Choline and Fatty Liver

I've been writing about non-alcoholic fatty liver disorder (NAFLD) since the early days of this blog, because it's an alarmingly common disorder (roughly a quarter of Americans affected) that is typically undiagnosed. It often progresses into its more serious cousin non-alcoholic steatohepatitis (NASH), an inflammatory condition that causes liver damage and can progress to cancer. In a number of previous posts, I pinpointed excess sugar and seed oil consumption as culprits in NAFLD and NASH (1, 2, 3, 4, 5).

Chris Masterjohn recently published two very informative posts on NAFLD/NASH that add a major additional factor to the equation: choline (6, 7). Choline is an essential nutrient that's required for the transport of fat out of the liver (8). NAFLD can be caused, and cured, simply by removing or adding dietary choline, and it appears to be dominant over other dietary factors including fat, sugar and alcohol. Apparently, certain researchers have been aware of this for some time, but it hasn't entered into the mainstream consciousness.

Could that be because the richest dietary sources are liver and eggs*? Choline is also found in smaller amounts in a variety of whole animal and plant foods. Most people don't get the officially recommended amount. From a recent review article (9):

Mean choline intakes for older children, men, women, and pregnant women are far below the adequate intake level established by the [Institute of Medicine]. Given the importance of choline in a wide range of critical functions in the human body, coupled with less-than-optimal intakes among the population, dietary guidance should be developed to encourage the intake of choline-rich foods.

I've dubbed beef liver the Most Nutritious Food in the World, Nature's Multivitamin, and I'll probably invent other titles for it in the future. Add yours to the comments.

Head over to Chris's blog and read about the classic studies he unearthed. And add The Daily Lipid to your RSS reader, because there's more interesting material to come!

The Sweet Truth about Liver and Egg Yolks
Does Choline Deficiency Contribute to Fatty Liver in Humans?


* For the brave: brain is actually the richest source of choline.

Text Messages and Public Health: Can They Remove Barriers for "Calling" 9-1-1?

Text messages are a great time saver. You do not have to have a long conversation with someone...instead you can just send a quick message like "I made it home safe!" or "Can you pick up milk on your way home?" These text messages work well to support our busy lives, but can they also be incorporated into effective public health interventions and systems?

This week, the Federal Communications Commission (FCC) announced that it is looking into letting citizens report crimes via text message. An article posted by Wired discusses the possibility and highlights some of the "barriers" that this new strategy could help to address. First and foremost, it could allow citizens to report a crime without being overheard if they were in dangerous situations (e.g., kidnapping, robbery). The FCC specifically pointed to the 2007 shootings at VirginiaTech and reported that texts could have allowed emergency personnel to respond more quickly and with a better understanding of the circumstances inside the campus buildings.

While at first glance, it may seem surprising to use text messaging for 9-1-1 reporting (due to potential logistical considerations and challenges), it would not be the first time that texts were being integrated into public health interventions and emergency response systems. For example:

• Text messages are used to disseminate key health messages to various priority populations. E.g., The Text4Baby campaign allows mothers to self select into their program by texting "Baby" to the program number. The mothers then receive weekly text messages (timed to their due date or baby's birth day) regarding key health issues for their babies (e.g., nutrition, immunizations, etc).

• Many workplaces and college campuses have signed up for emergency response systems that will send out automatic alerts to email and phones (via text message) during a crisis (e.g., shooter on site).

In the case of using text messages for "calling" 9-1-1, I wonder about how texts could influence a well documented social psychology barrier to calling for help. Those of you that took a social psychology course in college may remember the name "Kitty Genovese". She was a woman who was murdered outside her home in Queens, NY in 1964. At least one dozen people heard or observed her attack (lasting approximately 30 minutes), but there was much delay in anyone calling for help. A NY Times article running two weeks after her death was entitled, "Thirty-Eight Who Saw Murder Didn't Call Police". This case is widely discussed as an example of the "Bystander Effect", which is used to explain why many people do not help in emergency situations when others are present. Some hypotheses about the effect are that we just do what others are doing (i.e., nothing to help), we assume someone else is already calling/helping, or we assume that others are more qualified to help. Perhaps it is also too much trouble to call 9-1-1? They require a lot of information, we have to stay on the phone, etc. Perhaps a more "passive" option to report the information (like text messaging) would decrease resistance and the bystander effect?

In addition to the great potential with this strategy, there are also several barriers that must be addressed in the planning:

• Costs (equipment, training, staffing)
• Regulation and Oversight: Will text message support be required or voluntary at emergency centers? Who will conduct a formative and ongoing evaluation of the system?
  
