Advanced Mediterranean Diet

A study published today in the New England Journal of Medicine suggests that cutting back on calories will help you lose weight, and it doesn’t matter if the cut calories are fats, proteins, or carbohydrates.  These three main sources of calories are called macronutrients.

In other words: A calorie is a calorie is calorie.

Which is what was taught in medical school 30 years ago.

Short-term scientific studies over the last 15 years have suggested that the macronutrient composition of the diet was an important determinant of weight-loss success.  Some studies favored low-fat diets, others low-carb diets.  Others found no effect.

The study at hand was done under the auspices of the Harvard School of Public Health, Harvard Medical School, the Pennington Biomedical Research Center of the Louisiana State University System, and the National Heart, Lung, and Blood Institute.  The study authors, who rank among the best obesity researchers in the world, write:

The possible advantage for weight loss of a diet that emphasizes protein, fat, or carbohydrates has not been established, and there are few studies that extend beyond 1 year.

Methodology

811 overweight and obese adults were randomly assigned to one of four calorie-restricted diets with the following percentages of calories derived from fat, protein, and carbohydrates, respectively:

1) 20, 15, and 65%

2) 20, 25, and 55%

3) 40, 15, 45%

4) 40, 25, 35%

Participants were given group and individual instructional sessions frequently over a period of two years.  Baseline levels of caloric intake were calculated for each participant, then they were instructed how to reduce that intake by 750 calories per day.  The physical activity goal was 90 weekly minutes of moderate exercise.  Low-glycemic index carbohydrates were recommended in each diet.  Subjects were instructed to record food intake in a daily food diary and in a Web-based self-monitoring system.  Average age was 51.  Average weight was 93 kg (205 lb).  Average body mass index was 33.  Women were 64% of the subjects.

Results

80% of the subjects completed the two-year study.  Of these, average weight loss was 4 kg (8.8 lb).

Subjects in all groups lost about 6 kg (13.2 lb) on average, regardless of which diet they ate.

Subjects’ ratings of hunger, satisfaction, and satiety were similar for all diet groups.

People who faithfully attended instructional sessions definitely had better weight loss.

As measured after two years, weight loss amounts were quite similar whether someone ate 15% protein or 25% protein, 20% fat or 40% fat, 65% carbohydrate or 35% carbohydrate.

Fourteen or 15% of subjects over two years were able to lose at least 10% of their initial body weight.[Improved health usually requires loss of at least 5% of initial body weight.

Subjects who completed the study had an average weight loss of 6.5 kg (14.3 lb) at six months, which indicates a reduction of daily caloric intake of 225 calories (not the goal of 750).

Clinical markers of diet compliance confirmed that subjects generally had major problems adhering to  their assigned diets.

Seven percent of participants had “serious adverse events,” with no difference among the diets.  [No details provided.]

The Researchers’ Main Conclusion

Reduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrients they emphasize.

My Comments

Losing excess weight is hard!

If you want to lose excess weight, reducing caloric intake is important.  The researchers judged a food diary to be an important tool, and I agree.

Although average amounts of weight lost over two years is not much, some individuals do much better than average.  That could be you.

In case you’re wondering, the Mediterranean diet is closest to dietary pattern #3 above.  The Mediterranean diet is considered moderate or middle-of-the-road in terms of the three macronutients.  Pattern #1 is a standard low-fat diet.  Pattern #4 is reminiscent of the Atkins diet, which is low-carb.

Only one dietary pattern has been shown to prolong life and reduce rates of cancer (breast, colon, prostate, and uterus), cardiovascular disease (heart attacks and strokes), type 2 diabetes, dementia (both Alzheimers and vascular dementia, Parkinsons disease, chronic obstructive pulmonary disease, and melanoma.  That’s the Mediterranean diet.  Not low-fat.  Not low-carb.

The authors surmise that unspecified “behavioral factors” rather than macronutrient metabolism are the main influences on weight loss.  Allow me to name the major influential behavioral factors: commitment, discipline, and willpower.  These seem to be verboten in some quarters of the obesity research community.

