What are the four most common mistakes I see in the office when it comes to weight loss? Watch Dr. Nally on today’s PeriScope as he answers that question and many others. You can see it here with the live stream comments on: https://www.katch.me/docmuscles/v/392e5d3e-bb28-3176-a03a-83433878a5ce
Or see the video below:
In light of the fact that exercise DOES NOT cause weight loss, exercise has a fascinating ability to enhance ketosis. No, seriously, I don’t care what your trainer told you, you won’t loose weight with exercise, no mater how hard you try. However, exercise does help you body attain a ketogenic state.
When you exercise, the muscles take up glucose and oxygen to burn as their primary fuel. Exercise has actually been shown to enhance this process and reduce the “insulin resistance” effect that the the SAD diet (Standard American Diet) has on 2/3rds of the population (whether they realize it or not). Mild to moderate exercise like a walk or even a mild jog, and resistance training like weight lifting, yoga or Pilates increased the drive of the glucose into the cells and improves the ability of the cells to use the glucose.
In a person following a carbohydrate restricted diet (Ketogenic, Low-Carb, and even Paleolithic to some degree), the body maintains a stable level of blood sugar by releasing glycogen from the liver and gluconeogenisis as needed to support the 100 grams necessary per day required by the brain (the liver makes about 240 grams per day no mater what you do). In the absence of extra glucose as fuel, the body will then use triglyceride and/or ketones as fuel. Exercise improves the sensitivity to the small amount of glucose and actually ramps up the presence of ketones placing the person into a more ketogenic state.
This enhanced ketogensis is often experienced as “second wind” or “being in the zone” or even as an ability to “hyperfocus” during exercise. But the exercise levels must be in the mild to moderate range for this to be accomplished.
But, there’s a fine balance, if the muscles are pushed too hard to fast, lactic acid builds up because of a shift to an anaerobic state and the acid creates a stress response, triggering cortisol and increased glucose formulation, causing one to shift out of ketosis.
How do you know if you exercising too hard? You should be exercising hard enough to break a sweat, but not so hard that you can’t carry on a conversation with your partner at the same time. Over time, as the body becomes more effective at using ketones, you’ll find your exercise intensity can and will improve.
See Dr. Nally try to explain all this while riding his horse Bailey in the White Tank Mountains:
Or you can Katch it here: https://katch.me/docmuscles/v/ce43292a-296f-3de4-bf6f-d19cd688fc62
Have a great weekend!!
85% of the people that walk through my office doors have some degree of insulin resistance.
What is “insulin resistance?” It is an over production of insulin in response to ANY form of carbohydrate intake (yes, even the “good carbs” cause an insulin over-response in a person with insulin resistance.)
How do I know this? Because I routinely check insulin levels (I check them every three months) and the down stream markers of insulin on a large number of the patients that I see. I have been fascinated by the fact that a diet high in both sugar and fat [like the Standard American Diet, (SAD) diet] turn on the genetics leading to insulin resistance. Starch and sugar load the genetic gun.
Insulin acts like a key at the glucose doorway of every cell in your body. In many people, the insulin signal is blocked by hormones produced in the fat cell and the the insulin, acting like a “dull or worn out key” – can’t open the glucose doorway as efficiently.
So, the body panics, and releases extra insulin in response to the same load of carbohydrate or glucose. People with insulin resistance will produce between 2-20 times the normal amount of insulin in response to a simple carbohydrate load. Recent studies(1, 2) reveal high cholesterol and diets high in both fat and carbohydrate cause insulin resistance to progress or worsen.
So, instead of producing enough insulin to accommodate the one slice of bread or the one apple that you might eat, the insulin resistant person produces enough insulin for an entire loaf of bread or an entire bushel of apples. This excess insulin then stimulates one or all of the following:
If you are plagued by any or all of these, my first suggestion is to see your doctor and get screened for insulin resistance. I treat patients with these every day and have reversed these effects in thousands of patients with the correct diet and/or medications. Having seen these signs and patterns over the last 20 years of medical practice, I am still astonished every day by the dramatic effect our diet plays on the hormonal changes within the body. Remember that the food you eat is actually the most powerful form of medicine . . . and the slowest form of pernicious poison.
A ketogenic or carnivorous diet is your first step.
We take most insurances, however, check out my concierge program or my Direct Primary Care program if you are interested in an alternative to insurance.
References:
This aquaponics stuff is amazing! Came home today to crystal clear water. Even with 9 ducks and 11 fish in the pond, the two lightly planted grow beds and the bogs have cleared up the water with amazing speed. The algae has disappeared even in direct sunlight and temperatures in the 112-114 degree range over the last week.
So, in celebration of nature attaining pond water clarity in just two weeks, I added three more beautiful Koi.
It is fascinating how very calming it is to my soul to sit by the pond and watch the ducks & fish. It appears that a nearby hive of bees is using the pond for a water supply as there is always at lease 5-10 little honey bees driking at the water’s edge. I’ve seen dragon flies come by daily. What amazes me is that I’ve now seen more hummingbirds, cardinals and wrens in the last week than I’ve seen all year. My dogs love it and in the 114 degree weather, wading your feet in the water is so very refreshing.
You can see the progress of this pond over the last 9 months here at The Doc & The Horse.
Now to begin planting my leafy green veggies . . .
I recently read a blog post decrying anyone that would recommend a low carbohydrate / ketogenic diet to their patients.
What?!
In fact, this particular blog outlined a number of “adverse reactions” to a ketogenic diet, and based upon these perceived reactions, the writer advised severe caution with its use in just about anyone. It is important to note at the outset that most of the data this blogger quotes are from older studies completed in children for the treatment of epilepsy with specific liquid ketogenic dietary meal replacements. (Not what you’d expect in a low-carb / ketogenic diet for the average obese adult today.)
Thanks to recent misinformation by a number of medical professionals, including the person writing the blog referenced above, a poor understanding of fatty acid metabolism by the general community, and a distinct lack of understanding of human adaptability recorded over the last 5,000-6,000 years, there is still significant confusion about ketogenic diets.
It is important to recognize the crucial fact that the human body is designed to function quite well when supplied any of three macronutrients: carbohydrates, proteins or fats. It does so through an amazing series of enzymatic reactions referred to as the Krebs (tricarboxylic acid) cycle, producing needed ATP (adenosine triphosphate) required for our muscles to contract, our heart to beat and our diaphragm to expand our lungs. What’s even more amazing that that the body was designed to recognize the season we are in based up on the food we eat. That is, until we invented refrigerators in 1913. (Now our bodies think it’s year round summer time . . . wait . . . I live in Arizona where it is year round summer time.)
No, this is not a post about unplugging your refrigerator, living on solar, getting off the grid and saving energy.
Our bodies recognize the seasons we are in based upon inherent hormone release. The key hormone is insulin. Insulin can be looked at as the seasonal indicator to our bodies. Insulin production rises and falls based on our intake of carbohydrates (sugar, starches, some fibers). Insulin, essentially, tells our bodies when it is a “time of plenty” and when it was a “time of famine.” Why? You ask. We didn’t have refrigerators 100 years ago and you were lucky if you had a root cellar. The body needs to know when to store for the famine (the winter) that was around the corner. Insulin is that signal.
During the summer, potatoes, carrots, corn and other fruits are readily available. These are all starchy carbohydrates and they all require the body to stimulate an insulin response so that they can be absorbed. Insulin stimulates fat storage (J Clin Invest. 2000;106(4):473-481. doi:10.1172/JCI10842). Just like bears, our bodies were designed to store for the winter.During the winter, when carbohydrates were less prevalent, insulin production could and would decrease to baseline levels. This also is a natural phenomenon that occurs with fasting and even during lactation. (Kreitzman SN. Factors influencing body composition during very-low-caloric diets. Am J Clin Nutr. 1992;56(l Suppl):217S–23S.; Medical aspects of ketone body metabolism. Mitchell GA, Kassovska-Bratinova S, Boukaftane Y, Robert MF, Wang SP, Ashmarina L, Lambert M, Lapierre P, Potier E, Clin Invest Med. 1995 Jun; 18(3):193-216.)
If you think back in history, your grandparents probably used stored meats & cheeses that could be salted or smoked for preserving during this time of year. Those crossing the plains were commonly found with pemmican, a concentration of fat and protein used as a portable nutrition source in the absence of other food. (Chapter VIII. Narrative of the Life of David Crockett, of The State of Tennessee, Written by Himself, Sixth Edition [E.L. Carey and A. Hart:Philadelphia] 1834, 1837; Marcy, The Prairie Traveler, p. 31.) Think about conversations you may have had with your grandmother when she told you that for Christmas, she received an orange. A single orange for a gift?! Many of my patients drink 12-15 of them in a glass every morning. The winter diets of our grandparents were very low in starches and carbohydrates. When carbohydrate intake is low, little insulin is produced.
Again, insulin is the hormone that tells you that you’re in “a time of plenty” and stimulates weight gain and cholesterol production to prepare for winter. Those prescribing the use of ketogenic diets understand this innate human adaptive trait, and use it to effect changes in weight, cholesterol and other desired metabolic changes.
Now, let’s define the difference between ketosis and keto-acidosis and try to clarify the misinformation that is being spread around the blogosphere.
A ketone is a molecule the body produces from the breakdown of fat and some proteins (amino acids). There are specifically three types of ketones: beta-hydroxybutyric acid, acetoacetic acid and acetone. If ketosis was “bad,” then why would our bodies produce these molecules? They are not bad, and in fact, multiple studies show that the body is often more efficient and effective when it functions on ketones rather than glucose as its primary fuel source. The body can only supply a limited amount of sugar or glucose for fuel. If you talk to runners, marathoners or triathletes, they will tell you that after about 45-90 minutes of continuous endurance exercise the glucose supply runs out and they will experience what is termed a “bonk” (have a low-blood sugar or hypoglycemic episode). Unfortunately, our bodies can only store about 18-24 hours of glucose.
However, the body can store days upon days of fat in the form of triglyceride in the fat cells. Triglyceride is broken down into ketones. If glucose is the “unleaded” fuel, you can think of ketones as the “diesel fuel” that is easier to store and runs longer.
The average body functioning on ketones as the primary fuel will have a ketone level measured in the blood somewhere between 0.4 and 4 mmol/L. Because of a balance that is created by the use of ketones and a feedback mechanism that kicks in when the ketone level rises, the body will maintain a pH of around 7.4.
Ketoacidosis is dramatically different. If you are a type I diabetic, you don’t produce any insulin. The feedback mechanism regulating ketone use is broken and the ketone levels and triglyceride breakdown speeds up because the body can’t access glucose and can’t produce insulin. The ketone levels spike and the level can rise to > 25 mmol/L. In the presence of a high blood sugar and high ketone level, the acid level in the blood shifts to a pH of less than 7.3. This is referred to as metabolic acidosis and can be life threatening as the low pH shuts down the bodies’ enzymatic processes and a person becomes critically ill and without treatment, can die. (Kitabchi AE et al., Clinical features and diagnosis of diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults. www.uptodate.com, May 2015.)
If you’re not a type I diabetic, you have nothing to worry about. Regardless of what the “ketogenic nay-sayers” blog about, your liver makes approximately 240g of glucose per day, this stimulates a basal release of insulin which keeps the pH in check. It’s also what keeps weight loss at a consistent pace of around 2-10 lbs per month.
If you are a type I diabetic, don’t fret. Carbohydrate restriction can still be used very effectively. It just takes some balancing and understanding of your individual metabolism. Talk to your physician and/or medical bariatrician about how to follow a carbohydrate restricted diet while using insulin.
What about all the other “adverse effects” the blogosphere and other so-called experts claim about ketogenic diets?
Let’s take them on one by one. Are you ready?
