Tag Archives: obesity

Is Exercise Impotent In Preventing Obesity?

What if all that exercise that authorities have been recommending  is not helping to stem the rising tide of obesity?

What if all calories don’t have the same ability to add fat?

These twin heresies fly in the face of the usual dogma on the cause of obesity: more calories in (gluttony) than calories out (sloth). The skeptical cardiologist has been pondering these possibilities for some time, since reading Gary Taubes book Good Calories, Bad Calories.

I have been advising my patients through this blog and during office visits that added sugar and  refined  carbohydrates are much more of a culprit in their  weight gain than fat, thus embracing the concept that there are good calories and bad calories

Exercise and Obesity

5Boro Bike Riders crossing the summit of the Queensboro aka 59th Street aka "Feelin Groovy" Bridge

But I also spend a lot of time during my office visits discussing activity levels and encouraging my patients to engage in moderate aerobic physical activity for at least 150 minutes per week.

I do this because there is good evidence that regular physical activity is associated with lower cardiovascular risk, cancer risk, mortality, and improved brain, muscle, and bone function. Exactly  what level and type of exercise is needed to reap these benefits is still up for debate.

I, personally, engage in regular moderate exercise and I think it helps maintain my weight where I want it.

Throwing Down the Gauntlet

A recent editorial in the British Journal of Sport Medicine stridently  makes the claim that exercise is not useful for weight loss as conventional wisdom teaches and that the food industry has been promoting exercise while simultaneously promoting junk food and sugar-sweetened beverages (The link I provided is no longer active because the journal has removed the editorial -“This paper has been temporarily removed following an expression of concern.”)

The authors wrote:

“members of the public are drowned by an unhelpful message about maintaining a healthy weight through calorie counting, and many still wrongly believe that obesity is entirely due to lack of exercise. This false perception is rooted in the Food Industry’s Public Relations machinery, which uses tactics chillingly similar to those of big tobacco. “

Root Causes of Obesity

It would appear that science cannot tell us with total certainty what the cause of our current obesity epidemic is.

After publishing a paper in 2014 that suggested Americans had become less active over the last 20 years, Ladabaum, et al admitted this:

“Although there is no clear answer at this time regarding the relative contribution of energy intake or physical activity (or other variables including dietary components, patterns of activity, and environmental factors, including the gut micro biome) to the public health problem of obesity, we believe that public health messages should continue to emphasize the importance of both a healthy diet and remaining physically active throughout life.”

Is Exercise Amount  A Cause or Effect?

In my own practice, I have observed a tendency for  those patients who regularly exercise or have very physically active jobs to stay thin whereas those who don’t exercise, especially if they have sedentary jobs or are retired, tend to be obese and gain weight.

But, I also note that those patients who take my recommendations on exercise to heart  are also listening to my advice in other areas, including diet and medications and are, in general, much more proactive about their health.

Therefore, I can’t say for sure whether it is the exercise  or the other aspects of a healthy lifestyle (including diet)  being followed in any individual patient that is keeping the pounds off. How much my patients move during the day when they are not specifically exercising may also be playing a role and is hard for me to assess.

There is also the mind-boggling possibility, as Gary Taubes has written about (here and in his book Why We Get Fat) that our genetics are driving both our activity levels and our food consumption:

Ultimately, the relationship between physical activity and fatness comes down to the question of cause and effect. Is Lance Armstrong excessively lean because he burns off a few thousand calories a day cycling, or is he driven to expend that energy because his body is constitutionally set against storing calories as fat? If his fat tissue is resistant to accumulating calories, his body has little choice but to burn them as quickly as possible: what Rony and his contemporaries called the “activity impulse”—a physiological drive, not a conscious one. His body is telling him to get on his bike and ride, not his mind. Those of us who run to fat would have the opposite problem. Our fat tissue wants to store calories, leaving our muscles with a relative dearth of energy to burn. It’s not willpower we lack, but fuel. “

I’m not ready to accept the heresy that exercise and activity have nothing to do with weight gain or loss. I, like most cardiologists, walk the walk and talk the talk of regular vigorous exercise for health benefits, extended longevity, cardiovascular fitness and for helping in weight control.

Exercise is not the be all and end all of weight control because increased consumption of bad or good calories can overcome the most prolonged and intense workouts but it is a useful adjunct.

Still exercising regularly,

-ACP

Fructose and the Ubiquity of Added Sugar

Since realizing that sugar, and not fat, was the major problem in the modern Western diet, The Skeptical Cardiologist has been ratcheting down how much sugar he consumes to the smallest possible amount.

This has lowered what I like to call my “sugarstat,” and has made me exquisitely sensitive to the presence of added sugar in foods.

With this sensitivity comes the heightened realization that added sugar is everywhere.

The obvious sources are soft drinks and other sweetened beverages, candy, cakes, pies, cookies, donuts and fruit juices. Once you mostly eliminate such things from your diet you become aware of the “background” levels of added sugar in other foods.

For example, when I consume what many Americans probably perceive as a “healthy” granola bar (from even the most natural or organic of manufacturers), all I can taste is a sickly sugar taste overwhelming all the other ingredients.

Low-fat yogurt (which I have compared unfavorably to a Snickers Bar here) tastes like pure sugar mixed with odd chemicals and a vague dairy flavor.

Seemingly healthy sushi tastes too sweet to me as it turns out to have lots of sugar mixed in  the rice and the popular eel sauce is mostly made up of sugar.