• Interpretation of messages: Operators will need special training to (quickly) interpret and respond to text messages. Texts are often written in short hand, so you would need someone very skilled to decipher them accurately. It may also be time consuming to support the texting back and forth that may be required to receive all relevant information from the "caller" in order to dispatch an appropriate response.

Even with the barriers noted above, it does seem like text messages are a viable option to consider in order to increase timely and safe 9-1-1 reporting. However, the 9-1-1 system will need to think critically to develop the type of infrastructure that can keep up with our ever changing and expanding communication technology.

Glucose Tolerance in Non-industrial Cultures

Background

Glucose is the predominant blood sugar and one of the body's two main fuel sources (the other is fatty acids). Glucose, in one form or another, is also the main form of digestible dietary carbohydrate in nearly all human diets. Starch is made of long chains of glucose molecules, which are rapidly liberated and absorbed during digestion. Sucrose, or table sugar, is made of one glucose and one fructose molecule, which are separated before absorption.

Blood glucose is essential for life, but it can also be damaging if there is too much of it. Therefore, the body tries to keep it within a relatively tight range. Normal fasting glucose is roughly between 70 and 90 mg/dL*, but in the same individual it's usually within about 5 mg/dL on any given day. Sustained glucose above 160 mg/dL or so causes damage to multiple organ systems. Some people would put that number closer to 140 mg/dL.

The amount of glucose contained in a potato far exceeds the amount contained in the blood, so if all that glucose were to enter the blood at once, it would lead to a highly damaging blood glucose level. Fortunately, the body has a hormone designed to keep this from happening: insulin. Insulin tells cells to internalize glucose from the blood, and suppresses glucose release by the liver. It's released by the pancreas in response to eating carbohydrate, and protein to a lesser extent. The amount of insulin released is proportional to the amount of carbohydrate ingested, so that glucose entering the blood is cleared before it can accumulate.

Insulin doesn't clear all the glucose as it enters the bloodstream, however. Some of it does accumulate, leading to a spike in blood glucose. This usually doesn't exceed 130 mg/dL in a truly healthy person, and even if it approaches that level it's only briefly. However, diabetics have reduced insulin signaling, and eating a typical meal can cause their glucose to exceed 300 mg/dL due to reduced insulin action and/or insulin secretion. In affluent nations, this is typically due to type II diabetes, which begins as insulin resistance, a condition in which insulin is actually higher than normal but cells fail to respond to it.  The next step is the failure of insulin-secreting beta cells, which is what generally precipitates actual diabetes.

The precursor to diabetes is called glucose intolerance, or pre-diabetes. In someone with glucose intolerance, blood glucose after a typical meal will exceed that of a healthy person, but will not reach the diabetic range (a common definition of diabetes is 200 mg/dL or higher, 2 hours after ingesting 75g of glucose). Glucose tolerance refers to a person's ability to control blood glucose when challenged with dietary glucose, and can be used in some contexts as a useful predictor of diabetes risk and general metabolic health. Doctors use the oral glucose tolerance test (OGTT), which involves drinking 60-100g glucose and measuring blood glucose after one or two hours, to determine glucose tolerance.

Why do we care about glucose tolerance in non-industrial cultures?

One of the problems with modern medical research is that so many people in our culture are metabolically sick that it can be difficult to know if what we consider "normal" is really normal or healthy in the broader sense. Non-industrial cultures allow us to examine what the human metabolism is like in the absence of metabolic disease. I admit this rests on certain assumptions, particularly that these people aren't sick themselves. I don't think all non-industrial cultures are necessarily healthy, but I'm going to stick with those that research has shown have an exceptionally low prevalence of diabetes (by Western standards) and other "diseases of civilization" for the purposes of this post.

Here's the question I really want to answer in this post: do healthy non-industrial cultures with a very high carbohydrate intake have an excellent glucose tolerance, such that their blood glucose doesn't rise to a high level, or are they simply resistant to the damaging effects of high blood glucose?

The data

I'm going to start with an extreme example. In the 1960s, when it was fashionable to study non-industrial cultures, researchers investigated the diet and health of a culture in Tukisenta, in the highlands of Papua New Guinea. The eat practically nothing but sweet potatoes, and their typical daily fare is 94.6 percent carbohydrate. Whether or not you believe that exact number, their diet was clearly extraordinarily high in carbohydrate. They administered 100g OGTTs and measured blood glucose at one hour, which is a very stringent OGTT. They compared the results to those obtained in the 1965 Tecumseh study (US) obtained by the same method. Here's what they found (1):
Compared to Americans, in Tukisenta they had an extraordinary glucose tolerance at all ages. At one hour, their blood glucose was scarcely above normal fasting values, and glucose tolerance only decreased modestly with age. In contrast, in Americans over 50 years old, the average one-hour value was around 180 mg/dL!

