Tags Posts tagged with "Obesity"

Obesity

Studies have shown that eating grapefruit reduces your risk of developing diabetes.
Be wary of ‘no sugar added’ labels

By David Dunaief, M.D.

Dr. David Dunaif

We should all reduce the amount of added sugar we consume because of its negative effects on our health. It is recommended that we get no more than 10 percent of our diet from added sugars (1). However, we are consuming at least 30 percent more added sugar than is recommended (2).

Is all sugar bad for us? The answer is not straightforward. It really depends on the source, and when I mention “source,” my meaning may surprise you.

We know that white, processed sugar is bad. But, I am constantly asked which sugar source is better: honey, agave, raw sugar, brown sugar or maple syrup. None are really good for us; they all raise the level of glucose (a type of sugar) in our blood.

Two-thirds of our sugar intake comes from processed food, while one-third comes from sweetened beverages, according to the most recent report from the Centers for Disease Control and Prevention. (2) Sweetened beverages are defined as sodas, sports drinks, energy drinks and fruit juices. That’s right: Even 100 percent fruit juice can raise glucose levels. Don’t be deceived by “no added sugar” labels.

These sugars increase the risk of, and may exacerbate, chronic diseases, such as diabetes, heart disease, high blood pressure, cancer and obesity. This is such a significant problem that several legislative initiatives have been introduced that would require a warning label on sweetened drinks (3).

However, I did say that sugar’s source impacts its effect. Most fruits have beneficial effects in preventing disease, including diabetes, and do not raise sugar levels, even in patients with diabetes. It is a myth that whole fruit raises your sugar levels. However, dried fruits, fruit juice and fruit juice concentrate do raise your sugar levels. Note that sugar extracted from fruit has an effect similar to that of sugar added to foods and sweetened beverages. Let’s look at the evidence.

Heart disease

When we think of sugar’s effects, heart disease is not usually the first disease that comes to mind. However, results from a 20-year study of 31,000 U.S. adults showed that, when comparing those who consumed the least amount of added sugar (less than 10 percent of calories daily) with those who consumed 10 to 25 percent and those who consumed more than 25 percent of daily calories from sugar, there were significant increases in risk of death from heart disease (4). The added sugar was from foods and sweetened beverages, not from fruit and fruit juices. This was not just an increased risk of heart disease, but an increased risk of cardiovascular death. This is a wake-up call to rein in our sugar consumption.

Obesity and weight gain

Does soda increase obesity risk? An assessment published in PLoS One, a highly respected, peer-reviewed journal, showed that it depends on whether studies were funded by the beverage industry or had no ties to any lobbying groups (5). Study results were mirror images of each other: Studies not affiliated with the industry show that soda may increase obesity risk, while studies funded by the beverage industry show there may not be any association.

In studies without beverage industry funding, greater than 80 percent (10 of 12) showed associations between sugary drinks and increased weight or obesity, whereas with the beverage industry-funded studies, greater than 80 percent of them did not show this result (5 of 6). The moral of the story is that patients must be diligent in understanding how studies are funded; and if the results sound odd, they probably are. If this is the case, make sure to ask your doctor about the studies’ findings. Not all studies are equally well designed.

Diabetes and the benefits of fruit

Diabetes requires the patient to limit or avoid fruit altogether. Correct? This may not be true. Several studies may help change the long-standing, commonly held paradigm that fruit should be restricted in patients with diabetes and to prevent development of diabetes.

One study found that whole fruit may reduce the risk of diabetes by reducing inflammation and reducing insulin resistance (6). Specifically, results demonstrated a reduction in the inflammatory biomarker hsCRP. Ultimately, this may result in better glucose control. A potential reason for these impressive results may be the high levels of flavonoids, specifically anthocyanins and flavones.

Flavonoids, as a class, are phytochemicals (plant nutrients) that provide pigment to fruits and vegetables and may have substantial antioxidant activities. Substances that are high in these two flavonoids include red grapes, berries, tea and wine.

Another study, a meta-analysis that looked at three large studies, including the Nurses’ Health Study, NHS II, and the Health Professionals Follow-up Study, showed that those who consumed the highest amount of anthocyanins were likely to experience a 15 percent reduction in the development of type 2 diabetes (7). Researchers compared those in the highest quintile of anthocyanin consumption with those in the lowest quintile.

Specifically, at least two servings of blueberries per week were shown to reduce the risk of diabetes by 23 percent, and at least five servings of apples and pears per week were also shown to reduce the risk by 23 percent. These were compared to those who consumed less than one serving per month. This is a small amount of fruit for a significant reduction.

From the same three studies, it was also shown that grapes, bananas and grapefruit reduce the risk of diabetes, while fruit juice and cantaloupe may increase risk (8).

In still another diabetes study, involving those who were newly diagnosed with type 2 diabetes, the risk of increasing glucose levels was no greater in those who consumed more than two servings of fruit per day, when compared to those who consumed fewer than two servings per day (9).

The properties of flavonoids, which are found in whole fruit, may also result in anticancer and anticardiovascular disease properties, the opposite effect of added sugars (10).

Chronic disease incidence and complications from these diseases have skyrocketed in the last several decades. Therefore, any modifiable risk factor should be utilized to decrease our risk. By keeping added sugar to a minimum in our diets, we could make great strides in the fight to maintain our quality of life as we age.

