Obesity

Diets – Can They Result in Sustainable Weight Loss?

We are inundated from social media and other sources about diets and how well they work. In this post I’m going to describe the current most popular diets and how safe and effective they are at producing weight loss. I’m also going to write about the physiology of appetite, what controls appetite, and the mechanisms involved in weight regain after dieting. I will also discuss the ways people have discovered to maintain their weight loss. I am not going to discuss medicines for weight loss or bariatric surgery in this post. Those are subjects for another day. I did do a previous post on GLP1 agonists for weight loss. If you are interested you can link to that post here.

Energy Balance

Neither humans nor any other animal can survive without food. Our bodies convert food into the energy we need to keep our bodies intact and to be able to move about. The measure of the available energy in food is calories. A calorie is the amount of heat energy required to raise 1 gram of water by 1 degree centigrade. This is a very small amount of energy, so the unit we usually use is 1000 calories or kilocalories. When you see the number of calories on a food label, it is always means kilocalories even though it says “calories” on the label.

If on average we eat more calories than we use, our bodies store the extra energy as fat and we gain weight. If on average we use more energy than we get from our food, our bodies use the stored energy from fat and we lose weight. If on average we eat as many calories as we use, our weight is stable. We are in energy balance. We can also gain weight by increasing our muscle mass, but in this post I’m going to write about weight gain and loss as changes in body fat. This is an immutable law. Diet claims that calories don’t matter for weight loss are simply wrong. Calories in versus calories out sounds simple, but energy balance in our bodies is not simple at all.

Our intake of calories is controlled by our appetite and the control of appetite involves multiple hormones and neurotransmitters at multiple places in the brain and in the body. Control of appetite is very complex. I will write more about this later in this post.

Energy we use is of two types. A certain amount of energy is needed just to keep our bodies functioning. This is called the basal metabolic rate. It is also called resting energy expenditure (REE). It varies with weight. The average REE is 1 kilocalorie per hour per Kg (2.2 pounds) of body weight. That means that for a person who weighs 70 Kg (154 pounds) the REE would be 1680 kilocalories per 24 hours, just sitting on the couch. To calculate your own REE, divide your body weight in pounds by 2.2 and multiply that by 24. That will give you the number of calories you use in 24 hours just sitting on the couch during the day and sleeping at night. In general it is going to be in the neighborhood of 1500 to 2000 kilocalories per day.

The other type of energy we use is the energy required to move our bodies. These are called active calories. Active calories also based on body weight. For a 154 pound person, walking briskly burns 280 calories per hour. More vigorous activity burns more calories. Here is an extensive table from the Department of Health Services of Wisconsin that shows kilocalories burned for various activities at different body weights: CALORIES BURNED PER HOUR.

So what would it take for you to be in energy balance if you weigh 70 Kg (154 pounds) and do brisk walking for 30 minutes 5 days a week? Brisk walking uses 280 kilocalories per hour, so 140 kilocalories for each exercise session. That would be 700 kilocalories per week or an average of 100 kilocalories per day. Regular household activities burn about the same amount per hour as walking, so if you do household chores for 4 hours per day including weekends, that would be another 1,120 kilocalories per day. Your REE is 1680 kilocalories per day. You would be burning on average 100 active kilocalories per day for your walking and another 1,120 kilocalories a day for household chores for a total of 2900 kilocalories per day. That number will be a little higher if you weigh more that 154 pounds and a little less if you weigh less than 154 pounds. To be in energy balance you would need to eat no more than 2900 kilocalories per day. If you exercise more, you can eat more and stay in energy balance, but you would need to add a lot more exercise.

Fortunately, you don’t have to do all these calculations. In a normal weight person your body stays in energy balance automatically. Obviously, people who are overweight or obese either are not now, or at some point have not been in energy balance. It doesn’t take being out of energy balance much per day to cause significant weight gain. Lets suppose you take in 100 more calories per day than you use. It takes about 3500 extra kilocalories to gain a pound of fat. That would equal weight gain of fat at a rate of a pound every 35 days, or 10 pounds per year.

Being overweight or obese has serious health consequences that escalate with the degree of obesity. In order for overweight or obese people to avoid these consequences, they need to make a conscious effort to lose weight. That is where diets come in. Exercise is important too, but more for maintaining weight loss than losing weight. Of course exercise is good for you whether you lose weight or not.

Diets

I will write about the most extreme diets first, and then discuss the more moderate ones.

Keto (ketogenic) Diet

The brain is the second most active organ in the body after the liver. The brain normally uses glucose for energy but when glucose is not available and all the glycogen in the liver (which can be converted to glucose) is used up, the body starts to break down fat into something called ketones. The brain can use ketones for energy although it cannot use fat directly. The purpose of the ketogenic diet is to switch the whole body to the use of ketones for energy instead of glucose. This is accomplished by a high fat, very low carbohydrate and low protein diet. Protein has to be low because it can be broken down in the liver to form glucose. Carbohydrate is reduced to less than 50 grams per day which is less than the amount in a medium bagel. Protein is restricted to less than 1 gram per pound of body weight per day.

The ketogenic diet works because it decreases appetite, so despite eating calorie dense fat, total calories consumed are markedly decreased. It does lead to significant and fairly rapid weight loss. It is, however a markedly nutrient deficient diet. People who are on this diet must take supplemental multivitamins and minerals. Doing so keeps people from getting gross vitamin deficiency, but there is also a loss of micronutrients found in complex carbohydrates and it is unclear what the effects of this deficiency are. The ketogenic diet is very low in fiber, which alters the gut microbiome adversely. It decreases triglycerides and increases HDL, which are good, but it also increases LDL, which is bad. On the other hand, it decreases hypertension and has an anti-inflammatory effect. It is not clear whether the positive effects are outweighed by the LDL increase effects. So far, there is no evidence that ketogenic diets increase the risk of heart disease.

The main drawback of the ketogenic diet besides the nutritional deficiencies is that it is virtually impossible to stick to for more than a few weeks or months. Ketogenic diets do reduce insulin secretion since there is much less glucose for insulin to carry into the cells. The ketogenic diet may be useful in type 2 diabetics to reduce insulin resistance and decrease weight, particularly for diabetics in poor control. It is not a diet that can be maintained long term.

Very Low Calorie Diets

These diets restrict calories to 800 calories per day or less using proprietary liquid formulas that contain electrolytes and high protein to prevent muscle loss. VLCD diets lead to rapid and significant weight loss and are used primarily for people with severe obesity or medical complications of obesity. Such a diet should not be used without supervision of a physician. Again, like the ketogenic diet, VLCD diets should not be maintained long term.

Intermittent Fasting

Intermittent fasting is going without food for some period. Non-caloric drinks such as water or coffee are encouraged during fasting times. The simplest is restricted time eating. This involves skipping one or two meals per day and only eating during a restricted time. Whole day fasts can be once or twice a week or even every other day. One might think that a person would eat twice as many calories on a non-fasting day and so would not experience weight loss. This rarely happens. Intermittent fasting does reduce average calorie intake, and so people on any of the intermittent fasting regimens lose weight. People who start an intermittent fasting diet get very hungry at first on fasting days, but this hunger tends to decrease over time. It takes discipline to maintain intermittent fasting over a long period, but people who have the discipline to stick to the intermittent fasting regimen can stay on it long term. If the food they eat on non-fasting days is healthy (more on this later) then this can be a successful long term eating plan to maintain energy balance at a lower weight.

Paleo Diet

This is supposedly the type of diet that humans ate in the paleolithic period prior to agriculture when all humans were hunter gatherers. Of course people on the paleo diet do not become hunter gatherers. According to the Mayo Clinic a modern paleo diet includes fruits, vegetables, lean meats -especially game meats, fish, eggs, nuts and seeds. These are foods that in the past people could get by hunting and gathering. It doesn’t include foods that became more common when small-scale farming began about 10,000 years ago. These foods include grains, legumes and dairy products.

People on a version of the paleo diet do lose weight for exactly the same reason as weight loss on other diets. The average calorie intake on the paleo diet is substantially less than the standard American diet. It is not clear that excluding grains, legumes and dairy products is a good thing. Whole grains, legumes and dairy products supply high quality nutrients that may be missing in the paleo diet. The paleo diet is also more expensive and may be out of reach for lower income people. There are no long term studies of the health effects of the paleo diet.

Whole30 Diet

This is similar to the paleo diet but is recommended for 30 days. Foods to avoid are alcohol, sugar, dairy products and legumes and grains. There is a list of foods you can eat and all of these are unprocessed foods. The idea is that you reset your metabolism, and then you gradually add back the avoided foods and see how they make you feel. There is no evidence about the claimed long term good health effects of the Whole30 Diet. Like other diets that lead to fewer calories consumed, people do lose weight on this diet.

Plant based Diet

A plant based diet is exactly what it says. It is derived entirely from plants and eliminates all animal products including dairy products and eggs. The sources of protein are legumes, nuts, seeds, soy and lentils. Sources of fat are nuts, avocados, olive oil and vegetable oils. Plant based diets tend to focus on unprocessed foods. Unlike the other diets mentioned in this post, there is a lot of evidence that plant-based diets decrease the risk of developing diabetes (and also treat type 2 diabetes), decrease the risk of high blood pressure, heart disease and autoimmune diseases. Plant based diets have an anti-inflammatory effect, which probably is responsible for many of the benefits of plant based diets.

Unprocessed plant based food is more expensive than ultra processed foods and requires substantially more preparation time. People who live in poor neighborhoods often live in a “food desert” and unprocessed plant foods may not be available or be too expensive to buy. People who have low end jobs often have neither the time nor the equipment for food preparation. Although plant based diets have multiple health benefits, they are out of reach for a substantial part of the US population.

GOLO Diet

The GOLO diet is a proprietary diet plan you have to pay for. It is essentially a Mediterranean type diet that includes a supplement. The supplement has a lot of minerals and vitamins and there is no evidence that any supplement helps with weight loss. It is currently heavily advertised on television and social media. The research cited in all of these ads is research funded by the GOLO company. I will write about the benefits of the Mediterranean type diet next, but GOLO uses a standard dietary plan and a worthless supplement to make money. Don’t waste your money on this diet.

Mediterranean Diet

The original Mediterranean diet was the traditional diet of Crete, Greece and southern Italy in the 1960’s. Italians and Greeks no longer necessarily eat like this, but their original diet had lots of whole grains, vegetables and fish and used lots of olive oil. This type of diet has been studied more than any other and has very similar benefits to the plant-based diet. It reduces the risk of high blood pressure, diabetes, heart disease and autoimmune disorders. Here is the Mediterranean diet food pyramid from Wikipedia. It was developed by Oldways Trust, Harvard and the World Health Organization.

