Don't Buy Their Snake Oil

If researchers from Harvard University - Dr. Jorge Chavarro and Dr. Walter Willett - had merely published their data and encouraged additional study to validate their findings, I'd have nothing to write about today. In fact, I may have penned a quick post about the study since it did find some intriguing associations between diet and risk of infertility in women participating in the Nurse's Health Study II.

But, they didn't simply publish a paper. No, they also published a book - The Fertility Diet - that is now featured on the cover of Newsweek and also being touted in the media as the low-tech, do-it-yourself way to prevent and even reverse ovulatory infertility!

Worse though is the media advancing the findings in a way that implies the dietary strategy has been tested in infertile women!

Take a look at how MedScape opened their article - "Higher intake of monounsaturated fats; vegetable protein; and high-fiber, low-glycemic carbohydrates improved fertility outcomes in women with ovulatory disorder infertility, according to the results of a cohort study reported in the November issue of Obstetrics & Gynecology."

The data is not from women who specifically had a diagnosis of ovulatory dysfunction (irregular or absent menstruation). Rather, the data was from a cohort of women within the Nurse's Health Study II who were identified as actively trying to get pregnant during the period of follow-up data collection. That is a very different cohort of subjects than one exclusively made up of women with infertility, or a cohort designed as a comparison study of women with and without fertility issues due to ovulation!

But the thing that really irks me is the media falling all over itself to highlight one finding in particular, the supposed reduction of ovulatory dysfunction if women follow the dietary strategy outlined in the book - "their research shows that women who follow five or more of the tips could boost their fertility by up to 80 percent," is how the Boston Channel presented it.

Charles Platkin (Diet Detective) wrote, "In fact, the Nurses’ Health study showed that those who did not follow a healthy diet were six times more likely to experience infertility related to ovulation than women who did."

Oh really?

How about we look at the published data - let's look specifically at those cases with ovulatory disorder infertility published in the study:
Diet Score .Cases .RR (95% CI)
Q1 (lowest) _117 _1.00
Q2 _100 _0.68 (0.52 - 0.89)
Q3 _77 _0.65 (0.48 - 0.87)
Q4 _80 _0.53 (0.40 - 0.72)
Q5 _42 _0.34 (0.23 - 0.48)

Do you see a six-fold difference between Q1 and Q5? I didn't think so!

Do you see an 80% greater chance of pregnancy in those in Q5 than those in Q1? I didn't think so!

And as an aside - I don't get is how in Q4 they reported more cases of infertility, yet managed to report a lower RR? Anyone want to help me out with that one?

Anyway, I was scratching my head, trying to figure out how they came up with these incredible numbers - statistics being used to heavily promote the book right now - and they're in the study all right, in a theoretical computer model (which should be called a fantasy search for significance) run with different scenarios of possibilities, not data of real women eating in the real world!

As the researchers noted in their paper, "we calculated the population attributable risk associated with specific combinations of dietary and lifestyle factors to estimate the proportion of cases that may have been avoided had all the women in this cohort adhered to these habits."

So now, rather than state these numbers are based on computer models and are, at best, theoretical - they're promoting the book as if it's fact that the dietary strategies actually work.

And they're doing it in a way that is promoting the idea that a woman with ovulatory dysfunction can fix it herself, without medical intervention, and get pregnant on her own.

To say this is a travesty for women's health is an understatement!

Just when you think it's not possible, it really does get worse.

If the promotion of theoretical as fact isn't bad enough, here is a real hard fact that should send chills up your spine - while the majority of cases of ovulatory dysfunction are attributed to PCOS (polycystic ovarian syndrome), a large enough number are due to hyperprolactenemia, usually cased by a small tumor at the base of the brain. Yet, the book has absolutely no warning to women that a diagnosis for the cause of ovulatory dysfunction is critical before beginning the do-it-yourself diet approach.

Think about that for a moment.

Then consider that ovulatory dysfunction can also be due to disease of the pituitary, adrenal or thyroid glands. It can also be due to premature ovarian failure (premature menopause).

Without a diagnosis, you're flying blind as to cause and without any warning in the book about the many causes of ovulatory dysfunction, you may in fact be delaying critical medical intervention to resolve the problem if you simply take the book and run with the recommendations.

Oh and it just keeps going too. Also noticeably absent is any warning to women already experiencing ovulatory dysfunction that continuing to attempt pregnancy in the absence of regular menstruation is futile. In fact the book promotes the standard advice that one year of trying to get pregnant is recommended unless one is over 35, then six months of trying is appropriate before seeking a medical evaluation.

When a woman has a regular cycle, this advice is fine - when she has absent or irregular periods, she's wasting precious time continuing along and trying without a diagnosis because without ovulation there cannot be a pregnancy!

One recommendation in particular can also be problematic for a woman already experiencing ovulatory dysfunction - the recommendation to increase iron intake. You see, if the researchers who wrote the book bothered to look at the literature, they'd have learned that women with ovulatory dysfunction often have elevated stores of iron. As the researchers in the above linked study noted, "Because the periodic blood loss resulting from regular menstruation protects pre-menopausal women against excessive iron accumulation, oligomenorrhea and amenorrhea might contribute to the increase in ferritin observed in overweight and obese PCOS patients. When studying PCOS patients and control subjects as a whole, ferritin levels were increased in women with amenorrhea compared with women with regular menstrual cycles, whereas women with oligomenorrhea presented with intermediate values (means ± SD: amenorrhea 159 ± 144 pmol/l, oligomenorrhea 114 ± 95 pmol/l, and regular menstrual cycles 83 ± 51 pmol/l; F = 3.295, P = 0.040)."

Also of note is the fact that in the book they recommend reducing saturated fat intake to less than 8% of calories.

Where, pray tell, is the data to support that recommendation?

It certainly isn't in their published paper. In their published data, the women with the lowest risk of infertility not only consumed the highest level of total fat, but their intake of saturated fat was also higher than the other groups - in fact, their saturated fat intake accounted for 11.5% of calories.

But hey, let's not let the actual data get in the way of recommendations that align with the author's previous book, Eat, Drink and Be Healthy!

While we're at it, where is the data to support eating less meat? Their published data found absolutely no difference in heme iron intake between the various groups - none at all - yet they're promoting the idea that reducing red meat in the diet is going to make a difference in getting pregnant. Their data does not support this idea; and add to that this idea has not even been tested in women attempting to get pregnant, yet that doesn't stop them from making the recommendation.

Worse though (can it really get worse?) is the inclusion within the book of the politically correct idea that reducing or even eliminating red meat is better for the environment - who needs data when you can convince women to limit or eliminate red meat on emotion.

If you're a woman wanting to get pregnant, do you want to based your diet on politically correct advice or hard evidence?

Do you want to make changes to your diet based on theoretical computer models, or data from studies that have actually investigated how a change to diet improved pregnancy rates in those participating in the study?

As Albert Einstein once pointed out, "Only two things are infinite, the universe and human stupidity, and I’m not sure about the former."

Stupidity or just plain old ignorance contributes greatly to the millions of people who succumb daily to the latest or most heavily promoted "facts" generated by epidemiologist's findings concerning diet. Today it happens to be diet and fertility, tomorrow it'll be diet and aging, the next day diet and cancer.

The problem though, with such data from epidemiological studies on diet and lifestyle, remains (and will forever remain) that correlation does not imply causation. I don't know how many times that can be repeated, but it is true and will always be true. Just as it is true that eating red meat does not cause ovulatory dysfunction anymore than consuming high levels of non-heme iron prevents it. Just as consuming regular ice cream does not make you fertile anymore than restricting saturated fat to less than 8% of your calories will make you get pregnant.

That the media is heavily promoting this book only tells us one thing - they don't understand science, the scientific method, or the difference between correlation and causation. And they certainly have not read the study in full and then compared it to the book's recommendations.

No doubt the findings are intriguing, but they do not make a proven strategy or evidence-based approach to prevent or reverse ovulatory dysfunction.

What they do provide is a starting point to actually test the dietary strategies in women with ovulatory dysfunction. Until those studies are conducted, the book is merely speculation, potentially a waste of precious time or worse for a woman with ovulatory dysfunction.

On this book I have to strongly suggest taking a pass and instead do what's best - go to the doctor if you're having problems getting pregnant or have irregular or absent periods. Without a diagnosis, you're flying blind on assumptions - it's better to have a diagnosis and tackle the problem based on facts rather than guessing what's wrong. It's true that you can make changes in your diet and see improvement, just as it's true that if your ovulatory dysfunction is caused by a tumor your diet isn't going to make a difference.

Just because the book is from esteemed researchers at Harvard doesn't mean it isn't snake oil.

You are what your body does with what you eat

A newly published study, in the journal Lipids - Comparison of Low Fat and Low Carbohydrate Diets on Circulating Fatty Acid Composition and Markers of Inflammation - found that subjects given a low-carb diet experienced "profound alterations in fatty acid composition and reduced inflammation compared to a low fat diet."

The press release, issued from SUNY Downstate, sums it up completely:

Metabolic syndrome is a condition afflicting one quarter to one third of adult men and women and is an established pre-cursor to diabetes, coronary heart disease, and other serious illnesses. Patients have long been advised to eat a low-fat diet even though carbohydrate restriction has been found to be more effective at reducing specific markers, such as high triglycerides, characteristic of the syndrome. Now, a new study indicates that a diet low in carbohydrates is also more effective than a diet low in fat in reducing saturated fatty acids in the blood and reducing markers of inflammation.