Now let's take a look at the African Bantu in the Lobaye region of the Central African Republic. The Bantu are a large ethnic group who primarily subsist on a diverse array of starchy foods including grains, beans, plantains and root crops. One hour after a 100g OGTT, their blood glucose was 113 mg/dL, compared to 139 mg/dL in American controls (2). Those numbers are comparable to what investigators found in Tukisenta, and indicate an excellent glucose tolerance in the Bantu.

In South America, different investigators studied a group of native Americans in central Brazil that subsist primarily on cassava (a starchy root crop) and freshwater fish. Average blood glucose one hour after a 100g OGTT was 94 mg/dl, and only 2 out of 106 people tested had a reading over 160 mg/dL (both were older women) (Western Diseases: Their Emergence and Prevention, p. 149). Again, that indicates a phenomenal glucose tolerance by Western standards.

I have to conclude that high-carbohydrate non-industrial cultures probably don't experience damaging high blood glucose levels, because their glucose tolerance is up to the task of shuttling a huge amount of glucose out of the bloodstream before that happens.

Not so fast...

Now let's turn our attention to another study that may throw a wrench in the gears. A while back, I found a paper containing OGTT data for the !Kung San (also called the Bushmen), a hunter-gatherer group living in the Kalahari desert of Africa. I reported in an earlier post that they had a good glucose tolerance. When I revisited the paper recently, I realized I had misread it and in fact, their glucose tolerance was actually pretty poor.

Investigators administered a 50g OGTT, half what the other studies used. At one hour, the San had blood glucose readings of 169 mg/dL, compared to 142 mg/dL in Caucasian controls (3)! I suspect a 100g OGTT would have put them close to the diabetic range.

Wait a minute, these guys are hunter-gatherers living the ancestral lifestyle; aren't they supposed to be super healthy?? First of all, like many hunter-gatherer groups the San are very small people: the men in this study were only 46 kg (101 lbs).  The smaller you are, the more a given amount of carbohydrate will raise your blood glucose.  Also, while I was mulling this over, I recalled a discussion where non-diabetic people were discussing their 'diabetic' OGTT values while on a low-carbohydrate diet. Apparently, carbohydrate refeeding for a few days generally reverses this and allows a normal OGTT in most people. It turns out this effect has been known for the better part of a century.

So what were the San eating? The study was conducted in October of 1970. The San diet changes seasonally, however their main staple food is the mongongo nut, which is mostly fat and which is available year-round (according to The !Kung San: Men, Women and Work in a Foraging Society). Their carbohydrate intake is generally low by Western standards, and at times of the year it is very low. This varies by the availability of other foods, but they generally don't seem to relish the fibrous starchy root crops that are available in the area, as they mostly eat them when other food is scarce. Jean-Louis Tu has posted a nice analysis of the San diet on BeyondVeg (4). Here's a photo of a San man collecting mongongo nuts from The !Kung San: Men, Women and Work in a Foraging Society:

What did the authors of the OGTT study have to say about their diet? Acknowledging that prior carbohydrate intake may have played a role in the OGTT results of the San, they made the following remark:

a retrospective dietary history (M. J. Konner, personal communication, 1971) indicated that the [San], in fact, consumed fairly large amounts of carbohydrate-rich vegetable food during the week before testing.

However, the dietary history was not provided, nor has it been published, so we have no way to assess the statement's accuracy or what was meant by "fairly large amounts of carbohydrate-rich vegetable food." Given the fact that the San diet typically ranges from moderately low to very low in carbohydrate, I suspect they were not getting much carbohydrate as a percentage of calories. Looking at the nutritional value of the starchy root foods they typically eat in appendix D of The !Kung San: Men, Women and Work in a Foraging Society, they are fibrous and most contain a low concentration of starch compared to a potato for example. The investigators may have been misled by the volume of these foods eaten, not realizing that they are not as rich in carbohydrate as the starchy root crops they are more familiar with.

You can draw your own conclusions, but I think the high OGTT result of the San probably reflect a low habitual carbohydrate intake, and not pre-diabetes. I have a very hard time believing that this culture wasn't able to handle the moderate amount of carbohydrate in their diet effectively, as observers have never described diabetic complications among them.

Putting it all together

This brings me to my hypothesis. I think a healthy human body is extraordinarily flexible in its ability to adapt to a very broad range of carbohydrate intakes, and adjusts glucose tolerance accordingly to maintain carbohydrate handling in a healthy range. In the context of a healthy diet and lifestyle (from birth), I suspect that nearly anyone can adjust to a very high carbohydrate intake without getting dangerous blood glucose spikes. A low carbohydrate intake leads to impaired glucose handling and better fat handling, as one would expect. This can show up as impaired glucose tolerance or even 'diabetes' on an OGTT, but that does not necessarily reflect a pathological state in my opinion.

