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Focus less on balancing protein, carbohydrates and fats

By David Dunaeif, M.D.

Dr. David Dunaief

The road to weight loss, or even weight maintenance, is complex. There are many things that influence our eating behavior, including food addictions, boredom, lack of sleep and stress.

Knowing a food’s caloric impact doesn’t always matter, either. Studies assessing the impact of nutrition labeling in restaurants gave us a clear view of this issue: knowing an item’s calories either doesn’t alter behavior or can actually encourage higher calorie purchases (1, 2). The good news is that controlling weight isn’t solely about exercising willpower. Instead, we need to change our diet composition.

In my clinical experience, increasing food quality has a tremendous impact. Focusing on foods that are the most micronutrient dense tends to be the most satisfying, rather than focusing on foods’ macronutrient density, such as protein, carbohydrates and fats. In a week to a few months of emphasizing micronutrients, one of the first things patients notice is a significant reduction in cravings.

Are refined carbohydrates bad for you?

Generally, we know that refined carbohydrates don’t help. Looking deeper, a small, randomized control trial (RCT) showed refined carbohydrates actually may cause food addiction (3). Certain sections of the brain involved in cravings and reward are affected by high-glycemic foods, as shown with MRI scans of trial subjects.

Study participants consumed a 500-calorie shake with either a high-glycemic index or a low-glycemic index. They were unaware of which they were drinking. The ones who drank the high-glycemic shake had higher levels of glucose in their blood initially, followed by a significant decline in glucose levels and increased hunger four hours later. The region of the brain that is related to addiction, the nucleus accumbens, showed a spike in activity with the high-glycemic intake.

According to the authors, this effect may occur regardless of the number of calories consumed. Commonly found high-glycemic foods include items like white flour, sugar and white potatoes. The conclusion: Everyone, but especially those trying to lose weight, should avoid refined carbohydrates.

What’s the right balance of protein, carbohydrates and fats?

We tend to focus on macronutrients — protein, carbohydrates, and fats — when we look at diets. Which has the greatest impact on weight loss? In an RCT, when comparing different macronutrient combinations, there was very little difference among study groups, nor was there much success in helping obese patients reduce their weight (4, 5). Only 15 percent of patients achieved a 10 percent reduction in weight after two years.

The four different macronutrient diet combinations involved overall calorie restriction. In addition, each combination had either high protein, high fat; average protein, high fat; high protein, low fat; or low protein, low fat. Carbohydrates ranged from low to moderate (35 percent) in the first group to high (65 percent) in the last group. This was another well-designed study, involving 811 participants with an average BMI of 33 kg/m², which is classified as obese.

Focusing primarily on macronutrient levels and calorie counts did very little to improve results.

What’s the relationship between           micronutrients and weight?

In an epidemiological study looking at National Health and Nutrition Examination Survey data, results demonstrate that those who are overweight and obese tend to be micronutrient-deficient (6). Micronutrients include carotenoids, such as lutein, zeaxanthin, beta-carotene, alpha-carotene and beta-cryptoxanthin, as well as vitamin B12, folate and vitamins C, E and D.

Unfortunately, taking supplements doesn’t solve the problem; generally, micronutrients from supplements are not the same as those from foods. With a few exceptions, such as vitamin D and potentially B12, most micronutrient levels can be raised without supplementation, by increasing the variety of foods in your diet. Please ask your doctor.

Long-term benefits of reducing              cortisol levels

Cortisol raises blood-levels of glucose and is involved in promoting visceral or intra-abdominal fat. This type of fat can coat internal organs, such as the liver, and result in nonalcoholic fatty liver disease. Decreasing the level of cortisol metabolite may also result in a lower propensity toward insulin resistance and may decrease the risk of cardiovascular mortality.

The good news is that once people lose weight, it may be easier to continue to keep weight off. In a prospective (forward-looking) study, results show that once obese patients lost weight, the levels of cortisol metabolite excretion decreased significantly (7). This is an encouraging preliminary, yet small, study involving women.

Controlling or losing weight is not solely about calorie-counting. While calorie intake has a role, food’s nutrient density may be more important to your success and may play a significant role in reducing your cravings, ultimately helping you manage your weight.

