Refuse To Regain

BMI: Tool or Tyranny?

 by Barbara Berkeley, MD

The patient in front of me is Mr. C, a 308-pound man who has been sent by one of my favorite referring doctors. This doctor truly cares about the health of his patients and it shows. In fact, Mr. C’s physician is a triathlete, eats for health and practices what he preaches. He’s never been overweight. His clients are devoted to him and Mr. C is no exception. But Mr. C. is worried. He genuinely wants to lose weight but the doctor he so much wants to please has told him that he needs to reach 170 pounds: the white or “healthy” zone of the BMI chart. “Doc,” he says earnestly. “Is that possible? I’ve never been that light, not even in high school.”

Twenty years ago,the term BMI was part of the foreign language of doctors, a measurement that was recorded on the chart and remained obscure to patients. Today, nearly every dieter understands, (and sometimes obsesses about), his or her niche on the BMI chart.

BMI, or Body Mass Index, is a shorthand that describes the relationship between your body height and weight. The measurement first saw the light of day in the mid 1800s, invented by a scientist named Adolphe Quetelet. In order to compare peoples' masses, Quetelet proposed a method which divided weight by height squared. Current BMI figures are still based on the same equation: weight in kilograms/ height in meters squared. Today, high BMIs denote overweight and obesity.  The cut-offs are as follows: BMI of 25 or less = normal, BMI of 25 to 30 = overweight, BMI of 30 to 35 = obese, BMI of 35 or greater = morbid obesity. On many BMI charts, the obese weights are colored red, the overweight weights yellow and the normal weights white. (You can find a typical BMI chart on my practice's website: www.weightmp.com).

Because BMI looks at weight without distinguishing whether it is coming from fat, bone, or muscle, people with denser bone structure or those with large muscles masses can have high BMIs. I am frequently asked by patients whether a weight that increases or fails to drop might be coming from a new muscle-building gym regimen. Alas, the answer is generally no. Unless you are built like Dwight Howard or Arnold Schwarzenneger, the amount of muscle you gain in the average gym is not causing your BMI to rise. This is especially true for women, who can get great toning and definition from lifting, but are generally not capable of building large amounts of new muscle mass.

However, the major problem with BMI is not that it is inaccurate for the Greek gods among us. The major problem is in its low end, where it sets the bar for “normal”. The BMI chart, with it’s white, yellow and red sections shouts unequivocally that certain weights are unhealthy. These arbitrary divisions are at odds with the advice that obesity societies routinely give patients: that weight loss of 5-10% of current poundage can greatly reduce medical risk. So which is it? Do we need to lose just a bit or do we need to get ourselves all the way to the Promised Land….the white zone???

In my book, Refuse to Regain, I reference the work of Dr. Walter Willett of Harvard School of Public Health. Dr. Willett has been in charge of the comprehensive Nurse’s Health Study for some years, a study which shows that the risk of diabetes, hypertension, gallbladder and coronary artery disease starts to rise at BMIs that are far below the 25 we consider “just overweight.” Dr. Willett has said that this data was known, but ignored when committees set the “normal” cutoff for BMI. He believes that the reason is simple. If normal BMI were lowered to somewhere around 22, the vast majority of America would be classified as overweight.

While Dr. Willett is one my dietary and medical heroes, I have a somewhat different take on BMI. Yes, we know that weight gain impacts our health negatively. We know that even small amounts of weight gain put us at risk. But what happens once the horse is out of the barn? Once we have gained that weight, incurred that new risk, what then? Are the rules for “healthy” BMI the same after gain has occurred? This question brings us to a larger and more fascinating issue: Is there some permanent change that occurs within us once we have been overweight that changes those rules?I believe the answer is yes.

What I call POWs (previously overweight people) seem to be quite different from NOWs (never overweight people). As someone who was a NOW in my earlier years and is now a POW, I can attest to the fact that my physiology has changed. Can I prove this scientifically? No. We have now crossed over into the area of observation and opinion. Read on with that knowledge.

In my view, weight gain occurs when the normal mechanism that controls and stabilizes weight is damaged by over-exposure to elements of the SAD (standard American diet). Once the damage is done, I believe that we remain prone to weight gain. We can prevent this by avoiding the foods that caused the damage in the first place, but we must be extra careful. Most POWs cannot eat mindlessly anymore.

This tendency to weight regain may also have to do with fat cells which remain in the body, but which no longer contain fat. No one knows if depleted, empty cells signal the brain or cause other kinds of hormonal havoc. So what does this have to do with optimal BMI? When we gain weight, the body has to manufacture new fat cells to store the oily triglycerides which are being created. These cells are supported by a scaffolding of connective tissue and muscle. After weight loss, the fat cells are emptied, but some of the tissue may remain. Many POWs find that they simply cannot lose enough weight to reach the white area of the BMI chart. This may well be because the BMI chart is based on the weights of those who have never been heavy, in other words, the weights of NOWs. Since they have never manufactured new fatty tissue, their baseline weights are lower.

I love what I do, but I have written before about the one part of my job I don’t enjoy. That would be the very last phase of a patient’s weight loss. Almost without exception, my patients are unhappy with their final weights. This happens even when they have lost 60, 80, or 150 pounds. Each one longs to to get down “just a little more!” Each one feels like a failure for not reaching the white zone. This is the point at which BMI charts become tyrannical, and for no good reason. The rules for optimal BMI in the POW are different, just as pretty much everything else is different for POWs. Since there are no established guidelines for optimal weight in the POW, I can only offer my own take.

1. If you have been significantly overweight, a loss of 20% of your pounds is highly successful and is what I usually target. If you’ve lost more, great!!

2. Your optimal BMI should be the one at which you have eliminated or greatly minimized any weight related medical issues (especially blood pressure, diabetes, and lipids). In some people, remnants of the problem will remain, but the vast majority can expect significant improvement and decrease of medications.

3. Your optimal BMI should be one at which you can comfortably maintain.

Number three is probably the most important guideline, because weight loss is of no consequence if it ends in regain. POWs who push themselves to very low weights often do so at the expense of muscle tissue. If you start to look wasted, your vital muscle mass may be dissipating. At such low weights, and without muscle to help out with calorie burning, you will have to make do with what I call “two peas and a bean”. That’s not fun, that’s not life, and that’s not sustainable.