The things at the base of the pyramid are the things you eat the most and the things at the top of the pyramid you eat the least. Notice that red meat and butter are at the top of the pyramid. You don’t eliminate any class of food entirely in this diet, you just don’t eat the things at the top very often. Once again the diet includes mostly unprocessed foods and requires considerable food preparation.

The Standard American Diet (Also called the Western pattern diet)

Here is a description of the Standard American Diet from Wikipedia: The Western pattern diet is a modern dietary pattern that is generally characterized by high intakes of pre-packaged foods, refined grains, red meat, processed meat, high-sugar drinks, candy and sweets, fried foods, industrially produced animal products, butter and other high-fat dairy products, eggs, potatoes, corn (and high-fructose corn syrup), and low intakes of fruits, vegetables, whole grains, pasture-raised animal products, fish, nuts, and seeds.

It is no wonder that we have an epidemic of obesity! The standard American diet is almost the exact opposite of the Mediterranean diet and plant-based diets. It is very high calorie and high in ultra-processed foods. That is why all of the diets I described above cause weight loss. Almost anything is better than the standard American diet!

Weight Regain After Weight Loss

With any diet (other than the very low calorie diets) weight loss stabilizes after a while and then there is very frequently some weight regain. Why does this happen? During the evolution of the human species, obesity was very rare. Hunter gatherers, even the few modern ones that remain in remote parts of the world are not fat. In evolutionary terms, weight loss meant that there was not enough to eat, so metabolic strategies to conserve calories during times of starvation had high survival value. The result is that when we lose a significant amount of weight, the body thinks we are starving. Several things happen to conserve energy. The first thing is that the basal metabolic rate or resting energy expenditure (REE) decreases an average of 50 kilocalories per day, but people who are obese to start with and lose a significant amount of weight can have decreases of REE as much as 700 kilocalories per day. Another body adaptation to weight loss is that the muscles become more efficient and use less fuel. This means that the calories you burn per hour with exercise decreases as you lose weight.

Appetite

As I mentioned before, the control of appetite is complex. Almost all control of appetite is unconscious. Appetite can be consciously controlled only for a short time, just as we can consciously control our breathing for a short time, but most breathing is (fortunately) unconscious. The part of the brain that controls our appetite and food intake is the hypothalamus. The hypothalamus secretes some hormones on its own and controls other hormones and/or peptides that both increase and decrease appetite. One hormone that increases appetite is Ghrelin. It is secreted by the stomach, small intestine, pancreas and brain and has multiple effects. It increases appetite and food intake and promotes fat storage. Hormones that makes you feel full or satiated are Leptin and GLP1. Control of appetite is actually a lot more complicated than this. Below is a table taken from a review article about hormonal control of appetite. Here is a link to the full article. It is not for the faint hearted. Hormonal Regulators of Appetite

The table summarizes what we know about the hormones and peptides that increase appetite and stimulate feeding and those that make us feel full and inhibit feeding. As you can see, control of hunger and satiety is very complicated. All of this takes place outside of our conscious awareness.

Hunger	Hormone	Primary location of production	Receptors	Action
Hypothalamus
	NPY	Medial arcuate nucleus (also widespread in CNS	Y1, Y5	Stimulating feeding and atagonizing satiety
	AgRP	Medial arcuate nucleus	MC3R and MC4R antagonist	Stimulating feeding
Peripheral Peptides
	Ghrelin	Stomach	GHS-R1a	Stimulating feeding by increasing NPY/AgRP and antagonizing Leptin effects
Satiety
Hypothalamus
	POMC/a–MSH	Arcuate nucleus	NC3R and MC4R	Inhibiting feeding, stimulating basal metabolic rate and altering nutrient partitioning
	CART	Arcuate nucleus		Inhibiting feeding
Peripheral peptides
	Cholecystokinin	Duodenum, jejunum	CCK-A	Inhibiting feeding and stimulating gall bladder contraction, intestinal motility, and inhibition of gastric motility
	PYY	Ileum, colon, rectum	Y2	Inhibiting feeding by inhibition of NPY and stimulation of POMC
	PP	Pancreas	Y4, Y5	Inhibiting feeding
	Oxyntomodulin	Distal ileum and colon	GLP-1 receptor	Inhibiting gastric acid secretion, decreasing gastric emptying and decreasing pancreatic enzyme secretion
	GLP-1	Distal ileum and colon	GLP-1 receptor	Delaying gastric emptying, stimulating glucose-dependent insulin secretion, inhibiting glucagon secretion and stimulating somatostatin secretion
	GIP	Stomach, duodenum, jejunum	GIP receptor	Glucose-dependent insulin secretion, induction of beta cell proliferation, promotion of energy storage, enhancement of bone formation
	Insulin	Pancreas	Insulin receptor	Inhibiting feeding
	Leptin	Fat cells	Leptin receptor, Ob-Rb	Inhibiting NPY and AgRP and stimulating POMC and CART
	Adiponectin	Fat cells	Adipo R1, R2	Inhibiting feeding

With significant weight loss (10% or more) the hormones that control appetite shift toward the hormones that make us hungry. Those includes Ghrelin, NPY and AGrP. The hormones that make us feel full, including leptin and others decrease.

The result of all this is that even if we are sure we are staying on the same foods, we are unconsciously eating more of them. The result is weight regain. The bad news is that 80% of people who lose weight on diets regain a substantial portion if not all of the weight they lost within 1-5 years. The good news is that 20% of people maintain most of the weight loss they achieved even after 5 years. How do those 20% of people who lost 10% or more of their body weight keep from regaining weight? We actually know a lot about how they do it.

National Weight Control Registry

Here is the introductory paragraph from the National Weight Control Registry website:

The National Weight Control Registry (NWCR), established in 1994 by
Rena Wing, Ph.D. from Brown Medical School, and James O. Hill, Ph.D.from the University of Colorado, is the largest prospective investigation of long-term successful weight loss maintenance. Given the prevailing belief that few individuals succeed at long-term weight loss, the NWCR was developed to identify and investigate the characteristics of individuals who have succeeded at long-term weight loss. The NWCR is tracking over 10,000 individuals who have lost significant amounts of weight and kept it off for long periods of time. Detailed questionnaires and annual follow-up surveys are used to examine the behavioral and psychological characteristics of weight maintainers, as well as the strategies they use to maintaining their weight losses.

The extensive research on the 10,000 people in the registry who have maintained weight loss show the following things that they do. This list is again from the registry website.

98% of Registry participants report that they modified their food intake in some way to lose weight.
94% increased their physical activity, with the most frequently reported form of activity being walking.
There is variety in how NWCR members keep the weight off. Most report continuing to maintain a low calorie, low fat diet and doing high levels of activity.
78% eat breakfast every day.
75% weigh themselves at least once a week.
62% watch less than 10 hours of TV per week.
90% exercise, on average, about 1 hour per day.

If you want to check out the registry for yourself, here is the link: The National Weight Control Registry

What all this research means is that it is possible to maintain weight loss despite the cascade of hormonal mechanisms that kick in to conserve calories when weight loss happens that work to get us back to the weight that we were. It is possible, but not easy. It takes continual effort, although people in the registry do report that it gets somewhat easier over time.

Bottom Line

All diets when adhered to result in weight loss
Some eating plans are sustainable and are not nutrient deficient. These include intermittent fasting, plant-based diets and the Mediterranean diet.
More extreme diets such as the Keto diet, VLCD diets and Paleo diet are not sustainable and have various nutrient deficiencies.
Substantial weight loss triggers hormonal changes in the body that conserve calories. These changes are responsible for the fact that weight loss plateaus on almost any diet and significant weight regain even often back to the original weight occurs in 80% of people who lose a substantial amount of weight.
It is possible to maintain weight loss over many years, but it is not easy. Findings from the National Weight Control Registry suggest the following strategies to maintain weight loss
- Maintain a low fat low calorie diet
- Exercise at least an hour a day
- Weigh yourself at least once a week
- Watch less than 10 hours of TV per week

Osteoarthritis: Understanding Risk Factors & Effective Management

According to the World Health Organization as of 2019, 528 million people world wide were living with osteoarthritis, a more than one hundred percent increase since 1990. Osteoarthritis is the most common type of arthritis, affecting primarily the knees, hips, hands and spine. In this post I will write about the risk factors for developing osteoarthritis, both the ones you can’t do anything about and the things you can do to reduce your risk of developing osteoarthritis. Since osteoarthritis is so common, I will also write about the best way to manage osteoarthritis if you already have it.

Risk factors you can’t modify

Age

73% of people with osteoarthritis are over 55. The risk of osteoarthritis increases with increasing age. According to data from the CDC, osteoarthritis occurs in 3.6% in adults ages 18–34 to 53.9% in those age 75 and older.

Gender

The CDC estimates that about 1 in 4 women have been diagnosed with osteoarthritis, compared to about 1 in 5 men. The percentage of women with osteoarthritis increases after menopause. For example, among people aged 40–49, about 10% of women and 7% of men have knee osteoarthritis, but between the ages of 60–69, that prevalence rises to 35% in women and 19% in men.

Genetics

There is no gene for osteoarthritis. The genetic risk of osteoarthritis is the result of many genes, each contributing only a small amount of risk. The total genetic contribution to osteoarthritis is about 30%. In other words a little less than a third of cases of osteoarthritis are due to genetic factors.

History of joint trauma or injury

Any injury to a joint or a fracture involving a joint increases the risk of post traumatic osteoarthritis. For example the incidence of arthritis of the knee after ACL tears is as high as 60%.

Risk factors you can modify

Obesity

Maintaining the lowest weight that is practical for you reduces your risk of developing osteoarthritis of the hip and knee. Obesity markedly increased the risk of developing osteoarthritis and also serves as a multiplier for other risk factors.

Sedentary Lifestyle

Aerobic exercise and strength training decrease the risk of developing osteoarthritis. The best practice is to follow CDC recommendations: 150 minutes per week of moderate exercise such as brisk walking or 75 minutes of vigorous exercise such as running or cycling. Strength training twice a week.

Smoking

Smoking causes inflammation and double the risk of getting osteoarthritis. It is best to never start smoking. If you smoke, stopping smoking decreases your risk, although not as much as if you never smoked

Avoiding Certain Occupations and Sports

Occupations that involve long standing, bending and heavy lifting increase the risk of osteoarthritis, especially of the knees. They include workers in construction, firefighting, agriculture, fisheries, forestry, and mining. In a case-control study, men who worked for 11–30 years in building and construction work had a 3.7 fold greater risk of developing knee osteoarthritis.

Certain sports such as American football, soccer, competitive wrestling and competitive weight lifting are also associated with increased risk of osteoarthritis of the knee and ankle. There is conflicting evidence about long distance running. Some studies show increased risk, but one study showed that marathon runners have decreased risk of developing osteoarthritis.