References:

(1) Am J Pub Health 2013 Sep 1;103(9):1604-1609. (2) Am J Prev Med.2011 Oct;41(4):434–438. (3) Am J Clin Nutr Online 2013;Jun 26. (4) N Engl J Med 2009 Feb 26;360:859. (5) N Engl J Med 2009 Feb 26;360:923. (6) Medscape General Medicine. 2006;8(4):59. (7) Clin Endocrinol.2013;78(5):700-705.

Dr. David 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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Exercise without dietary changes may not help you lose weight. METRO photo
Exercise without dietary changes may not help you lose weight

By David Dunaief

Dr. David Dunaief

We’re just past the point on the calendar when those who committed to exercising more in the new year are likely to have fallen off their resolutions. If you’re still following through, congratulations!

Exercise has benefits for a wide range of medical conditions, from depression, insomnia, fatigue and balance to cognitive decline, chronic kidney disease, diabetes, cardiovascular disease and osteoporosis.

Will it help you lose weight, though? While gym membership ads emphasize this in January, exercise without dietary changes may not help many people lose weight, no matter what the intensity or the duration (1). If it does help, it may only modestly reduce fat mass and weight for the majority of people. It may, however, be helpful with weight maintenance.

Ultimately, it may be more important to examine what you are eating than to succumb to the rationalization that you can eat without care and work it off later.

Will exercise help you lose weight?

The well-known weight-loss paradigm is that when you burn more calories than you consume, you will tip the scale in favor of weight loss. The more you burn, the more you will lose. However, study results say otherwise. They show that in premenopausal women there was neither weight nor fat loss from exercise (2). This involved 81 women over a short duration, 12 weeks. All of the women were overweight to obese, although there was great variability in weight.

However, more than two-thirds of the women gained a mean of 1 kilogram, or 2.2 pounds, of fat mass by the end of the study. There were a few who gained 10 pounds of predominantly fat. A fair amount of variability was seen among the participants, ranging from significant weight loss to substantial weight gain. These women were told to exercise at the American College of Sports Medicine’s optimal level of intensity (3). This is to walk 30 minutes on a treadmill three times a week at 70 percent VO2max — maximum oxygen consumption during exercise. This is a moderately intense pace.

The good news is that the women were in better aerobic shape by the end of the study. Also, women who had lost weight at the four-week mark were more likely to continue to do so by the end of the study.

Other studies have shown modest weight loss. For instance, in a meta-analysis involving 14 randomized controlled trials, results showed that there was a disappointing amount of weight loss with exercise alone (4). In six months, patients lost a mean of 3.5 pounds, and at 12 months, participants lost about 3.75 pounds.

Does exercise play a role in weight maintenance?

Exercise may help with weight maintenance, according to observational studies. Premenopausal women who exercised at least 30 minutes a day were significantly less likely to regain lost weight (5). When exercise was added to diet, women were able to maintain 30 percent more weight loss than with diet alone after a year (6).

How does exercise help with disease?

Let’s look at chronic kidney disease (CKD), which affects roughly one in seven U.S. adults, as a simple example of exercise’s impact on disease (7).

Trial results showed that walking regularly could reduce the risk of kidney replacement therapy and death in patients who have moderate to severe CKD (8). There was a 21 percent reduction in the risk of kidney replacement therapy and a 33 percent reduction in the risk of death when walkers were compared to non-walkers.

Walking had an impressive impact, and the more frequently patients walked during the week, the better the probability of preventing complications. Those who walked between one and two times per week had 17 and 19 percent reductions in death and kidney replacement therapy, respectively, while those who walked at least seven times per week saw 44 and 59 percent reductions in death and kidney replacement. These are substantial results. The authors concluded that the effectiveness of walking on CKD was independent of kidney function, age or other diseases.

There are many benefits to exercise; however, food choices will have a greater impact on weight and body composition. The good news: exercise can help maintain weight loss and is extremely beneficial for preventing progression of chronic diseases, such as CKD.

By all means, exercise, but to lose weight, also focus on consuming nutrient-dense foods instead of calorie-dense foods that you may not be able to exercise away.

References:

(1) uptodate.com. (2) J Strength Cond Res. 2015 Feb;29(2):297-304. (3) ACSM.org. (4) Am J Med. 2011;124(8):747. (5) Obesity (Silver Spring). 2010;18(1):167. (6) Int J Obes Relat Metab Disord. 1997;21(10):941. (7) cdc.gov. (8) Clin J Am Soc Nephrol. 2014 Jul;9(7):1183-1189.