While there have been contradictory and confusing messages directed at health conscious consumers about dietary recommendations, most researchers agree on the need to limit inflammatory agents. In a report published today in the on-line version of the journal Lipids, researchers at the University of Connecticut, SUNY Downstate Medical Center in Brooklyn, and the University of Minnesota show much greater improvement in inflammatory markers in patients with metabolic syndrome on a very low carbohydrate approach compared to a low fat diet.

Lead researcher Jeff S. Volek, PhD, RD, associate professor of kinesiology at the University of Connecticut, describes the study as “adding to the evolving picture of improvement in general health beyond simple weight loss in keeping blood glucose and insulin under control.” The work is part of a larger study (currently under review) showing numerous improvements in blood lipids.

The current work concludes that “lowering total and saturated fat only had a small effect on circulating inflammatory markers whereas reducing carbohydrate led to considerably greater reductions in a number of pro-inflammatory cytokines, chemokines, and adhesion molecules. These data implicate dietary carbohydrate rather than fat as a more significant nutritional factor contributing to inflammatory processes.”

Richard Feinman, PhD, professor of biochemistry at SUNY Downstate Medical Center, adds, “The real importance of diets that lower carbohydrate content is that they are grounded in mechanism: carbohydrates stimulate insulin secretion which biases fat metabolism towards storage rather than oxidation. The inflammation results open a new aspect of the problem. From a practical standpoint, continued demonstrations that carbohydrate restriction is more beneficial than low fat could be good news to those wishing to forestall or manage the diseases associated with metabolic syndrome.”

One of the remarkable effects in the data presented that may have contributed to the results is that despite the three-fold greater saturated fat in the diet for the low carb group, saturated fat in the blood turned out to be higher in the low fat group due to the process known as carbohydrate-induced lipogenesis.

Dr. Volek points out that “this clearly shows the limitations of the idea that ‘you are what you eat.’ Metabolism plays a big role. You are what your body does with what you eat.”

Rules to Drink it Up!

Three rules specify the importance of adequate hydration and choosing beverages wisely.

Rule 9:

• Avoid foods or drinks sweetened with aspartame. Instead, use sucralose or saccharin. Be sure to count each packet of any of these as 1 gram of carbs.

Rule 10:

• Avoid coffee, tea and soft drinks that contain caffeine. Excessive caffeine has been shown to cause low blood sugar, which can make you crave sugar.

Rule 11:

• Drink at least eight 8-ounce glasses of water each day to hydrate your body, avoid constipation and flush out the by-products of burning fat.

Starting with the last one, drinking eight 8-ounce glasses of water, provides direction to make sure we consume enough fluids each day.

It's universally accepted that water is important; with disagreement as to whether fluid intake must be water itself or any beverage that helps provide hydration. I tend toward the belief that all fluids count toward water intake - if someone wants to drink water, great!; if someone wants to consume iced tea with lemon or a diet beverage, great! It's all good as long as we also are mindful of the other rules which have important considerations when choosing what to drink.

Rule nine limits consumption of artificial sweeteners and specifically suggests that we avoid aspartame (NutraSweet, Equal) because evidence suggests it stimulates insulin and may cause lowering of blood sugars. This in turn would trigger hunger and leave one open to eating more than desired. Else where in Atkins book he provides an allowance of three packets of articifical sweetener each day of the two he recommends. This limit isn't to say you can't have something sweet, but rather forces selection and limitation as you're starting a low-carb diet.

That one must count each packet of any artificial sweetener as 1g of carbs - this alone places a limit on how much you can have in a day, without stating it, if you're following rule three and getting the majority of your carbs from vegetables and salads. Long-term, into maintenance, this is an excellent rule - it limits your exposure to chemical sweeteners and lessens the chance you'll use them in excess if you continue to follow this rule for the rest of your life.

The potential of caffeine to affect insulin and blood sugars is also included in the rules. Each time you have caffeine, your body has an insulin response and the potential for cravings to be triggered. In addition to the potential for cravings being induced by caffeine, there is also the risk of feeling more hungry and eating more than you would had you not had the caffeine. While initially caffeine may supress the appetite, later after its effects are waning, you may actually feel more hungry than you would have had you not had the caffeine.

It is especially important in the first two weeks to do all you can to limit your cravings; as you can see from the above rules that are in place, many of them aid in limiting the cravings to keep you on track. It is also important to begin to fully understand "hunger" and how much sates your appetite rather than leaving you stuffed. By avoiding caffeine, limiting artificial sweeteners and keeping yourself hydrated you're accomplishing this goal.

Dehydration when following a low-carb diet, due to ketosis, is to be avoided. It will increase the concentration of ketones in your body and the result is less efficient buring of fat for energy. You'll also run a greater risk of getting constipated, as well as, a greater risk of painful headaches. Proper hydration while you're in ketosis will help to eliminate the ketones from your body in your sweat, urine and respiration - you need the water intake to accomplish this each day.

As an aside, I've found caffeine has little effect on me. Over the years I've noted that it's a "your mileage may vary" type thing and usually recommend an individual see how they feel with and without caffeine in their daily menu.

Rule Eight: Keep it Real

A low-carb dietary approach is easy to maintain almost anywhere you can eat - at home, on the road or in a restaurant. The key is to carefully consider your options available and understand where carbs are most likely to be found in things "allowed" when they're prepared by others. When you're cooking at home, you know what ingredients you're using; on the road or in a restaurant, odds are high that the chef is using ingredients you won't be including in a controlled-carb diet.

Rule 8:

• Eat out as often as you wish but be on guard for hidden carbs in gravies, sauces and dressings. Gravy is often made with flour or cornstarch, and sugar is sometimes an ingredient in salad dressing.

In an effort to keep it real, rule eight establishes that it's perfectly reasonable to eat out, with a caution to be aware of ingredients used in food preparation. As one more rule, it again repeats an underlying theme within all the rules - take responsibility for what you do eat.

Simply put, do not assume anything in a restaurant is acceptable unless you ask or ingredients are clearly stated on the menu! Where ingredients are not disclosed on a menu, learning how to ask and actually taking the time to ask about ingredients and food preparation is something you'll become accustomed to over time - and in the long-term will be an invaluable asset in your tool-box of strategies to insure you're eating controlled-carb for life!

When you eat out, in addition to the food you get, you're paying for a service - to have your food prepared - so be fully prepared to expect to be served acceptable food for your diet. Start by asking that things be prepared in a way that is acceptable for you or ask for guidance as to what else is acceptable if the chef cannot prepare something without particular ingredients. The basic ingredients, at minimum, you must insist are not included in your meal because of carbohydrate content are sugar, corn starch, arrowroot, potato starch and flour. The standard food ingredients to not be included are bread crumbs, breading, rice, pasta and potatoes, sugar based marinades, high carbohydrate salad dressings, etc.

In addition, you also want to be careful to avoid dishes prepared with shortening, margarine and other fats high in trans-fats. This isn't explicit to the rule above, but given our current knowledge, it's something to avoid when eating out.

If a restaurant is having a difficult time accomodating you, choose a simple salad wth oil and vinegar for your dressing, have a basic protein grilled (no marinade) baked or broiled, and some steamed vegetables.

In all the years I've restricted carbohydrate in my diet, I've never been unable to find something on a menu that's acceptable. Sometimes it means being a bit creative, but as long as a restaurant has basic foods, you can find something to eat as a meal while you're there.

Rule Seven: Use Your Smarts!

It's almost impossible to miss the recommendation to read labels on food packages these days. It's good advice no matter what dietary approach you decide to follow, and is front and center in the Rule of Induction (Atkins) too, found in rule number seven.

Rule 7:

• Don't assume any food is low in carbohydrate - instead, read labels. Check the carb count (it's on every package) or use a carbohydrate gram counter.

This rule establishs a lifelong habit that, as you continue along with a controlled-carb diet, will be invaluable to you. You're expected to make it a habit to read labels and take responsibility for your food choices at the start of a low-carb diet and as you continue along and lose weight.

Once firmly rooted as a part of your food selection process, reading labels makes you a smart and savvy shopper - with an ability to quickly identify packaged foods that are not your best bets nutritionally.

While the first couple weeks has an underlying encouragement to limit foods to those which are fresh, it is possible to include a wide variety of prepared and/or packaged foods, thus the potential to derail success if you're not careful with your choices. So, in the first couple of weeks this rule is invaluable anytime you're including packaged processed foods in your menus.

The reality is that most people will include some packaged foods, whether salad dressings or prepared foods, from the start; so making it a habit to read labels reinforces the requirement that one take responsibility for what they eat.

Over time, reading labels helps to develop a keen eye while enabling one to make good choices among the packaged foods they include in their day-to-day menus. As more and more variety is added to a low-carb diet, it is critically important to be in the habit of reading nutrition labels - not only for carbohydrate content, but to understand ingredients used since differing brands of same-type items varying greatly not only in carbohydrate content, but ingredients used in the preparation of the packaged or prepared food.