George Carlin had a famous comedy routine called “The Seven Dirty Words You Can’t Say on Television.”  Well these are The Three Dirty Words You Can’t Say in Obesity Research Reports:

Commitment            Discipline          Willpower

Steve Parker, M.D.

References:

Sacks, Frank M., et al.  Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, And Carbohydrates.  New England Journal of Medicine, 360 (2009): 859-873.

Parker-Pope, Tara.  Study Zeroes In on Calories, Not Diet, for Loss.  New York Times online, February 25, 2009.  Accessed February 28, 2009.

At some point during President Obama’s administration, we can expect a push for health care and health insurance reform.  The last serious attempt at it was in 1994 during the Clinton administration, headed by Hillary Clinton, our current Secretary of State.  Pundits predict Obama and the Democrats want a larger role for government.

In 2007, the New England Journal of Medicine published an article by Dr. Steven Schroeder, “We Can Do Better - Improving the Health of the American People.”  At the time, Dr. Schroeder was working in the Department of Medicine, University of California at San Francisco.  He opines that the “determinants of premature death” are a key measure of health status. Here’s a smattering of interesting quotes:

• Health is influenced by factors in five domains - genetics, social circumstances, environmental exposures, behavioral patterns, and health care. When it comes to reducing early deaths, medical care has a relatively minor role.  [These five domains are his determinants of premature death.]
• Even if the entire U.S. population had access to excellent medical care - which it does not - only a small fraction of these [early] deaths could be prevented.
• The United States spends more on health care than any other nation in the world, yet it ranks poorly on nearly every measure of health status.
• U.S. expenditures on health care in 2006 were an estimated $2.1 trillion, accounting for 16% of gross domestic product.  Few other countries even reach double digits in health care spending.
• . . . inadequate health care accounts for only 10% of premature deaths . . .
• The single greatest opportunity to improve health and reduce premature deaths lies in personal behavior [emphasis added].  In fact, behavioral causes account for nearly 40% of all deaths in the United States.
• Although there has been disagreement over the actual number of deaths that can be attributed to obesity and physical inactivity combined, it is clear that this pair of factors and smoking are the top two behavioral causes of premature death.
• If the public’s health is to improve, however, that improvement is more likely to come from behavioral change than from technological innovation.

From Dr. Schroeder’s article:

Figure 1.  Determinants of Health and Their Contribution to Premature Death.  Adapted from McGinnis et al.  Copyright 2007 Massachusetts Medical Society.  All rights reserved.

My Comments

Since health care determines only 10% of health status and premature death, let’s focus our health care reform attention on the other 90% - behavioral patterns, social circumstances, genetics, and environmental exposure.  Bigger bang for the buck.

Behavioral patterns cause 40% of poor health and premature death.  The politicians can tinker with  obesity, physical inactivity, and smoking if they wish to give the appearance of caring about our health.  Nowhere but politics is it more true that an ounce of image is worth a pound of performance.

But don’t we the people already know what to do to improve our health?

Leave health care and health insurance alone, or, better yet, improve them by diminishing government involvement.

Most of the burden of poor health and premature death falls on the Medicare population, over 65 years old.  Much of this burden is a result of many years of poor health choices, such as obesity, physical inactivity, improper food choices, and smoking.  But who pays the bulk of health care costs of those choices?  Not the people who made poor choices, but the younger, working taxpayers.

The U.S. Medicare payroll tax is 2.9% of gross compensation, and it’s paid by all working people, even healthy 20-year-olds who are barely making ends meet working at the “call center.”

People will make better lifestyle choices when they bear an immediate and/or direct cost for poor choices.  Let’s figure out how to do that, rather than have distant politicians and bureaucrats take over the health care and health insurance industries.

We’re smart enough to solve this problem.  But are we too lazy?

Steve Parker, M.D.

References and Additional Resources:

Schroeder, Steven A.  We Can Do Better - Improving the Health of the American People.  New England Journal of Medicine, 357 (2007): 1,221-1,228.

McGinnis, J.M., et al.  The case for more active policy attention to health promotion.  Health Affairs (Millwood), 21 (2002): 78-93.

Health care reform position papers from the Association of American Physicians and Surgeons.

Medicare information from the Association of American Physicians and Surgeons.