How to manage osteoarthritis of the knee

Weight loss

If you are significantly overweight or obese then weight loss will decrease stress on the knee thereby reducing pain and slowing the progression of the arthritis.

Exercise

Aerobic exercise helps pain from knee arthritis. The best exercise is walking or swimming or water aerobics. Strengthening exercises for the quadriceps muscle are also helpful. Here is a link to a good description of quad strengthening exercises: Knee Arthritis Exercises. Physical Therapy can also be helpful and can provide equipment like braces or heel wedges that can also reduce pain. There is also some evidence that tai chi reduces knee pain from knee arthritis. If you smoke, stopping smoking can reduce inflammation and therefore pain.

Medicines

The first medicines to try with the least potential for side effects are topical medicines that you rub on the knee. The most effective ones are diclofenac and capsaicin. Both of these are available over the counter. Topical lidocaine patches can help temporarily, but don’t last as long as the other two.

Oral medicines that are the most effective are NSAIDs like naproxen or ibuprofen in combination with acetominophen (Tylenol). Long term use of oral NSAIDS can occasionally cause bleeding ulcers or kidney damage. If you are taking NSAIDs long term, these need to be monitored by your doctor.

Alternative treatments like glucosamine, ginger and S-adenosylmethionine (SAM-e) seem to help some people and are safe long term. Chondroitin has not been shown to reduce pain.

Joint Injections

Steroid injections in the knee can give temporary relief. This can last for months. These are generally safe every 3 months for up to a year. These injections are easy to administer and can be done by most family physicians without need for referral. Over time, as arthritis worsens they tend to not work as well. Multiple steroid injections have been shown to worsen arthritis, so fewer injections are better.

Cartilage injections have shown no difference from placebo in controlled trials. Some people get some benefit, but this may well be a placebo effect.

Surgery

The only surgery shown to be effective is total or partial knee replacement. Arthroscopic knee surgery to “clean out the joint” has been shown to have no more than placebo effect.

How to manage osteoarthritis of the hip

Exercise

All of the aerobic exercise options for knee osteoarthritis also work for osteoarthritis of the hip, but water exercise or cycling is better than walking. Avoiding certain activities that stress the hip such as stair climbing, or active sports like tennis can reduce pain. Tai chi can also be helpful for hip osteoarthritis. Canes or walkers can be helpful, but need to be prescribed by a physical therapist who can decide on the best appliance and show how to use it properly.

Medicines

Topical medicines do not work as well for osteoarthritis of the hip as well as they do for the knee. Oral medicines are the same as medicines for osteoarthritis of the knee.

Joint Injections

Steroid injections of the hip can be helpful but have to be done using ultrasound or x-ray to make sure the needle is in the hip joint. They are much more difficult than steroid injections of the knee.

Surgery

Hip replacement is the only surgical option. It tends to be less painful post operatively than knee replacement and requires less rehabilitation by physical therapy.

How to manage osteoarthritis of the hands

Home management

Home management includes periodic resting of the hands when doing repetitive activities such as typing. Heat also helps. A warm compress or paraffin wax hand bath can soothe affected joints.

Some adaptations of daily activities may be helpful. Here are some suggestions from Arthritis Health by Veritas:

Wear coats and shirts with zippers instead of buttons
Use long zipper pulls which are also larger than regular zipper pulls and therefore easier to grasp. Specialized zipper pulls are made with looper cloth or nylon and allow the user to stick a finger through and pull down.
Choose lightweight cooking and gardening tools that are easier to lift and hold
Buy slip on shoes to avoid having to tie shoelaces

Occupational therapy can provide hand exercises as well as splints and other home aids.

Medicines

Topical medicines also work well for hand and wrist osteoarthritis. The other medicines for knee osteoarthritis also can be helpful.

Joint Injections

Steroid injections can be very helpful, but are somewhat more difficult to do than knee injections. Hand or wrist steroid injections are usually done by an orthopedist or rheumatologist.

Surgery

Surgery for hand osteoarthritis is not done very often and when done usually involves fusion of a joint to relieve severe pain.

Management of Osteoarthritis of the spine

Osteoarthritis can happen in any part of the spine, but osteoarthritis in the lumbar spine is the most common. The symptoms are back pain, and if a nerve root is compressed, then the pain can radiate down one leg (or one arm if the arthritis is in the cervical spine). Treatment depends somewhat on the symptoms, but like other forms of osteoarthritis non-medication treatment includes exercise, weight loss, tai chi, and physical therapy. Acupuncture helps some people. TENS units sometimes help as well. If you smoke, stopping smoking decreases inflammation and therefore pain.

Medicines

The same topical and oral medicines for knee arthritis also help for spinal osteoarthritis.

Injections

Epidural (just outside the spinal cord sack) injections can be helpful and when they work can last for months or even years. They have to be given by a pain management specialist under x-ray guidance.

Surgery

There are several kinds of spinal surgery. If the spinal osteoarthritis is severe enough to cause pressure on the spinal cord, then part of the vertebrae compressing the spinal cord are removed and the vertebrae are fused. If just the opening between the vertebrae is pressing on a nerve, then that opening is enlarged to take pressure off the nerve root. Surgery can also involve fusion of vertebrae at one or several levels to decrease pain. This kind of fusion surgery is not always successful long term and should be avoided if possible.

Bottom Line

Osteoarthritis is the most common form of arthritis and prevalence increases with age. Over half of people over 75 have osteoarthritis. Women are more commonly affected than men, especially after menopause. Thirty per cent of osteoarthritis is genetic and the rest due to other risk factors including previous joint trauma, obesity, smoking, sedentary lifestyle, certain occupations and certain sports. Avoiding obesity altogether or losing weight if you are overweight, regular aerobic exercise as well as strength training twice a week and stopping smoking if you smoke all decrease your risk of developing osteoarthritis. For those who have osteoarthritis Non-medication treatments should be tried first. Surgery is a last resort when other methods have failed.

New Drugs for Weight Loss – What are the Risks and Benefits?

Most people know these new effective weight loss drugs by their trade names: Ozempic, Wegovy and Mounjaro. Ozempic and Wegovy are different names for semaglutide. Mounjaro is the trade name for tirzepatide. All of these drugs are in the same class. They are called GL-P1 agonists. They mimic the action of a hormone called glucagon-like peptide. These drugs were developed to treat type 2 diabetes. They lower blood sugar by causing insulin release and also by delaying stomach emptying, which delivers less glucose to the bloodstream. The slowing of emptying from the stomach decreases appetite and causes an increased feeling of fullness. People on these drugs tend to reduce their calorie intake fairly markedly and that is how they work for weight loss.

Common Side Effects

The most common side effects of all these long acting medicines are nausea, vomiting, abdominal pain and diarrhea. These side effects usually disappear within a few weeks, and are less likely to happen if they are started at a low dose and increased gradually. Occasionally they are persistent. Some somewhat less common side effects include headache, fatigue, dizziness, constipation, heartburn, bloating, belching and flatulence (passing gas). People with diabetes can sometimes get low blood sugar. Again, most of these side effects usually go away within a week or two. Occasionally they can be persistent.

Rare Side Effects

These side effects are rare, but much more serious and can result in hospitalization. They include severe allergic reaction, acute pancreatitis, gall stones, acute kidney injury, suicidal thinking, and cancer of the thyroid.

Long Term Effects

The evidence so far is that stopping these medicines results in weight gain back to the original weight. That means that people are likely to have to stay on these medicines to maintain the weight loss. We know that the medicines are relatively safe when taken for two years, but we have no idea what long term side effects might be, or even if the medicines will continue to work past two years.

How well do they work?

The medicines are given by injection once a week and they work very well. These are the most effective medicines for weight loss that we have ever had, and there are some new ones in the pipeline that may even work better. As with any medicine, there are risks as I have documented above as well as benefits. You would not want to take one of these medicines unless the benefit exceeds the risk.

Who should take these medicines and who should not?

Obesity increases the risk of diabetes, heart disease and cancer, especially colorectal cancer. The best predictor of risk of disease from obesity is the waist circumference. Just take a tape measure and measure your waist at the level of the belly button. If you are female your risk of cancer starts to increase if your waist circumference is more than 31.5 inches. Your risk of cancer, especially colorectal cancer increases 5% for every inch above 31.5 inches. Above 35 inches the risk of diabetes, and cardiovascular disease starts to go up. For men the numbers are 37 inches for the risk of cancer going up and 40 inches for the risk of diabetes and cardiovascular disease.

The best treatment for obesity is prevention. That means eating unprocessed foods and regular exercise. If you are already overweight or especially if you are obese, it is very hard to lose weight and keep it off. Once you lose weight, your body thinks it is starving and all kinds of hormones and body changes kick in to try to get the weight back.

If your waist circumference is over 31.5 if your are female and 35 if you are male, then you are a candidate for one of these new weight loss medicines. For you the benefit likely outweighs the risk. If your waist circumference is less than those values, then the risk of taking these medicines is much higher than the potential benefit.

Cost

If your insurance does not cover medicines for weight loss the cost of these medicines may be prohibitive.

Wegovy costs $1,349.00 a month without insurance.

Ozempic costs $892.00 a month without insurance.

Muanjaro costs $1,300 a month without insurance.

Unfortunately many insurance plans do not cover weight loss medicines.

Diet and Heart Disease – Not as Simple as We Thought

We have all been told for years that the main dietary risk factor for heart disease and stroke is how much saturated fat we eat. We have also been told that eating foods high in cholesterol also increases risk of heart disease and stroke. Evidence is accumulating that consumption of saturated fat increases risk of heart disease and stroke little if at all. Since your body makes cholesterol itself, eating cholesterol rich foods has almost no effect on serum cholesterol. Other aspects of diet have a much greater effect on increasing the risk of heart disease and stroke. In this post I will summarize the evidence and spend some time discussing things we eat and drink that do substantially increase the risk of heart disease, stroke and other chronic diseases.

The Seven Country Study

The most famous study that led to the saturated fat hypothesis was carried out by Ancel Keys. The study started in 1956 and was published in 1978. He looked at the dietary patterns of 7 different countries. The countries included Finland, Greece, US, Italy, Yugoslavia, Netherlands and Japan. He found that saturated fat intake was correlated with increased risk of heart attack and stroke. The country with the lowest saturated fat intake was Crete in Italy, which also had the lowest incidence of heart disease and stroke of the 7 countries. The diet of Crete is the basis for the famous Mediterranean Diet.

Diets of free living humans are notoriously difficult to measure. Keys did his best to accurately determine diet. He had a subset of his subjects in each country weigh their food for a number of days, which is considered the gold standard for dietary studies. The problem with any population study like this is that populations in different countries differ in lots of other ways besides diet. Also diets are complex, so some other factor or factors in diet could account for the low heart disease incidence in Crete. Another problem was that diet was measured in Crete during Lent, when most people did not eat meat. All Keys could really say was that saturated fat intake was associated with heart disease, but he could not say that saturated fat caused heart disease.