Rule Six: Empower Yourself

You may recall that in rule one of the Rules of Induction (Atkins), those starting the first phase of the diet are reminded to eat regularly and develop a pattern of eating each day that they're comfortable with, be it three meals a day or four or five. Also within that rule was the caution not to go more than six waking hours without eating something. I bring rule one up again today because it complements rule six, which says:

Rule 6:

• Adjust the quantity you eat to suit your appetite, especially as it decreases. When you're hungry, eat the amount that makes you feel satisfied, but not stuffed. When you're not hungry, eat a small controlled carbohydrate snack to accompany your nutritional supplements.

Where rule one speaks to our need to establish good eating patterns to take with us as we lose weight and then maintain our weight, this rule helps us understand that over time, as our weight declines, our food intake will decline and we still need to be aware that even with a diminished appetite, it's important to nourish our bodies for good health.

So many diets play on our fears - and one of the biggest is our fear that we lack enough willpower to actually stick with a diet long enough to lose the weight; forget about keeping it off!

One of the draws of a low-carb diet is the natural appetite suppression that comes within a few days of carbohydrate restriction. A large number of studies have noted that even when allowed ad libitum access to any and all of the foods allowed on a low-carb diet, those who stick with the allowed foods experience a "spontaneous" reduction on caloric intake while consuming an adequate level of protein and dietary fats to sate appetite and lose weight.

Sometimes the appetite suppression is so good that it's easy to miss a meal or go without eating too long. This rule reminds us that adjusting our food intake as we lose weight is expected, but we do not need to limit our intake to a point where we're potentially doing more harm than good, nor to we have to rely solely on willpower to lose weight or live with hunger pangs as we lose - we need nutrients from food, we need energy from food (even while losing weight) and we need to establish good eating habits.

That means eating for both to nourish the body and to sate appetite; adjust how much you eat to satisfy your appetite, allow yourself - give yourself permission - to eat and feel satisfied. Satisfaction with your meals keeps you motivated as you lose weight.

This rule does have a caution and that is to be aware not to overeat and stuff yourself, not to gorge or binge. For some who are new to low-carb this may be something that could become problematic - eating too little and then binging - so the caution is there to listen to your body, pay attention to your appetite and learn when you're hungry and when you're satisfied. Over time, if you're paying attention to this you'll find your body really does trigger hunger when you're hungry and if you're eating well, establishing an eating pattern happens!

The last part, to include a small carbohydrate controlled snack with your supplements, reminds us that including nutritional supplements is considered a benefit on the diet and eating something small with them can help you with rule one to establish good eating habits!

Over time as you lose weight, your appetite is going to naturally diminish and your energy requirements will adjust too. This is something to be aware of for the long-term - what you eat when you start - whether it's 3000-calories or 2000-calories - is going to slowly decline in time as your body weight is reduced. Someone who weighs 300-pounds needs more calories each day to maintain their weight than someone who weighs 150-pounds. So, in the long term, this rule is establishing this in your mind to remember later, as you reach a lower weight - you won't eat the same as you do at the start of the diet!

Overall this rule fosters a sense of empowerment - the understanding that you can, perhaps for the first time in your life, listen to your body and learn how to eat well over the period of losing weight and then as you maintain your weight!

Life Gets in the Way

Just a quick post to let readers know that life has gotten a wee-bit hectic here and this week time is short for writing the continuation of the series in progress. I'll be back on Friday morning with the next installement - hope you'll come back then as we continue looking at the rules of induction (Atkins) and how they provide us with insights for long-term success!

Rule Three: Vegetables & Fruits are Heart of Controlled-Carb

We hear much of a healthy diet is from eating fruits and vegetables. Research suggests there is a strong correlation between "good" health and "bad" health over the long-term when comparing the dietary habits of those eating a diet rich with fruits and vegetables to those consuming less than recommended levels.

Diets that strategically restrict carbohydrate are often criticized for lack of fruits and vegetables in the dietary approach. Much like the second rule getting lost in translation, from an allowance of a large variety of meats, poultry, fish, shellfish and game to a requirement to eat "fatty steaks, bacon, brie and cheeseburgers," by those unconvinced a low-carb diet is scientifically supported, rule three is often either ignored in the media and/or used to show how unsustainable carbohydrate restriction is in the long-term for someone to do forever.

How about we take a look, and see what the third rule actually says, and what it "pearls" it contains in both the short and long-term, and where vagueness may lead to misinterpretation:

Rule 3:

• Eat no more than 20 grams a day of carbohydrate, most of which must come in the form of salad greens and other vegetables. You can eat approximately three loosely packed cups of salad, or two cups of salad plus one cup of other vegetables.

First, we know from the published books, that the Induction period is a minimum of two weeks; while one can, and many do, stay within the 20g of carbohydrate beyond two weeks, the above rule is in place for at least the first two weeks.

During this time, the person starting the low-carb diet is tasked with two things in this rule:

1. limiting carbohydrate to just 20g a day and
2. ensuring that most of those 20g carbs are from salad greens and other (allowed) vegetables.

As an example, the rule says this is "approximately" three loosely packed cups of "salad" (note not simply salad greens), or two cups of "salad" (again not simply salad greens) plus one cup of other (allowed) vegetables (without mention of raw or cooked state).

We also know that the plan includes a deduction of fiber, so the amount of non-starchy vegetables (and fruits which I'll get to in an upcoming post) - in cups - that one is expected to consume depends highly on which allowed vegetables are selected in a day. Regardless of which are included, a minimum 10g net (deducting fiber) must come from non-starchy vegetables!

We also plainly see that it is not *mandatory* to deduct fiber per the rule above; however, I strongly suggest folks do deduct fiber as it allows a greater intake of non-starchy vegetables, which are not only low in calories, but nutrient powerhouses. When you deduct the fiber, you're able to consume more essential nutrients than if you don't.

I've previously offered examples of how different selections of non-starchy vegetables may look in a day of eating on a plan allowing 20g net in a day. Once again, I am providing examples to emphasize, even at 20g net carbohydrate, where 10g net is the minimum, a low-carb plan - done properly - meets or exceeds intake recommendation of at least five servings per day in the Dietary Recommendations for Americans for fruits and vegetables.

Example 1

• 1-cup green beans (cooked measure)
• 2-cups Shredded Cos/Romaine Lettuce (raw)
• 4-pieces Crimini Mushrooms (raw)
• 1/4-cup Shredded Red Cabbage (raw)
• 4 Cherry Tomatoes (raw)
• 1-cup Spinach (raw)
• Total Carbohydrate = 18g
• Fiber = 8g
• Net Carbohydrate = 10g
• USDA Servings of fruits/vegetables = 5

Example 2

• 1/2 Avocado (raw)
• 3-cups Cos/Romaine Lettuce (raw)
• 4 Cherry Tomatoes (raw)
• 1/4 cup Shredded Red Cabbage (raw)
• 1-cup Spinach (cooked measure)
• 1/2-cup Broccoli Florets (raw)
• 1/2-cup Sliced Cucumber (raw)
• Total Carbohydrate = 24g
• Fiber = 14g
• Net Carbs = 10g
• USDA Servings of fruits/vegetables = 6

Example 3

• 2-cups Shredded Cos/Romaine Lettuce (raw)
• 1/2-cup Cherry Tomatoes (raw)
• 1-cup Spinach (cooked measure)
• 1/2-cup Asparagus (cooked measure)
• 1/2 cup Sweet Green Peppers (cooked measure)
• Total Carbohydrate = 21g
• Fiber = 9g
• Net Carbs = 12g
• USDA Servings of fruits/vegetables = 6

One can see from the examples above, depending on selections made from those fruits and vegetables allowed in the first two weeks, it is not difficult to meet the recommended intake of 5-or-more servings of fruits and vegatables.

The aim to include a minimum of 10g (of the 20g allowed) from non-starchy vegetables is a "must" in the rule above.

It is also clearly stated as a "minimum," and therefore understood that if you would like to include 12g, 15g or more from non-starchy vegetables in lieu of other foods that have carbohydrate, that is also allowed.

So, if one is cognizant of and desiring more than the minimum intake of fruits and vegetables, they are completely allowed to consume more - with the only restriction being not to exceed 20g net (deducting fiber) during the first two weeks.

Must you aim to consume half your allowed carbohydrate from fruits/vegetables? YES

Can you eat more fruits/vegetables (allowed ones), say 12g, 15g, 18g? YES

Can you deduct fiber? YES

Do you have to? NO (but doing so allows a greater intake of fruits/vegetables and associated essential nutrients)

With all that said, and focus on what all the rules mean for the long-term, I contend that one is expected to continue eating this level (as minimum each day) as they progress toward the long-term eating. I believe that this is one more "foundational" part of carbohydrate restricted diets in the long-term and something intended to be continued as one increases carbohydrate and includes a wider selection of foods, including more vegetables, fruits, nuts, seeds, legumes, and if desired, even whole grains.

Many folks say a low/controlled-carb diet is a way of life, yet find it difficult to take what they start with - 20g net (deducting fiber), of which most must be provided by non-starchy vegetables, a 10g minimum each day - and maintain that aspect as one solid foundation to build upon as they continue to lose weight and then maintain their weight.

Old eating habits start to creep back with more carbs; habits such as preferrentially selecting sweeter foods or grains (even if whole grain) with consumption of non-starchy vegetables waning as one re-introduces more carbohydrate.