Every person is different based on lifestyle, diet, personal history and genetics. Not everyone in affluent nations has a good glucose tolerance, and some people will never be able to handle starch effectively under any circumstances. The best way to know how your body reacts to carbohydrate is to test your own post-meal blood glucose using a glucose meter. They are inexpensive and work well. For the most informative result, eat a relatively consistent amount of carbohydrate for a week to allow your body to adapt, then take a glucose measurement 1 and 2 hours after a meal. If you don't eat much carbohydrate, eating a potato might make you think you're diabetic, whereas after a week of adaptation you may find that a large potato does not spike your blood glucose beyond the healthy range.

Exercise is a powerful tool for combating glucose intolerance, as it increases the muscles' demand for glucose, causing them to transport it out of the blood greedily after a meal. Any exercise that depletes muscle glycogen should be effective.


* Assuming a typical carbohydrate intake. Chris Kresser recently argued, based on several studies, that true normal fasting glucose for a person eating a typical amount of carbohydrate is below 83 mg/dL. Low-carbohydrate eating may raise this number, but that doesn't necessarily indicate a pathological change. High-carbohydrate cultures such as the Kitavans, Aymara and New Guineans tend to have fasting values in the low 60s to low 70s. I suspect that a very high carbohydrate intake generally lowers fasting glucose in healthy people. That seems to be the case so far for Chris Voigt, on his diet of 20 potatoes a day. Stay tuned for an interview with Mr. Voigt in early December.

Impressions from the Wise Traditions Conference

I spent last weekend at the Weston A. Price Foundation Wise Traditions conference in King of Prussia, PA. Here are some highlights:

Spending time with several people in the diet-health community who I’ve been wanting to meet in person, including Chris Masterjohn, Melissa McEwen and John Durant. John and Melissa are the public face of the New York city paleo movement. The four of us spent most of the weekend together tossing around ideas and making merry. I’ve been corresponding with Chris quite a bit lately and we’ve been thinking through some important diet-health questions together. He is brimming with good ideas. I also got to meet Sally Fallon Morell, the founder and president of the WAPF.

Attending talks. The highlight was Chris Masterjohn’s talk “Heart Disease and Molecular Degeneration: the New Paradigm”, in which he described his compelling theory on oxidative damage and cardiovascular disease, among other things. You can read some of his earlier ideas on the subject here. Another talk I really enjoyed was by Anore Jones, who lived with an isolated Inuit group in Alaska for 23 years and ate a mostly traditional hunter-gatherer diet. The food and preparation techniques they used were really interesting, including various techniques for extracting fats and preserving meats, berries and greens by fermentation. Jones has published books on the subject that I suspect would be very interesting, including Nauriat Niginaqtuat, Plants that We Eat, and Iqaluich Niginaqtuat, Fish that We Eat. The latter is freely available on the web here.

I attended a speech by Joel Salatin, the prolific Virginia farmer, writer and agricultural innovator, which was fun. I enjoyed Sally Fallon Morell’s talk on US school lunches and the politics surrounding them. I also attended a talk on food politics by Judith McGeary, a farmer, attorney and and activist, in which she described the reasons to oppose or modify senate bill 510. The gist is that it will be disproportionately hard on small farmers who are already disfavored by current regulations, making high quality food more difficult to obtain, more expensive or even illegal. It’s designed to improve food safety by targeting sources of food-borne pathogens, but how much are we going to have to cripple national food quality and farmer livelihood to achieve this, and will it even be effective? I don’t remember which speaker said this quote, and I’m paraphrasing, but it stuck with me: “I just want to be able to eat the same food my grandmother ate.” In 2010, that’s already difficult to achieve. Will it be impossible in 2030?

Giving my own talk. I thought it went well, although attendance was not as high as I had hoped. The talk was titled “Kakana Dina: Diet and Health in the Pacific Islands”, and in it I examined the relationship between diet and health in Pacific island cultures with different diets and at various stages of modernization. I’ve covered some of this material on my blog, in my posts on Kitava, Tokelau and sweet potato eating cultures in New Guinea, but other material was new and I went into greater detail on food habits and preparation methods. I also dug up a number of historical photos dating back as far as the 1870s.

The food. All the meat was pasture-raised, organic and locally sourced if possible. There was raw pasture-raised cheese, milk and butter. There was wild-caught fish. There were many fermented foods, including sauerkraut, kombucha and sourdough bread. I was really impressed that they were able to put this together for an entire conference.

