Advanced Mediterranean Diet

I just finished reading The Art and Science of Low Carbohydrate Living: An Expert Guide to Making the Life-Saving Benefits of Carbohydrate Restriction Sustainable and Enjoyable, by Stephen Phinney, M.D., Ph.D., and Jeff Volek, Ph.D. published this year.  I give it four stars per Amazon.com’s rating system (I like it).

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The authors medicalize overweight and obesity by naming the cause of most cases to be “carbohydrate intolerance,” along the lines of lactose intolerance and gluten intolerance.  Given the myriad illnesses and shortened lifespan associated with obesity, medicalizing it is reasonable.  Ask Gary Taubes why we get fat, and he’ll say it’s excessive consumption of carbohydrates, especially sugars and refined flours.  Ask Phinney and Volek, and they’ll say “carbohdyrate intolerance.”  For them, the “treatment” is avoidance of carbs.  I also referred to carbohydrate intolerance in my 2011 book, Conquer Diabetes and Prediabetes.

If a patient asks me why he’s fat, I guess I’d prefer to say “you have carbohydrate intolerance,” rather than “you eat too many carbs.”  It’s less confrontational and doesn’t blame the patient.

So how many of us in the U.S. have carbohydrate intolerance?  The authors estimate a hundred million or more - about a third of the total poplulation, or more, who could directly benefit from carbohydrate restriction.  I agree.

Before reading this book, I was convinced that carbohydrates are indeed major contributors to overweight and obesity, especially concentrated sugars and refined grains.  The authors cite much of the pertinent scientific/medical literature. 

Gary Taubes made the same case in his brilliant book, Good Calories, Bad Calories.  Dr. Robert Atkins argued the same in Dr. Atkins New Diet Revolution.  The problem is that many healthcare providers such as physicians and dietitians are biased against thosesources.  Physicians resist a non-physician such as Taubes giving them advice about the practice of medicine.  And most physicians over 45 still labor under the misconception that dietary cholesterol and total and saturated fat are major-league killers, so they’ve already dismissed Dr. Atkins and don’t have time to get caught up to date on the recent research.

Phinney and Volek have wisely targeted this work towards healthcare providers such as physicians, so it’s somewhat technical and clinical.  Both have Ph.D.s and Phinney is also an M.D.  The authors are respected researchers who thoroughly review the science behind low-carb eating.  They explain how high blood pressure, metabolic syndrome, type 2 diabetes, and other conditions are related to carb consumption.

I rate the book four stars instead of five only because it’s a little pricey at $29 (US).

Smart nutrition- and fitness-minded folks will also benefit from a reading.  For a more consumer-oriented book, I recommend the authors’ The New Atkins for a New You or Taubes’ Why We Get Fat.

Steve Parker, M.D.

The very-low-carb Spanish Ketogenic Mediterranean Diet cures metabolic syndrome, according to investigators at the University of Córdoba in Spain. 

The metabolic syndrome is a collection of clinical factors that are linked to high risk of developing type 2 diabetes and heart disease.  Individual components of the syndrome include elevated blood sugar, high trigylcerides, low HDL cholesterol, high blood pressure,  and abdominal fat accumulation.

Spanish researchers put 26 people with metabolic syndrome on the Spanish Ketogenic Mediterranean Diet for twelve weeks and monitored what happened.  At baseline, average age was 41 and average body mass index was 36.6.  Investigators didn’t say how many diabetics or prediabetics were included.  No participant was taking medication.

What’s the Spanish Ketogenic Mediterranean Diet?

Calories are unlimited, but dieters are encouraged to keep carbohydrate  consumption under 30 grams day.  They eat fish, lean meat, eggs, chicken, cheese, green vegetables and salad, at least 30 ml (2 tbsp) daily of virgin olive oil,  and 200-400 ml of red wine daily ( a cup or 8 fluid ounces  equals 240 ml).  On at least four days of the week, the primary protein food is fish.  On those four days, you don’t eat meat, chicken, eggs, or cheese.  On up to three days a week, you could eat non-fish protein foods but no fish on those days. 

How’s this different from my Ketogenic Mediterranean Diet?  The major differences are that mine includes one ounce (28 g) of nuts daily, less fish overall, and you can mix fish and non-fish protein foods every day.

