Transcript Fat Reform: Obesity Food Politics and The Perils of

FAT REFORM:
OBESITY, FOOD POLITICS AND THE
PERILS OF DIETARY CARBOHYDRATES
Jeffry N. Gerber, M.D., Denver’s Diet Doctor
Family Physician, Littleton Colorado
DenversDietDoctor.com
facebook.com/DenversDietDoctor
Disclosure
 I occasionally get paid to speak
 Recruit patients
 Physician referrals
 Promote better nutrition
Outline
 History and Politics
 Science of nutrition & the evidence
 Re-write the nutritional guidelines
 Summary and action plan
Diabesity: A Twin Epidemic
 The spectrum of Insulin Resistance
Obesity Statistics
 68% of adults overweight or obese
BMI ≥ 25
 34% of adults obese BMI ≥ 30
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Colorado the thinnest, 20% obese
 9% of adults diabetic
 33% of children and adolescents
overweight or obese
 Since 1977-1980 uh-oh!
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Obesity rates doubled in adults
 Obesity rates tripled in children and
adolescents
 The progression of insulin resistance

42% obese in 2030
 33% diabetic in 2050
Sources: TFAH, OECD, WHO, CDC, ADA
Historical Perspective
“I am such a glutton and sloth”
 Blame behavior and lifestyle choices
 Eating too much and exercising too little
 Researchers convinced
 Obesity is caused by positive energy balance!
 Health insurance will not pay for treatment
 Its your fault, your problem, you fix it!
Billion Dollar Weight Loss Industry
 The invention: Low fat, low calorie diets
 Carbohydrates are safe
 Examples of fad diets!
 Why are we still fat?
Food Politics: Nutritional Timeline
 USDA self policing
 The lipid hypothesis 1950’s
 Saturated fat and heart disease
 Ancel Keys observational studies
 Correlation does not equal causality
 Energy Balance
 Eat fat and get fat, eat less and exercise more
 Avoid caloric dense fatty foods
 A simple explanation
 McGovern select committee 1968-77
Dietary Guidelines for Americans 1980
“Contrary to widespread opinion, too much
sugar in your diet does not seem to cause
diabetes… There is also no convincing
evidence that sugar causes heart attacks or
blood vessel diseases”
Phillip Handler : “A vast nutritional experiment”
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Less saturated fats, less calories
More poly-unsaturated Vegetable oils
More carbohydrates, starches, sugars
More inexpensive food commodities
Weak evidence, the wrong tools!
Does Saturated Fat Cause Heart Disease?
http://www.awlr.org
 Outcomes looking at MI, death from MI and stroke
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Observational - 16 studies - No!
Observational - 8 studies - Yes but problematic!
Observational - 2 meta analysis, 350,000 subjects - No!
RCT’s - Clinical trials - 2 well done - No!
RCT’s - Clinical trials - 3 meta analysis - No!
RCT’s - Clinical trials - 1 meta analysis - Yes but problematic!
Food Politics: Agriculture
 Industrial revolution and the food commodities
 Corn, Wheat, Rice, Potatoes
 Sugars: Cane, Beet, HFCS
 Soybean and industrial Vegetable oils
 Whole foods expensive: Animals and other Plants
 Farming incentives, increase yields, GMO’s
Our Ancestors Before Agriculture
 Hunter gatherers and the Paleolithic era
 Whole, clean, unprocessed foods, some carbs
 Animals including Fish, seasonal Veggies, Fruits and Nuts
 Use of fire
 Agriculture and the Neolithic era
 Cultivate Grains and domesticate Animals for Dairy
 Modern civilization changing nutrition
Food Politics: Manufacturing and $ales
 Inexpensive raw materials
 Tasty, addicting and cost effective
 Processed and refined, more profitable
 Deceptive advertising: “healthy” foods
 The government working for the food industry
 The business is selling food, not health!
The Cost of Healthcare
 US healthcare spending
 US almost twice per capita
 US ~16% of the GDP vs. 8–10%
 US obesity and costs
 Cornell: $190.2 billion, 20.6% of
national health expenditures
 Gross underestimation
 Study design flawed
 Overweight excluded
 The cost of treating chronic disease
HBR, WHO, RTI, CDC, AHR, IASO
The Cost of Healthcare
 Healthcare industry
 Centers for Medicare and Medicaid (CMS) 1965
 Guidelines for the industry, public and private
 Treatment of illness and disease only
 Obesity not a medical condition
 2012 now paying primary care for counseling
 A reactive approach to healthcare
 Treating obesity complications is profitable
Evolution - are you kidding?
Nutrition changing humans in our lifetime!
The Food Revolution: Andreas Eenfeldt, M.D.
Fat Reform is Healthcare Reform
 Address obesity
 Save billions on complications
 Food industry regulation!
