The Huffington Post is at it again- by promoting a nutrition quiz from the Physicians Committee for Responsible Medicine (PCRM).  One would think that a group like PCRM would be a responsible group, with a website that would have credible information. However, PCRM is a vegan organization that promotes an anti-dairy, anti-meat, anti-seafood, anti-egg diet, and the purpose of their quiz was to help evoke those ideas.  They have also sent out news releases that are bias to  a vegetarian diet and argues for it with half-truths that do little to advance their position, and a lot to reduce their credibility.

Recent breaking news quoted a paper in that indicated that fish oil did not prevent recurrence of heart problems and “evidence fails to support their use.”  PCRM did not include the conclusion:

“However, a diet high in fatty fish (≥2 servings of marine fish per week) should continue to be recommended for the general population and for patients with existing CVD because fish not only provides omega-3 fatty acids but also may replace less healthy protein sources, such as red meat.”

PCRM is anti-fish, as well as anti-dairy, and they fail to note that the American Heart Association recommendations for two meals a day being replaced by fish.

Recently PCRM released another study showing E. Coli was in 48% of chicken bought in 10 cities by their group. What they failed to state was that the E.Coli was not the type that causes humans illness.  Further, the major outbreaks of food-borne illness have recently come from produce and peanuts – as they are grown in soil that contains E. Coli. and can be contaminated with salmonella.  There are many types of bacteria in the soil, and E. coli is a common soil bacteria, but it is not the same type as that which comes from feces.

If you were a Vegan this might be your view of food

Here is their quiz with Science and Evidence based medicine rebuttal:

(1) Skim milk has the same amount of calories as cola

Yes, they are anti-dairy, and this is suppose to scare people into thinking that dairy is bad. For those who can tolerate milk, those who are not lactose intolerant, milk is a great source of nutrients.  Cola, not so much. They say all you need is water, nothing else – and we agree, however,  milk can have plenty of nutrients in them and should not be over looked.

(2) Cheese and steak have the same amount of cholesterol.

The first question you should ask is- so what? Dietary cholesterol has a minimal effect on the blood level of  the body’s cholesterol, we have known this since I was in medical school ( 1980’s). You can see my last post about fats to see more. That different amounts of cheese as well as a porterhouse steak have the same amount of cholesterol means nothing.  Very few physicians look simply at the cholesterol level, unless it is either very high >250 – and then we look at the underlying lipid profiles.

(3) Cheese is 70% fat.

Some cheese is, but again, cheese in moderation is not a bad thing. Some cheese is not  70% fat. By the way, most nuts, which this group advocates, are also 70% fat. They go on to say that Americans are eating three times the cheese we did in the 1970′s – probably not the case for some. Cheese is something that should be used in moderation – as it is dense with calories

(4) Frequent consumption of hot dogs and bacon makes it more likely you will get colon cancer.

In the one study, that has many flaws, if you eat a diet rich in processed meats your risk of cancer is higher- by a small amount. But that is a correlation, and not necessarily a causation, and when you work out the statistics, your chance of eating that much (a lot ) is not much, and your chance of getting cancer from it is – well, we don’t know. We don’t advocate eating a lot of processed any food. They state that the recommended amount of processed meats would be “none” – we would disagree, as do bacon lovers everywhere.  The correlation is so small with this as to be stretched.

(5) Women who regularly eat soy have a lower cancer risk.

This is not necessarily so.   Comparison studies have been mixed- so the answer is, we don’t know.  PCRM based their information about population studies from Asia- but other factors these women have include (a) less obesity (b) more physically active (c) drink less alcohol (d) eat more fruits and vegetables. Until the issue becomes clearer, many doctors recommend that women who take hormonal therapy or who have estrogen-receptor-positive breast cancer avoid soy supplements because they contain high concentrations of isoflavones. But in general, it’s fine to eat moderate amounts of soy foods as part of a balanced diet. One to 3 servings of soy a day (a serving is about a half cup) is similar to an average Japanese woman’s daily soy intake. If you are taking hormonal therapy to fight off a hormone-receptor-positive breast cancer, and you are concerned about any phytoestrogen effects, ask your doctor or registered dietitian about how much soy you can eat.

(6) Salmon has cholesterol and fat

Ah yes it does, and to repeat- consuming cholesterol is not the issue. Salmon fat is high in omega-3 fatty acids and quite healthy. Eskimos and maritime Native Americans had a diet rich in salmon and the lowest rate of heart disease on earth.  There is not convincing evidence to advocate taking fish-oil capsules, there is still evidence that replacing two meals a week with fish is protective for the heart.

(7) An egg has more cholesterol than a Big Mac

Cholesterol is not an issue in diet but the 540 calories in a Big Mac compared to the 90 calories in a large egg is. The calories in a Big Mac come from 29 grams of fat, while only 5 grams of fat from an egg. While PCRM has an issue with dairy, as do some from the Paleo diet, eggs are a healthy source of protein.  If you get rid of the yolk you can get rid of a lot of the calories also. The amount of cholesterol is less important than the lower calories- and you could always use egg whites which have less fat, much less cholesterol, but a great source of protein.