Are BMI charts important at all? Yes. They remain vital for judging the weights of NOWs, like our kids, young adults and that minority who remains at normal weight. If we can prevent them from converting to weight gainers, they will not have to deal with the permanent changes that dog the rest of us. As parents, educators, doctors and public citizens, this is a worthwhile goal and one that our health care system should be targeting. But for the rest of us? Shoot for maintenance, comfort, health, mobility. These will stand you in good stead whatever your zone or color.      

“Lost”….and What Else We Might Lose

By Barbara Berkeley

My daughter and her friends have been posting excited messages on Facebook for weeks. “Lost”, ABC’s blockbuster mystery-on-an-island, is back for its final season! This is an occasion for special t-shirts, viewing parties and intense discussion. For fans of faux-terror, “24” is also back. “American Idol” has returned fueling speculation about its life without Paula and about who will replace Simon. Television takes up time. A lot of time. The SuperBowl is coming up. There’s a war going on for late night supremacy. And if you live in Cleveland, as I do, there are weekly hours of obligate viewing as LeBron, Shaq, and the Cavaliers continue their domination of the NBA.

Believe it or not, I am actually able to remember a time when television DID NOT EXIST! My father had a friend who owned a local furniture and appliance store and as a result was able to get one of the first TVs on the block. Most of the time there was a test pattern on the screen when you turned it on. Later, there was Milton Berle, Sid Caesar and Ding Dong School. Not much else. As time passed, the broadcast schedule grew and television watching became a family activity. This seemed to culminate in my preteen years when the whole family gathered to watch shows like Man from Uncle, The Defenders and Dr. Kildare. But television was still not primary in our lives. School activities, playing out in the street in front of our house and congregating on the stoop took up a lot more time and were a lot more fun.

When I first moved to Cleveland over 20 years ago, I remember being invited on a house tour that included some of the fanciest homes in the neighborhood. I remember being shocked by one house in particular which had TVs in just about every room and not a single book. Now, my own house has multiple TVs in many of the rooms and that includes one of those big flat screen babies…the better to watch every detail of every Cavs game.

So the question is: is all this TV good for us? In January, a study from Australia announced some sobering findings. Researchers studied 8,800 adults for a median time of 6½ years while looking at things like exercise, smoking, weight and television viewing time. Amazingly, each daily hour of television was associated with an 18% increase in death from heart disease and an 11% increase in death from all causes. This translated to a whopping difference between those who watched less than two hours of TV per day and those who watched over four. In fact, the big time viewers were 80% more likely to die of heart disease and 46% more likely to die of anything than those who showed viewing restraint! (By the way, a person’s weight was not a factor in this study.) The study authors postulated that this significant risk came from sitting still for prolonged periods. That interpretation is certainly possible, but is it necessarily true?

When we read the results of studies as reported in the news, it’s tempting to accept them at face value. But it is important to understand that epidemiologic studies like this one can prove association only…not causation. In other words, we can see that TV viewing and shortened life exist together, but not that one caused the other. Nevertheless, we must be intrigued by the relationship. It would have been interesting to look at those people who watched TV while on a treadmill or at those who frequently jumped around while watching (like certain basketball fans!). This might shed some light on whether it’s the sedentary behavior that causes the problem or something inherently unhealthy about living life vicariously through little images on a screen. Do Ph.D. candidates who spend hours in the library live shorter lives? Are some sedentary activities – say, writing poetry or meditating for extended periods – more conducive to health than others? We simply don’t know.

In the meantime, I doubt that this study will stop anyone from turning on the tube. For those of us of a certain age, though, its results remind us poignantly that there once was a world where playing on the street and sitting on the stoop seemed far preferable to parking yourself in front of an electronic gadget.

Shields Up! The Hunger Advantage

By Barbara Berkeley

What if you could cloak yourself in a defensive shield that warded off disease and extended your life? Would you do it? Would you take a pill that could do it for you? Many of us are already trying to, by swallowing tablets of antioxidants and resveratrol, swigging acai and pomegranate juice and downing loads of vitamins of uncertain benefit. But a growing body of research suggests that the solution may be as seamless and elegant as nature itself. It’s possible that we can activate just such a defensive shield this very moment...simply by eating less.

As readers of this site know, I am especially interested in the role of food choice in life extension. I am also deeply convinced that the hormone insulin is the central “superhormone” which mediates fat storage, obesity, inflammation and longevity. Whenever you read any research about overweight and its related conditions, you will find the fingerprints of insulin all over it. I also believe that a broken or poorly functioning insulin system is the reason that the vast majority of us develop modern disease. We don’t need to have diabetes or even elevated blood sugar to have a struggling insulin system. Defects in insulin signaling can be going on for years before we can detect them. This doesn’t mean that our bodies are not suffering.

Now, in a paper that is due to be published in Nature, German scientists have shown that we have a second defensive system which acts independently of our classic immune system. When we go without food for awhile, this system switches on. Surprise, surprise…the hormone which is responsible for flipping the switch is insulin. Once the system is activated, cells produce proteins which are capable of destroying harmful microbes and defending us against invasion from the outside. According to the the study director, “This happens every minute every day. What is fascinating about this is that a function of the immune system directly depends on how much and what we eat.” In other words, slightly stress your cells by making them hungry and your shields will go up.

This, and other research studies, provides a great deal of non-caloric food for thought. We know that obesity and the diseases it spawns lead to increased inflammation in the body and can result in reduced life span. We also know that uncontrolled inflammation is bad. Might it be that the habit of affluent societies to eat continually results in a chronically lowered defense system? If more invaders are able to penetrate our outer barrier, we would likely respond with aggressive inner defenses, in other words: inflammation!

One of the strategies for weight maintenance that I suggest in my book and that I continue to suggest to patients is that we spend parts of each day in the non-eating state. This allows insulin levels to fall. We now know that these lower levels can active the FOXO transcription factor; the messaging system which turns on defense genes.

So put up those shields and rethink that grazing habit. As those of us who are maintaining weight know, the body does best on small amounts of highly nutritious foods. Our miraculous physical plant is finely tuned and we may be best off if we stop trying to second guess it with pills, potions and manipulations. More and more, we are coming to know that a return to simple basics and a realignment with our genetic priorities is the only way to put nature to work for us.