People who adhered to the Mediterranean Diet did reduce their population risk of heart disease, but there is a lot more to the Mediterranean Diet than reduced saturated fats. It also includes little added sugar, lots of vegetables and fruit and mostly unprocessed foods. It is not clear that reduction in saturated fat is responsible for the health benefits of the Mediterranean Diet.

The Framingham Study

The next big population study was the Framingham Study. A large group of people in Framingham Massachusetts was followed over many years with surveys about diet, activity, smoking and laboratory measurements of total cholesterol, LDL, HDL and triglyerides among other measurements. Heart attacks, strokes, death from either of these things and death from any cause were recorded in the study group. This was the first large study that implicated cigarette smoking as a cause of cardiovascular disease and cancer. It was also found that the higher the total cholesterol and especially the higher the LDL (low density lipoprotein) the higher the risk of cardiovascular disease. It was also one of the first studies that showed that the higher the blood pressure, the greater the risk of cardiovascular disease. This was a tremendously important and well done study.

The Diet-Heart Hypothesis

The diet-heart hypothesis is that saturated fat is the main dietary cause of cardiovascular disease. It has been very influential over 60 years and is still promoted by the American Heart Association and many cardiologists. Here is the train of thought. The 7 country study implicated saturated fat as associated with cardiovascular disease. It has been found through multiple studies that saturated fat intake raises LDL (so called bad cholesterol). The Framingham study showed that increased LDL was a major risk factor for cardiovascular disease. Since saturated fat raises LDL, therefore saturated fat must cause cardiovascular disease.

That makes perfect sense, so many randomized trials were carried out to nail down the diet-heart hypothesis. Unfortunately, as is often the case with beautiful theories, further randomized trials did not consistently show the expected increase in heart disease from eating saturated fat. The other part of the hypothesis was that eating polyunsaturated fats would decrease the population risk of heart disease. That was based on the observation that consuming polyunsaturated fats decreased LDL levels. Randomized trials have generally failed to consistently show that eating polyunsaturated fats reduces the risk of cardiovascular disease.

Reduced Risk of Cardiovascular Disease in US

Heart disease was epidemic in the US, peaking in the 60’s. Since then, the incidence of heart disease in the US and most other developed countries has decreased by 60%! Scientists debate the cause for this decline. Although saturated fat consumption decreased some, Americans still eat much more saturated fat than the 5% of fat recommended by the American Heart Association. So the fact that we eat somewhat less saturated fat does not explain the remarkable decline in heart disease over the last 60 years. What else changed?

Cigarette Smoking

In the 1940’s half of all Americans said they smoked cigarettes. Smoking began to decline in the US in the 60’s and today only 11.5% of Americans smoke tobacco! This has to be a major factor in the decline of cardiovascular disease (and lung cancer).

High Blood Pressure

High blood pressure is a major risk factor for heart disease. The number of people with high blood pressure successfully controlled on medicine has more than doubled since 1960. This is clearly another major factor in the decline of cardiovascular disease

Trans Fats

The rise of trans fat consumption was an unintended consequence of the heart-diet hypothesis. Because animal fat (mostly saturated fat) was postulated to cause heart disease, the food industry started figuring out how to use vegetable oil to replace lard and butter, which were high in saturated fats. They needed something that would be solid, not liquid at room temperature. They discovered that if they partially hydrogenated vegetable oil, then it would be solid at room temperature and could substitute for lard and butter. They marketed these products as healthier because they were only partially saturated fats, not saturated fats. The medical establishment bought this story and recommended margarine as a substitute for butter and Crisco (the most successfully marketed shortening substitute) as healthier alternatives. I have been unable to find statistics on trans fat consumption in the US, but it was very large.

It turns out that consumption of trans fats markedly increased the risk of cardiovascular disease. For every 2% increase in the consumption of trans fats, heart disease increased by 23%. This is a shocking number! The consumption of trans fats certainly contributed to the epidemic of heart disease in the 50’s and 60’s. The FDA essentially banned the addition of trans fats to food in June of 1978. The elimination of trans fats is almost certainly another major factor in the decline of heart disease.

Interesterification

Since trans fats have been banned, food companies have come up with a new way to make vegetable oil solid and spreadable. It is called interesterification. It is complicated, but the simplest explanation is that it involves changing the arrangement of fatty acids on a glycerol backbone. These are fully hydrogenated fats, so are not trans fats. We know very little about how these new industrial fats affect human health, but the information we do have suggests that these new products may be just as bad for you as trans fats. You would do best to avoid them until we know more. More about how to do this later in this post.

Do we need to limit red meat consumption?

The main risk of consumption of any food is eating too much of it. It is total calorie intake that makes us fat, and being fat increases the risk of cardiovascular disease, diabetes and some cancers. Eating red meat by itself is very unlikely to increase your risk of heart disease as long as your total calorie intake is equal to the calories you burn up. So there is very little health risk to you in eating red meat, but there is a big risk to the environment. Cattle raising worldwide contributes about 16% of greenhouse gas emissions. Here is a link to a balanced discussion of greenhouse gas emissions from cattle raising: Livestock Don’t Contribute 14.5% of Global Greenhouse Gas Emissions.

The other thing to think about when consuming any meat product, including chicken is that almost all the meat you buy in the grocery store comes from giant factory farms, where animals are treated very inhumanely. That in itself is bad enough, but raising all those animals together increases risk of spreading disease to the people who eat them. Antibiotics are used in many factory farms to keep animals from getting sick. This contributes to the evolution of bacteria that are resistant to most antibiotics.

If you are not willing to give up eating meat entirely, try to find locally raised beef, pork and poultry. Farmer’s Markets are a good place to find meat from locally raised animals. It may be a little more expensive, but likely a lot safer.

What about eating fish?

If you are at high risk of cardiovascular disease or have cardiovascular disease then eating oily fish (salmon, sardines, anchovies, herring, mackerel, tuna, swordfish) twice a week reduces your risk of a heart attack by 50%. If you are at average risk, these fish don’t have unusual health benefits but if you like them, it’s fine to eat them. Because most of these fish contain some mercury they should probably be avoided by pregnant women and children. If you get canned tuna, get Pacific Island Tuna at Walmart. It is sustainably caught. Here is a link to an article from the Nature Conservancy about it: The Nature Conservancy. By the way taking fish oil is not nearly as good for you as eating fish.

Highly Processed Foods

There are convincing data that consumption of lots of highly processed foods leads to health concerns ranging from increased risk of obesity, high blood pressure, breast and colorectal cancer, to dying prematurely from all causes.These foods all also contain additives whose health effects have never been adequately tested. How do you recognize them? Just look at the label where the ingredients are listed. If there are more than two things you don’t recognize, put it back on the shelf. Here is an example of an ingredients list from a loaf of bread!

This is not bread you would want to eat! If you mostly stay out of the central aisles of the grocery store you will avoid most highly processed foods. Just be sure to look at the ingredients label before you buy anything.

It is all well and good for me to make these recommendations, but highly processed foods and factory farmed meat are cheap. People who are poor cannot afford to buy anything else. This is only one of the things that have led to the major health inequities that are present in this richest country in the world.

Foods that decrease risk of cardiovascular disease

Fiber

Increased dietary fiber has been shown to decrease risk of cardiovascular disease. This may well have to do with promoting a healthy microbiome in the intestine. Sources of fiber that promote growth of healthy gut bacteria are ones that contain inulin. The highest sources of inulin are leeks, asparagus, onions, wheat, garlic, chicory, oats, soybeans, and Jerusalem artichoke. Sourdough bread (no added sugar, honey, or high fructose corn syrup) is also a good source of fiber. Whole grains, fruits, nuts and vegetables are also good sources of fiber.

Fresh Fruits

Fresh fruits are a good source of fiber and also contain many beneficial nutrients including vitamins and antioxidants. Data from multiple studies show that eating fresh fruit daily reduces risk of cardiovascular disease.

Nuts

Eating a handful of nuts per day reduces your risk of heart disease by 20%. Peanuts are technically of legume, not a nut, but legumes reduce the risk of cardiovascular disease as well. Unsalted nuts are better for you than salted.

Whole grains

Whole grains are also a good source of fiber and other beneficial nutrients. Eating whole grains most days is associated with decreased obesity, diabetes and heart disease. Examples of whole grains are

Barley.
Bulgur, also called cracked wheat.
Farro.
Millet.
Quinoa.
Black rice.
Brown rice.
Red rice.
Wild rice.
Oatmeal.
Popcorn.
Whole-wheat flour.
Whole-grain breakfast cereals.
Whole-wheat bread, pasta or crackers.

Make sure to read the ingredients label for cereals and crackers. Don’t buy anything that has more than two ingredients you don’t recognize.

Fresh Vegetables

Fresh vegetables are also a good source of fiber. Sorry folks, but potato chips and french fries do not count as fresh vegetables! Once again eating fresh vegetables daily significantly lowers your risk of cardiovascular disease.

Bottom Line

Eating red meat and saturated fats does very little to increase your risk of heart disease, but it also does not reduce your risk. Raising livestock on factory farms causes significant harm to the environment and puts people at risk of infectious disease. Eating meat from locally raised animals is safer.

Eating high fiber foods, whole grains, nuts, fruits and vegetable does substantially reduce your risk of cardiovascular disease as well as cancer.

Eating highly processed foods, and this includes the new industrial fats made by interesterfication increases your risk of cardiovascular disease and cancer. The biggest risk of these is probably because they encourage people to eat more calories than they need and have almost certainly led to the epidemic of obesity.

The most concise recommendation for a healthy diet comes from author Michael Poulin: “Eat food (food is anything your grandmother would have recognized as food), mostly plants, not too much.”

Chronic Stress Response: It Can Make You Sick or Kill You

All mammals, including humans have an innate response to perceived threat or stress. The more common name for it is the “flight or fight” response. Our remote ancestors faced many real threats. Let’s say for example one encountered a saber tooth tiger. As soon as he (or she) saw the tiger, several things happened. Epinephrine and norepinephrine were released, speeding up the heart rate in preparation for running away. A surge of cortisol was also released, which increased glucose in the bloodstream for fuel for muscles and the brain. Cortisol also increases mental alertness. Inflammatory molecules were released to promote wound healing should that be needed.

This kind of acute stress response is a good thing. People or animals with this kind of response were more likely to survive and reproduce. Once the acute threat was over, all the hormones and neurotransmitters quickly returned to their baseline levels.

In today’s world, threats from predators are not a problem for the vast majority of people. The threats we perceive are things like poor work conditions; experiencing discrimination, hate, or abuse; poverty; homelessness; divorce or other family discord; having little control over outcomes; feeling overwhelmed.

