Yesterday, based on its normal calculations, NICE took the decision for a prostate cancer drug to be banned from provision by the NHS. Basically, the drug does not provide good value for money. This morning, a piece appears in the paper The Independent which highlights the fact that as is often the case, a charity is rails against NICE’s decision. The author of the piece, Jeremy Laurence, specifically mentions objections raised by the Prostate Cancer Charity regarding yesterday’s decision. He also cites objections raised by the charity Beating Bowel Cancer regarding a similar situation with a bowel cancer drug.

Jeremy Laurance makes the point that not all treatments can be made available to all patients irrespective of cost. And he also asks why the ire of charities always seems to be directed at NICE, and not the drug companies. After all, we know that pharmaceutical drugs have a generally spectacular mark-up, and there might be some room for some reduction in price while still preserving a healthy profit for the drug companies.

Jeremy Laurance asks if we should know if there is some conflict of interest within patients groups and charities, in the form of pharmaceutical funding. Back in 2008, Jeremy’s own publication conducted an investigation into such matters which it reported here. This article claims that Beating Bowel Cancer received 10 per cent of its income from drug companies.

I personally have looked into the funding of health charities before. My overwhelming experience is that it’s generally hard to find information about this and true transparency. This morning, I went looking for information about the funding of the Prostate Cancer Charity. I found this document which outlines the charity’s policy regarding funding from pharmaceutical companies. It was published in July 2008, and states is due for revision in July 2010, but it does not appear to have been reviewed.

Here’s a quote from the opening page of the document:

Whilst we acknowledge that support from pharmaceutical companies is an important resource, we recognise that partnerships with these companies should be approached with caution. The Prostate Cancer Charity seeks to make clear that it will not permit any company with a direct commercial interest in prostate cancer to influence its activities.

Would it be unduly cynical for some of us to have a ‘they would say that’ attitude to this statement? Here’s another quote, this one from the 2008 piece in the Independent. It comes from Tim Kendall, director of research at the Royal College of Psychiatrists:

Drug companies will try to do anything to align their interest with those of patients. They do things at every level of the health service and we know they do it with patient groups.

It is a multi-pronged approach to persuade patients that their drug is the one.

I’m of the mind that healthy choices need to be enjoyable and easy. I’ve noticed over the years that one thing that can have a corrosive effect here is just plain hunger. When individuals seek to improve their diet, particularly if the goal is to lose weight, then hunger often comes into it. Some people believe (consciously or unconsciously) that hunger means they must be in caloric deficit and therefore they must be losing weight. But even if weight loss is not the goal, many individuals will find themselves hungry because they have shifted towards a diet rich in fruits and vegetables, which have some nutritional merit, but generally fail to satisfy the appetite properly.

Just this week I saw a classic example of this. An overweight man told me how 3-4 months ago he’d decided, with the assistance of his girlfriend, to improve his diet. Out went a lot of rubbishy processed, grain-based foods. In came lots of fruit and vegetables in its place. Breakfast was now a grapefruit. Mid-morning snack was more fruit. Lunch was often a vegetable soup, followed by more fruit in the afternoon. His evening meal was decent (meat or fish with vegetables).

Anyway, what was the result of all this ‘healthy eating’. Two main things: almost perpetual hunger and zero weight loss. I admired this man’s ability to persist with this regime in the absence of any tangible benefit, but also how long it would be before he gets fed up with the hunger and stagnant weight and just defaults back to his original crappy (by his own admission) diet.

Of course, he won’t be the first person to lapse from some healthy eating regime. Many individuals have the experience of ‘toughing it out’ on a ‘diet’ for a limited period of time before ‘caving’ and feeling unable to resist foods such as bread, pasta, pizza, confectionary and patisserie. And while hunger appears to sap at the resolve, I’ve noticed consistently how keeping hunger at bay makes not having these foods so, so much easier.

When an individual does not let their appetite get out of hand, they usually find it relatively easy to eschew sandwiches at lunch and opt for a better option such as a salad or soup. I read a interesting piece in the New Scientist magazine yesterday that got me thinking about this phenomenon in a whole new way.

