Advanced Mediterranean Diet

I  recently read The Smarter Science of Slim, by Jonathan Bailor and published in 2012.   Per Amazon.com’s rating system, I give it four stars (”I like it”).

♦   ♦   ♦

Mr. Bailor’s weight-management diet avoids grains, most dairy, oils, refined starches, added sugars, starchy veggies, corn, white potatoes.  You eat meat, chicken, eggs, some fruit, nuts, seeds, and copious low-starch vegetables.  No limit on food if you eat the right items.   

It’s high-fiber, high-protein, moderate-fat, moderate-carb (1/3 of calories from carbohydrate,  1/3 from protein, 1/3 from fat).  He considers it Paleo (Stone Age) eating even though he allows moderate legumes and dairy (fat-free or low-fat cottage cheese and plain Greek yogurt).

Will it lead to weight lose? Quite probably in a majority of followers, especially those eating the standard, low-quality American diet.  When it works, it’s because you’ve cut out the fattening carbohydrates so ubiquitous in Western societies.  The protein and fiber will help with satiety.  Is it a safe eating plan?  Yes.

(For those with diabetes needing to lose weight, I prefer a lower carbohydrate content in the diet, something like Conquer Diabetes and Prediabetes: The Low-Carb Mediterranean Diet.  For non-diabetics, is Smarter Science better than my Advanced Mediterranean Diet 2nd Edition?  Of course not, silly!)

I don’t recall any recipes or specific meal plans.  You put your own meals together following his guidelines.

Our major points of agreement:
 - Exercise isn’t terribly helpful as a weight-loss technique for most folks.
 - We’re overweight because we eat too many starches and sweets.
 - Natural, minimally processed foods are healthier than man-made highly refined items.
 - No need to emphasize “organic” /grass-fed beef/free-range chicken.
 - We don’t do enough high-quality exercise.

I have a few problems with the book:
  - It says we’re eating less.  U.S. caloric consumption over the last several decades has increased by about 150 cals (630 kJ) a day for men and 300 cals (1260 kJ) for women.  The author seems to contradict himself at one point by favorably quoting Hilda Bruch’s writing that “…overeating is observed with great regularity” in the obese. 
  - Scary graphs showing increasing instances of heart disease and diabetes over time aren’t helpful because they ignore population growth.  The population-adjusted diabetes rate is indeed increasing whereas heart disease rates are decreasing.
  - It says the Calories In/Calories Out theory of overweight has been proven wrong.  This is by no means true.  It just hasn’t helped us much to reverse the overweight epidemic.  Sure, it’s often said that if you just cut a daily tablespoon of butter out of your diet, you’d lose 11 lb (5 kg) in a year, all other things being equal.  Problem is, all other things are never equal.  In reality, we replace the butter with something else, or we’re slightly less active.  So weight doesn’t change or we gain a little.
  - It says the “eat less, exercise more” mantra has been proven wrong as a weight loss method.  Not really.  See above.  And watch an episode of TV’s “The Biggest Loser.”  Exercise can burn off fat tissue.  The problem is that we tend to overeat within the next 12 hours, replacing the fat we just burned. I agree with the author that “eat less, exercise more” is extremely hard to do, which is the reason it so often fails over the long run.  As Mr. Bailor writes elsewhere: “Hard to do” plus “do not want to do” generally equals “it’s not happening.”  Mr. Bailor would say the reason it ultimately fails is because of a metabolic clog or dysregulation. 
  - He says there’s no relationship between energy (calorie) consumption and overweight.  Not true.  Need references?  Google these: PMID 15516193, PMID 17878287, PMID 14762332.  The author puts too much faith in self-reports of food intake, which are notoriously inaccurate.  And obese folks under-report consumption more than others (this is not to say they’re lying). 
  - Mr. Bailor’s assessments too often rely on rat and mice studies.
  - By page 59, I had found five text sentences that didn’t match up well with the numeric bibiographic references (e.g., pages 48, 50, 59).
  - S. Boyd Eaton is thrice referred to as S. Boyd.
  - How did he miss the research on high intensity interval training by Tabata and colleagues in 1996?  Gibala is mentioned often but he wasn’t the pioneer.
  - Several diagrams throughout the book didn’t print well (not the author’s fault, of course).
  - In several spots, the author implies that HIS specific eating and exercise program has been tested in research settings.  It hasn’t.