These are all things that produce the stress response, but unlike our remote ancestors, these threats are chronic. They are either lifelong or at least last a long time. Instead of returning to normal, the stress hormones and neurotransmitters stay elevated for long periods of time. A chronic stress response is definitely not a good thing!

Allostatic Load

The medical term for the acute stress response is called allostasis. Here is the definition of allostasis from Wikipedia: “Allostasis is the efficient regulation required to prepare the body to satisfy its needs before they arise by budgeting those needed resources such as oxygen, insulin etc., as opposed to homeostasis, in which the goal is a steady state.” Allostasis is an adaptive response to acute stress. Allostatic load on the other hand is the long-term result of failed allostasis, resulting in dysregulation (abnormal function) of multiple systems including the neuroendocrine, cardiovascular, immune, and metabolic systems.

Allostatic load is measured traditionally by 10 indicators of chronic stress. Primary indicators are the hormones and neurotransmitters released by stress. Secondary outcomes are measurements of the systemic effects of the primary indicators. All of these indicators are associated with the perception of stress. Below is a table showing the 10 indicators, how they are measured, and which body systems are affected. Here is a link to the full article from which this table comes: Allostatic Load: Importance, Markers, and Score Determination in Minority and Disparity Populations

Category	Marker	Functional purpose
Primary mediators	Dehydroepiandrosterone sulfate (DHEA), serum	Secreted by the adrenal glands. When high with stress it tends to lower cortisol and be protective in the stress response.
	Cortisol, urinary	Integrated measure of 12-hour hypothalamic–pituitary–adrenal axis activity. Secreted by the adrenal glands. Has multiple effects in stress response.
	Epinephrine, urinary	Integrated indices of 12-hour sympathetic nervous system activity. Sympathetic nervous system activation increases heart rate and blood pressure.
	Norepinephrine, urinary
Secondary outcomes	Systolic blood pressure	Indices of cardiovascular activity and major risk factor for vascular disease
	Diastolic blood pressure
	Waist–hip ratio	Index of long-term levels of metabolism and adipose (fat) tissue deposition. High value means fat around internal organs which increases inflammation and increases LDL (bad cholesterol) and triglycerides.
	High-density lipoprotein cholesterol	Index of atherosclerotic risk protection. Low value increases risk of heart disease.
	Total cholesterol	Index of long-term atherosclerotic risk
	Hemoglobin A1C	Integrated measure of high blood sugar over 2–3 months

Each indicator that is a certain distance out of the normal range counts as one point. The score can range from zero to ten. The higher the score, the greater the risk of illness or death.

Other Indicators

Although the ten indicators were the ones described in the original papers about allostatic load, other indicators have been used as well.

Heart rate variability is the normal beat to beat variability in the heart rate. In a healthy heart there is slight variation in the timing of one heartbeat to the next. Chronic stress reduces or even eliminates this beat to beat variation.
High sensitivity C-reactive protein (CRP). This is a measure of systemic inflammation that can result from chronic stress.

How is the stress reaction triggered?

The stress reaction begins in the brain. Something in the environment is perceived in a part of the front of the brain called the prefrontal cortex. This is the executive decision maker in the brain. If the prefrontal cortex perceives something in the environment as a threat, then it sends messages to the limbic system (the part of the brain that is involved with emotions). It also sends messages to centers lower in the brain, especially the hypothalamus. The hypothalamus sends messages to the adrenal glands which secrete cortisone, norepinephrine and epinephrine. The hypothalamus secretes DHEA. Messages from the hypothalamus are also sent to the white blood cells which secrete inflammatory chemicals called cytokines. All of this prepares the body to deal with the perceived threat. Different people may perceive different things as a threat. It is the reaction to perceived threats that causes allostatic load. If another person experiences the same thing in the environment as not a threat, then there is no stress reaction.

Diseases associated with high allostatic load (high chronic stress)

A high allostatic load score is not disease in itself, but if chronic stress continues then disease in the cardiac, metabolic, neuroendocrine and immune system can occur. Here is a list of diseases associated with persistent high allostatic load.

Heart disease, primarily progressive blockage of the coronary arteries. This can lead to angina and/or heart attack. Congestive heart failure and arrhythmia like atrial fibrillation can also occur
Peripheral arterial disease. That is blockage in arteries in the legs and sometime fingers.
High blood pressure
Stroke
Autoimmune diseases like rheumatoid arthritis or lupus
Diabetes
Fibromyalgia
Chronic Fatigue Syndrome
Dementia or decreased cognitive function
Depression
PTSD
Cancer, particularly breast and ovarian cancer. The increase in cancer is probably related to decreased immune system function

Allostatic Load and Mortality

Many studies have shown that people with persistently hight allostatic load have about a 25% higher premature death rate than people with low allostatic load.

Disparities in Health Outcomes

The response to chronic stress (allostatic load) may explain some of the disparities we see in health outcomes. We know, for example that Adverse Childhood Events (ACE), which include things like abandonment and abuse, increase the risk of many chronic diseases in adulthood. Studies have shown that adults with a history of ACE have high allostatic load scores.

African Americans have higher incidence of many cancers, as well as poorer outcomes from those cancers. They also have worse outcomes from heart disease, high blood pressure and diabetes. While a good portion of these poorer outcomes are related to lack of access to health care, these disparities persist to some degree even in middle class and upper middle class African Americans. Almost all African Americans have experienced or still experience racism on a chronic basis. African Americans of all social classes have higher allostatic load scores than caucasians. Chronic stress and response to it may be the common denominator for these disparities as well as for health outcome disparities in other marginalized populations.

How to reduce allostatic load

There is typically a long time between the presence of indicators of allostatic load and illness and death caused by diseases associated with these indicators. That presents an opportunity to reduce allostatic load before the chronic stress response leads to illness and death. So how do we reduce allostatic load?

Some of the things that cause allostatic load can only be reduced by societal changes. Things like poverty, structural racism and homelessness cannot be decreased by individual effort. Even these causes, though, can respond to the mind body methods discussed below. On the other hand, if you don’t have enough to eat, have no home, or have a job that gives you no control of your life, it is not likely that you will have the energy or the will, or the financial means to do many of the mind body methods discussed below. We should not be distracted from working to decrease the inequities that are responsible for societal causes of chronic stress.

Mind-Body Medicine

Remember that an external threat is first received by the peripheral nervous system and transmitted to the pre-frontal cortex. In order to reduce allostatic load we can either reduce the threat perception in the prefrontal cortex (top down) or reduce the transmission of threat in the peripheral nerves (bottom up).

Top Down Treatments

Top down treatments start with intentional activity in the prefrontal cortex. The idea is to decrease activation of the limbic system and the hypothalamus. This can be accomplished by mindfulness meditation, hypnosis (including self hypnosis), mental imagery and progressive muscle relaxation. All of these techniques when done regularly have been found to decrease allostatic load indicators and to reduce the risk of stress related illnesses.

Bottom Up Treatments

Bottom up treatments decrease the threat transmission to the prefrontal cortex. They include yoga, Tai Chi, massage and biofeedback. These treatments have also been shown to decrease allostatic load and to reduce stress related illness.

Bottom up and top down are somewhat of an oversimplification. All of these treatments have some aspects of both top down and bottom up. Yoga, for example includes aspects of meditation. The same goes for Tai Chi. Biofeedback involves some attention from the prefrontal cortex. Massage also includes progressive muscle relaxation.

Bottom Line

The body’s reaction to a perceived threat includes a complex cascade of messages from the executive center in the prefrontal cortex to multiple body systems including the nervous system, the endocrine system, the cardiovascular system and the immune system. All of these things prepare the body to deal with the threat. As long as the threat is short term the stress response is very useful to the organism.

Perception of chronic stress leads to continuous secretion of all the stress hormones and inflammatory cytokines and this leads to dysfunction of multiple body systems and eventually to illness and death.

Mind body treatments, both top down and bottom up can reduce the allostatic load (chronic stress response) and reduce the risk of stress induced illness and death.

Many causes of chronic stress have to do with the structure of our society, such as poverty, homelessness and structural racism. Individual effort is not likely to ameliorate the effect of these causes of chronic stress. All of us should be working toward societal change to reduce chronic stress response in marginalized populations.

Heartburn: Causes and Treatment

Heartburn is defined as burning pain in the chest behind the breast bone and sometimes into the throat. It often occurs after eating or at night. Heartburn is caused by acid in the stomach (where it belongs) coming up into the esophagus (where it does not belong). Normally there is a one way valve that lets food go into the stomach, but keeps acid from coming back up into the esophagus. This valve is called the gastroesophageal sphincter. When that sphincter doesn’t work well, it allows acid from the stomach to come back up into the esophagus. The medical term for back up of acid from the stomach into the esophagus is gastroesophageal reflux disease often abbreviated as GERD. GERD has become increasingly common in western countries. One in five people in the US suffer from some form of GERD!

In this post I will talk about the causes of dysfunction of the gastroesophageal sphincter that lead to GERD and the symptoms of heartburn. I will focus first on foods and lifestyles that increase your population risk of GERD and also foods and lifestyle changes that reduce your population risk of GERD.

Finally, I will talk about medicines for GERD and the risks of side effects from these medicines.

Things that Increase the Population Risk of GERD

Smoking

Smoking cigarettes has been shown to decrease the pressure of the gastroesophageal sphincter. That means that anything that increases the abdominal pressure, such as coughing or bending over overcomes the weak sphincter and leads to GERD. The population of people who smoke has almost twice the risk of GERD of people who do not smoke.

Foods that relax the gastroesophageal sphincter

Decreased muscle tone in the gastroesophageal sphincter can lead to GERD. The following foods decrease the muscle tone of the gastroesophageal sphincter.

Fried (greasy) foods
High-fat meats
Butter and margarine
Mayonnaise
Creamy sauces
Salad dressings
Whole-milk dairy products
Chocolate
Peppermint
High salt intake

Obesity

Obesity increases intra-abdominal pressure, which can cause GERD even with a well functioning gastroesophageal sphincter. Obesity also increases the risk of developing a hiatal hernia. This is when part of the stomach comes up through the diaphragm in the same opening the esophagus goes through. Small hiatal hernias usually cause no symptoms, but large ones can lead to GERD.

Sedentary Lifestyle

Studies have shown that couch potatoes have a higher risk of GERD even if they are not over fat.