The piece was written by psychologist Dr Roy Baumeister, co-author of the book Willpower. In the piece he makes the point that willpower is a bit like a muscle. Once it’s ‘exercised’, it is weaker for some time after. In other words, once someone has to be exert some willpower and self-discipline, their ability to do that again is diminished until the willpower has been rested for awhile. Could this help explain why dietary restraint over time almost always comes back to bite people in the bum?

But perhaps even more interesting is this scientific observation: if individuals are given sugar between two tests of self-control, they do better on the second one if they are given a sugary drink compared to an artificially sweetened one. Could it be that somehow sugar feeds the willpower ‘muscle’ and strengthen the resolve? It wouldn’t surprise me at all, given just how often people find keeping blood sugar levels stable and rampant hunger at bay makes healthy eating a relative breeze. I’ve also witnessed just how not being very hungry can lead to people automatically drinking less alcohol too.

There’s a killer paragraph in the New Scientist piece that I’m reproducing here in full:

This glucose research also suggests why dieting is so fiendishly difficult. In order to resist tempting foods, we need willpower but to have willpower, we must eat. The essence of dieting (restricting food intake) robs us of the psychological strength needed to succeed. Perhaps dieters should concentrate on filling up with healthy food so they have the willpower to resist fattening stuff.

Yes, yes and yes, Dr Baumeister! Psychology may be his thing, but I feel he may have missed another potential vocation as a weight loss and healthy eating expert.

References:

1. Baumeister RF. Weak will comes from tired mental muscles. New Scientist. 1 February 2012.

One specific form of honey that is renowned in natural medicine for its curative properties is manuka honey. I was interested to see that a recent study supports its use in chronic wounds [1]. The research involved assessing the impact of manuka honey on an organism known as Streptococcus pyogenese (S. pyogenes). This bacterium is commonly found in wounds that are chronically infected.

One characteristic of S. pyogenes is that it has the ability to clump together and cause what is called a ‘biofilm’. Biofilms can form when proteins on the bacterium attached to another protein (called fibronectin) on the surface of damaged tissue cells. The biofilm that can for as a result can protect the bacterium by making it inaccessible to antibiotics.

In this recent research, manuka honey was found to reduce the expression of the proteins it uses to attach to fibronectin, thereby disrupting the formation and maintenance of the biofilm. This research provides some insight in the mechanism through which manuka honey may prevent or treat wound infections. It is perhaps also worth bearing in mind that manuka honey has been found to inhibit literally dozens of bacterial species.

This piece of research reminded me of a conversation I had with a friend. His mother-in-law was in hospital and had been diagnosed with a chronic infection in an ulcer. My friend has some interest in natural medicine, did some on-line research, through which he learned about manuka honey and its potential for assisting wound healing. He took the idea to his mother-in-law’s doctors here in the UK. The response? They flatly refused to use it, though it was not clear quite what the objection was.

Research like this recent study should help mainstream acceptance of a nature substance which appears to have genuine value in the treatment of chronically infected wounds. This will be a good thing, as more widespread use is likely to save a lot of money and a lot of suffering.

References:

1. Maddocks SE, et al. Manuka honey inhibits the development of Streptococcus pyogenes biofilms and causes reduced expression of two fibronectin binding proteins. Microbiology. Published online ahead of print January 31, 2012

Here is a link to an item which aired yesterday on BBC Radio 4’s Today programme. There are comments from individuals within this item that leave one with the distinct impression that many health professionals are unaware of the issue of vitamin D deficiency in children. A lawyer who represented parents who were wrongly accused killing their child (who after death was diagnosed with rickets) tells of how a senior radiologist at Great Ormond Street Hospital (generally regarding as the UK’s ‘best’ children’s hospital) failed to recognise rickets or the importance of vitamin D.

The item features Dr Marta Cohen (from Sheffield Children’s Hospital) who has discovered vitamin D deficiency in 75 per cent of children who had died of sudden infant death syndrome. This does not mean that the vitamin D deficiency caused any or all of these deaths. Nevertheless, there are ways in which vitamin D deficiency might cause death, and it’s clearly valid for vitamin D deficiency to be considered in children who appear to have suffered abuse or have died suddenly.

Recently, the BBC featured paediatrician Dr Benjamin Jacobs who is seeing increasing numbers of children with rickets where he works at the Royal National Orthopaedic Hospital here in the UK (video below).

