FAT REFORM:OBESITY, FOOD POLITICS AND THE PERILS OF DIETARY CARBOHYDRATES

Jeffry N. Gerber, M.D., Denver’s Diet DoctorFamily Physician, Littleton Colorado DenversDietDoctor.comfacebook.com/DenversDietDoctor

Disclosures

None

Outline

History and Politics Science of nutrition & the evidence Re-write the nutritional guidelines Summary and action plan

Diabesity: A Twin Epidemic

The spectrum of Insulin Resistance

Obesity Statistics

Sources: TFAH, OECD, WHO, CDC, ADA

The progression of insulin resistance 44% obese in 2030 33% diabetic in 2050

Historical Perspective

Blame behavior and lifestyle choices Eating too much and exercising too little Obesity is caused by positive energy balance!

A simple explanation Health insurance will not pay for treatment

Its your fault, your problem, you fix it! The Lipid Hypotheses 1950’s

Avoid caloric dense fatty foods

“I am such a glutton and sloth”

USDA Dietary Guidelines 1977-1980

Less saturated fats, less calories More poly-unsaturated Vegetable oils More carbohydrates, starches, sugars More inexpensive food commodities Weak evidence, the wrong tools!

Phillip Handler : “A vast nutritional experiment”

Macronutrient Content

More refined carbohydrates and less saturated fat Total caloric intake increases from sugar consumption

-MMWR, Morbidity and Mortality Weekly Report, February 6, 2004 / Vol. 53 / No. 4

Does Saturated Fat Cause Heart Disease?

Outcomes looking at MI, death from MI and stroke Observational - 16 studies - No! Observational - 8 studies - Yes but problematic! Observational - 2 meta analysis, 350,000 subjects - No! RCT’s - Clinical trials - 2 well done - No! RCT’s - Clinical trials - 3 meta analysis - No! RCT’s - Clinical trials - 1 meta analysis - Yes but problematic!

http://www.awlr.org

Food Politics: Agriculture

Industrial revolution and the food commodities Corn, Wheat, Rice, Potatoes Sugars: Cane, Beet, HFCS Soybean and industrial Vegetable oils

Whole foods expensive: Animals and other Plants

Farming incentives, increase yields, GMO’s

Food Politics: Manufacturing and $ales

To sell refined and processed foods for profit Food commodities are the raw materials Tasty and addicting foods, eat more Deceptive advertising: “Healthy foods” Food lobbyists funding politicians Selling food not health

Our Ancestors Before Agriculture

Hunter gatherers and the Paleolithic era Whole foods, some carbs

Animals including Fish, seasonal Veggies, Fruits ,Nuts and Roots

Use of fire Agriculture and the Neolithic era

Cultivate Grains and domesticate Animals for Dairy Modern civilization changing nutrition

For better or worse

The Cost of Healthcare

World leader in healthcare spending since 1980 Treating chronic diseases

Medicare and Medicaid industry guidelines Treatment of illness and disease only

Obesity not a medical condition A reactive and costly approach to healthcare

Preventive services task force 2012, counseling Treating obesity complications is profitable

Evolution - Are You Kidding?

Nutrition changing humans in our lifetime!The Food Revolution: Andreas

Eenfeldt, M.D.

Fat Reform is Healthcare Reform

Address obesity Save trillions treating

complications Food industry regulation! Healthcare delivery

Nutrition and center stage Re-define healthy nutrition Re-educate

The perils of dietary carbohydrates In defense of dietary fat

Nutrition and Metabolism 101

Food metabolism All macronutrients are not created

equal Carbohydrates are fattening and

inflammatory Fats and proteins

Obesity is a chronic metabolic disease Insulin resistance Inflammation

Carbs

Fats

Proteins

Insulin and Insulin Receptors

One of several hormones Regulate energy and energy storage

Dietary carbohydrates, the primary fuel Turn on the insulin switch

Dietary proteins and fats, secondary fuels Minimal effect on insulin, essential

Insulin receptors normal function Cells, muscle, tissue absorb energy and nutrients Excess food energy converted to fat and stored Normally insulin will suppress appetite insulin promotes the release of stored energy

Basic physiology

Insulin Resistance

Years of carbohydrate overload More insulin is required Excess energy, stored as body fat Receptors become strained and resistant Beta cells strained, abnormal response A disease of insulin overload

Insulin resistance makes us hungry Fat cells literally starve lean body tissues Hypothalamus, Nucleus Accumbens

Eventual loss of central signals

Increased InsulinProduction

IncreasedResistance

(Hunger)

Weight Gain

Regulation of Food Intake

Leptin – Insulin – Amylin – PP - Ghrelin - PYY - GLP-1 Resistance changes signaling

Promotes inflammation and mitochondrial dysfunction

Inflammation and Adiposity

↑ IL-6

↓ Adiponectin

↑ Leptin

↑ TNFα

↑ Adipsin(Complement D)

↑ Plasminogenactivator inhibitor-1

↑ Resistin

↑ FFA

↑ Insulin

↑ Angiotensinogen

↑ Lipoprotein lipase

↑ Lactate

Type IIDiabetes

Hypertension

Dyslipidemia

Thrombosis

Atherosclerosis

InsulinResistance

Lyon CJ et al. Endocrinology 2003;144:2195-200; Trayhurn P et al. Br J Nutr 2004;92:347-55; Eckel RH et al. Lancet 2005;365:1415-28.

