How the NHS failed me and mine.
What it did, to the most important person
in my life and how it could happen to you unless
we do something about it!

Tuesday, 23 August 2011

Obesity (Again).

Being overweight remains in the news, with bulk of opinion being slanted toward the view that people who are in this state (obesity and the UK) are largely responsible for their own predicament. I not only find that somewhat cruel, but also founded in poor or even bad science.

I've already said in my previous post that is unlikely to be the fault of the 'fatties' but more of those who are advising them to eat a 'healthy diet' which in the DH 'speak' will largely be carbohydrate based and 'low fat'. In the latter's case that will be monounsaturated fats and polyunsaturated fats instead of saturated fats. Plant based oils (generally) then, in lieu of animal fats. This last bit of advice seems to fly in the face of the fact that homo-sapiens have some problems in metabolising some fats with CIS bonds (and even more problems with fats containing trans bonds). Animal fats such as lard, tallow and dripping, also contain quite large amounts of mono and polyunsaturated fats despite their undeserved reputation for being  entirely 'saturated'. Yet, it is patently obvious that this advice to avoid saturated fats and animal fats in particular, has done nothing to reduce the incidence of obesity and the associated risks of Diabetes, CHD, CVD and Cancer, because it continues to increase.

Looking in more depth at Nutrition and it's relationship with obesity we have to consider the mechanisms involved in becoming overweight. 'Hyperphagia' is synonymous with obesity, that is over-eating in simple terms. It can be a result of some genetic disorders or Diabetes, especially in Type 1's who inject insulin. It also manifests itself in Type 11's who are in advanced stages of the disease. High Carbohydrate diets typically can bring about this problem due to increased gene expression of the neuropeptide Y(NPY) in the hypothalamus, and causing a reduction in the expression of the hormone (CRH). What that means is that the brain is increasing its output of orexigenic (hunger generating) agents and decreasing output of anorectic (hunger suppressing) agents. This is how the brain stimulates our nutritional needs of hunger and satiety. So, it is evident that early stage diabetics (metabolic syndrome), Type 11 diabetics and the obese subjects will be permanently hungry. If, however we feed them a diet of fats and proteins and eliminate most carbohydrates, this phenomena is suppressed in a more 'normal' manner and appetite is curtailed at a much earlier stage in eating.

Forcing people then, to eat a 'healthy diet', two thirds of which is carbohydrate based, if we include the vegetables and fruit, is contributing to the obesity that it is meant to be reducing! Once we become 'insulin resistant' as well, we can arrive at a position where almost all intake is rapidly stored as fat, despite the fact that we are hungry, even starving, and our ability to 'feel full' is almost non-existent. Low carb diets, especially in the context of this section of society, are proven to have a considerable success in enabling obese and diabetics to attain an optimal weight and, more importantly, to maintain it. The mechanism is not fully understood, and there is considerable conjecture amongst biochemists that it may be down to ' metabolic advantage' with fats and proteins, or the satiety afforded by this food group actually reducing the calorie intake, or even the fact that increasing saturated fat intake, replaces vegetable/seed oil intake (generally Omega-6's) and that in itself helps to reduce obesity. Many hypotheses are propounded, reputations impugned, the science examined, re-examined and much that is known is based upon animal studies, not humans, but whatever the mechanism, it is certain that for most, a low or minimal diet of carbohydrates does bring about considerable weight loss and a 'normalisation' of blood sugars in most diabetics (Type 11's). Dogmatic views about diet and nutrition, without examining the science involved and ignoring outcomes, is what has brought about the ever rising tide of obesity and diabetes.

Those of us who are 'insulin resistant' respond to this more readily than any other cohort, and it is not a panacea for all, by any means, because all of us reach a plateau with our bodies, some quicker or slower than others. In fact being slightly over weight has some advantage for humanoids and was likely a defence mechanism against famine or periods when food was not abundant. The body in fact conserves energy in fat reserves and is quite loath to give them up, which is why so many dieters fail in their endeavours to lose weight because basal metabolism 'slows' as we begin to diet, especially with low fat/low calorie diets. Your body is attempting to 'save' you from yourself.
Completely Unnecessary Picture of Low Carber J- Lo

So why does mainstream advice for lowering the risk of obesity and the morbidity's that stem from it, continue to advocate measures, that are most likely to fail either in the short or long term? Well having your beliefs undermined, no matter how much evidence exists to prove you are wrong , is hard to bear, even for Doctors and Scientists.Being told what you want to hear, is comforting and reinforces preconceptions at the expense of the truth. Selection bias is something we are all guilty of at some time and I admit to it myself. We should not defend the indefensible but all too often the truth becomes clouded by hyperbole. Scientists delight in the rigour of 'peer review' often tearing quite good studies to pieces because 'they can' rather than due to any poverty of evidence. Equally as well they often lose the ability to reflect that 'correlation (and observation) does not prove causation' in the data they present. Which is why we get 'scare' stories extrapolated from views and opinions of Scientists, rather than hard evidence of harm.