Medicines

The Mayo Clinic has a list of medicines that either can irritate the esophagus (causing heartburn) or can cause GERD. Here is the Mayo Clinic list:

Medications and dietary supplements that can irritate your esophagus and cause heartburn pain include:

Antibiotics, such as tetracycline and clindamycin
Bisphosphonates taken orally, such as alendronate (Fosamax), ibandronate (Boniva) and risedronate (Actonel, Atelvia)
Iron supplements
Quinidine
Pain relievers, such as ibuprofen (Advil, Motrin IB, others) and aspirin
Potassium supplements

Medications and dietary supplements that can increase acid reflux and worsen GERD include:

Anticholinergics, such as oxybutynin (Ditropan XL), prescribed for overactive bladder and irritable bowel syndrome
Tricyclic antidepressants (amitriptyline, doxepin, others)
Calcium channel blockers, statins, angiotensin-converting enzyme (ACE) inhibitors and nitrates used for high blood pressure and heart disease
Narcotics (opioids), such as codeine, and those containing hydrocodone and acetaminophen (Norco, Vicodin, others)
Progesterone
Sedatives or tranquilizers, including benzodiazepines such as diazepam (Valium) and temazepam (Restoril)
Theophylline (Elixophyllin, Theochron)

Microbiome

It turns out that we have bacteria living in our mouth and esophagus as well as our colon (see my previous post on the microbiome: The Microbiome: How Our Own Bacteria Affect Our Lives). There is increasing evidence that when unhealthy bacteria (gram negative bacteria) replace healthy bacteria (gram positive bacteria) in the esophagus we are more likely to have GERD and a precancerous change called Barrett’s Esophagus. Unhealthy bacteria replacing healthy bacteria is called dysbiosis. It can be cause by eating too much fat, sugar, processed food and a low fiber diet.

Things that decrease population risk of GERD

Never smoking or quitting if you smoke

That’s pretty obvious. Enough said.

Maintaining normal body fat

BMI is not a very accurate measure of percent body fat. A better measure is waist to hip ratio. A healthy waist to hip ratio is .75 for women and .85 for men. A ratio of .85 or more for women and .90 or more for men is defined as obesity. It is a very easy measurement for you to do at home. Use a cloth tape measure and measure the circumference of your waist at the level of the belly button. Write that measurement down. Then measure the circumference of your hips at the widest part and write that measurement down. Use a calculator to divide the waist circumference by the hip circumference. If you fall into the over fat range, review my post The Psychology of Eating and How to Use It to Your Advantage.

Eat a high fiber diet low in fat, sugar and processed foods

Not only does this kind of diet increase the tone of the gastroesophageal sphincter, but it also leads to a healthy microbiome in the mouth and the esophagus, which further decreases the population risk of GERD and Barrett’s Esophagus. Here is a link to the Cleveland Clinic web page that lists 11 high fiber foods: 11 High Fiber Foods You Should be Eating.

Minimize the number of medicines you take

Certain prescription medicines may be necessary and unavoidable, but you can certainly minimize the over the counter medicines you take. Whenever your doctor recommends a prescription medicine, you should almost always ask if there are any non-medicine ways to treat the condition. There may not be, but you will never know if you don’t ask.

Medicines for GERD

Even if you do all the things to put yourself in a low risk population for GERD you still may suffer from GERD. Remember that risk is calculated for populations and has no meaning for an individual. You will either get GERD or you won’t. In other words individual risk is either zero percent or 100 percent.

If you do have GERD despite doing everything you can to put yourself in a lower risk population, you may need to take medicine to alleviate the symptoms and prevent precancerous changes of Barrett’s Esophagus.

H2 Blockers

These medicines block a histamine receptor called the histamine 2, abbreviated H2. They work by decreasing acid production in the stomach. These are the medicines with the least side effects including on the microbiome. They include:

Famotidine (Pepcid AC, Pepcid Oral, Zantac 360)
Cimetidine (Tagamet, Tagamet HB)
Nizatidine Capsules (Axid AR, Axid Capsules, Nizatidine Capsules)

Most people with GERD get symptom relief from these medicines. They used to be prescription only, but almost all of them are now available over the counter. A small percentage of people with GERD will not respond to H2 blockers.

Proton Pump Inhibitors (PPI’s)

PPI’s are the most potent inhibitors of production of stomach acid. PPI’s essentially block the production of all stomach acid. They include:

lansoprazole (Prevacid)
omeprazole (Prilosec)
pantoprazole (Protonix)
rabeprazole (AcipHex)
esomeprazole (Nexium).

Prevacid and Prilosec are available over the counter. The others are prescription only.

Remember that stomach acid is there for a reason. The hydrochloric acid in the stomach breaks down the food and the digestive enzymes split up the proteins. The acidic gastric juice also kills bacteria.

Because PPI’s are such potent inhibitors of stomach acid production, they increase the risk of certain intestinal infections, especially clostridium difficile infections. They also promote less healthy bacteria in the colon, even more so than antibiotics. Over the long term they can also cause osteoporosis (thinning of bones) and low magnesium levels.

Once started, they are difficult to stop. Stopping PPI’s causes a rebound production of stomach acid, much more than the normal amount. This leads to rebound symptoms of GERD. They have to be stopped gradually with H2 blockers used to slowly replace them. This regimen helps prevent rebound excess acid production.

Most people have no symptoms from short term use of PPI’s and some people have such severe GERD and/or Barrett’s esophagus that they must take PPI’s to get any relief. For this relatively small number of people, the benefit is much greater than the risk. People with symptoms of GERD should only use PPI’s as a last resort, when diet, lifestyle changes and H2 blockers fail to relieve symptoms.

Bottom Line

The symptom of heartburn is almost always due to stomach acid back-flowing into the esophagus where it does not belong. The medical term is GERD. Anything that tends to decrease the muscle tone of the valve between the esophagus and the stomach (gastroesophageal sphincter) increases the risk of GERD. Such things include smoking cigarettes, obesity, high sugar high fat foods with low fiber, certain medicines and a sedentary life style. Things that decrease the risk of GERD include not smoking, maintaining a normal body weight, eating a high fiber diet, regular exercise and minimizing taking over the counter medicines.

For people that have to take medicines for GERD symptoms, H2 blockers have fewer side effects and little effect on the microbiome. For the few people with GERD that don’t get relief from diet, lifestyle changes of H2 blockers, PPI’s may be necessary but have more severe short term and long term side effects including increased intestinal infections, promoting a less healthy microbiome and long term risk of osteoporosis and low magnesium levels.

High Blood Pressure: Silent and Deadly

This is the third post in a series on chronic diseases in the US.

Statistics

High blood pressure (hypertension) is the 5th leading cause of death in the US. In 2019 half a million people in the US died with hypertension as the cause or major contributing cause. Two thirds of all strokes and half of all heart attacks are caused by hypertension. The old definition of hypertension was a systolic blood pressure of 140 or greater and/or a diastolic blood pressure of 90 or greater. There is a new definition of hypertension that we will talk about later, but by the old definition, one out of every 4 people in the US have uncontrolled hypertension. By the new definition nearly half of people in the US have hypertension.

Definitions

The medical term for high blood pressure is hypertension. Blood pressure has two components. The systolic pressure is the pressure when the heart beats, forcing blood out of the left ventricle into the arteries of the body. The diastolic pressure is the pressure left in the arteries between beats. Both are equally important, and an increase in either one (or both) increases risk.

It has been known for a long time that there is a continuous increase in risk of cardiovascular disease and stroke as blood pressure rises. The lower your blood pressure the lower your risk. The spot on that blood pressure vs risk curve where we define the disease hypertension is arbitrary. The vast majority of deaths, strokes and heart attacks come from systolic blood pressures of 140 or higher and/or diastolic blood pressures of 90 or higher.

The new definition of hypertension

Blood pressure categories in the new guideline are:

Normal: Less than 120/80 mm Hg;
Elevated: Top number (systolic) between 120-129 and bottom number (diastolic) less than 80;
Stage 1: Systolic between 130-139 or diastolic between 80-89;
Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg

There are no new data on the continuous increase in risk as blood pressure rises. The American Heart Association and other associated groups have simply decided to change the spot on the risk curve where hypertension is defined. They point out that the risk of cardiovascular disease is 3.5 times higher in the Elevated category than in the normal category. That sounds like a lot, but three times a very small risk is still a very small risk.

Measurement of blood pressure

High blood pressure has no symptoms, so you don’t know if you have it unless you measure it. In order to figure out where you are on the blood pressure risk curve, you have to know what your average blood pressure is. Blood pressure should not be measured until you have been sitting quietly for 5 minutes. That clearly does not happen the vast majority of the time when the nurse or medical assistant takes your blood pressure in your doctor’s office. More likely you have rushed to get there, had trouble finding a parking place, walk into the office already agitated and anxious, and the nurse takes your blood pressure as soon as you sit down. That is a recipe for having a falsely elevated blood pressure!

Home blood pressure measurement

The best way to determine your average blood pressure is to measure it at home. There are lots of very reliable reasonably priced home digital blood pressure monitors. Choose one that has a cuff that goes on your upper arm, not your wrist. The wrist blood pressure monitors are not very accurate. Also check that the cuff is the right size for your upper arm. If your upper arm is very large, then you will need a monitor with an extra large cuff. It is a good idea to measure the diameter of your upper arm before you buy a blood pressure monitor. Here is a link to an article by Forbes Health that rates the top ten home digital blood pressure monitors: Best Blood Pressure Monitors of 2022. Note that the highest ranked one is not the most expensive one. Any of the OMRON monitors are good, so if that brand is what is available in your local pharmacy, that brand would be fine.

Measure your blood pressure twice a day for at least two or three weeks. You should sit quietly in a chair for five minutes before you measure your blood pressure. You should not measure your blood pressure right after you have had your morning coffee. Either measure it before coffee (or tea) or about two hours after your last cup. All of the good monitors keep a record of your blood pressures, and some of them will calculate the average for you.

What to do based on your average home blood pressure

Normal (less than 120 systolic and less than 80 diastolic): You don’t need to make any diet or lifestyle changes based on your blood pressure

Elevated (systolic 120-129 and less than 80 diastolic): Although your risk of cardiovascular complications is a little higher than if your systolic pressure was less than 120, it is not much higher. You might want to make some modest diet and lifestyle changes (which I will discuss later). You definitely do not need blood pressure medicine.

Stage 1 (systolic between 130-139 or diastolic between 80-89): This used to be considered normal by the old definition of hypertension. Blood pressure at this level bumps up your risk of stroke or cardiovascular disease by a bit more than the elevated category but it still would be considered moderate risk. You would definitely want to make some diet and lifestyle changes and if you did that you would likely still not need blood pressure medicine.

Stage 2 (systolic 140 or greater or diastolic 90 or greater): The risk of stroke or heart disease is substantially high and gets progressively higher as the blood pressure increases. You still should do diet and lifestyle changes, but you probably will also need blood pressure medicine. If you have stage 2 hypertension, you should definitely see your doctor.