Dr. David 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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By David Dunaief, M.D.

Dr. David Dunaief

Dear Santa,

It’s that time of year again and, like so many others, I have a last-minute request. You are a model for kindness and generosity around the world, for which I’m grateful. I would like you to be a role model in another arena, as well — health.

Kids marvel at your round belly, which shakes when you laugh like a bowl full of jelly. They literally feed that belly by setting out cookies and other sweets for you on Christmas Eve to sustain you during your travels.

I have nothing against your round belly, but I’m concerned about the message it sends. We’re currently facing an epidemic of overweight kids and an ever-increasing number of children with type 2 diabetes. According to the CDC, the percentage of U.S. children between ages 10 and 19 with type 2 diabetes nearly doubled from 2001 to 2017. You, Santa, with your influence, can help reverse this trend.

Obesity has a high risk of shortening your life span, not to mention affecting your quality of life. The most dangerous type of obesity is visceral adipose tissue, which means central belly fat. An easy way to tell if someone is too rotund is if their waistline, measured from the navel, is 40 inches or more for a man and 35 inches or more for a woman. Risks for pancreatic cancer, breast cancer, liver cancer and heart disease increase dramatically with this increased fat.

Santa, here is your opportunity to lead by example — and, maybe fit back into that skinny tracksuit you’ve had in the back of your closet since the 16th century, when you were trim.

Think of the personal advantages of losing that extra belly weight. Your joints won’t ache with the winter cold; it will improve your posture, so your back doesn’t hurt as much; and you will have more energy. Plus, studies show that a diet that emphasizes fruits, vegetables and whole grains can reverse clogged arteries and help you avoid strokes, heart attacks and peripheral vascular disease. With a simple change, like eating a small handful of raw nuts each day, you can reduce your heart disease risk significantly.

Losing weight will also change your center of gravity, which will make it easier for you to keep your balance on those steep, snowy rooftops. No one wants you to take a tumble and risk a broken bone – or worse.

Exercise will help, as well. Maybe this Christmas Eve, you could walk or jog alongside the sleigh for the first continent or so. During the “offseason” you and the elves could form small groups of workout buddies to keep each other on track with your workout goals. And who doesn’t love an impromptu game of tag with the reindeer? With time, you’ll start to tighten your abs and slowly see fat disappear from your midsection.

This might also make it easier to steal a base or two during the North Pole Athletic League’s Softball season. The elves don’t even bother holding you on base anymore, do they?

Of course, the cookies don’t help. You might take a cue from the reindeer, who love their raw carrots and celery. Broadcast 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.

And, of course, skip putting candy in our stockings. We don’t need more sugar, and I’m sure that, over the long night, it’s hard to resist sneaking a few pieces. Why not reduce the temptation? This will also help you minimize the waves of fatigue you feel as you pull your worldwide all-nighter.

As for your loyal fans, you could place active games under the tree. You and your elves could create an app or website with free workout videos for those of us who need them; we could follow along as you showed us “12 Days of Dance-Offs with Santa and Friends.”

You could gift athletic equipment, such as baseball gloves, footballs and basketballs, instead of video games. Or wearable devices that track step counts and bike routes. Or stuff gift certificates for dance lessons into people’s stockings.

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 be able to park the sleigh farther away and skip from chimney to chimney.

The benefits of a healthier Santa will ripple across the world. Your reindeer won’t have to work as hard. You might 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!

Wishing you good health in the coming year,

David

P.S. If you have a little extra room in your sleigh, I could use a new baseball bat. I know the Yankees need help, so I’ve been practicing.

Dr. David 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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Moderate exercise is better for weight maintenance than weight loss

By David Dunaief, M.D.

Dr. David Dunaief

It’s that time of year again, when exercise product commercials flood the airways. If you have “lose weight” on your list of 2022 resolutions, it’s helpful to consider what the research tells us about the relationship between exercise and weight loss.

Unfortunately, exercise without dietary changes may not actually help many people lose weight, no matter what the intensity or the duration (1). If it does help, it may only modestly reduce fat mass and weight for the majority of people. However, it may be helpful with weight maintenance.

Ultimately, it may be more important to reconsider what you are eating than to succumb to the rationalization that you can eat with abandon and work it off later.