Gastrointestinal (GI) disturbances – Yes. Any time you change your diet you may experience diarrhea, constipation or gassiness. Most of the time, this is because you are either 1) not eating enough leafy greens (fiber) or 2) you’re using a supplement that contains an artificial sweetener. Most of the studies on ketogenic diets did not incorporate fiber and the studies used to make this point were on children who used a ketogenic fat supplement shake or liquid preparations containing these artificial sweeteners to make them palatable. If you have spoken to any bariatrician, they will tell you, the best way to follow a ketogenic diet is to eat real food. If you want to read about the anecdotal GI effects of sweeteners, read the comment section in Amazon about the Haribo Sugar Free Gummy Bears.
Oh, by the way, 65% of patients in my practice following ketogenic diet see improvement in gastroesophageal reflux (GERD) symptoms. (Austin GL, Thiny MT, Westman EC, Yancy WS Jr, Shaheen NJ. A very low carbohydrate diet improves gastroesophageal reflux and its symptoms: a pilot study. Dig Dis Sci 2006;51:1307–2.)
Hair Loss/Thinning – Really?! It is important to note that hair loss/thinning can occur with any form of weight loss (Novak MA, Meyer JS. Alopecia: Possible Causes and Treatments, Particularly in Captive Nonhuman Primates. Comparative Medicine. 2009;59(1):18-26.) This is especially true if you are restricting calories, which was occurring in a number of the ketogenic dietary studies previously published. You do not and should not need to “restrict calories” if you are following a ketogenic diet correctly, and in fact, most people take in more than 1800 calories on a ketogenic diet. (Shai I, et al., N Engl J Med, 2008; 359:229-241.)
Inflammation Risk – In every patient that I have placed on a ketogenic diet in the last 8 years, all inflammatory markers including CRP, Sedimentation Rate and Uric Acid have all decreased. Inflammation gets better on an appropriately formulated ketogenic diet. The older studies of ketogenic diets in children contain most of their fat from Omega-6 fatty acids from vegetable oil which will increase inflammation and oxidative stress, spike the cortisol levels and have the secondary effect of actually raising the triglycerides. (Simopoulos AP,The importance of the ratio of omega-6/omega-3 essential fatty acids, Biomed Pharmacother., 2002 Oct;56(8):365-79.)
Kidney Stones/Gout – These (Kidney Stones & Gout) are both commonly caused by spikes in uric acid. As noted above, I’ve seen multiple cases in my practice where a ketogenic diet lowers uric acid. Only a small clinical trial has been published in the literature (and it wasn’t truely ketogenic), but the results point to the potential for ketogenic diets to lower uric acid. (Dessein PH, Shipton EA, Stanwix AE, et al. Beneficial effects of weight loss associated with moderate calorie/carbohydrate restriction, and increased proportional intake of protein and unsaturated fat on serum urate and lipoprotein levels in gout: a pilot study. Ann Rheum Dis 2000; 59:539-543.) Ketogenic diets also have the capacity to lower the formation of calcium oxalate stones through a secondary mechanism I won’t go into here. Are these a risk? Only if you cheat on your carbohydrate restriction. So, I warn patients. Don’t cheat.
Muscle Cramps/Weakness – The process of weight loss occurs by burning fat into CO2 and water. We breathe the CO2 out, but the water produced has to follow salts out through the kidneys. Hence, we lose salts. This can cause weakness and muscle cramps. The solution? Stop restricting salt on a low carbohydrate diet. We are the only mammal that restricts salt and we do it because low-fat diets cause us to retain water. Low carbohydrate diets do the opposite. Use sea salt or sip beef or chicken bouillon broth with your dinner. The use of yellow mustard also helps (the small amount of quinine in yellow mustard stops the cramping). If you have congestive heart failure, talk to your doctor about monitoring your salt intake in balance with your diuretic or water pill.
Hypoglycemia – If you read the ketogenic diet research, most of it was done on epileptic children. The diets called for a period of starvation, then the use of a ketogenic liquid based on the John’s Hopkin’s protocol. It is a well-known fact in medicine that starvation in children can frequently cause hypoglycemia, especially in children with other genetic or congenital defects leading to forms of epilepsy. In clinical practice, with ketogenic diet use in adults, hypoglycemia is rare.
Low Platelet Count (Thrombocytopenia) – Again, this was seen in the epileptic children who were placed into starvation first, then introduced a liquid fat replacement shake to stop intractable seizures. These liquids or shakes were often nutrient deficient in other essentials. Folic acid, B12 and copper deficiency can occur when not eating “real food.” Low platelet counts are rarely seen on ketogenic diets based around “real food.” Many children in the ketogenic studies had been on or were concomitantly on valproic acid for their seizures. Valproic acid is commonly known to cause thrombocytopenia (Barry-Kravis E et al, Bruising and the ketogenic diet: evidence for diet-induced changes in platelet function. Ann Neurol. 2001 Jan;49(1):98-103.; Kraut E, Easy Bruising, http://www.uptodate.com, May 2015.)
Impaired Concentration/Mood – A number of patients starting carbohydrate restriction will go through 2-4 weeks of carbohydrate withdrawal. This can be just as powerful as morphine withdrawal in some patients. Sugar is a drug and effects the same hedonic receptors that morphine does in the brain (Lustig, Robert H, Fructose: Metabolic, Hedonic, and Societal Parallels with Ethanon, Journal of the American Dietetic Association , Volume 110 , Issue 9 , 1307 – 1321.) Some patients will experience headache, tremor and decreased concentration while “withdrawing” off of starches and carbohydrates. Studies actually show that after a period of adaptation, cognitive function actually improves (Krikorian R, Shidler MD, Dangelo K, Couch SC, Benoit SC, Clegg DJ. Dietary ketosis enhances memory in mild cognitive impairment. Neurobiology of aging. 2012;33(2):425.e19-425.e27. doi:10.1016/j.neurobiolaging.2010.10.006.)
Metabolic Acidosis – As described above, this can occur in a type I diabetic, and metabolic acidosis has also been shown to occur in young children placed on severe carbohydrate and protein restriction, as was the case in some of the ketogenic dietary trials with epileptic patients. (Saxena VS, Nadkarni VV. Nonpharmacological treatment of epilepsy. Annals of Indian Academy of Neurology. 2011;14(3):148-152. doi:10.4103/0972-2327.85870.; The Ketogenic Diet: One Decade Later, Pediatrics March 2007; 119:3 535–543)
Osteoporosis/Osteopenia – If your ketogenic diet is “shake” or “meal replacement” based, you run the risk of mineral deficiency that could lead to Osteoporosis, however, if you are using real food, the opposite is true and most patients have improvement in their Vitamin D levels and bone density. (, , , Babette S Zemel, Progressive bone mineral content loss in children with intractable epilepsy treated with the ketogenic dietAm J Clin Nutr December 2008 88: 1678–1684; doi:10.3945/ajcn.2008.26099)
Easy Bruising – This is usually due to inadequate protein supplementation as was the case in much of the ketogenic literature where protein levels were also restricted. (Kraut E, Easy Bruising, http://www.uptodate.com, May 2015.)
Infections/Sepsis/Pneumonia – These have not been issues in the 8 years I have been using ketogenic diets with my patients. These issues were seen in the John’s Hopkins protocol with children who had epilepsy and other congenital disorders placed on a diet low in protein and carbohydrate. (Saxena VS, Nadkarni VV. Nonpharmacological treatment of epilepsy. Annals of Indian Academy of Neurology. 2011;14(3):148-152. doi:10.4103/0972-2327.85870.)
Pancreatitis – Patients who are insulin resistant or have impaired fasting glucose commonly have high triglycerides. Elevation in triglycerides itself is a cause of pancreatitis. Ketogenic diets lower the triglycerides. However, if a patient has not been following their diet as directed, spikes in the triglycerides can occur placing the person at risk for pancreatitis.
Long QT Intervals/Heart Arrhythmias – The list of things causing Long QT intervals and abnormal heart rhythms is long and variable (Acquired Long QT Syndrome. Berul C et al. www.uptodate.com, May 2015). It is well know that starvation, rapid weight loss and liquid protein diets can cause a delay in the conduction signal in the heart. Anyone wishing to start any diet should have an electrocardiogram (EKG) through their doctor to ensure that the diet (of any type) doesn’t exacerbate a prolonged QT interval.
Cardiomyopathy – Prolonged QT intervals have been associated with cardiomyopathy and the former can stimulate the later. Any diet that has the potential to prolong a QT interval has the potential to cause cardiomyopathy. Hence the need for regular EKG monitoring on any diet (Acquired Long QT Syndrome. Berul C et al. www.uptodate.com, May 2015).
Lipid/Cholesterol Changes – In the 8 years I have been applying ketogenic diets to patients, I have seen dramatic improvement in the triglycerides and HDL levels. The only time triglycerides rise over 100 is if the patient is using artificial sweeteners or is cheating on the carbohydrate restriction. Total cholesterol commonly rises, however, this is indicative of the fact that there is a shift in the LDL particle size and this affects the calculation of both total cholesterol and LDL-C. In light of this, most of my patients have dramatic improvement in triglycerides and small dense LDL particle number. I’ve included the common cholesterol changes I seen in my office as a few case reports to demonstrate the effectiveness of a ketogenic diet:
Myocardial Infarction – It is interesting that one blogger includes this on the list of adverse reactions, however, when you actually read the study, the author of the paper make an “assumption” that there was potential for heart attack due to an elevated total cholesterol, however, a correlation was never made. Again, in the 8 years I have been using ketogenic diets, I have seen dramatic improvement in cholesterol profiles, inflammatory markers, atherosclerosis and carotid intimal studies (Shai I et al, Circulation 2010; 121:1200-1208).
Menstrual Irregularities / Amenorrhea – It is well known that any diet causing protein or other nutritional deficiency will affect the menstrual cycle first and growth second. The only time menstrual irregularities occur with a ketogenic or Low-Carb diet is when a patient is not taking in enough protein or is not eating real food. What amazes me is that a properly applied ketogenic diet causes normalization of the menstrual cycle, and in my practice, I’ve had a number of women successfully be able to conceive after making a ketogenic dietary change.
Death – All cases of death related to ketogenic diets have been documented in children while using liquid formulas for ketosis to treat epilepsy. These cases revealed the formation of a prolonged QT interval leading to cardiomyopathy due to deficiency in selenium. This has been solved by the addition of selenium to the ketogenic supplement. (Stewart WA et al., Acute pancreatitis causing death in a child on the ketogenic diet, J Child Neurol. 2001 Sep;16(9):682.; Bergqvist AG et al, Selenium deficiency associated with cardiomyopathy: A complication of the ketogenic diet. Epilepsia. 2003 Apr;44(4):618-20.; Kang HC et al., Early and lat onset complications of the ketogenic diet for intractable epilepsy, Epilepsia. 2004 Sep;45(9):1116-23.; Kang HC et al, Efficacy and Safety of the Ketogenic diet for intractable childhood epilepsy: Korean Multicentric Experience, Epilepsia. 2005 Feb;46(2):272-9.) This does not happen when the diet is based on the use of real food instead of supplementation and has not been seen in adults.
For more details on the nutrient content of a ketogenic diet, see the recent article by a friend of mine, Maria Emmerich. She’s been creating ketogenic diets for years and has a number of fantastic books my wife and I have been using in our home over the last nine years. She is one among many that can give you some direction on how to devise a healthy, real food based ketogenic diet. See the page on my website here that will give you some direction in formulating your Ketogenic Lifestyle.
So, to celebrate Mother’s Day, today, with my family, I am going to indulge in some Low-Carb / Ketogenic Cheese Cake!! Happy Mother’s Day, to all of you and especially to all you mothers out there making a healthy difference in the lives of your families! (You can find the recipe for this delicious cheese cake here)
In the words of Sir William Ostler, “If it were not for the great variability among individuals, medicine might well be a science and not an art.”
