What are Your Patients Eating?Tom Ransom

Division of Endocrinology and Metabolism

Dec 6,2018

Faculty/Presenter Disclosure• Faculty: Dr. Tom Ransom

• Relationships with commercial interests: Advisory Boards: Sanofi, Lilly, Valeant, AstraZeneca, Nova Nordisk,

Amgen, Boehringer, Abbott

Speakers Bureau/Honoraria: Sanofi, Lilly, Valeant, AstraZeneca, Nova Nordisk, Amgen, Boehringer, Abbott

Grants/Research Support: Amgen, AstraZeneca, Novo Nordisk

Clinical Trial: Amgen, AstraZeneca, Novo Nordisk

Other: None

Disclosure of Commercial Support

• This program has received no financial support

• Potential for conflict(s) of interest:• None

Mitigating Potential Bias

• The information presented in this CME program is based on recent information that is “evidence-based.”

• This CME Program and its material has not been peer-reviewed, and all the recommendations involving clinical medicine are based on evidence that is accepted within the profession. All scientific research referred to, reported or used in the CME/CPD activity in support or justification of patient care recommendations conforms to the generally accepted standards.

Outline

• Define

• Basal metabolic rate/energy expenditure

• Trending diets• paleo

• Intermittent fasting

• Keto

• A few “tips”

• Discusion

ATP is the currency

Kreb’s Cycle

Food is the Fuel

Bomb Calorimetry

Atwater numbers

• Think caloric density• 1 gram protein = 4 kcal

• 1 gram CHO = 4 kcal

• 1 gram fat = 9 kcal

• 1 gram EtOH = 7 kcal

• 3500 kcal = 1 pound

One calorie is the amount of energy required to raise one gram of water one degree Celsius at sea level

Which meal has more calories?

Diet Induced Thermogenesis

Calories burnt during triathlons

Effects of Exerciseon Metabolic Rate

• Exercise dramatically increases metabolic rate

• Rate remains elevated for extended period afterwards (excess post-exercise O2consumption)• Duration depends on intensity of exercise

• Long-term exercise may elevate resting metabolic rate (RMR)

Speakman JR, et al: Proc Nutr Soc 2003; 62(3):621-34.

18

Glycogen

Associated with lots of water

Carbohydrate Loading

Carbohydrate Depletion (dehydration)

Weight change during a triathlon

TABLE 1. Body weights (kg) and changes in body weight (kg) of triathletes competing in the 2000 South African Ironman triathlon*** P < 0.0001. From: Sharwood: Clin J Sport Med, Volume 12(6).November 2002.391-399

The Good Old Days

A Pound a week is About Max

• Around 500 cal per day deficit

• Anything more is likely water

• Setting yourself up for rapid regain, i.e yoyo’ing

Hitting the Wall

40 seconds tops

Lose Weight Fast

“All my suppers are keto”

What Are the Side Effects?Right after your child starts the diet, she may feel tired. Other side effects include:•Constipation•Kidney stones•Slow growth and low weight•Weak bones (which may be more likely to break)•High cholesterol

Ketogenic diets for epilepsy

No Different From Atkins Induction

The Diets

•Carbohydrates cause release of insulin

•Insulin causes conversion of carbohydrates into fat and storage of fat

•Carbohydrates make you fat

•If you avoid carbohydrates you will reverse the process and lose weight

•Ketones in the blood show that you are burning fat and are a marker of success

MetaboSTIX

90 Dollar Starter Kit

Happy Anniversary!?

Typical Induction Menu

Breakfast • Bacon, 4 slices

Coffee, decaf, 8 ozScrambled eggs, 2

Lunch • Bacon cheeseburger, no bun

Small tossed salad, no dressingSeltzer water

Dinner • Shrimp cocktail, 3 ounces

Mustard, 1 teaspoonMayonnaise, 1 tablespoonClear consommé, 1 cupT-bone steak, 6 ouncesTossed saladRussian dressingSugar-free Jell-O, ½ cupWhipped cream, 1 tablespoon

Atkins Induction• Energy, kcal 1759

• Protein, g (% energy) 143 (33%)

• Carbohydrate, g (% energy) 15 (3%)

• Fat, g (% energy) 125 (64%)

• Alcohol, g (%) 0

• Saturated fat, g 42

• Cholesterol, mg 886

• Fiber, g 2

• Calcium, mg (% DV) 373 (37%)

• Iron, mg (% DV) 15 (86%)

• Vitamin C (% DV) 20 (33%)

• Vitamin A, RE (% DV) 799 (80%)

• Folate, μg (% DV) 143 (36%)

• Vitamin B-12, 5g (% DV) 11 (191%)

• Thiamin, mg (% DV) 0.7 (48%)

SOUNDS GREAT!

Colorectal Cancer

• The 1997 report of the World Cancer Research Fund and American Institute for Cancer Research, Food, Nutrition, and the Prevention of Cancer, reported that, based on available evidence, diets high in red meat were considered probable contributors to colorectal cancer risk.

• Proposed mechanisms: effects of fat on bile secretion, carcinogenic action of heterocyclic amines produced during cooking, low dietary fiber which facilitates movement of intralumenal carcinogens, out of the digestive tract, and promotes a protective biochemical environment

Osteoporosis

• Elevated protein intake encourages urinary ca losses and increases risk of fracture in cross-cultural and prospective studies.

