Public Comment Open at USDA

Last week, in the Atlanta Journal Constitution, an article revealed some
shocking school breakfast and lunch options: "Pop-Tarts and doughnuts
for breakfast for 2-year-olds. Rolls, chicken nuggets and French fries for
school lunches. Brownies given the same nutritional value as a slice of
whole-wheat bread."

This struck a chord with me since I recently posted on my blog about
the dismal lunches served in the Columbia Public Schools in Missouri.
One particularly disturbing lunch option - Smucker’s PBJ Uncrustable,
Pepperidge Farms Goldfish Pretzels, Rice Krispie Treat, 1% cholocate
milk, baby carrots and a fruit - is offered daily to students throughout the
district!

With 789-calories, the school's website highlights that the lunch contains
23g of protein (92-calories) and just 24% fat (189-calories; 21g); no
mention that this means the lunch also contains 508-calories from
carbohydrate (127g), or the equivalent of 32-teaspoons of sugar in a child's metabolism...not to mention if a parent packed such a lunch for their
child each day, they'd be branded as irresponsible and lending a hand
to the epidemic of childhood obesity!

With school back in session across many states, it seems we have a
pattern that shows school lunches are not as healthful as we're led to
believe!

Senatobia, Mississippi: Chicken Nuggets or BBQ Rib Sandwich, Mashed
Potatoes w/Gravy, Cheesy Broccoli, Hot Cinnamon Apples, Fruit Juice,
Yeast Roll, Gelatin. (assorted milk)

Randolph, Massachusetts: Nachos with cheese, beef, onion, tomato and
sour cream and fruit. (assorted milk)

Roff, Oklahoma: Corndog, tator tots, black-eyed peas, chocolate pudding
and milk.

Whittier, Massachusetts: Choice of Domino's of french bread pizza, small
salad, pretzel, assorted fruit. (assorted milk)

Folsom, New Jersey: Nachos with cheese or Smucker's PB&J, vegetable,
fruit and milk.

Ada, Oklahoma: Frito chili pie with cheese, green beans, garden salad,
rosy applesauce, salad bar and milk.

Benton, Arkansas: Pizza, corn, salad, half an orange, milk

Nachos, pizza, chicken nuggets, corndogs, frito chili pie....what is frito
chili pie anyway? And why are we not disturbed by these school lunches
offered to our kids each day?

Amazingly, each and every one of these lunches meet the minimum
standards for school lunches established by the USDA.

Which begs the question - how do we go about improving the minimum
standards for school lunches?

It turns out the Child Nutrition and WIC Reauthorization Act of 2004 is
up for review and revision in 2009, and you can provide comments about
ways to improve the school lunch program by either testifying at an
upcoming USDA Listening Session, or submit written comments online
or via mail.

If you'd like to submit comments online, you may at the Public Comment and Submission page.

If for some reason the above link fails to take you to the page for public
comment, the Docket ID is FNS-2008-0011 and the Docket Title is
Request for Public Comments for Use in Preparing for 2009
Reauthorization of the Child Nutrition Programs and WIC.

Investigate the Alternate Hypothesis

Ever since the publication of Gary’s Taubes’ Good Calories, Bad Calories, folks within the low-carb community have suggested and discussed various study designs to investigate the alternate hypothesis, the “Carbohydrate Hypothesis”, explored in the book. The biggest issue isn’t so much designing a study, but funding a study large enough and controlled enough to reach valid conclusions.

With obesity considered one of the most pressing health issues of our time, wouldn’t it be great if we could find the resources necessary to investigate, in a really well done trial, that alternate hypothesis?

Enter Project 10100 - a call for ideas to change the world by helping as many people as possible.

Project 10100 is accepting submissions of ideas for projects until October 20, 2008. One hundred ideas will be selected for public review and voting to narrow the field to twenty semi-finalists. An advisory board will then select five projects to fund from a commitment by Google of $10-million dollars.

One category is “Health” and the critera provided to help those submitting ideas includes:

Criteria:

Reach: How many people would this idea affect?
Depth: How deeply are people impacted? How urgent is the need?
Attainability: Can this idea be implemented within a year or two?
Efficiency: How simple and cost-effective is your idea?
Longevity: How long will the idea’s impact last?
Project 10100 may be a way to fund a study to investigate the Carbohydrate Hypothesis!

If you’d like to submit your ideas, you can go to the Project 10100 website, or directly to the submission page.

Gary Taubes - Columbia, MO - November 2008

Gary Taubes, author of Good Calories, Bad Calories and three time winner of the National Association of Science Writers’ Science in Society award, is scheduled to present his lecture, The Quality of Calories: Big Fat Lies: The Truth About Diet, Exercise and Obesity, on November 13, 2008 in Columbia, Missouri.

The event is sponsored by the Boone County Medical Society and the Department of Nutritional Sciences at the University of Missouri. It is free and open to the public. Registration is strongly recommended as seating is limited.

The presenation will take place at the Monsanto Auditorium (University of Missouri) at 2:30pm and will be followed by a reception in the McQuinn Atrium. More details are on the flyer below. To register online, click here.

Feeding Infants Fructose

Discussion: Consuming fructose during suckling may result in lifelong changes in body weight, insulin secretion, and fatty acid transport involving CD36 in muscle and ultimately promote insulin resistance.

That was the conclusion reached by researchers who published Dietary Fructose During the Suckling Period Increases Body Weight and Fatty Acid Uptake Into Skeletal Muscle in Adult Rats, in the journal Obesity.