We don’t have to avoid sugar completely; we still can satiate a sweet tooth by eating ripe fruits. Our access to fruit, even off-season, has expanded considerably. The most amazing thing is that fruit may actually reduce the risk of diabetes, something we thought for years might exacerbate it.

References: (1) health.gov: Dietary Guidelines for Americans 2015-2020, eighth edition. (2) cdc.gov. (3) reuters.com. (4) JAMA Intern Med. online Feb 3, 2014. (5) PLoS Med. 2013 Dec;10(12):e1001578. (6) J Nutr. 2014 Feb;144(2):202-208. (7) Am J Clin Nutr. 2012 Apr;95(4):925-933. (8) BMJ. online Aug 29, 2013. (9) Nutr J. published online March 5, 2013. (10) Plant Foods Hum Nutr. 2004 Summer;59(3):113-122.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

Taking a 20-minute power walk at lunchtime has numerous health benefits. Stock photo
Are activity and exercise the same?

By David Dunaief, M.D.

Dr. David Dunaief

Let’s begin with a pretest. I want to make it clear that a pretest is not to check whether you know the information but that you have an open mind and are willing to learn.

1) Which may have the most detrimental impact on your health?

a.   Smoking

b.   Obesity

c.   Inactivity

d.   A and C

e.   All have the same impact

2) People who exercise are considered active.

a.   True

b.   False

3) Inactivity may increase the risk of what? Select all that apply.

a.   Diabetes

b.   Heart disease

c.   Fibromyalgia

d.   Mortality

e.   Disability

With the recent wave of heat and humidity, who wants to think about exercise? Instead, it’s tempting to lounge by the pool or even inside with air conditioning instead.

First, let me delineate between exercise and inactivity; they are not complete opposites. When we consider exercise, studies tend to focus on moderate to intense activity. However, light activity and being sedentary, or inactive, tend to get clumped together. But there are differences between light activity and inactivity.

Light activity may involve cooking, writing, and strolling (1). Inactivity involves sitting, as in watching TV or in front of a computer screen. Inactivity utilizes between 1 and 1.5 metabolic equivalent units — better known as METS — a way of measuring energy. Light activity, however, requires greater than 1.5 METS. Thus, in order to avoid inactivity, we don’t have to exercise in the dreaded heat. We need to increase our movement.

What are the potential costs of inactivity? According to the World Health Organization, over 3 million people die annually from inactivity. This ranks inactivity in the top five of potential underlying mortality causes (2). The consequences of inactivity are estimated at 1 to 2.6 percent of health care dollars. This sounds small, but it translates into actual dollars spent in the U.S. of between $38 billion and $100 billion (3).

How much time do we spend inactive? Good question. In an observational study of over 7,000 women with a mean age of 71 years old, 9.7 waking hours were spent inactive or sedentary. These women wore an accelerometer to measure movements. Interestingly, as BMI and age increased, the amount of time spent sedentary also increased (4).

Inactivity may increase the risk of mortality and plays a role in increasing risks for diseases such as heart disease, diabetes and fibromyalgia. It can also increase the risk of disability in older adults.

Surprisingly, inactivity may be worse for us than smoking and obesity. For example, there can be a doubling of the risk for diabetes in those who sit for long periods of time, compared to those who sit the least (5).

By the way, the answers to the pretest are 1) e; 2) b; 3) a, b, c, d and e.

Let’s look at the evidence.

Does exercise trump inactivity?

We tend to think that exercise trumps all; if you exercise, you can eat what you want and, by definition, you’re not sedentary. Right? Not exactly. Diet is important, and you can still be sedentary, even if you exercise. In a meta-analysis — a group of 47 studies — results show that there is an increased risk of all-cause mortality with inactivity, even in those who exercised (6). In other words, even if you exercise, you can’t sit for the rest of the day. The risk for all-cause mortality was 24 percent overall.

However, those who exercised saw a blunted effect with all-cause mortality, making it significantly lower than those who were inactive and did very little exercise: 16 percent versus 46 percent increased risk of all-cause mortality. So, it isn’t that exercise is not important, it just may not be enough to reduce the risk of all-cause mortality if you are inactive for a significant part of the rest of the day.

In an earlier published study using the Women’s Health Initiative, results showed that those who were inactive most of the time had greater risk of cardiovascular disease (7). Even those who exercised moderately but sat most of the day were at increased risk of cardiovascular disease. Moderate exercise was defined as 150 minutes of exercise per week. Those at highest risk were women who did not exercise and sat at least 10 hours a day. This group had a 63 percent increased risk of cardiovascular disease (heart disease or stroke).

However, those who sat fewer than five hours a day had a significantly lower risk of cardiovascular events. And those who were in the highest group for regular exercise (walking seven hours/week or jogging/running four to five hours/week) did see more benefit in cardiovascular health, even if they were inactive the rest of the day. Sitting longer did not have a negative impact on the individuals in the high exercise level group.

Worse than obesity?

Obesity is a massive problem in this country; it has been declared a disease, itself, and it also contributes to other chronic diseases. But would you believe that inactivity has more of an impact than even obesity? In an observational study, using data from the EPIC trial, inactivity might be responsible for two times as many premature deaths as obesity (8). This was a study involving 330,000 men and women.

Interestingly, the researchers created an index that combined occupational activity with recreational activity. They found that the greatest reduction in premature deaths (in the range of 16 to 30 percent) was between two groups, the normal weight and moderately inactive group versus the normal weight and completely inactive group. The latter was defined as those having a desk job with no additional physical activity. To go from the completely inactive to moderately inactive, all it took, according to the study, was 20 minutes of brisk walking on a daily basis.

