Forks over Knives, a movie whose theme is in the title: food will replace surgical scalpels for cancer, heart disease, obesity, type 2 diabetes, and others.  Their answer is a “plant based” diet (Vegan).  The movie provides three live anecdotes to prove this, and star T. Colin Campbell and  Caldwell Esselstyn, Jr whose careers intersected with both having come to the same conclusion that a vegan lifestyle would eliminate heart disease, perhaps cancer, obesity, and other chronic illness.

The two stars of the movie, answering questions at its opening

The movie started with lots of video of obese people, and the movie ended with most of the people in the movie sitting down having a friendly, plant-based meal: great cinematic contrast as this small band of people fighting diseases by eating plants.

Some consider this movie  a documentary, especially those who advocate the whole plant (Vegan) lifestyle. It is not a documentary, a documentary is non-fiction, this is a movie, it is a hope, it is an unproven hypothesis.  As much as we (physicians) would love food to solve medical problems, and there is no doubt food can cause problems, but food, as medicine is another matter.

We are introduced to the narrator, Lee Fulkerson, who presents himself to a clinic while smoking a cigarette and having left behind two empty cans of an energy drink, and stating he earlier drank  a large cup of coffee.  The clinic is a family owned clinic  where the physicians, Drs. Matthew Lederman and Alona Pulde, promote a vegan lifestyle and will shop with the patients, cook with the patients, and watch their laboratory values improve. By the end of the film the narrator has lost weight, improved cholesterol, and improved his cardiac risk factors (they don’t tell you that the main reason for that improvement is he stopped smoking).

Lee Fulkerson looking over his lab results with Dr. Lederman

Much like the narrator doesn’t tell you that removing cigarettes, and weight loss were the primary improvement, the entire movie has a tendency to gloss over points, data, and misrepresent biology.

The good points of the movie are:

(1)  The doctors

It is great to see the physicians who take time with patients to change and impact their lives. Drs. Esselstyn, Matthew Lederman, and Alona Pulde whose fundamental belief in prevention is to impact what a patient eats. If you believe that food makes that fundamental impact on health, these physicians make a tremendous investment in their time to helping these patients. Many of us are teaching patients how to cook, and what to cook and more physicians are taking the course at Culinary Institute/Harvard to learn to these skills.  Changing lifestyle, spending time with patients, and having a positive impact is the ideal of primary care medicine.

Dr. Lederman and Pulde are a great team in this movie

(2)  Eating Healthier

Eating healthier is better than eating junk. No doubt the lady who ate her share of donuts into a heart attack helped herself by avoiding donuts. Whether she would have done just as well following a paleolithic diet as a vegan diet is debatable

Told she had to go to a rocker, Ms. Oswick found Dr. Esselstyn, and now lives without her donuts and chocolate

(3)   Feel Good Story

Watching a heartfelt good story: seeing people’s health improves, feeling better, and being more fit is a great story. Seeing physicians working to that end, as well as advocates of that position

The Incomplete Data
Cholesterol: The notions of cholesterol were not only out of date, but incorrect.  Early on the narrator states that cholesterol is what forms the plaques in the arteries of the body. To quote, “But when we consume dietary cholesterol, which is only found in animal foods like meat, eggs, and dairy products, it tends to stay in the bloodstream. This so-called plaque is what collects on the inside of our blood vessels and is the major cause of coronary artery disease.” This is not how plaque forms, and dietary cholesterol is far less important.  It may be that both T. Colin Campbell and Esselstyn were both trained in the era when cholesterol was thought to be the cause of the arterial plaques.  It isn’t and there are more discussions about this here.  Some people,  who have minor elevations of lipids,  can lower their lipid level (I avoid saying cholesterol because that is just not what we need to be talking about here)  through diet, exercise, and weight loss alone, but before throwing away medications and eating plants they should be  carefully monitored by their physician.

This is not a “minor slip up” in the movie- this is the first tenant of a plant based diet. It is also dangerously incorrect. Dietary cholesterol is avoided in a plant based diet, but a plant based diet does not avoid plaque in arteries.

The now clean arterial plaque:
One of Dr. Esselstyn associates had a heart attack- and they show the angiogram of his coronary arteries after the heart attack. You see the smooth arteries around this and then the ragged artery that caused the heart attack. After time on the plant based diet another angiogram was taken- and behold the artery is now clean.