 Healthcare delivery
 Nutrition center stage
 Re-define healthy nutrition
 Re-educate
 The perils of dietary carbohydrates
 In defense of dietary fat
Nutrition and Metabolism 101
 Food metabolism
 All macronutrients are not created equal
 Carbohydrates are fattening and inflammatory
 Fats and proteins
 Obesity is a chronic metabolic disease
 Insulin resistance
 Inflammation
Carbs
Proteins
Fats
Insulin and Insulin Receptors
 One of several hormones
 Regulate energy and energy storage
 Dietary carbohydrates, the primary fuel
 Turn on the insulin switch
 Dietary proteins and fats, secondary fuels
 Minimal effect on insulin, Essential
 Insulin receptors normal function
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Cells, muscle, tissue absorb energy and nutrients
Excess food energy converted to fat and stored
Normally insulin will suppress appetite
 insulin promotes the release of stored energy
 Basic physiology
Insulin Resistance
Increased Insulin
Production
 Years of carbohydrate overload
 More insulin is required
 Excess energy, stored as body fat
 Insulin receptors become strained and resistant
 Beta cells strained, abnormal response
 Vicious insulin resistance cycle
 Hunger an important component
 Insulin overload
Weight Gain
Increased
Resistance
(Hunger)
Hunger And Appetite
 Insulin resistance makes us hungry
 Fat cells literally starve lean body tissues
 Central hunger and reward centers of the brain
 Hypothalamus, Nucleus Accumbens
 Fluctuating blood sugars and hormones stimulate appetite
 Resistance directly or by Leptin or other hormones
 Eventual loss of central signals
 Only peripheral signals: swollen stomach
 Blame metabolism not behavior for obesity!
Regulation of Food Intake
 Leptin – Insulin – Amylin - Ghrelin - PYY - GLP-1
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Resistance changes signaling
 Leptin: Thermogenesis, immune system, premature ageing, chronic
disease, dementia, cancer, libido and fertility
 Insulin and IGF-1 (Insulin like growth factor): Premature ageing, cancer
Inflammatory Disease
 Adipocyte, fat cell toxicity
 Releases toxic substances as we gain weight
 Inflammatory protein signals: Hormones, cytokines
 FFA’s, lipid and cholesterol oxidation, Atherogenic
 Fuels insulin resistance and beta cell dysfunction
 Energy storage disease and energy overload
 Inflammation and metabolic derangement
 Dietary carb’s the trigger, not dietary fats
 A Chronic metabolic disease
Obesity: A Chronic Metabolic disease
Dyslipidemia
↑ Lipoprotein lipase
Inflammation
↑ IL-6
Hypertension
↑ Angiotensinogen
↑ Insulin
↑ CRP
Cancer
↑ FFA
↑ TNFα
↑ Adipsin
(Complement D)
Atherosclerosis
↓ Adiponectin
Premature
Ageing
↑ IGF-1
↑ Resistin
↑ Leptin
↑ Lactate
↑ Plasminogen
activator inhibitor-1
Metabolic Syndrome
Insulin
Resistance
Type
2 diabetes
Thrombosis
Lyon CJ et al. Endocrinology 2003;144:2195-200; Trayhurn P et al. Br J Nutr 2004;92:347-55; Eckel RH et al. Lancet 2005;365:1415-28.
Insulin Resistance Evaluation
Overweight
Obesity
Pre-diabetes
Type II Diabetes
(Metabolic Syndrome)
 Anthropometric measurements
 Medical and family history, physical
 2hr OGT, GTT
 Metabolic markers of inflammation
 HgA1c, c-peptide, Insulin, CRP, Thyroid, etc…
 Cholesterol testing as a marker for atherosclerosis
Insulin Resistance Treatment
 The food is the medicine
 Remove the fuel, dietary carbohydrates
 Turn off the insulin switch
 Control hunger and appetite
 Carbs are non-essential, optional
Insulin Resistance Treatment
 Dietary proteins
 Essential, healthy
 Dietary fats and cholesterol
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Essential, healthy
Caloric dense and filling
NOT inflammatory or atherogenic
One exception
 Carbs and fats together
 Standard American diet (SAD)
 Carbs are the catalyst
http://deliciouslyorganic.net
Insulin Resistance Treatment
 Medication
 Physiologic drugs
 Metformin, Byetta, Victoza, Symlin, Bydureon
 Rx appetite suppressants
 New and future drugs
 OTC market
 Treat co-morbidities
 Nutrition center stage
 Gastric bypass surgery
http://peaceloveandlowcarb.blogspot.com
Eat Real foods
 Focus on the carbohydrate content of food
 Glycemic index, carbohydrate gram counting
 Avoid high glycemic foods, processed foods
 Sugars, “healthy” no grains (Corn, Wheat, Rice), Potatoes
 Soy and ?Beans and other Legumes
 Eat low glycemic foods, whole and unprocessed
 Beef, Chicken, Fish, Pork, Eggs
 Green leafy Vegetables, fibrous Fruits, Nuts
 Low glycemic dairy like Cheese and Cream
Eat More Real Foods
 Natural healthy fats
 Low Glycemic, not fattening and not inflammatory
 Saturated, Mono, Omega 3’s, Vitamins A, D, E, K, B12
 Coconut oil, Olive oil, Avocado, Butter, Animal fat, Fish oil
 Caloric dense, promotes satiety
 Avoid industrial Vegetable oils, Margarine, Trans-fats,
Omega 6’s
 Low-Carb High Fat diet (LCHF)
 Control of appetite and promote weight loss
 Enhanced fat burning during exercise
 Quantity, calories and portion’s not the focus
Comparing Diets Head to Head
 Compare the macronutrient content
 % of calories from carbs, protein and fat
 Very low fat <10%, high carb, low calorie
 Very low carb <10%, high fat, LCHF, 1860’s
 Low-carb vs. Paleolithic diets
 Food quality important
 What diets are healthy and safe?