Risk factors for hypertension

Surprise, surprise! The risk factors for hypertension are almost the same ones that increase your risk of type 2 diabetes, heart disease, cancer, and stroke. They are:

Heredity (not simple and involving multiple genes each contributing a tiny part)
Increased body fat, particularly increased waist circumference
Sedentary lifestyle
Eating high sugar, high carbohydrate processed foods
Eating too much salt

Diet and lifestyle changes to decrease blood pressure

Reduce sodium in your diet. That means no added salt and staying away from high sodium foods. Here is a link to an article from drugs.com describing a 2 gram sodium diet: 2 Gram Sodium Diet. If you are simply not willing to get rid of added salt completely, switch to Morton’s Lite Salt. It is half sodium chloride and half potassium chloride. It tastes exactly like salt but has half the sodium of regular table salt.
All the other diet and lifestyle changes that would reduce blood pressure I have discussed in previous posts. Here are links to those posts: How to Lose Weight and Keep it Off. The Psychology of Eating and How to Use It to Your Advantage. Good Nutrition: A Review of the Evidence. Type 2 Diabetes Mellitus: Anatomy of an Epidemic.

Bottom Line

High blood pressure, even very high blood pressure has no symptoms. Because of that everyone should determine their average blood pressure at least once a year.
Home blood pressure measurement is the most accurate way to know your average blood pressure.
Measure your blood pressure twice a day for at least 2-3 weeks and calculate the average.
If your average blood pressure is in the elevated range or higher, then diet and lifestyle changes will help reduce it.
If you have stage 1 or 2 hypertension you should see your doctor.

Type 2 Diabetes Mellitus: Anatomy of an Epidemic

This begins a series of posts on chronic diseases. Nearly half of Americans suffer from at least one chronic disease. Chronic diseases include diabetes mellitus, high blood pressure, cancer, stroke, heart disease, respiratory diseases, arthritis, obesity, and oral diseases. Chronic diseases are responsible for 7 out or every 10 deaths in the United States. Almost of these diseases can be prevented or managed successfully.

Type 2 Diabetes mellitus has reached epidemic proportions in the United States. One in every ten people in the United States has type 2 diabetes mellitus. It is the 7th leading cause of death in the U.S. In this post I will talk about the causes of type 2 diabetes mellitus, how it can be prevented, and how it can be treated by diet and exercise modification.

Terminology

The correct terminology for excesssive blood sugar is diabetes mellitus.The greek word from which the word diabetes comes means ”a large discharge of urine.” Mellitus comes from the greek word meaning “sweet.” There is another kind of diabetes (large discharge of urine) called diabetes insipidus, which is a completely different disease. Diabetes insipidus is caused by a deficiency of a hormone called vasopressin that is secreted at the base of the brain.

There are two types of diabetes mellitus and they both cause high blood glucose but they have completely different causes. Type 1 diabetes mellitus is an autoimmune disease that destroys the beta cells in the pancreas, which are the cells that produce insulin. It usually occurs in childhood, often following a viral infection. It is much less common than type 2. People with type 1 diabetes mellitus have high blood glucose because they produce no insulin at all and have to be treated with insulin. People with type 2 diabetes mellitus make plenty of insulin, at least in the beginning of the disease. Their bodies are resistant to insulin, and even though their insulin levels are high, the insulin can’t carry glucose into the body’s cells like it is supposed to and the blood glucose rises. In the rest or this post I’m going to talk exclusively about type 2 diabetes mellitus.

Causes of type 2 diabetes mellitus

Type 2 diabetes mellitus is caused by a complex interaction between genetics and environment.

Heredity

Type 2 diabetes mellitus tends to run in families. The lifetime risk of developing type 2 diabetes mellitus is 40% for individuals who have one parent with type 2 diabetes (I will leave off the mellitus from here on out for the sake of brevity) and 70% if both parents are affected. We know some of the genes that are associated with risk of developing type 2 diabetes but they only account for about 20% of the heredity, so there are a lot more genes to find. Genetic risk is not destiny, though. Environment plays a huge role in the development of type 2 diabetes.

Causes of Insulin Resistance

Insulin resistance is the hallmark of type 2 diabetes. Insulin resistance starts well before the onset of diabetes. At first your pancreatic beta cells make enough extra insulin to keep your blood sugar normal. Eventually, though, they can’t keep up and blood sugar starts to rise. A number of things can lead to insulin resistance, which I will outline below.

Abdominal body fat

Increased waist circumference (greater than 40 inches for men and 35 inches for women) is a marker for what is called visceral fat, which means fat around the internal organs. Visceral fat is one of the main causes of insulin resistance. Just being over fat in general is also a cause of insulin resistance.

Sedentary Lifestyle

Lack of regular exercise causes insulin resistance. I will talk more about exercise later on when I discuss preventing and treating type 2 diabetes.

Diet

A diet high in processed foods with starchy carbohydrates and sugar (or high fructose corn syrup) causes increased insulin release and can eventually lead to insulin resistance.

Microbiome

The microbiome refers to the 100 trillion bacteria that live in our intestinal tracts. The bacteria in the microbiome help digest our food, regulate our immune system, protect against other bacteria that cause disease, and produce vitamins including B vitamins B12, thiamine and riboflavin, and Vitamin K, which is needed for blood coagulation. It turns out that the microbiome may also promote or reduce insulin resistance depending on what kinds of bacteria live in our intestine. Research about this is just beginning, but here is what we know so far. People with type 2 diabetes have a lower diversity of bacterial species in their gut. They specifically lack bacterial species that produce something called butyric acid. Increased bacterial diversity in the microbiome and especially bacteria that produce butyrates are associated with lower insulin resistance. At this point we don’t know if changing the microbiome will help treat or prevent diabetes, but this is an exciting possibility.

Prediabetes

When genetic predisposition and environment interact, insulin resistance starts to develop. There is a condition called prediabetes. It develops up to ten years before people develop frank type 2 diabetes. There are two tests used to diagnose prediabetes (or actual type 2 diabetes). One is called fasting blood glucose. The blood glucose is tested after fasting overnight. Another test is called hemoglobin A1C. It turns out that glucose in the blood forms a molecular bond with the hemoglobin in red blood cells. This molecular bond lasts for the life of the red cell, which is about 90 days. The amount of hemoglobin that is bonded to glucose is proportional to the average blood glucose level over the 90 day life of the red cell. We can measure the amount of hemoglobin bonded to glucose and that gives us a pretty good measure of the average blood glucose over the last 3 months.

Prediabetes is defined as a fasting blood glucose of 100-125 and/or a hemoglobin A1C of 5.7%-6.4%. If either one of these values is higher, then that makes the diagnosis of type 2 diabetes.

The importance of finding prediabetes is that by making diet and lifestyle changes people can prevent the onset of type 2 diabetes. It is much easier to prevent type 2 diabetes than it is to treat it once you already have it.

How to prevent or reduce insulin resistance (whether you have prediabetes or have progressed to frank type 2 diabetes).

Reduce body fat especially if you have excessive abdominal fat. Refer to my previous post (The Psychology of Eating and How to Use It Your Advantage) for tips on how to do this sustainably.
Increase your exercise. The CDC recommends 150 minutes a week of moderate exercise (brisk walking for 30 minutes, 5 days a week, for example) or 75 minutes per week of vigorous exercise (jogging or running for 25 minutes 3 days a week for example).
Avoid highly processed foods with added sugar, honey, maple syrup and especially high fructose corn syrup. Replace them with fresh fruit, fresh vegetables, fish and poultry.
Increase the soluble fiber in your diet. Soluble fiber promotes growth of diversity in your microbiome. Here is a link to an article from Healthline.com that identifies the top 20 foods with soluble fiber: Top 20 Foods High in Soluble Fiber
Eat fermented foods with live bacteria in them such as plain yogurt (sweeten with added fruit or berries, not sugar) sauerkraut, or kimchi. These add healthy bacteria to your microbiome. Here is another link to Healthline.com that lists a number of fermented foods that are good for you: 8 Fermented Foods and Drinks to Boost Digestion and Health.

Dietary Treatment of Type 2 Diabetes

If you already have type 2 diabetes you can do all of the things listed above to decrease insulin resistance, which means you may be able to get by on less or no medicines. If you are on any diabetic medicines other than metformin, you should let your doctor know of any changes you plan to make in your diet or exercise. He or she may want to reduce your medicines so you don’t get your blood sugar too low.

There are some additional dietary changes that may help your blood glucose be under better control and reduce or eliminate your diabetic medicines. These are things you definitely need to check with your doctor before you try them.

Ketogenic Diet

There is good evidence that a ketogenic diet is very good for people with type 2 diabetes.

What are ketones?

Normally your body uses glucose for energy for the brain and other body functions. Insulin carries the glucose into cells so they can use it for energy. If you don’t take in enough carbohydrates to produce glucose for energy, then your body starts to mobilize fat. Fat cannot be broken down to glucose, but it can be broken down to something called ketones. Your body and brain can switch over to using ketones for energy. Ketones require little or no insulin to get into cells.

What do you eat on a ketogenic diet?

A ketogenic diet is a very low carbohydrate high fat diet. That sounds unhealthy and it can be if you eat mostly saturated fats. A good ketogenic diet uses mostly healthy unsaturated fats. Here is a link to another Healthline.com article that discusses ketogenic diets for type 2 diabetes: How the Ketogenic Diet Works for Type 2 Diabetes. Do not start a ketogenic diet without checking with your doctor first!

Intermittent Fasting

Intermittent fasting means exactly that. Fasting means not taking in any calories for certain periods. There are all sorts of ways to do intermittent fasting. Most commonly, people fast for 24 hours every other day or they eat all their meals within a limited time period, between 7AM and 3PM for example. There is increasing evidence that intermittent fasting improves control of type 2 diabetes over and above the fat loss that results. Here is a link to a recent review article about the benefits of intermittent fasting for type 2 diabetes: Intermittent fasting: is there a role in the treatment of diabetes? A review of the literature and guide for primary care physicians.

It is important to drink plenty of water when doing intermittent fasting. If doing fasting for longer that 24 hours, one needs to drink liquids with electrolyes rather than plain water. People with type 2 diabetes should NOT start an intermittent fasting program without checking with their doctor.

Further Reading

If you want to read more about diet and lifestyle treatment of type 2 diabetes, here is a link to an excellent book by Dr. Jason Fung: The Diabetes Code: Prevent and Reverse Type 2 Diabetes Naturally.

Sugar and High Fructose Corn Syrup

Sugar (actually anything that tastes sweet) releases dopamine to pleasure centers in the brain. These are the same centers that get activated by things like cocaine, heroin, methamphetamine and alcohol. Anything that activates the pleasure centers has the potential to be addictive. Most experts agree that sugar (and high fructose corn syrup, which tastes even sweeter) are addictive. Here is a link to an article from Healthline.org that gives further information about the addictiveness of sugar: Is Sugar an Addictive Drug?