Don’t give up on exercise just yet, though. There is good news: Exercise does have benefits for a wide range of conditions, including chronic kidney disease, cognitive decline, diabetes, cardiovascular disease, osteoporosis, fatigue, insomnia and depression.

Exercise may not result in weight loss

The well-known weight-loss paradigm is that when more calories are burned than consumed, we will tip the scale in favor of weight loss. The greater the negative balance with exercise, the greater the loss. However, study results say otherwise. They show that in premenopausal women there was neither weight nor fat loss from exercise (2). This involved 81 women over a short duration (12 weeks). All of the women were overweight to obese, although there was great variability in weight.

However, more than two-thirds of the women gained a mean of 1 kilogram, or 2.2 pounds, of fat mass by the end of the study. There were a few who gained 10 pounds of predominantly fat. A fair amount of variability was seen among the participants, ranging from significant weight loss to substantial weight gain. These women were told to exercise at the American College of Sports Medicine’s optimal level of intensity (3). This is to walk 30 minutes on a treadmill three times a week at 70 percent VO2max — maximum oxygen consumption during exercise — or, in other words, a moderately intense pace. 

The good news is that the women were in better aerobic shape by the end of the study. Also, women who had lost weight at the four-week mark were more likely to continue to do so by the end of the study.

Other studies have shown modest weight loss. For instance, in a meta-analysis involving 14 randomized controlled trials, results showed that there was a disappointing amount of weight loss with exercise alone (4). In six months, patients lost a mean of 1.6 kilograms, or 3.5 pounds, and at 12 months, participants lost 1.7 kilograms, or about 3.75 pounds.

Exercise and weight maintenance

However, exercise may be valuable in weight maintenance, according to observational studies. Premenopausal women who exercised at least 30 minutes a day were significantly less likely to regain lost weight (5). When exercise was added to diet, women were able to maintain 30 percent more weight loss than with diet alone after a year in a prospective study (6).

Exercise and disease

Walking the dog several times a week is a good moderate exercise. METRO Photo

As just one example of exercise’s impact on disease, let’s look at chronic kidney disease (CKD), which affects 15 percent of adults in the United States, according to the Centers for Disease Control and Prevention (7).

Trial results showed that walking regularly could reduce the risk of kidney replacement therapy and death in patients who have moderate to severe CKD, stages 3 to 5 (8). Yes, this includes stage 3, which most likely is asymptomatic. There was a 21 percent reduction in the risk of kidney replacement therapy and a 33 percent reduction in the risk of death when walkers were compared to non-walkers.

Walking had an impressive impact, and results were based on a dose-response curve. In other words, the more frequently patients walked during the week, the better the probability of preventing complications. Those who walked between one and two times per week had 17 and 19 percent reductions in death and kidney replacement therapy, respectively, while those who walked at least seven times per week saw 44 and 59 percent reductions in death and kidney replacement. These are substantial results. The authors concluded that the effectiveness of walking on CKD was independent of kidney function, age or other diseases.

Therefore, while there are many benefits to exercise, food choices will have a greater impact on our weight and body composition. 

However, exercise can help maintain weight loss and is extremely beneficial for preventing progression of chronic diseases, such as CKD.

So, by all means, exercise, but also focus on consuming nutrient-dense foods instead of calorically dense foods that you may not be able to exercise away.

References:

(1) uptodate.com. (2) J Strength Cond Res. 2015 Feb;29(2):297-304. (3) ACSM.org. (4) Am J Med. 2011;124(8):747. (5) Obesity (Silver Spring). 2010;18(1):167. (6) Int J Obes Relat Metab Disord. 1997;21(10):941. (7) cdc.gov. (8) Clin J Am Soc Nephrol. 2014 Jul;9(7):1183-1189.

Dr. David 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. 

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Resolutions that focus on health and fitness are made each year. Numerous people are eager to lose weight, improve their physical fitness levels or even stop habits that can hinder their mental or physical wellness.

People have many options when they seek to lose weight. Fad diets may promise quick results, but highly restrictive eating plans or marathon workout sessions can be dangerous. Taking shortcuts or risks in the hopes of losing weight can lead to various health issues and ultimately put people’s overall health in serious jeopardy. Thankfully, there are many safe ways people can lose weight. The first step in safe weight loss is to visit a doctor and let him or her know your plans. The doctor can help determine if a specific eating plan or exercise routine is safe based on your current health.