The vendors. There was an assortment of wholesome and traditional foods, particularly fermented foods, quality dairy and pastured meats. There was an entire farmer’s market on-site on Saturday, with a number of Mennonite vendors selling traditional foods. I bought a bottle of beet kvass, a traditional Russian drink used for flavor and medicine, which was much better than the beet kvass I’ve made myself in the past. Beets are a remarkable food, in part due to their high nitrate content—beet juice has been shown to reduce high blood pressure substantially, possibly by increasing the important signaling molecule nitric oxide. I got to meet Sandeep Agarwal and his family, owners of the company Pure Indian Foods, which domestically produces top-quality pasture-fed ghee (Indian-style clarified butter). They now make tasty spiced ghee in addition to the plain flavor. Sandeep and family donated ghee for the big dinner on Saturday, which was used to cook delicious wild-caught salmon steaks donated by Vital Choice.

There were some elements of the conference that were not to my taste. But overall I’m glad I was able to go, meet some interesting people, give my talk and learn a thing or two.

No Matter How Graphic The Images, Fear Based Messages Will Continue To Be Ineffective For Prevention

All over the news in the past week, we have seen samples of the new graphic images being proposed for addition to cigarette packages. They include corpses and people dying of cancer. However, just because these images and warnings are larger and more graphic, does not mean that they will be effective in smoking prevention.

A story ran today on Boston.com called "Will graphic cigarette warnings help- or hurt?" Two experts in tobacco prevention are quoted regarding their concerns about the new images. Gregory Connelly of the Harvard School of Public Health points to the results coming from Canada after using similar images. Smokers there simply purchased sleeves to cover up the images on their cigarette packs. Also, the smoking rate did not go down. The second expert is a wonderful professor of mine from the Boston University School of Public Health, Dr. Michael Siegel. Dr. Siegel writes regularly regarding this topic on his blog, "The Rest of the Story: Tobacco Analysis and Commentary". In the Boston.com article, he states "I do not actually think it's going to have much of an impact". His argument- the images are too late. The smokers are seeing the images after they have already purchased cigarettes. And (drum roll please....) people already know smoking is bad for them.

As someone who grew up during the "This is your brain. This is your brain on drugs. Any questions?" era...I wonder why we have not made much progress since then? Numerous studies have shown that scare tactics (or fear appeals) are not effective for preventing or producing sustained reductions of Alcohol, Tobacco, or other Drug use among youth. In addition to the issues outlined above, there is another problem with the fear based approach:

Although the fear based messages may increase knowledge (e.g., if they did not know it already, smokers will learn that cigarettes are bad for them from the graphic images)- knowledge does not equal behavior change. Especially when you are dealing with an addictive behavior. Addictive behaviors like smoking and drug use are impacted by much more than a rational weighing of pros and cons. There is the biological component of addiction, local-state-national prevention policies, social norms around the behavior, consequences experienced (or not experienced), ease of access to the substance, social support for quiting, money to support the addiction, etc. As you can see, knowledge alone will not change this kind of complex behavior.

Many of the most successful prevention strategies around this and other public health issues will continue to be a refocus from increasing individual knowledge to changing an environment that supports the behavior. In other words, laws that create smoke-free workplaces and crack down on establishments that sell cigarettes to underage kids will always be more effective at keeping the population healthy versus trying to educate (or scare) one individual at a time.

The Twinkie Diet for Fat Loss

The Experiment

I've received several e-mails from readers about a recent experiment by nutrition professor Mark Haub at Kansas State university (thanks to Josh and others). He ate a calorie-restricted diet in which 2/3 of his calories came from junk food: Twinkies, Hostess and Little Debbie cakes, Dorito corn chips and sweetened cereals (1). On this calorie-restricted junk food diet (800 calorie/day deficit), he lost 27 pounds in two months.

Therefore, junk food doesn't cause fat gain and the only thing that determines body fatness is how much you eat and exercise. Right?

Discussion

Let's start with a few things most people can agree on. If you don't eat any food at all, you will lose fat mass. If you voluntarily force-feed yourself with a large excess of food, you will gain fat mass, whether the excess comes from carbohydrate or fat (2). So calories obviously have something to do with fat mass.

But of course, the situation is much more subtle in real life. Since a pound of body fat contains roughly 3,500 calories, eating an excess of 80 calories per day (1 piece of toast) should lead to a weight gain of 8 lbs of fat per year. Conversely, if you're distracted and forget to eat your toast, you should lose 8 lbs of fat per year, which would eventually be dangerous for a lean person. That's why we all record every crumb of food we eat, determine its exact calorie content, and match that intake precisely with our energy expenditure to maintain a stable weight.