(8) Milk, Beans, and broccoli are all high in calcium

This is true, and for those who need a good source of calcium but do not drink milk, there are some good alternatives. They point out that the calcium in the beans and broccoli is absorbed at a rate of  50-60%, while milk is just  32%. What they fail to point out is that 1/2 cup of broccoli contains 21 mg of calcium while 8 oz of nonfat milk contains 300 mg. That means from broccoli you get 11 mg of Calcium which is about 1 percent of the daily requirement. If you get non-calcium enriched milk you are still getting 100 mg of calcium or ten times the amount you would with broccoli.

Vegetarians may absorb less calcium than omnivores because they consume more plant products containing oxalic and phytic acids . Lacto-ovo vegetarians (who consume eggs and dairy) and non-vegetarians have similar calcium intakes. However, vegans, who eat no animal products and ovo-vegetarians (who eat eggs but no dairy products), might not obtain sufficient calcium because of their avoidance of dairy foods.

In the Oxford cohort of the European Prospective Investigation into Cancer and Nutrition, bone fracture risk was similar in meat eaters, fish eaters and vegetarians, but higher in vegans, likely due to their lower mean calcium intake.  It is difficult to assess the impact of vegetarian diets on calcium status because of the wide variety of eating practices and thus should be considered on a case by case basis.

(9) Fish and Beef have no fiber

Quite true- there is no fiber in meats. This is why a balanced diet contains fruits and vegetables. However, fish and beef contain better sources of fat absorbable vitamins, calcium, B12, protein, and other nutrients than vegetables do.

(10)  A skinless roasted chicken breast has more calories per ounce than soda or white rice

This is quite true- and mainly because of the fat content of the chicken. But chicken has more nutrients than white rice and more than soda.

PCRM also was responsible for the comments that E. Coli was found in many of the chicken products.  What they didn’t say was that the E. Coli they found were not the same as responsible for food borne illness.  In fact, the E. Coli they found was the kind commonly found in the soil, where the very plants grow that they advocate consuming. The pro-Vegan group also neglected to mention that the majority of Salmonella infections that have caused major outbreaks have come from agricultural products, including peanuts, that they advocate for a healthy diet.

It appears that PCRM is more propaganda than science. If you are going to advocate for a position, your position is diminished when you don’t tell the full story. If cornered in press conferences they avoid the answers to the questions. This is not a place to get information at all.

In the case of diet and lifestyle, there is a lot we do not know- but PCRM as a source of nutritional information is less than adequate, in that often it does not tell the whole story.  As a website for health and information it is more like a political party than a resource for those looking for evidence based medicine or science based medicine.

One of the misleading advertisements from PCRM

For real science- we are juggling what we eat to find the best fit

Re-reading the study about red meat and its increase in mortality, I continue to go back to the gold standard of lifestyle epidemiology- smoking.  People who smoke one pack of cigarettes a day have a 20-fold increase in lung cancer. 86% of all lung cancers in the United States occur with smokers, or ex-smokers.  One can reverse prove this- people who quit smoking decreased their risk of heart disease as well as lung cancer for every year they had stopped. This was the gold standard that all other lifestyle researchers are trying to find. After smoking the next great one was second-hand smoke, and sadly the correlations between mortality and second-hand smoke fell apart – although that did not stop public statements.

Still others try to find that meat, or fat, or carbs, or something causes an increase in the rate of death. So what did is the real red meat of this study (sorry).

What this paper discovered was that the increased risk is that less than one person in one hundred died (less than 0.2% with heart disease and 0.32% with cancer – as opposed to the gold standard of a 20 fold difference).  Let us put this into the context that the article did not, and that most media did not – that one person in one hundred over a 28 year period who died also smoke more, drank more, had less physical activity, and was obese.

The article states they did a multivariate analysis to adjust for age, race, smoking, drinking, activity, caloric intake, and obesity – and removing those factors they still have, in the highest quartile, the increased rate of death with less than a 1.2 fold difference (compared to 20 fold for smoking and lung cancer).  For those of you not statistically or mathematically prone, this simply means they found a way to negate the influence of each of those factors so that the simple and singular analysis of each quartile (quartile one being the lowest meat eaters and quartile 5 being the largest consumers of meat) stands alone. They do not show us this data – we just take them at their word that this person who died, the one person in 100 in 28 years, who drank more, smoked more, was obese, did minimal physical activity, and ate more meat- died because they ate more meat.

Some nutritionists think we should graze on plants

Does this study really tell us that substituting one meat free meal a week will decrease mortality? Not really.  This was a statistical trick to take the people from one quartile to another- and in that they reduced risk.

If you examine the raw data, without statistical manipulations- you find that death rates go down with increased meat consumption until the fourth and fifth quartile.

Does this article shed light on how we should eat or what we should eat? No, it does not. In fact, this article is a statistical nightmare of a piece that gained attention because of its conclusions.

Take heart, there have been prospective studies of diets to see how they work, and these have been short-term studies, but they were corrected for variables. The diets examined include low-carbohydrate diets, Mediterranean diets, the Ornish diet, and others (Gardner CD, Kiazand A, Alhassan S, et al.: Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women. JAMA 297:969–977, 2007) and Comparison of the Atkins, Ornish, Weight Watchers, and Zone Diets for Weight Loss and Heart Disease Risk Reduction: A Randomized Trial Michael L. Dansinger, Joi Augustin Gleason, John L. Griffith, Harry P. Selker, Ernst J. SchaeferJAMA. 2005;293(1):43-53.)