Regular exercisers were excluded from participation, and my sense is that exercise during the diet trial was discouraged. 

What Were the Results?

Metabolic syndrome resolved in all participants.

Three of the original 26 participants were dropped from analysis because they weren’t compliant with the diet.  Another one was lost to follow-up.  Final analysis was based on the 22 who completed the study.

Eight of the 22 participants had adverse effects.  These were considered slight and mostly appeared and  disappeared during the first week.  Effects included weakness, headache, constipation, “sickness”, diarrhea, and insomnia. 

Average weight dropped from 106 kg (233 lb) to 92 kg (202 lb).

Body mass index fell from 36.6 to 32.

Average fasting blood sugar fell from 119 mg/dl (6.6 mmol/l) to 92 mg/dl (5.1 mmol/l).

Triglycerides fell from 225 mg/dl to 110 mg/dl.

Average systolic blood pressure fell from 142 mmHg to 124.

Average diastolic blood pressure fell from 89 to 76.

So What?

A majority of people labeled with metabolic sydrome continue in metabolic sydrome for years.  That’s because they don’t do anything effective to counteract it.  These researchers show that it can be cured in 12 weeks, at least temporarily, with the Spanish Ketogenic Mediterranean Diet.

Very-low-carb diets are especially good at lowering trigylcerides, lowering blood sugar, and raising HDL cholesterol.  Overweight dieters tend to lose more weight, and more quickly, than on other diets.  Very-low-carb diets, therefore, should be particularly effective as an approach to metabolic syndrome.  It’s quite possible that other very-low-carb diets, such as Atkins Induction Phase, would have performed just as well as the Spanish Ketogenic Mediterranean Diet.  In fact, most effective reduced-calorie weight-loss diets would tend to improve metabolic syndrome, even curing some cases, regardless of carb content. 

Most physicians recommend that people with metabolic syndrome either start or intensify an exercise program.  The program at hand worked without exercise.  I recommend regular exercise for postponing death and other reasons.

Will the dieters of this study still be cured of metabolic syndrome a year later?  Unlikely.  Most will go back to their old ways of eating, regaining the weight, and moving their blood sugars, triglycerides, and HDL cholesterols in the wrong direction.

Steve Parker, M.D.

Reference: Pérez-Guisado J, & Muñoz-Serrano A (2011). A Pilot Study of the Spanish Ketogenic Mediterranean Diet: An Effective Therapy for the Metabolic Syndrome. Journal of medicinal food PMID: 21612461

Loss of excess weight is a mainstay of therapy for nonalcoholic fatty liver disease.  A very-low-carb diet works better than a reduced-calorie diet, according to a recent study in the American Journal of Clinical Nutrition.

Nonalcoholic fatty liver disease (NAFLD) occurs in 20 to 40% of the general population, with most cases occuring between the ages of 40 and 60.  It’s an accumulation of triglycerides in the liver.  For every week I work in the hospital, I see five or 10 scans (either CT scans or sonograms) that incidentally show fat build-up in the liver.

Nonalcoholic steatohepatitis (NASH) is a subset of NAFLD, perhaps 30% of those with NAFLD.  Steatohepatitis involves an inflammatory component, progressing to cirrhosis in 3 to 26% of cases. 

Researchers at the University of Texas Southwestern Medical Center assigned 18 obese subjects (average BMI 35) to either a very-low-carb diet (under 20 grams a day) or a low-calorie diet  (1200 to 1500 calories a day) for two weeks.  Liver fat was measured by magnetic resonance technology.  The low-carb groups’ liver fat decreased by 55% compared to 28% in the other group.  Weight loss was about the same for both groups (4.6 vs 4 kg). 

Bottom Line

This small study needs to be replicated, ideally with a larger group of subjects studied over a longer period.  Nevertheless, it appears that a very-low-carb diet may be one of the best dietary approaches to nonalcoholic fatty liver disease.  And I bet it’s more sustainable than severe calorie restriction.  The Ketogenic Mediterranean Diet, by the way, provides 20-30 grams of carb daily.

Steve Parker, M.D. 