Left is a clot, the artery on the right is free of clot - it is NOT reversed disease

This is misdirection to the viewers.  What they are seeing in that ragged artery is the remains of the clot in the artery that caused the heart attack. If a person survives, within a few days on aspirin that clot will disappear.  The associate credits Dr. Esselstyn with saving his life, by putting him on the plant based diet. But the misdirection is egregious, planned, and is often replicated on many websites that advocate a plant based diet — they will either show an artery of someone who had a heart attack with remaining clot, and then show a clean artery- or they will give you a slightly different two dimensional view of the artery that is more favorable.

The Norway Data
Dr. Esselstyn then shows the data of mortality from heart attacks and strokes of World War 2 Norway, which drops dramatically after the Nazi take over, and confiscate the meat supply.

The death rate dropped before the Nazi's took the Norwegians meats

The first question one would ask — if this is true, if by removing meat you immediately see a drop in strokes and heart attacks?  That is the implication. The problem is that Dr. Esselstyn’s conclusion about the data is missing a few points that might clarify the data:

The decrease in wartime heart disease and strokes was replaced with an increase in mortality from infectious disease, trauma (in war people tend to fire more bullets) – and in particular outbreaks of TB. The meats from the livestock were not taken by the Nazis until after this graph showed the dramatic decline (hence the drop was not because of less meat being consumed, in fact during this drop Norwegians consumed more meat  because the Nazis had told the Norwegians they were going to confiscate their livestock, so many Norwegians simply slaughtered their animals and didn’t raise new ones the following year. Meat consumption during this “fall in the graph” was almost double what it was during normal times.

The fish consumption during these times doubled. Not that eating more fish will decrease coronary disease (except in large population series this is a trend).

While others have pointed out that sugar consumption decreased, wheat consumption decreased and thus they became a paleo society with an emphasis on fish (thought Norwegians were Lutherans and turned out they were Pescatarians) – it is a long stretch that any single change in a diet would cause a single year dramatic decrease in cardiac mortality and strokes (but would be great if it did). It fits the theme of the movie that the change to a Vegan diet will, within a year, dramatically alter years of coronary artery accumulation of plaque – it won’t.

Dr. Campbell’s cancer study:
Rats given more milk protein have more “foci” of cancer than rats fed less milk protein. Several issues with this study, and those conclusions.  First, it wasn’t that the rats lived longer- they didn’t.  The rats died from being a part of an experiment, and some rats died before they were suppose to– those rats all were the rats getting less of “mothers milk protein.”

Campbell takes the one milk protein  and generalizes it to all animal proteins. Why? Proteins are chains of amino acids, and there is some magic about how a plant puts the amino acids together than an animal?  Casein is a bio-active group of proteins found in milk- it stimulates tissues to grow, which is what you want mother’s milk to do- it is not just a source of nutrition but is a “bioactive protein” meaning it helps to turn on certain proteins.  Take a rat liver, put it with a super high concentration of a protein that turns on proteins, and then add a cancer causing agent –well, it makes sense. But remember, these rats had better looking livers than the low protein rats (who died faster). Also  whey protein, another milk protein, has been demonstrated to have some opposite effect with tumor.  Some proteins are bio-active, and have effects when given in super concentrated form and isolated from their natural counter parts – like whey, they behave in not natural ways. Then to use this to make global conclusions about animal proteins is not science, it is prejudice. I discussed Dr. Campbell’s assumptions here.

Dr. Esselstyn’s patients:
Dr. Esselstyn took a bunch of patients with heart disease, convinced them to go on a Vegan diet (initially the group was allowed to have dairy til he met Dr Campbell then no dairy). Of this small group, six people dropped out. You can see more about his works on my previous post regarding him and this study.

While the study seems great, and they bring out two individuals who were a part of the original study (I think- they don’t really say that, and since the movie tends to gloss over details quite a bit one cannot make assumptions).

What is remarkable is that Dr. Esselstyn met with these patients every couple of weeks in his home. One sweet lady who had two heart attacks before 59 while eating a diet of chocolate and “every donut I could get my hands on and lots of gravy.” She also noted that Dr. Esselstyn, in spite of his “kind eyes” was quite strict “there’s the door.” That may explain why 6 of the original 24 dropped out.  Of the remaining 18 the math gets a bit fuzzy. 6 had “evidence of regression of disease” 11 stabilized.  But it turns out that Dr. Esselstyn’s math as presented was off, and not surprising, the data in this movie is driven by making a point, and not by precise details.

Esselstyn’s publication states he started with 22 patients, five dropped out, and six stayed on the diet but never came back for data collection—leaving Esselstyn with only 11 people in the study. The data from the  11 had  stabilization of their heart disease, but four people  had lesions that slightly progressed. The paper then looks at the method of regression of plaque, and these methods are now considered out-dated and of no use.