The Big Gift

By Barbara Berkeley

At this time of the year I’m always searching for motivating tips that will help my patients get through the holidays. I often remind people that their new eating habits are a gift they are giving themselves. “If you are going to give yourself that gift,” I say, “then DO it! Don’t pull it back at the last moment just because of the Christmas cookies!”

I think that maintainers understand more about this gift than dieters do. This is because we have to experience a period of prolonged maintenance to “get it”; to feel the true benefits of changed eating. While staying at a lower weight is part of that benefit, it is often a smaller part than we might have expected. The gift we receive is a feeling of being in healthy harmony. This harmony allows us to enjoy powers of energy, a new smoothness of mood, a feeling of strength, and a body that stays well when other bodies fail. Escaping from the daily fear of illness – that’s probably the ultimate maintenance gift.

We know that maintenance makes us feel better. But could the gift be even greater? Could maintenance be helping us to live longer?

Recent research in the field of caloric restriction continues to be intriguing. As most readers know, cutting calories leads to longer life and slower aging in most species. But how does that happen? A study from Mount Sinai School of Medicine, looked at this question and came up with the following answer: “It may not be about counting calories or cutting out specific nutrients, but how a reduction in dietary intake impacts the glucose metabolism, which contributes to oxidative stress.” (Dr. Charles Mobbs, principle investigator).

Oxidative stress is the damage done by substances called “free radicals” which are created as a byproduct of certain body processes. You can think of these free radicals as rogue particles which shoot through cells causing injury. When we take “anti-oxidant” vitamins, we are attempting to sop up these free radicals and thus get rid of them. A better approach would be to generate fewer free radicals (and less damage) in the first place. As it turns out, overeating – the great American pastime – appears to increase free radical damage. Restricting calories means less oxidative stress and healthier cells.

The Mt. Sinai team discovered that caloric restriction increased body levels of a substance called CREB binding protein, or CBP. High levels of CBP were associated with longer and healthier lives in worms and mice. In mammals, Dr. Mobbs believes that an equivalent effect might be seen at about a 30% reduction in calories.

If CBP levels are known to be high in mice who eat less, what would they look like in mice with sugar problems – in other words diabetic mice? Mobbs’ team discovered that CBP was low in these animals, predisposing them to accelerated aging and disease. It seemed that CBP might work by blocking glucose (sugar) processing in the cells. Higher CBP might mean less glucose metabolism and less free radical damage. Most intriguing, Mobbs found that CBP levels were quite fluid and responded to changes in blood sugar within hours of feeding. Calorie restriction elevated CBP for as long as restriction was maintained.

This research is another small piece of evidence that points to the wisdom of primary diet (eating as anciently as possible). It is intriguing on two levels. First is the issue of optimal meal frequency. Paleo diet afficianados have become interested in figuring out how often our ancient ancestors ate. It appears that many tribal peoples ate one large meal per day. This means that we may be optimally adapted to spending longer amounts of time in the non-eating state. The SAD encourages us to eat constantly and in large quantity. If Mobbs’ data translates to humans, overeaters would theoretically have a low level CBP and a higher incidence of aging and disease. Maintainers generally eat many fewer calories per day than their free-eating counterparts.

The second important issue raised by this study is the suggestion that cell aging and glucose metabolism are linked. If aging and age related disease can be lessened by reducing glucose metabolism, does this mean that we can create the same effect by lowering our S Food consumption? As we know, ancient diets were low in starches and sugars (carbohydrates). Our body design seems to reflect this by having difficulty dealing with large amounts of these substances.

Might eating anciently raise CBP levels? We won’t know until studies target humans. For now, most research is geared toward finding drugs that can mimic the effects of caloric restriction. But here’s the problem. Drugs take years to develop and, once developed, have the pesky habit of manifesting unpleasant side effects. If CBP turns out to be a real marker for the pace of aging wouldn’t it be great to have a portable CBP monitor? Perhaps someday, people will carry an “age-meter” instead of a glucometer. If you could painlessly monitor your longevity factor and aim to keep it over a certain level, wouldn’t it be easier to wait another hour for dinner or pass up pasta in favor of salmon and salad? In the meantime, I strongly believe that the gift of longer and healthier life is there for the taking. Keep starches and sugars low, eat with less frequency and in smaller quantities and use your scale as your longevity tester. If you are maintaining weight, chances are you have things in the right balance. Enjoy the holidays with the knowledge that your heart, your eyes, your kidneys, your liver, and your blood vessels – right down to your tiniest capillaries – are sending you grateful messages of thanks.

It Takes Two

By Barbara Berkeley

I don’t know how many of you make it a habit to follow the glut of weight-related research studies that are released each day. I try to hone in on those studies that seem novel or important. Despite trying to be selective, I am often rewarded with a DUH! experience. So many of these studies seem to ask the same questions and come up with the same conclusions. It makes me wonder why we are spending so much money to prove the obvious.

Here’s an example. This week, a study from the University of Houston reported that fitness levels decline after age 45 (big surprise, right?), but that people who stay at normal weight, don’t smoke and are physically active stay substantially more fit. Researchers looked at data on 3,429 women and 16,889 men collected between 1974 and 2006 before releasing the following conclusion: "These data indicate the need for physicians to recommend to their patients the necessity to maintain their weight, engage in regular aerobic exercise and abstain from smoking," Excuse me, but….DUH!

While the conclusions of the Houston study seem obvious, they still present a problem. In my world view, it’s simply not enough to tell people to exercise and maintain weight. Let me digress for a moment to explain why.

Recently, I rejoined a gym. I’d been absent from this particular gym for quite a while after leaving to follow my favorite aerobics instructor, Joe, who had decided to work at another place. But when Joe decided to move out of town several months ago, I rejoined the original facility. It had been eight years since I’d been there, and when I returned, I discovered a mini research experiment laid out before my eyes. The women who had been in my classes eight years before were now almost all overweight and were significantly less fit. These women are all avid exercisers. They still take multiple aerobics classes weekly. Despite this, a significant majority no longer look fit, weigh much more than they did, and can no longer exercise at high intensity. I suppose you could look at the Houston study and predict this decline, except for one thing. This decline has not been true for me personally. I still run, play singles tennis, and take aerobics classes that are as vigorous as the ones I took 10 years ago. My weight has not increased. From this, I must deduce that a deterioration in fitness and an age-related increase in weight are NOT inevitable. (At least not up until age 61…my current age). What to make of this?