Dr Jacobs makes the point that doctors are often failing to recognise and treat rickets appropriately. Dr Jacobs is quoted here as saying:

There are many other children who have less severe problems – muscle weakness, delay in walking, bone pains – and research indicates that in many parts of the country the majority of children have a low level of vitamin D.

It’s obviously not a good thing that so many children may be suffering from compromised health and possibly lose their lives as a result of vitamin D deficiency. What is good, though, is that this issue is getting mainstream attention, and that some dedicated individuals are doing what they can to raise awareness of this issue.

I came across this very interesting article today published on-line in the Scientific American. It features the ideas of Susan Cain, author of Quiet: The Power of Introverts. In the article, Susan makes the point that our society is set up to reward bold, extrovert individuals. As a result, introverts can sometimes feel the need to make themselves seem more extrovert than they are, and Susan claims that ‘… whenever you try to pass as something that you’re not, you lose part of yourself along the way.’

There’s much information in this article that really resonates with me. For example, I am the sort of person who much prefers a one-on-one dinner and the conversation that goes with it than a full-on party. It’s not so much that I don’t like groups, it’s more that I prefer more intimate environments. I also, like Susan and other introverts, really enjoy time on my own. For example, I can quite happily spend two or more days on my own writing without ever growing bored or lonely.

Another part of the interview I found really interesting concerned group-work. Here’s an extract from the piece:

When you’re working in a group, it’s hard to know what you truly think. We’re such social animals that we instinctively mimic others’ opinions, often without realizing we’re doing it. And when we do disagree consciously, we pay a psychic price. The Emory University neuroscientist Gregory Berns found that people who dissent from group wisdom show heightened activation in the amygdala, a small organ in the brain associated with the sting of social rejection. Berns calls this the “pain of independence.”

This would at least partly explain why I have a dislike of meetings. And the ones I go to rarely have more than two other people present.

It turns out that about one third to a half of us are introverts. And the article lists a few notable human introverts too, including Gandhi, Rosa Parks and Larry Page (co-founder and CEO of Google). Maybe it’s true that ‘Blessed are the meek, for they shall inherit the earth’.

Many men can find their excess fat to be stubbornly tenacious: after shifting a few or more pounds, they’ll go on to witness their weight quickly rebounding to where it was before. Scientific evidence suggests that this phenomenon is not necessarily the result of personal failings, but down to the body’s efforts to maintain fat levels as a certain ‘set point’. Understanding what determines this set point and how to lower it is critical to ensuring lasting weight loss success.

The central player in ‘set point theory’ is the hormone leptin. Leptin is secreted by fat cells and acts on a part of the brain known as the hypothalamus to speed the metabolism and suppress appetite. As we gain weight leptin levels rise to stop the rot. However, if for any reason leptin fails to do its job properly – a state known as ‘leptin resistance’ – the body will naturally gravitate to a weight that is often undesirable from a health and aesthetic standpoint.

One potential cause of leptin resistance is inflammation in the hypothalamus, and a known provoking factor here is spikes in blood sugar levels. The foods most likely to induce surges in sugar are those with added sugar, as well as many starchy carbohydrates including bread, potato, rice, pasta and breakfast cereals. Other inflammatory foods include so-called ‘omega-6 fats’ found in vegetable oils and margarine.

By inducing leptin resistance, a supposedly ‘healthy’ diet can actually lead to a sluggish metabolism and heightened hunger – not an ideal state of affairs for someone seeking to lose weight and keep it off. Critically, a diet more restricted in carbohydrate and replete with natural, unprocessed foods can put all this in reverse, allowing the body to settle at a lower and altogether more desirable weight.

But there’s another reason why curbing carbs can help men lose their guts for good: carbohydrate is the major stimulus for the secretion of insulin – the hormone chiefly responsible for the deposition of fat in the fat cells. So, a diet lower in carbohydrate facilitates fat loss by lowering insulin levels. Fat liberated in this way can fuel the body is essentially food. This way of eating can therefore turn men into ‘hibernating bears’ – able to subsist off their fat stores with their appetites naturally quelled – now we’re talking.