Americans for Free Choice in Medicine.

Health care reform position papers from The Cato Institute.

Campbell, Douglas J.  My Continuing Recovery from Third-Party Medicine.  Journal of American Physicians and Surgeons, 13 (2008): 113-114.  A quote:

I now believe more than ever that third-party-free medicine is better medicine both for patients and physicians, and has the hope of being sustainable.  I also find it fascinating to note that as soon as patients have to accept the financial consequences of their choices when it comes to prevention, cost of treatment, or even the cost of diagnosis, they immediately exercise a level of restraint and stewardship that is sadly lacking when a third party is involved.

The current issue of International Journal of Obesity has an article regarding acupuncture as a treatment for obesity.  People treated with acupuncture lost an average of 1.72 kg additional weight “compared to a control of lifestyle” (sic).    That’s an extra 3.8 pounds lost.

Who’da thunk it?

When tested under rigorous scientific conditions, acupuncture has generally been disappointing.

The authors conclude:

Our review suggests that acupuncture is an effective treatment for obesity. However, the amount of evidence is not fully convincing because of the poor methodological quality of trials reviewed. In conclusion, there is an urgent need for well-planned, long-term studies to address the effectiveness of acupuncture for treating obesity.

The “urgent need” for more studies is only felt among practitioners of acupuncture.

Steve Parker, M.D.

Reference:  Cho, S-H, et al.  Acupuncture for obesity: a systematic review and meta-analysis.  International Journal of Obesity, 33 (2009): 183-196.

On January 2, 2009, Health, the online version Health magazine published “America’s Top 10 Healthiest Diets,” composed by a panel of experts.  Number 9 is a Mediterranean-style diet, The Sonoma Diet, published in 2005 and created by Dr. Connie Guttersen.

Here’s my review of The Sonoma Diet: Trimmer waist, better health in just 10 days! 

The author attributes overweight to over-consumption of refined sugars and flours and other “fast-absorbing foods” that displace fruits and vegetables.  Her remedy is to eat controlled portions of the fresh, minimally processed whole foods of the healthy Mediterranean diet.  Portions are controlled by eating off 7 and 9-inch plates and from 2-cup bowls, covering percentages of the plate with protein foods, grains, fruits, and vegetables.  Fatty food portions are also controlled.  Allowable foods are numerous, including whole grain products, fruits, vegetables, chicken, lean beef, fish, poultry, pork, veal, low-fat dairy, legumes, eggs, nuts, and wine.

Her “Wave 1” lasts 10 days and is designed to teach portion control and to overcome habitual over-consumption of concentrated sugar, refined flours, and other highly processed foods.  Wave 2 includes more variety, adds fruit and wine (optional), fat-free yogurt, and more calories.  Both waves include unlimited particular vegetables characterized by high fiber and low calorie-density.  In Wave 3—the rest of your life—you eat more fruits and vegetables and continue to avoid fatty meats, fruit juices, potatoes, full-fat dairy, trans fats, saturated fats, sugary sweets, and refined grains.  She’s fanatical about avoiding saturated fats.

At first glance, it appears the author puts everyone on the same eating plan, whether a 325-pound ditch-digger or 150-pound desk jockey.  However, she allows “bigger men” and very physically active women the option of more snack calories, about 400 daily.  Dr. Guttersen never reveals how many calories are on the diet, nor how many should be.  A review in Consumer Reports estimated that calories on Sonoma were 1,390 per day.  That’s fine for most women, but inadequate for most men.  The extra snacks for men, along with unlimited veggies, should get them up to a more reasonable intake.

Consumer Reports calls Sonoma an “updated lower-carb diet.”  Sonoma may have more protein than the traditional Mediterranean diet, but it is by no means low in carbohydrates.

Dr. Guttersen recommends following her specific thrice-daily meal recipes for Waves 1 and 2, a total of 24 days.  But you are free to come up with your own meals based on the approved-foods list and plate percentages.  Her meals entail a significant amount of preparation, but the recipes look like they would be worth it.