All is not lost!

In another study, which evaluated 56 participants, walking during lunchtime at work immediately improved mood (9). This small study clearly shows that by lunchtime activity changed mood for the better, increasing enthusiasm and reducing stress when compared to morning levels, before participants had walked. Participants had to walk at least 30 minutes three times a week for 10 weeks; pace was not important.

So what have we learned thus far about inactivity? It is all relative. If you are inactive, increasing your activity to be moderately inactive by briskly walking for 20 minutes a day may reduce your risk of premature death significantly. Even if you exercise the recommended 150 minutes a week, but are inactive the rest of the day, you may still be at risk for cardiovascular disease. You can potentially further reduce your risk of cardiovascular disease by increasing your activity with small additions throughout the day.

The underlying message is that we need to consciously move throughout the day, whether at work with a walk during lunch or at home with recreational activity. Those with desk jobs need to be most attuned to opportunities to increase activity. Simply setting a timer and standing or walking every 30 to 45 minutes may increase your activity levels and possibly reduce your risk.

References: (1) Exerc Sport Sci Rev. 2008;36(4):173-178. (2) WHO report: http://bit.ly/1z7TBAF. (3) forbes.com. (4) JAMA. 2013;310(23):2562-2563. (5) Diabetologia 2012; 55:2895-2905. (6) Ann Intern Med. 2015;162:123-132, 146-147. (7) J Am Coll Cardiol. 2013;61(23):2346-2354. (8) Am J Clin Nutr. online Jan. 24, 2015. (9) Scand J Med Sci Sports. Online Jan. 6, 2015.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

A recent study showed that patients who are very obese could lose almost two decades of healthy living
Quality of life impacts are considerable

By David Dunaief, M.D.,

Dr. David Dunaief

The media is increasingly focused on covering obesity-related issues. With this in mind, let’s start off with a short quiz to test your knowledge of obesity-related issues. The answers and research are provided below. Regardless of your quiz score, it is important to understand the research.

1. Obesity reduces life span by up to:

A) Not at all

B) 4 years

C) 8 years

D) 10 years

2. Obesity shortens healthy years of life by:

A) 8 years

B) 12 years

C) 15 years

D) 20 years

3. Food cravings can be reduced for the short term by:

A) Counting to 20

B) Tapping your finger against your head

C) Watching TV

D) Texting on your cellphone

4. Obesity can lead to the following complication(s):

A) High blood pressure

B) Diabetes

C) Cancer

D) All of the above

Are you eager to find out the answers? I hope so, because there are some very salient points I am trying to make by providing multiple choice questions. The answers are: 1. D; 2. D; 3. B; 4. D. So how did you do? One of the questions was actually similar to a question on a medical website for doctors, so don’t be too hard on yourself if you did not get them all right. Let’s look at the research.

Mortality and effect on life span

Many of you know that obesity could have an impact on development of other chronic diseases and a decrease in quality of life, but to what extent? A 2013 study indicated that almost as many as one in five deaths in the U.S. is associated with obesity (1).

In a computer modeling study, the results showed that those who are obese may lose up to eight years, almost a decade, of their life span (2). But that is only part of the results. The other, more compelling result is that patients who are very obese, defined as a BMI >35 kg/m², could lose almost two decades of healthy living. According to the researchers, this means you may have diseases such as diabetes and cardiovascular disease. However, even those patients who were obese and those who were overweight also could have reductions in life span, up to 6 years and 3 years, respectively.

There were 3,992 adults between the ages of 20 and 79 evaluated in this study. The data was taken from an NHANES database from 2003 to 2010, which looked at participants who went on to develop diabetes and cardiovascular disease. Though this is not a clinical trial, and there is a need for more study, the results are eye-opening, with the youngest and very obese negatively impacted the most.

Cancer impact

Since it is very difficult to “cure” cancer, although hopefully someday soon we will, it is important to reduce modifiable risk factors. Obesity may be one of these contributing factors, although it is hotly debatable how much of an impact obesity has on cancer development.  The American Society of Clinical Oncologists (ASCO), in a position paper, supported the idea that it is important to treat obesity in the fight against cancer (3). The authors indicate obesity may make the prognosis worse, may hinder the delivery of therapies to treat cancer, and may increase the risk of malignancy.

Also, possibly reinforcing ASCO’s stance, a study suggested that upward of a half-million cases of cancer worldwide were related to being overweight or obese, with the overwhelming concentration in North American and Europe (4).

Possible solutions

A potential counterweight to both the reductions in life quality and life expectancy may be the Mediterranean diet. In a published analysis of the Nurses’ Health Study, results show that the Mediterranean diet helped slow shortening of the telomeres (5). Repeat sequences of DNA found at the end of chromosomes, telomeres, shorten with age; the shorter the telomere, the shorter life expectancy.

Thus, the Mediterranean diet may decrease occurrence of chronic diseases, increase life span and decrease premature mortality — hence, the opposite effect of obesity. In fact, it may help treat obesity, though this was not mentioned in the study. Interestingly, the effects of the Mediterranean diet were on a dose-response curve. The greater the adherence to the diet, rated on a scale of 0 to 9, the better the effect. Those who had an increase in adherence by three points saw a corresponding decrease in telomere aging by 4.5 years. There were 4,676 middle-aged women involved in this analysis. The researchers believe that the anti-inflammatory and antioxidant effects could be responsible for the diet’s effects.