Most annoying  is the current trend for restaurants to put a “balsamic glaze” loaded with sugar on perfectly good vegetables like brussel sprouts, ruining them for me.

Fructose and Processed Foods

A review article in the Mayo Clinic Proceedings (1) this month presents the case for fructose (from glucose and high-fructose corn syrup) being the major cause of our obesity and diabetes epidemics and thus, the major contributor to cardiovascular disease in the US.

Fructose is a monosaccharide that combines with the monosaccharide glucose to form sucrose, which is what most people recognize as sugar.

Processed foods commonly contain a lot of added fructose-containing sugar but also, increasingly they contain high fructose corn syrup (HFCS) which contains up to 65% fructose.

Large intake of fructose goes hand in hand with consumption of processed foods. Approximately 75% of all foods and beverages in the US contain added sugars. Consumption of added sugar by Americans increased from 4 lbs per person per year to 120 lbs per person per year between 1776 and 1994.

Thanks to a dramatic increase in sugar-sweetened beverages, American teenagers consume about 72 grams of fructose daily.

There are a substantial amount of observational, short-term basic science, and clinical trial data suggesting that all this added sugar, especially fructose, are posing a serious public health problem.

The article presents these data in detail and I’ll summarize the major points as follows:

  1. Fructose is the likely component of sucrose and HFCS that promotes insulin resistance.
  2. In animals and humans, replacement of starch (chains of glucose) with sucrose or fructose causes increase glucose and insulin levels and reduced insulin sensitivity.
  3. Fructose stimulates epigenetic changes and metabolic alterations that shunt calories into storage depots in abdominal fat cells.

In simpler language, fructose promotes abdominal fat build-up and makes you more likely to develop type 2 diabetes.

Fruits and Fructose

I’m sure many of you are thinking, “but fructose is the major sugar in fruit, should I stop eating fruit?”

The answer is NO! The fructose in fruit is not highly concentrated. Fructose makes up 1% of the weight of a pear for example. It is combined with all of the good things, including fiber and phytonutrients and vitamins, that make fruit good for you.

Eliminating added fructose (sugar and HFCS) is by far the simplest thing you can do diet wise to improve your health. If you avoid added fructose, you will be cutting out a lot of the processed foods and sugar-sweetened beverages which have no nutritional value but contribute to obesity and diabetes.

Fructose as Toxin

preserves
Real fruit (right) and “Just Fruit Spread” (left). Note the attempts to make the spread appear healthy by announcing that it is “non-GMO”, glutan-free, “organic” and “perfectly sweetened with fair trade cane sugar”. Cane juice is added sugar .

Robert Lustig, a pediatric endocrinologist has talked and written extensively about fructose as a “toxin.” You can watch him here. He’s also published a lot of books on the topic including one which identifies the 56 names under which sugar masquerades.

It’s probably not worth buying that book, but keep in mind that agave and evaporated cane juice are just different forms of sugar. Makers of organic and “natural” foods are   as guilty as food industry giants at adding sugar, but they try to pretend that “natural” sources of sugar are somehow better for you.

I don’t think the science on fructose is totally settled, however, and another recent review (from scientists not funded by the food industry) concluded:

“current evidence on the metabolic effects of fructose, as consumed by the majority of populations, is insufficient to demonstrate such a role in metabolic diseases and the global obesity epidemic”

Skeptically Yours,

Anthony C. Pearson, MD, FACC

1. Added Fructose: A Principal Driver of Type 2 Diabetes Mellitus and Its Consequences. Mayo Clin Proc. 2015:90(3);372-381. DiNicolantonio, JJ, O’Keefe, JH and Lucan SC

Trends in Fat and Yogurt Consumption: We Eat Less Fat yet Get Fatter

A recent paper in JAMA and a Seinfeld episode shed some light on the change in diet and fat consumption in Americans initiated by national nutritional recommendations beginning in the 1970s.

Based on weak to nonexistent scientific evidence Americans were told to consume less total fat and cut saturated fat consumption to less than 10% of calories.

The paper shows that women in the St. Paul-Minneapolis area  followed this advice and cut fat consumption as a % of total calories from 38.4% in 1980-1982 to 30.6% in 1995-1997. Saturated fatty acids dropped from 13.5 to 10.5%. (Since then, total fat % and SFA % has drifted slightly upward and calories downward )(for the full table see fat consumption table (PDF))

Media summaries and reports on this paper have emphasized that Americans have failed to cut their saturated fat consumption to meet recommendations of the USDA (<10%) and the American Heart Association (<6%) with a call for more promotion of these (mis)guidelines.

The skeptical cardiologist has a different take.

Interestingly total calories during these time intervals went up from 1645 to 1851. Thus, in replacement of the fat calories, the women were consuming the carbohydrates and sugars the food industry had obligingly added to food to make it more palatable,  “heart healthy” and comply with guidelines.

The authors discuss the fact that during these time intervals, despite slashing fat consumption,  overall rates of obesity substantially rose. Their explanation was that the women were “underreporting” fat consumption.

A simpler and more compelling explanation is that replacement of fat with carbohydrates along with overall increase in calorie consumption was the culprit.

The Non-Fat Yogurt Scam and Seinfeld

One ongoing contributor to the phenemon of replacing healthy real food fats with engineered, highly processed and highly sugared foods is the yogurt industry.

I wrote about the non fat yogurt scam about a year ago in this post.