We just got a sample pack of Lily’s Chocolate. This is a Stevia and erythritol sweetened chocolate that has no aftertaste and doesn’t cause the stomach upset that many experience with chicory root based products. I am always looking for good low carbohydrate alternatives for snacks, as rescue foods, or to assist in baking.
My wife found this chocolate in a recipe that Carolyn Ketchum had posted on her website, All Day I Dream About Food. It is quite tastey!! Thanks, Caroyln!! (By the way, I dream about food all day long, too.)
I scanned a copy of the wrapper for the Salted Almond & Milk Flavor. I have to admit, I ate half the bar. It was that good!!
For those looking for an alternative chocolate for a snack or to use in a recipe, this may be the answer. You can find their whole line of chocolates here.
Hope this helps.
Have you noticed that there are a large number of advertisements in the media about checking your testosterone or “Low T” Syndrome? It seems like this is the new advertising trend on the radio and late night TV.
Suddenly, everyone’s testosterone is low and men are complaining about their libido, . . . or are they?
If you practice medicine long enough, you’ll see a trend that seems to have arisen as our waistlines have expanded. About half of the men in my office with insulin resistance, pre-diabetes or diabetes have low testosterone levels. But this shouldn’t be a surprise. Type II diabetes, metabolic syndrome and insulin resistance are all driven by an over production in insulin in response to a carbohydrate load in the meal. Patients with these conditions produce between two to ten times the normal insulin in response to a starchy meal. A number of studies both in animal and human models demonstrate that insulin has a direct correlation on testosterone suppression in the blood. This has been demonstrated in both men and women. In fact, glucose intake has been shown to suppress testosterone and LH in healthy men by suppressing the gonadal hormone axis and more predominant testosterone suppression is seen in patient with insulin resistance or metabolic syndrome.
In fact, to put it simply, insulin increases the conversion (aromitization) of testosterone to estrogen in men (it does the opposite in women). Interestingly, Leptin resistance has a similar effect. I tend to see the worst lowering of testosterone in men with both insulin and leptin resistance.
How to you improve your testosterone? Supplemental testosterone has been shown to help, but it comes with some risks, including prostate enlargement and stimulating growth of prostate cancer. The most natural way to improve your testosterone is to change your diet.
A low carbohydrate or ketogenic diet turns down the insulin production and allows the testosterone to be available for use by the body. A ketogenic diet has the effect of reducing leptin resistance as well through weight loss. A simple dietary change of this type is frequently seen in my office to increase testosterone by 100-150 points.
What is a ketogenic diet? It is a diet that restricts carbohydrates to less than 50 grams per day, thereby causing the body to use ketones as the primary fuel source. So, for breakfast tomorrow morning, hold the oatmeal (1/2 cup of Quaker Instant Oatmeal is 31 grams of carbohydrates) and have the bacon and eggs. And, rather than have the cheesecake for desert this evening, have an extra slice of steak butter on your rib-eye and hold the potato.
Just thought you should know . . .
Now you have to watch your salt ingredients too. Store bought salts are starting to add dextrose for flavor. Dextrose is just another word for SUGAR!! Aaarrrrhhhhh!! Why do you need to add sugar to your salt? You don’t. Throw out any salt that contains dextrose. It will raise your cholesterol and cause weight gain.
Never noticed this until it was pointed out by Maria Emmerich. Thanks, Maria.
Many of you have already seen my article about sweeteners, which ones work well and which ones make you fat. If not click here for the article. Stevia is one of those sweeteners that doesn’t spike your insulin as long as it isn’t crystallized with dextrose or maltodextrin. I actually found the stevia plant at one of my nearby nurseries, thanks Moon Valley Nursery.
Here is the plant after two weeks in my aquaponics garden.
The leaf can be dried, crushed then used to sweeten food or drink. Can’t wait to try it.
I found that stevia grows quite well in an aquaponics environment. See the post here on my personal blog here: Aquaponics . . . my first attempt.
Don’t fear the fat. If you haven’t seen the movie Cereal Killers, you should watch it by clicking here. D.J. O’Neill ditches wheat and sugar in a food plan consisting of 70% fat – under the guidance of legendary South African Sports Scientist Prof. Tim Noakes.
Do you think it will catch on?
With a great deal of fear out there about this virus, a catchy little rhyme and song often helps to remind us about prevention. It’s interesting that potential pandemics bring out songs and rhymes. Isn’t this where “Ring around the Roseys” came from?
I have been seeing a large number of respiratory infections in my office over the last 3 weeks. These appear to be viral infections cause by Enterovirus D68 and have some significant respiratory consequences, especially in children with other lung problems.
EV-D68 is one of more than 100 types of enteroviruses. It was first identified in California in 1962. Since then, EV-D68 infections has not been commonly reported in the United States. There have been very few reports of this virus in the last few years, however, the circulation of specific types of enteroviruses is often quite unpredictable, and different types of enteroviruses can be common in different years with no particular pattern. Most enterovirus infections in the United States tend to occur in the summer and fall. EV-D68, similar to other enteroviruses, is known to cause infections primarily in children but has been known to infect adults.
EV-D68 can shed from an infected person’s respiratory secretions, such as saliva, nasal mucus, or sputum. The virus likely spreads from person to person when an infected person coughs, sneezes, or touches another surface. EV-D68 can cause mild to severe respiratory illness. Most of the children who have become very ill with EV-D68 infection in Missouri and Illinois had difficulty breathing, and some had wheezing. Many of these children had asthma or a history of wheezing.
Although there are no vaccines to prevent EV-D68 infections, clinicians should encourage their patients to follow these prevention steps:
• Wash hands often with soap and water for 20 seconds;
• Avoid touching eyes, nose, and mouth with unwashed hands;
• Avoid kissing, hugging, and sharing cups or eating utensils with people who are sick; and
• Disinfect frequently touched surfaces, such as toys and doorknobs, especially if someone is sick.
Ensure that patients with asthma regularly take prescribed medications and follow guidance to maintain control of their illness. They should also take advantage of influenza vaccine when available, because people with asthma have a difficult time with respiratory illnesses.
Hopefully, you and your family won’t have a problem with this virus this year. Follow the steps above to help prevent its spread and see your doctor if you begin to show signs of serious illness like fever, shortness of breath, persisting cough or worsening flu-like illness that is not improving.
Hypertension (elevated blood pressure) is one of the triad symptoms of metabolic syndrome. I see this to some degree a very large majority of the people seen in my office. Many people are so used to having borderline or elevated blood pressure, and not successfully controlling it through caloric restriction, they are told it is a “genetic problem,” placed on blood pressure medication and sent on their way. The problem is that most of these people will have a progressive elevation in blood pressure over time and these medications are continually raised until the person is on four or five different blood pressure medications at maximal doses. Again, their genetics are blamed and that is the end of it. Or is it?!
When I first started treating the insulin resistance problem in the human, rather than the blood pressure problem, I began to see immediate reductions in blood pressure within one to two weeks. So much of a reduction that if I didn’t warn the patient that they should begin to back down their medications, they would experience symptoms of dizziness, light-headedness, headache and a few patient’s nearly passing out. I often wondered why applying a ketogenic diet had such a profound effect on blood pressure so quickly. Dr. Robert Lustig helped answer that question for me.
In order to understand how the Standard American Diet (we call it the SAD diet in my office) raises your blood pressure, it is important to understand how the body processes the basic sugar molecule. Sugar is one glucose molecule bound to a fructose molecule. This is broken down in the body and 20% of the glucose is metabolized in the liver, the other 80% is sent on to be used as fuel throughout the body. Fructose, however, is where the problems arise. 100% of the fructose is metabolized in the liver, and the by product of fructose metabolism is increasing the liver’s production of MORE glucose and the byproduct of uric acid. Uric acid is produced and this inhibits the production of nitric oxide. The diminished nitric oxide in the presence of an increased level of glucose (stimulating increased insulin production) constricts the blood vessels and raises blood pressure. Yes, that donut you just ate raised your blood pressure for the next 12 hours.
All of this can be seen in the really complex diagram found in Dr. Lustig’s 2010 article:
So, how do you lower your blood pressure through diet? First, cut out all the simple sugars. These include anything with table sugar, high fructose corn syrup and corn syrup.
Second, limit your overall intake of other sources of carbohydrates including any type of bread, rice, pasta, tortilla, potato, corn and carrots. Realize that fruit is fructose, and when taken with other forms of glucose can have the same effect as table sugar.
Third, if you are taking blood pressure medications, see your doctor about close monitoring of your blood pressure as it can drop within 1-2 weeks of making these dietary changes.
A few of my patients have come in struggling with their weight this week, following what they assumed to be a low carbohydrate diet. They were eating yogurt for breakfast, a chicken salad for lunch, and chicken and vegetables for dinner. A true low carbohydrate diet is ketogenic (it derives fuel from ketones) and is the byproduct of fatty acid metabolism. That means your fuel is coming from fat, not protein or carbohydrate. The presence of glucose, fructose, lactose or other sugars (or many sugar alcohols) shut fatty acid metabolism down and halt the process of weight loss and frequently increase weight gain. Too much protein does the same thing. A chicken salad is not ketogenic. It may be low carb, but without adequate fat, the absence of glucose drives the body to use protein as it’s primary fuel source. It is essential to maintain ketosis that a low carbohydrate diet moderate the protein and increase the fats to upwards of 60-70% of the total caloric intake.
Bacon is a 50/50 food. (I’m not talking about turkey bacon . . . that’s not real bacon). Each slice of real bacon is at a minimum 3 grams (50%) fat, and 3 grams (50%) protein. No carbs there, either.
So, if you’re struggling with your weight loss on a low carb diet . . . your first step should be “BLT” it!
I recently read this counsel given at the Northland College by Principal John Tapene in 1959. It still applies to us today. It is a state of mind that applies to life and to all that we do, including our approach to weight loss. I paraphrase it below.
We frequently hear the cry from our teenagers and young adults, “what can we do, where can we go?”
My answer to them and to you is this: Go home, mow the lawn, wash the windows, learn to cook, build a raft, get a job, visit the sick, study your lessons and after you’ve finished, read a book. Your city or town doesn’t owe you recreational facilities and your parents don’t owe you fun. The world does not owe you a living.
On the contrary, you owe the world something. You owe it your time, talent and energy so that no one will be at war, in sickness and in loneliness as we have been in the past. In other words, grow up, stop being a crybaby, get out of your dream world and develop a backbone and not a wishbone. Motivation is a fire from within. If someone else tries to light that fire under you, chances are, it will only burn very briefly. Start behaving like a responsible person. You are important and you are needed. It’s too late to sit around and wait for somebody to do something someday. Someday is now, and that somebody is you.
“You want me to eat WHAT?! But that’s . . . ,it’s . . . FAT, really?”
” Yes, it is.”
Every day, instruction to my patients is initially seen as Food Pyramid heresy and My Plate iconoclasm. Yes, I want you to flip the Food Pyramid on its head, and push everything off My Plate and fill it with fat. . . Really. . . Yes, I do.
I was counseled by many school professors over the years that there are two things you should avoid talking about: Religion & Politics. The ketogenic or low carbohydrate dietary conversation involves both. “Fat Phobia” is a Religion. We have demonized fat and sainted the treadmill. You see, fat got a bad wrap when the bomb calorimeter was invented. We realized that there was twice as much energy found in fat that there was in carbohydrate or protein. Early nutritionists, understanding that heat is a form of energy, and realizing that energy is conserved, found that food substrates contain a set amount of energy that can be measured in a closed environment. Naturally, the Law of Thermodynamics got applied to lend understanding in how people gain or loose weight. We coined the term “you are what you eat” based upon our understanding of the Laws of Thermodynamics. The calorie became “king.”