Oh wait, we don't do that? Then how do so many people maintain a stable weight over years and decades? And how do wild animals maintain a stable body fat percentage (except when preparing for hibernation) even in the face of food surpluses? How do lab rats and mice fed a whole food diet maintain a stable body fat percentage in the face of literally unlimited food, when they're in a small cage with practically nothing to do but eat?

The answer is that the body isn't stupid. Over hundreds of millions of years, we've evolved sophisticated systems that maintain "energy homeostasis". In other words, these systems act to regulate fat mass and keep it within the optimal range. The evolutionary pressures operating here are obvious: too little fat mass, and an organism will be susceptible to starvation; too much, and an organism will be less agile and less efficient at locomotion and reproduction. Energy homeostasis is such a basic part of survival that even the simplest organisms regulate it.

Not only is it clear that we have an energy homeostasis system, we even know a thing or two about how it works. Early studies showed that lesioning a part of the brain called the ventromedial hypothalamus causes massive obesity (3; this is also true in humans, when a disruption results from cancer). Investigators also discovered several genetic mutations in rats and mice that result in massive obesity*. Decades-long research eventually demonstrated that these models have something in common: they all interfere with an energy homeostasis circuit that passes information about fat mass to the hypothalamus via the hormone leptin.

The leptin system is a classic negative feedback loop: the more fat mass accumulates, the more leptin is produced. The more leptin is produced, the more the hypothalamus activates programs to reduce hunger and increase energy expenditure, which continues until fat mass is back in the optimal range. Conversely, low fat mass and low leptin lead to increased hunger and energy conservation by this same pathway**.

So if genetic mutants can become massively obese, I guess that argues against the idea that voluntary food intake and energy expenditure are the only determinants of fat mass. But a skeptic might point out that these are extreme cases, and such mutations are so rare in humans that the analogy is irrelevant.

Let's dig deeper. There are many studies in which rodents are made obese using industrial high-fat diets made from refined ingredients. The rats eat more calories (at least in the beginning), and gain fat rapidly. No big surprise there. But what may come as a surprise to the calorie counters is that rodents on these diets gain body fat even if their calorie intake is matched precisely to lean rodents eating a whole food diet (4, 5, 6). In fact, they sometimes gain almost as much fat as rodents who are allowed to eat all the industrial food they want. This has been demonstrated repeatedly.

How is this possible? The answer is that the calorie-matched rats reduce their energy expenditure to a greater degree than those that are allowed free access to food. The most logical explanation for this behavior is that the "set point" of the energy homeostasis system has changed. The industrial diet causes the rodents' bodies to "want" to accumulate more fat, therefore they will accomplish that by any means necessary, whether it means eating more, or if that's not possible, expending less energy. This shows that a poor diet can, in principle, dysregulate the system that controls energy homeostasis.

Well, then why did Dr. Haub's diet allow him to lose weight? The body can only maintain body composition in the face of a calorie deficit up to a certain point. After that, it has no choice but to lower fat mass. It will do so reluctantly, at the same time increasing hunger, and reducing lean mass***, muscular strength and energy dedicated to tissue repair and immune function. However, I hope everyone can agree that a sufficient calorie deficit can lead to fat loss regardless of what kind of food is eaten. Dr. Haub's 800 calorie deficit qualifies. I think only a very small percentage of people are capable of maintaining that kind of calorie deficit for more than a few months, because it is mentally and physically difficult to fight against what the hypothalamus has decided is in your best interest.

My hypothesis is that, in many people, industrial food and an unnatural lifestyle lead to gradual fat gain by dysregulating the energy homeostasis system. This "breaks" the system that's designed to automatically keep our fat mass in the optimal range by regulating energy intake, energy expenditure and the relative partitioning of energy resources between lean and fat tissue. This system is not under our conscious control, and it has nothing to do with willpower.

I suspect that if you put a group of children on this junk food diet for many years, and compared them to a group of children on a healthy diet, the junk food group would end up fatter as adults. This would be true if neither group paid any attention to calories, and perhaps even if calorie intake were identical in the two groups (as in the rodent example). The result of Dr. Haub's experiment does not contradict that hypothesis.

So do calories matter? Yes, but in a healthy person, all the math is done automatically by the hypothalamus and energy balance requires no conscious effort. In 2010, many people have already accumulated excess fat mass. How that may be sustainably lost is another question entirely, and a more challenging one in my opinion. As they say, an ounce of prevention is worth a pound of cure. There are many possible strategies, with varying degrees of efficacy that depend highly on individual differences, but I think overall the question is still open. I discussed some of my thoughts in a recent series on body fat regulation (7, 8, 9, 10, 11).


