Calorie Myths

Should We Replace the Calorie System for Weight Loss?
Calories may not be an adequate way to represent the energy we need or would store. We all know people who eat little but stay heavy, and those who eat loads of junk food but are as skinny as a rail. How can that be? Are the heavy ones sneaking excess calories (maybe) – are the skinny ones with nervous energy just have a higher metabolism (whatever that means – and maybe they do).

So here are six common myths about calories and a few simple eating rules for eating.

Myth: Calories provide our Energy
Calories are not what provide the energy to fuel our body’s metabolism. Our metabolism is fueled by complex chemical reactions and energy is obtained by breaking molecular bonds of chemicals like adenosine triphosphate. A calorie is not a biology/biochemistry term, but a term mechanical engineers first used and adopted by physics.  The technical term of a calorie is this: one calorie is the amount of heat needed to heat one gram of water one degree Celsius. The calories we use are kilocalories- so multiply that by a thousand.

So calories don’t provide energy but are a measurement of the potential energy in a food.

Caloric History –
Bridging caloric physics to biology is largely credited to Wilber Olin Atwater (1844-1907), who applied the first law of thermodynamics to food: energy can be transformed, but it cannot be created or destroyed.  With that he began the use of the term of calories to food – and started measuring how food affected people, by measuring their conversions of oxygen to carbon dioxide and the calories of food. Atwater concluded that people ate too many sweets and fats and didn’t exercise enough.

Using this equipment Atwater was able to determine the relative input of food and exercise

In the early years of determining calories they would put food into a machine called a “bomb calorimeter” burn it- and see how much energy the food contained. This process has been refined, so that we know one gram of carbohydrates has four calories, one gram of protein has four calories, one gram of alcohol has seven calories, and one gram of fat has nine calories.

Myth: A calorie is a calorie
It doesn’t matter how many calories you consume, it matters what your body does with them. Your body will process those 100-calorie snacks differently than 100 calories of beef, or 100 calories of fish.

Your body cannot store protein, so when you need protein to rebuild cells, or after some muscle breakdown, it relies on your diet to get it. The various proteins are broken down in the intestines into amino acids – and your body has no idea if those amino acids came from a plant or beef. So the calories that are available in protein may not be available for energy, but instead used for building. Protein beyond that which is needed for the body’s function can be broken down and used by the body, and if too much of it is available it will be stored as fat.

Many fish are rich in calorie dense fatty acids, but your body cannot make these, so it relies on your diet to get them. Thus, the calories that are available from omega-3 fatty acids may never be used as energy, or stored as fat, because your body will be using them to build various functions.

Fructose, in its refined form, is passively absorbed by the intestines and about 1/3 of it becomes fat.  Doesn’t matter how much your body needs the fuel, one third of all fructose consumed is processed into fat.

Graph from tutorvista.com showing the different pathways of glucose Gand fructose

Myth: Low levels of Glucose are good for you
There is an ideal range for blood glucose levels- too low or too high and you won’t function.  Glucose is important to the body because  every cell in your body needs glucose to function, from the brain to the muscles. Glucose is the currency your body uses to provide energy. Glucose is so important that your body actively absorbs glucose from the intestines to the bloodstream using specialized glucose transport cells. As your body breaks down food into is basic components in the intestine, when a  molecule of glucose is available the glucose is actively transported from the intestine to the bloodstream where it can be used as fuel.

Fructose, in contrast, cannot be used by the human body as fuel. Fructose has to be changed into other products. Fructose is passively absorbed in the intestines – which means if there is a lot of fructose present, it is absorbed into your bloodstream from the intestines. Fructose in fruit, is complexed  with the fiber, and the fiber cannot be absorbed – so you eat the 100 calories of fruit your body cannot absorb the fructose that isn’t free from the fiber. But drink 100 calories of juice, which has a lot of free fructose, and chances are you will get all of the fructose and 1/3 will go down the fatty-acid pathway.

Common table sugar is made up of 1/2 fructose and 1/2 glucose. The high fructose corn syrup used to sweeten juices, soda, cookies, and many breads is higher in fructose than glucose. We recently wrote about the health risks of high fructose corn syrup.

The 100-calorie snacks are typically highly processed cookies, or snacks, and the processed sugar is broken down and quickly absorbed by the body and your body will store that excess as fat.