While the study was on rats, it’s interesting to look at the ingredients in baby formula sold in the United States (all of the below are the first few ingredients listed from peapod.com and do not include the brand name):

INGREDIENTS: Nonfat Milk, Whey Protein Concentrate, Corn Syrup Solids…

INGREDIENTS: Corn Syrup Solids, Partially Hydrolyzed Nonfat Milk and Whey Protein Concentrate Solids, Vegetable Oil…

INGREDIENTS: Corn Syrup Solids, Vegetable Oil (Palm Olein, Soy, Coconut, and High Oleic Sunflower Oils), Casein Hydrolysate …

INGREDIENTS: Corn Syrup Solids (43.2%), Soy Protein Isolate (11.5%), High-Oleic Safflower Oil (10.3%), Sugar (Sucrose) (8.4%), Soy Oil (7.7%), Coconut Oil (7.7%)….
Is there a connection with rising prevalence of childhood obesity and feeding infants corn syrup solids? Things that make you go ‘hmmmm’

My New Blog Home

Well, I decided to migrate my blog, Weight of the Evidence, to WordPress. This was due to Blogger locking my blog under the mistaken belief it was a “spam blog”. I have some minor work to do on the posts that migrated to get them properly tagged – but should have that complete by the end of next week.

For anyone who has my old blog address in their links (weightoftheevidence.blogspot.com) – please change the link to www.WeightoftheEvidence.com – Thank you!

Chew on this...

The Cochrane Database of Systematic Reviews recently withdrew a document within its collection - Advice on low-fat diets for obesity.

As we learn on The Cochrane Collection website, the editorial group responsible for this previously published document have withdrawn it from publication.

The reason cited for the withdrawal?

This review is withdrawn because it is very much out of date, as authors stated. None of the authors has any plans to update it.

Happy Trails to you....

http://www.youtube.com/watch?v=4IGtDPG4UfI

Two Year Dietary Trial Results: Low-Carb Better than Low-Fat

The study just published in the New England Journal of Medicine, Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet (free full-text), is quite a read, with lots of data and lots of findings to explore and look at!

First things first - the objective of the study was to compare the effectiveness and safety of weight loss diets over a two year period.

The dietary approaches included in the study:

• a low-carb diet, loosely based upon the Atkins diet, no calorie restriction
• a Mediterranean diet, calorie restricted, based on the recommendations of Dr. Willett & Dr. Skerrett (Eat, Drink & Be Healthy)
• a low-fat diet, calorie restricted, based on the American Heart Association guidelines

In addition to weighing participants each month and measuring waist circumference, the researchers measured at reporting invervals (6-months, 12-months and 24-months) total cholesterol, LDL, HDL, triglycerides, fasting blood glucose, fasting insulin, HbA1C, blood pressure, HOMA-IR, C-reactive protein, leptin, adiponectin, bilirubin, alkaline phosphatase, alanine aminotransferase and urinary ketones.

Enrolled in the study were 322 volunteers; they were provided their largest meal each day (lunch) at work, and given support and guideance about their diet throughout the study period. Of the 322 who started the trial, 95.4% completed one year, and 84.6% (272 participants) completed the 24-months - making this perhaps, the best adherence level in a dietary trial lasting two years!

So what happened? Let's look at the various outcome measures to see.

Weight Loss

The mean weight changes among the 272 participants who completed 24 months of intervention were:

–3.3 ±4.1 kg in the low-fat group (7.3-pounds)
–4.6 ±6.0 kg in the Mediterranean-diet group (10.1-pounds)
–5.5 ±7.0 kg in the low-carbohydrate group (12.1-pounds)
(p=0.03)

Overall, in the intent to treat data (which includes even those subjects that did not complete the study) the weight loss was reported as:

–2.9 ±4.2 kg for the low-fat group (6.4-pounds)
–4.4 ±6.0 kg for the Mediterranean-diet group (9.7-pounds)
–4.7 ±6.5 kg for the low-carbohydrate group (10.3-pounds)

The reason I note the two findings is that in the media reports, the trend appears they're reporting the intent-to-treat numbers, which are lower because they include the 50 subjects that dropped out. Those who actually completed the study are the data I prefer to look at for weight loss since it accurately presents how effective the dietary approaches are when continued for two years!

Waist Circumference

-2.8 ±4.3 cm in the low-fat group
-3.5 ±5.1 cm in the Mediterranean-diet group
-3.8 ±5.2 cm in the low-carbohydrate group

Lipid Profiles

The graph itself speaks volumes:

High-Sensitivity C-Reactive Protein, High-Molecular-Weight Adiponectin, and Leptin

The level of high-sensitivity C-reactive protein decreased significantly only in the Mediterranean-diet group (21%) and the low-carbohydrate group (29%), during both the weight-loss and the maintenance phases, with no significant differences among the groups in the amount of decrease.

During both the weight-loss and the maintenance phases, the level of high-molecular-weight adiponectin increased significantly in all diet groups, with no significant differences among the groups in the amount of increase.

Circulating leptin, which reflects body-fat mass, decreased significantly in all diet groups, with no significant differences among the groups in the amount of decrease; the decrease in leptin paralleled the decrease in body weight during the two phases.

Fasting Plasma Glucose, HOMA-IR, and Glycated Hemoglobin

Among the 36 participants with diabetes, only those in the Mediterranean-diet group had a decrease in fasting plasma glucose levels (32.8 mg per deciliter); this change was significantly different from the increase in plasma glucose levels among participants with diabetes in the low-fat group.

This is critically important to note - the low-fat group experienced a rise in fasting blood glucose over the course of the two years; this despite a greater calorie deficit than the other two diets, and a greater increase in physical activity! Yet, this type of diet is exactly how the ADA recommends people at risk for or diagnosed with diabetes eat, while expecting ever increasing doses of medication to cover their progressive decline in glycemic control.

It is also noteworthy that, "there was no significant change in plasma glucose level among the participants without diabetes." Basically those who did not have diabetes did not experience any change in their values over the period of the study.

What the researchers did not note in their written text of the results was this - the low-carb dieters had similar declines in their fasting blood glucose levels through month 12, followed by a progressive decline through month 24.