For the last sixty years (an entire generation of humans) we have based our diet around the calorimetry of food and have labeled them as good or bad based upon calories. To loose weight, we are taught, you either have to eat food containing fewer calories (fat has the most calories per volume so it must be bad!) or burn it off faster than you take it in (did you go exercise at that new gym next door), right? Wrong.
First, you and I are not bomb calorimeters. We are not closed systems. We harbor variable levels of symbiotic bacteria (these also burn fuel at variable rates) and our body temperatures fluctuate to regulate other enzymatic and hormonal processes.
Second, bomb calorimetery functions on the premise that volumes are also held at a constant. Human volume and density change daily. Simple chemistry tells us that volume = mass / density. The average human mass fluctuates by 5lbs every day and our density changes based upon our hydration status (the amount of water we drink). Because these two variables are not constant in a human being, it is impossible to correctly apply the Laws of Thermodynamics to the human body and accurately predict weight gain or loss.
Third, hormones! (Anyone married to a pregnant female understands that nothing is as it seems when hormones are involved.) We have a plethora of hormones that change the rate in which fuels are burned or stored in the human body. Our GI flora (symbiotic bacteria in the human gastrointestinal tract) are also affected by hormones and do not have set rates of fuel use or breakdown. What this means is that you and I process food at different rates and derive different levels of energy and fuel from the same donut. Genetics plays a leading role in how these hormones are used and turned on and off. Fat is burned or stored in the body based on a hormonal mechanism I described in a previous post you can read here.
Asking patients to reduce carbohydrate intake to less than 20 grams per day and increasing fat intake to up to 70% of total caloric intake is essentially 20th century nutritional apostasy.
The dietary concepts from the Food Pyramid and My Plate have been embraced by our country for over sixty years. Changing our views on these as a country will be for many like changing religions. For those of us “with eyes to see and ears to hear” our work is cut out for us.
A number of my patients have asked what I use personally as a protein supplement and whether I use protein shakes. I’ve struggled to find a great tasting protein shake that does not contain any artificial sweeteners (see my article The Skinny On Sweeteners) that raise the insulin levels. Most of the pre-prepared shakes (including the Adkins, EAS, Muscle Milk, and many others) will significantly slow weight loss and knock you out of ketosis due to an insulin response stim
ulated by drinking them.
My sweet wife just perfected our family’s favorite high fat, low carbohydrate protein shake. Oh, it’s good and it’s filling. You’ll love it and you won’t be hungry for at least 3-4 hours after savoring this sweet taste-bud sensation.
This is a great shake for a mid-meal snack or a quick meal on the go.
Dr. Nally’s Low Carb High Fat Protein Shake:
[One serving (~ 2 cups) is 4.5 grams of carbohydrate]
Blend to preferred texture. . . (may add more heavy whipping cream if it is still too thick).
Enjoy!!
I had the wonderful pleasure of being interviewed by London’s great Sam Feltham from SmashTheFat.com. Thanks for some great conversation Sam!
I look forward to chatting with Sam again soon. Check out the great interviews and coaching that they are offering at SmashTheFat.com
Ask yourself the following questions:
These are the ten most common signs of “burnout.” 46% of respondents in surveys indicate at least one of the above symptoms of burnout. Two or more of these imply that you are suffering from some degree of “burnout.” The classic triad of burnout is:
What is burnout? It is defined by “Mr. Webster” as “physical or mental collapse caused by overwork or stress.” But, that definition doesn’t seem to do it justice, and many people experiencing burnout don’t actually “collapse.” They do, however, become significantly less productive, depressed, and loose the enjoyment of life. Work begins to feel like slavery, exercise becomes a chore, food begins to have associations with guilt, friendships are seen as obligations and love looses its luster and looks more like a social construct.
Burnout is often likened to discontent, however, these are two very different emotional feelings. Discontent can be defined as dissatisfaction with ones circumstances. There are two kinds of discontent in this world: the discontent that works and the discontent that wrings its hands. The first kind often gets what it wants and the second looses what it has.
Burnout differs from discontent, in that continued work toward a goal brings on the triad of emotional exhaustion, depersonalization and the feeling of reduced personal accomplishment. Burnout is, in reality, the sum total of hundreds of thousands of tiny betrayals of purpose.
Burnout can occur in any field of work, however, a study published in the 2012 issue of JAMA reveals that over 40% of the ~800,000 U.S. physicians are experiencing burnout and are more prone to burnout than any other worker in the United States. The journal Academic Medicine recently reported that medical students, when compared to age-matched fellow college graduates, reported significantly higher rates of burnout.
So, how do you overcome burnout?
I’m an Osteopath. I see disease in the context and inter-relationship of the mind, body & spirit. Overcoming burnout requires one to restore balance in these three areas. I am impressed by the work of Charlie Hoehn in his book, Play it away: A workaholic’s cure for anxiety. Charlie does a wonderful job of describing the broken inter-relationship of the mind, body and spirit in a person experiencing burnout.
The first step to repairing the broken inter-relationship is to recognize and remove those anchors keeping you tethered to the feelings of burnout. The anchors are the stressors that cause you to worry on a daily and weekly basis. Journaling these stressors, writing them down in 3-5 word sentences is the start. Identify which of these stressors is the biggest or causes the most angst, then write out the following question. “How can I eliminate [stressor] from my life? Do this with the largest two or three stressors. Then write out a solution that is small and uncomplicated to each stressor. Put the solution to work immediately. If your solution has not improved your feelings of stress and anxiety within a week, then drop the first and try to find a second stressor, or otherwise switch to a second solution. Journaling these thoughts, questions, feelings and answers allows your mind to change from a self-centered focus to an action based focus. It clears the mind to move into action. Nothing is more important in reducing burnout, than nourishing the imagination. Using a journal helps stimulate thought and the imagination.
The second technique is scheduling some real play. Write down the five most fun activity involved with play that you did as a child. Then, set aside dedicated time for your favorite activity of play. It is essential that you actually schedule this play time into your daily activities. There are a couple of rules associated with play time.
“A lack of play should be treated like malnutrition: it’s a health risk to your body and your mind.” (Stuart Brown)
“Play is the highest form of research.” (Albert Einstein)
Technique number three is related to sleep. It is essential that you have a consistent bedtime and give yourself the opportunity to take an afternoon nap. You can optimize your sleep by turning off electronics before getting into bed, going to bed at the same time each night, decreasing the room temperature to 68-70 degrees Fahrenheit, draw the curtains to make the room dark, and use a relaxing loop of quite background sound like ocean waves, or the sound of a trickling stream to ease your mind (can be found on a number of apps).
It may take up to a week for your body to unwind and get used to this schedule. Also, schedule a 20 minute afternoon nap.
Meditation and/or prayer is the fourth technique. Sit or kneel, close your eyes and observe the thoughts that enter your mind for 10-15 minutes. Listen to and keep your breathing calm and deep. Pay attention to the rhythm of your breathing. Reading can also be a form of meditation and has become an important refreshing part of alleviating burnout. We can only be as good as the books that we read. Read, ponder over and talk about good books.
Fifth, eat healthy meals with healthy friends. Decrease the carbohydrates and increase the good omega 3 fats in your diet. The insulin response to carbohydrates stimulates the inflammatory and parasympathetic nervous system making you more fatigued and tired. Reduce the bread, rice, pasta, potatoes, carrots and corn intake in your diet.
Increasing the good fat in your diet (like Kerrygold Irish Butter, Coconut Oil, Olive Oil, and real animal fats) actually increases your bodies access to essential B vitamins and improves the use of Vitamin D. Making dietary changes become a habit is often easier when it is done with a friend. Schedule opportunities to eat healthy meals with family or friends attempting to do the same thing. You will help support each other and be more likely to succeed.
The last recommendation is spend time in nature. One weekend a month spend at least two hours out in nature. Take a hike, go on a nature walk, go camping, swim in the river, etc. Give yourself permission to unplug during these times. Then, pay close attention to how you feel when your in different environments.
In the words of Shakespeare, “Self-love, my liege, is not so vile a sin/As self-neglecting” (King Henry V, Act 2, scene 4).
I conclude with the rhetorical question, “If you work for a living, why do you kill yourself working?” (The Good, The Bad, and the Ugly)
Did you fall off the low-carbohydrate wagon this week? Did those donuts just call out your name as you walked by the bakery in the grocery store? Maybe you feel like you were shot out of the carbohydrate cannon, landing in the nearby Potato County? If so, you probably had a relapse. You were doing so well, then all the sudden, your will-power caved.
Relapse is not uncommon when making a dietary lifestyle change. What causes relapse? I often see people relapse back to the Standard American Diet, the SAD diet, because of a number of reasons.
First, it is important to recognize that there are a milieu of neuro-hormones that drive hunger cravings or suppression. Anything that triggers a change in these hormone levels can cause the carbohydrate cravings to kick in . . . and you find yourself stuffing yourself with “carbage.”
Second, is boredom. Many people find an increased nervousness when they get bored. They find that eating, with it’s calming parasympathetic nervous system effect, diminish the nervousness that arises out of boredom. They often create a near Pavlov’s type trigger to eat when they experience boredom and it is quickly interpreted as hunger. There is actually a release of endorphin associated with eating and chewing that suppresses stress and or anxiety. Reduction of stress, exercise, and journal writing have been found to help patient’s reduce the food cravings associated with boredom. It is important to have “rescue foods” like string cheese, a handful of almonds, beef jerky, or “fat bombs” available that can be used when you experience these symptoms.
Following the line of triggers, Pavlov demonstrated that repeated actions associated with rewarding consequences will form a physiologic trigger. Frequently. our desire to eat carbohydrates (“carb cravings”) are often tied to triggers. For example, growing up in my home as a child, our family frequently would relax by watching prime-time television while eating a large bowl of popcorn and a Pepsi. To this day, whenever I turn on the television in the evening, I get cravings for carbohydrates. It is important to look at what you were doing or what was going on around you at the time the craving occurred. Substitution of foods has helped to solve these cravings by replacing the popcorn and Pepsi with pork rinds and Diet Dr. Pepper. (Don’t cringe, pork rinds and guacamole tastes fantastic and is a very low carbohydrate substitute that works for me.)
Lastly, many patients fall off the wagon when they visit or have a meal with family. They are often made to feel guilty if they don’t eat Aunt Velda’s homemade chocolate chip cookies. They are afraid of offending their relatives if they don’t partake of those tasty cookies. The challenge is that cheating by eating the cookies causes an insulin spike and leads to 24-72 hours of carbohydrate cravings thereafter. Are those cookies worth 72 hours of carbohydrate cravings? Maybe. But it is important to consider helping Aunt Velda to understand what those cookies will do to you, and that you still care for Aunt Velda even if you don’t eat her chocolate chip cookies.
In many families, food is often associated with love. “If you don’t eat the food I made for you, you don’t really love me” is an underlying tone that can be found in many family dynamics that I see in my office. Some times bringing your own low-carb chocolate chip cookies, and offering one to Aunt Velda, will stimulate a conversation about your dietary changes and diffuse the guilt and offence that might arise.
Often, knowing what will cause you to fall off the wagon, helps to keep you on the wagon. What challenges have you had staying on the wagon?
Has your weight loss plateaued? Are you struggling to meet your weight loss goals? Have you struggled to lose weight in spite of doing everything “correctly?” Are you still struggling with those last few pounds?
You’re not alone. Many of my patients, myself included, have found themselves “stuck” in their weight loss progression. There are a number of reasons you may not be loosing weight, but one that I am seeing more and more frequently is “Pseudo-Cushings’s Syndrome.” Pseudo-Cushing’s Syndrome is a physiologic
hypercortisolism (high level of cortisol) that can be caused by a number of problems:
The psychiatric literature suggest that up to 80% of people with depressive disorders have increased cortisol secretion (1,2,3). 