What to eat

Breakfasts based on cereal and perhaps wholemeal toast might have healthy reputations, but the ability of such foods to cause gluts in insulin and disrupt leptin make them nutritional disaster areas. A better option would be, say, some Greek yoghurt with nuts (e.g. almonds and walnuts) and some fruit (berries are best on account of their low-sugar and highly nutritious nature). Eggs are another good breakfast option, particularly if coupled with some smoked salmon (see below) and tomato or wilted spinach for their nutrient value.

Sandwiches are off the menu at lunch, and are ideally replaced with meat, fish or an omelette with salad and/or cooked vegetables. Oily-fish such as salmon, trout, sardines or mackerel are particularly beneficial, as the ‘omega-3’ fats these contain are anti-inflammatory, and have been linked with enhanced health and weight loss. Olive oil-based salad dressing and butter on your vegetables are fine. This same format should be used for dinner. Other options include hearty soups, stews and casseroles, accompanied with some more salad or vegetables.

For some, it can be a long time between lunch and dinner, and this can cause our appetite to run out of control and weaken the resolve. A snack of a handful or two of nuts can do wonders in terms of tiding us nicely over until our evening meal and making healthy choices there a relative breeze even when eating out.

How to exercise

Those wanting to couple this dietary approach with exercise might hold back on churning through the miles on a treadmill, the pavement or bike: ‘aerobic’ exercises such as these has been found to be generally ineffective for the purposes of weight loss. The truth is, aerobic exercise doesn’t generally burn masses of calories, and can make us hungrier to boot. Short bursts of intense exercise interspersed with periods of relative rest (high intensity intermittent exercise) is a more time-efficient and effective way of getting fit and losing weight, and can boost leptin levels too.

Lack of sleep can make you fat

One other lifestyle factor that might be added into the mix is sleep. Sleep deprivation has the capacity to lower leptin levels and therefore predispose to the body keeping itself at a higher fat set point. No surprise then that short sleep is associated with heightened risk of obesity. Those feeling they should perhaps get more shut-eye might consider hitting the sack a bit earlier when opportunity allows.

I say that because back in the year 2000, many Israeli doctors went out on strike for about three months. This coincided with a very real drop in mortality rates. The situation was reported in the British Medical Journal [1], and I remember reading the article at the time. Here are some quotes from it:

Industrial action by doctors in Israel seems to be good for their patients’ health. Death rates have dropped considerably in most of the country since physicians in public hospitals implemented a programme of sanctions three months ago, according to a survey of burial societies.

The Israel Medical Association began the action on 9 March [2000]… Since then, hundreds of thousands of visits to outpatient clinics have been cancelled or postponed along with tens of thousands of elective operations.

In the absence of official figures, the Jerusalem Post surveyed non-profit making Jewish burial societies, which perform funerals for the vast majority of Israelis, to find out whether the industrial action was affecting deaths in the country.

“The number of funerals we have performed has fallen drastically,” said Hananya Shahor, the veteran director of Jerusalem’s Kehilat Yerushalayim burial society. “This month, there were only 93 funerals compared with 153 in May 1999, 133 in the same month in 1998, and 139 in May 1997,” he said.

Meir Adler, manager of the Shamgar Funeral Parlour, which buries most other residents of Jerusalem, declared with much more certainty: “There definitely is a connection between the doctors’ sanctions and fewer deaths. We saw the same thing in 1983 [when the Israel Medical Association applied sanctions for four and a half months].”

Motti Yeshuvayov of Tel Aviv’s only burial society said that he had noticed the same trend in the Tel Aviv metropolitan area in the past two months.

There are reports of similar drops in death rates when doctors have gone on strike in Canada and Los Angeles (though I’ve not been able to confirm the veracity of these reports) .

I don’t want to denigrate the whole of conventional medicine. Actually, some aspects of it (high-tech diagnostics, surgery and emergency medicine, for example) I think are broadly genuinely worthwhile. However, a lot of what we do in medicine I think is not as effective as we’ve perhaps been led to believe. It can also be very hazardous (and take lives) of course.

There’s a kinda cloak of respectability that still surrounds modern medicine. But the fact that death rates appear to fall when doctors go out on strike suggests that when we peel back that cloak, we find plenty of things we won’t like the look of.