We have moved beyond poorly done population studies – and are into trying to determine what is the best diet for people to consume.  We have more questions than answers – but the science tells us a few things:

Weight loss is good for all of us

(a) No matter which died patients are placed on, if it yields weight loss (probably meaning people are compliant on the diet)  reduced the cardiac risk factors including C-reactive protein, insulin levels, and reducing the low-density lipoprotein/high-density lipoprotein ratios.

(b) We really don’t know about fats, as much as we think we do

(c)  No one seems to like bread these days

(d) We all like grass fed beef, flaxseed fed chicken eggs, and anything that is free on a range (home on a range).

(e) We all like whole plants- but some of us like them more than others

(f)  Exercise is universally associated with better results, and you cannot exercise your way out of obesity.

To paraphrase Gary Taubes of “Good Calories, Bad Calories”- nutritional epidemiology is closer to pseudoscience than it is to science.

The Paleolithic diet presumes that foods eaten during the stone-age (Paleolithic era from 2.5 million years ago to 10 thousand years ago) are optimal foods for humans. The Paleolithic (Paleo) diet includes grass fed beef and other lean meats, fish, shellfish, fruits, vegetables,  eggs, nuts, but no grains, no dairy, no salt, no refined fats (butter or margarine) and no sugar or high fructose corn syrup.

Fanatical Diet (Lifestyle types)
There are three things one should never discuss in polite company, religion, politics, and diet. Getting into an argument with proponents of diets is like a democrat trying to convince a republican that Obama is ok. Each side will quote their own studies, statistics, and population studies. But the key to scientific study of the various diets is not what we presume from correlation, but from what we learn when that diet is placed into patients – in this case, the laboratory values of those who have the diet.

Diet proponents become fanatical about their diet (lifestyle) to the point of religious fervor. Seeking to prove that their diet is backed by science, proponents use population studies with associations that are only suggestive and not proof of causation. These associations become propaganda as the associations are repeated over and over, morphing from a suggestion to “proof.”

The Flaws of population studies or Correlation does not equal causation
The foundation of many diets are based on the correlation of what a population eats and what diseases they suffer from. In the Paleo diet the assumption about what they ate and the diseases they suffered from is a spurious correlation at best, and far from causation.

Population studies are flawed, as often we find that we don’t know as much about the population as the data might suggest. Take the Pima Indians of the Southwest. In 1990 a paper came out stating that the Pima Indians had a low incidence of fatal coronary heart attacks in spite of having a high rate of diabetes. The Pima Indians were called among the most studied populations, with an NIH post in Phoenix, and lots of studies showing the highest rate of diabetes in the world. When the population was examined more carefully, the Pima Indians had plenty of heart disease.

Step back from the most studied group in the United States with great statistics and physicians trained in modern medicine and then imagine making conclusions about what Chinese eat, or Mediterranean’s, or French. Those assumptions are more flawed, as are the statements about what diseases they do or do not have. Now step back further trying to determine what people of the Stone Age ate, what diseases they had, and we leave the tenuous role of suggestion and enter the role of outright guessing. Even if we have reasonable data (and often we don’t – even for the best studied people in the United States) the correlation between what people eat as a cause for what diseases they have is a fundamental flaw. Correlation does not equal causation.

The Best Diet or Lifestyle is?
When it comes to the best diet plan for a person – we just don’t know enough to say that one is better than another. There isn’t enough evidence to state that the Paleolithic (also called Paleo) diet is better than the Ornish, Southbeach, Pritiken, or pick one, or better than how you currently live your life.

We cannot broadly say that any given diet will prevent heart disease, cancer, arthritis, or even obesity. When someone tells you a diet can prevent such, they have gone from the realm of science to the realm of bs.

The Paleo Diet Premise:
The Paleo diet premise is that we should avoid certain foods because our body is not evolved to process those foods, and if it does process them it will lead to the chronic diseases of modern man – heart disease, strokes, cancer. Cavemen didn’t have those diseases, so we should eat like cave men. Of course, we don’t know about what diseases that cavemen had – especially when it comes to organ and soft tissue diseases, we just have a few fossils that we examine and look for evidence of known diseases. Would coronary artery disease show up in a fossil – nope? Would cancer show up in the fossil – bone cancer would (kind of a rare cancer) or cancer that went to the bone might – but it would be hard to tell if the fossil evidence.

We do know, from many hunter-gathering societies, that they live a short life, and not long enough to develop the diseases we associate with aging. All a person has to do to pass on their genes is make it into puberty, and to be effective to nurture the young, into the 30′s, and to see grandchildren and help child raising – into the early 40′s. That is what a simple civilization needs. After that, in any primitive society, the elderly become a burden – perhaps to be placed on an ice flow. People who live into their 40′s and 50′s may die of cancer, heart disease, or obesity- but they will have passed on their genetic code.

The Evolution of Homo Sapiens:
When Homo Erectus came out of Africa, they encountered a world that was much more varied in food sources than Africa. The brain of the human (H. sapiens) evolved, becoming much larger, and utilizing far more energy than the brains of the Australopithecus – about 10 percent more. More than any other species, humans evolved a brain that required more calories- and our brain metabolism accounts for up to 25% of our energy needs. Bigger brains and its increased requirements mean a richer diet- and modern hunter gathering species derive about half of the energy from animal foods – in contrast with other primates that have far fewer animal foods. While our ancestors the Australopithecus dined on plant foods, and had large mouths to grind up fibrous plants – humans are built, with smaller faces and jaws, to dine on energy rich animal foods.