According to an accompanying editorial, no individual component of the diet was identified as having beneficial effects by itself, so it may be the diet as a whole that is important (6).

Short-term solutions

There are easy-to-use distraction tactics that involve physical and mental techniques to reduce food cravings. These include tapping your foot on the floor, staring at a blank wall and, yes, alternating tapping your index finger against your forehead and your ear (7). The forehead and ear tapping was most effective, although probably most embarrassing in public. Among mental techniques, seeing pictures of foods that were unhealthy and focusing on their long-term detriments to health had the most impact (8). All of these short-term distractors were done for 30 seconds at a time. The results showed that in obese patients they indeed decreased food cravings.

Exercise impact

I have written about exercise and that it does not lead to fat percentage loss in adults. Well, before you write off exercise for fat loss, it seems that adolescents may benefit from exercise. In a randomized controlled trial, the gold standard of studies, results show that those in the resistance training group alone and those in a combined resistance and aerobic training group had significantly greater percentages of fat loss compared to a control group (9).

However, the aerobic group alone did not show a significant change in fat percent versus the control. There were 304 study participants, ages 14 to 18, followed for a six-month duration, and results were measured with MRI. The reason that resistance training was effective in reducing fat percentage may have to do with an increase in muscle mass rather than a decrease in actual fat. Still, exercise is important. It doesn’t matter if it decreases the fat percentage; it is still getting you to the goal.

Obesity can have devastating effects, from potentially inducing cancer or worsening it, to shortening life expectancy and substantially decreasing quality of life. Fortunately, there may be ways to help treat obesity with specific lifestyle modifications. The Mediterranean diet as a whole may be an effective step toward decreasing the burden of obesity and reducing its complications. Kids, teenagers specifically, should be encouraged to “Play 60,” as the NFL has encouraged, but also to do some resistance training. As we mentioned, there are simple techniques that may help reduce short-term food cravings.

References: (1) Am J Public Health. 2013;103:1895-1901. (2) The Lancet Diabetes & Endocrinology, online Dec. 5, 2014. (3) J Clin Oncol. 2014;32(31):3568-3574. (4) The Lancet Oncology. online Nov. 26, 2014. (5) BMJ. online Dec. 2, 2014. (6) BMJ 2014;349:g6843. (7) Obesity Week 2014 abstract T-2658-P. (8) Obesity Week 2014 abstract T-3023-OR. (9) JAMA Pediatr. 2014;168(11):1006-1014.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

Sedentary lifestyle increases risk in the young

By David Dunaief, M.D.

Dr. David Dunaief

First, the good news: We have made great strides in reducing mortality from heart attacks. When we compare cardiovascular disease — heart disease and stroke — mortality rates from 1975 to the present, there is a substantial decline of approximately one-quarter. However, if we look at these rates since 1990, the rate of decline has slowed (1).

Plus, one in 10 visits to the emergency room are related to potential heart attack symptoms. Luckily, only 10 to 20 percent of these patients actually are having a heart attack (2). We need to reduce our risk factors to improve this scenario.

Some risk factors are obvious, while others are not. The obvious ones include age (men at least 45 years old and women at least 55 years old), family history, high cholesterol, high blood pressure, obesity, sedentary lifestyle, diabetes and smoking. Less obvious risk factors include gout, atrial fibrillation and osteoarthritis. Lifestyle modifications, including a high-fiber diet and exercise, also may help allay the risks.

Let’s look at the evidence.

Obesity

On a board exam in medicine, if smoking is one of the choices with disease risk, you can’t go wrong by choosing it. Well, it appears that the same axiom holds true for obesity. But how substantial a risk factor is obesity? In the Copenhagen General Population Study, results showed an increased heart attack risk in obese

(BMI >30 kg/m²) individuals with or without metabolic syndrome (high blood pressure, high cholesterol and high sugar) and in those who were overweight (BMI >25 kg/m²) (3). The risk of heart attack increased in direct proportion to weight. Specifically, there was a 26 percent increase in heart attack risk for those who were overweight and an 88 percent increase in risk for those who were obese without metabolic syndrome. This study had a follow-up of 3.6 years.

It is true that those with metabolic syndrome and obesity together had the highest risk. But, it is quite surprising that obesity, by itself, can increase heart attack risk when a person is “metabolically healthy.” Since this was an observational trial, we can only make an association, but if it is true, then there may not be such thing as a “metabolically healthy” obese patient. Therefore, if you are obese, it is really important to lose weight.

Lifestyle modifications such as weight loss, physical activity and diet can help decrease the risk of heart attacks.

Sedentary lifestyle

If obesity were not enough of a wake-up call, let’s look at another aspect of lifestyle: the impact of being sedentary. A recent observational study found that activity levels had a surprisingly high impact on heart disease risk (4). Of four key factors — weight, blood pressure, smoking and physical inactivity — age was the determinant as to which one had the most negative effect on women’s heart disease risk. Those under the age of 30 saw smoking as most negatively impactful. For those over the age of 30, lack of exercise became the most dominant risk factor for heart disease, including heart attacks.

For women over the age of 70, the study found that increasing physical activity may have a greater positive impact than addressing high blood pressure, losing weight, or even quitting smoking. However, since high blood pressure was self-reported and not necessarily measured in a doctor’s office, it may have been underestimated as a risk factor. Nonetheless, the researchers indicated that women should make sure they exercise on a regular basis to most significantly reduce heart disease risk.

