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FAT REFORM: OBESITY, FOOD POLITICS AND THE PERILS OF DIETARY CARBOHYDRATES

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. Disclosures. None. Outline. History and Politics

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FAT REFORM: OBESITY, FOOD POLITICS AND THE PERILS OF DIETARY CARBOHYDRATES

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  1. 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

  2. Disclosures • None

  3. Outline • History and Politics • Science of nutrition & the evidence • Re-write the nutritional guidelines • Summary and action plan

  4. Diabesity: A Twin Epidemic • The spectrum of Insulin Resistance

  5. Obesity Statistics • The progression of insulin resistance • 44% obese in 2030 • 33% diabetic in 2050 Sources: TFAH, OECD, WHO, CDC, ADA

  6. Historical Perspective • 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 “I am such a glutton and sloth”

  7. USDA Dietary Guidelines 1977-1980 • Less saturated fats, less calories • More poly-unsaturated Vegetable oils • More carbohydrates, starches, sugars • More inexpensive food commodities • Weak evidence, the wrong tools! Phillip Handler : “A vast nutritional experiment”

  8. 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

  9. Does Saturated Fat Cause Heart Disease? • 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! http://www.awlr.org

  10. 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

  11. 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

  12. 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

  13. 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

  14. Evolution - Are You Kidding? Nutrition changing humans in our lifetime! The Food Revolution: Andreas Eenfeldt, M.D.

  15. 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

  16. 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 Fats Proteins

  17. 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

  18. Insulin Resistance • 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

  19. Regulation of Food Intake • Leptin – Insulin – Amylin – PP - Ghrelin - PYY - GLP-1 • Resistance changes signaling • Promotes inflammation and mitochondrial dysfunction

  20. Inflammation and Adiposity Inflammation Dyslipidemia Premature Ageing ↑ Lipoprotein lipase Hypertension ↑ Angiotensinogen ↑ IL-6 ↑ Insulin ↑ CRP ↑ FFA Liver & Gut Insulin Resistance ↑ IGF-1 ↑ Resistin ↑ TNFα ↑ Leptin Type II Diabetes Cancer ↑ Adipsin(Complement D) ↑ Lactate ↑ Plasminogenactivator inhibitor-1 ↓ Adiponectin Atherosclerosis Dementia Thrombosis Fertility 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.

  21. Insulin Resistance Evaluation • 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 Overweight Obesity Pre-diabetes (Metabolic Syndrome) Type II Diabetes

  22. Insulin Resistance Treatment • The food is the medicine • Remove the optional fuel • Less dietary carbohydrates • Turn off the insulin switch • Control hunger and appetite

  23. 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

  24. 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

  25. 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

  26. 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

  27. Calories consumed equal, Atkins LCHF diet better controls insulin, weight and appetite

  28. Lipid profile improved on Atkins LCHF

  29. 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

  30. Marcia at 262 lbs, BMI 41 • lost 70 lbs, now 192 lbs, 27% loss TBW, BMI 30

  31. 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

  32. David at 312 lbs, BMI 40 • http://mendosa.com • lost 153 lbs, now 159 lbs, 49% loss TBW, BMI 20

  33. 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

  34. Patrick at 220 lbs, BMI 32 • Lost 45 lbs, now 175 lbs, 20% loss TBW, BMI 24

  35. 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

  36. DrGerber 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%

  37. 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

  38. 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

  39. Good Food is Good Medicine! Jeffry N. Gerber, M.D. DenversDietDoctor.com facebook.com/DenversDietDoctor

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