Certain medications can affect metabolism and even contribute to weight gain, so a discussion with the doctor can help ensure people aren’t putting their health in jeopardy when their goal is to get healthy. It’s also vital that people trying to lose weight do not believe everything they read online.

Research published in The American Journal of Public Health in October 2014 found that most people who search the internet for tips on how to lose weight come across false or misleading information on weight loss, particularly in regard to how quickly they can shed some pounds. The Centers for Disease Control and Prevention advises the safest amount of weight to lose per week is between one and two pounds. People who lose more per week, particularly on fad diets or programs, oftentimes are much more likely to regain weight later on than people who took more measured approaches to losing weight.

In addition, the Academy of Nutrition and Dietetics notes it is better to lose weight gradually because if a person sheds pounds too fast, he or she can lose muscle, bone and water instead of fat. The calories in, calories out concept is something to keep in mind when attempting to lose weight. But metabolism and other factors, including body composition and physical activity levels, also are factors. How well one’s body turns calories into fuel also needs to be considered. The best ways to experiment are to start slowly. • Calculate the average daily calories consumed in a day using a tracker. This can be a digital app on a phone or simply writing down calories on a piece of paper. Track over a few days and see, on average, how many calories you’ve been consuming.

• Notice extra calories. Many diets can be derailed by eating extra calories that you don’t realize you’re consuming. That cookie a coworker insists you eat or the leftover mac-and-cheese from your toddler’s plate can be sources of extra calories. Be mindful of what’s being consumed, including sweetened beverages.

• Explore the science. According to the Scotland-based health service NHS Inform, one pound of fat contains 3,500 calories on average. Cutting calorie intake by 500 calories per day should see you lose 1 pound per week. The same goes in the other direction. Eating 500 more calories per day for a year can result in gaining close to 50 pounds. Small changes really add up.

• Eat filling foods. Choose low-calorie, high quality foods, like vegetables, whole grains and lean proteins. Meals that provide satiety can help eliminate between-meals snacks that can derail your weight loss efforts.

• Seek support as a way to create accountability. Share weight loss plans with a friend or relative who can help monitor your progress and keep you on track.

• Incorporate strength training. Good Housekeeping says the more lean muscle you have, the faster you can slim down. Start slowly with strength training, using free weights or body weights. Aim for strength workouts three to four times per week and alternate with calorie-blasting cardio. Explore safer ways to lose weight, including taking a gradual approach that promotes long-term weight loss.

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Focus on improving your health by making lifestyle modifications. METRO photo
The right motivators might be as important as dietary changes

By David Dunaief, M.D.

Excess weight has consequences, including chronic diseases such as cardiovascular disease, diabetes, osteoarthritis, autoimmune diseases and a host of others. Weight also has an impact on all-cause mortality and longevity.

In theory, losing weight should be simple: if we burn more kilocalories (energy) than we take in, we should lose weight. However, it is much more complicated.

Among factors that result in weight loss (or not) are stress levels. High stress levels can contribute to metabolic risk factors such as central obesity with the release of cortisol, the stress hormone (1). In this case, hormones contribute to weight gain.

It is hotly debated as to which approach is best for weight loss. Is it lifestyle changes 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 you follow.

But the debate continues as to which diet is best – for both weight loss and overall health. Let’s look at the evidence.

Low-carbohydrate vs. low-fat diets

Is a low-carbohydrate, high-fat diet a fad? In the publication of a 12-month randomized controlled trial (RCT), 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 lb), even though calories were similar and exercise did not change (2).

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 the inflammation biomarker C-reactive protein (CRP). There was also a reduction in the 10-year Framingham risk score, which estimates cardiovascular risk. However, there was no change in LDL (bad cholesterol) levels or in truncal obesity in either group.

There were 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 end points, which were 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.

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 (3).

Diet comparisons

Interestingly, in a meta-analysis (group of 48 RCTs), results showed that whether a low-carbohydrate diet (including the Atkins diet) or a low-fat diet (including the Ornish plant-based diet) was followed, there was a similar amount of weight loss compared to no intervention at all (4). Both diet types resulted in about 8 kg (17.6 lb) of weight loss at six months versus no change in diet.

In an accompanying editorial, 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 health risks. The author goes on to say that, for overall health and longevity and not just weight loss, micronutrients found in nutrient-dense foods may be the most important factor.