I happened to see the fantastic Seinfeld episode “The Non-Fat Yogurt” last night . In this episode Jerry, Elaine and George eat at a non-fat frozen yogurt shop. Everyone concurs that the yogurt is surprisingly delicious given that it is “non-fat” and begin eating it regularly.  Jerry and Elaine gain weight  and begin suspecting that the yogurt is not truly “non-fat”.

This episode aired in 1993 during the height of the shift toward unhealthy low fat, processed substitutes.  An analysis of the yogurt revealed that it was not non-fat and this is why they were gaining weight. In reality,  people get fat on truly non-fat yogurt (even Greek Yogurt) and non-fat cookies and non-fat smoothies and  anything with added sugar.

Fat consumption doesn’t make you fat.

Enjoy this snippet from the episode (and please excuse the bad language)

 

Scintillating Findings From New Orleans: Low Carb Diet Is Better than Low Fat for Losing Weight and Preventing Heart Disease

The SC and the Significant Other of the SC at Commander's Palace following an investigation of shrimp and grits.
The SC and the Significant Other of the SC at Commander’s Palace following an investigation of shrimp and grits.

The Skeptical Cardiologist is in New Orleans this weekend on a dedicated quest to research low carb diets.

The low fat diets recommended by government guidelines and national organizations like the American Heart Association don’t help most individuals lose weight and they don’t lower  the risk of heart disease. It’s very hard to understand why these are still promulgated by these organizations.

Some diets, such as the Atkins, South Beach and Paleo diets, advocate very low carbohydrate consumption and have helped many successfully lose weight.  However, due to the high fat in such diets, there has been concern about their overall effect on  cholesterol levels and heart disease.

A new study published in the Annals of Internal Medicine addressed the question of which of these dietary  approaches is best. Researchers at Tulane University (located inNew Orleans!)  randomly divided   148 obese (BMI>30) men and women (88% were women and 51% were black) into two  groups: a low-carbohydrate group that was encouraged to consume no more than 40 grams of carbohydrates  per day (the amount of two slices of  bread), and a low-fat group, which was encouraged to consume less than 30 percent of their calories from fat and 55 percent from carbohydrates (based on the National Education Cholesterol Program guidelines).

Interestingly neither group was instructed to lower their overall calorie consumption and both groups were instructed NOT to change their overall physical activity level (the researchers were trying to minimize factors effecting their results other than the percentage of fat/carbs).

The funding source for the study was the National Institutes of Health so we can consider the study unbiased by industry.

After 12 months, the low-fat group had lost 1.8 kg (2.2lbs=1kg) and the low-carb group had lost 5.3 kg.

The low-carb group had lost 8 pounds more, a difference that was highly  statistically significant (p<.001).

In addition, in the low-carb group fat mass had declined by 1.2% whereas it had risen by 0.3% in the low-fat group.

In other words, the low-carb group was losing body fat but the low-fat group was just losing lean body mass.

My patients, like most Americans, have had the lie that fat consumption causes obesity and contributes to fatty plaques in their arteries drummed into their heads for decades and fear low-carb diets because of concerns that they will cause their cholesterol levels to rise and increase their risk of heart disease.

This new study, however, showed that the low-carb diet (with almost double the amount of saturated fat consumed compared to low-fat diet) actually improved the subjects’ heart risk profile.

Low Carb Diet Improves Cardiac Risk Profile

At 12 months, there was no difference in the total or LDL (bad cholesterol) levels between the two groups. However, the good (HDL) cholesterol had significantly increased in the low-carb group causing a decrease in the ration of total to HDL cholesterol. The low-fat group had no increase in HDL. Triglycerides dropped in both groups but significantly more in the low-carb group.

Atherosclerosis is not just related to the cholesterol profile as I have discussed here,  but it is a complex process involving multiple factors, including inflammation.  A simple blood test, the C-reactive protein or CRP tracks inflammation. The CRP dropped by 6.7 nmol/L in the low-carb group and rose by 8.6 nm/L in the low-fat group. Lower CRP levels have been associated with lower risk of cardiovascular events in multiple studies.

This was a small study (but actually one of the largest prospective dietary studies available) but really well done.

The major take home points are as follows:

  1. Low-carb diets for many are a very effective weight loss approach
  2. Low-carb diets, even with their higher saturated and overall  do not adversely effect the cholesterol profile or increase risk of heart disease.
  3. This study suggests that low-carb diets improve good cholesterol, lower inflammation and are likely, therefore, long term to reduce the risk of heart attacks and strokes.

Realistic Dietary Approaches

I have found the extremely low-carb diets such as Atkins to be very hard for my patients to follow long term.  Some modification of  the strict limits on carb consumption are necessary I think to make diets interesting and healthy.

Although the goal of this study was to have the low-carb group consume less than 40 grams, the average carb consumption was 93 grams at 6 months and 127 grams at 12 months, a much more sustainable level of carb intake.

The first and most important thing anyone can do if they  want to lose weight and improve their cardiovascular risk profile is eliminate added sugar from their diet.

Sugar-sweetened beverages are an easy first step. But equally important is avoiding foods masquerading as healthy due to their low fat content. Low-fat yogurt and smoothies, for example, are loaded with empty sugar calories. You are much better off consuming the full fat varieties as I have pointed out here.

This is the Skeptical Cardiologist signing off from beautiful New Orleans where my next investigation will be on the cardiovascular consequences of crawfish étouffée plus dixieland jazz.