If one takes this rule, and continues to extend it --- fully --- until they reach 40g net carbohydrate each day (deducting fiber), they will be consuming incredibly healthful levels of fruits and vegetables, and will be able to eat a very wide variety of them too. That is, until 40g carbohydrate is achieved in the diet during weight loss, one must always include half those carbohydrates from fruits and vegetables with each incremental increase in carbohydrate. (Beyond that, it is increasingly difficult to continue adding more non-starchy vegetables and fruits due to their bulk; you can, of course - it's just not as easy to do).

Now that isn't exactly stated explicitly in the rule, but it is from my experience and those I've given assistance, one significant contributor to maintenance of weight in the long-term. That's because if you're aware of and including a lot of fruits and vegetables (specifically non-starchy vegetables and low-glycemic load fruits) it is difficult to consume excess calories each day over the long-term.

It becomes much easier to consume excess calories when you "play" the carb game (like many play the "points" game with Weight Watchers) and make choices to stay within a number, rather than focus on quality of choice.

But if you're committed to making sure that, no matter what intake of carbohydrate you reach (60g, 90, 120g or more), that you always are sure you include at least 10g net minimum at the start and then 20g minimum (net) from non-starchy vegetables/low glycemic-load fruits as you continue along, you'll have a favorable calorie intake that helps maintaining weight easier.

As you add back carbs, this rule must remain in your eating habits, even if you only stick with 10g net as minimum (which I don't suggest you do) as you're learning in the beginning - you cannot add back carbs and eliminate or reduce how many vegetables and salads you eat each day and expect to maintain your weight using grains, nuts, fruits, etc. as your primary source of carbohydrate later....you must always maintain a level of carbs from your vegetables and salad greens - even in maintenace.

This rule, like rule two, is taking you "back to basics" - helping you learn, step-by-step, how to nourish your body with high quality nutrients from real foods; over time you're encouraged to include a wider variety of non-starchy vegetables, low glycemic-load fruits, nuts, seeds, legumes and more, and the starting basics for the diet should be extended out for the long-term; that is, establish now, at the start, that as part of your long-term habitual diet, non-starchy vegetables and low-GL fruits will be a large part of your overall diet - your body will thank you!

Rule Two: Back to Basics

Over the last few decades, the population at large, has slowly been indoctrinated to fear dietary fat; to limit intake of dietary cholesterol; and to limit consumption of foods rich with saturated fat like meat, whole dairy, butter and eggs. This happened despite little evidence that such an approach to eating provided a long-term health benefit, or ability to maintain weight. But, with decades of reinforcement in the popular thinking, it's understandable how the second rule in the Rules of Induction is the most misunderstood and maligned of them all.

Let's take a look:

Rule 2:

• Eat liberally of combinations of fat and protein in the form of poultry, fish, shellfish, eggs and red meat, as well as pure, natural fat in the form of butter, mayonnaise, olive oil, safflower, sunflower and other vegetable oils (preferably expeller-pressed or cold-pressed).

Is it any wonder that, when a diet comes along and allows these foods, in complete contradiction to decades of fat phobia propoganda, it is vehemently opposed by the leading health organizations and government agencies? That we're innundated with dire warnings of consequence to health, heaped upon us in a concerted effort to discredit and dismiss anyone who says differently; despite scientific evidence and data supporting not only the inclusion of these foods in the human diet, but their inportant contributions to the human diet!

Ignore the man behind the curtain Dorothy....ignore that in the noble attempts to improve the health of our population, researchers and clinicians were lead astray by what we now know was half-truth data, published in the fifties and sixties.

They know it, we know it, but still it's difficult to come to grips with that fact and reverse direction after decades of building the foundation of a "truth" only to find it terribly flawed. It's often easier to continue on in the lie than face the fact you're wrong; moreso when the entire group and community you exist within endorses the continuation of the established dogma, despite the evidence to the contrary.

It's easier to "kill the messenger" than kill the flawed paradigm that hold these foods are to be limited, heck, even avoided at all cost.

To admit such is akin to killing thyself and the core set of beliefs one holds to be true.

Dramatic license here?

Sure, but it does speak of something critically important one must do for their long-term health when they begin to, perhaps for the first time in their life, establish good eating habits for the rest of their life.

Simply put, the second rule of induction grants us permission to dismiss everything we've been told and taught to hold as truth about eating, macronutrients (carbohydrate, protein, fat) and a "balanced, healthy" diet; allows us to re-learn what it means to be human and eat food; and encourages us to enjoy the experience of truly eating a healthy diet while losing weight and then continue to do so along the way to finally, once and for all, maintain that weight well into the future.

I'm quite the optimist aren't I?

Seriously, don't studies tell us again and again that dieting to lose weight fails, that all we really ever do is get good at losing weight, but we're never quite able to master maintaining our weight in the long-term?

Let's start by examining the very base reason most folks even begin a diet to lose weight - they're overweight or obese and have decided it's time to do something about it.

So they begin, they are off to a good start, they're motivated and continue to be motivated with each incremental decline they see on the scale.

Problem?

Absolutely - the focus is on the scale; the number on the scale matters most and damn the torpedos, no matter how inconvenient, stressful or annoying it is to weigh, measure and count every calorie, the individual is in a battle against their bathroom scale to reach a desired number in the shortest period of time possible.

Millions have mastered this task, only to have to repeat it again and again throughout their life. I apolgize now if this sounds crass, but anyone can lose weight with even just a small level of effort; it doesn't take an Einstein to eat less for weeks or months to reach a number on the scale; most will put up with high levels of discomfort to reach that goal - hunger, moodiness, irritability, stress and counting, measuring and weighing anything they consider putting in their mouth.

In the short-term, such measures do work; in the long-term they fail because the person has been mistakenly led to believe "if only..." they do this, measure that, control this and avoid that over the short-term, somehow that alone will enable them to maintain their new lower weight without much more than keeping on keeping on; except the keeping on part is next to impossible!

That's because the very dogmatic recommendations we're repeatedly told are balanced and healthy to lose weight are scaring people away from the very foods that we need to eat to thrive as humans; this forces an unnatural eating patten across the population due to a deeply flawed fear of dietary fat and cholesterol and leads to failure in the long-term because it is not only unsustainable, it's incompatible with true health in the longer term.

The heart and soul of our metabolism is the endocrine system - when it dysfunctions, a cascade of health problems follow - insulin resistance, high blood pressure, dyslipidemia, diabetes, and other chronic and debhilitating diseases.

Why then are we specifically told to avoid the very foods that fuel the proper function of this system?

The current recommendations not only scare us from healthy food, they make simply eating way too stressful for an average person - measure this, weigh that, watch this, avoid that, don't eat this, that's better, blah, blah, blah - who wants to deal with that much stress each day? Sure, a motivated person, desiring weight loss will submit to such stress to reach a goal - but then what happens? They do what is natural and human - they do what they need to do to relieve the stress and relax, are then an easy target to point to as someone lacking willpower, someone just not commited to sticking with it; someone who simply doesn't care and is lazy!

Anyone who has attempted to lose weight only to regain it can relate - no matter how hard you try to stick with a diet that is, for lack of a better phrase, "high maintenance" to follow each day for the rest of your life - sooner or later you find the "benefit" (weight on scale) isn't worth the time and "stress" (weighing, measuring, going hungry, chastising yourself for wanting to eat, etc.).

As I said in my last post, what if the problem isn't you or your "willpower," but a deep flaw within the recommendations that lead not to success, but failure in the long-term?

Here's the rule again:

Rule 2:

• Eat liberally of combinations of fat and protein in the form of poultry, fish, shellfish, eggs and red meat, as well as pure, natural fat in the form of butter, mayonnaise, olive oil, safflower, sunflower and other vegetable oils (preferably expeller-pressed or cold-pressed).

The short and long-term secrets within this rule include:

1. Eating "liberally" is not the same as eating until you are stuffed and goes hand-in-hand with rule 6, which we'll look at later this week. This rule is also a natural extention to rule 1 to eat regular sized portions.

2. You're allowed to eat animal foods such as meats, poultry, fish and eggs provides you with combinations of both fats and protein - necessary for health, losing and maintaining weight on a carbohydrate restricted diet.

Note that in the rule, no one is told they must eat "fatty meats" or must consume "bacon, brie and oodles of t-bone steaks." No, instead they're to eat foods that provide both fat and protein; they can choose whatever cuts they like, whatever combinations suit their tastes; whatever they prefer.

Want boneless skinless chicken breast? Allowed.

Want a filet mignon? Allowed.

Want some eggs? Allowed.

Want some dark turkey meat? Allowed

Want some salmon? Allowed.

This "allowance" of all things that provide a good fat-protein combination reinforces our mindfullness not to fear food, food is not the enemy!

Adding to this is that using fats and/or oils as part of your meals is allowed - from sources of natural, good fats and oils; with those natual oils being preferentially from expeller-pressed or cold-pressed sources.

Why are the animal products with combinations of fat and protein and the use of natural fats & oils so important?

By integrating both into your meals you are also beginning the process of balancing your essential fatty acid ratios in your eating from the fats found in these sources, and perhaps for the first time, consuming adequate protein, thus adequate essential amino acids.

Important too is to choose quality, eat well and enjoy your food and meals. Don't worry each day about how much fat is in a particular food or meal at this stage, over time you'll be able to "tweak" as you go and learn better how to nourish your body and eat what really is a well-balanced, healthy diet.

