FAT REFORM:
OBESITY, FOOD POLITICS AND THE
PERILS OF DIETARY CARBOHYDRATES
Jeffry N. Gerber, M.D., Denver’s Diet Doctor
Family Physician, Littleton Colorado
DenversDietDoctor.com
facebook.com/DenversDietDoctor
Disclosures
 None
Outline
 History and Politics
 Science of nutrition & the evidence
 Re-write the nutritional guidelines
 Summary and action plan
Diabesity: A Twin Epidemic
 The spectrum of Insulin Resistance
Obesity Statistics
 The progression of insulin resistance
 44% obese in 2030
 33% diabetic in 2050
Sources: TFAH, OECD, WHO, CDC, ADA
Historical Perspective
“I am such a glutton and sloth”
 Blame behavior and lifestyle choices
 Eating too much and exercising too little
 Obesity is caused by positive energy balance!
 A simple explanation
 Health insurance will not pay for treatment
 Its your fault, your problem, you fix it!
 The Lipid Hypotheses 1950’s
 Avoid caloric dense fatty foods
USDA Dietary Guidelines 1977-1980
Phillip Handler : “A vast nutritional experiment”
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Less saturated fats, less calories
More poly-unsaturated Vegetable oils
More carbohydrates, starches, sugars
More inexpensive food commodities
Weak evidence, the wrong tools!
Macronutrient Content
 More refined carbohydrates and less saturated fat
 Total caloric intake increases from sugar consumption
-MMWR, Morbidity and Mortality Weekly Report, February 6, 2004 / Vol. 53 / No. 4
Does Saturated Fat Cause Heart Disease?
http://www.awlr.org
 Outcomes looking at MI, death from MI and stroke
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Observational - 16 studies - No!
Observational - 8 studies - Yes but problematic!
Observational - 2 meta analysis, 350,000 subjects - No!
RCT’s - Clinical trials - 2 well done - No!
RCT’s - Clinical trials - 3 meta analysis - No!
RCT’s - Clinical trials - 1 meta analysis - Yes but problematic!
Food Politics: Agriculture
 Industrial revolution and the food commodities
 Corn, Wheat, Rice, Potatoes
 Sugars: Cane, Beet, HFCS
 Soybean and industrial Vegetable oils
 Whole foods expensive: Animals and other Plants
 Farming incentives, increase yields, GMO’s
Food Politics: Manufacturing and $ales
 To sell refined and processed foods for profit
 Food commodities are the raw materials
 Tasty and addicting foods, eat more
 Deceptive advertising: “Healthy foods”
 Food lobbyists funding politicians
 Selling food not health
Our Ancestors Before Agriculture
 Hunter gatherers and the Paleolithic era
 Whole foods, some carbs
 Animals including Fish, seasonal Veggies, Fruits ,Nuts and Roots
 Use of fire
 Agriculture and the Neolithic era
 Cultivate Grains and domesticate Animals for Dairy
 Modern civilization changing nutrition
 For better or worse
The Cost of Healthcare
 World leader in healthcare spending since 1980
 Treating chronic diseases
 Medicare and Medicaid industry guidelines
 Treatment of illness and disease only
 Obesity not a medical condition
 A reactive and costly approach to healthcare
 Preventive services task force 2012, counseling
 Treating obesity complications is profitable
Evolution - Are You Kidding?
Nutrition changing humans in our lifetime!
The Food Revolution: Andreas Eenfeldt, M.D.
Fat Reform is Healthcare Reform
 Address obesity
 Save trillions treating complications
 Food industry regulation!