References:

1. Doctors’ strike in Israel may be good for health. BMJ 2000;320:1561.1

It would be comforting to think of these events as isolated incidences in the scientific community. However, according to a recent piece in the British Medical Journal, scientific misconduct is ‘worryingly prevalent’, at least in the UK [1].

The BMJ sent out a questionnaire to more than 9,000 researchers and reviewers asking if they has knowledge of colleagues “inappropriately adjusting, excluding, altering, or fabricating data” for the purpose of publication. Of those who responded, 13 per cent admitted they had such knowledge. 6 per cent admitted they were aware of misconduct within their own institutions which remained insufficiently investigated.

On January 12, the Committee on Publication Ethics (COPE) held a summit to address the problem of research misconduct in the UK. Referring to the BMJ survey, the Chair of COPE Dr Elizabeth Wagner is quoted as saying “This survey chimes with our experience from COPE where we see many cases of institutions not cooperating with journals and failing to investigate research misconduct properly.”

In a recent editorial in the BMJ [2], Dr Wagner and the BMJ’s editor Fiona Godlee wrote: “There are enough known or emerging cases to suggest that the UK’s apparent shortage of publicly investigated examples has more to do with a closed, competitive, and fearful academic culture than with Britain’s researchers being uniquely honest.”

My feeling is if the culture wasn’t so ‘closed, competitive, and fearful’ we’d probably see that misconduct is even more prevalent than the recent BMJ survey suggests. And that’s a problem because we really do need to rely on the integrity of research findings in making truly informed decisions about health and the management of disease.

Personally, I’m delighted that institutions such as the BMJ and COPE are shining a light onto this issue and thinking about how we might curb research misconduct.

References:

1. Tavare A. Scientific misconduct is worryingly prevalent in the UK, shows BMJ survey. BMJ 2012;344:e377

2. Godlee F, et al. Research misconduct in the UK. BMJ 2012;344:d8357

But it’s not all sweetness and light with aspirin because this drug also has the potential for adverse effects too, and in particular the ability to induce bleeding in the lining of the gut.

A recent review in the Archives of Internal Medicine set about assessing the impact of aspirin on not just cardiovascular events, but risk of bleeding too [1]. The review took data from 9 studies in which aspirin was used in dosages ranging from 75 mg to 500 mg per day. In total, the studies involved over 100,000 people, and the average duration of the studies was 6 years.

The populations studied in the individual studies were free from known cardiovascular disease at the start (so-called ‘primary prevention’).

This review revealed that compared to placebo, aspirin:

• Reduced the risk of cardiovascular events (e.g. heart attacks and stroke, fatal and non-fatal) by 10 per cent.
• Did not reduce the risk of death from cardiovascular disease.
• Increased the risk of bleeding by 70 per cent.
• Increased the risk of ‘nontrivial’ bleeding by 31 per cent.
• Did not clearly reduce the overall risk of death.

The authors of this study conclude that ‘… routine use of aspirin for primary prevention is not warranted and treatment decisions need to be considered on a case-by-case basis.’

It’s likely that aspirin has some value for some people in terms of overall disease prevention and perhaps life extension. What this latest review suggests, however, that our faith in aspirin as a preventive medication is largely misplaced.

References:

1. Seshasai SRK, et al. Effect of aspirin on vascular and nonvascular outcomes. Arch Intern Med 9 Jan 2012 [epub ahead of print]

1. object to ‘my meat-based’ ‘diet

and/or

2. ask how they can apply the sort of dietary principles I espouse in the context of a vegetarian diet

First off, I don’t advocate a ‘meat-based’ diet. I advocate a diet with meat (and/or fish) in it (if you don’t object to eating meat/fish on moral/ethical grounds and there’s no other barrier such a religious or you just don’t like it). Let me make this clear, I have never (and will never) suggest to someone that they should eat flesh if, for whatever reason, they don’t want to. This blog post is most certainly not a tacit cry for vegetarians and vegans to reconsider their convictions or preferences.

However, the reason that I recommend that a diet includes flesh foods is because I believe that such a diet is more likely to supply the macronutrients (like protein and fat) and micronutrients (vitamin and minerals) necessary for optimal health and wellbeing. It seems some can thrive on vegetarian diet, but I’ve known lots of others who have not.