The reconstructed skull of Lucy, Australopithecus- large jar and muscles for eating plants

The Human skull is larger, larger brain- and jaws for more energy rich foods

Humans were successful, as the fossil record shows, because they were “flexible” eaters, using a wide variety of dietary strategies. If there were a lot of Elk, then we ate elk- berries, we picked berries. To state that our digestive system evolved only to eat some few items found in the Stone Age – has been disproven on the face of it. Our ancestors in Africa didn’t encounter Arctic char, whales, seals, salmon – and yet when they moved from that warm climate to the frozen north, they adapted quite well to a very high fat diet of primarily animal based diet that was clearly not available in Africa. The findings of starch grains from wild plants in grinding tools from sites in Italy, Russia, and the Czech Republic from the mid-upper Paleolithic era suggest that the production of flour was present 30,000 years ago.

Contrary to what Paleo proponents state: people made flour 30,000 years ago

How to eat like a caveman
There are some things about the Paleo diet that people avoid:

Excess sugars including fructose
Excess Omega 6 oils – including soy
Processed wheat, grains, and gluten
Dairy

What is the scientific evidence for this? It’s the simple premise that modern man has lifestyle illness from altering food, taking in too many calories, and if we would return to our ancestors roots (pun intended) we would avoid these highly processed foods and not suffer from the holy trinity of diabetes, obesity, heart disease, and maybe even cancer. There is not a single shred of evidence to support the premise of this diet.

An entire dietary regimen has been formed with plenty of books and websites to guide you through this. It has become so popular that the question becomes not the flawed premise for the diet, but rather how the diet would compare to other diets. If you want to eat like a caveman, then shop on the outside of your grocery store.  Everything on the inside of your grocery store is generally processed foods, and everything on the periphery of the grocery store is generally not processed.  On the periphery you will find the vegetables, fruits, meat counter, fish counter – although you might get in trouble with dairy, and before you check out they might have a cookie or two – or there might be a bakery (a big no no among the non-Geico types). But lets be clear- whatever the caveman could get that they could eat- they would eat, and if a caveman were to be around today- wait, we have them – well, they eat Poptarts.

In one real scientific study patients with known heart disease who were randomized to either the Mediterranean-like diet (based on whole grains, low fat dairy products, fish, fruit, and vegetables) or the Paleolithic diet (no grains or dairy but plenty of lean meat, fish, fruits, vegetables, root vegetables, eggs, and nuts) and those who undertook the Paleolithic diet were satisfied with less food. There was also a decrease in leptin in the Paleolithic group by 31% and by 18% in the Mediterranean group.

There have been other studies that show that people who go with this diet have improved laboratory values – less triglycerides, lower blood pressure, some weight loss, that the diet has a better glycemic index (the food doesn’t increase blood glucose levels as much). This diet compared to a standard diabetic diet did better. Those studies are short term, with small numbers of individuals, and hints of laboratory values.

So before one assumes I am putting this diet plan into the trash bit along with Ornish- there is clearly some data here that shows good nutritional sense in the food.

While highly processed carbohydrates transiently increases blood glucose levels more than whole grains – it does not mean that bread is bad for a person. At least we don’t know enough about this to state that today. Clearly, people who eat a lot of flour based products can get fat quickly, and getting off the bread and bakery products will help reduce weight, decrease hemoglobin A1C levels, decrease triglycerides, and overall be healthy.  Some people need to be told to never eat them again – as some alcoholics must never drink again- and some people are able to moderate them so they do minimal damage to the body.

Only a few studies have examined the effects of the Paleolithic diet on laboratory values that we associate as increased risk for disease – but again, those were laboratory values, not a long-term follow up for disease.

The premise for the Paleo diet may be flawed, but here are the parts of the Paleo diet that most would agree with:

(a) Highly processed grains – white flour, rolled oats- do cause a rapid increase in blood glucose levels and the body responds to that by increasing triglycerides and ultimately fat.
(b) Fish – as long as it is not contaminated with mercury, is a protein source that is high in Omega 3 fatty acids, which have been shown to be beneficial. If you have some great fish three or four meals a week it works out well.
(c) Vegetables and fruits are the basis for most diets- thus a vegetarian could participate in a Paleo diet easily. Too many people do not eat enough fruits or vegetables or look to them as snacks.
(d) The trend away from cattle feedlots and desire to have grass fed rather than grain fed beef. Grain fed beef is fatter and more prone to being infected with Salmonella or E.Coli than grass fed beef.  There is a wider variety of taste with grass fed beef, and most who find grass fed beef end up preferring its flavor. Grass fed beef is best cooked with Sous Vide cooking.
(e) If you eat more calories than you burn you will gain weight. But it is more than just calories – it is also the types of calories. Eating high glycemic index foods mean you will spike glucose pushing it into cells, where it will be quickly transformed and stored as fat. Low glycemic index foods will be slowly burned  - thus, calorie for calorie with the Paleo diet plan you will tend to burn the fuel from the food as opposed to store it.
(f) If you eat a majority of your food with highly processed grains instead of whole grains you will have a faster rise in blood sugar. Some attribute this rise to increased obesity and an increased load on the pancreas.

Overall- this is not a bad diet program. Nothing in it would appear to cause nutrient deficiencies and there is some preliminary evidence that this diet keeps a person more satisfied with less food. It is a low-carbohydrate diet, and those diets, in comparison to other diets, tend to produce faster and longer weigh loss.