Osteoarthritis

The prevailing thought with osteoarthritis is that it is best to suffer with hip or knee pain as long as possible before having surgery. But when do we cross the line and potentially need joint replacement? Well, in a recent study, those with osteoarthritis of the hip or knee joints that caused difficulty walking on a flat surface were at substantially greater risk of cardiovascular events, including heart attack (5). Those who had surgery for the affected joint saw a substantially reduced heart attack risk. It is important to address the causes of osteoarthritis to improve mobility, whether with surgery or other treatments.

Gout

When we think of gout, we relate it to kidney stones. But gout increases the risk of heart attacks by 82 percent, according to an observational study (6). Gout tends to affect patients more when they are older, but the risk of heart attack with gout is greater in those who are younger, ages 45 to 69, than in those over 70. What can we do to reduce these risk factors?

There have been studies showing that fiber decreases the risk of heart attacks. However, does fiber still matter when someone has a heart attack? In a recent analysis using data from the Nurses’ Health Study and the Health Professional Follow-up Study, results showed that higher fiber plays an important role in reducing the risk of death after a heart attack (7). Those who consumed the most fiber, compared to the least, had a 25 percent reduction in post-heart attack mortality.

Even more impressive is the fact that those who increased their fiber after the cardiovascular event had a 31 percent reduction in mortality risk. In this analysis, it seemed that more of the benefit came from fiber found in cereal. The most intriguing part of the study was the dose-response. For every 10-g increase in fiber consumption, there was a 15 percent reduction in the risk of post-heart attack mortality. Since we get too little fiber anyway, this should be an easy fix.

Lifestyle modifications are so important. In the Nurses’ Health Study, which followed 120,000 women for 20 years, those who routinely exercised, ate a quality diet, did not smoke and were a healthy weight demonstrated a whopping 84 percent reduction in the risk of a cardiovascular event such as a heart attack (8).

What have we learned? We can substantially reduce the risk of heart attacks and even potentially the risk of death after sustaining a heart attack with lifestyle modifications that include weight loss, physical activity and diet — with, in this case, a focus on fiber. While there are a number of diseases that contribute to heart attack risk, most of them are modifiable. With disabling osteoarthritis, addressing the causes of difficulty with mobility may also help reduce heart attack risk.

References: (1) Heart. 1998;81(4):380. (2) JAMA Intern Med. 2014;174(2):241-249. (3) JAMA Intern Med. 2014;174(1):15-22. (4) Br J Sports Med. 2014, May 8. (5) Presented Research: World Congress on OA, 2014. (6) Rheumatology (Oxford). 2013 Dec;52(12):2251-2259. (7) BMJ. 2014;348:g2659. (8) N Engl J Med. 2000;343(1):16.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

Skip the cookies and milk this year and reach for a piece of fruit or vegetable instead.

By Dr. David Dunaief

Dear Santa,

This time of year, people around the world are no doubt sending you lists of things they want through emails, blogs, tweets and old-fashioned letters. In the spirit of giving, I’d like to offer you ­— and maybe your reindeer — some advice.

David Dunaief, M.D.

Let’s face it: You aren’t exactly the model of good health. Think about the example you’re setting for all those people whose faces light up when they imagine you shimmying down their chimneys. You have what I’d describe as an abnormally high BMI (body mass index). To put it bluntly, you’re not just fat, you’re obese. Since you are a role model to millions, this sends the wrong message.

We already have an epidemic of overweight kids, leading to an ever increasing number of type 2 diabetics at younger and younger ages. From 2005 to 2007, according to the CDC and NIH, the prevalence of diabetes increased by an alarming rate of three million cases in the U.S. The rate is only getting worse. It complicates the issue that approximately two-thirds of the U.S. population is overweight and/or obese. This is just one of many reasons we need you as a shining beacon of health.

Obesity has a much higher risk of shortening a person’s life span, not to mention quality of life and self-image. The most dangerous type of obesity is an increase in visceral adipose tissue, which means central belly fat. An easy way to tell if someone is too rotund is if a man’s waist line, measured from the navel, is greater than or equal to 40 inches and for a woman is greater than or equal to 35 inches. The chances of diseases such as pancreatic cancer, breast cancer, liver cancer and heart disease increase dramatically with this increased fat.

Santa, here is a chance for you to lead by example (and, maybe, by summer, to fit into those skinny jeans you hide in the back of your closet). Think of the advantages to you of being slimmer and trimmer. For one thing, Santa, you would be so much more efficient if you were fit. Studies show that with a plant-based diet, focusing on fruits and vegetables, people can reverse atherosclerosis, clogging of the arteries.

The importance of a good diet not only helps you lose weight but avoid strokes, heart attacks, peripheral vascular diseases, etc. But you don’t have to be vegetarian; you just have to increase your fruits, vegetables and whole grain foods significantly. With a simple change, like eating a handful of raw nuts a day, you can reduce your risk of heart disease by half. Santa, future generations need you. Losing weight will also change your center of gravity, so your belly doesn’t pull you forward. This will make it easier for you to keep your balance on those steep, icy rooftops.

Skiing is a great way to get fit.

