Tags Posts tagged with "Obesity"

Obesity

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.