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

Disclosures None

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

Diabesity: A Twin Epidemic The spectrum of Insulin Resistance

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

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

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!

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

Does Saturated Fat Cause Heart Disease? http://www.awlr.org 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!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lipid profile improved on Atkins LCHF

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. 136:384-389, February 2006

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

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

lost 153 lbs, now 159 lbs, 49% loss TBW, BMI 20 David at 312 lbs, BMI 40 http://mendosa.com lost 153 lbs, now 159 lbs, 49% loss TBW, BMI 20

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

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

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%

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

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