 

 

Smoothies: Kings of Sugar Masquerading As Healthy Food Choice

I have had a vague interaction with smoothies in the past, but after a recent jam session with my bassist daughter and drummer son, my daughter enthusiastically recommended we get a smoothie. “Smoothie” was entered into the Apple map app and a remarkable number of establishments serving this concoction popped up.

Smoothie sales have taken off in the last decade as consumers are apparently seeking healthier alternatives to carbonated beverages.

This was my first experience with Smoothie King which is the biggest and oldest chain of smoothie purveyors. According to their web site:

Since Steve Kuhnau created the first Smoothie Bar in 1973, Smoothie King has grown to over 650 locations across three continents. From the US to the Republic of Korea, Singapore and the Cayman Islands, our purpose continues to impact millions of lives around the globe.

Our quest is simple: Make living a healthier more active lifestyle delicious and nutritious. Whether you’re trying to lose a few pounds, have a little more energy at the end of the day or simply feel better about your diet, each and every Smoothie we make is blended for a specific purpose. Which is why we call them “Smoothies With A Purpose.”

This sounds spectacularly good: who wouldn’t want to lose a few pounds, have more energy at the end of the day and feel better about their diet.

Smoothie-King-New-Store-Design-interiorThe Smoothie King store was disturbingly sterile with an intense corporate feeling and had a bewildering array of choices. I could choose from Fitness Blends, Energy Blends, Slim Blends, Wellness Blends or Take a Break Blends.

 

There are 17 “Slim Blends” to choose from. The Angel Food  (“treat your body like an angel”(I have no idea what that means)) Slim Blend contains 350 calories, 84 grams of carbohydrates, 75 grams of sugar, 4 grams of protein, and 6 grams of fiber. This comes from strawberries (I saw no real strawberries behind the counter),bananas, non-fat milk (when I asked about getting whole milk the girl behind the counter told me that they didn’t even use real non-fat milk just a powder), vanilla, turbinado (fancy and deceptive word for brown sugar) and soy protein.

What’s wrong with this? A smoothie from SmoothieKing marketed as a Slim Blend contains 75 grams of sugar, the equivalent of 19 cubes of sugar. There only 39 grams of sugar in a 12 ounce coca-cola thus the small 20 oz “Slim Blend” contains the equivalent of two cans of coca-cola in sugar. There may be some useful nutrients in this monstrosity but predominantly you are getting loads of sugar in a highly concentrated form.

As I’ve pointed out here and here, there is reason to believe that sugar contributes more to obesity and heart disease than fat. Its hard to understand how this Slim Blend would contribute to weight loss in any way. It is just another stealth dessert similar to what Starbucks promotes as I’ve discussed here. What the food industry has done to smoothies is eerily similar to what happened to yogurt which I call the no fat  yogurt scam.

Most people have figured out for good weight control and health they should avoid sodas and sugar-sweetened beverages (even my 19 year old daughter has) but smoothies are masquerading as healthy choices for slimming, for fitness or wellness when they are (in the case of ones from SmoothieKing and presumably most similar chains) an absolutely horrible dietary choice.

What we have here is the classic food industry approach to marketing: Take real food ingredients like fruits, which are healthy choices when consumed in their original state, process  them, industrialize them, add sugar and promote them as healthier dietary choices.

Add in the veneer of promoting fitness or weight loss or wellness by adding magically powerful elixirs or powders and  the duped public will line up and sales will skyrocket. Unfortunately, despite claims of health benefits, consumers will end up less healthy.

 

 

 

 

 

In Defense of Real Cheese

Ah Cheese. A most wondrous and diverse real food.
wensleydaleOf the thousands of delightful varieties, let us consider Wensleydale, the 33rd type of cheese requested by John Cleese of Ye Olde Cheese Emporium proprietor, Henry Wensleydale (Purveyor of Fine Cheese to the Gentry and the Poverty Stricken Too) in the Monty Python sketch, Cheese Shop.

The cheese I have in front of me from Wensleydale creamery (which owes its continued existence to being the favorite cheese of  Wallace (of Wallace and Gromit fame)) lists  the following ingredients:

  • pasteurized cow’s milk
  • cheese cultures
  • salt
  • rennet
  • annato (a natural coloring that gives cheese and other foods a bright orange hue. It comes from the Bixa orellana, a tropical plant commonly known as achiote or lipstick tree (from one of its uses))

Other than annato, the above ingredients are components of all cheese and signify that it is a non processed, nonindustrial product.

A 1 oz serving of this cheese (28 grams), like cheddar cheese (“the single most popular cheese in the world”), provides 110 calories, 80 of which are from fat (9 grams total fat, 6 grams saturated fat), 25 grams of cholesterol, 170 mg of salt and around 200 mg of calcium.

For the last 40 years, Americans have been mistakenly advised that all  saturated fat in the food is bad and contributes to heart disease. Since cheese contains such a high proportion of saturated fat, it has also been targeted. Dietary recommendations suggest limiting real cheese consumption and switching to low-fat cheese.

This concept is not supported by any recent analysis of data, and as I’ve pointed out in a previous post, saturated fat does not contribute to obesity, nor is it clearly associated with increased heart disease risk. There are many different saturated fats and they have varying effects on putative causes of heart disease such as bad/good cholesterol and inflammation. In addition, the milieu in which the fats are consumed plays a huge role in how they effect the body.

