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

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. Disclosure • I occasionally get paid to speak • Recruit patients • Physician referrals • Promote better nutrition

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 • 68% of adults overweight or obese BMI ≥ 25 • 34% of adults obese BMI ≥ 30 • Colorado the thinnest, 20% obese • 9% of adults diabetic • 33% of children and adolescents overweight or obese • Since 1977-1980 uh-oh! • Obesity rates doubled in adults • Obesity rates tripled in children and adolescents • The progression of insulin resistance • 42% 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 • Researchers convinced • Obesity is caused by positive energy balance! • Health insurance will not pay for treatment • Its your fault, your problem, you fix it! “I am such a glutton and sloth”

7. Billion Dollar Weight Loss Industry • The invention: Low fat, low calorie diets • Carbohydrates are safe • Examples of fad diets! • Why are we still fat?

8. Food Politics: Nutritional Timeline • USDA self policing • The lipid hypothesis 1950’s • Saturated fat and heart disease • Ancel Keys observational studies • Correlation does not equal causality • Energy Balance • Eat fat and get fat, eat less and exercise more • Avoid caloric dense fatty foods • A simple explanation • McGovern select committee 1968-77

9. Dietary Guidelines for Americans 1980 “Contrary to widespread opinion, too much sugar in your diet does not seem to cause diabetes… There is also no convincing evidence that sugar causes heart attacks or blood vessel diseases” • 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”

10. 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

11. 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

12. Our Ancestors Before Agriculture • Hunter gatherers and the Paleolithic era • Whole, clean, unprocessed foods, some carbs • Animals including Fish, seasonal Veggies, Fruits and Nuts • Use of fire • Agriculture and the Neolithic era • Cultivate Grains and domesticate Animals for Dairy • Modern civilization changing nutrition

13. Food Politics: Manufacturing and $ales • Inexpensive raw materials • Tasty, addicting and cost effective • Processed and refined, more profitable • Deceptive advertising: “healthy” foods • The government working for the food industry • The business is selling food, not health!

14. The Cost of Healthcare • US healthcare spending • US almost twice per capita • US ~16% of the GDP vs. 8–10% • US obesity and costs • Cornell: $190.2 billion, 20.6% of national health expenditures • Gross underestimation • Study design flawed • Overweight excluded • The cost of treating chronic disease HBR, WHO, RTI, CDC, AHR, IASO

15. The Cost of Healthcare • Healthcare industry • Centers for Medicare and Medicaid (CMS) 1965 • Guidelines for the industry, public and private • Treatment of illness and disease only • Obesity not a medical condition • 2012 now paying primary care for counseling • A reactive approach to healthcare • Treating obesity complications is profitable

16. Evolution - are you kidding? Nutrition changing humans in our lifetime! The Food Revolution: Andreas Eenfeldt, M.D.

17. Fat Reform is Healthcare Reform • Address obesity • Save billions on complications • Food industry regulation! • Healthcare delivery • Nutrition center stage • Re-define healthy nutrition • Re-educate • The perils of dietary carbohydrates • In defense of dietary fat

18. 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

19. 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

20. Insulin Resistance • Years of carbohydrate overload • More insulin is required • Excess energy, stored as body fat • Insulin receptors become strained and resistant • Beta cells strained, abnormal response • Vicious insulin resistance cycle • Hunger an important component • Insulin overload

21. Hunger And Appetite • Insulin resistance makes us hungry • Fat cells literally starve lean body tissues • Central hunger and reward centers of the brain • Hypothalamus, Nucleus Accumbens • Fluctuating blood sugars and hormones stimulate appetite • Resistance directly or by Leptin or other hormones • Eventual loss of central signals • Only peripheral signals: swollen stomach • Blame metabolism not behavior for obesity!

22. Regulation of Food Intake • Leptin – Insulin – Amylin - Ghrelin - PYY - GLP-1 • Resistance changes signaling • Leptin: Thermogenesis, immune system, premature ageing, chronic disease, dementia, cancer, libido and fertility • Insulin and IGF-1 (Insulin like growth factor): Premature ageing, cancer

23. Inflammatory Disease • Adipocyte, fat cell toxicity • Releases toxic substances as we gain weight • Inflammatory protein signals: Hormones, cytokines • FFA’s, lipid and cholesterol oxidation, Atherogenic • Fuels insulin resistance and beta cell dysfunction • Energy storage disease and energy overload • Inflammation and metabolic derangement • Dietary carb’s the trigger, not dietary fats • A Chronic metabolic disease

24. Obesity: A Chronic Metabolic disease Dyslipidemia Hypertension ↑ Lipoprotein lipase Inflammation ↑ Angiotensinogen ↑ IL-6 Premature Ageing ↑ Insulin ↑ CRP ↑ FFA ↑ IGF-1 Cancer ↑ Resistin ↑ TNFα ↑ Leptin Insulin Resistance ↑ Adipsin(Complement D) ↑ Lactate ↑ Plasminogenactivator inhibitor-1 Atherosclerosis ↓ Adiponectin Type2 diabetes Metabolic Syndrome 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.

25. 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

26. Insulin Resistance Treatment • The food is the medicine • Remove the fuel, dietary carbohydrates • Turn off the insulin switch • Control hunger and appetite • Carbs are non-essential, optional

27. 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

28. Insulin Resistance Treatment • Medication • Physiologic drugs • Metformin, Byetta, Victoza, Symlin, Bydureon • Rx appetite suppressants • New and future drugs • OTC market • Treat co-morbidities • Nutrition center stage • Gastric bypass surgery http://peaceloveandlowcarb.blogspot.com

29. Eat Real foods • Focus on the carbohydrate content of food • Glycemic index, carbohydrate gram counting • Avoid high glycemic foods, processed foods • Sugars, “healthy” no grains (Corn, Wheat, Rice), Potatoes • Soy and ?Beans and other Legumes • Eat low glycemic foods, whole and unprocessed • Beef, Chicken, Fish, Pork, Eggs • Green leafy Vegetables, fibrous Fruits, Nuts • Low glycemic dairy like Cheese and Cream

30. Eat More Real Foods • Natural healthy fats • Low Glycemic, not fattening and not inflammatory • Saturated, Mono, Omega 3’s, Vitamins A, D, E, K, B12 • Coconut oil, Olive oil, Avocado, Butter, Animal fat, Fish oil • Caloric dense, promotes satiety • Avoid industrial Vegetable oils, Margarine, Trans-fats, Omega 6’s • Low-Carb High Fat diet (LCHF) • Control of appetite and promote weight loss • Enhanced fat burning during exercise • Quantity, calories and portion’s not the focus

31. 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 • Low-carb vs. Paleolithic 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)

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

33. Lipid profile improved on Atkins LCHF

34. Advanced Lipids and LCHF Diets • Favorable LDL subclasses or particle sizes • Healthy HDL-C increases, Triglycerides decrease • 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

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

36. 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

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

38. 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

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

40. 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

41. 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%

42. Author: Gary Taubes Nutrition and the history of weak science • 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

43. 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

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