• Feskanich, Am J Epidemiol 1996

• When carbohydrate is limited and a ketotic state is induced, this effect is magnified by the metabolic acidosis produced. In a study of 10 healthy individuals who were put on a low-carbohydrate, high-protein diet for six weeks urinary calcium losses increased 55% (from 160 to 248 mg⁄d, P < 0.01).

• Reddy, Am J Kidney Dis 2002

Cardiovascular Disease

• Such diets are high in cholesterol and saturated fat

• In a small study, individuals on a high-protein diets against medical advice had increased fibrinogen, lipoprotein (a), and C-reactive protein, and demonstrable progression of coronary artery disease

• Fleming, Angiology 2000

• Evidence indicates that meals high in saturated fat impair arterial compliance, increasing the risk of cardiovascular events in the postprandial period. A recent study showed that the consumption of a high-fat meal (ham-and-cheese sandwich, whole milk, and ice cream) reduced systemic arterial compliance by 25% at 3 hours and 27% at 6 hours

• Nestel, J Am Coll Cardiol 2001

Impaired Renal Function

• Individuals who consume large amounts of protein, particularly animal protein, risk significant kidney damage.

• The American Academy of Family Physicians notes that high animal protein intake is largely responsible for the high prevalence of kidney stones in the United States and recommends protein restriction for the prevention of recurrent nephrolithiasis.

• Protein increases renal acid secretion, ca resorption from bone, reduction in renal calcium resorption, increases uric acid and decrease the solubility of calcium oxalate

• Goldfarb, Am Fam Physician 1999

Nurses’ Health Study

• For each 10g/day increase in protein consumption there was an adjusted decrease in GFR (glomarular filtration rate) of 1.69 ml/min per 1.73 m2 in women with mild renal insufficiency (GFR 56-80 ml/min).

• Further analysis suggest restriction non-dairy animal protein was beneficial

Nothing Special

• Review of 107 low-carbohydrate dietary trials

• “…weight loss while using low-carbohydrate diets was principally associated with decreased caloric intake and increased diet duration but not with reduced carbohydrate content.”

• Bravata, JAMA 2003

The New England PapersSmaha et al 348:2074, 2003Foster et al 348:2082, 2003

• 1st paper• N=132 at start, 79 finished 6 month protocol

• Low-fat arm -271 calories/day

• Low CHO arm -469 calories/day

• 189calories x 182 days = 34,778 calories which more than accounts for the observed weight difference of 3.9 kg

The New England PapersSmaha et al 348:2074, 2003Foster et al 348:2082, 2003

• 2nd paper• N=63 at start, 37 completed the 1 yr protocol

• No dietary data

• Initial differences in weight reduction lost at 12 months

1yr Low CHO Vs. Low Fat

Overweight and diabetes prevention: is a low-carbohydrate-high-fat diet recommendable?

Brouns, Eur J Nutr. 2018 Jun;57(4):1301-1312

• (1) any diet type resulting in reduced energy intake will result in weight loss and related favorable metabolic and functional changes;

• (2) short-term LCHF studies show both favorable and less desirable effects;• (3) sustained adherence to a ketogenic LCHF diet appears to be difficult. A

non-ketogenic diet supplying 100-150 g carbohydrate/day, under good control, may be more practical.

• (4) There is lack of data supporting long-term efficacy, safety and health benefits of LCHF diets. Any recommendation should be judged in this light.

• (5) Lifestyle intervention in people at high risk of developing type 2 diabetes, while maintaining a relative carbohydrate-rich diet, results in long-term prevention of progression to type 2 diabetes and is generally seen as safe

Intermittent Fasting

• If I skip a meal I should lose weight

• From the weight loss registry• Eat breakfast

• Exercise

• Low GI diet

Examples

What about grazing?

• We conclude that in addition to the amount and type of food eaten, the frequency of meals may be an important determinant of fasting serum lipid levels, possibly in relation to changes in insulin secretion.

• Effects of meal frequency on weight loss and body composition: a meta-analysis.• Schoenfeld , Nutr Rev. 2015• initial results of this meta-analysis suggest a potential benefit of increased

feeding frequencies for enhancing body composition, these findings need to be interpreted with circumspection.

Most of my suppers are paleo

Jenkins DJ. Metabolism 2001

•The Simian Diet

• It works but is not practical

• It lowered my LDL by almost 50% to well below 2

Questions that guide my suggestions in clinic

• ?skip meals

• ?snack – what

• ?hungry a lot

• ?liquids

• ?emotional eating

• ?cravings/”addictions”

• ?any main issue

• ?typical day

Most common bits of advice I give

• Boost or Ensure – just like Bucley’s “Tastes awful but it works”

• Eat like a kid

• Three less bites

• Three weeks no pop

• One double-double is 12 pounds per year

• One can of pop is 15 pounds per year

• Google portion distortion

• Exercise in a chair

Modification of diet is often the major factor that will lead to a healthier weight• 30 pounds a year 3 years in a row is a strong predictor of long term

success

• Sustainability is key

• Most diets safe

• Give a behavior change 2 or 3 months

• No easy fix

• Exercise helps

• Number needed to council is not that high but it takes time

• You can make a difference