 Low carb high fat (LCHF) diets improve health!
 Greater weight loss, improved lipids and blood sugar
 Dozens of RCT’s, Stanford (2007), Duke (2004), Penn (2003), (2011)
Calories consumed equal, Atkins LCHF diet
better controls insulin, weight and appetite
Lipid profile improved on Atkins LCHF
Advanced Lipids and LCHF Diets
 Favorable LDL subclasses or particle sizes
 Healthy HDL-C increases, Triglycerides decrease
 Other markers
 Apo-B, LDL particles
 Lpa, genetic markers
 Advanced labs
 Berkeley Heart Lab
 NMR Liposcience
 VAP Cholesterol
Effects of LCHF diet on emerging plasma markers, Richard
J. Wood, et al. J. Nutrition. 136:384-389, February 2006
 Marcia at 262 lbs, BMI 41
 lost 70 lbs, now 192 lbs, 27% loss TBW, BMI 30
Dr Gerber Patient: Marcia
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Female age 45, 5’7”, 262 lbs, BMI 41
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OGT performed, FBS=96, 1HR=180, 2Hr=129
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HgA1C=6.4%, c-peptide=4.7
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TRG=221, HDL=36, TC=148, LDL=69, NON-HDL=112, TC/HDL=4.2, LDL Pattern A/B
8 months later lost 70 lbs, 192 lbs, BMI 30, 27% loss of body weight
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FBS 76
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HgA1C=5.1%, ?c-peptide
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TRG=147, HDL=40, TC=186, LDL=121, NON-HDL=151, TC/HDL=5.2, ?particle size
 David at 312 lbs, BMI 40
 http://mendosa.com
 lost 153 lbs, now 159 lbs, 49% loss TBW, BMI 20
Dr Gerber Patient: David
 Male, age 71, 6’3”, 312 lbs, BMI 40
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OGT: FBS=105, 1HR=219, 2HR=201
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HgA1C=6.8%
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TRG=193, HDL=28, TC=225, LDL=158 , NON-HDL=197
 2 years later, lost 153 lbs, 159 lbs, BMI 20, 49% loss of body
weight
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OGT: pending, FBS normal
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HgA1C=4.6%
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TRG=109, HDL=40, TC=155, LDL=93, NON-HDL=115
 Patrick at 220 lbs, BMI 32
 Lost 45 lbs, now 175 lbs, 20% loss TBW, BMI 24
Dr Gerber Patient: Patrick
 Male, age 53, 6’, 220 lbs, BMI 32
 OGT performed, FBS=86, 1HR=148, 2HR=103
 HgA1C=5.4%, c-peptide=4.1
 TRG=133, HDL=47, TC=238, LDL=164 , NON-HDL=191, TC/HDL=5.1
 7 moths later lost 45 lbs, 175 lbs, BMI 24, 20% loss of body
weight
 FBS=77
 HgA1C=5.1%, c-peptide=0.9
 TRG=75, HDL=78, TC=200, LDL=75 , NON-HDL=122, TC/HDL=2.6
Dr Gerber Patient: Eric
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Age 43, lost 10 pounds on a Paleo diet, 183 lbs, BMI 25
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Berkeley Heart Lab
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Triglycerides and HDL-C improved, LDL-C, Apo-B unchanged
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LDL subclasses (particle size) remained favorable, 9p21 genetic markers at risk
Carotid IMT, 39 yrs., heterogeneous plaque <20%
Author: Gary Taubes
Nutrition and the history of weak science
 2002 New York Times Magazine:
What If It’s All Been a Big Fat Lie
 2008: Good Calories Bad Calories
 2010: Why We Get Fat: And What To
Do About It
 2011 New York Times Magazine: Is
Sugar Toxic
 2012 Newsweek: Why the Obesity
Campaign is failing
Nutrition for the New Millennium
 Re-defining healthy nutrition
 Less refined and processed foods
 More whole foods including natural fats
 New federal dietary guidelines
 Food industry regulation
 Re-define healthcare delivery
 Nutrition centerstage
 Control the cost of healthcare
Good Food is Good Medicine!
Jeffry N. Gerber, M.D.
DenversDietDoctor.com
facebook.com/DenversDietDoctor