Exercise will help, as well. Maybe for the first continent or so, you might want to consider walking or jogging alongside the sleigh. As you exercise, you’ll start to tighten your abs and slowly see fat disappear from your mid-section, reducing risk and practicing preventive medicine. Your fans everywhere leave you cookies and milk when you deliver presents. It’s a tough cycle to break, but break it you must. You — and your fans — need to see a healthier Santa. You might let slip that the modern Santa enjoys fruits, especially berries, and veggies, with an emphasis on cruciferous veggies like broccoli florets dipped in humus, which have substantial antioxidant qualities and can help reverse disease.

As for your loyal fans, you could place fitness videos under the tree. In fact, you and your elves could make workout videos for those of us who need them, and we could follow along as you showed us “12 Days of Workouts with Santa and Friends.” Who knows, you might become a modern version of Jane Fonda or Richard Simmons!

How about giving athletic equipment, such as baseball gloves, baseballs, footballs and basketballs, instead of video games? You could even give wearable devices that track step counts and bike routes or stuff gift certificates for dance lessons into people’s stockings. These might influence the recipients to be more active.

By doing all this, you might also have the kind of energy that will make it easier for you to steal a base or two in this season’s North Pole Athletic League’s Softball Team. The elves don’t even bother holding you on base anymore, do they?

The benefits to a healthier Santa will ripple across the world. Think about something much closer to home, even. Your reindeer won’t have to work so hard. You might also fit extra presents in your sleigh. And Santa, you will be sending kids and adults the world over the right message about taking control of their health through nutrition and exercise. That’s the best gift you could give!

As you become more active, you’ll find that you have more energy all year round, not just on Christmas Eve. If you start soon, Santa, maybe by next year, you’ll find yourself parking the sleigh farther away and skipping from chimney to chimney.

Wishing you good health in the coming year,

David

P.S. I could really use a new baseball glove, if you have a little extra room in your sleigh.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

Exercise and diet are key to losing weight.

By David Dunaief, M.D.

The more we seem to know about obesity as a chronic disease, classified this way first by the American Medical Association, the worse we in the medical community seem to have done to prevent and treat it and its complications. There are more obese people now than those who are overweight (1). Why would it be so difficult to treat a disease that has a simple solution, lose weight? How hard could that be, right?

If it were so simple to lose weight, we would not have an epidemic on our hands. We compete with internal and external forces, including forces from the food industry working to influence us every day. What is the problem with being obese? The issue with weight is not about vanity. The issue is that obesity creates medical complications and is second only to smoking in causing premature deaths (2). The research implies that weight loss in obese patients reduces the risk of death (3).

Life-threatening complications from obesity include multiple cancers, heart disease, stroke, diabetes, and nonalcoholic fatty liver disease. Is there something we can do about it? Simply, yes. Weight loss may have to do, at least in part, with the timing of when we eat. Also, exercise may help us increase lean muscle mass while decreasing body fat. Diet, of course, is important. A Mediterranean diet has only been shown to help with weight loss, not contribute to weight gain. There is too much doom and gloom about obesity. We need to focus on possible solutions first! Let’s look at the research.

Timing! Timing! Timing!

We have always been told not to eat late at night. Is there some truth to this, or is it an old wives’ tale? Well, it may be partially true; however, it may have more to do with how many hours we have access to food during a 24-hour period. Let me explain. In a recent study involving mice, results showed that those mice restricted to a 12-hour food consumption period in a 24-hour day were thinner than those allowed to eat anytime during the 24 hours. They may also have had reversal of metabolic disease, such as type 2 diabetes, in those mice who had pre-existing disease (4). Those that had access 24/7 became more obese and chronically ill. It did not matter which diet the mice ate.

Timing/access to food was the most important factor over the 38-week study. In fact, those that were initially given 24-hour access and then switched to the 12-hour limited access actually lost weight! Surprisingly, those that were limited to 12-hour food access could even cheat occasionally on the weekends, and it did not have a negative impact on their results. There were four diet groups — high fat and sucrose (a type of sugar), high fat, high fructose and typical diet. Of course, we are not mice. However, these are encouraging results.

Restricting eating to 12 consecutive hours during the day doesn’t seem like too much of a hardship. Now we need a randomized controlled trial in humans. In the meantime, I would suggest implementing these findings, even though we are not mice. There is no downside. In a previous study by the same research group, results showed that mice who had eight hours of access to food during a 24-hour period also showed considerably better results than those that had 24-hour access (5). Both mice groups were fed high-fat diets. The only difference was that one group was time restricted to eight hours of food exposure. The food-restricted mice saw an increase in prevention of metabolic parameters including diabetes, obesity and liver disease. The results also showed that restricting time to food decreased inflammation and improved energy expenditure. However, eight hours is more difficult to manage than 12 hours of access to food in a 24-hour cycle.

Mediterranean-type diet to the rescue

The Mediterranean diet has been valuable for a number of different chronic diseases, and obesity is no exception. In a meta-analysis (involving 16 randomized controlled trials, the gold standard of studies), the results showed that the Mediterranean-type diet was significantly better at helping patients lose weight when compared to a control diet (6). The longer the participants were on a Mediterranean-type diet, the greater the weight loss. Thus, this type of diet seems to get better with time. The meta-analysis involved over 3,000 participants. In none of the studies did any group on the Mediterranean diet gain weight.