The high drop out rate could mean people either could not tolerate the diet, or died, or were asked to leave. The other issue is these patients had other interventions, such as statin agents that really do reduce arterial plaque formation. Esselstyn’s paper that does not rise to the evidence based medicine for major research. It is quite small, highly selective of the patients, not controlled for other interventions with heart disease (some patients had angioplasties, heart surgeries, and etc) – thus we cannot determine which intervention for this small group of individuals worked, if any. Why Esselstyn didn’t keep the other drop-outs on to serve as a control is deeply flawed.  Throughout the years on this diet variables changed – such as removing dairy products, and even if there was a dietary answer to heart disease, it would be lost in the details.

As a personal anecdote, my father had a heart attack in 1979, was forced to retire at age 55, did not have angioplasty (not available then) and loves sugar, ice cream, peanut butter, meat,  cheese, but he stopped smoking, retired, and 33 years later (and a few stents and an implantable defibrillator later). Looking at his previous angiograms- his disease has regressed (in spite of not being on a plant based diet, not being on a paleo diet, and not probably eating things that most diet zealots would shun). That is a series of 1, not 11 – but has as much validity as Esselstyn’s work.  The question is, was it diet that did this for these 11 people? What happened to the others? What does this mean? The answer is that this is as much of an anecdote as my dad is.

The China Project
T. Collin Campbell, a physiologist, calls this massive study the highlight of his career.  With his Chinese counterpart, Dr. Chen,  they took the simple hypothesis: diet effects disease rate.  By choosing rural villages with stable diets, and known health and mortality statistics assumptions could be made about how diet effects health.

Campbell and Chen with their monograph

The film shows the proud researchers, with reams of data, and the NY Times Jane Brody column (Brody is not an authority figure but the implication that the NY Times said this was a good study is another logical fallacy called “appeal to authority.”).

There are major problems with the China Study – the blood samples of all individuals was pooled and studied – avoiding individual variation. The statistics for heart disease in rural villages in the 1970′s (they used this data for their study) was imperfect at best, and if you ask Chinese cardiologists today the current statistics – 30 years later – are poor.  Heart disease is underestimated now, and even more 30 years ago. The same with cancer statistics, and most rural Chinese statistics.

The China Study has been uniquely reviewed and dissected by  Denise Menger of rawfoodsos.com.  She points out how the data sometimes shows the opposite of what is stated (much like this movie).  For example, the meat eaters of one village had lower levels of the diseases.

OVERALL
This is a movie, and not a documentary. This is a movie that advocates a plant based (Vegan) diet will solve heart disease, cancer, and other ailments- and presents inadequate and skewed data to that end. To be clear, there is no substantial data that proves their point, and the data they use is skewed if not outright incorrect.  It is a warm, feel good movie with some great people.

IF you wish to have a whole plant diet – then do so..  If you think you can throw your medicine away and just eat plants, do not do this without medical supervision – and by that I mean the MD or DO who prescribed the medication for you, or a physician that will monitor your blood levels of lipids, glucose, etc.

When the Archives of Internal Medicine published the article “Red Meat Consumption and Mortality” all I could think of is “here we go again.”

First to go through this paper- which is a statistical population study from the Health Professionals Follow-up Study (HPFS) and the Nurses’ Health Study (NHS). Of the 140,000 combined participants they tossed out 20,000 because of a history of the diseases reported or those who did not fill out the forms perfectly.

To start with – this is not a study where people were followed from baseline to death to see if what they ate contributed, and determining amounts along with following other variables as they progress (lifestyle issues with exercise, smoking, etc). This instead is a study based on food questionnaires, and statistical analysis. Correlation does not imply causation.

One has to be careful with epidemiological studies, as they are not  proof of a cause, rather they point to a number of variables that might be involved to form a hypothesis. It is these same types of statistical studies that told us that women should use hormone replacement therapy because it prevents heart attacks in 1991, only to be told 11 years later that it might cause heart attacks. It is a sampling bias of those individuals who choose to participate in the studies that led to the erroneous conclusions.

The second issue with these studies is the ability of the food questionnaire and its accuracy. This has been studied – that is, the ability of people to recall and fill out what they ate. We do this in our office all the time- ask people what they eat—and since we are involved in weight loss and healthy lifestyle here is what we can say: people have no ability to remember what they ate, how much they ate much beyond the last day. When studied by others, looking at the questionnaire (FFQ or Food Frequency Questionnaire) in the Nurses’ Health Study was found to be useless. As reported by others, the accuracy of the questionnaire compared to reality was unacceptable.

For example, 20 per cent of the nurses reported living on 1200 calories per day or less, and low intake of red meat, and 20 percent report over 2000 calories a day.

