DIETS IN AMERICA:IS THERE HOPE IN THE LAND OF

BROBDINGNAG???!!!

ANDREW T. TORKELSON M.D.

ITS ALWAYS IN THE NEWS!

BRIGET JONES’ DIET !!???

3900

EXPANDING WAISTLINES:USA!

MORBID OBESITY,ONCE RARE,BMI>40,WAS 1IN 200 ADULTS IN 1986, BY 2000 IT WAS 1 IN 50.

IN THE TEEN POPULATION,IN 1991 11% WERE OBESE,5 YEARS LATER 22% WERE OBESE!

AMONG AMERICANS 20-74, 15% WERE OBESE IN 1980,BY 1999 27% WERE OBESE.

AT THIS MOMENT 45% OF WOMEN AND 30% OF MEN ARE ON A DIET!

FAT AND GETTING FATTER

TERRORISM IN AMERICA!!!

WHAT IS BEST FOR BABY??!!

FUTURE PATIENTS!!!!

BMI AND RISK!!

MINUTES FOR A BIG MAC!!!!

Primary Prevention in Finland

Between 1972 and 1992, cardiac mortality declined 55% in men and 68% in women.

Fruit and vegetable consumption increased three - fold.

Total fat consumption decreased from 38% to 34% of total calories.

Primary Prevention Continued….

Saturated fat declined from 21% to 16%.Polyunsaturated fats increased from 3% to 5%.Cholesterol intake declined by 16%.

These diet changes explain the 38mg/dl declinein serum cholesterol in the society.

THE FINNS HAVE IT FIGURED !

Secondary Prevention in France:Lyon Heart Study

After a first MI, patients were randomized to a Mediterranean diet vs a control diet.

Mortality was reduced by 70% in the treatment group.

Food Intake: Lyon Heart Study

Food Group Control (gr/day)

Mediterranean (gr/day)

P Value

Bread 145 167 0.001 Cereals 99 94 0.22 Legumes 9.9 19.9 0.07 Veggies 288 316 0.07 Fruits 203 251 0.007 Ham/Offal 13.8 6.4 0.01 Meat 60.4 40 0.009

Food Intake, continued….

Food Control (gr/day)

Mediterranean (gr/day)

P Value

Poultry 52.8 57.8 0.42

Cheese 35 32 0.25

Butter 16.6 2.8 0.001

Margarine (Rapeseed)

5.1 19 0.001

Oil 16.5 15.7 0.65

Fish 39.5 46.5 0.16

Key Numbers: Lyon Heart Study

Nutrient Control Mediterranean P Value

Total Calories

2140 1928 0.001

Total Lipids

32.7 30.5 0.008

Alcohol 6.4 5.5 0.19

NEWS FLASH!!!!!!!!!!!!!!!!!!!!!!

MEAT FUTURES ARE UP, AS ARE PRICES IN THE MARKET.

THE BREAD BAKERS ASSOCIATION GATHERS TO DISCUSS THE THREAT OF THE ATKINS DIET TO THEIR INDUSTRY AND HOW TO RESPOND TO IT.

RECENT NATIONAL NEWS PROGRAMS RAISE NEW CONCERNS ABOUT LOW CARBO DIETS,BUT FOR SOME REASON SHOW NO CONCERN ABOUT HIGH CARBO DIETS!

EATING ATKINS IN AMERICA!

IS IT REALLY THE BACON DIET!!??

20 TO 100 GRAMS OF CARBO A DAY EAT NATURAL NONPROCESSED CARBOS VEGGIES ARE BEST! NO JUNK FOODS,AVOID HIGH GLYCEMICS! FATS ARE OK,BUT NO TRANS FATS,LIQUID AT ROOM

TEMPERATURE. EXERCISE AND DRINK 64 OZ OF WATER A DAY!

ATKINS IS EVERYWHERE!!!

WILLIAM BANTING 1860!!!!!

HE WAS THE FIRST PERSON TO DESCRIBE A LOW CARBO DIET.

AT AGE 66 “DISGUSTED”WITH HIS WEIGHT , HE RESTRICTED HIS CARBOHYDRATE INTAKE.

HE LOST 46 POUNDS! “THE GREAT CHARM AND COMFORT OF THIS

SYSTEM IS THAT ITS EFFECTS ARE PALPABLE WITHIN A WEEK OF TRIAL AND CREATES A NATURAL STIMULUS TO PERSEVERE!”

LOW CARBO DIETS,JAMA 4/9/03:IS IT THE CARBS OR THE CALORIES?