Since this is a review, I feel obligated to criticize something.  So . . .  1. Dr. Guttersen never discusses reasonable goal weights.  2. She doesn’t understand that jogging and biking are aerobic exercises, not strength training.  3. She doesn’t discuss exercise much, although does recommend it and gives good basic advice.  4.  She recommends breakfast cereals with at least 8 grams of fiber per serving.  These are unpalatable and, fortunately, rare.  [Three grams per serving is fine.]  5. Sonoma is not as customizable as I would prefer.  6. Cold-water fatty fish should have made it onto her list of Top Ten Power Foods.

Dr. Guttersen provides an extensive scientific reference section, which is both admirable and helpful.  Another feature I love is the pull-out section in the back of the book which summarizes the approved foods and depicts the plates and bowls with food percentages.  Pin these to your refrigerator or take to the grocery store.  An entire chapter is devoted to common problems of dieters, such as eating at restaurants.

The Sonoma Diet is a masterful application of the Mediterranean diet to weight loss.  I congratulate Dr. Guttersen.

Steve Parker, M.D.

References:  ConsumerReports.org in May, 2007, rated seven popular book-based diet plans.

According to Wikipedia, Valentine’s Day was originally a pagan festival that was renamed after two early Christian martyrs.

In addition to roses and cards, chocolate is often presented as a gift on Valentine’s day.  Chocolate is derived from the Theobroma cacoa, the cocoa tree.  “Theobroma cacao” means “food of the gods.”

Over the last few months I wrote a series of posts on dark chocolate:

• Health benefits of dark chocolate
• If dark chocolate is healthy, what’s the right dose?
• Dark chocolate: Love it or hate it?
• Try some dark chocolates

Happy Valentine’s Day!  I hope you have someone special to celebrate with.  If not now, then next year.

Steve Parker, M.D.

Owners of capital will stimulate the working class to buy more and more of expensive goods, houses and mechanical products, pushing them to take more and more expensive credits, until their  debt becomes unbearable. The unpaid debt will  lead to bankruptcy of banks, which will have to be  nationalised, and the State will have to take the road which will eventually lead to  communism. 

                                                -Karl Marx, in Das Kapital, 1867

I read this at SpokeUp.com today, thanks to Han Mfn’ Solo.  I can’t seem to find my copy of Das Kapital, to verify the quote.  And I couldn’t find the quote at Google Book Search.  [I’m always alert for Internet hoaxes.]

If true, the quote is a chilling reminder of what’s happening in the U.S. economy and Washington, D.C. now.

What’s this got to do with weight loss, health, and longevity?  Just imagine what would happen to your health and longevity under communism.  It ain’t good.  But most of us would lose weight!

Steve Parker, M.D.

Additional Resources:  The Gulag Archipelago by Aleksandr Solzhenitsyn.  [If you don’t think Man has the capacity to commit pure evil, this book will convince you otherwise.]

Mild Cognitive Impairment (MCI) is considered a precursor to dementia, although it does not always lead to dementia.

A study published this month in the Archives of Neurology indicates that adherence to the Mediterranean diet reduces both the risk of developing MCI and the risk of MCI conversion to Alzheimer dementia.  The story was reported today and yesterday by US News & World Report, USA Today, Bloomberg, and others.

Methodology

1,393 residents of a multi-ethnic community in New York were enrolled in the study.  They were mentally normal at baseline and followed for an average of 4.5 years.

Another 482 residents were identified as having Mild Cognitive Impairment at baseline, and were followed an average of 4.3 years.

All participants were screened for cognitive impairments and surveyed to get an idea of usual food intake.  Researchers used a 10-point scale to describe an individual participant’s adherence to the Mediterranean diet.  The higher the score, the greater the participant’s adherence.  Participants were then divided into thirds (tertiles) based on whether adherence was low, medium, or high.  Average age of study subjects on entry was 77.

Results

275 of the 1,393 participants who were mentally normal at baseline developed Mild Cognitive Impairment over the 4.5 years of follow-up.  Compared to those participants in the lowest third of Mediterranean diet adherence, those in the middle third had 17% less risk of developing MCI, and those in the highest third had 28% less risk.

Of 482  participants with Mild Cognitive Impairment at baseline, 106 later developed Alzheimer disease.  Compared with participants in the lowest third of adherence, those in the middle third had 45% less risk of developing Alzheimer disease, and those in the highest third had 48% less risk.