I believe that this is a case of “It takes two.” During weight loss, many of my patients will do everything that is asked of them to control food, yet will refuse to exercise. In the case of the women at my gym, they were happy to exercise, but probably were not vigorously controlling the foods they ate. Some exercisers simply “lean” too much on exercise. By this, I mean that they have the unsupported belief that exercise is a cure-all. Others believe that restricting calories is a cure-all. There is, indeed, a cure-all, but it is the consistent combination of proper fuel with proper body tone. These two elements are actually one. They cannot be separated. Because maintenance is supported by two equal pillars, it isn’t enough to counsel patients (as suggested by the Houston study) to exercise more and “maintain their weight.” For people like my gym companions maintaining weight equates with exercising more. This advice essentially gives the same direction twice. Long term fitness requires a tough two-pronged attack. Proper fueling. Proper exercise. Got to have both.

While the Houston study made me yawn, a second study that appeared this week provided the “Wow” experience. This fascinating research from the University of Alabama reported that as few as 80 minutes of either aerobic or resistance exercise stopped the reaccumulation of the specific kind of fat you want to avoid—visceral fat. Visceral fat is the highly dangerous adipose that accumulates inside the abdomen and lives around and inside vital organs. It is visceral fat that produces dangerous chemicals and which sends fatty acids into the bloodsteam. It is visceral fat which is responsible for the byproducts of obesity: hypertension, hyperlipidemia and diabetes. In this study, a group of 45 white women and 52 African-American women were treated with a weight loss diet and either aerobic, resistance exercise, or no exercise. After weight loss was achieved (about 24 pounds on average), the two exercise groups were instructed to continue their activities at a rate of 40 minutes twice weekly and the non-exercisers were told to continue being sedentary. At the end of one year, those who continued exercising (either resistance or aerobics) had regained ZERO visceral fat (!) Those who quit exercising, or never exercised to begin with had regained about 33 percent of their visceral fat.

It is worth noting that there was some regain even in the exercisers (perhaps related to the lower levels of exercise required by the study), but that none of it was inside the abdomen.
Once again, the case can be made that exercise is a vital element in weight maintenance. But it is not the only element. It takes two. We tend to rely too much on one side of the weight loss/maintenance equation, a rookie error that can lead to disaster. A balanced approach is needed because nature has designed us with bodies that seek balance. Proper Fuel. Proper Tone. It’s a beautiful thing.

Natural Remedies: Who’s Watching the Store?

By Barbara Berkeley

Let’s have a show of hands. How many of you have a history with dietary supplements or “natural” remedies? Ever tried that miracle pill for weight loss that beckons so alluringly from the pages of your favorite magazine? What about Metabolife? Hydroxycut? TrimSpa? Colon cleanses? Weight loss vitamins? Supplements for sexual enhancement? Natural remedies for menopause?

These products are sold over the counter and over the Internet. Because a doctor’s prescription isn’t necessary, they appear to be safe. But are they? The fact is that there is so little oversight of natural and herbal products that it’s impossible to know.

According to a Harris poll, the majority of American consumers believe that over the counter dietary supplements are monitored by a government agency like the FDA. Two thirds of consumers believe that supplements are required to carry warning labels about harmful side effects. Neither belief is true.

Physicians are also relatively uninformed about supplement safety. About one third of medical residents in one survey were unaware that herbal remedies were unregulated and the majority did not know that it was their job as physicians to report suspicious side effects to the FDA.
In 1994, Congress passed what many believe to be an unfortunate piece of legislation. Called DSHEA (the Dietary Supplement Health and Education Act), this act removed much of the FDA’s power over supplements. Prior to this time, herbal products were treated as food additives and manufacturers were required to show proof of safety. With the advent of DSHEA, over the counter supplements were assumed to be safe and therefore to require no governmental regulation. In other words, it was now the responsibility of manufacturers to police their own products.

The politics which led up to the passage of DSHEA are compellingly documented by NYU professor Marion Nestle in her book, “Food Politics.” This is a weighty book, but one that I heartily recommend to those of you who are interested in the powerful interests behind the foods we eat. Suffice it to say that, in the case of DSHEA, those with a financial interest in keeping supplements deregulated won the day. Now, in an era when big bucks can be made from treatments for obesity, erectile dysfunction and other lifestyle related conditions, we have a growing and largely uncontrolled problem.

According to an October 15 editorial in the New England Journal of Medicine:

“…a wide range of dietary supplements have been found to be contaminated with toxic plant material, heavy metals, or bacteria. Of particular concern are the dozens of dietary supplements that are contaminated with prescription medications, controlled substances, experimental compounds, or drugs rejected by the FDA because of safety concerns.”

Weight loss remedies and sexual performance drugs are among the top candidates for potential contamination. As of July , the FDA had an alert on 75 contaminated weight loss supplements. And the tampering was not minor. The NEJM article cites a natural remedy which actually contained over three times the recommended daily dose of the prescription drug Meridia. Other drug contaminants included unapproved anorectics, diuretics, antidepressants and tranquilizers.
A major concern for patients taking contaminated supplements is drug interaction. When physicians prescribe medication, pharmacies and doctors check to make sure that patients are not taking drugs that can be harmful when used together. Because so many of those looking for weight loss also suffer from hypertension, elevated sugar, cholesterol problems, GERD and the like, this population is often taking other medications when they add a supplement. This puts overweight supplement users at increased risk for interaction with hidden drug contaminants. Drug interactions can be very serious. In the Fen-Phen days, for example, we learned that the combination of two relatively benign weight loss medications led to irreversible heart valve damage.

In order to evade the FDA, supplement manufacturers have turned to doctoring their supplements with drugs which have been slightly altered so as to avoid chemical detection. The problem with these newly altered compounds is that they have not been previously tested for human use. According to the NEJM for example, a changed form of fenfluramine (a diet medication) found in supplements was linked to severe liver failure in various reports.