 Healthcare delivery
 Nutrition and center stage
 Re-define healthy nutrition
 Re-educate
 The perils of dietary carbohydrates
 In defense of dietary fat
Nutrition and Metabolism 101
 Food metabolism
 All macronutrients are not created equal
 Carbohydrates are fattening and inflammatory
 Fats and proteins
 Obesity is a chronic metabolic disease
 Insulin resistance
 Inflammation
Carbs
Proteins
Fats
Insulin and Insulin Receptors
 One of several hormones
 Regulate energy and energy storage
 Dietary carbohydrates, the primary fuel
 Turn on the insulin switch
 Dietary proteins and fats, secondary fuels
 Minimal effect on insulin, essential
 Insulin receptors normal function
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Cells, muscle, tissue absorb energy and nutrients
Excess food energy converted to fat and stored
Normally insulin will suppress appetite
 insulin promotes the release of stored energy
 Basic physiology
Insulin Resistance
Increased Insulin
Production
Weight Gain
 Years of carbohydrate overload
 More insulin is required
 Excess energy, stored as body fat
 Receptors become strained and resistant
 Beta cells strained, abnormal response
 A disease of insulin overload
 Insulin resistance makes us hungry
 Fat cells literally starve lean body tissues
 Hypothalamus, Nucleus Accumbens
 Eventual loss of central signals
Increased
Resistance
(Hunger)
Regulation of Food Intake
 Leptin – Insulin – Amylin – PP - Ghrelin - PYY - GLP-1
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Resistance changes signaling
 Promotes inflammation and mitochondrial dysfunction
Inflammation and Adiposity
Inflammation
Dyslipidemia
Premature
Ageing
↑ Lipoprotein lipase
↑ IL-6
↑ Angiotensinogen
Hypertension
↑ Insulin
Liver & Gut
↑ CRP
↑ FFA
↑ TNFα
Cancer
↑ Adipsin
(Complement D)
Dementia
↓ Adiponectin
Fertility
Insulin
↑ IGF-1
Resistance
↑ Resistin
↑ Leptin
↑ Lactate
Type II
Diabetes
↑ Plasminogen
activator inhibitor-1 Atherosclerosis
Thrombosis
Lyon CJ et al. Endocrinology 2003;144:2195-200; Trayhurn P et al. Br J Nutr 2004;92:347-55; Eckel RH et al. Lancet 2005;365:1415-28.
Insulin Resistance Evaluation
Overweight
Obesity
Pre-diabetes
Type II Diabetes
(Metabolic Syndrome)
 Anthropometric measurements
 Medical and family history, physical
 2hr OGT, GTT
 Metabolic markers of inflammation
 HgA1c, c-peptide, Insulin, CRP, Thyroid, etc…
 Cholesterol testing as a marker for atherosclerosis
Insulin Resistance Treatment
 The food is the medicine
 Remove the optional fuel
 Less dietary carbohydrates
 Turn off the insulin switch
 Control hunger and appetite
Insulin Resistance Treatment
 Dietary proteins
 Essential, healthy
 Dietary fats and cholesterol
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Essential, healthy
Caloric dense and filling
NOT inflammatory or atherogenic
One exception
 Carbs and fats together
 Standard American diet (SAD)
 Carbs are the catalyst
http://deliciouslyorganic.net
Insulin Resistance Treatment
 Medication
 Physiologic drugs
 Metformin, Byetta, Victoza, Bydureon, Symlin
 Rx appetite suppressants
 New and future drugs
 OTC market
 Treat co-morbidities
 Nutrition center stage
 Gastric bypass surgery
http://peaceloveandlowcarb.blogspot.com
Eat Real foods
 Focus on the carbohydrate content of food
 Avoid high glycemic foods, processed foods
 Eat low glycemic foods, whole and unprocessed
 Healthy natural fats
 Butter, Animal fat, Coconut oil, Olive oil, Avocado, Fish oil
 Low-Carb High Fat (LCHF), Ancestral diets
 Control of appetite and promote weight loss
 Enhanced fat burning during exercise
 Quantity, calories and portion’s not the focus
Comparing Diets Head to Head
 Compare the macronutrient content
 % of calories from carbs, protein and fat
 Very low fat <10%, high carb, low calorie
 Very low carb <10%, high fat, LCHF, 1860’s
 LCHF vs. Ancestral diets
 Food quality important
 What diets are healthy and safe?
 Low carb high fat (LCHF) diets improve health!