With fat and protein providing the vast majority of "essential" nutrients, this liberal approach at the start of your weight loss diet takes you "back to basics" and with time, provides you the opportunity to not only learn how to eat well for the long-term, but to actually enjoy your meals again - without fear that you're killing yourself with every bite!

Establishing Good Eating Habits: Rule One

Odds are, overweight or not, by the time a girl reaches adulthood, she's tried one or more diets to lose weight or not gain weight; with boys, the incidence of dieting in the teenage years is less prevalent. In early adulthood this often continues, with many women and men developing what is termed "disordered" eating habits; skipping breakfast or other meals, relying on meal replacement products, like ready-to-drink shakes, rather than eat food for all meals, eating lots of small things on the run, or going long hours without eating anything, then taking one large meal at the end of the day, in the belief that will keep thier calorie intake lower over the day.

These types of habits aren't necessarily "eating disorders," though they may be part of one; more often than not, they are habits that one develops over time that are counter-productive to developing and maintaining a healthy relationship with food, and can stand in the way of long-term success when one loses weight and tries to maintain that loss over the long-term.

Food, while an easy target of blame in the weight loss game, is not an enemy to be avoided or held in disdain; it is essential to our health and well-being and, in the long-term, it's not simply learning what to eat that helps one maintain weight, but how to eat that sets the stage for long-term success.

With this understanding, it is easier to see why I believe the first rule in the Rules of Induction (for the Atkins diet) is the most important:

Rule 1:

• Eat either three regular-size meals a day or four or five smaller meals. Do not skip meals or go more than six waking hours without eating.

The first rule is straight forward and critically important not only in the first two weeks, but throughout the entire weight loss period, and then for maintaining weight in the long-term.

The reason is simple - it establishes that one doesn't need to eat in a typical three-meal-a-day pattern, but highlights the importance that eating regularly - even simple smaller meals multiple times each day - is a habit to continue with if you're already doing so, or establish now as you begin and continue to learn how to eat properly for the rest of your life.

Without establishing this as habit, you'll leave yourself open to disordered eating habits and continue to view food and eating as something bad or to be avoided. Now is the time to set aside all that disdain for food, eating, portions, and all that and dismiss that thinking so you can begin to learn to love food again!

This is the first step to "get back to basics" - a means to develop a healthy relationship with food and avoid continuing in a disordered eating pattern that is counter-productive in the long-term. In anything you do in life, be it your job, your hobbies, or anything else that requires skill, one thing that clearly sets apart those who succeed from those that fail is the feeling of confidence in ones ability. Few are "born naturals" in a given situation - most take the time and put in an effort to learn and do along the way, to build their confidence and master whatever it is they enjoy.

This is no different; by taking the time to work on this as you start a diet to lose weight, you will develop not only a sense of confidence that food is really not an enemy (since you will be losing weight while you establish good eating habits), you will also learn to listen to your body and take cues based on hunger to learn when to eat in a pattern that is in synch with your body. This is because eating regularly keeps your metabolism functioning and enables your metabolism to hum along nicely.

If you read the rule, you'll notice it says " three regular-size meals a day or four or five smaller meals" which hints at learning how much is enough; stated another way, portion size is important. If you're inclined to eat three meals a day, these meals will be larger than if you are inclined to eat four or five smaller meals.

We know from the various publications written by Dr. Atkins, that Induction is not a license to overeat or stuff ourselves. In my view, this Induction period is an opportunity to learn what a "portion size" means to you as an individual.

So many weight loss diets prescribe specfic weights and measures, claiming such portions are more than adequate for anyone attempting to lose weight.

But let's be honest - how many are truly satisfied after eating a tiny 2-to-3 ounce portion of bonless, skinless chicken breast? If you're one of the few who find this intake adequate for you and you're satisfied and not hungry, great!

If not, maybe the problem isn't you, or as you are often told, your lack of willpower, but instead that you have not eaten enough to adequately provide for your needs.

Listen to that - have some more - and as you begin to feel that sense of "satisfied," not stuffed, but satisfied and confident you've eaten well, without worry that you're going to be hungry again way too soon, then stop eating.

In this period, you are allowed to portion your meals as "regular-size" meals, keeping in mind that you won't eat larger portions just because you can. If three "regular-size" meals isn't your style, you simply adjust to more "smaller sized" meals in a regular pattern throughout the day.

The key here is to develop good eating habits and then maintain them as you move along.

Long-term this rule is the "golden rule" of maintenance. It is the most important rule of all the rules if you ask me!

By the time you reach maintenance, if you have been following this rule all the time - not just in induction - you're not only eating an adequate level of calories, no longer in ketosis and at your goal weight - you're also in the habit of eating portions that are "normal" for you and eating regularly to keep your metabolism working at a steady pace.

You've also learned that skipping meals may lead to eating more when you do eat and that it is best to keep your appetite sated by eating regularly for your particular needs - whether it is three regular meals each day or four or five smaller meals each day; and you may also have learned you're less likely to snack as often because your appetite is sated with regular meals!

This rule firmly establishes that you are tasked with setting the frequency of your eating pattern, sticking with an eating pattern that is regular, and develop a sense of what your needs are, learn what your "portion size" is in meals, and learn how to eat regularly instead of fearing food or your appetite!

Over the long-term you'll set the stage for success with this rule because you're allowing yourself to establish a healthy relationship with food and come to know that food is not your enemy, eating well is not a bad thing, and that enjoying your meals is truly a wonderful thing!

What's Stress Got to Do With It?

Getting away on vacation is always so relaxing - there is nothing like kicking back and just doing whatever, whenever you want! Not only does getting away from the daily grind of life allow to you unwind and not think about much, it relaxes body and mind, which reduces stress that you often don't realize you have in your daily life. So while I often get emailed asking "you're going away again?" - I can't help but resume my blog posts with a study just published in Nature Medicine, Neuropeptide Y acts directly in the periphery on fat tissue and mediates stress-induced obesity and metabolic syndrome.

As was reported in the Washington Post today, "Scientists reported yesterday that they have uncovered a biological switch by which stress can promote obesity, a discovery that could help explain the world's growing weight problem and lead to new ways to melt flab and manipulate fat for cosmetic purposes.

In a series of experiments on mice, researchers showed that the neurochemical pathway they identified promotes fat growth in chronically stressed animals that eat the equivalent of a junk-food diet. Researchers found that laboratory mice subjected to daily stress and also fed a high-fat diet for a few weeks became obese. (Georgetown University Medical Center) The international team also showed that blocking those signals can prevent fat accumulation and shrink fat deposits and that stimulating the pathway can strategically create new deposits -- possibly offering new ways to remove fat as well as to mold youthful faces, firmer buttocks and bigger breasts.

"It's very exciting," said Zofia Zukowska of Georgetown University's Department of Physiology and Biophysics, who led the research, published online by the journal Nature Medicine. "This could be revolutionary.""

The study findings are being heavily reported in the media and most are highlighting the potential for pharmaceutical development, but few are talking about the real implications of the findings - can reduction of stress in real life lead to lower weight and a decreased risk of developing chronic disease?

Before I delve into that, first let's see what the researchers did in their experiments. The study was an animal model that involved mice. The researchers divided the mice into various groups - some ate a "normal" mouse diet, some ate a high fat, high sugar "junk-food" mouse diet. To see the effect of stress on the mice with each diet, some mice were highly stressed while others were allowed to carry on as mice do in their cages.

Unstressed mice consuming the "normal" diet did not gain weight.

Unstressed mice consuming the "junk food" diet did not gain weight.

Stressed mice consuming their "normal" diet did not gain weight.

Stressed mice consuming the "junk food" did gain weight.

This finding, especially if replicated in future studies, is critically important in our understanding of diet and health. This is because the findings showed that it was not diet alone that stimulated weight gain, nor was it stress alone. It was the specific combination of stress coupled with what researchers described as a "high-fat, high-sugar" diet that led to weight gain.

And not just any weight gain, but specifically fat accumulation in the belly - visceral fat; which we now understand is more detrimental to long-term health than subcutaneous fat which accumulates in places like the butt, thighs or arms. The stressed mice consuming a junk food diet also experienced glucose intolerance, elevated blood pressure, inflammation of the blood vessels and fat accumulation in the liver and in muscle tissue.

Simply put, they developed Metabolic Syndrome.

They did this not consuming excessive calories either - the researchers noted that the weight gain and fat accumulation in the stressed mice consuming the junk food diet was greater than expected given the calories consumed. Yet the mice consuming the same diet who were not stressed did not gain weight.

So it wasn't just the diet that mattered, it wasn't just stress that mattered; what mattered was the stress together with a junk food diet that conspired with each other to disrupt the production and pathways of neuropeptide Y (NPY).

Which leaves me wondering and pondering about many of the different dots still to be connected as we move forward to resolve the "obesity epidemic"...in the coming days I'm going to present additional data and studies to see what dots we might connect and what might be our solutions in the future.

I'll leave you with what Lou Shuler noted in his Male Pattern Fitness blog yesterday:

So, according to news reports, the "breakthrough" is a magic bullet that will selectively reduce fat deposits. Then there's some kind of opposite pill that will put fat on in selected places. If it works out in human experiments, somebody will make billions of dollars off these pills. I'm happy for them -- I wouldn't mind having some extra commas on my balance sheets -- but let's not forget that it'll be years before people will be able to use this chemical liposuction.