If we look at the data provided, we can see something important changed - the quality of the carbohydrate they consumed seems to have declined. If you look at the table providing details of the dietary intakes, one major change in the low-carb group between moth 12 and month 24 pops out - as the study progressed, the consumed less and less fiber on average, compared with their baseline intake. Now early on, that's to be expected. Later, as carbohydrate is increased - if quality whole foods are the choice - fiber typically increases!

In contrast, insulin levels decreased significantly in participants with diabetes and in those without diabetes in all diet groups, with no significant differences among groups in the amount of decrease.

Among the participants with diabetes, the decrease in HOMA-IR at 24 months was significantly greater in those assigned to the Mediterranean diet than in those assigned to the low-fat diet.

Again, in the text, the researchers do not note if there were changes in HOMA-IR in the low-carb group. There was - over the 24-month period, the HOMA-IR in those with diabetes, following the low-carb diet, declined by 1.0; in those with diabetes following the low-fat diet the decline was 0.3; and in those with diabetes following the Mediterranean diet the decline was 2.3.

The last item reported in the section was the HbA1C levels. Among the participants with diabetes, the proportion of glycated hemoglobin at 24 months decreased by:

0.4 ±1.3% in the low-fat group
0.5 ±1.1% in the Mediterranean-diet group
0.9 ±0.8% in the low-carbohydrate group

The changes were significant only in the low-carbohydrate group.

The lower HbA1C is perhaps one of the most important outcomes of this study. The diabetics, in the low-carb group, were able to lower their levels by 0.9 over the 24 months and this was significantly greater than those in the two other diets. Unfortunately the researchers did not include the baseline HbA1C for participants, so we do not know what the reduction really means.

Liver-Function

Tests Changes in bilirubin, alkaline phosphatase, and alanine aminotransferase levels were similar among the diet groups

Alanine aminotransferase levels were significantly reduced from baseline to 24 months in the Mediterranean-diet and the low-carbohydrate groups.

The Good, Bad, and Why oh Why?

Overall, most reporting on the study today, feel the research team did a good job designing the study and executing it, many applauding the high rate of retention in the study for two years. I too am impressed that the participants remained committed to the trial, their assigned diets, and the longer-term outcome measures!

I personally would have liked more information than was published.

Key information regarding the baseline diet was not included in the data - not published items include how many calories were consumed, on average, at baseline; nor do we know how much protein, carbohydrate, fat or fiber was in the baseline dietary habits of those participating. While obviously not critical, it is 'nice to know' data.

I also would have liked to see the researchers have the courage to actually follow the Atkins dietary approach, and not make changes based on a number of assumptions.

We do not, for example, know what the outcome would be if the participants on the low-carb dietary arm had not been told to specifically choose vegetable based fats over animal fats. Atkins does not specifically state you must eat butter, but the diet allows butter. In addition, encouraging the consumption of plant-based proteins over animal proteins is another tweak that may not have had any effect, or may have had a positive or negative one. We simply do not know because the researchers encouraged plant-based protein consumption rather than leave the dietary recommendations as they are - meats, eggs, poultry, fish, tofu and such are allowed, ad libitum. [please see update below!]

The reporting in the media, as my earlier post highlights, has been quite an eye-opener. I'm not sure if those quoted realize it or not, but their reaction to the study is quite telling, especially those with the strongest vested-interests in maintaining the status quo.

In the Wall Street Journal, Robert Eckle, the past president of the American Heart Association and a professor of medicine at the University of Colorado Health Sciences Center, said he was not ready to recommend an Atkins-type low-carb diet based on the results. People on a low-carb diet increased their consumption of saturated fat, he said, which could not be good for them in the long run.

Did he even bother to read the findings?

Or maybe he was just disappointed the AHA's recommended diet - the diet recommendations the low-fat group were instructed to follow - did so poorly compared to the other two?

Did he know that the study author, Dr. Meir Stampfer of Harvard Medical School, in the same article, said "It is time to reconsider the low-fat diet as the first choice for weight loss and for cardiovascular health, it is not the best."

I think tomorrow, we'll take a fun ride through many of the quotes and opinions offered on this study!

In the meantime, what are your thoughts? Feel free to leave comments!

UPDATE 7/18/08

I received an email today from a friend who asked one of the researchers about the reference to plant-based (vegetable) fats and proteins. Dr. Shai assured him that the low carbohydrate group was not advised to consume a vegetarian low-carb diet, nor were they specifically restricted from eggs, cheese, red meat, poultry or fish. Due to dietary restriction (religious) the group would not, for instance have a cheeseburger or butter on top of their steak. Olive oil featured prominently. The participants did read the Atkins diet book. And the examples provided of the types of meals was "For example, a plate could include : fish or fried/not bread coated chicken/or red meet, broccoli and mushrooms coated with eggs, roasted eggplants, vegetable salad (peppers, cucumber, green leaves, notlettuce) with olive oil dressing.

One Study, A Myriad of Opinions

The buzz across the internet today is the findings from the paper, Weight loss with a Low Carbohydrate, Mediterranean, or low fat diet, published in the New England Journal of Medicine.

The headlines are all over the place regarding what the results mean:

Low-Carb and Low-Fat Diets Face Off

Dr. Meir Stampfer, the study's senior author and professor of epidemiology and
nutrition at Harvard School of Public Health, told ABC News: "The low-carb diet
was the clear winner in providing the most weight loss."

The Never-Ending Diet Wars: Why Atkins Still Doesn't Beat Low-Fat Diet

"An optimal diet is one that is low in fat (because fat, whatever the type, has
9 calories per gram versus only 4 calories per gram for protein and
carbohydrates). When you eat less fat, you consume fewer calories without
having to eat less food, because the food is less dense in calories, as well as
low in refined carbohydrates."