 Greater weight loss, improved lipids and blood sugar
 Dozens of RCT’s, Stanford 2007, Duke 2004, Penn 2003, 2011
 Meta analysis , Santos 2012
Calories consumed equal, Atkins LCHF diet
better controls insulin, weight and appetite
Lipid profile improved on Atkins LCHF
Advanced Lipids and LCHF Diets
 Favorable LDL subclasses or particle sizes
 Triglycerides decrease, healthy HDL-C increases
 Other markers
 Apo-B, LDL particles
 Lpa, genetic markers
 Advanced labs
 Berkeley Heart Lab
 NMR Liposcience
 VAP Cholesterol
Effects of LCHF diet on emerging plasma markers, Richard
J. Wood, et al. J. Nutrition. 136:384-389, February 2006
 Marcia at 262 lbs, BMI 41
 lost 70 lbs, now 192 lbs, 27% loss TBW, BMI 30
Dr Gerber Patient: Marcia
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Female age 45, 5’7”, 262 lbs, BMI 41
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OGT performed, FBS=96, 1HR=180, 2Hr=129
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HgA1C=6.4%, c-peptide=4.7
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TRG=221, HDL=36, TC=148, LDL=69, NON-HDL=112, TC/HDL=4.2, LDL Pattern A/B
8 months later lost 70 lbs, 192 lbs, BMI 30, 27% loss of body weight
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FBS 76
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HgA1C=5.1%, ?c-peptide
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TRG=147, HDL=40, TC=186, LDL=121, NON-HDL=151, TC/HDL=5.2, ?particle size
 David at 312 lbs, BMI 40
 http://mendosa.com
 lost 153 lbs, now 159 lbs, 49% loss TBW, BMI 20
Dr Gerber Patient: David
 Male, age 71, 6’3”, 312 lbs, BMI 40
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OGT: FBS=105, 1HR=219, 2HR=201
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HgA1C=6.8%
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TRG=193, HDL=28, TC=225, LDL=158 , NON-HDL=197
 2 years later, lost 153 lbs, 159 lbs, BMI 20, 49% loss of body
weight
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OGT: pending, FBS normal
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HgA1C=4.6%
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TRG=109, HDL=40, TC=155, LDL=93, NON-HDL=115
 Patrick at 220 lbs, BMI 32
 Lost 45 lbs, now 175 lbs, 20% loss TBW, BMI 24
Dr Gerber Patient: Patrick
 Male, age 53, 6’, 220 lbs, BMI 32
 OGT performed, FBS=86, 1HR=148, 2HR=103
 HgA1C=5.4%, c-peptide=4.1
 TRG=133, HDL=47, TC=238, LDL=164 , NON-HDL=191, TC/HDL=5.1
 7 moths later lost 45 lbs, 175 lbs, BMI 24, 20% loss of body
weight
 FBS=77
 HgA1C=5.1%, c-peptide=0.9
 TRG=75, HDL=78, TC=200, LDL=75 , NON-HDL=122, TC/HDL=2.6
Dr Gerber Patient: Eric
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Age 43, lost 10 pounds on a Paleo diet, 183 lbs, BMI 25
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Berkeley Heart Lab
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Triglycerides and HDL-C improved, LDL-C, Apo-B unchanged
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LDL subclasses (particle size) remained favorable, 9p21 genetic markers at risk
Carotid IMT, 39 yrs., heterogeneous plaque <20%
Author: Gary Taubes
Nutrition and the history of weak scientific evidence
 2002 New York Times Magazine:
What If It’s All Been a Big Fat Lie
 2008: Good Calories Bad Calories
 2010: Why We Get Fat: And What To
Do About It
 2011 New York Times Magazine: Is
Sugar Toxic
 2012 Newsweek: Why the Obesity
Campaign is failing
Nutrition for the New Millennium
 Re-defining healthy nutrition
 Less refined and processed foods
 More whole foods including natural fats
 New federal dietary guidelines
 Food industry regulation
 Re-define healthcare delivery
 Nutrition centerstage
 Control the cost of healthcare
Good Food is Good Medicine!
Jeffry N. Gerber, M.D.
DenversDietDoctor.com
facebook.com/DenversDietDoctor