Here are a few scientific references- I’m sure we will add more as time goes on

Low incidence of fatal coronary heart disease in Pima Indians despite high prevalence of non-insulin-dependent diabetes. RG Nelson, ML Sievers, WC Knowler, BA Swinburn, DJ Pettitt, MF Saad, IM Liebow, BV Howard, and PH Bennett
Circulation. 1990;81:987-995

Food for Thought: Dietary change was a driving force in human evolution. Wm R Leonard. Scientific American. December 2002: 107-114.

A Paleolithic diet is more satiating per calorie than a Mediterranean-like diet in inviduals with ischemic heart disease. Jonsson, et. Al. Nutrition & Metabolism 2010, 7:85

Thirty thousand-year-old evidence of plant food processing. A Revedin, et al Proc. Nat. Acad. Sci, November 2010: 107:18815-18819

Dr. Esselstyn noted the risk of heart disease in rural China was low in the 1970’s – and presumed that they didn’t have a “western diet.” Now there are two flaws in his population statistics: First in the 1970’s in rural China most individuals were starving to death – it was the end of the cultural revolution and any source of food that could be found and eaten was. The second issue is if you examine data from The China Study you will see that heart disease mortality was lowest in the rural communities that were able to eat more meat. In The China Study (again, I promise this will be a topic later) – they used mortality statistics from the time during the end of the Cultural Revolution. Rural China was starving then, all trees had been used for fuel, there were virtually no birds left (combination of deforestation and hungry humans) and rice was used for the army.

Dr. Esselstyn then talks about Norway during World War 2, when they were occupied by the Nazi Germany, and how that heart disease diminished as the Norske were forced to eat a plant based diet. That was a great assumption to make, but when examining the data from Norway there are a few interesting factoids – Meat consumption dropped 60% but fish increased 200 per cent. Vegetables and potatoes increased but sugar decreased by half. And when the data is put to a microscope in 1942 and 1943 when mortality declined, animal proteins were still higher than before the war. It appears that Norway suffered from increasing fish (great source of Omega 3 fatty acids) and foraged for foods such as wild greens, grew and ate a lot of potatoes, but had a low amount of sugars and almost no margarine (I don’t know a respectable Norwegian today who cooks with margarine). The sad part of the war was the increase of mortality from infectious diseases – especially pneumonia (my mother’s cousin who fought for the resistance died of this, as did many of his comrades).

Norway in WW2 ate a lot of fish- and this roe was popular

He followed these patients for up to 12 years – his numbers are confusing as he started with 24 patients and six dropped out (leaving 18). One of the 18 died from his heart disease (leaving 17). At ten years there were 11 patients. They did angiography and reported a regression of 11 lesions with 14 remaining stable.

Angiogram- xray - of a plaque. Not enough to do surgery on though

When any study talks about a “cardiac event” it means to most of us a heart attack. If you have a small lesion in a coronary artery and then that lesion accumulates a blood clot that is what a heart attack is. The blood clot (from platelets – a sticky component of blood that helps you clot ) blocks the flow of blood to the heart muscle. If the clot blocks blood flow for a long time then the heart muscle dies and you have a myocardial infarction, if it opens up then all you have is a heart attack. This has little to do with the size of the lesion, and more to do with the complex chemistry of the coagulation system. Hence, taking aspirin a day or Plavix is more beneficial.

The other major problem with the study is that these individuals were on lipid lowering medications. Dietary reduction of lipid level (Cholesterol and lipoproteins such as VLDL, HDL) is about ten per cent on average, but never more than twenty per cent. However, lipid-lowering medications – such as Crestor – can remarkably lower levels of the lipids. In addition, lipid-lowering medications are best for reducing inflammation. They are anti-inflammatory to blood vessels, meaning in addition to lowering the lipids and cholesterol, their main effect is to reduce the chance of having a “coronary event.”

Crestor shown to be effective at decreasing the plaque in arteries

One of my cousins, preventing heart disease and eating fat

What we think we know about how the body reacts and what we really know are two different things – here are some popular myths through the years as they relate to diets.  The most dangerous assumptions about diets come from population studies, you have heard them,  this population did that, and here is why this diet is great…

Seven-Country Study:

Warning against all fats- he became the cover boy for Time in 1961

From the 1960’s through the 1970’s the primary focus of the American Heart Association to the Congressional Paper by McGovern in 1976 was cholesterol.  It was wrong – but the ramifications of this public policy live on in many nutritional books today. Ancel Keys, a physiologist, promoted this based on the “seven country study” where he concluded serum cholesterol was strongly associated with heart disease, therefore a diet low in cholesterol would reduce heart disease. The statistical data did not back up his conclusion- he left out the “French” paradox – and ignored the Japanese increase in meats after he war with a reduction in strokes and heart disease. We now know the “epidemic” of heart disease was more related to the increase in cigarette smoking than diet changes.

Now we have science (and my previous post have discussed this particular diet) – and science has shown that it is not cholesterol, nor is it dietary cholesterol, nor is it even saturated fat that is the problem. We  have also discovered that margarine- which is trans-fat, is probably one of the worse things that a person could have.

Keys later in life said cholesterol wasn’t so important. He then discovered olive oil, and was one of the founders of the Mediterranean Diet. He lived to be 101.