Healthy Diets Shown to Have Benefit Despite Modest Weight Losses

In a tightly controlled dieting experiment, obese people lost an average of just
6 to 10 pounds over two years. The study, published Thursday in The New
England Journal of Medicine, was supposed to determine which of three types of
diets works best. Instead, the results highlight the difficulty of weight loss
and the fact that most diets do not work well.

More Evidence that Diets Don't Work

After two years of effort the dieters lost, on average, 6 to 10 pounds. The
study, funded in part by the Atkins Research Foundation, seemed designed to
prove that low-carb diets trump low-fat diets. But in the end, all it really
showed is that dieters can put forth tremendous effort and reap very little
benefit.

Diet Study: Hold the Carbs, Not the Fats

Low-carbohydrate and so-called Mediterranean diets may be more effective than
low-fat diets, according to a major new study published in tomorrow’s New
England Journal of Medicine.

Against the Grains

Carbohydrates have taken another hit. A new study finds that a low-carb diet
results in greater weight loss and better cholesterol readings than a low-fat
regimen that promotes a lot of grains and fruits.

Diet Plans Produce Similar Results

New research shows that Mediterranean and low-carb diets are just as good and
just as safe as the low-fat diet often prescribed by doctors, a revelation that
should give people more choices in eating well.

Unrestricted Low-Carb Diet Wins Hands Down

The similar caloric deficit achieved in all diet groups suggests that a
low-carbohydrate, non–restricted-calorie diet may be optimal for those who will
not follow a restricted-calorie dietary regimen.

Atkins Diet is Safe and Far More Effective Than a Low-Fat One, Study Says

The controversial Atkins diet is just as effective and safe as a conventional
low-fat diet, a two-year study has found. Researchers found that
overweight volunteers shed more pounds on the low carbohydrate regime than they
did on an orthodox calorie-controlled diet.

Low-Carb and Mediterranean Diets May Equal Watching Fat Intake

Explain to interested patients that the study suggested low-carbohydrate and
Mediterranean diets could be as effective as the traditionally recommended
low-fat diet for weight loss.

It's amusing that each of the above headlines are all reporting on the same study!

Later today, in another post, we'll set aside the headlines and simply look at the study itself and the results.

Shame on Missouri!

Yes this is going to be a rant!

Yesterday I was alerted to the newly proposed changes, open for public comment, in the Missouri Eat Smart Guidelines - standards for school lunches (and breakfast) in my state. When I first opened the document, I was not surprised by the incremental reduction of dietary fat and the push for more fiber, especially with whole grains.

What did surprise me was the absolute lack of attention to nutrient-density at each category level. Oh, there is a minimum which applies to each category - the minimums established by the USDA that establish minimum calories, fat not to exceed 30%, acceptable levels of protein, cholesterol, sodium and fiber, along with target minimums for calcium, iron, and vitamins A and C.

So the committee drafting the newly proposed "expemplary" category didn't think it wise to perhaps set the bar higher - ya know, establish benchmark minimum for other micronutrients...maybe the same ones identified as deficient in our children in Missouri?

Hey, the starting document to consider this could be the Missouri Department of Health & Senior Services (DHSS) recently published Dietary Intake Summary Report for school year 2000-2001 - in it the DHSS reported finding the vast majority (greater than 50%) of all children in the state fail to meet RDA requirements for vitamin A, iron, calcium, folate and zinc, and 25% fail to meet requirements for protein, vitamin B6 and vitamin C.

HELLO!

We have a serious problem with malnutrition and the best the Missouri Eat Smart Guidelines committee can come up with is stricter limits on dietary fat and increasing fiber?

Has the committee that drafted this guideline even looked at what is being served in our schools?

Columbia public schools offer this delight each day:
Smucker's PBJ Uncrustable, Pepperidge Farms Goldfish Pretzels, Rice Krispie Treat, 1% cholocate milk, baby carrots and a fruit.

Can you imagine what would be said to a parent packing such a lunch for their child?

But guess what? That lunch conforms to the standards for low-fat with just 21g of dietary fat (24% of calories) - just ignore the fact that once protein is tallied, carbohydrate accounts for 508 of the 789 calories - that's 127g of carbohydrate, or the equivalent of 32-teaspoons of sugar in a child's metabolism in one meal!

But hey, it provides 6g of fiber - above the target 5g standard, right?

The public schools have the audacity to call that abomination a nutritious lunch?

Oh, and don't get me started on the soy-based products being used in meals and that fact not being disclosed to parents, unless of course, they poke around to read the allergen lists.

Beef Tacos on the menu?

I'd expect they're made with beef, wouldn't you? Nope...they're based on an "enriched" product schools purchase - made with some beef and an ingredient listed as "VPP" - vegetable protein product - better known as soy protein.

Chicken Nuggets on the menu?

I'd expect they're breaded chicken pieces, wouldn't you? Nope...they're also based on an "enriched" product schools purchase, already prepared - made with some chicken and an ingredient listed as ISP - isolated soya protein.

Think it can't get worse?

I don't think schools do much more than open a can, heat and serve these days - just reading through the spreadsheets available online makes that pretty clear - almost everything sold in school breakfast and lunches are convenience foods, from various vendors, that are nutritionally bankrupt, but easy to heat and serve.

If a parent were to habitually feed their child that crap, at the very least they'd be chastized as irresponsible - yet this is how the schools operate each day, serving what can only be called food-garbage each day and they have audacity to label them "healthful" and nutritious.

When you have a chance, read through the proposed Missouri Eat Smart Guidelines, then let the committee know what you think in the open public comments!

If people don't start speaking up, and demanding truly nutrient-dense meals for their children, it's only going to get worse!

Caution: Childhood Obesity

In the last month, two major media sources (Washington Post and Time magazine) have devoted page upon page to the epidemic of childhood obesity.

