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

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Disclosures

 None

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

 The progression of insulin resistance  44% 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  Obesity is caused by positive energy balance!

 A simple explanation  Health insurance will not pay for treatment  Its your fault, your problem, you fix it! The Lipid Hypotheses 1950’s  Avoid caloric dense fatty foods

USDA Dietary Guidelines 1977-1980

Phillip Handler : “A vast nutritional experiment”      Less saturated fats, less calories More poly-unsaturated Vegetable oils More carbohydrates, starches, sugars More inexpensive food commodities Weak evidence, the wrong tools!

Macronutrient Content

  More refined carbohydrates and less saturated fat Total caloric intake increases from sugar consumption -MMWR, Morbidity and Mortality Weekly Report, February 6, 2004 / Vol. 53 / No. 4

Does Saturated Fat Cause Heart Disease?

http://www.awlr.org  Outcomes looking at MI, death from MI and stroke  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

Food Politics: Manufacturing and $ales

  To sell refined and processed foods for profit Food commodities are the raw materials  Tasty and addicting foods, eat more  Deceptive advertising: “Healthy foods”  Food lobbyists funding politicians  Selling food not health

Our Ancestors Before Agriculture

   Hunter gatherers and the Paleolithic era  Whole foods, some carbs  Animals including Fish, seasonal Veggies, Fruits ,Nuts and Roots  Use of fire Agriculture and the Neolithic era  Cultivate Grains and domesticate Animals for Dairy Modern civilization changing nutrition  For better or worse

The Cost of Healthcare

   World leader in healthcare spending since 1980  Treating chronic diseases Medicare and Medicaid industry guidelines  Treatment of illness and disease only  Obesity not a medical condition  A reactive and costly approach to healthcare  Preventive services task force 2012, counseling 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 trillions treating complications Food industry regulation!

Healthcare delivery  Nutrition and 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 Proteins Carbs 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  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  Receptors become strained and resistant  Beta cells strained, abnormal response  A disease of insulin overload Insulin resistance makes us hungry  Fat cells literally starve lean body tissues  Hypothalamus, Nucleus Accumbens  Eventual loss of central signals

Increased Resistance (Hunger) Weight Gain

Regulation of Food Intake

 Leptin – Insulin – Amylin – PP - Ghrelin - PYY - GLP-1  Resistance changes signaling  Promotes inflammation and mitochondrial dysfunction

Inflammation and Adiposity

Premature Ageing Liver & Gut ↑ CRP ↑ TNF α ↑ IL-6 Inflammation Dyslipidemia ↑ Lipoprotein lipase ↑ Angiotensinogen ↑ Insulin Hypertension ↑ FFA ↑ IGF-1 ↑ Resistin Insulin Resistance ↑ Leptin Cancer ↑ Adipsin (Complement D) ↑ Lactate Type II Diabetes Dementia ↓ Adiponectin ↑ Plasminogen activator inhibitor-1 Atherosclerosis Fertility 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 (Metabolic Syndrome) Type II Diabetes

    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 optional fuel  Less dietary carbohydrates  Turn off the insulin switch  Control hunger and appetite

Insulin Resistance Treatment

  Dietary proteins  Essential, healthy Dietary fats and cholesterol  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, Bydureon, Symlin   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  Avoid high glycemic foods, processed foods  Eat low glycemic foods, whole and unprocessed  Healthy natural fats Butter, Animal fat, Coconut oil, Olive oil, Avocado, Fish oil    Low-Carb High Fat (LCHF), Ancestral diets 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  LCHF vs. Ancestral 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  Meta analysis , Santos 2012

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 Triglycerides decrease, healthy HDL-C increases 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

  Female age 45, 5’7”, 262 lbs, BMI 41  OGT performed, FBS=96, 1HR=180, 2Hr=129  HgA1C=6.4%, c-peptide=4.7

 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   FBS 76 HgA1C=5.1%, ?c-peptide  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  OGT: FBS=105, 1HR=219, 2HR=201  HgA1C=6.8%  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  OGT: pending, FBS normal  HgA1C=4.6%  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

   Age 43, lost 10 pounds on a Paleo diet, 183 lbs, BMI 25 Berkeley Heart Lab  Triglycerides and HDL-C improved, LDL-C, Apo-B unchanged  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 scientific evidence

     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

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