Cancer is a weighty topic

We are always looking for cures for cancer. It is one of the more prevalent conglomerations of diseases. What might exacerbate cancer risk? If you guessed obesity, you would be right. Interestingly, it may have to do with duration of obesity that increases risk for cancer. This applies to multiple types of cancer. In a recent study, results showed that eight more cancers are associated with being overweight and obese, according to the International Agency for Research on Cancer (IARC), including mostly gastrointestinal cancers (liver, gallbladder, stomach and pancreas), as well as meningioma, thyroid, multiple myeloma and ovarian cancers (7). As we know, ovarian and pancreatic cancers tend to present with symptoms in the later stages and so are more lethal. This is added to the five cancers already known to be associated with obesity: esophageal, colorectal, uterine and post-menopausal breast cancers, plus renal cell carcinoma (kidney cancer).

The reasons for this association may have to do with the dysregulation of sex hormone breakdown and increased inflammation associated with body fat. According to the IARC, losing weight may be a way to reduce cancer risk, although studies that have shown this effect have been animal studies. However, this is pretty good motivation to lose weight. In another study, the results show the longer the duration of obesity, the greater the risk of developing cancer (8). According to the study results, for every 10 years of being overweight/obese, there was an additional 7 percent increase in the risk for several different cancers. The study involved over 70,000 postmenopausal women for a mean duration of 12.6 years.

Finally, the beverage industry’s black eye

A recent scientific review found that Coca-Cola and PepsiCo have spent millions and millions of dollars trying to influence medical organizations and public health institutions. They have put these groups in precarious situations by offering them money to help fund their organizations’ work, while asking them to back down on pressing issues such as a soda tax (9). The American Academy of Nutrition and Dietetics is, unfortunately, an example. However, the Institute of Medicine (IOM) has said that research shows soda has a strong association with the obesity epidemic (10). The moral of the story: We can and need to do a better job treating obese patients. One possible way to lose weight may be to restrict our access to food to the same 12-hour period each 24-hour cycle. Also, a Mediterranean diet has only been shown to cause weight loss, not weight gain.

References: (1) cdc.gov. (2) Lancet. online July 13, 2016. (3) Obes Rev. 2007;8(6):503-513. (4) Cell Metab. 2014;20(6): 991–1005. (5) Cell Metab. 2012;15(6):848-860. (6) Metab Syndr Relat Disord. 2011 Feb;9(1):1-12. (7) N Engl J Med. 2016;375:794-798. (8) PLoS Med. online August 16, 2016. (9) Am J Prev Med. online October 10, 2016. (10) hsph.harvard.edu/nutritionsource/sugary-drinks-fact-sheet.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.

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We didn’t make up that headline. That is the name of an actual recent military study, the second of its kind, that found at least 9 million American youths are too overweight to serve in the armed forces.

That’s about a quarter of our young people between ages 17 and 24, according to population statistics from the U.S. Census Bureau.

Being overweight or obese is the top medical reason preventing young people from enlisting, according to the military study. One retired Army general called childhood obesity “a potential threat to our national security” in the future.

In case anyone was unsure of whether we have a weight or obesity problem in this country, that fact should really hammer it home. The military study gives a snapshot of what is occurring throughout our entire nation.

The problem is parents.

Some may feel outrage to see this blunt statement in ink, but the fact is that parents are responsible for teaching their kids, partly by example and partly by directive, how to eat healthy and live a healthy lifestyle that includes physical activity.

It’s true there is a degree of health and nutrition education in schools and, of course, schools should strive to offer healthy food in their breakfast and lunch programs. However, school districts should only be supplementing what parents are supposed to do in their own homes. An obvious reason for this is that children spend a tremendous amount of time with their parents and learn the most from them and their examples throughout their lives. And it is up to parents to raise their children and show them how to make good decisions, not the public school system.

Of course there are medical conditions that cause weight gain, such as hypothyroidism and Cushing’s syndrome, and complicate matters. But those conditions — both of which are much more prevalent in females than males, who are the primary target for military recruitment — certainly do not account for anywhere near all of the overweight young people. In fact, both conditions are more likely to affect older people than children and young adults.

Some may argue that it’s hard to teach kids about proper nutrition when they are bombarded by fast food ads, or when the parents are busy working to support the family. But we’re not saying parenting is easy — we’re saying it’s a parent’s job.

Teaching kids how to eat healthy and exercise is important and many parents need to step up their game, or it’s not just our military recruitment numbers that will suffer.

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Weight loss should be a rather simple concept.  It should be solely dependent on energy balance: the energy (kilocalories) we take in minus the energy (kilocalories) we burn should result in weight loss if we burn more calories than we consume. However, it is much more complicated. Frankly, there are numerous factors that contribute to whether people who want to or need to lose weight can.

The factors that contribute to weight loss may depend on stress levels, as I noted in my previous article, “Ways to counter chronic stress.” High stress levels can contribute to metabolic risk factors such as central obesity with the release of cortisol, the stress hormone. (1)  Therefore, hormones contribute.

Another factor in losing weight may have to do with our motivators.  We will investigate this further. And we need successful weight management, especially when approximately 70 percent of the American population is overweight or obese and more than one-third is obese. (2)

Recently, obesity in and of itself was proclaimed a disease by the American Medical Association. Even if you don’t agree with this statement, excess weight has consequences, including chronic diseases such as cardiovascular disease, diabetes, osteoarthritis and a host of others, including autoimmune diseases.  Weight has an impact on all-cause mortality and longevity.

It is hotly debated as to which approach is best for weight loss.  Is it lifestyle change with diet and exercise, medical management with weight loss drugs, surgical procedures, or even supplements? The data show that, while medication and surgery may have their places, they are not replacements for lifestyle modifications; these modifications are needed no matter what route is followed.