Washington Post: Young Lives at Risk: Our Overweight Children

Time: Our Super-Sized Kids

There is no doubt in my mind that there are, indeed, more children who are much heavier today than there were when I was growing up, and that parents of obese children should have access to resources to help them help their child.

What I find disturbing is that the current level of alarm, hysteria and obsession with children's growing waistlines hasn't caused any to pause, step back, and examine the facts. Instead, it seems, the drum beats on to reduce calories, reduce fat, add mroe fruits and vegetables, lots of whole grains and increase activity.

The message is part of a perpetual campaign to convince our population that we must do it "for the children," with an indictment against parents who are said to not see nor do anything about their fat children; that the community, doctors, schools, health organizations, the food industry and the government must lead these wayward parents to understand how to improve both diet and activity levels for their children.

We see and read about extreme cases of childhood obesity, extreme examples of poor eating habits, and extreme lifestyle habits; we're reminded that is how it happens - too much food and not enough activity, the recipe for growing fat children in America today.

But excess accumulation of fat isn't the only problem - we're also hit with the sobering reality that, in addition to heavier children, our children are also growing sick sooner; we're told of children with type II diabetes (once called "adult onset" diabetes since it was virtually unheard of in children or teens), dyslipidemia, PCOS, metabolic syndrome, precocious puberty, high blood pressure, heart disease and more. The statistics are frightening and we're constantly reminded that today's children will likely die earlier than their parents if we don't do something!

The mind-numbing statistics, experts expressing grave concerns, fine examples of poor eating habits, and images of the most extreme cases of obesity in children all work to create a strong sense that we all must do something, that all of our children are at risk, that the future is at stake if we don't do the right thing and do it now!

Is the hype really helping?

Are the solutions on the table going to work not only to prevent childhood obesity, but reverse it in those children whom are already obese?

Considering the solutions presented today is identical to the solutions offered throughout the past three decades, I can only conclude things will get worse not better; the longer it goes on, the stronger the pressure on parents will grow to 'get with the program' and follow the direction of the expert recommendations.

As parents, we have an obligation to protect our children, keep them safe, nurture them and do the best we can as we raise them.

My previous post provided an example of how the current guidelines to use BMI as the gold standard measure of overweight and obesity in children is problematic. The fact that a child can be a normal healthy weight in one month and then overweight or obese in another without any change in weight or height tells us the charts are inaccurate. The fact that the hypothetical child would have dropped from 59th to 52nd percentile for weight on the traditional chart, but went from normal to overweight on the BMI chart, speaks volumes about its deep flaws.

What's telling is that almost all the comments left in the hypothetical 'set-up' of the situation post were the belief the child gained weight. That is understandable, given the repeated message we all hear that overeating and inactivity make you gain weight. If the child now had a BMI indicating she was overweight, she must have gained weight if her BMI just two months ago said she was normal-healthy weight. Too bad it wasn't true.

If we, as parents and a nation, truly wish to resolve the issue of childhood obesity, we must begin to re-examine our assumptions and how we've arrived where we are today. Our children are not only growing fatter, they're growing sicker, and doing the same thing with only the volume turned up on the message isn't going to change this. Throwing medication at the problem isn't going to make it go away. Surgical intervention isn't going to reverse it, and certainly can't prevent it before the fact.

We have the answer, yet we ignore it.

We'll explore that in another post coming soon!

In the meantime, feel free to leave your comments about the issue of childhood obesity, its causes and its solution.

Nothing Changed But Her Age

In my earlier post, about the little girl, absolutely nothing changed in two months, other than she was now 3-years 10-months old and before was 3-years 8-months old.

I charted the hypothetical little girl at 3-years 8-months as standing 38" tall and weighing 34.5-pounds - placing her in the 84th percentile for BMI for age, the top of the "normal healthy weight" classification. With no upward growth and no weight gain in two months, this same child would now be in the 85th percentile for BMI for age, making her "at risk for overweight" in some circles, or simply "overweight" in others.

Interestingly, if we calculate her traditional fall on the height and weight charts, her weight at 3-years 8-months places her in the 59th percentile for weight for age; at 3-years 10-months it's dropped to the 52nd percentile for weight for age. Yet this child is now labeled as being among the statistics of overweight and/or obese children.

The dirty little secret about children's BMI charts is they slope downward starting at age 2 until about age 6! Take a look:

How often do we read or hear how parents are totally blind to their child's weight problems?

How many out there realize the difference between "normal healthy weight" of a three year old girl and 'at risk for overweight" (or overweight) is just 0.5-pounds, to be classified "overweight" (or obese) it's just one more pound if you use the BMI for age chart?

How many realize that within as short a period of time as a month, with no gain or loss and no upward growth a child can move from one category, normal healthy weight, up to overweight?

Yet this is the "gold standard" we parents are told is best to determine if our child is overweight or obese, in need of intervetion to prevent them from becoming an obese adult!

What do you think?

You can go play with the calculators available online:

Children's BMI Calculator

Children, Age 2 to 20, Growth Chart Percentiles Calculator

How Does It Happen?

Imagine for a moment, you're a parent - of an adorable 3-year old girl. Since birth she's thrived and is quite the little social butterfly now that she's getting older. She eats well, plays hard and is just a delight. Your last visit to the pediatrician, when she was 3-years 8-months old, went great - with all the alarms about childhood obesity, you were pleased the doctor was so proactive to weigh and measure her, even more happy when he declared she was a healthy weight and doing great!

Fast forward a couple of months, today your little girl has what seems to be a cold that's progressing, so you make an appointment and the doctor's office squeezes you in.

When you arrive, the nurse takes you into the exam room, weighs and measures your daughter (just like last time) and takes her temperature. She asks you to wait a few minutes, the doctor will be in soon.