Meanwhile, anybody can stop eating junk food now. Today. The FDA doesn't have to give you permission to not enter the drive-through. The U.S. Patent Office doesn't have to put its seal on your decision not to supersize. It's here, it's free, it's open-source. It's dietary Linux. It doesn't discriminate by race, gender, religion, or income.

And it couldn't be simpler: All you have to do is eat something besides junk food.

It's so easy I couldn't even write a book about it. Chapter 1 tells you not to eat junk food. There is no chapter 2.

Why isn't that discovery being treated as the breakthrough, and the possibility of magic pills as an interesting sidebar?

Oh, yes - and as requested in emails while I was away, some pictures from our vacation:

Driving a boat on Norfork Lake, AR:

The big guy, with a mighty big fish:

My little guy, two months shy of his third birthday!

Oh, Yeah, That'll Work

An article in Sunday's Independent (UK) paints an ominous picture of what may be coming down the pike as a way to solve the epidemic of childhood obesity; simply take these children from their families and place them in care of the state.

"Doctors are calling for the parents of obese children under the age of 12 to be targeted under child protection laws and for their offspring to be taken into care."

Next month a motion will be presented at the British Medical Association (BMA) conference that will include provision for social workers to "treat childhood obesity as neglect" and allow state intervention, including removal from the home.

"Dr Matt Capehorn, who will present the motion on obesity in Torquay, said: "No healthcare professional would want to break up a family unit but this has to be considered if the child's health is being put at risk." Dr Capehorn, a GP, runs an obesity clinic in Rotherham, South Yorkshire."

The motion comes on the heels of our own American Medical Association releasing its latest Expert Committee Recommendations on the Assessment, Prevention and Treatment of Child and Adolescent Overweight and Obesity document on June 6, 2007. Noticably absent - media coverage to highlight its release!

Take some time to read it, I'll be writing more in depth about what appears to be in the works for us here in the United States! I'll note where the evidence stands for the recommendations in the document and point out data that's obviously being ignored in the efforts to reduce the prevalence of obesity in children.

Keep in mind as you read the document, this is from the same organization led by Dr. William Plested III, president of the American Medical Association, who was quoted as saying at a recent Rotary Club meeting in Jacksonville, Florida, “We’re going to pay for this with a generation of ‘fatsos’ with every disease you can imagine.”

Nice, huh?

Back to Our Regularly Scheduled Program

You may recall the alarming headlines reported here that suggested a high-fat meal was very risky to endothelial function; one went so far as to suggest just one bite of a burger might kill you!

Seems some researchers thought maybe it's a good idea to see what effect a high-protein (low-carb) and low-fat (high-carb) habitual diet might have on endothelial function over a longer period of time - say, maybe a year?

Wonder why you haven't seen any headlines on the latest study - Effects of weight loss on a low-carbohydrate diet on flow-mediated dilatation, adhesion molecules and adiponectin - published in the British Journal of Nutrition?

Might be because the researchers found nothing significantly different between the two diets, and noted "weight loss does not improve FMD [flow mediated dialation]."

Paper gets published, media sees it, notes noting to see here, no sexy headlines....not quite juicy enough to waste readers time with (even though it contradicts those one-meal experiements), so let's just move on.

But wait!

Just because the study objective was to see effect (benefit or risk) on FMD, adhesion molecules and adiponectin, was there anything else they measured that did have significance and is worthy of our time to look at?

How about we take a look?

Two groups of subjects were randomized into two different dietary protocols - the first included 13 people assigned a low-carbohydrate diet (40% protein, 27% carbohydrate and 33% fat; 26g fiber daily); the second included 12 people assigned the high-carb diet (20% protein, 60% carbohydrate, 20% fat; 40g fiber daily).

Both groups were weighed, measured, poked and prodded and followed up with a 6-weeks, 12-weeks and 52-weeks. Measurements and testing included weight, BMI, blood pressure, cholesterol, glucose, insulin, CRP, VCAM1, sICAM1, E-selectin, P-selectin, and total adiponectin. In addition, vascular measurements were taken for blood pressure analysis and endothelium-dependent FMD, along with an assortment of other tests.

The various measurements were duly recorded for baseline and re-measured during follow-ups, and were included in the final paper. Some critically important measures were statistically significant, but not the focus of the study design; thus not highlighted in the abstract conclusions.

We hear a lot about how low-carb diets are bad for cholesterol.

In this study, like others, total cholesterol, LDL and triglycerides were lowered over the course of the year and HDL rose while following the low-carb diet.

Total Cholesterol:
Baseline = 5.3
52-weeks = 4.62
[low-fat group went from 5.7 to 4.94]

LDL:
Baseline = 3.5
52-weeks = 2.69
[low-fat group went from 3.8 to 3.07]

HDL:
Baseline = 1.3
52-weeks = 1.44
[low-fat group went from 1.3 to 1.34]

Triglycerides:
Baseline = 1.7
52-weeks = 1.07
[low-fat group went from 1.4 to 1.34]

Intriguing too was the improvements with glucose and insulin following the low-carb diet:

Glucose (fasting):
Baseline = 5.9
52-weeks = 5.19
[low-fat group went from 5.8 to 5.5]

Insulin (fasting):
Baseline = 16.9
52-weeks = 7.28
[low-fat group went from 12.1 to 5.22]

An interesting finding was that adiponectin, a hormone involved in a number of metabolic processes, including glucose regulation and fatty acid catabolism, "did not change significantly after 12 weeks of weight loss" (p=0.10), but increased (good) at the last measurement, 52-weeks, at the end of the study (p=0.05).

Blood pressure (not high at baseline) improved, from 122/75 at baseline to 115/68 at the 52-week measure; for those on the low-fat diet, blood pressure increased from 122/75 at baseline to 130/74 at 52-weeks.

It's clear in the data that both dietary approaches offered improvements with weight loss in the above measures of risk factors. Something though wasn't "right" to help with, improve, endothelial-dependent FMD. We'll explore potentials in a moment.

Somethign troubling that seems glossed over - the higher blood pressure in those following the low-fat diet - where at baseline their blood pressure averaged 122/75, at 6-weeks it improved to 115/72 and again improved at 12-weeks was similar at 118/70. What happened between the 12-week measure and the blood pressure reading at week 52, when blood pressure was now averaging 130/74?

This is something I would consider worthy of noting, even maybe point out and suggesting additional questions and investigation as to why!

In the discussion section, the researchers stated that "The main finding of the present study was that weight loss on a low-carbohydrate diet which brought about reductions in glucose, insulin and LDL-C did not improve FMD either after short-term weight loss or long-term weight maintenance. Irrespective of diet composition weight loss had beneficial effects in the short term on adhesion molecules and blood pressure and in the longer term on adiponectin and P-selectin. There appears to be a delay in improvement in both adiponectina nd P-selection as these molecules did not improve until weight loss had been maintained for a year."

They went on to add, "Lack of change in FMD in the present study confirms our previous finding that weight loss does not improve FMD...One of our goals with the dietary intervetion was a reduction in LDL-C which we achieves, 18% at 6-weeks and nearly 30% at the end of the study with no effect on FMD."

The researchers also noted that "The present study was also designed to achive a reduction in glucose in a 6-week weight loss intervention on a more moderate diet of 6000kJ and we achieved this but with no effect on FMD."

And, "A complex physiological response such as FMD may be related to LDL and glucose cross-sectionally and in post hoc analyses but these may not be casually related but correlate in some circumstances with the real unmeasured mediator of change. For instance, oxidative stress may be a major factor in reducing NO bioactivity but reducing LDL levels may have no effect on this even though the endothielial cell is clearly heathier as judged by a reduced adhesion molecules."

In the end, they concluded that "weight loss on a low-carbohydrate, low-saturated fat diet, does not improve FMD despite improvement in cardiovascular risk factors. The improvement in adiponectin was delayed."

So what was their error of omission?

Well, for one they failed to note the problematic rise in blood pressure observed in the subjects following the low-fat diet. But, let's set that aside for a moment.

They also failed to note that the above failure to improve FMD was also observed in subjects following the low-fat diet; one that happened to be designed well enough to match the American Heart Association recommendations!

Yet even that low-fat diet (20% of calories from fat) didn't help improve FMD, despite their weight loss, improvement in glucose, insulin and cholesterol; but this was left unsaid.

I'm not surprised.

So, what we're left with is the stated null finding of those on the low-carb diet, with no real statement that neither dietary approach did much for FMD.

I hate to say it, but there was also a lack of curiosity as to why this was.

It's pretty much accepted dogma that a low-fat diet improves the cardiovascular system, thus would exert a postive - significant - effect on endothelial-dependent FMD. It didn't, yet the researchers didn't say "hey, wait, this low-fat diet didn't help either" and instead highlighted that the low-carb diet didn't improve FMD in their conclusions.

Some questions really do need to be asked.

First, how did the low-carb diet look compared with the habitual diet?

We know subjects were consuming, on average, 11.4mJ each day (2725-calories) as their habitual diet. The weight loss diet was 6000kJ each day (1430-calories). They followed the weight loss phase of the diet for six weeks and lost 5.8kg, or 12.75-pounds.

Let's do math!