The China Study

Colin Campbell pooled blood samples from 100 remote villages in China, and based on the data came to the conclusion (which he had come to before) that those who had vegetable proteins lived the longest, and animal proteins were the primary cause of heart disease, cancer, and halitosis (ok maybe not halitosis).

The data in his study did not support his conclusions (which were remarkably made into a best selling book).  In fact, most of the data in the study, when critically examined came to the opposite conclusion. For example – the one village with the highest consumption of meat (twice that of even US populations) had the lowest incidence of cancer and heart disease.

Another bit of data – the higher the processed wheat and sugar in the diets- the greater incidence of heart disease.

For those who live in China – including remote rural China- they eat everything- all proteins, from animals, to insects, to anything that moves, walks, and crawls. Ask them what they eat for protein – and well, another story.

This has become the calling card for vegans everywhere- stating that this shows that their diet will allow them to live the longest and healthiest life.  Sadly- the study is horribly flawed and bias. A great review of this work is done by rawfoodsos.com

The Norwegian Study

Norway was invaded by Germany in World War 2 – the Germans confiscated all animal proteins to feed their soldiers  and Norwegian mortality True,  true and unrelated. Animal protein went down, fish went up 200 per cent, and sugars, flours, and processed goods were highly rationed. The other problem – mortality dropped in 1941 and Germany invaded in 1942. Other issues- in wartime, deaths from other causes – trauma (guns), pneumonia, and other infectious disease increase before a person has a chance to choke off the coronary artery.

Paleo-Diet

Ok, there are a few of these people who gather and hunt left but what we cannot conclude is that they were disease free, that they had few dental carries (cavities) and they lived in the garden of Eden. This is made up- totally made up. Sells a lot of books though.

Strong Heart Studies – the Pima Indians

When I arrived as a vascular surgeon to Arizona, I was told that the Pima Indians had something about them because they didn’t suffer from heart disease. In fact, it was such a strong issue that a study was made up – the Strong Heart Study.  This was at odds with medicine since the Pima Indians have the highest rate of diabetes in the world. Turns out, as they examined them – most Pimas die of heart disease.  Simply put- their hearts were no different than anyone else’s and their rate of death from heart disease was higher than the population.

The lesson from the Pima Indians is this—even with NIH people, and fully staffed health service- the statistics kept were not that great. Imagine a third world country, or even a number of studies done years’ ago- the statistics about what causes mortality is quite suspect.

So here is what we know from modern science and diets:

Conclusions from population studies are often flawed by the people who study them – and they come to conclusions that are often not backed by the evidence. Filled with confirmation bias, these studies are all but useless for making any conclusions to how food will affect health. Some useful things – fish are good, lots of sugar not so good, meat is ok.

With Evo we will examine some simple variables—body fat, muscle mass – some lipids and some liver profiles. Based on that we will see how his body is reacting to this. If we see anything that worries us, we will stop.

Thankfully Evo will not drink bad beer – only great craft beers.  Besides sausages- I hope to have him over to my house for some Wiener Schnitzel (it is German – and Evo will bring the beer).

I don't know much about beer - but I'll bet Evo likes this one

Who knows- perhaps the world needs more of the “Evo diet.”

Physician disclaimer time: do not attempt this diet on your own. You need a physician supervision for something like this- unless of course Evo and I write the book- in which case we will happily autograph books of  ”The Evo Diet” – please order ten at a time.

You can follow Evo’s diet journey on his blog:

http://funanymore.com/2011/09/27/brewdiet-the-beginning/

Heart disease happens when the arteries feeding the heart become infiltrated with plaques – and these plaques happen to contain fat, cholesterol, white blood cells. If the plaque builds up slowly the flow of blood to the heart diminishes and people develop chest pain or angina. If that plaque ruptures and causes the artery to close- that is a heart attack or myocardial infarction.

Plaque formation was thought to be because of a person’s diet – since the plaques had high levels of fat and cholesterol, it was thought that a diet that was low in fat and cholesterol would minimize a person’s risk of heart disease. Sometimes that is true- but not always- as the French have shown us- with a diet high in fat and cholesterol and one of the lowest levels of heart disease in the western world.

It turns out the instigator of plaque formation are the lipo-proteins that carry cholesterol and triglycerides. Think of LDL, HDL, VLDL, and IDL (low density lipoprotein, high density lipoprotein, very low density lipoprotein, and intermediate density lipoproteins) as boxcars that carry cholesterol and triglycerides. Those lipoproteins set off an inflammatory reaction in the blood vessel (they become oxidized) and that leads to plaque formation. The more of those proteins a person has, the higher the likelihood that they will develop heart disease.

Think of LDL as “lousy.” The HDL levels are associated with fewer tendencies for heart disease – but they still can cause inflammation of the artery, and a problem. Hence, artificially raising HDL levels causes more issues with heart disease (as was recently discovered in the niacin trials). HDL levels are seen in people who have more omega-3 fatty acids in their diets, but increasing their levels is still harmful.

The more lipoproteins your body makes the higher incidence of heart disease you will have.

It has only been recently that science has recognized that one must measure the lipoproteins directly. Not indirectly by measuring cholesterol – as the laboratories do today. In the recent article from the Journal of the American Medical Association, they measured LDL-cholesterol in people placed on diets rich in soy proteins, fiber, and walnuts – showing a decrease in the LDL-cholesterol – a classic mistake. LDL-cholesterol does not measure the total number of lipoproteins. The amount of lipoproteins one has depends on how much cholesterol and triglycerides the lipoproteins have to carry. If a person has a lot of cholesterol and/or triglycerides in the blood the body will make more lipoproteins. If you have too many, those lipoproteins will get into the wall of the artery and lay down their cholesterol and triglycerides (which are fats).