Reference:  Browning, Jeffrey, et al.  Short-term weight loss and hepatic triglyceride reduction: evidence of a metabolic advantage with dietary carbohydrate restriction.  Am J Clin Nutr, May 2011 vol. 93 no. 5 1048-1052.  doi: 10.3945/​ajcn.110.007674

Several mainstream media sources recently touted the Mediterranean diet as an effective method for prevention of the expected middle-age weight gain.  Reuters is one source, for example.  Men on the Mediterranean diet gained 2 lb (about a kilogram) less than other men over six years.  Mediterranean-dieting women gained weight too, but a whole 0.77 lb (0.35 kg) less than others.

Big whoop.

The media attention was based on a Spanish study of over 10,000 men and women university graduates over the course of six years.  Average baseline age was 38.  A Mediterranean diet score was calculated based on a food frequency questionnaire given only at the start of the study.  Adherence with a Mediterranean-style diet was judged for each individual as either low, medium, or high.

You’d think this research report would tell you how much weight these folks gained on average over six years, and how many pounds less if one followed the Mediterranean diet.  Think again.  No such luck, which reminds me of one of my favorite aphorisms: “eschew obfuscation.”

I had to do my own calculations based on Table 3.  And I still don’t know how much the average person in this cohort gained over six years.

I am a die-hard Mediterranean diet advocate.  It’s linked to myriad health benefits.  I’d love to believe it prevents middle-age weight gain.  But the results of this study are so modest as to be almost nonexistent.

Steve Parker, M.D.

Reference:  Beunza, J., Toledo, E., Hu, F., Bes-Rastrollo, M., Serrano-Martinez, M., Sanchez-Villegas, A., Martinez, J., & Martinez-Gonzalez, M. (2010). Adherence to the Mediterranean diet, long-term weight change, and incident overweight or obesity: the Seguimiento Universidad de Navarra (SUN) cohort American Journal of Clinical Nutrition DOI: 10.3945/ajcn.2010.29764

The weight-loss drug sibutramine (Meridia) should be withdrawn from the U.S. market, suggests an editorialist in the September 2, 2010, New England Journal of Medicine.  Based on a clinical study in the same issue, it’s more accurate to conclude that sibutramine shouldn’t be prescribed for people who aren’t supposed to be taking it in the first place.

Sibutramine is sold in the U.S. as Meridia and has been available since 1997.  Judging from the patients I run across, it’s not a very popular drug.  Why not?  It’s expensive and most people don’t lose much weight.

The recent multi-continent SCOUT trial enrolled 9,800 male and female study subjects at least 55 years old (average age 63) who had either:

1. History of cardiovascular disease (here defined as coronary artery disease, stroke, or peripheral artery disease)
2. Type 2 diabetes plus one or more of the following: high blood pressure, adverse cholesterol levels, current smoking, or diabetic kidney disease.
3. Or both of the above (which ended up being 60% of the study population)`.

Here’s a problem from the get-go.  For years, Meridia’s manufacturer and the U.S. Food and Drug Administration have told doctors they shouldn’t use the drug in patients with history of cardiovascular disease.  It’s not the scary “black box warning,” but it’s clearly in the package insert of full prescribing information.

Half the subjects were randomized to sibutramine 10 mg/day and the other half to placebo.  All were instructed in diet and exercise aiming for a 600 calorie per day energy deficit.  They should lose about a pound a week if they followed the program.  Average follow-up was 3.4 years.

What Did the Researchers Find?

Forty percent of both drug and placebo users dropped out of the study, a very high rate.

As measured at one year, the sibutramine-users averaged a weight loss of 9.5 pounds (4.3 kg), the majority of which was in the first 6 weeks.  After the first year, they tended to regain a little weight, but kept most of it off.

Death rates were the same for sibutramine and placebo.

Sibutramine users with a history of cardiovascular disease had a 16% increase in non-fatal heart attack and stroke compared to placebo.  To “cause” one heart attack or stroke in a person with known cardiovascular disease, you would have to treat 52 such patients.

Folks in the “diabetes plus risk factor(s)” group who took sibutramine had no increased risk of heart attack or stroke.

So What?

Average weight loss with sibutramine isn’t much.  Nothing new there.  [Your mileage may vary.]

People with cardiovascular disease shouldn’t take sibutramine.  Nothing new there.