A short time passes and the doctor comes in, examines your daughter and doesn't think it's something that needs antibiotics and explains how to monitor her fever and keep her hydrated. He then says, we need to talk about her weight, her BMI places her in the 85th percentile, which puts her at risk for overweight.

You're stunned!

How could this have happened in just two months?

How is it possible you've not seen this coming?

What Do the Obese Think?

A recent survey found that being obese invites social discrimination, but the obese do not wish to be labeled as "sick" or diseased. As noted in the press release about the survey findings:

"Obese people frequently feel overwhelmed and disheartened by the publicity about their condition," he said. "They often feel disrespected and not understood by medical practitioners. Our participants express the view very forcefully that they feel victimized by current social attitudes about obesity. To be told that, in addition to the problems that they recognize only too well, they are now regarded as 'sick' is unlikely to assist them to find a solution."

Study participants said they find it difficult to act on the health messages about obesity, he said. Most participants reported that they had tried weight loss remedies that their physician recommended and were generally dissatisfied with the help doctors provide.

Health care providers' efforts to convince overweight patients to lose weight are largely unsuccessful, Komesaroff believes, possibly because they do not understand the key issues that obese people face.

More A to Z Diet Trial Data

Readers may recall that last year, in March 2007, a study was published from a dietary trial comparing four dietary approaches for weight loss: Atkins, Ornish, LEARN and Zone - the A to Z Weight Loss Study.

Many reading through the findings cried foul - those in the Ornish group hadn't reduced their fat sufficiently, those in the Atkins group consumed more carbohydrate than recommended, and so on.

In my blog post I noted "...this study failed to achieve compliance out of the gate!"

I also noted that "We have before us is a study that really does indicate carbohydrate restriction can work well over a period of one year. Without sub-group analysis to evaluate results tied to compliance (hey, some of the participants had to be doing the various diet right, dontcha think?) we can't know just how effective doing Atkins or any of the diets is with good compliance though since the researchers didn't take their data to that level of analysis in this paper."

Ask and ye shall have an answer!

A follow-up paper was published in the International Journal of Obesity - Dietary Adherance and Weight Loss Success Among Overweight Women: Results from A to Z Weight Loss Study.

As the researchers note in the background of their abstract: "Dietary adherence has been implicated as an important factor in the success of dieting strategies; however, studies assessing and investigating its association with weight loss success are scarce."

Their objective?

"We aimed to document the level of dietary adherence using measured diet data and to examine its association with weight loss success."

And so they performed a secondary analysis on the data from the trial and lo' and behold, those who closely adhered to the dietary recommendations of their assigned diets were found to have greater weight loss when compared with those less compliant with their dietary recommendations.

The researchers found that "within each diet group, adherence to score was significantly correlated with 12-month weight change."

Atkins rs= 0.42 p=0.0003
Zone rs= 0.34 p=0.009
Ornish rs= 0.38 p=0.004

When comparing the highest level of compliance with the lowest the researchers noted significant differences in weight loss in the Atkins group!

Atkins
Highest compliance = 8.3kg
Lowest compliance = 1.9kg
p = 0.0006

Zone
Highest compliance = 3.7kg
Lowest compliance = 0.4kg
p = 0.12

Ornish
Highest compliance = 6.5kg
Lowest compliance = 1.7kg
p = 0.06

The researchers concluded, "Regardless of assigned diet groups, 12-month weight change was greater in the most adherent compared to the least adherent tertiles. These results suggest that strategies to increase adherence may deserve more emphasis than the specific macronutrient composition of the weight loss diet itself in supporting successful weight loss."

The Other Side of the Obesity as Disease Debate

Obviously the debate about classifying obesity a disease is not a new idea, for years various researchers, special interest groups and organizations have debated the merits of defining obesity as a disease, with each round of reasoning and review of the evidence leading to the determination that obesity is not a disease unto itself, leaving it to remain categorically a health issue - a risk marker and a condition one is better to address than to ignore, but not a disease in need of specific medical intervention per se, but a condition with treatment options at the discretion of those within the medical community treating obese patients.

This distinction is important - while medical interventions are available, they are not the sole option for those who are obese; nor are all individuals with a BMI of 30 or greater automatically deemed to have a chronic disease in need of treatment by licensed healthcare professionals. If someone is obese, they are clearly able to seek medical treatment if they desire that option, just as they can opt instead to join Weight Watchers, read and follow the South Beach Diet on their own, or, gasp!, do nothing if their obesity is not causing them other health problems.

In order to fully understand the implications of the current position foisted in the Obesity Society white paper, it's important to look at the arguments as they've developed over the years. One exceptionally well written paper was published in October 2001 in the International Journal of Obesity - Is Obesity a Disease?

In that paper, the authors take time to review and discuss the "characteristics of obesity to determine if they fit the common and recurring elements of definitions of disease." They utilize a sample of definitions of disease taken from "authoritative English language dictionaries" to determine a common understanding of what defines "disease" and from there, examine if obesity fits the definition.

They tell us, "we identified the following common and recurring components:

(a) a condition of the body, its parts, organs, or systems, or an alteration thereof;
(b) resulting from infection, parasites, nutritional, dietary, environmental, genetic, or other causes;
(c) having a characteristic, identifiable, marked, group of symptoms or signs;
(d) deviation from normal structure or function (variously described as abnormal structure or function; incorrect function; impairment of normal state; interruption, disturbance, cessation, disorder, derangement of bodily or organ functions)

Then ask, "[h]ow well does obesity fit the definition of disease?"

Using the above criteria for disease, they evaluate whether defining obesity as a disease can be accomplished within the definition of disease.

There should be little disagreement that obesity satisfies conditions (a) and (b) above. That is, (a) an excess accumulation of fat can certainly be thought of as a condition of the body, and as for (b), the list of potential causes is so extensive that the causes of obesity must surely be found there.