* ob/ob and db/db mice. Zucker and Koletsky rats. Equivalent mutations in humans also result in obesity.

** Via an increase in muscular efficiency and perhaps a decrease in basal metabolism. Thyroid hormone activity drops.

*** Loss of muscle, bone and connective tissue can be compensated for by strength training during calorie restriction. Presumed loss of other non-adipose tissues (liver, kidney, brain, etc.) is probably not affected by strength training.

Kids, Gender Identity, and Bullying: Moms Fight Back

Last week on Facebook, no less than ten friends posted a link to the Nerdy Apple Bottom website post "My son is gay". The post was written by the mother of a 5-year old boy who dressed as Daphne (from Scooby Doo) for Halloween. She talks about his arrival at school in his costume and the harsh reaction received...mostly from other parents. She documents her internal reaction to this reception, which prompted much discussion and cheering among my Facebook friends:

"If you think that me allowing my son to be a female character for Halloween is somehow going to 'make' him gay, then you are an idiot. Firstly, what a ridiculous concept. Secondly, if my son is gay, OK. I will love him no less. Thirdly, I am not worried that your son will grow up to be an actual ninja so back off".

As of tonight, this post had 41,311 comments.

Coincidentally, the November 15th edition of People Magazine runs a story called "A Tale of Acceptance". The story profiles a Seattle mother named Cheryl Kilodavis who also has a 5-year old son that likes to dress up as a girl character. When the behavior began three years ago, she and her husband discussed it and decided to let him dress how he liked. In order to help other kids accept him, Cheryl decided to write a children's story. She calls her self-published book, "My Princess Boy".

Cheryl first shared the book at her son's school. The vice principal loved it and put copies in all the classes. Cheryl soon had orders from nine other schools and now that there has been so much press coverage, the family is searching for a publisher and trying to keep up with the book requests.

Of course, not all of the press has been positive. A New York Times article late last week discussed some therapists' concerns about these young boys being "outed" by their parents by having their pictures posted on YouTube, blogs, and talk shows. Some commenters wonder why these mothers do not protect their children from ridicule by making them dress in costumes that are more gender appropriate.

The discussion of bullying and suicide over the past few months has seemed to provide a real "teachable moment" for this country. People want to talk about it (as evidenced by the 41,000+ comments on the Nerdy Apple Bottom site). People want to teach kids how to respect themselves and each other. Therefore, they seem fascinated by "My Princess Boy", which uses words and illustrations that can allow even the youngest children to participate in the discussion around personal expression and acceptance. These blogs and books and support from children's schools can really help to change the social norms around what is "normal" behavior and dress. We must be creative in designing a way to evaluate these normative changes. Hopefully we will see a reduction in negative outcomes for students (e.g., reports of bullying, rates of depression, and suicide). But hopefully we will also see a reduction in risk factors further up stream, like attitudes around acceptance and gender roles.

Observations from France

I recently got back from a trip to the UK and France visiting family and friends. It was great to see everyone, eat great food and even do some unexpected foraging (chestnuts, mushrooms, walnuts, blackberries). French people are in better general health than most industrialized nations. The obesity, diabetes and heart disease rates are all considerably lower than in the US, although still much higher than in non-industrial cultures. Here are a few of my observations about French food:

1. The French diet generally contains a lot of fat, mostly from traditional animal sources such as dairy and pork fat. Industrial seed oils have crept into the diet over the course of the 20th century, although not to the same degree as in most affluent nations. People seem to think that eating a lot of fat is unhealthy, particularly the younger generation, but they do it anyway. I had dinner with my family at a traditional restaurant in Lyon (a "bouchon Lyonnais" called Stepharo) last week. Before we ordered, they immediately brought out crispy fried chunks of pork skin and fat (I'm not claiming this is healthy!). The entree was a salad: a bed of lettuce piled high with chicken livers, herring, and "pig's feet". The pigs feet were essentially gobs of pork fat. It was a very good meal that I'll continue describing later in the post. I think it's worth pointing out that Lyon is in Southern France. Is this the "Mediterranean diet"?
   
2. French people eat organs. Yes, they never got the memo that muscle meat is the only edible tissue. A typical butcher or even grocery store will have liver, tripe, kidney and blood sausage on full display next to the meat. If you want to make a French person angry, try selling them a chicken or a rabbit without the liver, gizzard and heart. The main course at Stepharo was a large "andouilette", or tripe sausage, baked in mustard sauce. This was a typical traditional restaurant, not a hangout for gastronauts.
   