Mr. Bailor’s exercise prescription is the most exciting part of the book for me.  His review of the literature indicates you can gain the weight-management and health benefits of exercise with just 10 or 20 minutes a week.  NOT the hour a day recommended by so many public heath authorities.  And he tells you how to do the exercises without a gym membership or expensive equipment.  That 20 minutes is exhausting and not fun.  You have fun in all the hours you saved.  If this pans out, we’re on the cusp of a fitness revolution.  Gym owners won’t be happy.  Sounds too good to be true, doesn’t it?

One component of the exercise program is high intensity interval training (HIIT), which I’m recently convinced is better than hours per week of low-intensity “cardio” like jogging. Better in terms of both fitness and weight management.

The resistance training part of the program focuses on low repetitions with high resistance, especially eccentric slow muscle contraction.  This is probably similar to programs recommended by Doug McGuff. John Little, Chris Highcock, and Skyler Tanner.  I’m no authority on this but I’m trying to learn.  By this point in the book, I was tired of looking up his cited references (76 pages!).  I just don’t know if this resistance training style is the way to go or not.  I’ll probably have to just try it on myself. 

I admire Mr. Bailor’s effort to digest and condense decades of nutrition and exercise research.  He succeeds to a large degree.

Steve Parker, M.D.
 

God, help us figure this out

A few months ago, several of the bloggers/writers I follow were involved in an online debate about two competing theories that attempt to explain the current epidemic of overweight and obesity.  The theories:

1. Carboydrate/Insulin (as argued by Gary Taubes)
2. Food Reward (as argued by Stephan Guyenet)

The whole dustup was about as interesting to me as debating how may angels can dance on the head of pin. 

Regular readers here know I’m an advocate of the Carboydrate/Insulin theory.  I cite it in Conquer Diabetes and Prediabetes: The Low-Carb Mediterranean Diet and The Advanced Mediterranean Diet: Lose Weight, Feel Better, Live Longer (2nd edition).  But the Food Reward theory also has validity.  They’re both right, to an extent.  They’re not mutually exclusive.  The Food Reward theory isn’t as well publiziced as Carbohydrate/Insulin.

Dr. Guyenet lays out a masterful defense of the Food Reward theory at his blog.  Mr. Taubes presents his side here, here, here, here, and here.  If you have a couple hours to wade through this, I guess I’d start with Taubes’ posts in the order I list them.  Finish with Guyenet. 

You’d think I’d be more interested in this.  I’m still not.

Moving from theory to real world practicality, I do see that limiting consumption of concentrated refined sugars and starches helps with loss of excess body fat and prevention of weight regain.  Not for everbody, but many.  Whether that’s mediated through lower insulin action or through lower food reward, I don’t care so much. 

Steve Parker, M.D.

h/t Dr. Emily Deans

Rapper Fat Joe is in a YouTube video talking about his 100-lb (45 kg) weight loss by eating low-carb.  He’s not doctor, but he knows a lot about preventing diabetes and heart disease.  He’s livin’ it.

Steve Parker, M.D.

h/t Tom Naughton

U.S. obesity rate over last 40 years

Beth Mazur over at Weight Maven has posted a lecture by Dr. Stephan Guyenet in which he outlines the changes in American diet over the last 100 years.  It’s only 16 minutes long.  You may  find an explanation for our excess weight problem. 

Steve Parker, M.D.

  Dr. Barry Sears (Ph.D., I think) recently wrote about a lecture he attended by a dietitian affiliated with “The Biggest Loser” TV show.  She revealed the keys to weight-loss success on the show.  Calorie restriction is a major feature, with the typical 300-pounder (136 kg) eating 1,750 calories a day.  On my Advanced Mediterranean Diet, 300-pounders get 2,300 calories (men) or 1,900 calories (women). 

Although not stressed by Dr. Sears, my impression is that contestants exercise a huge amount. 