If you have a lot of triglycerides it will bump off the cholesterol and you will make more proteins to carry the triglycerides. Your cholesterol level will be low, but your number of lipoproteins will be high- and thus, even with low cholesterol you will have a high incidence of heart disease. This explains some of the seemingly contradictory data of people who had low LDL-cholesterol levels but a higher incidence of heart disease – when that blood was looked at later they were found to have a high level of the LDL proteins.

We still don’t understand everything about the biology of the formation of plaque but we do know this: genetics determines most of the level of cholesterol, and if your level is high reducing it with medication will reduce the incidence of heart attacks and strokes. If you have genetically high triglyceride levels, the same applies.

In terms of diet- dietary cholesterol has minimal impact on blood cholesterol. Triglyceride level can be greatly impacted by diet – however.

To reduce triglycerides in your diet, here are some suggestions:

* Eat fewer calories if you are overweight. Excess calories are converted into triglycerides and stored as fat.
* Avoid trans fats, found in some fried foods and commercial baked products.
* Replace saturated fat (found in animal fat and some tropical oils) for mono-unsaturated fat (found in olive/canola/peanut oils, etc.).
* Consume at least 2 servings of cold water fish each week, such as salmon, mackerel, tuna, lake trout, herring, and sardines (all of which are high in omega-3-fatty acid). *Include into your diet other foods high in omega-3 fatty acid, such as ground/milled flaxseed, walnuts, almonds, canola or soybean oil, etc.
* Avoid refined foods and foods that contain sugar (such as white flour, desserts, candy, juices, fruit drinks).
* Choose carbohydrates that have 2 grams fiber or more per serving, such as brown rice, whole wheat bread, and whole grain cereals.
* Consume at least 2-3 cups of vegetables and 1 cup of fruit each day.
* Follow your doctor’s advice regarding alcohol. Alcohol increases triglyceride levels for some individuals. If you have high triglycerides and do consume alcohol (such as red wine), it is recommended to limit intake to 5 ounces per day or limit it entirely.
* Exercise to burn excess calories, aiming for at least 30 minutes of physical activity on most days of the week.

Medications
People who have high triglycerides and low HDL or high LDL levels may require medications as well as diet modifications. Patients with triglycerides in the very high range (over 500 mg/dL) generally will require medications, because triglyceride levels this high may cause an acute inflammation of the pancreas.

The results, as they were with President Eisenhower- are not likely to be different.  Eisenhower ended up eating almost nothing but Melba toast and grapefruit, obsessed with his cholesterol level, and having more heart attacks until the last one killed him.

What is the evidence that a vegan diet is healthier for a person than a diet with animal proteins? None. There is no evidence that a diet that is based around plants or a diet with low animal fat does little.

Some will cite epidemiologic data- a poor source for data less than a level one.  If you cite epidemiologic data you have to explain all the data—and often they ignore the “French Paradox.”  Or ignore that while the Japanese eat little meat and have few heart attacks – their average consumption has increased over 22 percent with no increase in heart attacks (often people cite data from post World War 2 Japan, and not current Japan – and then ignore the data about stroke rate). When all epidemiologic studies are examined – one cannot justify a plant based diet on those.

Some cite the Journal of the American Medical Association (JAMA) study claiming that an animal based diet had more mortality than a plant based diet – but few have read the study.  While Dr. Ornish jumped on this study, saying it justified what he has been telling people- apparently he didn’t read the study either.

This study divided people into two groups- the low-carb group received 37 to 60 percent of their calories from carbohydrates (that isn’t low carbohydrate by any standard). The meat group was not divided out for those who smoked and were overweight (a higher portion of the meat group smoked and were obese). The vegetable group had 30 per cent of their calories from animals, as opposed to 45% for the meat group (so not really a vegetable group).  Once again, an epidemiologic study  and it is flawed.

What we do know from science about low-density-lipoproteins is that they fall into two groups- one group is far more deadly than the other, causing the majority of atherosclerotic plaques.  That is the group with the high tri-glyceride levels is the one that is deadly. Of this there is no doubt in the scientific community.  When the Very Low Density Lipoprotein and apo B – leading to high low density lipoprotein – leads the the increased in artery plaque leading to heart attacks and strokes.  The lower the triglyceride levels then the lipoproteins secreted by the liver become the subspecies of intermediate-density lipoproteins, which are far less cause of atherosclerosis than the others.  Where does the triglycerides come from? Not animal proteins, but primarily carbohydrates.

Bottom line from science – the more triglycerides – result in atherogenic small, dense LDL proteins – and this happens from carbohydrate rich foods.

What about Greece, and Southeast Asia, and Japan(after world war 2) . These populations barely had enough food to survive.  They didn’t use refined carbohydrates – and ate whatever they could. It was not the low-intake of saturated fat that protected them, rather the relative lack of a refined carbohydrate leading to low triglyceride levels. Still, those studies, championed by the late Ancel Keys, are still cited.  This in spite of overwhelming evidence to the contrary.