In the study the first table showed that the highest reported red meat consumption was associated with smoking, drinking more, obesity, and higher calories. Oh wait- have you ever heard that smoking, obesity, eating more calories, or drinking more might lead to an early death? Perhaps you have, in fact, there are some correlations (which don’t imply causation) for these, and there are some great prospective studies showing that obesity leads to early death.  Of course, in any statistical paper you can remove the confounding factors – and THEY DID NOT in this paper.

One other cute correlation- in the data, those who report eating the most red meat had the lowest cholesterol levels. Yes, that is odd isn’t it. Readers of this blog know that cholesterol and meat have less to do with one another – and that isn’t a statistical issue, that is just basic biology.  Eating more meat does not mean you will have a higher cholesterol – having bad genetics does.

Here is what three systematic reviews of prospective studies show in the relationship between saturated fat and heart disease- zip. There has been a consistent lack of an associated between saturated fat intake and heart disease. While this new study statistically makes the argument that changing diet would decrease events from heart disease and cancer, when looked at (references below) none of the pooled studies show a change in that risk relationship. And, when some studies have shown a change in risk, when the data was examined there was no difference in mortality. While some say red meat clearly is bad, the evidence is anything but clear. Proving again that population studies, without isolating the variables, without having a scientific basis, are worthless.

Finally, the science of red meat—what do we know? Red meat is a large category of meats includes everything from bacon (considered “processed” by some and delicious by others) to cows raised on grain, and cows raised on grass. Grass fed beef have higher levels of omega-3 fatty acids. Consuming different red meats mean you are consuming different levels of ingredients. Lumping them together is just sloppy science.

Nothing like great grill marks on a steak

Skeaff CM, Miller J. Dietary fat and coronary heart disease: summary of evidence from prospective cohort and randomised controlled trials. Ann Nutr Metab 2009;55:173–201.

Mente A. A systematic review of the evidence supporting a causal link between dietary factors and coronary heart disease. Arch Intern Med 2009;169:659–69.

Siri-Tarino PW, Sun Q, Hu FB, Krauss RM. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Am J Clin Nutr 2010;91:535–46.

Mom prefers Sous Vide to the traditional roasted turkey

Thanksgiving is my favorite holiday- for so many reasons. But the turkey can be a pain — a pain to make properly, and then a pain because you have so much of it that one tires of turkey leftovers after a day or so.  The answer- making Turkey Sous Vide.

Sous Vide is a method of cooking that we have advocated for a while.  Don’t have a Sous Vide machine? Treat yourself and start changing the way you cook. It allows low temperature cooking, so that the meats are not overly dry. The most common reason people go to an emergency room on Thanksgiving is they get a piece of dry turkey caught in their throat. With Sous Vide, the turkey won’t be dry (of course, if you swallow too large a piece it can still get stuck).

The previous posts have talked about Sous Vide but there are a number of places that sell the equipment for the home cook to do Sous Vide cooking easily.  Most people need to get a water oven and a machine that does vacuum sealing of the food.  You can use the link above to purchase the Sous Vide machine, or you can find them at places like  Sur Le Table and William-Sonoma.  Mine was purchased from William-Sonoma and I have demonstrated its use at their stores.

Turkey

The first key is to butcher the turkey into its parts.  This makes the bird manageable.  As  you can see from the video, I love to do that myself, but if you have a good butcher they will do that for you. You can also purchase the pieces individually from the butcher if you like.  Some purchase just breast, some thighs.  It is cheaper to purchase the entire bird, though, and have the butcher break down the bird, including splitting the breasts.

This allows the turkey parts to be cooked at temperatures and times individually for them. It also allows you to cook the entire turkey Sous Vide and those parts you won’t use can be frozen for up to six months (avoiding those many recipes for turkey soups, turkey casseroles, and turkey curry).

To Brine or not Brine

Many talk about placing the turkey into a brine in order to help the turkey stay moist through cooking.  The brine has little to do with a turkey being moist. A brine is a solution of salty water, and some place other herbs and sugar in it- that draws water out of the turkey, especially the skin. It does not make the turkey more moist when cooking it.  Over cooking turkey in an oven is easy- over cooking turkey Sous Vide is impossible.

I find brines and marinades to be messy.  But having a turkey broken down into its parts makes it easier to handle.

Instead consider seasoning the turkey with Kosher Salt for a day. Less messy than making up a brine.  Salting the turkey helps the skin become crisp.

Seasoning the turkey:

A simple salt and pepper seasoning works well on the turkey. You won’t need olive oil on it, and we will take care of that great herb flavor with our cachet of herbs.  Salt and pepper the skin.  There are a number of poultry rubs available- and you may prefer those.