Calories Don’t Matter if Your Body Can’t Use Them or Get to Them
People cannot digest the cell walls of plants, like fruits and vegetables. This means humans cannot get at those calories without cooking or mechanically breaking down those cell walls. Raw foodies take advantage of this, unable to get most of the calories from vegetables and fruits; they are able to consume large amounts of calories and still lose weight.

Myth: Exercise burns calories
A patient came to me having gained a few pounds over a month and said, “I know for a fact that I exercise 1900 calories a day.” That is impressive, so I asked how he did it- he said that he used an elliptical machine for 45 minutes a day, and the calories he used were based on what the dials on the elliptical machine said. Funny thing – look at those machines or those iPhone apps and they tell you that you are burning hundreds of calories a day – but they are not only inaccurate, they are misleading.

The average male burns a bit over 2000 calories a day- and if you work out for an hour a day you will probably only burn another 100 calories in an  hour. Discouraged? Don’t be. The majority of your calories are burned by your heart pumping, your lungs breathing, your brain thinking. Plus all those things you do during the day matter. The more involved you are in what you do, and increasing your activity, the better you will feel and the less likely you will be to waste calories on crummy food.

The easiest way to increase what you burn is to increase the things you do daily. Remember when you were a kid, and you were always on the go? It is time to get that spirit back- walk more, play more, have more fun- get out of that chair and off the couch. That will burn more exercise than going to the gym and watching your friends work out. You know that tiny lawn you have- get a push lawnmower and use that.

Exercise is good – it is empowering, it gets you out of the house.  Get a Nike Fuelband or some monitor, and use it – plan to exceed your daily activity until you get to an average of 10,000 steps a day.

 

Just Do It

Myth: The reason you are not loosing weight is you are not eating enough

Fred weighed 400 pounds, and he decided to get a Lap-Band to help him lose weight. He hit a plateau after 18 months when he weighed 250 pounds, so he asked me, if he needed to eat more to lose weight.  My answer is, “Yes, it needs to be more fruit and more vegetables- not processed. What it does not need to be is yogurt, cheese, or nuts.”

Fred was eating a lot less food, less than he had in years, but it was still enough to sustain his weight at 250 pounds (he wanted to get to 190 pounds). It was a combination of not just how much he ate, but also when he ate.

If you eat all of your calories at one time your body has to decide to do with the excess fuel. Does it store it, or does it burn it. Sometimes it isn’t that you are not eating enough – sometimes it is that you need to spread that same amount of calories throughout the day.

it isn’t just how much you eat – it is also when you eat and what you eat that determines your health

Myth: It isn’t the calories it is the insulin response to calories
This popular theory goes like this: you eat too many carbohydrates, the insulin level spike, store that as fat while stimulating the fat to store yet more fat and drive a person to eat more simple carbohydrates. People like the simplicity often pontificate that we should eat our calories from protein – be they Paleo, Atkins, low-carb types, or proponents of the glycemic index. People who previously ate a lot of processed food and move into more protein will lose weight – but the body isn’t just that simple.

But the body is even more complex than that – and measurements taken are not insulin levels, but often glucose levels in response to what is believed to be insulin.

Some people just are lucky
Did you ever meet someone who could eat huge amounts of food and never gain an ounce? They can eat junk food, or violate every “rule” and yet not gain a bit. They are just burners.

So they can consume 5000 calories and yet look great – while you have ice cream every night for a week and come away with an extra pound.

Think of people like cars.  Some cars are very efficient at burning gas – the Toyota Prius, Honda Civic – they are like the skinny little friends who eat lots of junk food while looking slim.  Some cars are gas-guzzlers – they are larger, don’t look as sleek – that is like many people. Both get the same amount of gasoline, but they use it differently.

Calories are Still Pretty Good for measuring
Overall, as we demonstrated with the beer and sausage diet as well as the eggs and beer diet – when you cut down on the number of calories you consume, you will loose weight. While there are some clear exceptions, the body isn’t simple, and the use of calories as a measurement of what you consume works out pretty well.

A few simple rules:

(1) Eat lots of fruit and vegetables.

(2) Lean meats are just fine

(3) Have fish twice a week

(4) Make sure you have nutrient rich foods

(5) Increase your daily activity – walk more, get up more – use that nervous energy

And if you think a lettuce wrap is better for you than bread – you are missing the point.