People with significant stressors in their life have been show to have a raised cortisol secretion. Chronic stress induces hyperactivity of the hypothalamic-pituitary-adrenal axis causing an over production of cortisol and normalization of their cortisol levels occurs after resolution of the stressor. This cortisol response is not high enough to lead to a true Cushing’s Syndrome, but effects ones ability to loose weight.
I suspect this is becoming more prevalent due to the high paced, high-stress, always on, plugged in, 24 hour information overload lives we live.
What is cortisol? It is a steroid hormone made naturally in the body by the adrenal cortex (outer portion of the adrenal gland). Cortisol is normally stimulated by a number of daily activities including fasting, awakening from sleep, exercise, and normal stresses upon the body. Cortisol release is highest in the morning, helping to wake us up, and tapers into the afternoon. Cortisol plays a very important role in helping our bodies to regulate the correct type (carbohydrate, fat, or protein) and amount of fuel to meet the bodies physiologic demands that are placed upon it at a given time (4,5,6).
Under a stress response, cortisol turns on gluconeogensis in the liver (the conversion of amino acids into glucose) for fuel. Cortisol, also, shifts the storage of fats into the deeper abdominal tissues and turns on the maturation process of adipocytes (fat cells). In the process, it suppresses the immune system to decrease inflammation during times of stress (7,8,9). In the short run, this is an important process, however, when cortisol production is chronically turned up, it leads to abnormal deposition of fat, increased risk of infection, impotence, abnormal blood sugars, head
aches, hypertension and ankle edema, to name a few.
The chronic elevation in cortisol directly stimulates an increase in insulin by increasing the production of glucose in the body, and cortisol blockaids the thyroid axis. Both of these actions halt the ability to loose weight, and drive weight gain.
Cortisol also increases appetite (10). That’s why many people get significant food cravings when they are under stress (“stress eaters”). Cortisol also indirectly affects the other neuro-hormones of the brain including CRH (corticotrophin releasing hormone), leptin, and neuropeptide Y (NPY). High levels of NPY and CRH and reduced levels of leptin have also been shown to stimulate appetite (10-11).
How do you test for Pseudo-Cushing’s Disease?
Testing can be done by your doctor with a simple morning blood test for cortisol. If your cortisol is found to be elevated, it needs to be repeated with an additional 24 hour urine cortisol measurement to confirm the diagnosis. If Cushing’s Syndrome is suspected, some additional blood testing and diagnostic imaging will be necessary.
How do you treat it?
First, the stressor must be identified and removed. Are you getting enough sleep? Is there an underlying infection? Is there untreated anxiety or depression present? Are you over-exercising? These things must be addressed.
Second, underlying depression or anxiety can be treated with counseling, a variety of weight neutral anti-depressant medications or a combination of both. Many of my patients find that meditation, prayer, and journaling are tremendous helps to overcoming much of the anxiety and depression they experience.
Third, adequate sleep is essential. Remove the television, computer, cell phone, iPad or other electronic distraction from the bedroom. Go to bed at the same time and get up at the same time each day. Give yourself time each day away from being plugged in, logged in or on-line.
Fourth, mild intensity (40% of your maximal exertion level) exercise 2-3 days a week was found to lower cortisol; however, moderate intensity (60% of your maximal exertion level) to high intensity (80% of your maximal exertion level) exercise was found to raise it (12). A simple 20 minute walk, 2-3 times per week is very effective.
So, the take home message . . . It’s not the stress that’s killing us, it’s our reaction to it.
References:
Intent
The intent of this brief is to analyze the burden of obesity in the United States and to recommend policy changes to reduce the medical costs of obesity imposed upon the individual and country as a whole.
Introduction
Conventional fat reduction/caloric restriction guidelines for the treatment of obesity and associated cardiovascular disease, diabetes, cancer, and hypertension have been recommended since the early 1970’s. Because these guidelines are based on questionable evidence, the cost of obesity has dramatically risen to almost 21% of overall health care costs in the United States (1). This brief will analyze the current medical cost of obesity and will explain why the current obesity reduction guidelines perpetuate the problem. In addition, the brief will examine the impact of government agricultural policy on dietary habits, and will recommend changes to farm subsidy legislation in order to reduce the incidence of obesity and decrease costs to the healthcare system.
History & Background
The Cost of Obesity on the Nation
As of 2012, obesity accounts for nearly 21% of overall health care costs in the United States. An obese person incurs $2741 more in medical expenses per year than his or her non-obese counterpart (1). Medicare spending has increased per person per year by $600 for each obese beneficiary (includes out-patient and prescription drugs) and Medicaid beneficiary prescription drug spending increased by $230 per year per obese person. Private insurance has increased by $248 for prescription drugs and $443 for in-patient services for each obese beneficiary per year (2). That adds up to $190.2 billion spent annually on obesity-related medical problems (3). This is a drastic change. Health care costs related to obesity were $85.7 billion (9.1% of overall health care costs) in 2006 and $61.2 billion (6.5% of overall health care costs) in 1998 (4).
The most recent Center for Disease Control statistics reveal that 35.7% of the U.S. adult population is currently obese and another 33% is overweight. Over 78 million adults and 12.5 million children are obese (5). The addition of 30 million people to the health care roles (current estimation of the Affordable Care Act including Medicaid expansion) means that an estimated $27 billion (in 2012 dollars) more will be spent per year on obesity-related health care costs.
Impact of Government Policy on Consumption
The ‘Farm Bill’ was originally enacted as part of President Franklin D. Roosevelt’s Agricultural Adjustment Act of 1933, which provided subsidies to American farmers in the midst of the Great Depression. Since that time the federal government has paid farmers not to grow seven specific crops – known as commodities – with the intent of decreasing the supply, increasing the demand, and thereby raising the price (7). Dr. Susan Blumenthal, former Assistant Surgeon General and current SNAP to Health project director, writes, “The Farm Bill has since expanded to include many different categories or ‘titles.’ The last bill to be authorized, in 2008, had 15 titles, including nutrition (food stamps), crop subsidies, conservation, livestock, crop insurance and disaster assistance. The 2008 Farm Bill approved $300 billion in spending: 67% was spent on food stamps; 15% on agricultural subsidies; 9% on conservation; and 8% on crop insurance” (8).
The U.S. Department of Agriculture (USDA) Subsidy Programs tend to favor, either directly or indirectly, foods that increase obesity and other diseases. These subsidies support commodity crops, specialty crops, dairy products, livestock, and federal purchase programs. Their justification is that they help to stabilize prices in agricultural commodity markets by balancing supply and demand (9). Between 1995 and 2011, $277.3 billion were given in farm subsidies to almost 40% of U.S. farmers. Arizona received $1.1 billion (mainly for cotton); however, only 7% of Arizona farms received subsides during this period (10). These subsidies are incentives to grow and produce specific commodities that have a higher monetary return. Subsidies also act as a disincentive for farmers to grow fruits and vegetables which fall under the “specialty crops” category. This restricts both small and large farmers from diversifying their crops, and limits fruit and vegetable production (11).
Arizona farms received $25.3 million in dairy subsidies from 1995-2011 and $29.5 million in livestock subsidies during that same period (9). Arizona ranks 2nd nationally in its production of cantaloupe & honeydew melons, head & leaf lettuce, spinach, broccoli, cauliflower and lemons, all of which are “specialty crops” and do not receive subsidies (12). The most recent statistics show that the top five states receiving subsidies are Iowa, Texas, Illinois, Nebraska and Minnesota, with Kansas coming in at a close sixth. The majority of these subsidies are for corn ($81.7 billion), soybeans ($26.4 billion), rice ($13.3 billion) and wheat ($34.4 billion) from 1995-2011 (10). It is important to note that the Renewable Fuel Standard of 2012 (legislation protecting the corn-ethanol lobby) mandates that 37% of the corn harvest be used in ethanol production (13).
The food subsidies above have been in place since the Food, Conservation & Energy Act of 2002 and renewed in 2008. They were only to be available for a period of five additional years and were set to expire September 30, 2012. However, the American Taxpayer Relief Act of 2012 (H.R. 8), enacted by Congress and signed into law by President Barack Obama, included provisions that extended these subsidies until September 30, 2013 (20).
For many low-income Americans and especially children, federal programs have a direct and significant influence on food choices. 
Over 30 million children receive government subsidized school lunch through National School Lunch Program (NSLP) administered by the USDA Food and Nutrition Service (14). USDA-purchased meats, dairy products, grains, fruits, and vegetables are supplied to schools for use in meal programs. Current school lunch recommendations on calorie intake set by the USDA and The Healthy, Hunger-Free Kids Act of 2010mandate school lunches provide 650-850 calories per meal to the 30 million children currently enrolled in this program (15). Interestingly, that is the same caloric count of a Big Mac®, small fry and Diet Coke® from McDonalds® (16). The rational for these purchase decisions are based upon agricultural support goals and adherence to national dietary guidelines (14). A study published in the journal Economics and Human Biology reveals that a person’s body mass index (BMI) increased faster if that personwere on food stamps, and the BMI increased at a faster rate while on the Supplemental Nutrition Assistance Program (SNAP). “We can’t prove that the Food Stamp Program causes weight gain, but this study suggests a strong linkage,” said Jay Zagorsky, co-author of the study and a research scientist at Ohio State University’s Center for Human Resource Research (17). However, much of the food available through the SNAP programs are refined, subsidized high-carbohydrate containing foods.
The price of food influences an individual’s consumption choices (6). Foods that are refined contain increased amounts of sugar or high-fructose corn syrup. These foods contain more caloric density and are often cheaper and more easily accessible. These are foods that are usually found in the center of the grocery store and frequently on sale at the end-caps of each isle. Nutrient-dense, higher fiber foods are frequently associated with higher prices and are consumed less often. These are the foods you usually find around the peripheral areas of the grocery store (fruits, vegetables, etc.) Current food subsidy policy found in the Food, Conservation and Energy Act of 2008 extension mandated by the American Taxpayer Relief Act of 2012 drives up the price of fruits, vegetables, and meats. This policy also turns people toward lower cost foods that are higher in simple carbohydrates and caloric density. Thus, current policy is actually making obesity worse and making America fatter. Research completed at the University of Illinois at Chicago reveals that small taxes or price changes do not produce a change in a person’s BMI; however, more significant price change has a measurable and significant effect on weight in both adults and children. Price increases of 100-150% have been shown to change purchasing behavior and thereby affect health (18). An example of this is the tax levied on cigarette smoking.
The USDA disagrees with the amount of influence they have over the individual American’s food choices. They state openly on their website that “Some public health advocates have argued that falling real, or inflation-adjusted, prices for many high-calorie foods encourage people to buy and consume more of these foods, leading to poor diet quality and rising rates of obesity. A closer look at how consumers respond to food price variation–over time, across geographic markets, in different types of stores, and in response to taxes and subsidies–reveals how food prices affect people’s food choices, and their waistlines. In short, price matters, but not very much, and it is not the only factor” (19).