I have always been puzzled by the public’s willingness to take over-the-counter remedies and supplements. Recently, a company that I’d never heard of sent me some sample diet cookies. They came in a box, each one in an open cellophane sleeve along with a little printed information sheet. Forget it! I wasn’t eating those nor would I allow any of my staff to consume them. I’m probably on the extreme end, but I am suspicious enough of the safety of plain old food without adding unknown substances to my diet. My gastroenterologist husband is always taking care of people with salmonella, e. coli and other forms of food poisoning. And those are from foods that ARE regulated (although not enough…a subject for a future post).

Whenever we swallow something, we are giving that substance a pass key to our bloodstream, our heart, our brain. Should we really trust pills and potions whose provenance is uncertain at best? Even in the best of circumstances, natural does not mean innocuous. Remember that many potent medicines are herbal, including digitalis which helps the failing heart contract, and yew which yields a potent cancer chemotherapy. Add to this the issues of uncertain quality control and hidden contaminants and we have an industry in dire need of regulation. In this cynical age we must consider the possibility that some supplement providers may be more interested in our dollar than in our health. At this moment, there is little guidance to help us distinguish the good from the bad. Unfortunately, it appears that the bad can be very bad indeed. Until the current regulatory situation changes, the burden is on each of us as individuals to take a long, critical look at the “cures” we choose to swallow.

Surprise! Re-Creation vs. Reactivity

By Barbara Berkeley

Whenever possible, I am for re-creating health rather than of reacting to it with medications. The difference goes something like this: Say you have a house that doesn’t suit you. It leaks, it’s drafty and the walls are unstable. One approach to the problem is to patch the plumbing, inject insulation and shore up the walls. A more drastic, but more profound solution is to tear down the house and create another one. The new house can have only the best materials and can be built to reflect everything that is known about keeping houses strong. Although it’s a lot more work, most of us would choose the rebuilt house anytime. Patching will always be patching.

Having said this, Don and I choose to live in a 150-year-old home which is in constant need of repair. Recently, an underground pipe broke and was reconnected by a new length of PVC and some expensive clamps. After the entire area was recovered and re-seeded, water began to well up through the ground. Much to the surprise of the plumbers (who had spent days digging up the site), the leak was coming from a completely different area. The break which had been repaired probably had nothing to do with the original flood, but had occurred as a side effect of the excavation.

Then there was the tale of the 220 electric line that supplies our house, also underground. That got cut during some yard work. Rather than run an entirely new line, it was repaired in a way that was meant to be permanent. A year later, steam began to rise from the area. The line was leaking electricity into the dirt and steam cooking it. Electricity was also being transmitted through the ground to pipes entering the basement and giving us shocks when we turned on the shower. The electricians were surprised. How did that happen? Plumbing and electrical work should be fairly straightforward, but even they are a little more complicated than they might appear.

How about the human body?

The human body is a universe unto itself, stunningly and endlessly complex. The degree of technological sophistication we’ve now achieved makes it seem as if we know a lot about ourselves. But we’ve only just scratched the surface. Putting a patch on bodily problems leads to a lot of “surprise” moments and some of those moments can be a lot more painful than a spark from the shower handle.

Take the diabetes drug Avandia. By 2007, this drug had been on the market for 8 years and had been used by over 8 million people. Surprise! It turned out that the drug raised the risk of heart attack by 43%. Avandia was a medication that helped sensitize the body to its own insulin. Since we know that diabetics have a vastly increased risk of heart disease, it only seemed to make sense that improving insulin would make heart disease better. In the case of Avandia, it didn’t.
How about all those antioxidants we’re taking? Up until now, the science has seemed to be simple. Our body produces molecules called ROS (reactive oxygen species) in response to all sorts of stressors. These ROS act like small bullets, bouncing around the body and damaging healthy cells. Anitoxidants disable ROS. Therefore, the logic: ROS bad, antioxidants good.
But fruit fly research at UCLA recently revealed that ROS have an additional function. Elevated levels of ROS serve as a communicator which signals blood cells to responds to an immune threat. The investigators expressed surprise.

"On the one hand, it's good to have antioxidants to reduce the amount of reactive oxygen in our body that causes DNA damage," the investigators said. "But if we find that those blood stem cells aren't primed to respond because the ROS levels are reduced, that would not be a good thing. Our findings raise the possibility that wanton overdose of antioxidant products may in fact inhibit formation of cells participating in innate immune response."

And here’s a third example. The ACCORD study was a comprehensive study of type 2 diabetics. The study was out to prove what seemed to be the obvious: that lowering blood sugar aggressively prevented diabetic complications. Instead, the glucose-lowering part of the study was halted early due to an increase in cardiovascular deaths among those with the most tightly controlled sugars.

Cleveland Clinic cardiologist Steven Nissen was quoted as saying: “This result really does defy conventional wisdom. I suppose it wouldn’t have been a major surprise if there was no effect, but to show harm is really a big surprise. This effect could have been due to some of the drugs being used to lower glucose levels, which may have other effects that cause harm.”
Surprise yet again!

We do not read about increased risk in people who rebuild their houses. The data on eating diets which are primary in form (based on foods that are not altered, but come directly from nature) are uniformly positive. I have yet to see a study that decried the effects of increased exercise. We are able to easily measure improvements in blood pressure, lipids and insulin resistance in people who lose weight and keep it off. The data on the consumption of fruits and vegetables as natural antioxidants and nutrients is convincing, whereas little benefit has been shown in virtually any of the trials done with vitamin supplements.

I am a doctor and I believe strongly in the benefits that modern medicine can bring. I am not anti-medication. But we have come to rely too much on medicines and to use them to the exclusion of the therapies which might truly work…lifestyle therapies that we ourselves must administer. We have come to believe too much in our ability to understand the intricacies of the human body, a hubris which can be costly. The task for each of us, patient and doctor alike, is to decide when medicines are helpful and necessary and, when we use them, to follow the physician’s dictum to “do no harm”. Wherever we can, we should choose to create health by rebuilding and perfecting our own physical bodies. In the case of life re-creation, we not only do no harm, we also build a stronger, safer house; one we can live in confidently for a lifetime.

Insulin and Dementia: Taming the Spider

By Barbara Berkeley

It’s funny how we tend to think of the brain as a different kind of organ, one that has jobs that are quite distinct from the activities going on in the rest of us. But nothing could be further from t truth. The brain is fed by the same blood vessels and blood supply as the rest of the body. It is completely and intimately connected to the moment to moment choices made by that body. If you don’t believe me, just think of what happens a few minutes after you take a shot of tequila. The alcohol started in your stomach but suddenly it’s right there in your brain urging you to join the conga line.