An FDA advisory panel reviews sibutramine in mid-September.  Are they likely to recommend withdrawal of the drug from the marketplace?  No.  They’ll remind doctors not to use it in patients with cardiovascular disease, and perhaps phrase that as a “black box warning.”

Steve Parker, M.D.

Reference:  James, W. Philip, et al.  Effect of sibutramine on cardiovascular outcomes in overweight and obese subjects.  New England Journal of Medicine, 363 (2010): 905-917.

 For overweight and obese women, loss of between five and 10% of body weight significantly reduces urine leakage.  According to the research report in last month’s Obstetrics & Gynecology journal, weight loss should be the first approach to urine leakage in overweight and obese women.

The other word for urine leakage is incontinence: an involuntary loss of urine.  It’s a major problem that isn’t much talked about.  It’s not exactly dinner-party conversation material.  You can imagine its effect on quality of lifeIn the U.S., leakage of urine on at least a weekly basis is reported byone in 10 women and one in 20 men.  It’s more common at higher ages and in women.  Just looking at non-pregnant women, incontinence affects 7% of women aged 20-39, 17% of those aged 40-59, and 23% of women 60-79 years old.

The study at hand involved 338 overweight and obese women: average age 53 (minimum of 30), average body mass index 36, average weight 92 kg (202 lb).  For participation, they had to have at least 10 incontinence episodes per week.  On average, they reported 24 leakage episodes per week (10 stress incontinence, 14 urge incontinence).  All women were given a “self-help incontinence behavioral booklet with instructions for improving bladder control.”  They were randomized to two different weight-loss programs, but I won’t bore you with the details.  The diets were the standard reduced-calorie type.  One diet group had many more meetings than than the other.

The women kept diaries of leakage, and even collected urine soaked pads for weighing.

Results

Eight-five percent of the women completed the 18-month study.

By six months, 89 of the women has lost five to 10% of body weight; 84 lost over 10%.  As expected, when measured at 18 months, only 61 women were in the “five to 10% loss” category; 71 were in the “over 10%” group. 

Greater amounts of weigh loss were linked to fewer episodes of leakage.  Maximal improvement in leakage episodes were seen in the women who lost between five and 10% of body weight, with no additional benefit to greater degrees of weight loss, generally.

Women who lost 5-10% of their body weight were two to four times more likely to achieve at least a 70% redcution in total and urge incontinent episode frequency compared with women who gained weight at 6, 12, and 18 months.

Weight loss works better for stress incontinence than for urge incontinence.

Three of every four women who lost five to 10% of body weight said they were moderately or very satisfied with their improved bladder control.

Bottom Line

Weight loss is usually not a cure for incontinence, but a reasonable management option for overweight and obese women.  It’s going to take loss of five or 10% of body weight.  Other options  include drugs, surgery, Kegel exercises, and just living with it.

Five or 10% weight loss for a 200 pound woman is just 10 or 20 pounds.  That degree of weight loss is also linked to lower risk of diabetes and hypertension: even more reason go for it.  

Does it work for men?  Who knows?

Steve Parker, M.D.

Reference: Wing RR, Creasman JM, West DS, Richter HE, Myers D, Burgio KL, Franklin F, Gorin AA, Vittinghoff E, Macer J, Kusek JW, Subak LL, & Program to Reduce Incontinence by Diet and Exercise (2010). Improving urinary incontinence in overweight and obese women through modest weight loss. Obstetrics and gynecology, 116 (2 Pt 1), 284-92 PMID: 20664387

UT Southwestern Medical School investigators recently determined that avoiding obesity is better at preventing high blood pressure than is being physically fit, although both work.

Keeping blood pressures down at reasonable levels is important in prevention of heart attacks, strokes, aneurysms, heart failure, and kidney failure.

Details are at my recent Self-NutritionData Heart Health Blog post.

Steve Parker, M.D.

We have a guest post today, from Matthew Papaconstantinou, Ph.D.  Dr. P was born and raised in Greece.  As a biologist and native of the Mediterranean basin, he closely follows the latest research on the health benefits of the Mediterranean Diet and its use as part of a behavioral weight loss program.  He has a blog at his website, WeightLossTriumph.com.

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As a result of the rapid rise in obesity during the last decade, it is now estimated that one-half of all US adults are overweight or obese [1].  These statistics reflect in the number of gastric bypass surgeries, which skyrocketed from 20,000 in 1995 to 171,000 in 2005.