 

REFERENCES:

Here are some older references that I found -

Atwater, W. O. (1895). Methods and Results of Investigations on the Chemistry and Economy of Food. Bulletin 21, U.S. Department of Agriculture, Office of Experiment Stations, Government Printing Office, Washington, D.C.

Atwater, W. O., and Rosa, E. B. (1899). Description of a New Respiration Calorimeter and Experiments on the Conservation of Energy in the Human Body, Bulletin 63, U.S. Department of Agriculture, Office of Experiment Stations, Government Printing Office, Washington, D.C.

Atwater, W. O., and Benedict, F. G. (1905). A Respiration Calorimeter with Appliances for the Direct Determination of Oxygen, Carnegie Institute of Washington, Washington, D.C.

Obesity and Patients

Obesity and Patients
This is probably one of the best videos that I have seen recently about the causes of obesity and how we treat our patients. It is something that we physicians must remind ourselves of constantly: to treat patients with compassion and empathy.

But the second message is also important: we don’t know what causes obesity – and the old thoughts about eating too much are no longer valid. We do know this, it isn’t what you eat, it is how your body processes the food. Too much processed grains, sugars, carbohydrates – are not good – and moving away from a diet of those will be important to the lifestyle change any who wish to lose weight and keep it off will have.

If you wish to lose weight, we know that you must change what you eat. The one thing all experts agree upon now is this: avoiding processed grains and free sugars. Both plant strong diets, and paleo diets preach this. It isn’t just calories.

So the first step for many of my patients is this: learn to cook – and for me- this is the mission for all of my patients. And we like it when they start young.

JJ and the kitchen

Starting kids early – learning to cook, appreciating good food- is one of the best starts you can do for your family

The Bad Fat isn’t Bad and the Good Fat isn’t Good

President Eisenhower followed a low-cholesterol diet with military precision. But his cholesterol continued to climb. Even with exercise and strictly eating no foods with fat. He listened to the best medical advice of the day- and they were wrong.

President Eisenhower could not have been more frustrated. Following the advice of his cardiologist and General Thomas Mattingly, and the famed Paul Dudley White, Eisenhower was eliminating all cholesterol and fat from his diet. But every time they would take his blood level his cholesterol was higher.  He was no stranger to exercise, he gave up smoking in 1949, and days he would just have grapefruit with some melba toast.  The blood cholesterol would come back, higher than before. It was so frustrating that the White House physicians seeing him would make up numbers to tell him that it was getting better. But it didn’t. Eisenhower was crippled in retirement by his heart disease – determined to eat as prescribed, he ended his days as a cardiac cripple.

Lyndon B Johnson had a heart attack while he was a senator. General Thomas Mattingly was also his physician. Mattingly prescribed the same low fat diet that he had given to President Eisenhower. For months after his first attack Johnson followed it to the letter, shedding some 4o pounds and feeling better. But still his cholesterol was high.

LBJ, a heart patient, tried the “low cholesterol, low fat” diet, but realized his cholesterol didn’t change – so he gave it up. Remarkably, once he started eating the beef from his ranch his cholesterol decreased.

Johnson fell back into his old habits, and had another heart attack, which derailed his presidential ambitions for a while. Finally, in retirement Johnson started to follow the regime again – but noticed that when he started to eat beef from his ranch, his cholesterol went down. He came to his own conclusions, stopped trying to avoid beef- and enjoyed the bounties of his retirement. He enjoyed friends coming to the ranch, with frequent barbecues – often coming late for dinner.

For years America was told that saturated fat is bad for your heart. It was based on a faulty principle – that the fat in the arteries came from the fat in the blood which came from the fat in the diet. While it makes sense, it wasn’t until after Johnson and Eisenhower died that science discovered that dietary fat contributes only a small amount to blood lipid levels. The idea was popularized by Ancel Keys.

But in spite of evidence to the contrary, once a popular notion is in the press, it stays there. Which brings us to President Clinton. The president enjoyed his burgers, and when he had his heart attack he began to examine the notion that plant based diets would reverse heart disease. His disease arteries bypassed, he turned to Dr. Dean Ornish. Ultimately, Clinton became a vegan. Was it a wise choice? President Clinton is a smart fellow, but if he were to critically go through medical journals he might question his choice. ,

It has been 16years since Dean Ornish published his data showing a 3 per cent reduction in the plaques seen by coronary angiograms on a select group of patients who followed his Ornish diet and “lifestyle” plan. To be exact: the 28 patients who followed his plan had a 1.75% decrease in atherosclerotic plaque after one year and 3.1% decrease after five years. With the control group there was an increase of 2.3% in one year and 11.8% at five years.