Here’s a couple of anecdotes…

A few years back a vegetarian friend of mine was losing her hair in clumps. We looked at the usual stuff here including thyroid function and iron levels, but seemed to draw a blank. She took it upon herself to introduce fish into her diet. Shortly after her hair loss ceased. And not long after that she fell pregnant (after many years of trying). The fish may have nothing to do with these positive changes. But then again it might.

Several years ago, I was talking with a lady I met at an event. She told me she’d been a vegetarian for many years and had experienced gradually declining health. This culminated in her becoming so weak that one day she collapsed in the street. When she came round she found that she was being attended to by some kind souls. She was intuitively drawn to say ‘get me a kebab’. Someone acted on her instructions, she ate the kebab, re-introduced meat into her diet and in her own words ‘never looked back’.

Now, these are merely anecdotes and again, this is not to say someone simply can’t thrive on a vegetarian diet. My belief though is that, generally speaking, eating a vegetarian diet (and particularly a vegan one) makes it harder to enjoy peak health.

I recently came across this article in the on-line magazine Psychology Today. It provides some evidence that most vegetarians end up reverting to a diet with flesh foods in it. A poll of ex-vegetarians revealed common reasons for reversion include things like hassle and food cravings, but the most common cited reason of all was health (see below).

I don’t have anything against vegetarians, and actually admire the moral and ethical principles some exhibit. But I do struggle a bit sometimes when I see someone eating in a way which can be compromising their health (sometimes a lot). While it is possible to apply the sort of principles I espouse to a vegetarian diet to some degree, I’d be lying if I said I thought such a diet is likely to be as good for health as a more omnivorous one.

After weight loss, there is a decline in energy expenditure that reflects both the loss of metabolically active tissue plus an additional 300–400 kcal/d, which may be termed “adaptive thermogenesis…

In other words, metabolism reduces to an extent greater than is expected solely as a result of weight loss. For example, while body weight declines by 10 per cent, say, metabolism may fall by 15 per cent or more.

The authors go on to add:

Decreased energy expenditure after weight loss would have little consequence if it were easy to sustain a corresponding reduction in energy intake to maintain a reduced body weight. As anyone who has attempted to sustain weight loss can attest, this is not the case.

Well said.

Some of the mechanisms here included reduced activity in a part of the nervous system called the ‘sympathetic’ nervous system, as well as changes in hormones that affect metabolism including thyroxine and leptin.

Leptin is a particularly interesting hormone in that it secreted by fat cells and acts on a part of the brain called the hypothalamus to speed the metabolism and suppress appetite. I first became aware of the importance of this hormone by reading the blog of Stephan Guyenet. I ended up writing a blog post about it here.

As we gain weight and accumulate fat, more leptin is made (in theory) to help keep things in check. When we lose weight, leptin levels generally fall which can stifle the metabolism. It can also make people hungrier. One of the ways this can manifest is as reduced satisfaction from food. In other words, for a given amount and type of food people tend to feel less satisfied once they’ve lost weight than they were when they were heavier. The risk here, of course, is that people may then be ‘driven’ to eat more.

The paper published yesterday featured an experiment designed to assess the effects of leptin on people who had lost weight [1]. 10 obese individuals were fed a liquid diet offering 800 calories a day until they had lost about 10 per cent of their weight. This took anything from 36 to 62 days. Metabolism was measured before and after weight loss. Also, individuals were tested in terms of their response to eating including how satisfied they felt after food.

After weight loss, on separate occasions, individuals were injected with leptin or placebo (5 weeks each).

1. Total calorie burn fell by about 700 calories a day due to weight loss when individuals were injected with placebo. But with leptin, the reduction was much less (about 400 calories a day).
2. Calories metabolism per kg of ‘lean mass’ (muscle) also fell as a result of weight loss, but this was not the case when leptin was being administered.

In short, leptin helped individuals maintain their metabolism after weight loss – just as we’d expect. Plus, when the individuals were on leptin, they derived more satisfaction for a given amount of food.

What we have here is some evidence, at least, that we stand a better chance of losing weight and keeping it off if we have good functioning leptin. Problems with leptin functioning – also known as ‘leptin resistance’ – is now emerging as a major factor in weight control issues. Inflammation in the hypothalamus appears to be one cause of leptin resistance. And one thing we can do here to help is to avoid foods that are inflammatory in nature. Spikes in blood sugar promote inflammation, so this is yet another reason for not eating a diet based on blood sugar disruptive carbohydrate including many starchy staples.