Although surgical and pharmacological interventions have been successful in treating obesity and preventing its commorbidities, behavioral weight loss approaches that focus on diet and exercise are considered the most effective treatments for obese people.

Behavioral weight loss programs aim at helping participants modify their eating and exercise habits through a number of educative sessions with nutritionists, exercise physiologists and behavioral therapists. However, for the treatments to be effective, the patients must complete the program.  Attrition is one of the major problems of behavioral programs as the number of people who drop out can be as high as 80%.

Using The Mediterranean Diet (MD) as Part of Behavioral Weight Loss Treatment

A recent study by Corbalan et al. evaluated the effectiveness of a behavioral therapy program that was based on the principles of the MD for treatment of obesity [2]. The purpose of this study was to assess whether this program can help participants lose weight and to determine the main obstacles to weight loss.

Why The MD?

Why did they choose the MD as part of this behavioral program? Well, an extensive body of scientific research has shown that the MD is related to lower occurrence of obesity.

MD Promotes Weight Loss

The ATTICA study is a good example [3].  This study, conducted in 2006, evaluated the nutritional habits of 3042 inhabitants of the province of Attica (Athens, Greece), by means of a diet score that incorporated the inherent characteristics of this diet. An inverse correlation between Body Mass Index (BMI) and adherence to the MD was observed—the higher the MD score, the lower the prevalence of overweight, obesity, and central adiposity was.

Of course, it has been suggested that it is not the MD that protects people from obesity, but other aspects of the MD lifestyle (i.e, engagement in outdoor activities, less stress, etc) that may lower BMI levels. Interestingly, the Attica study found that the inverse association between MD adherence and obesity holds true even after adjusting for potential confounders, such as physical activity status. This is a great indication that the Mediterranean diet alone protects against obesity.

It is interesting to note here that, for the majority of the Mediterranean basin inhabitants, the dietary intake is nowadays far from the MD dietary recommendations. This explains why 27% of males and 39% of females living today in the Greek Mediterranean islands are obese [4]. Forty years ago, farmers from the island of Crete had one of the healthiest lifestyles compared to other participants of the “Seven Countries Study” [5]. Today, mean weight has increased by 44lb, placing more than 80% of Cretan farmers in either the obese or overweight category [6].

The Study

But lets continue on the objective of the Corbalan study. Can an MD-based cognitive behavioral therapy be used for the treatment of obesity? What are the main obstacles to weight loss in a Mediterranean population?

This study recruited 1406 Spanish people who were all overweight or obese, aged 20-65 years old. The program lasted for 34 weeks and consisted of 4 components.

• Behavioral techniques—keeping dietary records and change the immediate environment in a way that is conducive to weight loss
• Physical activity—30 minute moderate intensity activity, 3 times a week (10,000 steps a day)
• Nutritional education—basic concepts in nutrition
• Diet—the Mediterranean Diet

Participants consumed 1351 calories per day. This was 67% of their normal daily energy intake, before the program began.  The macronutrient components of the MD were 30-35% fat, 50% carbs, and 15-20% protein and the participants were instructed to use olive oil as the only source of cooking fat. The subjects were also advised to consume at least 300 g of fruits and unrestricted amount of vegetables.

The Results

At the end of the treatment, participants lost on average 17.2 lb. The attrition was as low as 4%, which shows that the participation and adherence was far superior than that observed for other cognitive-behavioral techniques.

Based on a questionnaire that the subjects completed, a “Barriers to Weight Loss” score was calculated, which allowed the investigators to identify which were the main barriers to losing weight. “Loss of motivation”, “stress-related eating” and “eating when bored” were the most common obstacles experienced by those who did not achieve their weight loss goal.

On the other hand, those who succeeded by losing at least 10% of their initial weight, adopted the habit of “writing down absolutely everything”. This allowed them to be aware of what they were eating, control their behavior and monitor their progress.

Conclusion

The study concluded that “behavioral therapy, accompanied by food habit control, caloric reduction, and balanced nutrient distribution based on the Mediterranean diet is useful for weight loss and the improvement of certain alterations associated with obesity.”