Comments From the Study Authors

. . . potentially beneficial effects for mild cognitive impairment or mild cognitive impairment conversion to Alzheimer’s disease have been reported for alcohol, fish, polyunsaturated fatty acids (also for age-related cognitive decline) and lower levels of saturated fatty acids.

The Mediterranean diet tends to improve cholesterol levels, overall blood vessel function, reduce inflammation, and lower blood sugar levels, all of which could help preserve brain function.

My Comments

No surprise here.

The traditional Mediterranean diet has long been associated with lower risk of developing dementia, both Alzheimer and vascular dementia.  Vascular dementia results from multiple strokes or poor blood flow to the brain.  Since Mild Cognitive Impairment precedes Alzheimer dementia, it makes sense that the Mediterranean diet could help prevent both.

The lead author of the study at hand, Dr. Scarmeas, also reported in 2007 that the Mediterranean diet also prolongs life in established Alzheimer patients.

Steve Parker, M.D.

Reference:  Scarmeas, Nikolaos, et al.  Mediterranean Diet and Mild Cognitive Impairment.  Archives of Neurology, 66 (2009): 216-225.

Additional Resource:  Oldways’ Mediterranean diet information

On January 2, 2009, Health, the online version of Health magazine published a list of “America’s Top 10 Healthiest Diets,” composed by a panel of experts.  Number 9 on the list was The Sonoma Diet.  Number 8 was YOU - on a Diet.

I’m interested in both of those diets because they are Mediterranean-style.

Here’s my review of YOU - on a Diet, a book by Michael Roizen, M.D., and Mehmet Oz, M.D., published in 2006.  Oz is the doctor you see so often on Oprah’s TV show.

These authors absolve you of responsibility if you are fat: the problem is a brain chemical imbalance.  Take the authors’ weight-loss advice, and they promise to balance the chemicals, without hunger, without thinking about how much you’re eating.

Sound too good to be true?

Roizen and Oz recommend eating whole grain products, fruits, vegetables, nuts, olive and vegetable oils, fish, eggs, chicken, and low-fat dairy.  Alcohol and specific commercial fast foods are allowed.  This is healthy, Mediterranean-style eating.  The foods are readily available and easy to prepare.  Forty-two recipes are provided.  No beef, pork, potatoes, or peas.  Other forbidden or strictly limited items are simple sugars, high fructose corn syrup, enriched/refined flour, trans fats, and saturated fats.

The authors tell you what to eat daily for one week.  Week two is the same, and helps to establish new habits.  Variety is limited by design.  They say that too much variety leads to overeating.  You choose from among four different breakfasts and four lunches.  Seven different evening meals are spelled out for you, taking 30 minutes or less to prepare.  You repeat the pattern until you reach the authors’ healthy goal: waist circumferences of 32.5 inches or less for women, 35 or less for men.  Weight is not important in this scheme.  Although never divulged by the authors, I estimate you are allowed 1,450 calories per day.  There is no allowance for your sex or baseline weight.  Roizen and Oz don’t want you to focus on calories.

Incredibly, they don’t  address what you do after you reach your goal waist size.  Just add more of the same foods?  How much?  Can you ever again eat beef, pork, potatoes, or peas?  Maintenance of weight loss is certainly problematic, but that’s no reason to ignore it.

The authors make several controversial claims without offering supportive documents such as scientific references or a bibliography.  I guess we are supposed to just trust them since they are medical doctors. Examples: 1. Having sex will curb your appetite, 2. Aluminum in deodorants promotes weight gain, 3. ½ tsp of cinnamon daily will help you lose weight, 4. Red pepper helps with weight loss, 5. Willpower is not important because it always fails, 6. Eating 70 calories of nuts 20 minutes before meals will help you avoid overeating.

Roizen and Oz provide great information on the process of digestion and the importance of exercise.  Their exercise program is detailed and readily achievable: 30 minutes of daily walking, along with strength training.

The book is a quick, easy read.  The cutesy style will amuse some readers, irritate others.  Lots of pop celebrity references.  And neologisms, such as “YOU-reka!”  Sexual intercourse is mentioned more than anyone would expect.

