Tuesday, May 20, 2014

Fat and Always Hungry? No, cutting the carbs won't cure your weight struggle.

It’s 10 AM Sunday and quite frankly, I’d much prefer to be leisurely finishing my coffee after my blueberry pancakes-topped with a dollop of vanilla yogurt and heated real maple syrup. But Ludwig and Friedman’s Always Hungry? Here’s Why piece in the NY Times  today compelled me away from my plate.

To start, let’s get a title change, please, let’s say Here’s What We Think based on virtually no research at all. This is an opinion piece stating two doctors’ theories about why we get fat and what we should do about it. Period. But with the sensational image and title you, like most people, will be drawn into more myths about weight management.

Here’s where we agree—and disagree

Do you just eat bread for your meal?
Agree: There are factors outside of your control that may contribute to your size. Genetics and the presence of fat cells exert their influence. Once you have gained to a higher weight with an increase in fat cells, you will be fighting an uphill battle to lose that weight and keep it off—without disordered behaviors.  And it’s not your fault. For more on this see Professor Lowe’s work on weight suppression and bulimia. 

Agree: Metabolic rate slows down with food restriction—that’s indisputable from the research. Obese individuals who have undergone extreme low calorie diets will have a lower metabolic rate as a result of the decrease in muscle mass that results, compared to same weight controls who had not dieted. Less aggressive approaches to dietary activity change tend to spare the muscle loss and help maintain metabolic rate.

Before dieting...
But the authors state that metabolic rate also decreases with weight increase:  “…factors in the environment have triggered fat cells in our bodies to take in and store excessive amounts of glucose and other calorie-rich compounds. Since fewer calories are available to fuel metabolism, the brain tells the body to increase calorie intake (we feel hungry) and save energy (our metabolism slows down).” Yet there appears to be few examples of this cited in the scientific literature, with the exception of a possible rare genetic mutation, not likely the cause of obesity in the greater population.

And the temporary slowed metabolic rate seen with weight loss has been demonstrated to be reversed with weight restoration in the obese (albeit a small sample size studied) and more dramatically in those who are underweight with anorexia, summarized well by Carrie Arnold in ED Bites.  In practice we see dramatic increases in metabolic rate—calories burned and required each day—with weight gain in anorexic individuals at least until they have restored to their healthy state.

Agree: Insulin increases nutrient uptake and in excess causes weight gain. And carbohydrate results in an increase in insulin secretion.

Disagree: Ludwig and Friedman’s leap that foods that increase insulin secretion should therefore be reduced or avoided for weight management is faulty reasoning—unless there is a documented underlying metabolic abnormality. A relatively small percentage of the total population has PCOS or hyperinsulinemia—a faulty regulation of insulin. For these individuals, addressing carbohydrate amount or glycemic load (impact of a food on raising blood sugar) has a positive impact. But there’s no evidence that a low carbohydrate diet is any better at long-term weight management than any other dietary intervention. 

In addition, while individual foods and their glycemic index—the amount they raise blood sugar (and therefore subsequent insulin levels) may seem valuable, practically speaking they have less impact.  You see, we generally don’t eat single nutrients like carbohydrate. Rather, we eat mixed meals, containing protein, fat and carbohydrate. And in this combination, the impact on insulin levels that even the white potato might have if eaten solo is minimized with that piece of chicken and the added olive oil or nuts in the salad.

This banana chocolate pastry has plenty of fat to lower its glycemic load!
(From Tartine Bakery, San Francisco)
And did you know that many of the villainized desserts have a minimal impact on insulin levels? Peanut M&Ms aren’t much different than lentils (see glycemic load—the best measure of blood sugar impact which considers portion) and cheesecake made in it’s full fat recipe will no doubt come in quite low as well.

I don’t share this to promote a diet full of low nutrient, processed foods. Rather, to make a point. Viewing foods as good and bad will do nothing to help you manage your weight—nor your mental health. In fact, there’s plenty of evidence that feeling deprived by denying yourself foods you enjoy leads to rebound overeating.

The authors also state “what if it’s not overeating that causes us to get fat but the process of getting fatter that causes us to overeat? Unfortunately, I think they have oversimplified their hypothesis.