Condition (c) poses a problem. Indeed, obesity can be diagnosed visually from physical proportions, or with the help of height and weight measurements. In cases of doubt, body composition methodologies offer numerous methods to measure body fat to the required degree of precision. However, there are no signs that inevitably characterize the condition other than the excess adiposity, which is the definition of obesity. The causes of obesity are numerous and diverse, ranging from and including combinations of environmental, behavioral and genetic aspects of energy intake, partitioning and expenditure. Its common accompaniments¾impaired glucose tolerance, dyslipidemia, hypertension¾are not inevitably present. Thus, condition (c) is met, but only in a circular or tautological sense: the only characteristic (pathonomic), identifiable sign of obesity is also the characteristic which defines obesity, ie fatness.

Condition (d) is even more problematic. The deviations specified range from simple deviation from normality, to impairment, interruption or cessation of vital functions. Moreover, what is meant by deviation from normality is not clear¾it can imply undesirable variation or simple statistical rarity.

Evidence for impaired physical and social functioning in severe obesity (eg BMI>40) clearly exists. In these cases, excess fat is usually accompanied by various signs of impairment and it can be argued that severe or extreme obesity would usually meet condition (d) for most definitions of disease, including those which specify impairment of function.

However, impairment is not inevitable or even usual in most persons who meet the present BMI or percentage fat criteria for obesity. In contrast to severe obesity, mild obesity only 'threatens' eventual impairment inasmuch as a risk factor, by definition, confers a greater probability of some future adverse event. Yet its association with these events is, at our present state of understanding, probabilistic. We cannot foretell who will develop an obesity-related health problem. In fact, some persons who meet the criteria for obesity will live long lives free of any of the morbidities known to be influenced by obesity. We are therefore placed in the conceptually awkward position of declaring a disease which, for some of its victims, entails no affliction.

Many obese persons are competent, functioning members of society. Nor do these persons necessarily subjectively consider themselves impaired, except perhaps insofar as they feel themselves victims of social discrimination. They might fail to meet some arbitrary standard of physical fitness (eg climbing stairs, running) but such a standard would also exceed the capability of many non-obese but sedentary individuals. While physical fitness is desirable, its absence has not generally been considered an impairment. It would be possible to set an arbitrary standard of fitness which many obese and non-obese people would fail to meet, and to consider this as evidence of impairment; however the present criteria for obesity do not do so.

A further conceptual problem arises when obesity occurs in a disease such as Cushing's Syndrome. Obesity is one of the components or signs of that syndrome. Is the obesity which is a sign of Cushing's disease, itself a separate disease?

In sum, to call obesity defined solely on the basis of a BMI or percentage body fat in excess of some threshold a disease leads immediately to the following problems:

• the only sign or symptom may be the excess fat which is also the only defining feature of the condition¾there are no other inevitable clinical or subclinical signs;


• many obese persons suffer no impairment as a consequence of their obesity;


• it ignores the probabilistic nature of the relation between obesity and consequent adverse events which is accurately conveyed by the term risk factor;


• it poses conceptual problems, eg is the obesity which is a sign of a disease, itself a disease?

They continue on, at great length about the various ethical issues involved - from the creation and fostering of a victim 'mentality' of the obese, to the issue of responsibilities that range from patient behaviors to obligation to provide medical treatment, from the problems of vested interests leading the cause to declare obesity a disease to determining who pays for treatments.

They come full circle and conclude, "None of the foregoing is meant to argue that obesity is not a public health problem of the first magnitude. However, it would be a mistake to attempt to label it a disease in the traditional sense in order to emphasize its importance if it does not meet reasonable criteria for such diseases. Conceptual clarity is a cardinal virtue in science and philosophy and it should not be sacrificed to expediency.

Finally, it seems neither logically necessary nor tactically essential to have obesity labeled a disease in order for it to be taken seriously. Public health measures and preventive medicine often receive generous funding (eg annual physical examinations, immunization programs, smoking cessation campaigns, promotion of exercise and active lifestyles). Whether and how our institutions and organizations pay for obesity treatment should ultimately depend on what health outcomes we value, how much we value them, and the cost of achieving them, not on whether obesity is labeled a disease."

Is Obesity a Disease?

I left readers with photos of three incredibly fit men on Friday - each is an elite athlete in the octagon, practicing mixed martial arts, at the top of their game.

I asked one question, aside from the UFC, what do they share in common?

Many answered they all share the common BMI classification "obese" - although that is correct, the answer I was going for was they're all "diseased" and in need of medical treatment for their obesity according to the authors of a new white paper published by the Obesity Society.

That's right, if the opinions expressed in this white paper are adopted, the men pictured would all be considered suffering a chronic, debilitating disease which needs treatment by healthcare professionals.

The committee that drafted the position paper took the unusual step to discard the evidence-based (forensic) model and opted for a philosophical argument from a utilitarian perspective.

While they credit themselves for taking this approach because "there can be no higher authority than reason," they ignore the important qualification for something to be declared a disease - is it a disease?

This abandonment of evidence, data and scientific inquiry undermines their approach by simply skirting the true purpose to determine if something is rightly, indeed, a disease state. To get around this wee inconvenience, instead they argue "...the utilitarian argument can address the question "should obesity be declared a disease?" as opposed to "is obesity a disease?"

The ramifications of this mind-bending mental-gymnastics are far-reaching, the authors ignore the moral and ethical can of worms opened if their position is adopted, with their beliefs trumping evidence as they remain steadfast in the belief that it doesn't matter *if* obesity is a disease, it should be declared one anyway because,

"Many obese people are desperate for treatment - the number of people who self-treat and those treated by commercial programs is larger than the number currently treated by the medical establishment. If obesity were considered a disease and entitled to the same considerations given to other diseases, treatment paradigms would change fundamentally...If treatment were covered, more physicians would be likely to engage patients in treatment protocols. The FDA would come under pressure to approve obesity drugs, and physicians would be more likely to use obesity drugs in treatment...With this increased attention, medical treatment options, especially drug treatment, likely would become more aggressive. Medical treatment and obesity surgery would be given more attention by physicians, health administrators, insurance companies, and employers, resulting in greater access by patients to higher quality care."