Why Current Dietary Guidelines Have Not Been Effective
Why do we get fat? Why have we not been successful in losing weight via diet and exercise? The obesity paradox was described by Jules Hirsch of Rockefeller University, who proposed two opposing hypotheses:
The 1977 Dietary Goals for the United States – the first comprehensive statement by any branch of the federal government about the American diet – supported the first theory. The Guidelines were heavily influenced by the American Heart Association’s position that fat intake alone would cause heart disease. The USDA 2011 Dietary Guidelines imply that the “people who are the most successful at achieving and maintaining a healthy weight do so through continued attention to consuming only enough calories from foods and beverages to meet their needs and by being physically active.” (15)
Current research contradicts the caloric restriction or “calorie in – calorie out” theory. Scientific evidence clearly demonstrates the domino effect of carbohydrate or starch intake increasing insulin levels which thereby stimulates obesity by raising cholesterol and triglyceride levels. Time Magazine recently published evidence that the longstanding recommendations to “eat less high-fat red meat, eggs and dairy and replace them with more calories from fruits, vegetables and especially carbohydrates” is now seen as incorrect (45). Even our medical textbooks from 1965, like the introductory chapter of the Handbook of Physiology, make it clear that carbohydrate intake cause weight gain and raise triglyceride and cholesterol levels (22), (23), (24).
Current Policy
The current version of the Farm Bill was set to expire September 30th, 2013. If it had been allowed to expire, the results would have returned us to the 1949 Farm Bill legislation and theoretically double the price of milk. However, this would have had the effect of freeing up over $5 billion dollars of federal spending per year and would also lead to decreased consumption of a major source of carbohydrates in the standard American diet like wheat and corn. Senator Debbie Stabenow (D-MI), and chairwoman of the Senate Agriculture Committee, had repeatedly said she was opposed to an extension; however, she agreed to a compromise extending the bill for another year to help the farmers experiencing serious drought conditions in 2012 (7). Two additional extensions were passed in the House and Senate, but because these differed so significantly, it was referred to a House-Senate Conference Committee to work out the compromise details. With only $23 billion in spending reductions, The Agricultural Act of 2014 was passed on January 29, 2014 (46).
Outcomes and Stakeholders
If the United States continues its current course, up to 58% of the population will be obese by 2030 (26). Many believe that the USDA Dietary Guidelines are to blame. Richard David Feinman, President of the Nutrition and Metabolism Society and Professor of Cell Biology at SUNY Downstate Medical Center said, “The previous Guidelines have not worked well. It is unreasonable to ask the Dietary Guidelines Advisory Committee (DGAC) to audit its own work. An external panel of scientists with no direct ties to nutritional policy would be able to do a more impartial evaluation of the data. This would be far better for everyone.” (27) A recent Gallup Poll reveals that 63% of Americans believe the USDA Guidelines that a low fat, calorie restricted diet will help in reduction of obesity, and the same study showed that 48% of Americans worry about their weight “all of the time or some of the time” (28). Recent evidence from the Women’s Health Initiative Dietary Modification Trial studying 49,000 women supports Dr. Feinman’s conclusion above. It did not show any statistically significant evidence that following a low-fat or caloric restricted diet had any effect upon obesity (29). Other nutritional experts from the Salt Institute and the National Health Coalition have expressed their support for significant changes to the USDA Dietary Guidelines (30). The Weston A. Price Foundation, which according to its website is “dedicated to restoring nutrient-dense foods to the human diet through education, research and activism,” also supports the view that the current USDA Dietary Guidelines have been a significant cause of obesity and have been an active voice promoting legislative change (31).
On the other hand, the Sugar Association has issued statements that sugar is not the cause of obesity and “continually eating too much food and sedentary lifestyles are the major contributing factors to increasing rates of obesity – not sugar intake” (32). In addition, the American Beverage Association has stated that sugars are not the problem with obesity, but instead, “overweight and obesity are a result of an imbalance between calories consumed and calories burned” (33).
Attempts at modifying the Farm Bill with legislation like the 2012 DeMint Amendment (SA 2276 ) were supported by both Arizona Senators McCain (R-AZ) and Kyl (R-AZ) with a “Yes” vote, as well as Senators Ayotte (R-NH), Brown (R-MA), Burr (R-NC), Coats (R-IN), Coburn (ROK), Cornyn (R-TX), DeMint (R-SC), Graham (R-SC), Hatch (R-UT), Heller (R-NV), Johnson (R-WI), Lee (R-UT), McConnell (R-KY), Murkowski (R-AK), Paul (R-KY), Rubio (R-FL), Sessions (R-AL), and Toomey (R-PA). However, because of a large lobbying agricultural coalition, it was voted down (34). Changing farm subsidies will be a great challenge as 40% of the farmers in the U.S. now have some degree of dependence upon these subsidies. The following agricultural groups have historically had significant monetary interest in the farm subsidies that these amendments would affect:
The following groups have formed coalitions in support of the Farm Bill: Health/Food Justice/Farm Group partnerships, Specialty Crop Farm Bill Alliance, Community Food Security Coalition, Center for a Livable Future at Johns Hopkins University, Collaboration for a Healthy Sustainable Food System, and the Healthy Farms, Healthy People: A Farm & Food Policy Summit for a Strong America.
The American Heart Association’s position is that the Farm Bill needs to be modified to include increased access to fruits and vegetables (35). The American Medical Association’s position in 2008 and 2011 has been for cutting the size and budget of the current Farm Bill (36). The American Osteopathic Association does not currently have a formal position on the Farm Bill.
If certain crops like corn or wheat were no longer subsidized,drastic changes will be likely in the food manufacturing industry, which would likely be the largest proponent against change. Unintended consequences of modifying the Farm Bill and not extending its subsidies could have the short term effect of escalating the price of a number of commodities to two to three times their current price. For example, the price of milk would increase to $6-$8 dollars a gallon without federal subsidies (37). This would likely deter the use of carbohydrates containing dairy products, but may also increase the price of meats and cheeses as well.
The USDA’s Rural Development Progress Report claims that the subsidies it distributed “saved more than 75,000 jobs” in 2006 and over 400,000 jobs in 2011 (38), (39). They claim that without federal farm subsidiesthere would be significant loss of jobs; however, studies from the Cato Institute actually show the opposite.
“Job gains are weak and population growth is actually negative in most of the counties where farm payments are the biggest share of income. Job growth is decidedly weak in the counties most dependent on farm payments. The vast majority of such counties (483) had job gains below the 19 percent national average from 1992 to 2002. A considerable number (167) had outright job losses over the period. In short, farm payments are not yielding robust economic and population gains in the counties where they should have the greatest impact. If anything, the payments appear to be linked with sub-par economic and population growth. To be sure, this quick comparison cannot answer whether growth would have been even weaker in the absence of the payments. Still, farm payments appear to create dependency on even more payments, not new engines of growth” (40).
As of 2010, obesity costs about $73.1 billion per year in lost productivity in the United States (43). The worsening obesity epidemic poses further workforce productivity losses up to 20% more by 2030. Even small improvements in obesity will improve workforce productivity and has substantial potential for savings. Currently, the Affordable Care Act allows employers to charge obese employees 30-50% more for health insurance. Without correcting this epidemic, it may be impossible for many to afford health care, opting out to pay the less expensive tax penalty. This would have the effect of increasing commercial premiums across the country, feasibly pushing private insurance companies out of business and forcing a single payer governmental system.
Recommendations
This brief points out that the overall U.S. healthcare costs associated with obesity have increased by 68% in the last fourteen years. It provides evidence that using current dietary low-fat caloric restriction guidelines show poor statistically significant improvements in obesity. And it provides evidence that obesity is not caused by excessive caloric intake and fat, but by insulin response to carbohydrate intake. Lastly, this analysis provides evidence that the Farm Bill propagates continued worsening obesity rates in the US by providing access to cheap, fattening food.
The USDA 2011 Dietary Guidelines need to be revised to reflect current evidence-based obesity prevention and weight reduction research. The guidelines should include information about limiting the intake of foods high in carbohydrates.
The food subsidy extension provided in the American Taxpayer Relief Act of 2012 was extended five years by the Agricultural Act of 2014. Had it been allowed to expire, it would have saved the country over $200 billion over the next ten years. However, because of so many entitlements involved in this bill, the House and Senate convened in Conference that resulted in a compromise of only $23 billion dollars in spending reductions, the first SNAP reforms since 1996 reducing waste, but did nothing in eliminating subsidies that drive or influence eating behavior (46).
When significant price changes occur, eating behavior will change. As the price of fattening carbohydrates increases, people will eat less of them, leading to a national decrease in obesity and overweight. The current reforms did nothing that will change our dietary behavior.
1. Cornell University. Obesity accounts for 21 percent of U.S. health care costs, study finds. Science Daily. [Online] April 9, 2012. [Cited: January 5, 2013.] http://www.sciencedaily.com/releases/2012/04/120409103247.htm.
2. Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates. Eric A Finkelstein, Justin G Trogdon, Joel W Cohen and William Dietz. Health Affairs, 28, Bethesda, MD : Project HOPE, 2009, Vol. 5. 10.1377/hlthaff.28.5.w822.
3. Begley, Sharon. As America’s Waistline Expands, Costs Soar. Reuters. [Online] Thompson Reuters, April 30, 2012. [Cited: January 5, 2013.] http://www.reuters.com/article/2012/04/30/us-obesity-idUSBRE83T0C820120430.
4. Ungar, Rick. Obesity Now Cost Americans More In Healthcare Spending Than Smoking. Forbes. [Online] 4 30, 2012. [Cited: January 5, 2013.] http://www.forbes.com/sites/rickungar/2012/04/30/obesity-now-costs-americans-more-in-healthcare-costs-than-smoking/.
5. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 2009–2010. NCHS data brief, no 82. Hyattsville, MD : National Center for Health Statistics, 2012, 2012.
6. Poverty and Obesity: The Role of Energy Density and Energy Costs. A Drewnowski, SE Specter. s.l. : American Journal of Clinical Nutrition, 2004, Vols. 79:6-16.
7. Laprete, Jay. U.S. Farm Bill. Times Topics. [Online] The New York Times, December 31, 2012. [Cited: February 11, 2013.] http://topics.nytimes.com/top/reference/timestopics/subjects/f/farm_bill_us/index.html?offset=0&s=newest.
8. SNAP to Health. U.S. Farm Bill: Frequently Asked Questions. SNAP to Health. [Online] CSPC / Snap to Health, 2013. [Cited: February 11, 2013.] http://www.snaptohealth.org/farm-bill-usda/u-s-farm-bill-faq/.
9. USDA. Agricultural Marketing Service. Commodity Purchasing. [Online] January 22, 2013. [Cited: February 10, 2013.] http://www.ams.usda.gov/AMSv1.0/ams.fetchTemplateData.do?template=TemplateQ&navID=Commodity%20Purchasing%20Main%20Page&rightNav1=Commodity%20Purchasing%20Main%20Page&topNav=&leftNav=CommodityPurchasing&page=CommodityPurchasing&resultType=&acct=cmdtyprchs.
10. Environmental Working Group. United States Summary Information. EWG Farm Subsidies. [Online] 2012. [Cited: February 10, 2013.] http://farm.ewg.org/region.php?fips=00000.
11. Monke, Jim. Farm Commodity Programs: Base Acreage and Planting Flexibility. Washington, DC : Congressional Research Services, 2003.
12. Arizona Farm Bureau Federation. AG Facts. Arizona Farm Bureau. [Online] 2013. [Cited: February 15, 2013.] http://www.azfb.com/ag-facts.html.
13. Children of the Corn: The Renewable Fuels Disaster. The American. [Online] American Enterprise Institute, January 4, 2012. [Cited: February 15, 2013.] http://www.american.com/archive/2012/january/children-of-the-corn-the-renewable-fuels-disaster.
14. USDA Food & Nutrition Service. National School Lunch Program. USDA Food & Nutrition Serivce. [Online] June 21, 2012. [Cited: February 15, 2013.] http://www.fns.usda.gov/cnd/lunch/.
15. U.S. Department of Agriculture (USDA). USDA 2010 Dietary Guidelines. USDA Center for Nutrition Policy and Promotion: Dietary Guidelines for Americans. [Online] U.S. Government Printing Office, January 31, 2011. [Cited: January 5, 2013.] http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/Chapter2.pdf.