But, the debate continues as to which diet is best. We would hope patients would not only achieve weight loss, but also overall health.

Let’s look at the evidence.

LOW-CARBOHYDRATE DIETS VS. LOW-FAT DIETS
Is a low-carbohydrate, high-fat diet a fad?  It may depend on diet composition.  In a newly published study of a randomized controlled trial (RCT), the gold standard of studies, results showed that a low-carbohydrate diet was significantly better at reducing weight than low-fat diet, by a mean difference of 3.5 kg lost (7.7 lbs.), even though calories were similar and exercise did not change. (3)
The authors also note that the low-carbohydrate diet reduced cardiovascular disease risk factors in the lipid (cholesterol) profile, such as decreasing triglycerides (mean difference 14.1 mg/dl) and increasing HDL (good cholesterol). Patients lost 1.5 percent more body fat on the low-carbohydrate diet, and there was a significant reduction in inflammation biomarker, C-reactive protein (CRP). There was also a reduction in the 10-year Framingham risk score. However, there was no change in LDL (bad cholesterol) levels or in truncal obesity in either group. This study was 12 months in duration with 148 participants, predominantly women, with a mean age of 47, none of whom had cardiovascular disease or diabetes, but all of whom were obese or morbidly obese (BMI 30-45 kg/m2).
Although there were changes in biomarkers, there was a dearth of cardiovascular disease clinical endpoints.  This begs the question; does a low-carbohydrate diet really reduce the risk of developing cardiovascular disease (CVD) or its subsequent complications?  The authors indicated this was a weakness since it was not investigated.
Digging deeper into the diets used, it’s interesting to note that the low-fat diet was remarkably similar to the standard American diet; it allowed 30 percent fat, only 5 percent less than the 35 percent baseline for the same group.  In addition, it replaced the fat with mostly refined carbohydrates, including only 15 to 16 g/day of fiber.
The low-carbohydrate diet participants took in an average of 100 fewer calories per day than participants on the low-fat diet, so it’s no surprise that they lost a few more pounds over a year’s time.
Patients in both groups were encouraged to eat mostly unsaturated fats, such as fish, nuts, avocado and olive oil.
As David Katz, M.D., founding director of Yale University’s Prevention Research Center noted, this study was more of a comparison of low-carbohydrate diet to a high-carbohydrate diet than a comparison of a low-carbohydrate diet to a low-fat diet. (4)
Another study actually showed that a Mediterranean diet, higher in fats with nuts or olive oil, compared to a low-fat diet showed a significant reduction in cardiovascular events- clinical endpoints not just biomarkers. (5)  However, both of these studies suffer from the same deficiency: comparing a low-carbohydrate diet to a low-fat diet that’s not really low-fat.

DIET COMPARISONS
Interestingly, in a meta-analysis (a group of 48 RCTs), the results showed that whether a low-carbohydrate diet (including the Atkins diet) or a low-fat diet (including the Ornish plant-based diet), the results showed similar amount of weight loss compared to no intervention at all. (6)  Both diet types resulted in about 8 kgs. (17.6 lbs.) of weight loss at six months versus no change in diet.  However, this meta-analysis did not make it clear whether results included body composition changes or weight loss alone.
In an accompanying editorial discussing the above meta-analysis, the author points out that it is unclear whether a low-carbohydrate/high animal protein diet might result in adverse effects on the kidneys, loss of calcium from the bones, or other potential deleterious health risks.  The author goes on to say that for overall health and longevity and not just weight loss, micronutrients may be the most important factor, which are in nutrient-dense foods.
A recent Seventh-day Adventist trial would attest to this emphasis on a micronutrient-rich, plant-based diet with limited animal protein.  It resulted in significantly greater longevity compared to a macronutrient-rich animal protein diet. (7)

PSYCHE
Finally, the type of motivator is important in whatever our endeavors.  Weight loss goals are no exception.  Let me elaborate.  A recently published study followed West Point cadets from school to many years after graduation and noted who reached their goals. (8)  The researchers found that internal motivators and instrumental (external) motivators were very important.  The soldiers who had an internal motivator, such as wanting to be a good soldier, were more successful than those who focused on instrumental motivators, such as wanting to become a general.   Those who had both internal and instrumental motivators were not as successful as those with internal motivators alone.  In other words, having internal motivators led to an instrumental consequence of advancing their careers.
When it comes to health, an instrumental motivator, such weight loss, may be far less effective than focusing on an internal motivator, such as increasing energy or decreasing pain, which ultimately could lead to an instrumental consequence of weight loss.
There is no question that dietary changes are most important to achieving sustained weight loss. However, we need to get our psyches in line for change. Hopefully, when we choose to improve our health, we don’t just focus on weight as a measure of success.  Weight loss goals by themselves tend to lead us astray and to disappoint, for they are external motivators.  Focus on improving your health by making lifestyle modifications.  This tends to result in a successful instrumental consequence.

REFERENCES
(1) Psychoneuroendocrinol. online 2014 April 12.  (2) JAMA 2012;307:491–497.  (3) Ann Intern Med. 2014;161(5):309-318.  (4) Huffington Post. Sept 2, 2014.  (5) N Engl J Med. 2014 Feb 27;370(9):886.  (6) JAMA. 2014;312(9):923-933.  (7) JAMA Intern Med. 2013;173:1230-1238.  (8) Proc Natl Acad Sci U S A. 2014;111(30):10990-5.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website www.medicalcompassmd.com and/or consult your personal physician.

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