Back to President Clinton – a vegan diet will not save his heart. Saturated fat is not what led to the atherosclerotic plaques – rather, it was the abundance of triglycerides from highly processed and abundant carbohydrates. What he has done that will help him is, lose weight, have heart surgery, take medication –but  in terms of diet, President Clinton falls into what Eisenhower did, as well as every anorectic—when the only thing they can control is diet, they will fall victim to fads that sound healthy, are promoted by TV MD’s – but have no science to back them up.

If you want to be a vegan for health, there is no data to support that. In fact, vegans have a life expectancy that is less than pescetarians (fish eaters) and omnivores.President Clinton – a Vegan

The rotisserie is one method to make perfect chicken. This unit is at Wm Sonoma

Such dry chickens are not only unpleasant to eat- but are the types of meats that can become stuck causing what we call a food bolus.  With a food bolus you feel as if you swallowed a golf ball. Nothing else will go down. Sometimes you can’t even swallow saliva.

You may have experienced a partial one of these when you swallowed a piece of meat and you could feel it go down.  When it gets stuck- big problem.  My patients with the LAP-BAND must have moist chicken- dry chicken will become stuck and make an otherwise pleasant evening turn into a retching mess.

Chicken recipes they strive for this nirvana of chicken – sometimes with complicated instructions – but there are two methods to cook the perfect chicken. One is cooking the chicken Sous Vide, and then you have the perfectly cooked chicken needing only a quick fry to make the skin crispy. For those who have skinless chicken breasts (no accounting for taste) – Sous Vide is the perfect method to prepare the chicken.

For those who, think that a crispy chicken skin represents the best pleasure – cook the chicken on a rotisserie.  You can buy rotisserie chickens from the supermarket- but often the skin is moist with fat, and the breast is overcooked, although not dry.   If you have a home rotisserie unit you can save this most delightful part for yourself (and once you have had perfect chicken skin, crispy- you will never want to go back.

For those who believe that chicken skin is evil- I would ask you to produce one scientific paper showing such- you can’t find one. The reason you cannot find one is because they don’t exist.  They don’t exist because there is nothing wrong with chicken skin – nothing. It will not raise your cholesterol it will not raise your low density lipoprotein (LDL- remember, bad is lousy – so lousy for LDL  and “happy” for HDL).  You might read “summary “ articles from National councils or consensus reports- but there is not one shred of evidence in the scientific literature that the skin of chicken is “bad” for you – in any manner, anywhere.  Or you can listen to Rocco – a chef with no medical training who wrote a best seller, or you can listen to Dr. Oz, who can’t cite a reference either.  Or you can enjoy chicken skin knowing that a guy who does weight loss for a living says you can eat it.

Buy a rotisserie unit.  There are a bunch of them out there- it is become quite popular,  although I cannot tell you the plus or minus of any one of those units- I can tell you that many do not make the chicken hot enough to crisp the skin.  What to do? Borrow one from a friend- ask around (most of them are in closets) and try one.  If a local fancy food store is demonstrating them- try their product.

I have a 1957 Roto Broil 400 – it is as old as I am but works great (like me).  There are a bunch of great brands out there today- and if any of you have them and they work- please comment.

My Roto Broil 400 was made the year I was born, 1957. Still works great

Until then- your mom was right- the best thing is in the skin  – but not the vegetable skin – it is the chicken skin (oh, and pork belly skin is pretty good too).

Recipe for these is pretty simple.  Have a fresh, whole chicken – remove all the giblets and other parts.  Rub the chicken with extra virgin olive oil. Season the chicken with salt, pepper, and garlic granules.  No need to stuff the chicken.

Truss the chicken- and place in the unit for 15 minutes per pound.  Warning- chicken skin is addicting.

If you have a home rotisserie unit and it works well for you – please comment! Let me know the name, the make and how you make your perfect chicken.

When it comes to finding simple things to lose ten pounds in a year, often the answer is easy.  It means changing your tastes – and finding something that is a lower calorie alternative or substitution for what you normally drink.

Soda pop is nothing but pure liquid calories – and often I see people walk around with a huge container filled with soda from some convenience store.  Did you know that a can of soda is about 100 calories for 8 ounces? There it is– a simple way to save ten pounds in a year.

I don’t think that even diet soda is a great thing for the health-conscious consumer- but it is a step to better health.

Still, be on the look out for liquid calories that add up quickly for your weight gain.

The 20 ounces bottle of Sunkist soda is 325 calories! That isn’t “natural goodness” in there– that is the same amount of calories as over a dozen chocolate chip cookies.

Snapple 20 ounces is 250 calories. Drink one of those a day above what you burn for calories and at the end of the year you will have gained 25 pounds!

And don’t forget that cup of latte you get – well, the Starbucks Frappuccino (13.7 ounce bottle) is 290 calories! A simple cup of coffee with a teaspoon of sugar and creamer is 25 calories (add ice in the summer to make a cold coffee drink).

So, when it comes to liquid calories- water is best, calorie free, and will quench your thirst. If you “must” drink soda– don’t drink the kind with sugar or high fructose corn syrup – instead, drink zero calorie soda.

Other healthy alternatives include Propel Fit Lemon, only 25 calories, or Desani Plus Pomegranate Blackberry, zero calories. Sobe Lean Mango Melon is 12.5 calories.  And for your water you can always purchase packages of Crystal Lite to place in the water– zero calories!

Remember, changing 100 calories a day is 10 pounds in a year. So think about those liquid calories – and try some new ones.