3. French people fiercely defend the quality of their food. Have you heard of the abbreviation AOC? It stands for "Appellation d’Origine Contrôlée", or controlled designation of origin. A familiar example is Champagne, which has the AOC label. You can't call your sparkling wine Champagne unless it comes from the region Champagne. However, that's only half the story. AOC also designates a specific, traditional production method, in this case called the "méthode champenoise." The AOC label can apply to a variety of food products, including wine, butter, cheese, honey, mustard and seafood, and is a guarantee of quality and tradition. 44 cheeses currently have the AOC designation, and these are commonly available in markets and grocery stores throughout the country (1). These are not fancy products that only the wealthy can afford-- many of them are quality foods that are accessible to nearly everyone. AOC defines many aspects of cheese production, often requiring a minimum amount of pasture time and specifying livestock breeds. The US has a few products that are regulated in a similar fashion, such as Bourbon whiskey, but generally we are far behind in assuring food quality and transparency.
4. French people cook. There is less outsourcing of food processing in France, for several reasons. One reason is that restaurants are generally expensive. That trend is changing however.

I don't think the French diet is optimal by any means. They eat a lot of white flour, some sugar, seed oils and other processed foods. But I do think the French diet has many good qualities, and it certainly poses a number of problems for the mainstream concept of healthy food. Hence the "French paradox."

Marie Claire Blogger vs. Mike & Molly: A "Heavyweight" Fight

Last week a blogger for Marie Claire Magazine named Maura Kelly posted an article called, "Should 'Fatties' Get a Room? (Even on TV)?" The post is focused on a new fall sitcom for CBS called "Mike & Molly". I must disclose that I have not watched this show, but have read that it centers on a couple that meets at an Overeaters Anonymous Group. Ms. Kelly takes a strong position that this show is "promoting obesity" and is grossed out by having to watch two obese people make out (or do anything else, like walk across a room).

As you can imagine, this post has been met with quite a reaction, including 3,195 reader comments (as of tonight) that prompted Ms. Kelly to post an update (aka apology). The update apologizes to those readers that were offended (many of which state that they have since canceled their Marie Claire subscription) and offers that perhaps her strong reaction to these overweight actors comes from her own history as an anorexic. The gist I get from the comments, is that most readers do not feel the apology is sincere and expected a better response from Marie Claire (that would include firing Ms. Kelly and/or making it clear that they will not support this type of discrimination). There has also been a strong response from the celebrity community, including Sharon Osborne on "The Talk" who said that she was appalled and wondered about what Ms. Kelly would think of her. Sharon admitted that she's 30 pounds overweight...should she not be allowed to kiss her husband or walk across the room?

According to the Centers for Disease Control and Prevention (CDC), 34% of adults are overweight and about the same percentage are obese. If approximately 70% of our adult population is overweight or obese, why don't we have more characters that accurately reflect what people actually look like and the challenges that they face? Hasn't there been some effort to portray more diverse characters in other ways (e.g., race and ethnicity)? Why would being overweight be so offensive to the viewing population? And is Mike & Molly really the first show to do this? Growing up, I was a fan of the sitcom "Roseanne" (1988-1997). The primary couple on the show (Rosanne Barr and John Goodman) were very overweight and struggled quite openly with weight, diet, and exercise on the show. Perhaps my memory is fuzzy, but I never remember hearing that viewers were horrified by these characters showing affection on the show.

Ironically, as I was getting ready to put this post together today, I caught the Oprah show. She had on Portia Di Rossi who discusses her battle with Anorexia and Bulimia in her new book "Unbearable Lightness".

Portia spoke about her breakout role in Ally McBeal in the 1990s. Many of you may remember the media headlines at that time calling the three female leads "Scary Skinny" (which they were- Portia was down to 82 pounds at one point). Ironically, she specifically discussed her fear about a scene where she seduces her boss in her lingerie in the law office. Although she was skeletal and sick looking, did we hear from viewers or writers that they were "grossed out" to watch her make out with her boss on the show?

So what is best for viewers? What messages regarding "normal" should we be sending to viewers? If actors are too skinny, the concern is that the image is not realistic and it is causing young girls to have eating disorders trying to achieve this ideal. However, when a show like Mike & Molly is showing characters that accurately represent 70% of the population, there is also controversy. From a public health perspective, I would say that characters should accurately reflect the viewing population- people tend to respond to people that they can relate to. If you are creating a health communication product (e.g., poster or brochure), you test it with the target audience to make sure that they connect to the images. If you are concerned about "promoting obesity", then have the characters modeling healthy behaviors. For example, Mike & Molly are attending an Overeaters Anonymous Group, which means they are taking steps to improve their lifestyle.

I for one, would be very happy to see more realistic characters on television. I would also like to see research on how those characters can be used as a health communication tool to promote positive body image and health behaviors among the viewing population.