A Seventh-Day Adventist trial would attest to the benefits of emphasizing a micronutrient-rich, plant-based diet with limited animal protein. It resulted in significantly greater longevity compared to a macronutrient-rich animal protein diet (5).

Psyche

Finally, the type of motivator is important, whatever our endeavors. Weight loss goals are no exception. A published study followed West Point cadets from school to many years after graduation and noted who reached their goals (6). 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, focusing on an internal motivator, such as increasing energy or decreasing pain, could ultimately 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. 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) Ann Intern Med. 2014;161(5):309-318. (3) Huffington Post. Sept 2, 2014. (4) JAMA. 2014;312(9):923-933. (5) JAMA Intern Med. 2013;173:1230-1238. (6) Proc Natl Acad Sci U S A. 2014;111(30):10990-10995.

Dr. David 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.

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By David Dunaief, M.D.

Dr. David Dunaief

Obesity is continuously covered in the media. And rightly so. Its economic cost to the U.S. is massive: in 2016, the cost of chronic diseases for which being obese or overweight is a risk factor totaled over $480 billion in direct health care costs and $1.24 trillion in lost economic productivity (1). These startling numbers don’t even consider the human cost of these diseases.

Obesity and its effect on life span

It’s well-known that obesity could have an impact on development of other chronic diseases and decrease 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 (2).

In a computer modeling study, results showed that those who are obese may lose up to eight years, almost a decade, of their life span (3). But that is only part of the picture. 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 could have reductions in life span, up to six years and three years, respectively.

This study evaluated 3,992 adults between the ages of 20 and 79. 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, 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 (4). 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 America and Europe (5).

Possible solutions

A potential counterweight to both the reductions in life quality and life expectancy may be a Mediterranean-type diet. In a published analysis of the Nurses’ Health Study, results show that the Mediterranean diet helped slow shortening of the telomeres (6). 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-type diet may decrease occurrence of chronic diseases, increase life span and decrease premature mortality — countering the effects of obesity. In fact, it may help treat obesity, though this was not mentioned in the study. Interestingly, 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 (7).

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 alternating tapping your index finger against your forehead and your ear (8). The forehead and ear tapping technique 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 (9). These short-term distractors were done for 30 seconds at a time. The results showed that they decreased food cravings in obese patients.

Exercise impact

I have written that exercise does not lead to fat percentage loss in adults. The results are different for adolescents, though. In a randomized controlled trial, results show that those in a resistance training group and those in a combined resistance and aerobic training group had significantly greater percentages of fat loss compared to a control group (10).

Interestingly, 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 may have to do with an increase in muscle mass rather than a decrease in actual fat.

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 do some resistance training. As we mentioned, there are simple techniques that may help reduce short-term food cravings.

References:

(1) “America’s Obesity Crisis,” Milken Institute. October, 2018. (2) Am J Public Health. 2013;103:1895-1901. (3) The Lancet Diabetes & Endocrinology, online Dec. 5, 2014. (4) J Clin Oncol. 2014;32(31):3568-3574. (5) The Lancet Oncology. online Nov. 26, 2014. (6) BMJ. online Dec. 2, 2014. (7) BMJ 2014;349:g6843. (8) Obesity Week 2014 abstract T-2658-P. (9) Obesity Week 2014 abstract T-3023-OR. (10) 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.      

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Leah Dunaief

By Leah S. Dunaief

So, how are those New Year’s resolutions going? Do you even remember what they were? If you are sticking to them, heartfelt congratulations. You are one of few with the discipline and tenacity to hang on. But if you are in the majority for having slipped or temporarily abandoned your resolves, here is some help. It’s called habits.

Habits can be a valuable tool to change your life, both for the better and not. By that I mean, we can slip into some unwelcome behaviors and they become habits almost before we realize it. Or we can consciously take control and set out to break or redefine or make new ones, and as they become part of a routine, they become easier to follow.

This is all far simpler than it sounds, of course. There is a whole branch of science dealing with habits, the unconscious behavioral patterns formed to deal with actions. “We do not so much direct our own actions as become shaped by them,” wrote Jeffrey Kluger in his introductory chapter for a special edition from Time Inc. called “The Power of Habits.”