FOOD NO.OF DIETS MEAN G/DAY MEDIAN G/DAY

CARBOS 38 29 30

PROTEIN 26 96 95

FAT 26 104 99

CALORIES 38 1446 1454

EAT MORE LOSE LESS!!!

FOOD NO. OF DIETS MEAN MEDIAN

CARBO 157 236 211

PROTEIN 150 89 83

FAT 150 69 57

CALORIES 157 1913 1740

CARBOS:THE DATA IS LIMITED!

3268 PTS IN 94 DIET TRIALS “INSUFFICIENT DATA TO MAKE RECOMMENDATIONS

FOR OR AGAINST LOW CARBO DIETS. IN PUBLISHED STUDIES WEIGHT LOSS IS

ASSOCIATED WITH DECREASED CALORIC INTAKE AND DIET DURATION,BUT NOT WITH REDUCED CARBO INTAKE.

ON AVERAGE LDL,TRIGLYCERIDES,GLUCOSE AND INSULIN LEVELS DECREASED ON LOW CARBO DIETS

SUBSTITUTE 10% OF TOTAL CALORIES WITH CARBOS AND

LOOK AT THE CHOL/HDL RATIO!

-0.15

-0.1

-0.05

0

0.05

0.1

0.15

0.2

CARBS BUTTER PALM AVG DIET MAYO OLIVE OIL SOY/OIL RAPESEED

ATKINS AND GLYCEMIC INDEX

GLYCEMIC LOAD AND hs- CRP!

HS-CRP

0

1

2

3

4

5

6

Q1 121 Q2 151 Q3 166 Q4 180 Q5 208

WHY ARE EGGS BAD FOR US??

EGG CONSUMPTION AND RISK OF CARDIOVASCULAR DISEASE :

JAMA 4-21-99 37851 MEN AND 80082 WOMEN, AVERAGE AGE 59. NO KNOWN CAD DIABETES OR CANCER. HEALTH PROFESSIONALS AND NURSES HEALTH

STUDIES DATABASE. THE OBJECT WAS TO LOOK FOR AN ASSOCIATION

BETWEEN EGG CONSUMPTION AND RISK OF CHD AND STROKE.

EGGS AND RISK OF STROKE?!!

Age adjusted and multivariate risk

00.20.40.60.8

11.21.41.6

<1 WEEK 1 WEEK 2-4 WEEK 5-6 WEEK >1 DAY

EGGS EATEN

RIS

K O

F S

TR

OK

E

EGGS AND RISK OF CAD!

Age adjusted and multivariate risk for CAD

0

0.2

0.4

0.6

0.8

1

1.2

1.4

<1 1 EGGS 2-4 EGGS 5-6 EGGS> 1/DAY

OTHER FOOD INTAKE VS EGGS!

0

100

200

300

400

500

600

<1 1 EGGS 2-4 EGGS 5-6 >1 DAY

CHOL INTAKEPROTEINCARBOS

CONCLUSIONS IF ANY!

213 MG OF CHOLESTEROL PER EGG. IN THE FRAMINGHAM STUDY EGG CONSUMPTION

DID NOT CORRELATE WITH SERUM CHOLESTEROL OR RISK OF CHD!

BY THE KEYS FORMULA,1 EGG SHOULD INCREASE SERUM CHOLESTEROL BY 4%,WHICH SHOULD INCREASE CHD RISK BY 8%. THIS STUDY DID NOT SHOW ANY INCEASED RISK!

NEJM MAY 22,2003:LOW CARBO # 1!

132 SEVERELY OBESE PTS,BMI 43! RANDOMISED TO 30 G OR LESS OF CARBOS OR A CALORIE

AND FAT RESTRICTED DIET(500 CALORIE DEFICIT A DAY) 40% OF PTS DROPPED OUT!!!! WEIGHT LOSS AT 6 MONTHS WAS GREATER IN THE LOW

CARBO GROUP,5.7 VS 1.8 KG. NO DIFFERENCE IN LDL OR HDL CHOL,BUT TRIGS WERE

REDUCED IN THE LOW CARBO GROUP BY 20% VS 4% IN THE LOW FAT GROUP.

METABOLIC SHIFT!!!!!!!!

THEY SHOULD DO BETTER!!

NEJM MAY 22, 2003:LOW CARBO #2!

63 NONDIABETIC PATIENTS,BMI 34,RANDOMISED TO A LOW CARBO DIET(<20 G/DAY) OR TO A LOW FAT HIGH CARB DIET,LOW CALORIE(1200-1800 CAL/DAY),60% OF CALORIES FROM CARBS.