16. ABC News. ABC News. Medical Unit. [Online] ABC News Internet Ventures, September 30, 2012. [Cited: April 14, 2013.] http://abcnews.go.com/blogs/health/2012/09/30/school-lunch-showdown-850-calorie-meals-compared/.
17. Ohio State University. Food Stamp Use Linked To Weight Gain, Study Finds. Science Daily. [Online] August 12, 2009. [Cited: April 13, 2013.] http://www.sciencedaily.com /releases/2009/08/090810122139.htm.
18. Food Prices and Obesity: Evidence and Policy Implications for Taxes and Subsidies. L Powell, F Chalupka. 1, Illinois : The Milbank Quarterly by Wiley Periodicals Inc, 2009, Vol. 87.
19. Jessica Todd, Biing-Hwan Lin. Amber Waves Online Magazine. U. S. Department of Agriculture Economic Research Service. [Online] September 2012. [Cited: February 10, 2013.] http://www.ers.usda.gov/amber-waves/2012-september/what-role-do-food-and-beverage-prices.aspx.
20. American Taxpayer Relief Act of 2012. U.S. Government Printing Office. [Online] Jan 12, 2012. [Cited: February 10, 2013.] http://www.gpo.gov/fdsys/pkg/BILLS-112hr8enr/pdf/BILLS-112hr8enr.pdf.
21. Bruch, Hilde. The Importance of Overweight. Michigan : Norton, University of Michigan, 1957.
22. Taubs, Gary. Good Calories, Bad Calories: Fats, Carbs, and the Controversial Science of Diet and Health. New York : Anchor Books, 2007. 978-1-40000-3346-1.
23. Role of Insulin in Endgenous Hypertriglyceridemia. GM Reave, RL Lerner, MP Stern, JW Farquhar. s.l. : Journal of Clinical Investigation, 1967, Vols. 46(II):1756-67.
24. High-Carb Diets Questioned. Kolata, G. 235(4785):164, s.l. : Science, 1987, Vol. 9.
25. U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Washington, D.C. : U.S. Government Printing Office, 2001.
26. Global Burden of Obesity in 2005 and Projections to 2030. T Kelly, W Yang, C-S Chen, K Reynolds and J He. 8 July 2008, New Orleans : International Journal of Obesity, 2008, Vols. 32, 1431–1437. doi:10.1038/ijo.2008.102.
27. In The Face Of Contradictory Evidence: Report Of The Dietary Guidelines For Americans Committee. Adele H Hite, Richard D Feinman, Gabriel E Guzman, Morton Satin, Pamela Schoenfeld, Richard J Wood. 10, s.l. : Nutrition, 2010, Vol. 26. DOI: 10.1016/j.nut.2010.08.012.
28. A Dugan, F Newport. Gallup Wellbeing. Gallup. [Online] August 17, 2012. [Cited: April 13, 2013.] http://www.gallup.com/poll/156710/americans-say-low-fat-diet-better-low-car.aspx.
29. Low-fat dietary pattern and weight change over 7 years: the Women’s Health Initiative Dietary Modification Trial. . Howard BV, Manson JE, Stefanick ML, et al. s.l. : JAMA, 2006, Vols. 295:39-49. doi:10.1001/jama.295.1.39.
30. Healthy Nation Coalition. Healthy Nation Coalition. Healthy Nation Coalition. [Online] Adrienne Larocque, PhD, 2012. [Cited: March 8, 2013.] http://www.forahealthynation.org/.
31. Judith McGeary, Esq. Legislative Updates. The Weston A. Price Foundation. [Online] December 11, 2012. [Cited: March 9, 2013.] http://www.westonaprice.org/legislative-updates/policy-update-farm-bill-and-gmos.
32. The Sugar Association. Sugar and Your Diet. Sugar.org. [Online] 2012. [Cited: March 9, 2013.] http://www.sugar.org/sugar-and-your-diet/caloric-intake.html.
33. American Beverage Association. Obesity. American Beverage Association. [Online] 2013. [Cited: March 9, 2013.] http://www.ameribev.org/nutrition–science/obesity/.
34. Library of Congress. S.Amdt.2276 to S.3240. Congress.Gov. [Online] March 8, 2013. [Cited: March 9, 2013.] http://beta.congress.gov/amendment/112th-congress/senate-amendment/2276.
35. The American Heart Association. Policy Brief – The Farm Bill. The American Heart Association. [Online] 2012. [Cited: April 14, 2013.] http://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_429110.pdf.
36. AMA: Report of Reference Committee . Malechek, Lindsay. 2011.
37. Wolf, Jim. Senate, House agriculture committees in deal to avert milk price spike. Reuters. Sun, Dec 30, 2012, 2012.
38. USDA. USDA Rural Progress Report. USDA. [Online] December 2006. [Cited: April 14, 2013.] http://www.rurdev.usda.gov/rd/pubs/2005_06_Prog_Report.pdf.
39. —. USDA Rural Developement 2011 Progress Report. USDA Rural Developement. [Online] December 2011. [Cited: April 14, 2013.] http://www.rurdev.usda.gov/Reports/RD%20Progress%20Report%202011–Smallest(2).pdf.
40. Slivinski, Stephen. Rural Subsidies. Cato Institute. [Online] July 2009. [Cited: March 9, 2013.] http://www.downsizinggovernment.org/agriculture/rural-subsidies.
41. Obesity prevention: the role of policies, laws and regulations. Swinburn, Boyd A. New Zeland : BioMed Central Ltd., 208, Vol. 5:12. 10.1186/1743-8462-5-12.
42. Begley, Sharon. As America’ss Waistline Expands, Costs Soar. Reuters. [Online] Thompson Reuters, April 30, 2012. [Cited: January 5, 2013.] http://www.reuters.com/article/2012/04/30/us-obesity-idUSBRE83T0C820120430.
43. The Costs of Obesity in the Workplace. E Finkelstein, M DiBonaventura, S Burgess, B Hale. 10, Illinois : Lippincott Williams & Wilkins, 2010, Vol. 52. doi: 10.1097/JOM.0b013e3181f274d2.
44. Rudd Center For Food Policy & Obesity. Search Legislation Database. Yale Rudd Center. [Online] Rudd Center, 2013. [Cited: January 5, 2013.] http://www.yaleruddcenter.org/legislation/search.aspx.
45. Walsh, Bryan. “Ending The War on Fat.” TIME Magazine. June 12, 2014.
46. Lucas, Frank D. “Agricultural Act Summary.” House Agricultural Committee. [Online] Jan 29, 2014. [Cited June 28, 2014.] http:// http://agriculture.house.gov/farmbill
The only way to successfully loose weight is to modify or turn off the mechanisms that stimulate fat storage. For years we have been told that this was just a problem of thermodynamics, meaning the more calories you eat, the more calories you store. The solution was, thereby, eat less calories or exercise more, or both. We are taught in school that a 1 gram of carbohydrate contains 4 kcal, 1 gram of protein contains 4 kcal, and 1 gram of fat contains 9 kcal.
It’s easy to see that if I’m going to limit my calories, cutting out fat is the first step. For the last 65 years, we as a society have been doing just that, cutting out fat, exercising more and eating fewer calories. What has it done for us? It’s made us fatter! (1)
Some may argue that we really aren’t eating fewer calories and exercising more. But most people I have seen in my office have tried and tried and tried and failed and failed and failed to loose weight with this methodology. The definition of insanity is “doing the same thing over and over and expecting a different result.”
Most of my patients are not insane, they recognize this and stop exercising and stop restricting calories . . . ’cause they realized, like I have, that it just doesn’t work! If you’re one that is still preaching caloric restriction and cutting out fat, I refer you to the figure above and the definition of insanity . . .
So, if reducing the calories in our diet and exercising more is not the mechanism for turning on and off the storage of fat, then what is?
Before I can explain this, it is very important that you appreciate the difference between triglycerides and free fatty acids. These are the two forms of fat found in the human body, but they have dramatically different functions. They are tied to how fat is oxidized and stored, and how carbohydrates are regulated.
Fat stored in the adipose cells (fat cells) 
as well as the fat that is found in our food is found in the form of triglycerides. Each triglyceride molecule is made of a “glyceride” (glycerol backbone) and three fatty acids (hence the “tri”) that look like tails. Some of the fat in our adipose cells come from the food we eat, but interestingly, the rest comes from carbohydrates
(“What! Fat comes from sugar?! How can this be?!!“)
We all know that glucose derived from sugar is taken up by the cells from the blood stream and used for fuel, however, when too much glucose is in the blood stream or the blood sugar increases above the body’s comfort zone (60-100 ng/dl), the body stores the excess. The process is called de novo lipogenesis, occurring in the liver and in the fat cells themselves, fancy Latin words for “new fat.” It occurs with up to 30% (possibly more if you just came from Krispy Kream) of the of the carbohydrates that we eat with each meal. De novo lipogenesis speeds up as we increased the carbohydrate in our meal and slows down as we decrease the carbohydrate in our meal. We’ve known this for over 50 years, since it was published by Dr. Werthemier in the 1965 edition of the Handbook of Physiology (2).
While we know that fat from our diet and fat from our food is stored as triglyceride, it has to enter and exit the fat cell in the form of fatty acids. They are called “free fatty acids” when they aren’t stuck together in a triglyceride. In their unbound state, they can be burned as fuel for the body within the cells. I like to think of the free fatty acids as the body’s “diesel fuel” and of glucose as the body’s version of “unleaded fuel.” The free fatty acids can easily slip in and out of the fat cell, but within the adipose cell, they are locked up as triglycerides and are too big to pass through the cell membranes. Lipolysis is essentially unlocking the glycerol from the free fatty acids and allowing the free fatty acids to pass out of the fat cell. Triglycerides in the blood stream must also be broken down into fatty acids 
before they can be taken up into the fat cells. The reconstitution of the fatty acids with glycerol is called esterification. Interestingly, the process of lipolysis and esterification is going on continuously, and a ceaseless stream of free fatty acids are flowing in and out of the fat cells. However, the flow of fatty acids in and out of the fat cells depends upon the level of glucose and insulin available. As glucose is burned for fuel (oxidized) in the liver or the fat cell, it produces glycerol phosphate. Glycerol phosphate provides the molecule necessary to bind the glycerol back to the free fatty acids. As carbohydrates are being used as fuel, it stimulates increased triglyceride formation both in the fat cell and in the liver, and the insulin produced by the pancreas stimulates the lipoprotein lipase molecule to increased uptake of the fatty acids into the fat cells (3).
So when carbohydrates increase in the diet, the flow of fat into the fat cell increases, and when carbohydrates are limited in the diet, the flow of fat out of the fat cells increases.
Summarizing the control mechanism for fat entering the fat cell:
These two mechanisms ensure that there is always unleaded (glucose) or diesel fuel (free fatty acids) available for every one of the cells in the body. This provides the flexibility to use glucose in times of plenty, like summer time, and free fatty acids in times of famine or winter when external sources of glucose are unavailable.
The regulation of fat storage, then, is hormonal, not thermodynamic. Unfortunately, we’ve know this for over 65 years and ignored it.
We’ve ignored it for political reasons, but that’s for another blog post . . .
References:
1. James, W. J Intern Med, 2008, 263(4): 336-352
2. Wertheimer, E. “Introduction: A Perspective.” Handbook of Physiology. Renold & Cahill. 1965.
3. Taubs, G. “The Carbohydrate Hypothesis, II” Good Calorie, Bad Calorie. Random House, Inc. 2007, p 376-403.
About half of those who see me in my practice, here in Surprise, Arizona, are over the age of 60. It is a pleasure working with them, but I have found that there is a different acronym code for texting that is necessary. Maybe this will help. . .