Sure, having more fat cells may contribute to our struggle if attempting to lose weight. But it’s not simply a macronutrient issue. Being larger presents more challenges for being active; larger individuals report being subjected to fat shaming while exercising—presenting its own challenges.

Rebound binge eating following starvation—think dieting—has been well documented as well. All or nothing thinking—what I call the “what the heck effect” results in overeating when you believe you’ve already blown it.

Our over-scheduled lives with multiple competing needs don’t help us either. Multitasking while eating makes us less aware of what we are consuming and contributes to overeating. And the larger the containers or plates we are eating from, the more we will over-consume (see Prof.Wansink's extensive work on this).

Time and money constraints add flames to the fire—we take little time to plan, shop and eat mindfully. In fact, our cognitive ability is compromised by these stressors and worsened when we diet. Perceiving that we won’t have enough food to meet our wants or needs, referred to as scarcity creates a range of secondary effects. Poor decision making, impaired ability to organize and follow through and hyper-focusing on the immediate benefits without considering the long term consequences of food choices are well researched and described in the fascinating new book, Scarcity.

Unrealistic goals set by national organizations  and by ourselves adds to the problem. If 150 minutes per week plus 2 days of muscle strengthening/wk is unattainable, why bother?

Further, the food industry isn’t all bad. (And no, I am not a paid consultant to any food company!) They are the ones who bring us the convenience of precut and cleaned vegetables and canned, high fiber, low glycemic legumes. They allow us the convenience of reheating frozen brown rice and quick cook barley. And they have given us a range of milks in every fat percentage we could ask for, and yogurts of every style—Greek and higher protein, sweetened, full fat, real sugar, artificial sugar and no added sugar. But many of the choices remain ours.

So what’s the solution to our climbing weights beyond a healthy range?

  • Move away from dieting and that sense of scarcity.
  • Set realistic goals for change—be it frequency of a home-cooked meal or a visit to the gym.
  • Begin to work on behaviors; separate eating from distractions, and delay seconds (see older posts on this blog for help)
  • Include a range of foods and nutrients. Include high fiber, whole grains and legumes, fruits and vegetables, nuts and healthy oils; protein-rich foods such as poultry and fish, and less frequently red meat; low fat milk and yogurt and modest amounts of cheese.
  • As part of a balanced meal, by all means enjoy your rice, breads and pasta, too. And you know my stand on baked goods! All or nothing approaches to dietary change will get you nowhere.
Thanks for reading and for passing this on via FB, Pinterest, Twitter...

Thursday, May 8, 2014

From the Land of Oz: Hillary's Hyman and Detox Diets

Wouldn't you just love to find a cure for your struggles?
Hyman's suggestion that my diet is the reason for my
MS is beyond insulting.
Let’s give a round of applause ladies and gentleman to Dr. Mark Hyman for finding the answer to all of our weight loss troubles! Dr. Mark Hyman’s Book, The Blood Sugar Solution 10-Day Detox Diet: Activate Your Body's Natural Ability to Burn Fat and Lose Weight Fast, is a New York Times bestseller. His book is a guided weight loss and detox program that claims to be the solution in preventing disease, losing weight and reducing insulin levels in just 10 days. His book provides meal plans, recipes, shopping lists, recommended medications, supplements, and more. Written by an MD, there must be truth to his detox diet claims, right?

About that M.D. credential

A Medical Doctor, meaning “teacher of medicine” is an honorable profession that rightfully holds esteem in society. Often times, when you are diagnosed with a condition, such as Type 2 Diabetes, you see a team of clinicians with varying credentials. Understanding what an MD, RD, NP, RN, PA or PhD are and their scope of practice is important to know and understand when it comes to your treatment plan.

In a nutshell, a doctor (MD), assesses the condition, forms a plan and treats the condition. An MD has extensive education in anatomy, biology, physiology, and chemistry and is an expert on injuries, diseases and drug therapy. That being said, a doctor (as well as an NP, RN and PA) has very little education in nutrition and is far from qualified as an expert in nutrition. Unless a doctor is an RD (Registered Dietitian) or has an advanced degree in nutritional science (think PhD), they should not proclaim themselves nutrition experts. Similarly, an RD, an expert in nutrition and dietetics should not prescribe medicine or formulate a plan for surgery as this is outside their scope of practice.

