 24 months. The most important thing when getting started is to exercise at least a little, five to 10 minutes, on most days of the week. And don’t overdo it in terms of intensity. Start low, go slow. After three months, exercise will be a habit. Prolongation of your exercise sessions will be easy as your amazing body responds gradually to the workload through the process called physical conditioning.
If walking 30 minutes daily is too hard for you at first, try walking just an extra 10 or 20 minutes daily. If you can do that but it’s a bit of a strain, gradually (every two weeks) increase your walking time by five minutes daily until you are up to 30 minutes. Average walking pace is 2 mph (3.2 km/h). Once you can comfortably handle 30 minutes daily, the next step is to increase your walking pace to 3 or 4 mph (4.8–6.4 km/h) for the entire 30 minutes. Four mph (6.4 km/h) is definitely a brisk walk. It’s difficult for many people to sustain over 30 minutes until they work up to it gradually. This is often done by walking at two paces, normal and brisk, during an exercise session. You might walk five minutes at normal pace, then five minutes briskly, alternating every five minutes until the session is over. Every two to four weeks, you can increase the minutes of brisk pace and taper off the normal pace. You’re able to do this easily because your level of fitness is increasing.
I’m asking you to walk briskly (3–4 mph or 4.8–6.4 km/h) for 30 minutes most days of the week. This brisk pace burns roughly 200 calories per session, in case you’re wondering. If you eat a 400-calorie muffin, it provides enough energy for a one-hour brisk walk. If you don’t burn the muffin calories as exercise or basal metabolism, they’ll turn into body fat. (But you’re not eating muffins anymore, are you?!)
If you prefer physical activity other than walking, the general rule is to start slowly and gradually increase your effort (intensity) until you’re up to about 30 minutes of moderate-intensity exercise most days of the week. Start low, go slow.
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Quote of the Day
Certainly, by the last decade of the [20th] century, some lessons had plainly been learned. But it was not yet clear whether the underlying evils which had made possible its catastrophic failures and tragedies—the rise of moral relativism, the decline of personal responsibility, the repudiation of Judeo-Christian values, not least the arrogant belief that men and women could solve all the mysteries of the universe by their own intellects—were in the process of being eradicated. On that would depend the chances of the twenty-first century becoming, by contrast, an age of hope for mankind.
Paul Johson in Modern Times (revised 1991 edition)
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Origins and Definition of the Mediterranean Diet
ORIGINS
It all starts with Ancel Keys.
Keys was the leader of the team who put together the Seven Countries Study, which seemed to demonstrate lower rates of coronary heart disease in countries consuming less saturated fat. [Coronary heart disease is the leading cause of death in Western cultures.] He also found that cardiovascular disease rates rose in tandem with blood cholesterol levels. The two countries particularly illustrative of these connections were Italy and Greece, both Mediterranean countries.
The other countries he analyzed in Seven Countries were the United States, Yugoslavia, Japan, Finland, and the Netherlands.
Keys and his wife Margaret, a biochemist, drilled deeper in to the “Mediterranean diet” that was characteristic of Italy, Greece, and other countries on or near the Mediterranean Sea in the 1950s and 1960s. [“Diet” in this context refers to the usual food and drink of a person, not a weight-loss program.] Their efforts culminated in the publication of several best-selling Mediterranean diet books in the 1970s, and Keys’ photo on the cover of Time magazine in 1961.
Thus began the still-popular healthy Mediterranean diet.
Oldways Preservation Trust re-invigorated the Mediterranean diet around 1990, helping the public incorporate Mediterranean diet principals into everyday life. Oldways founder, K. Dun Gifford, passed away within the last year.
DEFINITION
There is no monolithic, immutable, traditional Mediterranean diet. But there are similarities among many of the regional countries that tend to unite them, gastronomically speaking. Greece and southern Italy are particularly influential in this context.
So here are the characteristics of the traditional Mediterranean diet of the mid-20th century:
•It maximizes natural whole foods and minimizes highly processed ones
•Small amounts of red meat
•Less than four eggs per week
•Low to moderate amounts of poultry and fish
•Daily fresh fruit
•Seasonal locally grown foods with minimal processing
•Concentrated sugars only a few times per week
•Wine in low to moderate amounts, and usually taken at mealtimes
•Milk products (mainly cheese and yogurt) in low to moderate amounts
•Olive oil as the predominant fat
•Abundance of foods from plants: vegetables, fruits, beans, potatoes, nuts, seeds, breads and other whole grain products
•Naturally low in saturated fat, trans fats, and cholesterol
•Naturally high in fiber, phytonutrients, vitamins (e.g., folate), antioxidants, and minerals (especially when compared with concentrated, refined starches and sugars in a modern Western diet)
•Naturally high in monounsaturated and polyunsaturated fats, particularly as a replacement for saturated fats
CONTROVERSIES
Keys has been criticized for “cherry-picking” the data that linked saturated fat consumption with increased heart disease. In other words, the allegation is that he used information if it supported his theory, while ignoring data that was contrary or neutral. Subsequent studies indicate a weak link, if any, between saturated fat consumption and heart disease. A list of the pertinent studies de-linking heart disease and saturated fat is at my Advanced Mediterranean Diet Blog.
The Seven Countries Study included only men. It’s practical implications, therefore, may not apply to women.
The traditional Mediterranean diet is increasingly a thing of the past as Mediterranean countries adopt the Western diet characterized by “fast food” and highly processed foods.
FUN FACTS FOR FOOD GEEKS
Ever heard of K rations used by the U.S. military in World War II? Keys invented them. He earned Ph.D.s in biology and physiology. Keys lived to age 100 and was said to be intellectually active through his 97th year.
PS: The Mediterranean diet has too many carbohydrates (55% of total energy) for for most people with diabetes. Hence, the Low-Carb Mediterranean Diet.
References:
Keys, Ancel. Coronary heart disease in seven countries. Circulation, 41, (1970) supplement I: I-1 through I-211.
Keys, Ancel. Seven Countries: A Multivariate Analysis of Death and Coronary Artery Disease. Harvard University Press, 1980.
Oldways website.
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Two-Minute Online Diabetes and Prediabetes Risk Test
In the U.S., 24 million people have diabetes, mostly type 2. That’s one in 10 adults. The number for those over 60 is two in 10.
Fifty-seven million have prediabetes; that’s one of every three adults. Most of them are unaware of it.
The American Diabetes Association offers an online diabetes and prediabetes risk assesment. The Centers for Disease Control says one of every three people born in 2000 will develop diabetes. A few risk factors are age over 45, family history of diabetes, sedentary lifestyle, and overweight or obese. Why not recommend the test to someone you know who may be at risk?
Steve Parker, M.D., author of Conquer Diabetes and Prediabetes: The Low-Carb Mediterranean Diet
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Diabetic Mediterranean Diet 