1. FAT REFORM: OBESITY, FOOD POLITICS AND THE PERILS OF DIETARY CARBOHYDRATES
Jeffry N. Gerber, M.D., Denver’s Diet Doctor
Family Physician, Littleton Colorado
DenversDietDoctor.com
facebook.com/DenversDietDoctor

2. Disclosures
None

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

4. Diabesity: A Twin Epidemic
The spectrum of Insulin Resistance

5. Sources: TFAH, OECD, WHO, CDC, ADA
Obesity Statistics
The progression of insulin resistance
44% obese in 2030
33% diabetic in 2050
Sources: TFAH, OECD, WHO, CDC, ADA

6. Historical Perspective
“I am such a glutton and sloth”
Blame behavior and lifestyle choices
Eating too much and exercising too little
Obesity is caused by positive energy balance!
A simple explanation
Health insurance will not pay for treatment
Its your fault, your problem, you fix it!
The Lipid Hypotheses 1950’s
Avoid caloric dense fatty foods

7. USDA Dietary Guidelines 1977-1980
Phillip Handler : “A vast nutritional experiment”
Less saturated fats, less calories
More poly-unsaturated Vegetable oils
More carbohydrates, starches, sugars
More inexpensive food commodities
Weak evidence, the wrong tools!

8. Macronutrient Content
More refined carbohydrates and less saturated fat
Total caloric intake increases from sugar consumption
-MMWR, Morbidity and Mortality Weekly Report, February 6, 2004 / Vol. 53 / No. 4

9. Does Saturated Fat Cause Heart Disease?
Outcomes looking at MI, death from MI and stroke
Observational - 16 studies - No!
Observational - 8 studies - Yes but problematic!
Observational - 2 meta analysis, 350,000 subjects - No!
RCT’s - Clinical trials - 2 well done - No!
RCT’s - Clinical trials - 3 meta analysis - No!
RCT’s - Clinical trials - 1 meta analysis - Yes but problematic!

10. Food Politics: Agriculture
Industrial revolution and the food commodities
Corn, Wheat, Rice, Potatoes
Sugars: Cane, Beet, HFCS
Soybean and industrial Vegetable oils
Whole foods expensive: Animals and other Plants
Farming incentives, increase yields, GMO’s

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

12. Our Ancestors Before Agriculture
Hunter gatherers and the Paleolithic era
Whole foods, some carbs
Animals including Fish, seasonal Veggies, Fruits ,Nuts and Roots
Use of fire
Agriculture and the Neolithic era
Cultivate Grains and domesticate Animals for Dairy
Modern civilization changing nutrition
For better or worse

13. The Cost of Healthcare World leader in healthcare spending since 1980
Treating chronic diseases
Medicare and Medicaid industry guidelines
Treatment of illness and disease only
Obesity not a medical condition
A reactive and costly approach to healthcare
Preventive services task force 2012, counseling
Treating obesity complications is profitable

14. Evolution - Are You Kidding?
Nutrition changing humans in our lifetime!
The Food Revolution: Andreas Eenfeldt, M.D.

15. Fat Reform is Healthcare Reform
Address obesity
Save trillions treating complications
Food industry regulation!
Healthcare delivery
Nutrition and center stage
Re-define healthy nutrition
Re-educate
The perils of dietary carbohydrates
In defense of dietary fat

16. Nutrition and Metabolism 101
Food metabolism
All macronutrients are not created equal
Carbohydrates are fattening and inflammatory
Fats and proteins
Obesity is a chronic metabolic disease
Insulin resistance
Inflammation
Carbs
Fats
Proteins

17. Insulin and Insulin Receptors
One of several hormones
Regulate energy and energy storage
Dietary carbohydrates, the primary fuel
Turn on the insulin switch
Dietary proteins and fats, secondary fuels
Minimal effect on insulin, essential
Insulin receptors normal function
Cells, muscle, tissue absorb energy and nutrients
Excess food energy converted to fat and stored
Normally insulin will suppress appetite
 insulin promotes the release of stored energy
Basic physiology

18. Insulin Resistance Years of carbohydrate overload
More insulin is required
Excess energy, stored as body fat
Receptors become strained and resistant
Beta cells strained, abnormal response
A disease of insulin overload
Insulin resistance makes us hungry
Fat cells literally starve lean body tissues
Hypothalamus, Nucleus Accumbens
Eventual loss of central signals

19. Regulation of Food Intake
Leptin – Insulin – Amylin – PP - Ghrelin - PYY - GLP-1
Resistance changes signaling
Promotes inflammation and mitochondrial dysfunction

20. Inflammation and Adiposity
Premature
Ageing
Dyslipidemia
↑ Lipoprotein lipase
↑ Angiotensinogen
Hypertension
↑ IL-6
↑ Insulin
↑ CRP
Liver & Gut
↑ FFA
Insulin
Resistance
↑ IGF-1
↑ Resistin
↑ TNFα
↑ Leptin
Type II
Diabetes
Cancer
↑ Adipsin (Complement D)
↑ Lactate
↑ Plasminogen activator inhibitor-1
↓ Adiponectin
Atherosclerosis
Dementia
Fertility
Thrombosis
Lyon CJ et al. Endocrinology 2003;144: ; Trayhurn P et al. Br J Nutr 2004;92:347-55; Eckel RH et al. Lancet 2005;365:

21. Insulin Resistance Evaluation
Overweight
Obesity
Pre-diabetes
(Metabolic Syndrome)
Type II Diabetes
Anthropometric measurements
Medical and family history, physical
2hr OGT, GTT
Metabolic markers of inflammation
HgA1c, c-peptide, Insulin, CRP, Thyroid, etc…
Cholesterol testing as a marker for atherosclerosis

22. Insulin Resistance Treatment
The food is the medicine
Remove the optional fuel
Less dietary carbohydrates
Turn off the insulin switch
Control hunger and appetite

23. Insulin Resistance Treatment
Dietary proteins
Essential, healthy
Dietary fats and cholesterol
Caloric dense and filling
NOT inflammatory or atherogenic
One exception
Carbs and fats together
Standard American diet (SAD)
Carbs are the catalyst

24. Insulin Resistance Treatment
Medication
Physiologic drugs
Metformin, Byetta, Victoza, Bydureon, Symlin
Rx appetite suppressants
New and future drugs
OTC market
Treat co-morbidities
Nutrition center stage
Gastric bypass surgery

25. Eat Real foods Focus on the carbohydrate content of food
Avoid high glycemic foods, processed foods
Eat low glycemic foods, whole and unprocessed
Healthy natural fats
Butter, Animal fat, Coconut oil, Olive oil, Avocado, Fish oil
Low-Carb High Fat (LCHF), Ancestral diets
Control of appetite and promote weight loss
Enhanced fat burning during exercise
Quantity, calories and portion’s not the focus

26. Comparing Diets Head to Head
Compare the macronutrient content
% of calories from carbs, protein and fat
Very low fat <10%, high carb, low calorie
Very low carb <10%, high fat, LCHF, 1860’s
LCHF vs. Ancestral diets
Food quality important
What diets are healthy and safe?
Low carb high fat (LCHF) diets improve health!
Greater weight loss, improved lipids and blood sugar
Dozens of RCT’s, Stanford 2007, Duke 2004, Penn 2003, 2011
Meta analysis , Santos 2012

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

29. Lipid profile improved on Atkins LCHF

30. Advanced Lipids and LCHF Diets
Favorable LDL subclasses or particle sizes
Triglycerides decrease, healthy HDL-C increases
Other markers
Apo-B, LDL particles
Lpa, genetic markers
Advanced labs
Berkeley Heart Lab
NMR Liposcience
VAP Cholesterol
Effects of LCHF diet on emerging plasma markers, Richard J. Wood, et al. J. Nutrition. 136: , February 2006

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

32. Dr Gerber Patient: Marcia
Female age 45, 5’7”, 262 lbs, BMI 41
OGT performed, FBS=96, 1HR=180, 2Hr=129
HgA1C=6.4%, c-peptide=4.7
TRG=221, HDL=36, TC=148, LDL=69, NON-HDL=112, TC/HDL=4.2, LDL Pattern A/B
8 months later lost 70 lbs, 192 lbs, BMI 30, 27% loss of body weight
FBS 76
HgA1C=5.1%, ?c-peptide
TRG=147, HDL=40, TC=186, LDL=121, NON-HDL=151, TC/HDL=5.2, ?particle size

33. lost 153 lbs, now 159 lbs, 49% loss TBW, BMI 20
David at 312 lbs, BMI 40
lost 153 lbs, now 159 lbs, 49% loss TBW, BMI 20

34. Dr Gerber Patient: David
Male, age 71, 6’3”, 312 lbs, BMI 40
OGT: FBS=105, 1HR=219, 2HR=201
HgA1C=6.8%
TRG=193, HDL=28, TC=225, LDL=158 , NON-HDL=197
2 years later, lost 153 lbs, 159 lbs, BMI 20, 49% loss of body weight
OGT: pending, FBS normal
HgA1C=4.6%
TRG=109, HDL=40, TC=155, LDL=93, NON-HDL=115

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

36. Dr Gerber Patient: Patrick
Male, age 53, 6’, 220 lbs, BMI 32
OGT performed, FBS=86, 1HR=148, 2HR=103
HgA1C=5.4%, c-peptide=4.1
TRG=133, HDL=47, TC=238, LDL=164 , NON-HDL=191, TC/HDL=5.1
7 moths later lost 45 lbs, 175 lbs, BMI 24, 20% loss of body weight
FBS=77
HgA1C=5.1%, c-peptide=0.9
TRG=75, HDL=78, TC=200, LDL=75 , NON-HDL=122, TC/HDL=2.6

37. Dr Gerber Patient: Eric
Age 43, lost 10 pounds on a Paleo diet, 183 lbs, BMI 25
Berkeley Heart Lab
Triglycerides and HDL-C improved, LDL-C, Apo-B unchanged
LDL subclasses (particle size) remained favorable, 9p21 genetic markers at risk
Carotid IMT, 39 yrs., heterogeneous plaque <20%

38. Nutrition and the history of weak scientific evidence
Author: Gary Taubes
Nutrition and the history of weak scientific evidence
2002 New York Times Magazine: What If It’s All Been a Big Fat Lie
2008: Good Calories Bad Calories
2010: Why We Get Fat: And What To Do About It
2011 New York Times Magazine: Is Sugar Toxic
2012 Newsweek: Why the Obesity Campaign is failing

39. Nutrition for the New Millennium
Re-defining healthy nutrition
Less refined and processed foods
More whole foods including natural fats
New federal dietary guidelines
Food industry regulation
Re-define healthcare delivery
Nutrition centerstage
Control the cost of healthcare

40. Good Food is Good Medicine!
Jeffry N. Gerber, M.D.
DenversDietDoctor.com
facebook.com/DenversDietDoctor