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

Disclosure I occasionally get paid to speak Recruit patients Physician referrals Promote better nutrition

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

Diabesity: A Twin Epidemic The spectrum of Insulin Resistance

Obesity Statistics Sources: TFAH, OECD, WHO, CDC, ADA 68% of adults overweight or obese BMI 25 34% of adults obese BMI 30 Colorado the thinnest, 20% obese 9% of adults diabetic 33% of children and adolescents overweight or obese Since uh-oh! Obesity rates doubled in adults Obesity rates tripled in children and adolescents The progression of insulin resistance 42% obese in % diabetic in 2050

Historical Perspective Blame behavior and lifestyle choices Eating too much and exercising too little Researchers convinced Obesity is caused by positive energy balance! Health insurance will not pay for treatment Its your fault, your problem, you fix it! I am such a glutton and sloth

Billion Dollar Weight Loss Industry The invention: Low fat, low calorie diets Carbohydrates are safe Examples of fad diets! Why are we still fat?

Food Politics: Nutritional Timeline USDA self policing The lipid hypothesis 1950s Saturated fat and heart disease Ancel Keys observational studies Correlation does not equal causality Energy Balance Eat fat and get fat, eat less and exercise more Avoid caloric dense fatty foods A simple explanation McGovern select committee

Dietary Guidelines for Americans 1980 Contrary to widespread opinion, too much sugar in your diet does not seem to cause diabetes… There is also no convincing evidence that sugar causes heart attacks or blood vessel diseases Less saturated fats, less calories More poly-unsaturated Vegetable oils More carbohydrates, starches, sugars More inexpensive food commodities Weak evidence, the wrong tools! Phillip Handler : A vast nutritional experiment

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! RCTs - Clinical trials - 2 well done - No! RCTs - Clinical trials - 3 meta analysis - No! RCTs - Clinical trials - 1 meta analysis - Yes but problematic!

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, GMOs

Our Ancestors Before Agriculture Hunter gatherers and the Paleolithic era Whole, clean, unprocessed foods, some carbs Animals including Fish, seasonal Veggies, Fruits and Nuts Use of fire Agriculture and the Neolithic era Cultivate Grains and domesticate Animals for Dairy Modern civilization changing nutrition

Food Politics: Manufacturing and $ales Inexpensive raw materials Tasty, addicting and cost effective Processed and refined, more profitable Deceptive advertising: healthy foods The government working for the food industry The business is selling food, not health!

The Cost of Healthcare US healthcare spending US almost twice per capita US ~16% of the GDP vs. 8–10% US obesity and costs Cornell: $190.2 billion, 20.6% of national health expenditures Gross underestimation Study design flawed Overweight excluded The cost of treating chronic disease HBR, WHO, RTI, CDC, AHR, IASO

The Cost of Healthcare Healthcare industry Centers for Medicare and Medicaid (CMS) 1965 Guidelines for the industry, public and private Treatment of illness and disease only Obesity not a medical condition 2012 now paying primary care for counseling A reactive approach to healthcare Treating obesity complications is profitable

Evolution - are you kidding? Nutrition changing humans in our lifetime! The Food Revolution: Andreas Eenfeldt, M.D.

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

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

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

Insulin Resistance Years of carbohydrate overload More insulin is required Excess energy, stored as body fat Insulin receptors become strained and resistant Beta cells strained, abnormal response Vicious insulin resistance cycle Hunger an important component Insulin overload

Hunger And Appetite Insulin resistance makes us hungry Fat cells literally starve lean body tissues Central hunger and reward centers of the brain Hypothalamus, Nucleus Accumbens Fluctuating blood sugars and hormones stimulate appetite Resistance directly or by Leptin or other hormones Eventual loss of central signals Only peripheral signals: swollen stomach Blame metabolism not behavior for obesity!

Regulation of Food Intake Leptin – Insulin – Amylin - Ghrelin - PYY - GLP-1 Resistance changes signaling Leptin: Thermogenesis, immune system, premature ageing, chronic disease, dementia, cancer, libido and fertility Insulin and IGF-1 (Insulin like growth factor): Premature ageing, cancer

Inflammatory Disease Adipocyte, fat cell toxicity Releases toxic substances as we gain weight Inflammatory protein signals: Hormones, cytokines FFAs, lipid and cholesterol oxidation, Atherogenic Fuels insulin resistance and beta cell dysfunction Energy storage disease and energy overload Inflammation and metabolic derangement Dietary carbs the trigger, not dietary fats A Chronic metabolic disease

Obesity: A Chronic Metabolic disease IL-6 Adiponectin Leptin TNF α Adipsin (Complement D) Plasminogen activator inhibitor-1 Resistin FFA Insulin Angiotensinogen Lipoprotein lipase Lactate Type 2 diabetes Hypertension Dyslipidemia Thrombosis Atherosclerosis Insulin Resistance Metabolic Syndrome 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: CRP Inflammation Cancer IGF-1 Premature Ageing

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

Insulin Resistance Treatment The food is the medicine Remove the fuel, dietary carbohydrates Turn off the insulin switch Control hunger and appetite Carbs are non-essential, optional

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

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

Eat Real foods Focus on the carbohydrate content of food Glycemic index, carbohydrate gram counting Avoid high glycemic foods, processed foods Sugars, healthy no grains (Corn, Wheat, Rice), Potatoes Soy and ?Beans and other Legumes Eat low glycemic foods, whole and unprocessed Beef, Chicken, Fish, Pork, Eggs Green leafy Vegetables, fibrous Fruits, Nuts Low glycemic dairy like Cheese and Cream

Eat More Real Foods Natural healthy fats Low Glycemic, not fattening and not inflammatory Saturated, Mono, Omega 3s, Vitamins A, D, E, K, B12 Coconut oil, Olive oil, Avocado, Butter, Animal fat, Fish oil Caloric dense, promotes satiety Avoid industrial Vegetable oils, Margarine, Trans-fats, Omega 6s Low-Carb High Fat diet (LCHF) Control of appetite and promote weight loss Enhanced fat burning during exercise Quantity, calories and portions not the focus

Comparing Diets Head to Head Compare the macronutrient content % of calories from carbs, protein and fat Very low fat <10%, high carb, low calorie Very low carb <10%, high fat, LCHF, 1860s Low-carb vs. Paleolithic 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 RCTs, Stanford (2007), Duke (2004), Penn (2003), (2011)

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

Lipid profile improved on Atkins LCHF

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

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

Female age 45, 57, 262 lbs, BMI 41 OGT performed, FBS=96, 1HR=180, 2Hr=129 HgA1C=6.4%, c-peptide=4.7 TRG=221, HDL=36, TC=148, LDL=69, NON-HDL=112, TC/HDL=4.2, LDL Pattern A/B 8 months later lost 70 lbs, 192 lbs, BMI 30, 27% loss of body weight FBS 76 HgA1C=5.1%, ?c-peptide TRG=147, HDL=40, TC=186, LDL=121, NON-HDL=151, TC/HDL=5.2, ?particle size Dr Gerber Patient: Marcia

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

Male, age 71, 63, 312 lbs, BMI 40 OGT: FBS=105, 1HR=219, 2HR=201 HgA1C=6.8% TRG=193, HDL=28, TC=225, LDL=158, NON-HDL=197 2 years later, lost 153 lbs, 159 lbs, BMI 20, 49% loss of body weight OGT: pending, FBS normal HgA1C=4.6% TRG=109, HDL=40, TC=155, LDL=93, NON-HDL=115 Dr Gerber Patient: David

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

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

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

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

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

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