Herbs:

With Sous Vide the best way to permeate the turkey with sage, rosemary, thyme, and even basil if you like- is to roll these up in a plastic wrap. Cut off both ends and drop this into the bag.  If you put the herbs in directly there will be bits of turkey that will have intense flavor, and other bits that have none.

Duck Fat or Butter:

Placing either duck fat or butter in the bag will bathe the turkey during the time it is in the water oven. Some prefer one over the other- some even use a bit of olive oil. Butter is easy because it is solid at room temperature and melts nicely in the water oven.  Duck Fat, if kept in the refrigerator is solid at cool temperatures also.  Olive oil isn’t solid at room temperature and may be pulled out by the vacuum sealer, unless you are careful.

Water Oven Time:

Once sealed, they can be placed into the water bath kept at 150 degrees F.  Breast is done in 2.5 hours, thighs about 2 hours. They can stay in for longer- so if the guests are not quite ready, you can relax knowing that the turkey will not over cook.

Simple Sear:

When you are ready, have a hot grill to sear the turkey skin and provide that crispness to it. Whether you use a grill, grill pan, or hot oil – it is only two minutes a side.

Pre-Left overs:

If you find that you will have more turkey than you need- leave the turkey in the vacuum sealed bag. Put it into an ice bath immediately to stop the cooking and cool it down. Then freeze it. The turkey will be ok for up to six months.  Three months after last Thanksgiving we placed turkey breast back into the Sous Vide for 30 minutes to “re-warm” it (an oven, microwave, or stove will dry it out) – and had the most delicious, most amazing turkey breast — far better for sandwiches than anything you could purchase.
–
Want to smell that stuffing– simple- make your favorite stuffing and bake it– the house will smell like thanksgiving and no choking on dry turkey!

Who would have imagined that my patient, Evo, would have lost 14 pounds on the “beer and sausage” diet (now called the Evo diet).

From the medical side there are two other benefits — his triglyceride level dropped by half, his cholesterol dropped by a third, and his “good” cholesterol increased.  There was never an increase or a blip in any of the liver enzymes.  His fat mass dropped, the only non-fat mass of his that decreased was that tissue associated with and supporting the fat mass (I know, sounds complicated).  His muscle mass maintained itself.

One important lesson learned: we do not know enough about science and medicine and diets to be able to say anything to anyone about which diet is healthy and which is not. But let me give you an example – we had more data points for this one month of the Evo diet than Ornish had for his diet program.

The famous Ornish line is that his data showed a decrease in “Plaques” of patients who had heart disease. This was based on less than 20 patients, including the control group.  He has since gone on to show poor data with prostate cancer, as well as aging. The data that Ornish has isn’t good, and when you look at the data we generated in one month from the Evo diet, one could assume that we would find people would do better not doing the Ornish diet and following the Evo diet.  This is said with a smile, because never has a “lifestyle” and diet – such as Ornish, been propagated with less data and more press.  Ok- there is also the China Project (a single misuse of data to say the same thing).

The second important part of Evo’s diet was this: there was a simple and yet profound control of the portion sizes that he had. It was measured, it was regulated to around 1500 calories per day.  Based on that,  Evo lost more than we would expect him to have lost. Why? No clue.

What can you take away from this: First, if you want to have a diet begin by strictly regulating portions. Portion control is a key for any weight loss, including weight loss surgery.  Limit your portions, and thus your calories, and you should lose weight.  The advantage of beer and sausages is that they come in nice units that you can measure.

Processed meats appear to increase risk of colo-rectal cancer

What you should NOT take away from this: beer and sausage are not “diet foods.” Beer and sausage were, in this case, a tool for great portion control. And Evo ate more than just sausage. He ate what came with it.  When I cooked for him he had the peppers and onions that went with my famous recipe (recipe will be on terrysimpson.com later). He had bread (yes, I know some of you think bread is the devil’s tool) – if it came with the sausage.

The final message is most important- We don’t understand food as well as Ornish, Atkins, or pick some diet guru would have you believe.

This is going to be the next wave in medicine– medical tourism, done by US surgeons who operate overseas, to provide better care, better outcomes, better environment – and even better equipment, than can be offered in the United States.

Medical Tourism- new concept- US Surgeons working abroad

Medical Tourism has taken a new step. Some think that medical tourism is new- it isn’t.  People have traveled to get the surgery by the team, or the surgeon they wanted for years. Sometimes they do this for economic reasons- but often patients  do this because they want to go where they can have the best hands working on them.