Our hunter gatherer ancestors did not have to worry about addiction, because things that tasted sweet were rare and seasonal. In our society, sweet tasting food is everywhere and easily available. That, of course, is a recipe for addiction.

Sucrose and fructose

The vast majority of the sweetener that is added to processed foods (or that we add on purpose) is either sugar (sucrose) or high fructose corn syrup. Sucrose is also what makes honey and maple syrup taste sweet. High fructose corn syrup tastes sweeter than sucrose and is also considerably cheaper. That is why it is so prevalent in processed foods.

Americans eat an average of 37 pounds per person per year of high fructose corn syrup and 52 pounds of sugar per person per year. This is a huge health problem as I will outline below.

Sucrose is broken down in the body to glucose and fructose. Glucose is used as fuel for the body and especially the brain. If we take in more glucose than we need immediately for fuel the excess gets stored. Some is stored in the liver as glycogen. Glycogen gives us a ready energy source and is easily converted back to glucose. Any extra glucose is used to make triglycerides, which are then stored as fat. It is much harder to mobilize fat from storage.

Fructose is a much bigger problem. Fructose can only be broken down in the liver. Fructose is found in small quantities in fresh fruits, but eating sugar and/or especially high fructose corn syrup produces more fructose than the liver can handle. This excess fructose causes fat deposits in the liver (called fatty liver disease). The medical term is NAFLD (non alcoholic fatty liver disease). More than 25% of the population in the United States has NAFLD. The excess fat in the liver causes inflammation and twenty to thirty percent of people with NAFLD progress to something called NASH (non alcoholic steatohepatitis). Between five and twelve percent of people with NASH progress to cirrhosis of the liver. NASH is now a much more common cause of cirrhosis of the liver than alcoholism! Even more disturbing is that 2.6% of people with cirrhosis from NASH develop cancer of the liver.

Lets do a little math. If we randomly choose 1000 adults in the United States, 250 of them will have fatty liver (NAFLD). That is one in every four people. Of that 250, 75 will develop inflammation of the liver (NASH). Of that 75, 9 will develop cirrhosis of the liver. Think about those numbers for a minute. Eating foods with added sugar or especially high fructose corn syrup causes cirrhosis of the liver in 9 out of every thousand adults in the United States. If we choose a hundred people with cirrhosis from NASH, three of them will get liver cancer. That is a huge burden of disease! If you want to read more, here is a link to the NIH: How high fructose intake may trigger fatty liver disease

How to avoid high fructose corn syrup

You should look at the labels of everything you buy in the grocery store or convenience store. Foods that contain high fructose corn syrup have to list it on the label. You would be surprised at the number of foods that have high fructose corn syrup added. Here is a link to a web page that lists 23 different foods that often have high fructose corn syrup added: 23 Surprising Foods That Contain High Fructose Corn Syrup. If you stay away from the middle aisles in the grocery store as much as you can, then you will avoid most of these foods. I would strongly suggest that you not buy anything that contains high fructose corn syrup.

What about sugar, honey and maple syrup?

Sugar, honey and maple syrup are all sweet because they are or contain sucrose. Once again, the operative word is moderation. It is not going to damage your health to have an occasional cookie, piece of cake, piece of pie or small bowl of ice cream. It should be less than once a week, though. You have to be vigilant not to buy food that has ”stealth” sweeteners added. Soft drinks are the worst. Mountain Dew, for example has 46 grams of sugar per can. It is best to avoid soft drinks altogether. For other grocery items I can’t emphasize enough to read the labels.

Bottom Line

Sugar and high fructose corn syrup are addictive. In excess both of them are toxic to the liver and can lead to cirrhosis of the liver and liver cancer. They also make people fatter with all the health risks of obesity. Read the labels when you grocery shop and avoid foods containing high fructose corn syrup. Limit foods containing sugar, honey or maple syrup to less than once a week.

Good Nutrition: A Review of the Evidence

The previous post was about how to change your food environment so that you automatically eat fewer calories. This post is the first of several to discuss the evidence (or lack thereof) about what constitutes a healthy diet. Before I get to that though, I discovered a newer book by Brian Wansink, the author of Mindless Eating that I discussed in the last post. This one was published in 2014 and is called Slim by Design. Mindless Eating Solutions for Everyday Life. It is also very much worth reading.

What kinds of foods are healthy?

There is so much conflicting information about what makes for a healthy diet that it’s enough to make you crazy. It comes from books, web pages, newspaper articles and any other media you can name.

I think the most succinct description of a healthy diet comes from the journalist and author Michael Poulin: ”Eat food (food is anything your grandmother would have recognized as food), mostly plants, not too much.” That is excellent advice but I will expand on that short definition to give you something a little more useful.

Mediterranean Diet

The mediterranean diet has been the subject of more research than any other way of eating. It is the traditional diet of southern Italy. It has been shown to reduce the risk of heart disease, stroke and dementia. The mediterranean diet consists of very little meat and sweets. Fish is a bigger part of the diet as well as lots of fruits and vegetables, and whole grains including bread and pasta. The main fat is olive oil, Most descriptions of the diet include red wine, but that is controversial. I will talk about alcohol intake later. Here is a link to the OldWays version of the mediterranean diet food pyramid.

For most Americans, this would be a very big change, not a small one. If you want to adopt the mediterranean diet whole hog, more power to you. It clearly is a very healthy diet and has the most research supporting it. Remember however that whatever you do needs to be a permanent change in the way you eat. If this is a big change from the way you eat now, that kind of big change may not be sustainable for you.

Unprocessed foods

If the mediterranean diet is too much of a stretch for you, you could work toward buying and preparing unprocessed (or minimally processed) foods. Unprocessed foods include fresh fruits, fresh vegetables and fresh or frozen meat, poultry or fish. Frozen or canned fruits and vegetables count as minimally processed foods as long as nothing else (like sugar, preservatives or other food additives) has been added to them. Oils are processed foods, but vegetable oils, particularly olive oil have significant health benefits. There is good evidence that eating predominantly unprocessed foods does not lead to obesity and diabetes. They also decrease risk of heart disease and stroke. Here is an article from Healthline.com that summarizes the health benefits of unprocessed foods: 21 Reason to Eat Real Food.

By definition many unprocessed foods (other than fresh fruit and some vegetables) require more food preparation and cooking. For those of you who have busy lives with jobs to go to and children to care for, taking more time to prepare food may sound impossible. On the other hand, what is more important than your own health and especially that of your children? There are shortcuts to healthy food preparation. I’m sure most of you know many of them but food preparation shortcuts will be the subject of another post.

Processed and highly processed foods

Processed foods contain sugar, sometimes fats, preservatives, emulsifiers, artificial colors, thickeners, etc. Sugars go by many different names. If anything on the label ends in the letters ose, then that means that sugar has been added. Honey and maple syrup also contain sugar (more about sugar in the next post). Although all of the food additives have been approved by the FDA, that does not mean that many of them have had adequate testing in humans. We have no idea whether many of these additives are safe. Sixty per cent of them have no research showing they are safe in humans. Here is a link to an article from Healthychildren.org that discusses the effect of food additives on children: Additives: What Parents Should Know.

Food additives have to be listed on the food label. A good rule of thumb is that if the label has two things on it that you don’t recognize, don’t buy it!

Fat

I’m sure that you have heard fat is bad for you, especially saturated fat. I’m sure you have also heard that fat has more calories per gram than carbohydrates (9 calories per gram of fat versus 5 calories per gram of carbohydrates) and that eating fat will make you fat. The real story is a lot more complicated.

Eating fat stimulates very little insulin release and release of insulin makes you hungry. Eating fat makes you feel more full and therefore less hungry. That is a good part of the reason that the old Atkins diet worked. If you eat lots of fat, you actually eat less calories because you are not as hungry.

Saturated fats

While it is true that eating lots of saturated fat (animal fat and coconut oil) increases your risk of heart disease and stroke, eating modest amounts increases your risk very little if at all. You can have your bacon and eggs once or twice a week and your steak or pork chop occasionally and be just fine. Grass fed beef has healthier fat content than grain fed beef. Moderation is the key here. Most Americans eat far too much beef and pork. Americans eat 82 pounds of beef per person per year and 66 pounds of pork per person per year! Remember the mediterranean diet food pyramid? Beef and pork are at the top of the pyramid, so that means you should eat those the least. By the way, using a little butter is fine.

Unsaturated fats

Extra virgin olive oil is the healthiest choice and actually tends to lower blood cholesterol values. Extra virgin olive oil is not processed and is the best olive oil to use. It has a low smoke point, so is not good for cooking at high heat. Avocado oil and peanut oil have high smoke points and are great for things like stir fry. Most vegetable oils on the market are a blend of canola, corn, soybean, safflower, palm and sunflower oils. These tend to be highly processed and are not as good for you. You are better off using extra virgin olive oil, avocado oil and/or peanut oil.

Trans fats

Trans fats are partially hydrogenated vegetable oils. They include things like margarine and Crisco. The food industry developed these so they would be solid at room temperature. They were initially thought to be healthier than butter and lard, but research has shown that they cause more cardiovascular disease than saturated fats. They should be avoided entirely.

Fish

Eating fish, particularly oily ocean fish, is very good for you. It significantly lowers the risk of cardiovascular disease and stroke. Unfortunately most of these fish are top predators, which means that mercury contamination does exist. Pregnant women and children have to be a little careful about how much fish and which fish they eat. The levels are too low in most fish to affect non pregnant adults. Here is a link to a chart from the FDA that is very helpful in deciding which fish to eat and which to avoid: Advice About Eating Fish.

Poultry

Broiled or baked chicken or turkey is healthier than beef or pork, but there are some caveats. A lot of chickens and turkeys are raised on factory farms. They are given hormones and low doses of antibiotics to make them grow faster. The practice of giving low dose antibiotics to livestock markedly increases bacteria that are resistant to most antibiotics and that infect humans. When you buy chicken or turkey check the label to make sure antibiotics and hormones were not used in their growth.

Free range on the label does not mean much. Factory farms leave open a chicken house door into small fenced in spaces. The chickens are ”free” to go outside, but none of them do. Organic chicken from a farmer’s market is a much healthier and environmentally safe option. The same goes for eggs. If you can buy fresh eggs from a farmer it will be better for you and for the environment.

Bottom Line

Fresh or frozen fruits and vegetables, seeds, nuts and whole grains should make up the majority of what you eat daily. Use olive oil, avocado oil and peanut oil as your primary sources of fat. It is ideal to eat fish at least once or twice a week. Beef, pork and sweets should be the smallest amount of what you eat, no more than once or twice a week. Chicken and turkey are good for you, but check the labels to make sure they have not been raised with antibiotics and hormones. Get organic chicken and eggs from farmers markets if you can.