Go to the link above and you’ll learn that all contestants are paid to participate.  In researching my Conquer Diabetes and Prediabetes book, I learned that the actual Biggest Loser wins $250,000 (USD).  Also, “The Biggest Loser” is an international phenomenon with multiple countries hosting their own versions, with different pay-off amounts.  A former winner, Ali Vincent, lives in my part of the world and still has some celebrity status.

This TV show demonstrates that the calories in/calories out theory of body weight still applies.  Including the fact that massive exercise can help significantly with weight loss.  In real-world situations, exercise probably contributes only a small degree to loss of excess weight.  The major take-home point of the show, for me, is that you can indeed make food and physical activity choices that determine your weight.

Most of us watch too much

I know losing 50 to 10o pounds of fat (25–45 kg) and keeping it off for a couple years is hard; most folks can’t do it.  Do you think you’d be more successful if I gave you $250,ooo for your success?

Steve Parker, M.D.

The (Cleveland) Plain Dealer reports the sad and disturbing case of an 8-year-old boy being removed from his family home and placed in foster care simply because government bureaucrats thought his mother didn’t do enough to reduce his weight. He weighed over 200 pounds (91+ kg).

I don’t have all the details of the case.  But this just seems wrong.  Very wrong. 

Kudos to the reporter, Rachel Dissell, for well-done article. 

Steve Parker, M.D.

Daily work-related energy expenditure over the last half-century in the U.S. has decreased by over 100 calories.  This may well explain the increase in body weights we’ve seen, according to a 2011 article in PLoS ONE.

I sorta hate to open this can o’ worms, but it’s important.  As a population, are we fat because we eat too much or because we burn too few calories in physical activity?  Or is it a combination?  The correct answer may help us learn how to reverse the trend.

Methodology

Authors of the study at hand estimated the amount of energy (calories) necessary to perform various jobs, then noted changes in numbers of people employed in those jobs over time.  In the early 196os, for example, nearly half of U.S. jobs required at least moderate intensity physical activity, compared to less than 20% demanding that degree of energy now.  The authors note the dramatic shift from manufacturing to service-type jobs over the last 50 years.  Service jobs, like mine, often entail a lot of sitting and standing around. 

They chose to ignore how much energy we expend in exercise, figuring what we do in a 40-hour work week overwhelms the 1-2 hours of  exercise we may do.

Researchers’ Findings and Conclusions

They found that work-related daily energy expenditure has decreased by over 100 calories over the last half-century, which (in the authors’ view) would account for a significant portion of the increased body weight we’ve seen.  Since physically demanding jobs are unlikely to see a resurgence, the authors advocate physically active lifestyles away from workplace. 

Discussion

Surveys indicate that only one in four of us fulfill the federal physical activity guidelines: 150 minutes a week of moderate intensity activity or 75 minutes a week of vigorous intensity activity.  When activity is actually measured with an accelerometer, only one in 20 achieve that lofty goal.  We over-estimate how much we exercise, and under-estimate how much we eat.

The researchers cite studies showing significantly increased average per capita calorie consumption in the U.S. over the last several decades.  Some experts estimate the caloric increase is in the range of 500 a day for adults; the authors here think that’s too high but don’t offer a specific alternative. Looking at one of their references (Hall et al), they must think the increase is closer to 200 calories a day, comparing 2005 to 1975.

Several studies suggest that average daily energy expenditure has not decreased in developed countries, at least from the 1980s to the present.   A strength of the current study at hand is that it spans about 50 years, up to 2008.

My sense is that both calorie consumption (too much) and physical activity (too little) contribute to our overweight problem that started 40 or 50 years ago.  Excessive consumption is the predominant factor.  To ”exercise off”  the calories in a Snickers candy bar, you’d have to jog for an hour.  If you’re watching your weight, you’ll have more success if you just skip the Snickers.

In case you couldn’t tell,  I still believe in the “calories in/calories out” model of overweight and obesity, aka “the energy balance equation.”  At the same time, I believe certain calories are more fattening than others: concentrated sugars and refined starches.

Steve Parker, M.D.