For those unaware of the various philosophical approaches, Utilitarianism is the idea that the moral worth of an action is solely determined by its contribution to overall utility, that is, its contribution to happiness, satisfaction, preferences or pleasure as summed among all persons affected. This is a form of consequentialism - the moral worth of an action is determined by its outcome - the ends justifies the means.

Because it is an 'ends justifies the means' line of thinking, it can be characterized as a quantitative and reductionist approach to ethics. And to be sure, this issue has far reaching ethical and moral implications - in the stroke of a pen, this perspective potentially takes 1/3 of our population and defines them as diseased, in need of medical intervention and treatment, by way of the crudest measure of obesity - the BMI.

As the three men in Friday's post highlight, obesity as defined by BMI is unreliable, thus flawed as a measure to determine if one is obese. This flaw isn't news, it's well established in the medical and research community as problematic, which is a reason why many continue to suggest the utilization of more refined measures, like waist-hip ratio and/or an actual measure of body fat percentage.

But even this well known flaw does not stop the authors from even suggesting the BMI standard be LOWERED to classify obesity! That's right, not only do these folks think we should abandon medical standards and wax lyrical about how obesity should be declared a disease, they also feel the BMI needs to be lower too!

Sandy Szwarc at Junkfood Science has a well written article about the paper already, so I'll skip the points she already made. I'll note here that one sentence bears repeating about why the philosophical approach in this paper is wrong, "By this logic, or course, poverty could be a disease... Black or ethnic minority a disease... Old age a disease... Homosexuality a disease... Ugliness a disease... Low intellect or literacy a disease."

In addition to the points made by Sandy, a big issue remains - what about the legal issues and medical ethics involved if obesity were declared a disease?

First and foremost is that should obesity be declared a disease, therefore a chronic medical condition, it would then follow that only licensed healthcare professionals would be qualified to treat obesity. The treatments would, of course, include a handful of diet pills, lifestyle interventions and/or bariatric surgery. Fully medicalized as a disease, obesity would no longer be 'treated' outside the licensed medical community because anyone offering services to the obese would be practicing medicine without a license since all disease treatments are the protected domain of licensed healthcare professionals.

More importantly however, is the problematic position "declaring obesity a disease" becomes for the healthcare professional. We'll explore these issues throughout the coming week.

What do you think? Should obesity be declared a disease? Why or why not?

What Do You See?

Other than being UFC fighters, what do these three men, Shane Carwin in the top photo and Cain Velasquez to the left and Brad Morris to the right in the bottom photo, share in common?

Guess in the comments and I'll explain on Monday!

Dr. Westman: Yet Another Possible Explanation

After reading the findings comparing the Masai, and the rural and urban Bantu in Tanzania, Dr. Eric Westman penned a reply to the British Journal of Sports Medicine:


Yet another possible explanation
Eric C Westman, researcher Duke University

Thank you for this contemporary assessment of dietary intake among the Masai pastoralists. Through the paradigm-shifting lens of a recent comprehensive summary of the lack of science to implicate saturated fat as a cause for heart disease [1], and new studies which suggest carbohydrate to be more worrisome than saturated fat for atherogenesis [2-4], there is a simple explanation for why the Masai do not develop atherosclerosis despite consuming a high-fat diet that the authors did not consider: high-fat diets (not containing man-made fats) are not atherogenic.

1. Taubes G. Good Calories, Bad Calories. Knopf Publishing, 2007.
2. Krauss RM et al. Separate effects of reduced carbohydrate intake and weight loss on atherogenic dyslipidemia. Am J Clin Nutr 2006;83:1025-31.
3. Mozaffarian D et al. Dietary fats, carbohydrate, and progression of coronary atherosclerosis in postmenopausal women. Am J Clin Nutr 2004;60:1102-3.
4.Volek JS et al. Dietary carbohydrate restriction induces a unique metabolic state positively affecting atherogenic dyslipidemia, fatty acid partitioning, and metabolic syndrome. Prog Lipid Res 2008;Mar 15 (Epub ahead of print]

Blood Sugar Control Useless?

In what has to be one of the most irresponsible reporting on study data I've ever seen, the New York Times today headlined Tight Rein on Blood Sugar Has No Heart Benefits, penned by Gina Kolata.

Throughout the entire article we find statements without qualification as to how study participants were attempting to lower blood sugars:

Two large studies involving more than 21,000 people found that people with Type 2 diabetes had no reduction in their risk of heart attacks and strokes and no reduction in their death rate if they rigorously controlled their blood sugar levels.

[...]

Thus both studies failed to confirm a dearly held hypothesis that people with Type 2 diabetes could be protected from cardiovascular disease if they strictly controlled their blood sugar.

[...]

Still, said Dr. John Buse, president for medicine and science of the diabetes association, the blood sugar/cardiovascular disease hypothesis has failed for people with established Type 2 diabetes.

For these patients, “intensive management of A1C for cardiovascular risk probably isn’t worth it,” Dr. Buse said.

The two studies both sought to control blood sugars through intensive use of pharmaceuticals - with no control group to compare findings in those utilizing dietary and lifestyle interventions shown to improve blood glucose and HbA1C levels (carbohydrate restriction) with lower levels of medications or no medication.

The blanket statement that the trials " failed to confirm a dearly held hypothesis that people with Type 2 diabetes could be protected from cardiovascular disease if they strictly controlled their blood sugar" leaves out one critical qualification - the sentence should end with "through intensive use of medication."