In the same vein, we tend to believe that Alzheimer’s disease is a mysterious ailment that appears out of the blue and has no connection to the rest of our body. After all, it’s a brain disease, and in our conceptual framework the brain is mysterious, foreign and disconnected.
Recent research refutes this idea and forces us to look, yet again, at the effects of the Standard American Diet (SAD) on every aspect of our human form. This time, the subject is dementia. Researchers at the International Conference on Alzheimer’s Disease held in Vienna predicted that by 2040 one third of the 81 million expected cases of AD will directly result from obesity and the diabetes it spawns.

Let me digress here for a moment and give you my thoughts about diabetes. We waste far too much precious time setting cut-offs for where diabetes begins. We pay far too little attention to warnings about diabetes if we have normal blood sugar. Any time we become insulin resistant (meaning that our insulin system stops sending effective signals and begins to compensate with insulin overproduction), we are part of the diabetes continuum. This is true whether blood sugar is “normal” or not. Millions of people have insulin resistance with normal sugars and are never even labeled pre-diabetic. This situation can go on for years while they continue to eat insulin stimulating diets and do untold harm to their bodies. Insulin resistance is likely if you are overweight or have been overweight. It also becomes more common as we age. The SAD encourages and promotes this problem by asking our body to secrete so much insulin so constantly (in response to the massive amount of starch and sugar we consume). So let’s look at the research below in the following light; if you are reading this as a dieter or maintainer, there is a good chance that you are or have been insulin resistant.

Here’s what was reported by Dr. Susan Craft, an AD researcher and what you need to know:

“A large body of work now suggests that insulin resistance increases the risk of Alzheimer’s by multiple mechanisms, Dr. Craft said. Far from being active only in the periphery, insulin binds to receptors located throughout the brain….High levels of insulin in the brain can induce a brain insulin-resistance by removing the insulin receptors from the nerve cell membranes.”

In the rest of the body, insulin resistance starts off a cascade of problems that affect the health of blood vessels. It’s not surprising that recent findings point to the same phenomenon in the brain. Brain insulin resistance seems to lead to vascular dysfunction. Blood supply to all tissues is critical, but particularly so to the brain, where blockages in the delivery of oxygen via the blood stream can lead to multiple small mini-strokes. These small areas of damage can add up to a larger picture of dementia.

Dr. Zaldy Tan of Harvard Medical School reported additional startling findings at the Alzheimer’s Conference. Subjects with insulin resistance and elevated insulin production had decreases in the actual volume of their brains. These decreases were equivalent to 6 years of brain aging!These subjects didn’t have to be technically diabetic to show such changes.

If you are an RTR reader, you’ve undoubtedly noted my preoccupation with what I call “S Foods” (starches and sugars) . This preoccupation is really just another way of saying that I’m very, very fixated on insulin. And for good reason. Read any research on obesity, diabetes, cholesterol, heart disease, cancer and the word INSULIN will be present. Insulin is a spider sitting in the middle of the web of modern disease. Modern eaters have a problem with insulin and they certainly don’t need any more of it. Eating excessive starches and sugars asks the body to continue deploying the struggling insulin system. It’s simply foolish. And foolhardy.

This discussion also gives us the opportunity to revisit the vital importance of exercise in a maintainer’s life. We all should recognize that exercise sensitizes muscles to insulin, allowing a fragile system to work better. Says Dr. Craft, “Exercise is the most potent insulin-sensitizing agent we have. A single bout of aerobic exercise improves insulin sensitivity for 24 hours. It’s much more potent than any medication.” She goes on: “Caloric restriction also lowers hyperinsulinemia and improves insulin sensitivity.”

So what can we do to protect ourselves from Alzheimer’s Disease? We can eat small amounts of high quality foods. We can make sure that these foods are quite low in starches and sugars. We can exercise. Sound familiar? It should, because the same prescription could be given to prevent and defeat diabetes, high cholesterol, heart disease, stroke, obesity, high blood pressure, premature aging, increased cancer risk and most of man’s other modern diseases. Maybe we could put it this way: we simply need to tame the spider. It’s all quite simple and elegant, not the twisted conundrum that optimal diet is made out to be. Luckily, all of the things that we maintainers are doing to keep weight at bay turn out to have the added benefit of chasing away our other metabolic demons. It’s a nice little extra, isn’t it?

The Baby. The Bathwater.

By Barbara Berkeley

Ever feel like you’re running a mad dash just to keep up with the latest diet and exercise recommendations? Instant communication is a wonderful thing, but it can be frankly overwhelming when every day brings a new study, a new conclusion and something new to worry about.

The most damaging period in my personal dietary history was the “fat-free” era. It was during these years that I gained 20 pounds while eating “healthily.” For me, the no-fat craze was manna from heaven; the ultimate opportunity to eat unlimited bread and large plates of pasta. So long as the spaghetti sauce was fat-free and the bread had fat-free jelly, I was golden. At first, I was bewildered by the scale. Had a microgram of fat snuck into my diet somewhere? Were the labels wrong? Were those Entenmann’s Fat Free cookies a sham? I was doing it all correctly, following all of the latest rules, yet I was getting fatter by the day!!!!

The fat-free era picked up steam in the 1980s after research pointed to the idea that saturated fat might be making us sick. But since dietary concepts are so complicated, we invoked our usual response to lifestyle advice: throwing the baby out with the bathwater. It was easier to cut out ALL fat thus demonizing one dietary element while elevating another. Suddenly fat was bad. Very bad. And carbs were good. Very, very good.

Of the fat-free days, Dr. Walter Willett of the Harvard School of Public Health has observed: “This campaign to reduce fat in the diet has had some pretty disastrous consequences...One of the most unfortunate unintended consequences of the fat-free crusade was the idea that if it wasn't fat, it wouldn't make you fat. I even had colleagues who were telling the public that you can't get fat eating carbohydrates. Actually, farmers have known for thousands of years that you can make animals fat by feeding them grains, as long as you don't let them run around too much, and it turns out that applies to humans. We can very easily get fat from eating too many carbohydrates, and the public was really directed to only focus on fat calories, when we really have to keep an eye on calories no matter where they're coming from.” (The underlining is mine)

My body certainly recognized the fat-gaining properties of carb loading. Like the fat cells of a corn-fed steer, my adipose tissue responded by swelling exponentially. Now, 20 years later, it’s turned out that we need fat. We don’t have to throw it all overboard. Why do we have to be such diet lemmings? Someone announces a finding and we all run to follow. We really should check to see if we’re going over a cliff before we join the mad dash.