It should not be countenanced and I have always believed that all of us  need to be as objective as possible in our search for truth, even when that truth challenges our basic and long held belief system. 'On the word of no-one' (Nullias in Verba), only the proof, is what we need.

This post has been devoid of links thus far. I've saved them  to the end. I've used some before, so don't be surprised to see them again. They all possess the 'gold standard' of trials, they are RC T's.
      1. Brehm BJ, et al. A Randomized Trial Comparing a Very Low Carbohydrate Diet and a Calorie-Restricted Low Fat Diet on Body Weight and Cardiovascular Risk Factors in Healthy Women. J Clin Endocrinol Metab 2003;88:1617–1623.
      2. Samaha FF, et al. A Low-Carbohydrate as Compared with a Low-Fat Diet in Severe Obesity. N Engl J Med 2003;348:2074–81.
      3. Sondike SB, et al. Effects of a low-carbohydrate diet on weight loss and cardiovascular risk factor in overweight adolescents. J Pediatr. 2003 Mar;142(3):253–8.
      4. Aude YW, et al. The National Cholesterol Education Program Diet vs a Diet Lower in Carbohydrates and Higher in Protein and Monounsaturated Fat. A Randomized Trial. Arch Intern Med. 2004;164:2141–2146.
      5. Volek JS, et al. Comparison of energy-restricted very low-carbohydrate and low-fat diets on weight loss and body composition in overweight men and women. Nutrition & Metabolism 2004, 1:13.
      6. Yancy WS Jr, et al. A Low-Carbohydrate, Ketogenic Diet versus a Low-Fat Diet To Treat Obesity and Hyperlipidemia. A Randomized, Controlled Trial. Ann Intern Med. 2004;140:769–777.
      7. Nichols-Richardsson SM, et al. Perceived Hunger Is Lower and Weight Loss Is Greater in Overweight Premenopausal Women Consuming a Low-Carbohydrate/High- Protein vs High-Carbohydrate/Low-Fat Diet. J Am Diet Assoc. 2005;105:1433–1437.
      8. Gardner CD, et al. Comparison of the Atkins, Zone, Ornish, and learn Diets for Change in Weight and Related Risk Factors Among Overweight Premenopausal Women. The a to z Weight Loss Study: A Randomized Trial. JAMA. 2007;297:969–977.
      9. Dyson PA, et al. A low-carbohydrate diet is more effective in reducing body weight than healthy eating in both diabetic and non-diabetic subjects. Diabet Med. 2007 Dec;24(12):1430-5.
      10. Shai I, et al. Weight loss with a low-carbohydrate, mediterranean, or low-fat diet. N Engl J Med 2008;359(3);229–41.
      11. Krebs NF, et al. Efficacy and Safety of a High Protein, Low Carbohydrate Diet for Weight Loss in Severely Obese Adolescents. J Pediatr 2010;157:252-8.
      12. Summer SS, et al. Adiponectin Changes in Relation to the Macronutrient Composition of a Weight-Loss DietObesity (Silver Spring). 2011 Mar 31. [Epub ahead of print]
      13. Daly ME, et al. Short-term effects of severe dietary carbohydrate-restriction advice in Type 2 diabetes–a randomized controlled trial. Diabet Med. 2006 Jan;23(1):15–20.

      Thursday, 4 August 2011

      Obesity - The Bing Crosby Approach.

      "Accentuate the positive, eliminate the negative!" That is the 'spin' of politicians and doctors,  who wish those endowed with excessive subcutaneous fat to be nudged into a healthier paradigm for life. Yet most of their 'crooning' is patently wrong. It is said that more and more of us are getting fatter, and as a consequence, putting ourselves at higher risks for heart disease, diabetes, liver and kidney failure, together with a myriad of co-morbidity's associated with the 'obesity explosion'.

      Fellow blogger the masked crusader has a rather darkly humorous solution, but his description of the obese as 'pie eating lardbuckets' is somewhat harsh to say the least, because it is the advice that many of his colleagues provide to 'fatties' that is fueling the crisis. It is also obvious that his cunning plan to recycle the result of liposuction is fatally flawed. The energy needs to enable such a 'rendering' would far outstrip that provided by the resultant product. So, put down that pie and pay attention!

      Obesity is defined by having a Body Mass Index of 30kg/m2, which can be ascertained by dividing your weight in kilo's by your height squared. For someone 6ft tall (1.8mt) and 11 stone (70 kgs) that would be a BMI of 21.60kg/m2. There are, as one can imagine, quite a few people with lots of muscle who would then be called 'overwieght' (BMI of 25 - 29.90) and even obese, so the formula does not fit all. In fact, whilst subcutaneous fat is an indicator of obesity, it is visceral fat (the fat around internal organs) that is a better predictor of disease.