References:

Church, T., Thomas, D., Tudor-Locke, C., Katzmarzyk, P., Earnest, C., Rodarte, R., Martin, C., Blair, S., & Bouchard, C. (2011). Trends over 5 Decades in U.S. Occupation-Related Physical Activity and Their Associations with Obesity PLoS ONE, 6 (5) DOI: 10.1371/journal.pone.0019657
 

Swinburn, B., et al.  Increased food energy supply is more than sufficient to explain the U.S. epidemic of obesity.  American Journal of Clinical Nutrition, 2009 (90): 1,453-1,456.  

Hall, K.D., et al.  The progressive increase of food waste in America and its environmental impact.  PLoS ONE, 2009, 4(11): e7940.  doi: 10.1371/journal.pone.0007940

A comment left under my recent Diabetic Mediterranean Diet blog post on healthy weight ranges reminded me about the waist-hip ratio.

The risk of heart and vascular disease is more closely linked to distribution of excess fat than with degree of obesity as measured by overall weight or body mass index. Waist-hip ratio (WHR) is a measure of abdominal or central obesity, the type of fat distribution associated with coronary artery disease. A high ratio indicates the android body habitus. To determine your waist-hip ratio:

1. While standing, relax your stomach—don’t
     pull it in. Measure around your waist mid-
     way between the bottom of the rib cage and
     the top of your pelvis bone. Usually this is at
     the level of your belly button, or an inch
     higher. Don’t go above the rib cage. Keep the
     measuring tape horizontal to the ground and
     don’t compress your skin.
2. Then measure around your hips at the
     widest part of your buttocks. Keep the tape
     horizontal to the ground and don’t compress
     your skin.
3. Divide the waist by the hip measurement.
     The result is your waist-hip ratio.

For example, if your waist is 44 inches (112 cm) and hips are 48 inches (122 cm): 44 divided by 48 is 0.92, which is your waist-hip ratio.

Scientists haven’t yet determined the ideal WHR, but it is probably around 0.85 or less for women, and 0.95 or less for men. Ratios above 1.0 are clearly associated with risk of cardiovascular disease such as heart attacks. The higher the ratio, the higher the risk. Compared with body mass index, WHR is a much stronger predictor of coronary artery disease. Several of the other obesity-related illnesses are also correlated with WHR, but the relationship between WHR and cardiovascular disease is particularly strong.

Steve Parker, M.D.

I have a stack of scientific articles I’ve been meaning to review in depth and blog about.  But I have to finally admit I don’t have the time.  Here they are.  Click through for details.

1. Long-term calorie restriction in humans appears highly effective in reducing atherosclerosis risk factors (lab tests) and actual carotid artery atherosclerosis. Only 18 study subjects, however.
2. A very-low-carbohydrate diet improved memory in older adults with mild cognitive impairment over six weeks.  Twenty-three subjects were randomized to either high-carb or very-low-carbohydrate diet.  The low-carbers improved verbal memory performance, lost weight, reduced fasting blood sugar and fasting insulin levels.  Ketone levels were positively correlated with memory performance.
3. A high-fat diet impairs cognitive function and heart energy metabolism in young men.  Sixteen test subjects.  Crossover study design with a five-day high-fat diet deriving 75% of energy from fat, compared to a low-fat diet deriving 23% of energy from fat.  High-fat diet led to impaired attention, speed, and mood.  I’m sure low-carb bloggers have been all over this.  At first blush, it appears they were testing during “induction flu” phase of very-low-carb eating, between days 2 to 7 of a new ketogenic diet.  It takes several weeks to adapt metabolism to running almost entirely on fat rather than standard carbohydrates.  Suspect results would have been different if given time to adapt.
4. Weight-loss with the laparoscopic gastric banding procedure has poor long-term outcome, according to Belgian surgeons reporting on 82 patients.  Four in 10 patients had major complications.  Nearly half of the 82 patients needed to have the bands removed, and six of every 10 required some kind of re-operation.
5. Trust me, you DON’T want age-related macular degeneration.  Women, reduce your risk of ARMD with a healthy lifestyle, including regular exercise, avoidance of smoking,  and by eating abundant plant foods (vegetables [including orange and dark leafy green ones], fruits, and whole grains) and limit foods high in fat, refined starches, sugar, alcohol, and oils.  At least according to these researchers. 
6. Leafy green vegetables and olive oil are linked to reduced heart disease (CHD) in Italian women.  Fruit consumption had no effect.  This is from a subset of the huge EPIC study, following 30,000 women over almost eight years.
7. The Mediterranean diet protects against metabolic syndrome, reducing risk by about a third according to a huge meta-analysis from Greek and Italian investigators.  It works best in Mediterranean countries. 
8. The Mediterranean diet was linked to slower rates of cognitive decline in Chicago residents over the course of almost eight years.  The comparison diet was the Healthy Eating Index-2005.  Of the 3,800 participants, about two-thirds were black.  A Manhattan population showed lower risk of dementia when eating Mediterranean-style.