I had a feeling of déjà-vu-all-over-again when I saw the cover of Time magazine on August 9th. At first, I was excited by the topic: The Myth About Exercise.

For years I had been telling my patients to stop putting so much stock in exercise as a weight-loss tool. A steady stream of overweight patients who were also tennis players, weight lifters, and aerobic steppers had taught me that exercise was not the driving force in weight loss. Weight loss was created by caloric restriction and by proper food choice. Period. Finally, a major news source was reporting this observation. In the article, Dr. Eric Ravussin, a well-known exercise researcher from Lousiana State University was quoted as saying, “In general, for weight loss, exercise is pretty useless.” I was gleeful. This sounded like me talking.

To support its point, the article cited a study of 464 overweight women who were divided into four groups. One group was to stay sedentary, while the other three were to exercise with a trainer at various levels (72, 136 and 194 minutes per week). No dietary changes were made. At the end of six months, there was no weight difference between groups. Exercise had not caused weight loss. Other similar evidence bolstered the contention that exercise did not help dieters lose pounds.

Time concluded: “All this helps explain why our herculean exercise over the past 30 years—all the personal trainers, StairMasters and VersaClimbers; all the Pilates classes and yoga retreats and fat camps—hasn’t made us thinner…From a weight-loss perpective, you would have been better off sitting on the sofa knitting.”

This is just the kind of major media pronouncement that gets behavioral stampedes going. After the cover story appeared, I noticed that a number of patients began to reference it as a reason to give up exercise. Did I hear the patter of little lemming feet?

The fact that exercise alone does not cause weight loss says absolutely nothing about the value of exercise to dieters and maintainers. In my experience, exercise is absolutely vital to successfully flipping the lifestyle switch. Exercise builds cardiovascular resilience, improves mood (some studies show it is as good as antidepressant medication), decreases insulin resistance problems, refocuses our attention on staying well and keeps us in a particular kind of connection with our bodies. Like most elements of wellness, the truth about exercise is nuanced rather than obvious.

The month after the Time article came out, a much quieter and less heralded piece appeared in the Mayo Clinic Proceedings. Several major medical centers had cooperated on a study of 3044 women and had followed their fitness since 1971. Each of these women had an early sugar problem, either undiagnosed diabetes or something called “impaired fasting glucose.” The latter term refers to those who have a morning blood sugar of between 100-125. Such sugar problems are extremely common in overweight people.

As I’ve written before, most of the patients I care for have problems processing blood sugar. Patients who I’ve seen in the past, and who return to me years later, will often have developed impaired fasting glucose in the interim. If you are (or were) very overweight, the chances are good that sugar issues were involved somewhere along the line. As you probably already know, sugar-processing problems cause the body to over-secrete insulin: the fat storage hormone. At the same time, muscles (which usually burn sugar) stop accepting sugar as fuel. The result of these two derangements is that blood sugar is diverted to fat . Weight gain escalates and can continue unchecked. For overweight and obese people, studies that look at sugar problems are highly relevant.

The multicenter study followed these sugar-challenged women for 16 years and evaluated their level of fitness by determining how long and intensely they could perform a treadmill test. In the end, less fit women had a greater risk of death from all causes. Most fit women had the lowest risk. This protective effect held true even for women of higher weights. The least fit overweight women had more than twice the death rate of the most fit overweight women. In fact, the importance of fitness was so great that it trumped the effect of BMI as a predictor of death from all causes.

This study is just one of a sea of reports that confirm the profound benefit of exercise. Yet if we focus our sites solely on weight loss, we might easily conclude that exercise is worthless.
With fully two-thirds of us overweight, diet studies make good headlines. But studies were never meant to be read in isolation. In research, each theory and each conclusion must be weighed against the body of evidence that has come before. Individual conclusions may be diametrically opposed. Over time, the weight of one perspective will outbalance another. We must be patient. Unfortunately, this long view is not included in the way diet and nutritional studies are currently promoted. Each new pronouncement makes the front page and is heralded on the crawl under the nightly newscast. Then, we are off chasing the latest theory and the baby is gone with the bathwater.

So, here is some advice for all interested parties. When the latest diet discovery hits, take a deep breath, do your homework. Use common sense. Don’t let the diet-tip du-jour move you from your well-considered strategy. Stick with a life plan that closely mirrors the way man has always eaten and behaved; one that includes plenty of simple, unadorned, natural foods, and simple, unadorned, natural physical movement. Change course only when the weight of significant evidence compels you to institute a thoughtful change of heart.

Muscle: It’s the Real Deal

By Barbara Berkeley

The common wisdom tells you to build it. Most people think they don’t have enough of it. Fitness experts tout it as something almost magical. But what’s the real deal with muscle?

I have the strange habit of reading certain research papers repeatedly. The tendency to read things over and over may be inherited. My father loves to read certain books dozen of times. We have a copy of “Shogun” at my house that is literally falling apart; ditto “Prizzi’s Honor,” “Lonesome Dove,” and “The Godfather.” But research papers? I can only say that there are just some articles that I enjoy as much as a novel! When I found myself re-reading (for the umpteenth time) my favorite paper on muscle, it occurred to me that perhaps I should share the love.

My dog-eared, underlined, thinning favorite paper is called “The Underappreciated Role of Muscle in Health and Disease.” It was published in the American Journal of Clinical Nutrition in 2006 and is one of the only reviews I’ve ever read that focuses on exactly what muscle does. We talk an awful lot about muscle, but its real importance – the vital role that muscle plays – is virtually never discussed. For those of you who would like to slog through the scientific jargon, I’ve provided a link to the paper. If you’d prefer the CliffsNotes version, read on.