References:

1. Kissileff HR, et al. Leptin reverses declines in satiation in weight-reduced obese humans. Am J Clin Nutr [epub 11 Jan 2012]

The video features two doctors from the same centre. One seems more in-tune with conventional thinking than the other. The first tells us that while close to 500 women would need to be treated for one to develop diabetes, in comparison only about 150 would need to be treated to prevent a heart attack or stenting or some other cardiac event. Just let the second figure sink in for a bit. For each 150 women treated, 149 will not benefit in terms of saving them from a cardiac event. The miracles of modern medicine!

But for me the really interesting part of the video came when the second doctor popped up and suggested that cholesterol may not be the issue, but inflammation is a more likely culprit and perhaps it’s that we should be seeking to control (not cholesterol levels). Give that doctor a medal.

References:

1. Culver AL, et al. Statin Use and Risk of Diabetes Mellitus in Postmenopausal Women in the Women’s Health Initiative. Arch Intern Med. 2012;0(2012):20116252-9.

This week, I came across another study which provides evidence for the idea that different forms of calorie can have differing impact on body weight (as well as body composition) [1]. Here, in brief, is what the study entailed:

25 adult men and women spent some time being assessed to ascertain the number of calories required to maintain a stable weight. Then they were randomised to one of three diets, each of which contained a different amount of protein (low, normal and high). The number of calories contributed by protein, carbohydrate and fat respectively for the three diets was:

• Low protein – 6:42:52
• Medium protein – 14:41:44
• High protein – 26:41:33

You’ll notice that percentage of calories from carbohydrate was essentially the same for all three diets – only protein and fat intakes were different. The individuals were fed these diets in a very controlled environment for a period of 8 weeks.

One other thing: these diets supplied about 40 per cent more calories than estimated to be required for weight maintenance. This equated to overfeeding of an average of about 950 calories a day.

The researchers assessed a number of body parameters including body weight, fat mass and lean mass (muscle, essentially). Here’s a summary of the findings (all figures are kilograms):

In summary, the most notable findings were, I think:

• The amount of fat gained was essentially the same (irrespective of dietary composition).
• The normal and high protein diets both led to an increase in lean mass (muscle) that was roughly equal in weight to the fat that was accumulated.
• The low protein diet led to less weight gain overall, principally because it did not contribute to lean mass gain (actually some lean mass was lost).

The main conclusion drawn by the authors was that when people are overfed, the fat they accumulate is not influenced by the amount of protein they consume (only the total number of calories).

That observation is supported by their data, but another way of interpreting the same data would be to say that when people over-consume food, the percentage of calories coming from fat have no bearing on fatness. This perhaps contrasts with what most people might imagine, as many believe is easier for dietary fat to end up as fat in our tissues than carbohydrate or protein.

Another thing that this study appears to show is that when protein is low and fat is high, less weight is gained overall than when, relatively speaking, protein is higher and fat is lower. This finding does appear to provide evidence that contradicts the idea that all calories influence body weight identically whatever their form (a calorie is a calorie).

What is also true is this study also found that if we’re looking to maintain (or perhaps build) muscle, it makes sense to eat adequate amounts of protein. The diets richer in protein led to improved body composition compared to the low-protein diet.

OK, one could argue there’s some interesting stuff here, but I would also argue that this study tells us very little indeed that has real relevance to people seeking to lose weight or maintain a healthy weight. And that’s because in this study, the individuals were essentially compelled to eat much more than they ordinary would. In the real world, when people overeat they usually do it all by themselves (without being asked to or remunerated for it).

So, what is it that causes people to overeat? There are many factors here, but let me list just a few:

1. Too little protein

Study after study shows that for a given number of calories, protein sates the appetite more effectively than either carbohydrate or fat.

2. Too little fat

Quite a lot of people find that for food to be satisfying, it helps for it to contain a decent quantity of fat. I have this going on: a chicken leg leaves me feeling much better sated than a dry breast.