Medical tourism within the US is common. People traveling from one coast to another to get the right surgeon, with the right team to do their operation.  A friend of mine needed a rare operation (thoracic aneurysm) , and I sent them to Houston – where they have done more than anywhere else.  In my own practice we’ve had hundreds of patients come to Arizona to have us do their weight loss surgery.

In the history of surgery- the fathers of American Surgery would take patients overseas, operate on them where hospitals had perfected techniques.  Halsted- who was the founding surgeon at Johns Hopkins, spent years going overseas to learn and perfect techniques. Over time the US became a leader in surgery and then tourism shifted where  patients  would come to the US for their surgery.  From the 1940′s til recently   surgeons from overseas would come to the US to learn, but that has shifted away from the US again.

Today laparoscopic procedures that have been perfected outside the US, and patients travel outside the US for procedures they can’t get here. Some of the procedures can be done here,  such as gastric plication. But with gastric plication  patients are getting them from surgeons that have little experience, and centers that are not familiar with how to take care of the patients from nursing to radiology.Gastric plication is a simple surgery in concept, but not in terms of technique. Unlike stapling, you can’t just cut on the dotted line. But- in Baja they have done more than anyone in North America.

Halsted - father of American Surgery - first medical tourist surgeon

Medical tourism is needed for two reasons first is the economics of medicine in the US. Because so many people can’t get insurance, or have such high deductibles that they have to take their health care in their own hands. For them, getting an operation at a price less than in the US- and with more experience, with US surgeons is revolutionary.The second is they can easily go somewhere and have the US surgeon do their operation in a facility that exceeds any facility in the US.

Our teaming up with Dr. Ortiz in Baja represents the new wave of medical tourism – bringing together international expertise, surgical skill, and compassion.

Sometimes all you want for breakfast is a cup of coffee-- and that's ok

Everyone knows:  Always   eat Breakfast

There   are   a lot   of   variations   of   this   axiom.

“Breakfast   is   the   most   important   meal   of   the day.”

“Breakfast makes it so you won’t be hungry later.”

“Breakfast jump starts your metabolism”

“You need to eat a large breakfast”

“Breakfast   is   the   most   important   meal   of   the day.”

All of those are FALSE.

Breakfast is NOT the most important meal of the day- so don’t force it. The reality is that most people are not ready to eat breakfast when they first wake up.  So why does “everyone” say this? Some of this data was based on the Iowa Breakfast study- which was more than a single paper- but a group of observations made over a number of years and published. There have been a number of other studies showing that kids who eat breakfast do better in school than kids who do not. However, there are a lot of variables not accounted for in those studies.

In addition- a few other items were not taken into account: if you wake up at 4 am to do chores until 7 am, then have breakfast and go to school, you will do better in school than someone who wakes up at 4 am, does chores and doesn’t get breakfast.

Regarding most breakfast studies — funded by, and poor research  done, from cereal companies. Doesn’t mean they are bad studies- but they all fall into poor categories of evidenced based research.

“Breakfast makes it so you won’t be hungry later.”

A recent study showed that people who eat a large breakfast are not affected by how much they eat later in the day. Meaning that eating a large breakfast won’t keep you from snacking, or eating less the rest of the day.

You wonder where people come up with this idea– but when it is put to the scientific test- the breakfast you consume does not reduce food you consume later. Not one bit. No relation- no correlation.

Breafast buffet is not your friend

“Breakfast jump starts your metabolism”

They also found that eating less in the morning contributed to overall weight loss (if you eat less calories you will lose more weight).  There is a simple truth about weight loss – if you eat more calories than you burn, you will gain weight. If you eat big breakfasts and lots of other calories you will gain weight.  Breakfast does not jump start your metabolism- your body does that.

Again- how would you measure a “jump start” to metabolism? There are ways- but activity itself increases heart rate, breathing, and over all muscle activity. If you take comatose patients and measure their oxygen consumption and carbon dioxide production- and cycle feeds – the feeds do not increase metabolism. Another study took college football players and put them into a hospital and fed them. They were allowed to do a few walks- but not much more.  It was activity that increased metabolism- not food. Any food will increase some metabolism – but a breaking of the fast does NOT do any sort of jump start.

“You need to eat a large breakfast”

Want to just have a smoothie or yogurt or some oatmeal to start your day? Go ahead. You want to wait for a couple of hours after you get up before having something to eat- that works too. But if you eat a large breakfast – you still need to work off those calories.

You think this is an important meal?

The great thing about breakfast foods: You can eat them anytime! Who doesn’t like eggs for dinner? And after a long day- nothing is more refreshing than a blueberry smoothie to take the edge off hunger, and let you relax for a bit.  We have recipes for smoothies containing micronutrients, fibers, and supplements – a simple smoothie can be a pleasant treat after a long day of work, taking the edge off hunger so you can make a great dinner.