The Tell Tale Signs

So, how do you know if these self-proclaimed “wholistic” MD’s (as Dr. Hyman calls himself) have gone too far? Well, Dr. Mark Hyman produced a perfect example for us to explore.

There are no shortcuts to getting healthy and fit.
The first sign of quackery is the guaranteed “quick fix” that we all secretly want. We hate to be the bearer of bad news, but anytime a doctor (yes, that includes Dr. Oz), or medical professional for that matter, guarantees over 7 lbs of weight loss in 2 weeks without vigorous physical activity, then you may want to assess whether their techniques are safe and can be maintained for the long-term. For reference, the Academy of Nutrition and Dietetics, considers healthy weight loss of ½ -2 lbs. per week with a balanced/portioned diet and regular vigorous physical activity. Even this guidance is quite controversial, as the long term data gives little support that that lost weight is maintainable. Dieting leads to deprivation and long term struggles with rebound over eating and weight gain.

In one of the first pages of Dr. Hyman’s book, he catches eager readers by telling a story of Janet, a 48 year old woman who lost 11 pounds in 10 days by eliminating fish, gluten, dairy, sugar, all grains, beans and legumes, all processed foods, all refined vegetable oils, alcohol and caffeine. Is it not obvious? Of course she lost a ton of weight in a short amount of time, virtually every food group was eliminated! But successful weight management needs to address thoughts and behaviors, so that dietary changes can be maintained. Rigid rules will only lead to failure.  Haven’t we all seen this?

You, on a diet.
The second sign of “wait, this book or treatment plan is a crock” is the all mighty powerful “DETOX”.  According to Dr. Hyman, virtually all foods lead to weight gain and illness, so a 10 day detox is warranted to get rid of decades of food toxins and promote weight loss. Makes sense, right? Well, no. The problem with this, is that our body naturally detoxifies itself. The liver, kidneys and colon filter out toxins and bacteria in the body. Therefore, eliminating essential foods and nutrients for a body cleanse/detox does not make sense at all. The last thing we need is to narrow our selection of foods for no good reason!

What happened to 'an apple a day keeps the doctor away?'

Eliminating whole categories of foods from your diet for weight loss is just absurd. It is not realistic to think you can survive a diet that is limited in variety and nutrients without serious consequences—low energy, increased thoughts and preoccupation, nutritional deficiencies, to name a few. It is also not realistic to think that you will continue to have an abundance of weight loss post “detox” as behavior and dietary changes do not magically occur in 10 days. Further, rebound overeating results from deprivation. This, combined with slowed metabolic rate from your body perceiving starvation will only result in weight regain. 

What Is The Magic Pill?

You're really gonna give these up? Until you lose weight? 
Then what?
We challenge you to realize that there is no cookie-cutter way to treat chronic conditions such as obesity, diabetes and inflammatory conditions as Dr. Hyman suggests. Standards of practice and research-proven methods exist to guide people toward health. And there is individual variation in our calorie and nutrient needs and healthy weight ranges. Self-help/”wholistic”/detox “treatment plans” are damaging—they don’t take into consideration these individual needs nor consider the impact on a person’s medical status as a whole. They offer false hope that if you just follow (this most un-followable plan) you will cure your ills and be happy. 

We challenge you to do your research, recognize what the credentials mean and be cautious of the quackery rules of advice. And by you, we include very intelligent readers who might've been pulled into believing this misinformation--like Bill and Hillary Clinton, who endorse Hyman's sensational promises.
Avoid triggering and false messages from shows like Dr. Oz and books like Dr. Hyman’s. And if it sounds too good to be true, it probably is!

This piece was written primarily by my awesome intern, Lakisha Dubar--with direction and editing by yours truly. Please share your thoughts with us! As always, thanks for reading, and sorry for the long wait--I had to travel to San Francisco for these photos!