3. Too much carbohydrate

Eating a carbohydrate rich diet can cause cycles of blood sugar high and lows. Lows in blood sugar (or even just rapidly reducing sugar levels) can cause hunger and food cravings (particularly for sugary/sweet/starchy foods).

4. Too much carbohydrate again

A lot of carbohydrate can cause elevated levels of insulin – the hormone chiefly responsible for fat storage in the body. This can make fat hard to shift from the fat cells. That’s a shame, because fat liberated in this way can provide fuel for the body, and is essentially food. It is possible that liberated fat helps quell the appetite through this mechanism, but that’s not going to happen so well if the diet is rammed full of carbohydrate and causing chronically elevated levels of insulin.

Let’s put this in reverse, though. Imagine what would happen if less carbohydrate was eaten. Insulin levels may well come down and now fat can get out of the fat cells, where upon it can ‘feed’ us and keep us nicely satisfied. The proportionally more fat and protein in the diet might help here too. Time and again I’ve seen individuals who adopt a lower-carb diet relatively rich in protein and fat they automatically eat less (often several hundred calories less each day) than they ordinarily do, and the research bears this out too.

Overfeeding studies like the one described above can be interesting, but they don’t really help people who want to lose weight. What we really need to know if what to eat to facilitate fat loss and keep hunger at bay.

References:

1. Bray GA, et al. Effect of Dietary Protein Content on Weight Gain, Energy Expenditure, and Body Composition During Overeating – A Randomized Controlled Trial. JAMA 2012;307(1):47-55

In the podcast below, my friend Carl Munson and I discuss my new book Escape the Diet Trap – lose weight for good without calorie-counting, extensive exercise or hunger.

More details about the book can be found here.

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The full Introduction to the book is available via Facebook.

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2. Adding aerobic exercise to a ‘diet’ generally does precious little to improve the results

These facts (and they are facts) appear to defy logic and common sense. But as I describe in my new book Escape the Diet Trap published today, there are several well-understood mechanisms through which ‘eating less and exercising more’ destines the majority of us to weight loss failure.

One thing calorie-controlled diets have been shown to do is stifle the metabolism. But the extent of this can be profound. In a seminal study I describe in my book known as the ‘Minnesota Experiment’ (conducted shortly after the 2nd World War), a 1,600 calorie-a-day diet led to weight loss of 20-26 per cent in a group of men over a 24-week period, but their total energy expenditure fell by almost 40 per cent.

Many men also became so hungry they obsessed about food and had little interest in anything else. Some of them experience debilitating physical and mental symptoms. This, by the way, was on a diet containing more calories than many weight loss diets advocate. The diet was also rich in carbohydrate and low in fat – precisely the sort of diet health professionals and our governments usually advocate for weight loss.

When the men were allowed to eat in an unrestricted manner again, they generally consumed huge quantities of food and. By the time their eating naturally returned to normal levels, their fat levels were, on average, 75 per cent higher than when they started.

The Minnesota experiment is just one study, but its findings I think reflect the experiences of countless individuals who:

1. have eaten less (gone on a diet) and lost weight
2. have got hungry and ‘toughed this out’
3. have had their weight loss plateau
4. have defaulted and found themselves eating almost uncontrollably
5. have regained weight quite rapidly
6. have ended up heavier than they were before

It is the crashing failure of calorie-based approaches to weight loss than cause my sometimes to rail against articles such as this one. In short, it raises our awareness of the fact that many people are unaware of the calorific nature of foods including hummus (a blend of chick peas/garbanzo beans, sesame seed paste, olive oil and lemon juice).

Hummus might indeed be calorific, but one could argue that the quality of those calories are decent enough. All the constituents of this food are essentially whole and minimally processed. It contains a reasonable blend of protein, fat and carbohydrate. It’s a food that is likely to sustain us quite well. Could we say that for a not-so-calorific food like spinach or broccoli? I do have some reservations about hummus, but this has nothing to do with its calorific nature, and is actually related to the fact that beans (and other legumes) are relatively rich in substances called lectins that can be toxic to the body.

The point is this: judging a food by its calorific content is misguided at best. Not only does ‘calorie control’ rarely lead us to lasting weight loss, it can cause us to eschew nutritious, healthy foods in favour of nutrient-depleted junk (including many processed foods marketed to slimmers).