Cheese vary widely in taste, texture and color and the final ingredients depend on a host of different factors including:

  • the type of animal milk used
  • the the diet of the animal
  • the amount of butterfat
  • whether the product is pasteurized or not
  • the strain of bacteria active in the cheese
  • the strain of mold active in the cheese

As a result the bioactive ingredients in cheese will vary from type to type.

Recent scientific reviews of the topic note that dairy products such as cheese do not exert the negative effects on blood lipids as predicted solely by the content of saturated fat. Calcium and other bioactive components may modify the effects on LDL cholesterol and triglycerides.

In addition, we now know that the effect of diet on a single biomarker is insufficient evidence to assess CAD risk; a combination of multiple biomarkers and epidemiologic evidence using clinical endpoints is needed to substantiate the effects of diet on CAD risk.

Some points to consider in why dairy and cheese in particular are healthy:

  • Blood pressure lowering effects.  Calcium is thought to be one of the main nutrients responsible for the impact of dairy products on blood pressure. Other minerals such as magnesium, phosphate and potassium may also play a role. Casein and whey proteins are a rich source of specific bioactive peptides that  have an angiotensin-I-converting enzyme inhibitory effect, a key process in blood pressure control. Studies have also suggested that certain peptides derived from milk proteins may modulate endothelin-1 release by endothelial cells, thereby partly explaining the anti-hypertensive effect of milk proteins.
  • Inflammation and oxidative stress reduction. These are key  factors in the development of atherosclerosis and subsequent heart disease and stroke. Recent animal and human studies suggest that dairy components including calcium and or its unique proteins, the peptides they release, the phospholipids associated with milk fat or the stimulation of HDL by lipids themselves, may suppress adipose tissue oxidative and inflammatory response.

Government and health organization nutritional guidelines have had a huge and harmful impact on what the food industry presents to Americans to eat. The emphasis on reducing animal fats in food led to the creation of foods laden with processed vegetable oils containing harmful trans-fatty acids.  This mistake has been recognized and corrected, but the overall unsupported  concept of replacing naturally occurring saturated fats with processed carbohydrates and sugar is ongoing and arguably the root of the obesity epidemic in America.

Converting mistaken nutritional guidelines into law

The USDA in 2012 following an act of Congress stimulated by Michelle Obama, changed the standards for the national school lunch and breakfast guidelines, for the first time in 15 years.

The law was intended to increase consumption of fruits, vegetables, whole grains and promote the consumption of low-fat or nonfat milk. It seemed like a good idea and likely to counter increasing obesity in children. However, the original recommendations were modified by Congress, due to heavy food industry lobbying, to allow the small amount of tomato paste in pizza to qualify as a vegetable.

Unfortunately, the food industry has responded by providing products which meet the government’s criteria for healthy lunches, but in actuality are less healthy.

Dominos Pizza, as a recent New York Times article pointed out, is now providing a specially modified pizza to schools which is unavailable in their regular stores. Their so-called “Revolution in School Pizza” is a…

line of delicious, nutritious pizzas created specifically for schools delivered hot and fresh from your local Domino’s Pizza store. Domino’s Pizza Smart Slice is the nutritious food that kids will actually EAT and LOVE!

school_lunch_anatomyofsliceThis pizza, in contrast to the pizza sold in Domino’s stores, utilizes a “lite” Mozarella cheese to cut fat content, a pepperoni with lower sodium and fat content, and a crust that contains 51% whole grain flour.

This “smart slice” replaces dairy fat with carbohydrates; there is no evidence that this will improve obesity rate or reduce heart disease  In fact, this change may lead to less satiety and a tendency for the children to want to snack on further carbohydrate or sugar-laden products when they get home. Furthermore, as critics have suggested, it may promote the consumption of  “unhealthy” versions of pizza that are sold in stores.

If we are going to make laws that promote healthy eating, we have to be absolutely certain that they are supported by scientific evidence. These School Lunch Program Standards are an example of how getting the science wrong or getting ahead of the science can lead to worse outcomes than if there were no laws regulating school diets.

Hopefully, you will continue to consume real full-fat cheese without concerns that cheese is “artery-clogging” and you will be more successful in obtaining the “fermented curd” than John Cleese’s Mr. Mousebender was below:

 

 

 

 

 

Are You Fed Up With Sugar?

A new documentary  movie, Fed UP, released May 9 and a   New York Times Editorial published  today are helping to focus the country’s attention on a new paradigm for what makes us fat and the importance of added sugar in causing obesity and chronic diseases. I highly recommend both viewing the movie and reading the editorial.

As I’ve pointed out here and here and as eloquently summarized by Gary Taubes in “Good Calories, Bad Calories” and “Why We Get Fat”, the concept of replacing fat with carbohydrates is not making America healthier.

The NY Times editorial and an article published by the same authors in JAMA focus on an alternative view of why people get fat. The generally accepted view is based on the (seemingly immutable)  first law of thermodynamics, that you gain weight because you have consumed more calories than you have burned with exercise. People get fat due to lack of willpower in either consuming too many calories or not exercising enough. In this paradigm, all calories are equal in their effects. To lose weight you merely need to cut back on how many calories you consume. Unfortunately, calorie restriction for weight loss fails almost all the time.