      The recent survey on health and obesity from the NHS shows some quite interesting data, especially on diet (although it will take some time to read all 112 pages), which does show that advice to eat '5-a-day' is working with the 5 to 15 year old's as consumption has doubled. All people are also eating less trans-fats, saturated fats and sugar than 10 years ago, and calorific intake has tended to decrease since 2006. Yet we are still getting fatter, have more diabetes and heart disease (despite the fatalities from it decreasing). We are as a whole also taking more exercise, with a 7% increase (absolute) between 1997 and 2008, with men exercising much more than women. Surely, it is sensible to assume then that this advice, issued to the public and taken up, should have made some inroads into the obesity epidemic, even if only small, but it hasn't, if anything things are getting worse! Could it be that the advice is wrong? Err... well yes!

      Looking at the advice we have; eat less fat, eat '5-a-day', take exercise, don't smoke, drink only a little of alcohol, don't eat sweets or sugary drinks, and of course consume carbohydrates in vast quantities, up to two thirds of your food intake (when you take fruit and vegetables into account). Now that we have been doing that for about thirty years, at ever increasing frequency, we are then told that; we are all lying about what we eat and we are eating far too much, remembering of course that average calorific intake has diminished since 2006, which together with lack of exercise (or not enough of it) is the reason for the spread of obesity and disease. So by 'accentuating the positives' of low fat, exercise, and non-smoking, and 'eliminating the negatives' of saturated fat, meat, alcohol, lack of exercise etc. etc. we have achieved, well nothing!

      Now we are told, that if we are above a certain BMI, we smoke, or drink above a certain limit, that we will be proscribed from various treatments on the NHS, because it's all our own fault and we are a bunch of lying, drunken, "pie eating lardbuckets", who do not deserve the largess of the NHS to help us fix the problems that ensue from our aberrant behaviour. What a crock of s**t! What about the other cohorts in society, who run in marathon's or just run in the the vain hope of 'super fitness' and end up in dedicated 'sport injury clinics' in the NHS? Or those who diet to the point of death, because society's model of beauty is a size 6, or indeed children diagnosed with ADHD, because their parents take the advice of the DH and feed them sugar laden grain products for breakfast, because it's 'healthy grains', pasta (wholewheat of course) and bread with almost every meal (brown of course). Surely all of these are equally responsible for their plight as is anyone who is said to be a chronic 'over eater'. This is Eugenics for 'fat people' and in my view is bordering on racism for adiposity.

      You get fat not because you eat too much, or don't exercise but because you eat the wrong things, usually based on the advice of the Dept. of Health, or Heart UK, or Diabetes UK or one of the other self serving organisations we allow to govern our lifestyle choices, simply because they are heeded as being 'expert', when in truth they preach misguided and unscientific dogma. Despite the fact that they have been doing so since the late 1970's with no tangible proof of success, or indeed any evidence to support their ludicrous claims that they 'know best'. Often their advice is based upon Food Industry claims completely unsupported by any evidence because they want to sell you something. Or indeed some pseudo science from the USA that has long been disproved as fantasy.

      There is no evidence that fat, makes you fat. None at all. Never. There is no evidence that eating saturated fat causes heart disease. In fact there is considerable evidence that the converse is true, with low carbohydrate, high fat and protein diets being the best solution for weight loss and health. There are many proofs of this but the most meaningful is the biochemistry involved in food intake. Carbohydrates are the food group that requires an insulin reaction to enable them to be metabolised, and conversion to glucose, no matter what their glycemic index is, will be extremely rapid, and more importantly virtually completely, to provide energy needs. The problem is that glucose, if not used up immediately is stored as fat and it is very difficult to utilise all of the glucose from a high carbohydrate meal immediately no matter how much exercise is taken. Fats and proteins are somewhat different in that they are not metabolised rapidly but quite slowly and not with the same ruthless efficiency as carbohydrates. Protein intake is needed for cellular generation from the amino-acids formed from their product in the body, so little is stored as fat. Fat is metabolised very slowly and with very low efficiency with nearly half of intake being 'wasted' and passed as ketones in urine. And of course, the 'calories in calories out' paradigm peddled as the 'gold standard' for diet is fatally flawed because of this.

      The use of a 'low carb' diet has proved to be the most effective for weight loss for over a hundred years and it's modern equivalent 'The Atkins Diet', the 'Paleo Diet' or indeed any of the more up to date versions of diets reliant on fats and proteins in varying mixes to achieve a reductions in body fat are in the ascendant, yet the DH and Doctors generally seem hell bent on ignoring evidence of its efficacy. I find it difficult to see why.

      It seems perverse to refuse treatment to any sector of society however guilty they may be of their predicament at the same time as providing it to others who are intrinsically as guilty, but worse have deliberately pursued a reckless course of exercise, or driven too fast, when drunk, or taken drugs. Fat people have usually tried hard on low calorie diets, or worse taken some of the awful, and generally useless drugs for obesity and consistently failed. If healthcare continues down the road of diets that set up the obese to fail, they are just as complicit as those they refuse to treat, indeed more so. Taken to extreme, why not have an undertaker posted permanently at A&E to wait whilst undeserving patients expire?

      I seem to remember that a certain Steve Field, once head 'honcho' at the RGCP (now replaced by the excellent Claire Gerada) was a bit of a 'lard bucket' at the same time as he was selling us the idea of a 'healthy diet', didn't seem to work for him either! (Sorry, couldn't resist).