↑ CRP

Inflammation

Cancer

↑ IGF-1

Premature Ageing

Liver & Gut

Dementia

Fertility

Insulin Resistance Evaluation

Overweight Obesity Pre-diabetes(Metabolic Syndrome)

Type II Diabetes

Anthropometric measurements Medical and family history, physical 2hr OGT, GTT Metabolic markers of inflammation

HgA1c, c-peptide, Insulin, CRP, Thyroid, etc… Cholesterol testing as a marker for atherosclerosis

Insulin Resistance Treatment

The food is the medicine Remove the optional fuel

Less dietary carbohydrates Turn off the insulin switch Control hunger and appetite

Insulin Resistance Treatment

Dietary proteins Essential, healthy

Dietary fats and cholesterol Essential, healthy Caloric dense and filling NOT inflammatory or

atherogenic One exception

Carbs and fats together Standard American diet (SAD) Carbs are the catalyst

http://deliciouslyorganic.net

Insulin Resistance Treatment

Medication Physiologic drugs

Metformin, Byetta, Victoza, Bydureon, Symlin Rx appetite suppressants New and future drugs OTC market

Treat co-morbidities Nutrition center stage

Gastric bypass surgery

http://peaceloveandlowcarb.blogspot.com

Eat Real foods

Focus on the carbohydrate content of food Avoid high glycemic foods, processed foods Eat low glycemic foods, whole and unprocessed

Healthy natural fats Butter, Animal fat, Coconut oil, Olive oil, Avocado, Fish oil

Low-Carb High Fat (LCHF), Ancestral diets Control of appetite and promote weight loss Enhanced fat burning during exercise Quantity, calories and portion’s not the focus

Comparing Diets Head to Head

Compare the macronutrient content % of calories from carbs, protein and fat

Very low fat <10%, high carb, low calorie Very low carb <10%, high fat, LCHF, 1860’s

LCHF vs. Ancestral diets Food quality important

What diets are healthy and safe? Low carb high fat (LCHF) diets improve health!

Greater weight loss, improved lipids and blood sugar Dozens of RCT’s, Stanford 2007, Duke 2004, Penn 2003, 2011 Meta analysis , Santos 2012

Calories consumed equal, Atkins LCHF diet better controls insulin, weight and appetite

Lipid profile improved on Atkins LCHF

Effects of LCHF diet on emerging plasma markers, Richard J. Wood, et al. J. Nutrition. 136:384-389, February 2006

Advanced Lipids and LCHF Diets

Favorable LDL subclasses or particle sizes Triglycerides decrease, healthy HDL-C

increases Other markers

Apo-B, LDL particles Lpa, genetic markers

Advanced labs Berkeley Heart Lab NMR Liposcience VAP Cholesterol

Marcia at 262 lbs, BMI 41 lost 70 lbs, now 192 lbs, 27% loss TBW, BMI 30

Female age 45, 5’7”, 262 lbs, BMI 41 OGT performed, FBS=96, 1HR=180, 2Hr=129

HgA1C=6.4%, c-peptide=4.7

TRG=221, HDL=36, TC=148, LDL=69, NON-HDL=112, TC/HDL=4.2, LDL Pattern A/B

8 months later lost 70 lbs, 192 lbs, BMI 30, 27% loss of body weight FBS 76

HgA1C=5.1%, ?c-peptide

TRG=147, HDL=40, TC=186, LDL=121, NON-HDL=151, TC/HDL=5.2, ?particle size

Dr Gerber Patient: Marcia

David at 312 lbs, BMI 40 http://mendosa.com

lost 153 lbs, now 159 lbs, 49% loss TBW, BMI 20

Male, age 71, 6’3”, 312 lbs, BMI 40

OGT: FBS=105, 1HR=219, 2HR=201

HgA1C=6.8%

TRG=193, HDL=28, TC=225, LDL=158 , NON-HDL=197

2 years later, lost 153 lbs, 159 lbs, BMI 20, 49% loss of body weight

OGT: pending, FBS normal

HgA1C=4.6%

TRG=109, HDL=40, TC=155, LDL=93, NON-HDL=115

Dr Gerber Patient: David

Patrick at 220 lbs, BMI 32 Lost 45 lbs, now 175 lbs, 20% loss TBW, BMI 24

Dr Gerber Patient: Patrick

Male, age 53, 6’, 220 lbs, BMI 32

OGT performed, FBS=86, 1HR=148, 2HR=103

HgA1C=5.4%, c-peptide=4.1

TRG=133, HDL=47, TC=238, LDL=164 , NON-HDL=191, TC/HDL=5.1

7 moths later lost 45 lbs, 175 lbs, BMI 24, 20% loss of body weight

FBS=77

HgA1C=5.1%, c-peptide=0.9

TRG=75, HDL=78, TC=200, LDL=75 , NON-HDL=122, TC/HDL=2.6

Age 43, lost 10 pounds on a Paleo diet, 183 lbs, BMI 25

Berkeley Heart Lab

Triglycerides and HDL-C improved, LDL-C, Apo-B unchanged

LDL subclasses (particle size) remained favorable, 9p21 genetic markers at risk

Carotid IMT, 39 yrs., heterogeneous plaque <20%

Dr Gerber Patient: Eric

Author: Gary Taubes

2002 New York Times Magazine: What If It’s All Been a Big Fat Lie

2008: Good Calories Bad Calories 2010: Why We Get Fat: And What

To Do About It 2011 New York Times Magazine:

Is Sugar Toxic 2012 Newsweek: Why the

Obesity Campaign is failing

Nutrition and the history of weak scientific evidence

Nutrition for the New Millennium

Re-defining healthy nutrition Less refined and processed foods More whole foods including natural fats New federal dietary guidelines

Food industry regulation Re-define healthcare delivery

Nutrition centerstage

Control the cost of healthcare

Good Food is Good Medicine!

Jeffry N. Gerber, M.D.DenversDietDoctor.comfacebook.com/DenversDietDoctor