As a family practice physician and bariatrician, my job is to examine and treat the “Diseases of Civilization.” The Diseases of Civilization are those diseases arising out of the changes induced by industrializing and modernizing a society of people. These include diseases like diabetes, dyslipidemia (abnormal cholesterol), heart disease, hypertension, gout, vascular disease, & stroke. It is interesting that the so called Diseases of Civilization didn’t really appear on the scene until the early 1900’s. Yes, we have now identified some of these diseases in the early Egyptians, but to my point, as a society modernizes or industrializes, certain types of disease begin to arise. The Canadian cardiologist William Osler, one of the founding professors of John’s Hopkins Hospital, documented the first “syndrome” associated with narrowing of the arteries causing heart disease at the turn of the 19th century, and in 1912, the American Cardiologist James Herrick is credited with the discovery that narrowed arteries cause angina, a form of chest pain with exertion.
Today we know that underlying each of these diseases is the phenomenon of insulin over production, which seems to arise between five and twenty years prior to the onset of the Diseases of Civilization. Metabolic Syndrome, Dysmetabolic Syndrome or Syndrome X is the name we’ve given to the presentation of three or more of these diseases at once in one person. There is still argument as to whether insulin over production is the chicken or the egg, but what I see clinically has convinced me that insulin is culprit.
Insulin is a very powerful hormone that acts as a key, opening a door in just about every cell in the body, letting glucose (the primary form of fuel derived from carbohydrate) into the cell. For reasons that appear to be genetic, this key becomes “dull” in a portion of the population and does not unlock the door fast enough to lower the blood sugar. So, the body panics, and stimulates production of additional insulin, 2-10 times more in many people. However, the insulin that was produced initially, eventually kicks in. This extra insulin, acting at a slower rate, is the underlying culprit to the Diseases of Civilization.
How, you ask? Let me explain.
Insulin does more than just open the door for glucose.
1. Insulin causes weight gain. It turns on the storage of fat by activating an enzyme called lipoprotein lipase, pulling the triglycerides out of the cholesterol molecules and depositing them in the adipose tissue (fat cells).
2. Insulin raises cholesterol. It drives increased triglyceride production in the liver, especially in the presence of fructose.
3. Insulin triggers atherosclerosis. Triglycerides are essentially the passenger in the LDL (bad cholesterol) molecule. Higher triglycerides cause increased LDL production leading to increased atherosclerosis (narrowing of the arteries).
4. Insulin causes gout & kidney stones. Insulin increases uric acid production and in a round about way can increase calcium oxylate as well, increasing the risk of kidney stones and gout.
5. Insulin raises blood pressure. Insulin stimulates the retention of sodium, causing and increase in blood pressure.
6. Insulin makes inflammation worse. Insulin drives the inflammatory cascade and increases free radicals, and stimulates the inflammatory hormones causes arthritis, allergic rhinitis, psoriasis, dermatitis, and inflammatory bowel problems to be amplified.
My intent is not to demonize insulin. It is an essential hormone, however, when five to ten times the normal amount of insulin is being produced, you’re going to amplify the problems above by five to ten times normal. Type II Diabetes is really just a consequence of 15-20 years of over production of insulin.
This isn’t just something that affects humans. either. We have been seeing this in other species of the animal kingdom as well. Take for example my wife’s horse, Jazz. She’s a beautiful grey Arab/Saddle-Bred who kept having problems with laminitis, or more colloquially known as “founder.” Her diet consisted predominantly of alfalfa at the time, considered a moderate starch containing form of feed.
Laminitis is a progressively increasing tenderness to the hoof of horses or cattle that can be disabling and if not treated appropriately can cause permanent lameness in the animal. Recent literature in the veterinary world have identified that animal diets high in starch have a propensity to cause laminitis as well as colic. First identified in the equine community in the 1980’s with glucose tolerance tests, insulin resistance has been identified as a significant factor in hoof disease. The use of Corn, Oats, Barley or even Alfalfa as a primary form of feed for a horse with insulin resistance greatly increases the risk of laminitis.
Like Jazz, many horses in the arid Arizona climate are fed primarily with oats and alfalfa. Jazz was tested and found to have insulin resistance. Since Jazz has been placed on a much lower starch containing feed, she has had no further problems with laminitis. We converted all our horses to Bermuda grass.
Our family and our horses are all now on Low-Carb diets to some degree and have been for the last seven years. No further hoof problems with the horses, and 55 lbs of weight loss with normalization of cholesterol in their owner, me.
For those with interest, studies reveal feeds in order of the highest to lowest starch (carbohydrate) content to be: Sweet Feed, Corn, Oats, Barley, Wheat Bran, Beat Pulp, Alfalfa, Rice Bran, Soybean hulls, Bermuda Grass. Take a look the Low Carbohydrate help section in the menu above to see the carbohydrate content of many of the foods for human consumption.
It’s time we recognize that our diet and lifestyles have lead us to the Diseases of Civilization, and those diets and lifestyles have even effected our animals.
When you visit your doctor, he or she will probably measure your height and your weight. Then a Body Mass Index (BMI) will be calculated and placed on your chart. The BMI has actually become one of the standard “vital signs” required at a doctor visit over the last five years. This was not something that physicians started measuring on their own, it is a required measurement most health insurance plans insist upon before they will pay for the visit. BMI is an interesting and arguably worthless measurement. It was developed by a Belgian physicist by the name of Adolphe Quetelet some time between 1830-1850. Quetelet was a “Social Physicist,” trying to combine probability and statistics with the study of sociology (1). BMI was originally called the “Quetelet Index” and was designed specifically to measure averages among large populations in sociology or epidemiological studies (2).
BMI = mass (kg) / [height (m)]²
However, it wasn’t Quetelet that got BMI placed on the medical chart. BMI was made popular by the infamous Ancel Keys (the same Ancel Keys responsible for the flawed Seven Countries Study) in his July 1972 article published in the Journal of Chronic Disease. Ancel Keys, himself, explicitly stated that BMI was designed specifically for population studies, and inappropriate for evaluation of individual health (2). But, because of the ease of measurement, and the fact that Life Insurance companies had been using BMI to set your insurance premiums since the 1970’s, Health Insurance companies adopted it as a measure of overall health. In 1985, because BMI found great favor in epidemiological research, the National Institutes of Health (NIH) adopted it as the method to identify and define obesity in patients. And, in 1998 the NIH identified the BMI cutoffs – 25 for overweight, 30 for obesity – as easy numbers that could be remembered and used to counsel patients on weight reduction and health.
The problem with BMI is that it doesn’t actually identify a person with excessive fat accumulation. BMI is a height to weight ratio. It doesn’t account for fat at all. Using the NIH guidelines, the Terminator, with an estimated BMI of 31, would be considered obese. (You try telling the Terminator that he is obese, and see what happens.) Because, muscle weighs twice as much when compared to an identical volume of fat, Mr. Schwarzenegger (or anyone with increased muscle mass), will have a higher scale weight. This raises the BMI calculation, giving a false indication of increased health risk.
I was recently asked about a study published in The American Journal of Medicine that was recently commented on in Scientific American regarding BMI vs Muscle Mass as a predictor of longevity. The assumption is that just because your doctor measures BMI, it must be a great tool predicting health outcomes. The assumption is absolutely wrong. We know from multiple studies, including the article sited above, that increase muscle mass increases overall health, decreases the likelihood of insulin resistance and diabetes, reduces the risk of heart disease, and extends longevity. How can a measure of height to weight predict longevity? It can’t. The only reason BMI is on the medical chart, thanks to the NIH, is so that the physician gets paid. 
In actuality, the most effective way of measuring a persons health is to simply measure body fat. This can easily be done by measuring waist circumference with an inexpensive tape measure. It can also be done with a simple bioelectrical impedance measurement. The gold standard for measuring body fat is to strip you down naked and dip you in a tub of water, measuring the water displacement. (I have very few patient’s that will return to my office after doing that, so we don’t use it very often, but it is effective).
The answer to the question is “NO,” the Terminator is NOT obese. And, if he shows up in my office, I’m not going to comment about his BMI.
1. Eknoyan, Garabed (2007). “Adolphe Quetelet (1796–1874)—the average man and indices of obesity”. Nephrology Dialysis Transplantation 23 (1): 47–51.
2. Keys, Ancel; Fidanza, Flaminio; Karvonen, Martti J.; Kimura, Noboru; Taylor, Henry L. (1972). “Indices of relative weight and obesity”. Journal of Chronic Diseases 25 (6–7): 329–43
Many patients come to my office desiring to loose weight, but complain of no self-control. They feel they cannot loose weight because they don’t have the willpower. Willpower, or self-control, is an elusive and mysterious thing. “If only I had more self-control,” I hear people say, “I could . . . ” exercise regularly, eat right, avoid drugs and alcohol, save for retirement, stop procrastinating, achieve a noble goal, or loose weight. A 2011 American Psychological Association study reveals that almost 30% of those interviewed felt that lack of willpower was the greatest barrier to making a change in any of these areas.
So what is “willpower” or “self-control?” It is the ability to resist short-term temptations in order to fulfill a long-term goal. 
I meet and work with people every day who feel they have no willpower. In actuality, will power and self-control are learned behaviors that develop over time. Anyone can have willpower, you just have to understand how willpower in certain areas can be strengthened and what makes it weak. In fact, a 2005 study showed that self-discipline or willpower was more important than IQ in academic successes. This study also found that increased self-discipline lead to less binge eating, higher self-esteem, higher grade point averages, better relationship skills and less alcoholism. Fascinating isn’t it!?
The answer can be found in a quote from Henry P Liddon, “What we do upon some great occasion will probably depend on what we already are; and what we are will be the result of previous years of self-discipline.” This means that willpower or self-control can be learned or improved. How, you ask?
First, you must establish and write down a reason or motivation for change. In addition, that change must fulfill a clear goal. Just wanting to loose weight isn’t good enough. You have to be motivated because of a consequence that arises from the obesity or overweight. And, you “loosing weight” isn’t a clear goal. You must set a weight reduction goal. It has to be clearly written down with your motivational reason. Willpower or self-control cannot begin to form until these two steps occur.
Second, you must begin to monitor your behavior toward that goal. When it comes to weight loss, I ask every one of my patient’s to keep a diet journal. In this journal they are asked to write down every thing they eat and drink. The night before, they are to write down their plan for tomorrow’s meals, then the next evening, they account for their success or failure by journaling on that same page what they actually ate and drank, then after comparing what they did, they plan for tomorrow and journal why they were successful or why they weren’t. It’s the last part that is so powerful, a short 3-5 minutes of self-introspection. Self-introspection is the key to behavioral change. It is the key that allows a person to see their habits and then make very small changes that break bad habits, solidify good habits and strengthens willpower.
Third, willpower is developed over time. It is developed by being accountable to ones-self on very little things every single day. But it MUST be written down. If I planned to eat bacon and eggs for breakfast and I didn’t, why? When I look at my day, I may realize that I went to bed too late to get up early and cook bacon and eggs. So, instead, I ate a yogurt that was in the fridge. I am accountable to myself. If I plan to eat bacon and eggs tomorrow, I must either go to bed earlier, prepare them the night before, or throw out the yogurt . . . so not to be a temptation again. This is written down and I make a very small change tomorrow.
Over time, this self-introspection becomes easier and easier, to the point that you do it sub-consciously. It is this sub-conscious self-introspection and change will be seen by others as self-control or willpower. Just like a working or strengthening a muscle, recording short goals and and accounting for them makes your self-discipline stronger. The self-discipline muscle becomes more powerful. In time, a split second decision not to binge on that piece of cake will be seen as strong willpower by those around you. You’ll recognize that it’s just flexing your self-discipline muscle.
So, my next question to you is . . . where’s your diet journal?