Each day, we're to believe, the subjects were in a calorie deficit of 1295-calories. Six weeks is 42-days, so over the period, a calorie deficit of 54,390 calories - enough to theoretically lose 15.5-pounds. Hmmm....Okay, so it's pretty clear they did not really follow the diet as planned, since it's clear they consumed more calories than was reported. Happens all the time, no biggie.

Except, we have no idea what the excess calories were, so we have a confounding variable here. Did they eat pie? Did they eat broccoli? Did they eat fatty meat instead of lean meat? Did they skip the oatmeal and eat eggs? Who knows?

It's also noteworthy that the low-fat dieters ate a habitual diet of 10.8mJ daily (2581-calories) and were placed on the same weight loss calorie level. So they were in a calorie deficit of 1150-calories each day, or a six week deficit of 48,342-calories. This theoretically would result in a weight loss of 13.8-pounds; they lost 5.9kg (13-pounds). Did they cheat less? Did they stick to the diet more carefully? Who knows?

But, we can be sure we have a confounding variable here - something doesn't add up, and it looks like that something is calorie intake. It appears it was higher than the dietary protocol called for; and an increased calorie intake we have no idea what foods/macronutrients it came from.

So then, is there anything else? Let's see how macronutrient intake changed on the low-carb diet.

At baseline, their habitual diet - 2725-calories - was from 39.6% carbohydrate (270g), 19.6% protein (133.5g) and 36.5% fat (110.5g). We do not know the baseline intake for fatty acids, but do know the dietary protocol was strict - saturated fat 7%, PUFA 6% and MUFA 13% of calories.So, while following the weight loss diet, the macronutrient profile changed to provide 1430-calories each day, of which 33% were carbohydrate (118g), 40% protein (143g) and 27% fat (43g) with 7% from saturated fat (11.1g), 6% from polyunsaturated fat (9.5g) and 13% from monounsaturated fat (20.7g).

The first glaring disparity is the protein-to-fat intake, for every 1g of fat, they were expected to consume 3.3g of protein; this is a highly unusual pattern, heavy with protein and too lean - if you review other studies on "low-carb" diets, the fat intake is usually higher than the level in this protocol and protein typically lower; of note, this intake ratio is next to impossible without some funky planning. I'd like to know how much soy was a part of this diet? How much of the diet was comprised of non-fat dairy? How much fish was allowed, and what type was it? Were protein shakes or supplements part of the protocol? If so, which type of isolate dominated?

Without this specific data, it's difficult to say one way or another if the foods included may have contributed to the null finding or not.

So here, we have a potential confounding variable that is unexplored.

Anything else?

Well, from the data we do know, it seems we find an inadequate level of polyunsaturated fats - with just 9.5g each day; a level at which the subjects are unable to meet essential requirements for omega-6 or omega-3 fatty acids!

I am really starting to wonder why researchers designing diet protocols that are inadequate for known essential nutrients?

The Institute of Medicine (IOM) clearly states in the Daily Recommended Intake documentation, the MINIMUM required each day from omega-6 is 5% to 10% of calories and the MINIMUM requirement each day from omega-3 is 0.5% to 1% - when calories are adequate to maintain weight. In absolute terms - absolute gram minimums - the IOM states that adequate intake of omega-6 fatty acid is 14g-17g for men (depending on age) and 11g-12g for women (depending on age); and that adequate intake of omega-3 fatty acids is 1.6g for men and 1.1g for women.

Combined, the absolute minimum intake for essential fatty acids is between 15.6g-17.6g for men and 12.1g-13.1g for women.

In this study, even if every last gram of polyunsaturated fat was an omega-3 or omega-6, these subjects were deficient for essential fatty acids with only 9.5g of polyunsaturated fats as part of the diet.

So, again, confounding variable - huge confounding variable!

And the researchers question why the diet didn't have an effect on FMD?

Perhaps the researchers haven't read the data showing improvement in cardiovascular health when essential fatty acid intake is optimized to meet or exceed current recommendations?

Recent evidence of the role of omega-3 polyunsaturated fatty acids on blood pressure control and hypertension-related complications

Omega-3 Fatty Acids: Role in Cardiovascular Health and Disease

Fish Oil and Endothelial Function

I can't say it enough - I love good data, but studies like this, with macronutrient intakes, as percentage of calories, is highly confounded data. Designing a dietary approach to lose weight or maintain weight, macronutrient percentages are often inefficient and do not meet essential nutrient requirements.

I'd really like to see some researchers start designing studies to ensure adequate intake of essential nutrients within the calorie deficits - until we start to look at the nutrient-quality of weight loss diets, I'm afraid we're not going to make much progress to provide the public with sound, scientifically supported recommendations.

Thursday Finds...

Hat tip to Lou Schuler to the link featuring the level of stupidy some sink to as a form of protest - seems Mark McGowan, a "performance artist" and VEGETARIAN in the UK ate a dead dog to protest fox hunting.

What will he do for an encore?

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PJ, over at the Divine Low-Carb, has a piece about Low-Carb and Gardens.

"Today I was reading the blog Weight of the Evidence, and she was talking about trying to successfully live, let alone lowcarb, on a pitifully small amount of money.

It got me thinking about gardens. You know, the last century's radical shift away from gardening is not just about free time. If anything people have more free time than they ever did, culturally -- they just have other priorities, of course. I suspect it's more about a trend of basically avoiding responsibility, in a way. I don't mean if you don't have a garden you're irresponsible (haha!), I mean that as a culture at large it seems like we grow more and more toward "paying someone to feed us or fix us."

Go on...you know you want to continue reading....

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The obese seem to be viewed with greater disdain than smokers, at least in the UK.

Poll data released shows 66% public there supports the idea of denying surgery to obese people; just 33% said those who smoke should be denied surgery.

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Sounds suspiciously carbohydrate-restricted to me...

Can you feed yourself with $3.00 a day?

The challenge is one millions Americans face each day - feeding themself and their family with just $3.00 per person, per day.

Patt Morrison wrote of her experience trying to do shop with $21 for a week as a vegetarian in the LA Times.

In the long run, it takes money to eat thin and healthy. For $3 a day — which is what you get when you divide 30 days into the $155 monthly food stamp allowance for one person — you wind up on the fatty-salty-sugary-canned-processed-bottled diet. Get heart disease on $3 a day! Ask the government how! [empahsis hers]

She highlighted that "Several members of Congress took the food stamp challenge, and now two of them, a Missouri Republican and a Massachusetts Democrat, are trying to make the food stamp fund a little bigger and to guarantee that combat-zone pay doesn't knock military families off the food stamp eligibility list (yes, there are food stamp debit cards in the pockets of U.S. military uniforms)."

Which led me to The Congressional Food Stamp Challenge, a blog detailing the experiences of two members, during the week May 15 to 21, as they lived with a budget of just $3.00 a day to feed themself.

As congresswoman Jan Schakowsky noted in her reflections of the week, "Living on food stamps is not just about the food. It takes a lot of planning ahead to live on a food stamp budget, and still, even if you get the calories you need, you can’t get the nutrients. Maybe some nutrition expert can figure out how one can eat healthily on a food stamp diet, but I can’t see how it’s done. Fruits and vegetables, especially fresh ones, are very expensive relative to foods like pastas and bread."

The Washington Post featured the experiences of Representative Tim Ryan, who found "He made some poor choices when he shopped for the $21 worth of food, and the country's food stamp program is not sufficient for the 26 million Americans who rely on it."

What started the challenge was two representatives, Jo Emerson (R-MO) and Jim McGovern (D-MA), calling on their colleagues to join them in raising awareness of hunger and what it's like to live on just $3.00 per day. Only two members joined them - Tim Ryan (D-OH) and Jan Schakowsky (D-IL) in the challenge.

"I've been a little low on energy, but I feel guilty about complaining about anything," said McGovern, who took the challenge with his wife; each lost about five pounds. "For us, this is an exercise that ends Tuesday. For millions of people, this is their life."McGovern said he faced down many temptations at several receptions and fundraisers -- the duck rolls, the crab cakes, the red wine.

"Every time I thought, 'I wish I could have that scallop wrapped in bacon,' at the back of mind I thought, 'Why are you complaining? This is the way people live every day,' " he said.

The Southeast Missourian featured Jo Emerson's experience, "Most people on a day-to-day basis don't think about the fact that there are millions of people in this country who have to make a choice every day about how much they're going to spend on food," Emerson said.

And, who knew? "I'll save over a dollar by blowing my low-carb diet," Emerson said.

Which got me thinking, what would I do if I only had $21 for the week to feed myself?

What would be more important - satiety or nutrient-density; could I manage both?

More importantly, would I be able to feed our family of three, with just $63 for the week and still feed my child a nutrient-rich diet?

What compromises would I make in my diet to assure his diet was healthy?

I'm up for the challenge, as is my husband - later today, with just $63 in my pocket, I'll shop for a week of groceries, commited as a family to only eating what we're able to purchase with that sum next week.

We'll begin this evening, and continue through lunch on Friday next week.

In doing this I hope to learn even more about nutrition and provide my readers with insights about how possible it is to maintain a controlled-carb diet while on a tight budget.

I'd like to invite my readers to join me and use the comments section to share ideas, tips and frustrations as we journey together through the challenge.