Bottom line: This is a fair weight-loss program for most overweight women.  After they reach their goal waist size, however, they are left without guidance.  This is worrisome, and almost guarantees weight regain.  So I don’t recommend the book.  We have many science-based methods for prevention of weight regain.  For women over 210 pounds and for nearly all overweight men, 1,450 calories per day is not enough.  These folks won’t be able to follow the diet for more than four days—their hunger will be too great.

The book is a still a consistently good seller, so I wouldn’t be surprised if the authors fix these problems in a second edition.

Steve Parker, M.D.

One of my frustrations with office-based medical practice is the lack of time available for patient education.  “Doctor,” after all, is derived from the Latin word for “teacher.”

The U.S. healthcare system (”non-system” would be more like it) pays physicians to do procedures and handle acute medical problems.  So that’s what you get.

There’s not much pay for thoughtful reflection, in-depth analysis, preventive care, or advice on nutrition, exercise, and healthy lifestyles.  These are called “cognitive services.”  Doctors who do too much of this either go out of business or make a very poor living.  You can’t feed a family simply on the personal satisfaction of a job well done.

When it comes to medical information, the Internet is an absolute fire hose of nonsense.  It’s a quagmire of crass commercialism and quackery.  Sure, there are scattered islands of reliable information.  But you must be careful and consider the source.

Speaking of reliable sources . . .

Dr. James Hubbard publishes a magazine, My Family Doctor: The Magazine That Makes Housecalls.  Dr. Hubbard’s mission for the magazine is . . .

. . . to help empower you to live your healthiest life.  Within these pages you’ll gain in-depth knowledge about how your body works, advice to help you make informed decisions about your well-being, and solid information based on proven evidence, not fickle fads.

I read Dr. Hubbard’s My Family Doctor blog regularly and have read a few issues of his magazine.  You can depend on his team of healthcare professional writers to provide science-based information.  Highly recommended.  A subscription to the magazine is only $28/year.  If not for yourself, why not send it to someone you care about?

Steve Parker, M.D.

Full disclosure:  This is not a paid advertisement.  Dr. Hubbard and I have no financial ties.

I recently blogged about the health benefits of dark chocolate.

At great personal risk, I have been self-experimenting with various brands and strengths of commercially available chocolate.

Here are a few you might want to try.  I liked them all.

• Lindt Excellence Intense Dark 70% Cocoa Extra Fine Dark Chocolate.  Made in France.  Lindt also makes an Extra Dark Excellence 85% Cocoa.
• Ghirardelli Intense Dark Twilight Delight, 72% Cacao.  Smooth, velvety mouth feel.
• Botticelli Signature Premium European Dark Chocolate, 70% Cocoa.  But fine print says “Product of Canada.”  Harder than the first two and perhaps not quite as tasty.
• Green & Black’s Organic Dark Chocolate, Dark 70%.  Made in Italy.  Easy to break off a small neat dose, which is very helpful in prevention of over-eating.
• Dove 63% Cacao Silky Smooth Extra Dark Chocolate Promises.  Individually wrapped pieces weight 8 grams and have 44 calories.  Again, potentially helpful to prevent over-eating.
• Endangered Species Chocolate All-Natural Dark Chocolate with Deep Forrest Mint, 72% Cocoa.  Made in U.S.A.
• Cacao Reserve by Hershey’s, 65% Dark Chocolate with Cacao Nibs.  “Ground nibs, the heart of the cacao bean.”  Crunchy bits.  This is my favorite thus far.

Taste preferences are quite subjective.  My favorite won’t be yours.  Many variables affect the taste of a batch of chocolate, even from the same maker.  Many people find dark chocolates to be unpleasantly bitter.

If you feel guilty about the calorie and fat content of chocolate, remember that dark chocolate is an excellent source of fiber!  Four and a half grams of fiber per 40 gram serving.  But, remember, the medicinal dose of dark chocolate may be 20 grams or less every three days, on average.

I found these chocolates at supermarkets and drugstores in the Phoenix, Arizona, metropolitan area.  Do you have any favorites that are widely available?

Steve Parker, M.D.