He points out, by quoting Léon Dumont — the 19th century French psychologist and philosopher — that “a garment, after having been worn a certain amount of time, clings to the shape of the body better than when it was new. There has been a change in the tissue, and this change is a new habit of cohesion.” That is certainly true of the old, comfy pair of slippers that, despite their age, you hate to replace them, and the old pair of pants that have come to fit you like a glove.

Accordingly, the manner of our actions “fashion for themselves in the nervous system more and more appropriate paths.” Kluger here is again quoting Dumont, who studied the science of laughter, of gratitude, of empathy and, for our purposes here, the science of habits.

William James, the American philosopher greatly influenced by Dumont, suggested that people were little more than “bundles of habits.” The point of all this is to build on the idea that if we can shape our brains and the rest of our nervous systems the way we shape a pair of pants, we can control and redirect our lives to follow the actions we wish to take, namely our resolutions to be better.

Think about how many of our daily moves are just programmed in. We get up in the morning and automatically brush our teeth, take a shower, dress, put up the coffee, get our keys, slide behind the wheel of the car, place the coffee cup in the holder, drive to work, all probably while thinking of something else. Occasionally we are surprised to find we have arrived at our destination without consciously paying attention to the route. Almost all of that execution was the result of habit.

Well, suppose you built another step in there, like running 20 minutes on that treadmill or stationary bike collecting dust in your basement before you got into the shower. You like to watch the morning TV shows? Jog along with them as you watch. If you repeat that action for awhile, it could become a habit and presto! You are doing the recommended minutes of exercise a week without the ironclad discipline seemingly required each day.

It just becomes as much a habit as brushing your teeth. If you are forever locked into dipping into the candy jar in the evenings, and you find you are gaining weight, substitute chilled blueberries or red grapes from a cut-glass bowl within reach of your fingers. Of course you have to remember to buy the blueberries or grapes beforehand, wash them and keep them in the refrigerator at the ready.

Complex habits, like procrastination or chronic lateness or smoking are harder to unlearn — but not impossible. We can rewire ourselves, using substitutions or rewards, splinting a bad habit onto a good one for support or hanging out with those whose actions we would like to emulate.

Here’s the bottom line: We can do it. It will just take time for a new behavior to feel part of our routine, an average of two weeks or so. To become a habit will average 66 days.

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By losing just 10 pounds, you can prevent deadly illness, alleviate daily pain and improve your quality of life. Stock photo

By David Dunaief, M.D.

Some research shows that obesity may be reaching a plateau. Is this true? It depends on how the data is analyzed. According to one study, yes; it has plateaued when looking at short, two-year periods from 2003 to 2011 (1).

However, another published study shows a picture that is not as positive (2). The study’s authors believe obesity has not plateaued; when looking over a longer period of time, statistics suggest that obesity has reached a new milestone. There are now more obese patients in the United States than there are overweight patients. And no, it is not because we have fewer overweight patients. This is based on a study that reviewed data from the National Health and Nutrition Examination Survey (NHANES). These results were in adults over the age of 20. This should be an eye-opener.

Unfortunately, according to one study, the probability is not very good for someone to go from obese to “normal” weight in terms of body mass index (3). In this observational trial, results show that an obese man has a 0.5 percent chance of achieving normal weight, while a woman has a slightly better chance, 1 percent. This study used data from the UK Clinical Practice Datalink. The data were still not great for men and women trying to achieve at least a 5 percent weight loss, but better than the prior data. Patients who were more obese actually had an easier time losing 5 percent of their body weight.

What are two major problems with being obese? One, obesity is a disease in and of itself, as noted by the American Medical Association in 2013 (4). Two, obesity is associated with — and is even potentially a significant contributor to — many chronic diseases such as cardiovascular disease (heart disease and stroke), high blood pressure, high cholesterol, atrial fibrillation, diabetes, cancer, cognitive decline and dementia. When I attended the 28th Blackburn Course in Obesity Medicine in June 2015 at Harvard Medical School, a panel of experts noted that there are over 180 chronic diseases associated with obesity.

In this article, we will focus on one significant multifaceted disease, cancer. Watch out for cancer One of the more unpredictable diseases to treat is cancer.

What are the risk factors?

Beyond family history and personal history, obesity seems to be important. In fact, obesity may be a direct contributor to 4 percent of cancer in men and 7 percent of cancer in women (5). This translates into 84,000 cases per year (6). On top of these stunning statistics, there is about a 50 percent increased risk of death associated with cancer patients who are obese compared to those with normal BMIs (7).