 

The alternative view of obesity posits that underlying genetic factors exacerbated by lifestyle factors such as inadequate sleep, stress and by poor quality of diet are the major reasons for obesity. These factors lead to increase in fat storage which , in turn, means less metabolic fuels available for activity. This causes an increase in hunger and a reduction in metabolic activity, muscular efficiency and physical activity.  The combination of increased energy intake and reduced energy expenditure causes obesity.

Insulin is the major hormone involved in fat metabolism and of all the things we eat highly refined and rapidly digestible carbohydrates cause the greatest insulin response. Thus, the authors write 

By this way of thinking, the increasing amount and processing of carbohydrates in the American diet has increased insulin levels, put fat cells into storage overdrive and elicited obesity-promoting biological responses in a large number of people. Like an infection that raises the body temperature set point, high consumption of refined carbohydrates — chips, crackers, cakes, soft drinks, sugary breakfast cereals and even white rice and bread — has increased body weights throughout the population.

Fed Up, the movie, focuses on how American diets became awash in added sugar and what the consequences of that has been. Dr. Robert Lustig a pediatric endocrinologist at the University of California, San Francisco is an advisor to the film and has spoken and written eloquently on this new paradigm for obesity and the dangers of processed food, fructose and sugar as in this video.

.

 

Here’s the trailer for Fed Up.

The film has a limited release and may not be showing in your town,  but you can check out some actions the film’s web site proposes  (supporting a proposed tax on soda and  sugary beverages, investigating your school’s nutrition policy, taking a 10 day no-sugar challenge) here.

 

 

 

Full Fat Dairy Lowers Your Risk of Obesity

ButterWhen i tell my patients that I am fine with them consuming full fat dairy products including butter I see  a mixture of responses. For many, there is a great relief that the butter they have been avoiding for the last 20 years (or consuming guiltily) can now be used. For others, the prospect of consuming full fat milk, cheese or yogurt still seems risky. After all, they have been hearing from the American Heart Association, the USDA nutritional guidelines and pretty much every nutritional advice column for the last 30 years that these products increase their risk of heart disease and contribute to obesity. Why should they believe their local cardiologist, a lone voice promoting full fat dairy against a chorus of naysayers?
Hopefully, by continuing to present scientific research on the topic I can make this concept more acceptable and counter the misinformation that is so prevalent

Researchers in Sweden have followed a cohort of rural men for over 12 years. In a previous study they found that daily intake of fruit and vegetables in combination with a high dairy fat intake was associated with a lower risk of coronary heart disease. Recently they examined their data to answer the question : how does dairy fat intake impact on the risk of developing central obesity in this middle-aged male cohort?

What is central obesity?

Central obesity refers to fat that builds up inside the abdomen. It is often measured by measuring the waist circumference: > 102 cm for males and 88 cm for females is a  marker of central obesity. Central or abdominal obesity indicates insulin resistance and is part of the metabolic syndrome and well known to increase the risk of diabetes.  It is also associated with heart disease, various cancers, and dementia. In this Swedish study, central obesity was defined as waist hip ratio ≥ 1.
The study found that 197 men (15%) developed central obesity during follow-up. A low intake of dairy fat at baseline (no butter and low fat milk and seldom/never whipping cream) was associated with a higher risk of developing central obesity (OR 1.53, 95% CI 1.05-2.24) and a high intake of dairy fat (butter as spread and high fat milk and whipping cream) was associated with a lower risk of central obesity (OR 0.52, 95% CI 0.33-0.83) as compared with medium intake (all other combinations of spread, milk, and cream) after adjustment for intake of fruit and vegetables, smoking, alcohol consumption, physical activity, age, education, and profession

Yes, these data show that participants were three times more likely to develop central obesity if they consumed skim milk and no butter compared to those who drank high fat milk and butter.

This is not an isolated finding. There is a wealth of data supporting the concept that full fat diary is less associated with obesity and markers of the metabolic syndrome, diabetes and insulin resistance.

120px-CheeseAnother recent study in a Basque population in Spain found that  participants with low or moderate consumption of cheese (high fat) compared to high consumption of cheese (high fat) had a higher prevalence of excess weight

Why do people falsely believe that fat in general and high fat dairy in particular promotes obesity?

In the past, supporters of this concept (and there are less and less in the scientific world)  would point to the energy density of fat which contains 9 calories per gram compared to 4 calories per gram for carbohydrates or protein. Obviously, if obesity is determined by calories in versus calories out then the food with more % fat compared to carbs or protein is providing more calories. All things being equal, one could expect to grow fatter on the higher % fat diet. All things are not equal, however, because one doesn’t determine how much one consumes based on the volume or weight of the food entering the mouth.

There are far more complex factors at work. How does the mixture of food components effect satiety? What is the insulin response to the food? What are the other components of the food such as vitamins, fiber, calcium and how do they interact with food absorption and metabolism?

So, even though this contradicts what has been drummed into your head for 30 years: eat full fat yogurt , cheese and milk , not fat-free, if you want to avoid getting fat

It’s Time to End the War on Fat: Dietary Fat Doesn’t Make You Fat or Give You Heart disease.

Most cardiologists don’t spend a lot of time talking about diet with their patients. When they do, they usually cite the mainstream maxim that you should cut down on saturated fat by reducing red meat consumption, choosing low-fat or skim dairy products, and lean cuts of meat. Patients are referred to standard recommendations that conform to this advice that comes from the American Heart Association.