In 16 years no one has reproduced that data. No one. Still, from one old paper Dean Ornish has made a career; first being the anti-Atkins, and riding the anti-cholesterol, low-fat band wagon with the same religious fervor as Keyes did thirty years before. Ornish has since become the lead health-blogger for Huffington Post, has influenced Bill Clinton – turning him into a vegan, and is favorably mentioned by Dr. Oz.

The difficulty is this: science has caught up with him, and we know a lot more about how atherosclerotic plaques form. We know that dietary lipids and their carriers are far less important that what the body makes. We know that the dietary component is far more related to the trigycerides – and triglycerides are raised much more by the grains and pastas that Ornish preaches on (in his trial, the “Ornish lifestyle” patients had a rise in their triglycerides).

What Ornish and his crew call a landmark paper, would not be accepted by the same journals today for a number of reasons:

(a) No one compares angiograms – a two-dimensional photograph of an artery – because they can be manipulated so easily and interpreted differently from one experienced radiologist or cardiologist to another. Depending on the angle you take the angiogram from, you can show a reduction in plaque by varying the recorder by a few degrees. Today intra-vascular ultrasound is the test of choice – this gives us a three dimensional view of the artery, from within the artery. The recent article in The New England Journal of Medicine, comparing lipid medications and their long-term effect on atherosclerotic plaque, is the most accurate measurement of plaque and its formation.

(b) We know about the science of lipids, plaque formation, and how we can manipulate those to provide a better answer for atherosclerosis that does not involve severe manipulations of a diet. For example, it appears it is the carrier proteins that cause the damage to the arteries – and more carrier proteins are made in response to certain stimuli (triglycerides being one).

(c ) There were deep and troubling issues with the groups of patients serving as controls. For example, we do not know how many pack-years of smoking were in one group or the other. This is not a minor flaw, as science understands the highly inflammatory changes that are made with smoking as opposed to those made with hyperlipidemia.

(d) Lipid lowering drugs were used in some, and not others – however, the drugs today are far better, and more targeted than before.

To this day when most talk about saturated fat we are given “alternatives” like margarine, olive oil, oils from nuts, seeds, and the like.  They are suppose to be better for us than “animal fat.” They are not.

We built pyramids – food pyramids, based on avoiding certain foods. We went out of our way to define the chemical nature of fats: polyunsaturated, monounsaturated, a trans-fats. We made charts so we could keep track of which fats were the “good fats,” so we could tell patients to eat these.

Monounsaturated fat Polyunsaturated fat
Olive oil Corn oil, Grapeseed oil
Avocados Fatty fish
Almonds, peanuts, macadamia nuts Walnuts, sunflower seeds, flaxseed
 

 

Then of course we had to tell people what was “bad” because it caused problems so we made tables like this:

Saturated fat Trans fat
Beef, lamb, pork Margarine (stick form)
Ice cream Fried foods (french fries, breading)
Milk, cream Crackers, popcorn, chips
Lard Shortening

 

But wait – then we had to tell what to change in their diet so we made tables like this one:

 

Less Healthy Better Choice
Beef that is corn-fed Beef that is grass-fed
Butter Olive oil
Standard eggs Eggs high in omega-3 fatty acids
Ice cream Frozen yogurt
Milk Fat-free milk, soy milk, almond milk
Shortening, lard Grape seed oil, canola oil, vegetable oil

Did I mention we were wrong?

In science we make a hypothesis – then we test the hypothesis – then based on our findings we refine things, test again, and somewhere we develop a theory that explains the nature of things. In this case – food.

When the USDA and Europeans looked at the data to make recommendations about fat, they cherry-picked the data about saturated fats. Meaning, in spite of studies showing that saturated fat did not increase heart disease, in spite of studies showing that polyunsaturated fats may be worse than saturated fats, they pressed through guidelines and recommendations that were based not on critical thinking, but the bias of the committee members.

Remember: in those days, everyone had the thought that the fat laden arteries of people with coronary artery disease came from butter, animal fat, and the like.

Heart artery plaque- low fat diet doesn’t prevent this

What do we do?

It turns out that saturated fat is not bad for a person, and the studies showing we should substitute with other fats were wrong.