For the smoothie and other recipes go to terrysimpson.com

Artificial sweeteners are either the saving grace of America, or the devil. The first issue with artificial sweeteners came to light when cyclamates (the first marketed artificial sweeteners) were found to cause cancer in rats. So in 1969 cyclamates were taken off the market. Saccharin was the next agent, but many didn’t like its after taste. Then came aspartame (Equal). This had no bitter after taste and became the favorite until someone started a rumor that aspartame killed ants, and was originally developed as a rat poison – this is untrue on both counts.

First, aspartame was developed as an artificial sweetener and second, it does not kill ants (I tried it, as have a lot of others – sadly it doesn’t work). Splenda does contain calories (because of our FDA regulations it is allowed to be listed as “zero calories” but it is not). Splenda has 3.36 calories per packet (1 gram). It tastes like sugar and is generally easy to cook with – however; one package of Splenda is 600 times sweeter than an equal amount of sugar.

Two other sweeteners have joined the market in the United Sates. Stevia- is a product of several plants and was recently approved as a food additive in the United States, and Truvia (a proprietary blend of Stevia made by Coca-Cola and Cargill the Pepsi produce it PureVia). These are essentially all the same. There are some other sugar-alcohols like Xylitol that function as sweeteners.

The issue with artificial sweeteners has been getting use to the sweet taste, and thus an increase in appetite. In rats that are consuming artificial sweeteners there is an increase in their body weight over time as they increase the amount of food they consume. Not that we are rats – but avoiding the overly sweet taste is important. And there is no accident that while many of my weight loss patients consumes large quantities of “diet cola” – they still consume a lot of calories to go with them. It is also no accident that once our patients get off artificial sweeteners, they lose more weight.

People who drink sodas that have artificial sweeteners have a sixty percent increase in stroke and heart disease. Sixty percent!

How do you gain weight with artificial sweeteners? Since they are so sweet, you naturally want food to balance out the sweetness. Increasing the quantity of food allows you to increase the bitter, sour, and other sensations to balance the sweet taste. Remember, your palate always wants to return to a balance.

Overall –avoid the artificial sweeteners. Still- what is better than artificial sweeteners in soda? Simple water. It is free (unless you are in a city where the water tastes bad) and is regulated more tightly than most things

Imagine a way that the government could reduce the level of obesity and it would cost nothing.  The government had that chance- and they blew it.

The US Department of Agriculture denied a request by New York State to run a pilot program where the city of New York would not allow people to purchase soda, or other sugar sweetened beverages, using food stamps. There are at least seven other states requesting such pilot programs.

It is not surprising that the opposition to this proposal came from the beverage industry who said, “It’s another attempt for government to tell people what they can and can’t drink. Singling out one specific item is discriminatory and unfair.”

Really? No one is saying they can’t drink soda – simply that the government won’t purchase items that are not in line with the intent of the food stamp program which is, “to provide for improved levels of nutrition among low-income people each month.”

The USDA said that city retailers would not be prepared to implement the new policy.  The food stamp program is run with a debit-style card. If a beneficiary is purchasing items from the grocery store not covered by food stamps, such as tobacco or alcohol, the cashier collects the money for those items after the food is deducted.

The original Food Stamp Act prohibited purchase of “soft drinks,” but that was changed because of regulatory issues-, which are now overcome thanks to technology. In fact, New York City officials stated that the “program’s electronic benefit card looks and acts like a credit or debit card” and that it only covers “some of the items in a typical s hopping cart, so program participants are already accustomed to supplementing their purchases with personal funds.”

The USDA also said “the proposal lacked rigorous methods to asses changes in sugar sweetened beverage consumption resulting from the new policy and the effects of those changes on obesity and health.”  A pilot program doesn’t have to prove that sugar sweetened beverages are not “food.” Even the original act prohibited these items.

The government purchases millions of gallons of sugar laden drinks for food stamp holders every day. Obesity is the number two killer in the United States – and by denying this simple pilot program are paying for obesity.  Preventing obesity costs nothing – paying for the effects of obesity costs everything.

References:

US Department of Agriculture. The Food Stampe Act of 1964. http://www.fns.usda.gov/snap/rules/Legislation/pdfs/PL_88-525.pdf.

Jessica Shahan, Associate-Administrator, Supplemental Nutrition Assistance Program, USDA, to Elizabeth Berlin, Executive Deputy Commissioner, New York State Office of Temporary Disability Assistance. August 19, 2011.