There ya’ go.  This is better than letting the articles just sit in my briefcase for months on end, eventually to be thrown out.

Steve Parker, M.D.

In the past it was pretty easy to find tables of recommended healthy body weights.  Not so much anymore.  Most of the experts want you calculate your body mass index, recommending the healthy BMI range as 18.5 to 24.9.  I recently spent an hour putting together a healthy weight range based on BMIs.  Since I have many readers outside the U.S., I use both U.S. customary and metric numbers.

Metropolitan Life Insurance Company last published its ideal weight and height table in 1983.  The US Department of Agriculture abondoned its 1995 healthy weight table by the turn of the century recommending BMI calculation instead.  Of note is that the upper end of its weight ranges was a BMI of 25; the lower ends were all BMIs of 19. 

Body Mass Index (BMI) is your weight in kilograms divided by your height in meters squared (kg/m²).  A pound equals 454 kilograms. An inch equals 2.54 centimeters.  There are 100 centimeters in one meter. Thus, a 5-foot, 4-inch woman (1.63 meters) weighing 200 pounds (91 kilograms) has a BMI of 34.2.  Perhaps you’re starting to understand why this weight standard isn’t too popular yet.

 To learn your own BMI but skip the math, use an online calculator.

 To see if your BMI is in the healthy range of 18.5 to 24.9, find your height in the table below, then look to the healhy weight ranges to the right.  Measure your height without shoes and weight without clothes.

Table of Healthy Weight Ranges Based On Body Mass Index: 18.5 to 24.9

       Height               Weight in lb        Weight in kg

5’0” or 152 cm             95 - 128             43.0 - 58.0

5’1” or 155 cm             98 - 132             44.4 - 59.8

5’2” or 157 cm           101 - 137            45.8 - 62.1

5’3” or 160 cm           105 - 141             47.6 - 63.9

5’4” or 163 cm           108 - 146             48.9 - 66.2

5’5” or 165 mc           111 - 150             50.3 - 68.0

5’6” or 168 cm           115 - 155             52.0 - 70.3

5’7” or 170 cm           118 - 160             53.5 - 72.5

5’8” or 173 cm           122 - 164             55.3 - 74.3

5’9” or 175 cm           125 - 169             51.7 - 76.6

5’10” or 178 cm         129 - 174             58.5 - 78.9

5’11” or 180 cm         133 - 179             60.3 - 81.8

6’0”  or 183 cm          137 - 184             62.1 - 83.4

6’1” or 185 cm           140 - 189              63.5 - 85.7

6’2” or 188 cm           144 - 195             65.3 - 88.4

6’3” or 191 cm           148 - 200             67.1 - 90.7

6’4” or 193 cm           152 - 205             68.9 - 92.9

BMIs between 25 and 29.9 designate “overweight” and accurately describe about 35 percent of the United States population.

A BMI of 30 or higher defines “obesity” and indicates high risk for poor health. About 30 percent of us are obese. At a BMI of 35 and above, incidence of death and disease increases sharply.

The BMI concept is helpful to researchers and obesity clinicians, but the number doesn’t mean much yet to the average person on the street and to many physicians. It should be used more widely. (I know, I know: it’s not perfect. Do you have a better, cheap, widely applicable standard?)  Know your BMI. If it’s under 25, any excess fat you carry is unlikely to affect your health and longevity; your efforts to lose weight would be purely cosmetic.

Steve Parker, M.D.