This is the first study to show that a dietary/behavioral treatment based on the MD is effective and can be used in clinical practice.

References

1. Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL: Overweight and obesity in the United States: prevalence and trends, 1960-1994. Int J Obes 22:39-47, 1998.
2. Effectiveness of cognitive-behavioral therapy based on the Mediterranean diet for the treatment of obesity. Corbalán MD, Morales EM, Canteras M, Espallardo A, Hernández T, Garaulet M. Nutrition. 2009 Jul-Aug;25(7-8):861-9.
3. Association between the prevalence of obesity and adherence to the Mediterranean diet: the ATTICA study. Panagiotakos DB, Chrysohoou C, Pitsavos C, Stefanadis C. Nutrition. 2006 May;22(5):449-56. Epub 2006 Feb 2.
4. Nutrient intake in relation to central and overall obesity status among elderly people living in the Mediterranean islands: The MEDIS study. Tyrovolas S, Psaltopoulou T, Pounis G, Papairakleous N, Bountziouka V, Zeimbekis A, Gotsis E, Antonopoulou M, Metallinos G, Polychronopoulos E, Lionis C, Panagiotakos DB.
5. Keys A, Blackburn H, Menotti A, Buzina R, Mohacek I, Karvonen MJ, et al. Coronary heart disease in seven countries. Circulation 1970;41(Suppl. 1):1e211.
6. Prevalence of obesity and physical inactivity among farmers from Crete (Greece), four decades after the Seven Countries Study.Vardavas CI, Linardakis MK, Hatzis CM, Saris WH, Kafatos AG.

Dietitian Melanie Thomassian at her Dietriffic blog April 27, 2010, notes that nuts are not fattening, contrary to popular belief.  This is documented in a guest post by Matthew Denos.  Most of the evidence refers to almonds, so I’m not sure other nuts would be equally non-fattening. 

We’re talking about one or two ounces (up to 60 grams) a day.  Could someone gain fat weight eating more than that?  Probably, especially if they have a high-carbohydrate eating pattern.  Do I have scientific studies to back me up?  No. 

Nuts are a classic component of the traditional Mediterranean diet, which is one reason I included them in the Ketogenic Mediterranean Diet.  The other reason is that nut consumption is associated with lower heart disease risk.

Steve Parker, M.D.

I loved the sound of this phrase - hari hachi bu - even before I knew what it meant.

“Hari hachi bu” comes from the Japanese islands of Okinawa.  It refers to eating a meal until you’re only 80% full, then stop eating.  It’s a method to control weight. 

Okinawa, remember, is one of the longevity hot spots in Dan Buettner’s Blue Zones. 

But would it really work for many in Western culture?  Probably not.  We don’t have the discipline to stick with it long-term.  Maybe for a day.

One of the currently popular dieting gimmicks is to eat every 3-4 hours while awake.  The rationale is, “you need the energy.”  If you eat 5-6 meals a day, you’re not cutting back on total calories even if you eat only until 80% full.

As long as you’re eating a fair amount of carbohydrates, you can store plenty of energy as glucose in glycogen - in your liver and muscles - to easily live without eating for at least 8-12 hours.  So, there’s no “need” to eat every 3-4 hours.  If there were, we would have gone extinct years ago.  At rest, you’re getting about 60% of your energy supplied by metabolism of fats, not carbohydrates.  Most people can live without all food, but not water, for about two months.

Plenty of people have said, “I’m going to lose weight by cutting back on food intake.”  I don’t have scientific data to back it up, but I’d bet that a food diary works better.

A simple weight-loss or management plan that would work better for Western world inhabitants would be:

Don’t eat anything man-made.

So off limits are bread, rolls, soft drinks, table sugar, high fructose corn syrup, pancakes, pizza, potato chips, Pringles, pies, cookies, cake, casseroles, cannolis, Doritos, Ding-Dongs, Snickers, etc.  I’d complicate it just a bit by also avoiding naturally starchy foods like potatoes and corn. 

For those who don’t like the negativity of “don’t eat that,” here’s the positive spin:

Eat only natural, minimally processed food.

In other words, eat fresh fruit, fresh vegetables, eggs, meat, chicken, fish, olive oil, nuts, etc.  These are God-made foods, not man-made.

Steve Parker, M.D.