Before you agree, here are our "rules" for the week:

1. The budget for food, all food, is limited to just $3.00 per person in our households each day ($21 per week, per person), so if you're single, you have $21....a couple has $42....each child adds $21. One major caveat - we cannot use anything during the week we already have in the house unless we deduct the cost of it from our budget - so if you're using chopped garlic in a jar already in your refrigerator, deduct the price from your budget for the week! Same goes for spices, cooking oils, and such since it's unlikely we'd have a stocked pantry if we were living life routinely on $21 a week per person!

2. We can shop for, prepare and cook whatever we want to eat, but cannot eat free food at business functions, meetings, work, or other places; but we can sample from tasting stations in grocery stores, and eat at parties we attend, hosted by friends or family (but not business functions!)

3. If you have a child in school, buying school lunch, the cost of the lunch is part of your budget....or you can pack their lunch for the week to buy more groceries. Or you can opt not to include your child in the budget and only do this yourself (and/or with your spouse).

4. We can eat out, but any cost to eat out must come from our $21 a week per person, so if we plan to eat out, we need to plan the cost and keep it within that amount when we do eat out. Friends and family cannot pay for us to eat out during the week, nor can the business expense account pick up the meal.

5. The budget does not include paper products, cleaning products, or non-food items available at grocery stores (lightbulbs, batteries, etc.); the budget does include alcohol, so shop wisely if you want a drink with dinner or use wine in cooking!

6. The budget does include condiments, spices, supplements, and anything you'd consume as part of your "diet," but does not include over-the-counter medications or prescription medications.

7. The challenge includes preparing and eating what you are able to purchase throughout the coming week, and any meals eaten out, since it's one thing to have to shop with a limited budget and another to live with it for a week.

Who will join me this week?

Those participating in the challenge are encouraged to email me photos of their groceries for the week, along with recipes and meal ideas and insights about your experiences during the week. I'll highlight them here on my blog next week and open discussion about the various challenges we all faced, and the things we learned along the way!

Impact of Community Based Diet Intervention, More than BMI

There's been a lot of fuss over the publication of the Shape Up Somerville: Eat Smart Play Hard.™, initiative results in the May issue of Obesity. (abstract)

As noted in the abstract, the objective "was to test the hypothesis that a community-based environmental change intervention could prevent weight gain in young children" as reflected in the change in BMI z-score.

In total, 1,178 children were enrolled - 385 in Somerville (the intervention group), and two control communities, one enrolling 561 children to be followed, the other 232 children to be followed. All the children were in grades 1 through 3 at the beginning of the study period, school year 2003-2004 (September to June).

The intervention was intensive, and expensive.

Overall, the researchers started with a $1.5-million dollar CDC grant. And, if that were not enough, the Tufts website notes the grant "received supplemental support from The US Potato Board, Dole Food Company, Blue Cross and Blue Shiled of MA. It is also supported through generaous donations by Whole Foods Market, WGBH, New Balance, Gaining Ground, Annie’s Homegrown, Stonyfield Farm, Organic Valley, White Wave, Earthbound Farms, Shaw’s Supermarkets, Cabot Creamery, Friendship Dairies, Newman’s Own, The Vermont Bread Company, and the Kashi Company."

The Wall Street Journal included some idea of this supplemental support in quantifiable terms...

"...the Tufts researchers helped the city win a grant from the Robert Wood Johnson Foundation for a bigger-ticket item, an extension of a bike path that will eventually go all the way to Boston. "

"...the City Council came up with its own ideas: reimbursements on gym membership for city employees and dozens of new bike racks for schools and streets."

"...Dr. Economos persuaded a Whole Foods store to donate about $35,000 in fresh produce."

"...a Department of Homeland Security grant is providing fitness equipment at fire stations and chefs to train the firefighters about nutrition and healthy meals."

"...a doctor sponsors the community fun run."

So, it's hard to add up all the additional monies and in-kind donations to know the true cost of the initative, but Somerville has secured an additional $1.5-million dollars to continue the efforts.

What exactly happened in Somerville that so much attention is focused on this small town?

Throughout the city of Somerville, the efforts to place the towns children on a diet and increase activity included:

• School lunches, classroom snacks and fundraisers revamped


• Teachers were trained to implement the new health curriculum, called The HEAT Club (Health Eating and Active Time)


• School Staff Role Modeling implemented


• After school program policies created for snacks


• After School policies for physical activity developed


• Increased time for recess, lunch, and physical education


• Annual height and weight data collected with reports for parents


• Monthly newsletter was sent to parents


• Monthly community newsletter to community members


• Parent education forums held for non-english speaking parents


• Area restaurants developed "Shape Up Approved" menu items


• Safe Routes to School maps were created


• Crosswalks were re-painted in thermoplastic material


• Bike racks installed at elementary schools


• School nurses and area Pediatricians were educated about taking weight and height of children

I don't think they missed an opportunity to intervene, do you? No Child Left Behind - heck, this was an "in your face" intervention, with no one left behind.

Throughout Somerville, it was impossible to escape the Shape Up Somerville messages.

So you'd think the results would be impressive given the media's attention the last few weeks.

The researchers trumpted "A community-based environmental change intervention decreased BMI z-score in children at high risk for obesity. These results are significant given the obesigenic environmental backdrop against which the intervention occurred. This model demonstrates promise for communities throughout the country confronted with escalating childhood obesity rates."

Based on their results that found over eight months, "At baseline, 44% (n = 385), 36% (n = 561), and 43% (n = 232) of children were above the 85th percentile for BMI z-score in the intervention and the two control communities, respectively. In the intervention community, BMI z-score decreased by –0.1005 (p = 0.001, 95% confidence interval, –0.1151 to –0.0859) compared with children in the control communities after controlling for baseline covariates."

Simply put, the kids in the intervention group gained about 1-pound less than the kids in the two control towns who received no intervention.

They didn't lose weight, they just gained less, which is expected - growing children gain weight each year (or are supposed to).

Within the full-text we find a curious table designed to highlight the effect of this intervention, Estimated intervention effect over 8 months on a child at the 75th percentile BMI z-score, which seems contrary to the objective of reducing the incidence of overweight and obesity, which is defined as a BMI that places a child in the 85th percentile or higher.

Nonetheless, the researchers included it to show how the intervention would effect children at the 75th percentile - children, it should be noted, already within the definition of a "healthy weight" for age.

It seems to have escaped many that with or without intervention such a child would remain within "normal, healthy" weight, as evidenced in the table data included.

Case in point - highlighted in the table - a boy, at baseline 8-years old has a BMI of 17 and is in the 75th percentile. Eight months later, without intervention (it's hypothesized) he might grow about an inch-and-a-half and gain 5.07 pounds; with intervention, just 4.25-pounds (a difference of 0.82-pounds, or about 12-ounces).

Without intervention the child's BMI is now 17.4; with intervention it is now 17.17 - in both instances the BMI increased, right?

But in both instances the child in this scenario fell on the charts, going from the 75th percentile to the 73.9 percentile without any intervention and the 71.1 with intervention, and at a cost of $1.5-million to keep this hypothetical child well within "normal" when he would have remained there anyway?

I wondered, what happened to the kids who were overweight or obese to start - the 170 of 385 children in the intervention.

As I combed through the data, another curiosity - no data was provided to show the intervention was effective for this particular subset of children within the intervention group.

Why was that data not provided?

I would think that would be the icing on the cake for the researchers to highlight the benefit of such an intense intervention, wouldn't you?

So, I got to thinking, what changes, based on the data provided, might happen for a child within this group?

The researchers neatly summed up the hypothetical child within normal, so how about we create the same table for a child who was at the 95th percentile at baseline to see what might happen.

Johnny is 8-years old, he stands 4' 2.25" and weighs 72-pounds - BMI 20.1, 95th percentile.

In eight months, like the scenario presented by researchers, he now stands 4' 3.75" (growing 1.5") and without intervention is likely to weigh 77-pounds (gained five pounds); with intervention he'd weigh about 76-pounds (gained four pounds).

Without intervention he's fallen to the 93.8 percentile; with it he's fallen to the 93rd percentile.

Yes - with or without intervention this hypothetical child went from "overweight" to "at risk for overweight" - which begins to explain the absence of data on the subject of where the children were on the charts at the end of the study period.

I'm not trying to say we shouldn't try to help children engage in more activity or eat a healthier diet, but quite frankly, these results are not as impressive as we're being led to believe.

We have no data to look to in our understanding of how this type of aggressive community-based intervention impacted children already underweight or at the bottom of "normal, healthy" weight; we have no clue as to how this type of intervention impacted those children who were well within "normal, healthy" weight; and without the hard data we don't know that any of this helped those children at risk for or already overweight!

I'd like to see the data and also see someone investigate impacts in other areas of life, like reading and math scores. Sandy Szwarc, over at Junkfood Science, pointed out that "While the school year was absorbed in diet and exercise, (after the Shape Up program was completed in 2005) the average reading test scores among Somerville kids are 15.4% below state average, and their math test scores are a whopping 26% below those of kids in the rest of the state."

I did some poking around and found the Somerville MCAS testing stats online; in the 2003/04 school year, third grade reading scores indicated that 44% needed improvement or were failing; in the 2004/05 school year - these same students, now 4th graders, tested in ELA (english language arts) showed 63% now needing improvement or failing, and 73% needed improvement or were failing math (not tested in 3rd grade).

Just some food for thought, and a hat tip to Sandy for the educational impacts that may be part of the intiatives overall impact not recorded in the results that are focused on BMI z-scores.