What about with breast cancer?

The story may be surprising and disappointing. According to an analysis of the Women’s Health Initiative, those who were obese had increased risks of invasive breast cancer and of death once the diagnosis was made (8). The severity of the breast cancer and its complications were directly related to the severity of the obesity. There was a 58 percent increased risk of advanced breast cancer in those with a BMI of >35 kg/m2 versus those with normal BMI of <25 kg/m2. And this obese group also had a strong association with estrogen-receptor-positive breast cancer.

However, those who lost weight did not reduce their risk of breast cancer during the study. There were 67,000 postmenopausal women between the ages of 50 and 79 involved in this prospective (forward-looking) study. The researchers do not know why patients who lost weight did not reduce their risk profile for cancer and suggest the need for further studies. This does not imply that lifestyle changes do not have a beneficial impact on breast cancer.

What can we do?

We find that fat is not an inert or static substance, far from it. Fat contains adipokines, cell-signaling (communicating) proteins that ultimately may release inflammatory factors in those who have excessive fat. Inflammation increases the risk of tumor development and growth (9).

There is a potentially simple step that obese cancer patients may be able to take — the addition of vitamin D. In a study in older overweight women, those who lost weight and received vitamin D supplementation were more likely to reduce inflammatory factor IL-6 than those who had weight loss without supplementation (10). This was only the case if the women were vitamin D insufficient. This means blood levels were between 10 and 32 ng/mL to receive vitamin D.

Interestingly, it has been suggested that overweight patients are more likely to have low levels of vitamin D, since it gets sequestered in the fat cells and, thus, may reduce its bioavailability. Weight loss helps reduce inflammation, but the authors also surmise that it may also help release sequestered vitamin D. The duration of this randomized controlled trial, the gold standard of studies, was one year, involving 218 postmenopausal women with a mean age of 59.

All of the women were placed on lifestyle modifications involving diet and exercise. The treatment group received 2,000 IU of vitamin D3 daily. Those women who received vitamin D3 and lost 5 to 10 percent of body weight reduced their inflammation more than those in the vitamin D group who did not lose weight.

What does medicine have to offer?

There are a host of options ranging from lifestyle modifications to medications to medical devices to bariatric surgery. In 2015, the FDA approved two medical devices that are intragastric (stomach) balloons (11). The balloons are filled with 500 mL of saline after inserting them in the stomach via upper endoscopy. They need to be removed after six months, but they give the sense of being satiated more easily and help with weight loss.

One, the ReShape Dual Balloon, is intended to go hand-in-hand with diet and exercise. It is meant for obese patients with a BMI of 30-40 kg/m2 and a comorbidity, such as diabetes, who have failed to lose weight through diet and exercise. In a randomized controlled trial involving 326 obese patients, those who received the balloon insertion lost an average of 14.3 lb in six months, compared 7.2 lb for those who underwent a sham operation.

Lifestyle modifications

In an ode to lifestyle modifications, a study of type 2 diabetes patients showed that diet helped reduce weight, while exercise helped maintain weight loss for five years. In this trial, 53 percent of patients who had initially lost 23 lb (9 percent of body weight) over 12 weeks and maintained it over one year were able to continue to maintain this weight loss and preserve muscle mass through diet and exercise over five years (12). They also benefited from a reduction in cardiovascular risk factors. In the initial 12-week period, the patients’ HbA1C was reduced from 7.5 to 6.5 percent, along with a 50 percent reduction in medications.

We know that obesity is overwhelming. It’s difficult to lose weight and even harder to reach a normal weight; however, the benefits far outweigh the risks of remaining obese. Lifestyle modifications are a must that should be discussed with your doctor. In addition, there are a range of procedures available to either help jump start the process, to accelerate progress or to help maintain your desired weight.

References: (1) JAMA 2014;311:806-814. (2) JAMA Intern Med 2015;175(8):1412-1413. (3) Am J Public Health 2015;105(9):e54-59. (4) ama-assn.org. (6) cancer.gov/cancertopics/factsheet/risk/obesity. (7) N Engl J Med 2003;348:1625-1638. (8) JAMA Oncol online June 11, 2015. (9) Clin Endocrinol 2015;83(2):147-156. (10) Cancer Prev Res 2015;8(7):1-8. (11) fda.gov. (12) ADA 2015 Abstract 58-OR.

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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