Scott-Thomas C. Food stamp soda exemption in NYC is discriminatory, says industry. Food Navigator-USA. May 5, 2011. http://www.foodnavgator-usa.com/Business/Food-Stamp-soda-exemption-in-NYC-is-discriminatory-syas-industry

JAMA, September 28, 2011 Vol 306, No. 12 page 1370-1371

Many people today are talking about diets that are “gluten-free.” Restaurants are offering “gluten-free” menus. There are websites, chiropractors, and others proclaiming that going on a gluten-free diet will provide improved health. But lets be clear- unless you have an allergy to gluten, removing gluten from your diet will not provide better health, weight loss, but eliminating gluten will dramatically limit what you can eat.

But there are some people who are “allergic” to gluten- and for them having a gluten free diet is the difference between health and illness – between a risk of some rare cancers for which we don’t have great treatment for. We call that condition celiac disease – for those who have celiac disease, being gluten free is critical. Other names for this disease include celiac sprue, gluten sensitive enteropathy, non-tropical sprue, and a few other names.

Gluten is a protein that is found in wheat, barley, rye, and oats. Gluten is a protein that allows wheat to have “elasticity” – meaning you can roll out the dough- or toss it in the air and make a great pizza crust. You can’t do that with non-gluten grains—no one can make a pizza or great bread from corn alone. Gluten is also used to thicken soups, ketchup, soy sauce, and is found in almost every processed food out there. Take gluten out of the American diet and you will be challenged to find good alternatives.

When a person is allergic to gluten their symptoms include malnutrition, anemia, osteoporosis, infertility, short stature, and inability to thrive. However, the “classic” symptoms are not necessarily common. There are a number of patients who have silent celiac disease, where they will be discovered to have atrophy of their absorptive surface of the small bowel without any symptoms, or just mild symptoms such as an iron deficiency anemia. There are a number of forms of celiac disease that respond well to a gluten free diet – and remain normal after introduction of gluten into the diet.

Celiac disease is best diagnosed with a biopsy of the small intestine. Most often the biopsy is performed endoscopically from the first part of the small bowel, the duodenum. However, those biopsies can be negative, and more distal small bowel may show the classic pathologic appearance. Those biopsies most often have to be done surgically, or with advanced endoscopic equipment.

The small bowel, under a microscope, has many small finger-like projections called villi. These serve to increase the surface area of the small bowel to allow for maximum absorption of nutrients. In celiac disease, there is atrophy of these villi – seen microscopically- and this improves when gluten is removed from the diet.

Above normal villi, below- atrophied

While celiac disease is classically called an “allergy” to gluten – it does promote some antibodies against the connective tissue elements – leading some to call this an auto-immune disease. However, when the foreign protein is withdrawn, there is no residual auto-immune function. The “auto-antibodies” may simply reflect the gluten protein unfolded – and having a similar structure to the bodies own endomysium protein.

There have been various reports about the prevalence of celiac disease – ranging from 1:300 among Northern Europeans (Celtic) to 1:122. There is a large genetic distribution of the disease – with a high concordance among identical twins of up to 70 per cent. There are some genetic markers that have a high association with celiac disease, but the expression of the disease is variable – meaning that the genetic marker is a tendency but not a certainty of celiac disease. If everyone who had the genetic markers were to develop the disease, it would be estimated that 1 in 22 people would have this. However, this is not the case.

Diagnosis of celiac disease is made based on clinical suspicion of the classical presentation (iron deficiency, osteoporosis, with abdominal complaints) followed by some tests. A biopsy is the most reliable test, however there are blood tests ( IgA anti-gliadin and IgA anti-endomysial and anti-tissue transglutaminase) that are over 90 per cent accurate. Even with a negative blood test but a high enough suspicion, duodenal biopsy or even surgical biopsy is warranted.

There are plenty of questions about celiac disease- we don’t know the actual prevalence in the population, we don’t know if being gluten free as demonstrated by follow up biopsy has a lower incidence of lymphoma.

What we do know is that gluten is not a health issue in people who do not have celiac disease. Gluten-free will not cure autism. Gluten free will not facilitate weight  loss. There are, however,  groups who will claim that gluten is a health issue- there is no basis for this claim. If someone has told you to remove gluten from your diet, and you do not have a test showing celiac disease (one of the tests listed above)- please see a physician to resolve this.

For people who have celiac disease- there is a bit of culinary hope. Thomas Keller, one of the world’s greatest chefs and owner of Ad Hoc, French Laundry, Per Se, and Bouchon- has developed a flour that works well. You can purchase it from Williams-Sonoma.

Thomas Keller has come up with a great flour, gluten Free.