This is certainly what I did for 30 years until I started examining the research supporting these recommendations in detail. It’s a lot easier to give advice to your patients when it conforms to what they are hearing from nutritional authorities. If it doesn’t conform, you have a lot of ‘splaining to do. If doctors spend time teaching or discussing diet with our patients, we do not get reimbursed for it.

However, a close examination of the research on dietary fat and heart disease shows that there is no good evidence supporting these recommendations.

The two major fallacies are:

Eating high fat foods will make you fat.

Eating high fat or cholesterol laden foods raises your cholesterol, thereby promoting the development of heart disease

Dietary Fat and Obesity

Although these concepts have become ingrained in the consciousness of Americans, they are not supported by scientific studies; more and more researchers, nutritional scientists, and cardiologists are sounding the warning and trying to change the public’s understanding in this area.

It seems logical that the fat that we consume goes into the body and is then converted into fat that appears on our thighs or belly and lines our arteries. This logic, and weak epidemiologic studies, led to national nutritional recommendations, beginning in 1977, that Americans cut back on fat (particularly saturated fat). The food industry seized on these recommendations and began providing consumers with “low-fat” alternatives to standard foods. To make these low-fat foods palatable, sugar had to be added. Often,  due to a surplus of industrial farm produced corn, sweetening was accomplished with high-fructose corn syrup. This graph shows what happened with weight in the US:
obesity rates

Beginning in the late 1970s, the percentage of people with BMI > 30 (considered obese) increased dramatically.
More and more evidence points to increased consumption of sugar, HFCS, and refined carbohydrates as the root cause of this obesity epidemic.
I tell my overweight patients that reducing sugar and refined starch is the most important thing that they can do to shed excess pounds.  They should avoid processed foods which the food industry have manipulated to make more palatable and less healthy. This means, among other things, avoiding or minimizing drinking sugar-sweetened beverages and avoiding “drinking your calories,” cutting way back on donuts, pastries, and potatoes and when consuming pastas or breads, try to make them whole-grain.

Dietary Fat and Heart Disease

I don’t tell my patients to cut fat consumption; this advice runs counter to everything they have heard about diet and heart disease. I encourage them to consume full fat dairy and this is considered particularly heretical.

However, as I have discussed in previous posts, there is no evidence that dairy fat increases cardiovascular risk. In fact, all studies suggest the opposite: a lower risk of heart disease associated with full fat dairy consumption.

Just as all fats are not the same (consider trans, saturated and unsaturated), all saturated fats are not the same. Some, particularly, the shorter chain fatty acids found in dairy, have beneficial effects on the lipid profile and likely lower overall cardiovascular risk.

What about red meat? All of my patients have received the dogma that they need to cut back on red meat. It hasn’t come from me (not since I began looking at the scientific evidence). When I look at my patients’ cholesterol profile before and after they institute what they perceive as the optimal “heart-healthy“ diet (cutting back on saturated fat and increasing carbohydrates by reducing meat consumption and shifting to skim or low-fat dairy products), their LDL or “bad” cholesterol has dropped a little, but proportionally their HDL or good cholesterol has dropped more and their triglycerides have gone up. What is the overall effect of this dietary change? There are no studies demonstrating that this change improves your heart health.

A recent systematic review and meta-analysis of 20 studies which included 1,218,380 individuals found no relationship between red meat consumption and coronary heart disease, CHD, (or diabetes). Conversely, processed meat intake was associated with a 42% higher rate of CHD and 19% higher risk of diabetes.

Analysis of data from the Multi-Ethnic Study of Atherosclerosis population indicates

After adjustment for demographics, lifestyle, and dietary confounders, a higher intake of dairy saturated fat was associated with lower cardiovascular disease risk [HR (95% CI) for +5 g/d and +5% of energy from dairySF: 0.79 (0.68, 0.92) and 0.62 (0.47, 0.82), respectively].

There also appears to be no association between red meat consumption and mortality in Asian countries

The Womens Health initiative was started in the early 1990s to test the hypothesis that a low fat diet would lower risk of cancer, stroke and heart attacks.Women were aged 50-79 at trial enrollment in 1993-98 and were followed for an average of 8.1 years. By the end of the first year, the low-fat diet group reduced average total fat intakes to 24 percent of calories from fat, but did not meet the study’s goal of 20 percent. At year six, the low-fat diet group was consuming 29 percent of calories from fat. The comparison group averaged 35 percent of calories from fat at year one and 37 percent at year six. Women in both groups started at 35-38 percent of calories from fat. The low fat diet group also increased their consumption of vegetables, fruits, and grains.
The study design reflected a widely believed but untested theory that reduction of total fat would reduce risks of breast or colorectal cancers. Among the 48,835 women who participated in the trial, there were no significant differences in the rates of colorectal cancer, heart disease, or stroke between the group who followed a low-fat dietary plan and the comparison group who followed their normal dietary patterns.

Yes, “widely believed but untested theory” is a great description of the current recommendation to cut saturated fat because no prospective trial has proven any benefit to this approach in reducing cardiovascular disease.

There is some evidence (but still fairly weak) to support the idea that replacing saturated fat with unsaturated fat is beneficial. Thus, the popularity of the Mediterranean diet which utilizes olive oil liberally. There is good evidence that industrially produced trans-fatty acids (from products designed to take the place of inappropriately demonized butter) increase cardiovascular risk. However, this evidence does not extend to natural trans-fatty acids such as those coming from the udders of cows.