Still the ideas of eating “healthy” for many people means avoiding red meat, avoiding saturated fats, even though the evidence for this is almost non-existent.

How We Live:

Which brings us to one simple fact: how we live is more important than how when we die- especially if the quality of life is less than satisfying. I doubt Eisenhower enjoyed his last days as much as Lyndon Johnson.

But let me bring one simple point: learn to cook. Appreciate fresh food. Yes, you can live on processed food but you cannot thrive.

 

REFERENCES:

In 2003, a meta-analysis of over 50 trials was published examining the relationship of dietary fat to serum cholesterol levels (Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serumlipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr 2003;77:1146–55.).  The conclusion was that saturated fat increases the levels of low-density lipoprotein (LDL) and high-density lipoprotein (HDL) but without changing the ratio of total to the HDL cholesterol.   They concluded that using cholesterol alone as a marker of risk was unreliable. This was because if you replace the saturated fat with carbohydrates or tropical oils if you examine the effects on HDL and apolipoprotein B. They concluded that “… we can never be sure what such fats and oils do to coronary artery disease risk.” To translate that from doctor-scientist language: we can improve some laboratory markers, but really not by any mechanism that makes a difference from what we know.

While a systematic review of randomized trials showed that when saturated fats are replaced by polyunsaturated fats there is a reduction in the laboratory marker for risk of heart disease, there was no association with mortality from heart disease.  To emphasize this: the laboratory values of the patients studied improved, but their mortality didn’t. The review also showed that monounsaturated fat intake significantly increased cardiac events, but no effect from the intake of saturated or polyunsaturated fat. Let me emphasize that: Monounsaturated fats, by at least one study, not only didn’t improve issues with the heart- the patients in that study did worse.

When examining other prospective studies about the risk of saturated fat and cardiovascular disease, there has been a consistent lack of an association between fat intake and heart disease, stroke, or total cardiac events.

Cohort studies show that by replacement of saturated fats with unsaturated fats, or carbohydrates – and examining the hazard ratios for heart attacks and deaths from heart disease were as follows: 0.87 for polyunsaturated fat, 1.19 for monounsaturated fat, and 1.07 for carbohydrates.  For those not familiar with statistics, these are essentially no difference, and if these small statistical numbers are accepted than polyunsaturated fat shows an alarming trend. So here is a study that indicates (with as much precision as most studies these days) that polyunsaturated fats are worse for you than saturated fats.

There is a difference between protection against what we define as risk of heart disease and death from heart disease.  Risk reduction means that we lower the laboratory values of factors we associate with risk – but the end point is death.  In a meta-analysis published in 2010 (Ramsden CE, Hibbeln JR, Majchrzak SF, Davis JM. N-6 fatty acid-specific and mixed polyunsaturated dietary interventions have different effects on CHD risk: a meta-analysis of randomised controlled trials. Br J Nutr 2010;104:1586–600.) examined seven different trials, they found that there was a risk reduction but no change in mortality.  Another study (Skeaff CM, Miller J. Dietary fat and coronary heart disease: summary of evidence from prospective cohort and randomized controlled trials. Ann Nutr Metab 2009;55:173–201.  ) had eight trials found “There is probably no direct relation between total fat intake and risk of CHD (heart disease).

The advice of the USDA is reflected in places like WebMD, recounted in public service commercials, and recited as gospel by health care workers everywhere.  Giving false impressions about what an appropriate diet is.

 

LAP-BAND: Not Just for Women

Lap-band surgery is not just for women. Lap-band surgery is also successful with men. Obesity is at an all time high in our country.  While women and men both struggle with their weight, men generally have different reasons for wanting to lose weight than women.  For men, weight loss is not usually about trying to look like one of Hollywood’s elite, it is about maintaining vitality. They want to have energy to play with the kids, compete for a better job, to be able to exert themselves physically without feeling run down or being out of breathe.

The cycle of losing weight, gaining it back, losing it again, is not only frustrating, it also adds stress to the heart and other major organs.  Carrying extra weight puts additional strain on joints, and makes it difficult to active, because you tire much quicker than when you are at a normal body weight.
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Does Lap-band Surgery Prevent Cancer?

According to The National Cancer Institute (NCI), obesity increases the risk of many cancers, including  breast cancer and cancer of the endometrium, colon, kidney, and esophagus.  Additional studies show links between obesity and cancers of the gallbladder, ovaries, pancreas, and stomach.

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