The story of muscle starts and ends with protein. Proteins, made up of various amino acids, are the materials that build our organs and repair the damage we incur every day just from living. We cannot survive without a steady supply of proteins because this daily wear and tear causes unavoidable organ breakdown. Proteins repair this damage. Think of yourself as a building that is exposed to the environment 24/7. As your paint starts to wear away and your façade starts to weather, there are workmen who are constantly repairing the damage. They are fixing you up with buckets of protein.

Eating foods with proteins provides a flood of amino acids to your body. These are reassembled into new combinations to form the exact proteins needed for that day’s repair. The need for amino acids is a 24 hour-a-day situation. So here’s a question: Where do amino acids come from if you’re not eating or if you are asleep? The answer is: from muscle. Muscle is a bank. Your body withdraws protein from muscle to accomplish repairs. When you eat, most of the protein you ingest actually goes to replace what’s been “borrowed” from your muscle in the hours before.

People who are obese actually have larger stores of muscle than lean people. Studies have shown that these big banks of muscle can keep protein levels normal after as many as 60 days of fasting! On the flip side, when muscle shrinks to about half of its normal amount, life can no longer be supported. Observation of people who have undergone starvation conditions has shown that it is the critical loss of muscle mass that leads to death. Once there is no longer enough protein in the bank, repair ceases and so does life.

Muscles are even more important protein “lenders” when we suffer from conditions that greatly accelerate the body’s need for protein. Injuries, illnesses, operations, burns, cancer, chemo, and other physical stresses greatly increase demands for repair proteins. Sometimes, a seriously ill person can have protein needs that can be as much as four times those of a healthy person. These can’t be met through diet alone, so the muscle bank is accessed for massive withdrawals. Those who start out with a large amount of muscle mass will have a greater likelihood of getting through such an event.

Since our muscular bank account is so vital, we need to worry about that fact that we can lose muscle as a consequence of aging. Loss of muscle is called “sarcopenia” (sarco=muscle, penia=impoverished) and it is a common problem for older people. Sarcopenia is estimated to occur in about 30% of those over 60. Sarcopenic people are frail, tend to have more falls, and have more difficulty with daily activities. As we saw above, decreased muscle mass not only means weakness, but an inability to fight off serious illness.

What about the much touted ability of muscle tissue to burn calories? Muscle burns calories when it remodels itself by either adding to or breaking down its mass. These processes take energy and, as we’ve discussed, are constantly occurring because of the withdrawal and redeposit of protein which is normal operating procedure. However, larger muscle masses have higher rates of turnover and calorie burn than smaller masses. A young man, for example, might have about 80 pounds of muscle which burns 485 calories per day. An elderly woman is likely to have just 30 pounds of muscle, providing only 120 calories of burn. This calorie burn is independent of exercise, by the way. It is part of the “resting metabolism”; calories which are burned when we simply sit still. You can see that the metabolic difference between the young man and the older woman is quite large. Now you know why your 17-year-old son can eat seemingly endless amounts of food without weight gain. You can also understand why building extra muscle might help you to maintain weight loss. Even at rest, the extra muscles and their turn over will burn extra calories for you. The problem is that building extra muscle is not all that easy, especially if you are a woman or are older.

When people become obese, they do not gain fat alone. They also gain muscle which supports the heavy fat tissue. This can potentially be used to the overweight person’s advantage. Theoretically, if this extra muscle can be preserved during weight loss, the calories it burns will make weight maintenance more likely. We also know that we can increase the rate of muscle turnover by providing a stream of amino acids in the diet. These amino acids start the muscles to work, but the fuel the muscle uses to build and rebuild itself actually comes from FAT. In fact, fat is “the preferred energy substrate of resting muscle.” 

 Thus, we have the rationale for recommending higher protein diets for weight loss. Theoretically, the hefty amount of amino acids gets that big muscle mass turning over. Turn-over then contributes to fat burning. In addition, dietary protein keeps muscle mass from disintegrating as weight is lost. The idea is to get fat to burn preferentially while leaving the dieter with a hefty amount of calorie-burning muscle. In our clinic, we use high-protein liquid drinks and one dinner meal to get weight loss. We find that the combination works very well, perhaps for this reason. We might also extrapolate that continuing to eat diets that focus on goodly amounts of protein will stimulate muscle to maintain itself, turn over actively, and burn fat calories in the process.

Muscle also plays a pivotal role in insulin resistance, which can lead to diabetes. Normally, insulin tells the muscles to accept sugar from the blood. This is one of the ways that insulin keeps blood sugar controlled. As weight gain progresses, many people develop insulin resistance; an inability of the muscle to take up sugar when insulin calls. The body compensates by making too much insulin which in turn leads to high blood pressure, cholesterol and triglyceride problems and eventually, high sugar in the blood.

The question is, why should muscles become resistant to insulin?

While we’re still not sure, this paper notes that people with insulin resistance have muscles which have become filled with fatty globules, visible on MRI. This inappropriate fat storage seems to be linked to insulin resistance and may reflect a problem with the muscle mitochondria, small cellular engines which normally burn fat. Instead of fat being burned, it is being deposited within the muscle. Physical activity seems to tell the mitochondria to work properly. “…As little as a single bout of exercise…can transiently reverse insulin resistance,” the paper reports. This is crucial information for those of you who either have or have experienced insulin resistance. Keep exercising to keep your mitochondria burning fat rather than storing it. This will lessen resistance problems.

What about ways to preserve or build the muscle mass you have? Once you become sarcopenic , it is very hard to reverse the loss. Efforts should focus on preserving the mass you have as a young- or middle-aged person. Remember that the goal of exercise should not be simply to grow big muscles. The effect that exercise has on getting the muscles to work efficiently at a cellular level is just as important even though it can’t be seen with the naked eye.

The bottom line? No one seems to have exact recommendations for protein intakes. Don’t be afraid to add some low-calorie protein shakes or bars to your regimen if you are trying to build and maintain muscle. Make sure that you are getting adequate protein, particularly if you are vegetarian and most specifically if you are vegan. Keep up your exercise, not only to preserve the muscle you have, but to assure that it works properly. Keep exercising throughout your life in order to minimize your chances of sarcopenia as you age. Maintain muscle at good levels in order to give yourself the best chance of weathering unintended storms like illness or injury.
Like most of our body parts, muscle is not as simple as it seems. We will benefit greatly by feeding it, building it and taking care of it. If I fall in love with any other research papers anytime soon, I’ll be sure to share them.