Mounting evidence suggests that replacing fat or saturated fat in the diet with carbohydrates, however, contributes to obesity, insulin resistance, diabetes, and thereby may increase your risk of cardiovascular disease.

Organic Milk, Grass-fed Cows and Omega-3 Fatty Acids

The skeptical cardiologist has to admit that when he drinks milk or puts it in his coffee or cooks with it he almost exclusively drinks “organic”, non-homogenized milk obtained from dairy cows which are grass-fed and spend most of their lives grazing in a pasture.. In previous blogs I’ve laid out the evidence that supports that dairy products in general do not increase the risk of heart and vascular disease and, in fact, may lower that risk.

Full fat dairy has gotten a bad rap because it contains high levels of saturated fat. However, just as total fats were inappropriately labeled as bad , it is now clear that all saturated fats are not bad for the heart.

Although I recommend full fat dairy products to my patients I haven’t emphasized the organic or grass-fed aspect because I didn’t think there was enough good evidence that this is healthier than other kinds of milk and it is more expensive. There is evidence from small studies that cows consuming a more natural diet of grass and legumes from a pasture have higher levels of omega-3 fatty acids in their milk than those confined indoors and eating corn.

I keep my eyes (and ears) open for papers in this area.. One such paper appeared in the online peer-reviewed publication PLOS recently. I was driving to the hospital, listening to NPR when I first heard about it. Melissa Block was interviewing NPR correspondent Allison Aubrey . Her take, in a more subdued written form here is similar to many news outlets.

Allison summarized the findings as follows

The researchers compared organic and conventional milk head-to-head. They analyzed about 400 samples over an 18-month period, to account for seasonal differences. And the samples were taken from, you know, all different parts of the country. And they found that organic milk had about 62 percent more of the heart healthy omega-3s, compared to conventional milk.

When asked for an explanation she said

It really comes down to watch what the cows were eating. Organic milk is produced from cows that spend a lot more time out on pasture, and they’re munching on grasses and legumes. And these greens are rich in omega-3 fatty acids. So as a result, the milk they produce has more omega-3 fatty acids.

Wait a minute! I said , you’re confusing “organic” and “grass-fed” or “pasture raised ” they are two totally different things although they can overlap. I totally get the concept of a healthier diet for the cows increasing omega-3s in their milk but I haven’t seen anything that would suggest reducing pesticide or antibiotic usage does that. The radio did not respond. Also, I asked, is it possible to use the term omega-3 without prefacing it with “heart healthy”?

Once you start demanding to know more about the conditions of the cows that made the milk you drink things can become complicated. A cow can be grass-fed but not pasture raised, meaning that it stayed indoors and was fed hay. A cow can be outside “grazing ” but be given corn to eat. Prior to looking at the PLOS one article, I did not assume organic implied anything about how the cows were fed or grazed.

It turns out that in 2010 the USDA announced guidelines that mandated, among other things, for a dairy to be called “organic”, its dairy cows had to spend at least 120 days grazing on pasture.Thus, there is some correlation between organic and pasture raised/grass-fed but not a complete one.

The PLOS one study looked at geographical variation in the difference between organic and conventional milk fatty acid content. Northern California was the only region in which there was no significant difference. The authors speculated that this was because conventional farmers in Norther California usually have cows that roam on the pasture and eat grass and legumes. Thus, it appears the differences between organic and conventional milk are primarily due to what the cows were eating rather than the presence or absence of pesticides, antibiotics, GMOs, or hormones.

Allison Aubrey went on to say

But you know, I should say that there’s a trade-off here because in order to get all these extra omega-3s, you’ve got to drink whole milk. And you know, if you opt for the low-fat dairy – say, 1 percent fat -you’ve skimmed off most of these omega-3s. So the question is, you know, can you afford the extra calories in fat. If you choose the whole milk, you might need to trim a few calories from elsewhere in your diet.

To which I responded “Yes, by all means drink whole milk, there is no evidence that it adds to obesity. You will naturally want less calories down the line and you will get the benefit of good saturated fats.”

I'll continue to pay extra to drink milk from Trader's Point Creamery that I pick up at Whole Foods. I like their milk because I've visited their farm in Indiana and talked to their (plastic surgeon) owner and I like what he says on the website about their milk (ignoring the part about a “better immune system”.

We let our cows graze on 140 acres of pesticide free pasture, which results in milk with more healthy fats like Omega 3 and CLA (conjugated linoleic acid). Grassfed milk also contains more nutrients like beta carotene and vitamins A and E than milk produced using standard feeds. To all of us this means more nourishment and a better immune system for our bodies.

I’m going to end with the summary from the PLOS one article (DMI=dry matter intake, LA=linolenic acid, an omega-6 fatty acid) which emphasizes the importance of grazing and forage-based feeds not the organic aspects of milk.

We conclude that increasing reliance on pasture and forage-based feeds on dairy farms has considerable potential to improve the FA profile of milk and dairy products. Although both conventional and organic dairies can benefit from grazing and forage-based feeds, it is far more common—and indeed mandatory on certified organic farms in the U.S.—for pasture and forage-based feeds to account for a significant share of a cow’s daily DMI. Moreover, improvements in the nutritional quality of milk and dairy products should improve long-term health status and outcomes, especially for pregnant women, infants, children, and those with elevated CVD risk. The expected benefits are greatest for those who simultaneously avoid foods with relatively high levels of LA, increase intakes of fat-containing dairy products, and switch to predominantly organic dairy products.