40% DROPPED OUT(AGAIN!!) NO SIGNIFICANT DIFFERENCE IN WEIGHT AT 12 MONTHS(-

4.4% LOW CARB vs 2.5% LOW FAT) LDL CHOLESTEROLS WERE THE SAME,HOWEVER

TRIGLYCERIDES WERE REDUCED BY -28% IN THE LOW CARB GROUP vs +1% IN THE LOW FAT GROUP AND HDL INCREASED BY 18% VS 3 %

THE AGONY OF THE LONG DISTANCE DIET!!!!!!!!!!!!!

WHY/HOW DOES THIS HAPPEN??

WE FOUND THEM!!!!!!!!!!!!!!!!

AMERICAN DIETARY REALITY!

139 MEALS OUT,60% FAST FOOD! 56 GALLONS OF SODA A YEAR !!!!!!!!!!!!! 34 TEASPOONS OF SUGAR PER DAY!! A 30 %

INCREASE FROM 10 YEARS AGO. 4 FOLD INCREASE IN FRENCH FRIES CHIPS ETC

COMPARED TO 30 YEARS AGO. “SUPERSIZE IT”!!!! FOOD IS CHEAP AND ADS PROMOTE IT!

TIL DIETS DO US PART!!!

Physical Activity and All-Cause Mortality

<500

500-999

1000-1499

1500-1999

2000-2499

2500-2999

3000-3499

>3500

1.0

.72

.2 1 .2 1

The Harvard Alumni Health StudyThe Harvard Alumni Health StudyRelative Risk of DeathRelative Risk of Death

kcals/wk< 2000

Kcal/wk

> 2000 Kcal/wk

• n=16,936• Age 35-74• Physical Activity

Questionnaire• 12-16 years of Follow-up

• n=16,936• Age 35-74• Physical Activity

Questionnaire• 12-16 years of Follow-up

• 28% mortality reduction with higher activity group

• Effect of Phys. Activity is independent of other RF’s

• 28% mortality reduction with higher activity group

• Effect of Phys. Activity is independent of other RF’s

ConclusionsConclusions

NEJM 1986;314:605-613

1.0

.78

.73

.63

.62

.52

.46

.62

GO THE MED WAY!!!!NEJM.6-26-03

ZORBAS DIET! HIGH MED vs LOW!

FOOD AVG GR/DAY LOW MED%>AVG HIGH MED%>AVG

VEGGIES 549 G/D 18% 80%

FRUITS/NUT 362 G/D 23% 76%

LEGUMES 9.1 G/D 23% 76%

DAIRY 196 G/D 69% 32%

MEAT 120 G/D 56% 42%

FISH 23 G/D 20% 70%

POTATOES 88G/D 42% 56%

EGGS 16 G/D 49 50%

MODIFIED MEDITERRANEAN ATKINS DIET! USA SOLUTION!?

HIGH FRUIT AND NUT CONSUMPTION REDUCED DEATH FROM ANY CAUSE BY 18%

A HIGH RATIO OF MONOUSATURATED LIPIDS TO SATURATED LIPIDS REDUCED DEATH BY ANY CAUSE BY14%

OTHER COMPONENTS WERE INSIGNIFICANT!? COMBINE THESE FINDINGS WITH GLYCEMIC INDEX,REDUCED

PROCESSED FOOD,HIGHER INTAKE OF “GOOD” FATS AND PROTEIN INSTEAD OF CARBOS

YOUR HIGH SCHOOL WEIGHT! DAILY

EXERCISE!!!!!!

“MODERATE ALCOHOL USE,DAILY VITAMIN

WHOLE GRAIN FOODS ONLY,PLANT OILS,OLIVE,CANOLA,SOY,SUNFLOWER

PEANUT

ALL THE VEGETABLES YOU CAN EAT! FRUITS ARE FINE!

FI FISH,POULTRY,EGGS,0-2

TIMES/DAY

DAIRY 1-2 TIMES/DAY

NO SUGAR,WHITE

FOOD

MEAT

MODIFIED ATKINS DIET!!??

ALL FATS ARE NOT BAD!!

RESTRICT CARBOS !!

THINK ABOUT WHAT YOU EAT!!

EAT VEGGIES INSTEAD OF BREAD!

WATER INSTEAD OF SODA!

NO SWEETS

IS THIS IMPOSSIBLE!!??

Xavier’s Quotes on Provence

“There is no time in Provence”! “Why read the newspaper?” “What’s for lunch, dinner.” “Yes, we like to relax; two hour lunches, longer dinners!” “You have sugar, we have wine.” “No, we don’t believe in regular exercise but we are

active.” “We aren’t fat, but we smoke a lot.”

DIET=MONEY=POLITICS!!!

IS THERE NO HOPE??!!??

AMERICAN IDEAL VS REALITY!