Super Size Me - the Swedish Experiment

A research from Linkoping University, Sweden, published in the medical journal "Gut", showed that regular indulging in fast food caused, in less than 4 weeks, a pathologic rise in the level of a liver enzyme, alanine aminotransferase (ALT) in the blood. The fast food experiment subjects aimed for a body weight increase of 5-15% by eating at least two fast food-based meals a day with the goal to double the regular caloric intake in combination with adoption of a sedentary lifestyle for four weeks. They limited their daily exercise to less than 5000 steps for 4 weeks. The authors suggested that an increased flow of monosaccharides to the liver could induce the production of the enzyme in the liver cells. The authors, therefore, recommended that physicians should include not only questions about alcohol intake, but also recent excessive food intake, when evaluating reasons for a new elevation of ALT.

An article in the Guardian gave a little history how the Dr. Fredrik H Nystrom's Swedish experiment design was influenced by Morgan Spurlock's 2004 documentary "Super Size Me", in which Spurlock ate nothing but McDonald's food for a month. You may remember that doctors urged him to abandon his experiment after getting the results of blood tests which show that his liver is so badly damaged it looks as though it is the result of heavy drinking. The results of the Swedish study did document liver enzyme test abnormalities, but those were not as dramatic as Spurlock's.

It is actually not necessarily a matter of whether the food is consumed from McDonald's, a family restaurant, or cooked at home. It is not entirely a matter of whether the food is "fast food" or a fully served multi-course meal in a fancy restaurant. The central issue is all about choices. How many calories, how many of those are proteins, how many are from carbs, and how many are from fat. Wherever you eat, you have to make the best choices regarding the portions and the quality of food. Stay healthy!

Reference:

Fast food based hyper-alimentation can induce rapid and profound elevation of serum alanine aminotransferase in healthy subjects. Stergios Kechagias, Åsa Ernersson, Olof Dahlqvist, Peter Lundberg, Torbjörn Lindström, and Fredrik H Nystrom. Gut 2008 Feb 14; [Epub ahead of print] PMID: 18276725

Roundup - What's the Problem?

"... as an adult, we understand even if you ruin an appetite, there's another appetite coming right behind it. There's no danger in running out of appetites. I've got millions of them." --Jerry Seinfeld. The "Heart Attack" episode.


Fact: When food is in short supply, obesity as a public health problem does not exist. As a matter of fact, being obese under those circumstances signifies being wealthy or of higher economic status than the average population. Look at countries where some are living in poverty, and others are more affluent. Which segment of that society has a problem with obesity?

Fact: When food is made available and affordable, in the presence of abundance, the average person will eat more. Much more. Bigger portions. It is surprising to see people who immigrated as adults from less affluent countries continuing to eat the portions and at the times that they were used to, and stay slim. They have already developed the habits and controls and they stay satisfied with the portions and types of food that they used to consume. Their first generation kids, however, who were not raised in such a controlled environment, may become overweight or obese.

Fact: When food is not only made available in abundance 24 hours a day, but is also advertised all day long, people tend to consume even more. And branding does affect their choices.

Fact: Social networks can strongly enhance the spread of obesity.

One conclusion I can draw here is that: External influences tend to have a stronger effect on controlling how much we eat than spontaneous internal influences, in the average person. It takes a conscious effort and proper habit building and modifications to overcome those external influences. That we are victims of an environment and a culture that facilitates (or may even encourage) habits that will make us unhealthy, the only true refuge is our own ability to change habits and behaviors that developed under those circumstances. Although I stress on over-eating as a deadly habit, it is important to notice that serious under-eating as in anorexia nervosa is at least as deadly, if not more.

Remember, weight control is achieved through three elements:

1. Diet (portion acontrol and quality control)

2. Exercise or physical activity

3. Behavioral change towards healthy habits

Everything else (a diet program, a trainer, a pill, a surgical operation) is a tool that helps you control your energy storage (and, consequently, the weight of fat) through one or more of the above mechanisms.

Stay healthy! Happy Holidays!

Obesity Among Friends, Spouses, Siblings and Neighbors

Obesity has become an epidemic. Right? We hear this all the time. Well, isn't the term "epidemic" used often for diseases that are spread from a person to a person, like infectious diseases? Could the phenomenon of the prevalence of obesity be actually behaving as an infectious process? Could the benefits of obesity control, likewise, spread in an epidemic (good) way? Should the treatment of obesity be considered not only a form of individual therapy, but also, and probably more importantly, a treatment of public health proportions and general community benefits?

A very important article appeared in the July 26, 2007 issue of the New England Journal of Medicine "The Spread of Obesity in a Large Social Network over 32 Years" by Drs. Nicholas A. Christakis and James H. Fowler from Harvard Medical School, Boston and University of California, San Diego, San Diego. The researchers analyzed the nature and extent of the person-to-person spread of obesity as a possible factor contributing to the obesity epidemic. To do so, they evaluated a social network of 12,067 people assessed repeatedly from 1971 to 2003 as part of the Framingham Heart Study.(1) They examined whether weight gain in one person was associated with weight gain in his or her friends, siblings, spouse, and neighbors.

What they found? A person's chances of becoming obese increased by 57% if he or she had a friend who became obese. The type of friendship appeared to be important. Between mutual friends, a person's risk of obesity increased by 171% if the other became obese. In contrast, the influence did not appear to be statistically significant when one person, but not the other, defined the relationship as a friendship. The sex also appeared to be important. When analysis singled out same-sex friendships, the probability of obesity in a person increased by 71% if the friend became obese. For friends of the opposite sex, however, the probablity of obesity did not increase significantly. Among friends of the same sex, a man had a 100% increase in the chance of becoming obese if his male friend became obese, whereas the female-to-female spread of obesity was not as significant.

How about siblings? If one sibling became obese, the other's chance of becoming obese increased by 40%. As for married couples, if one spouse became obese, the likelihood that the other spouse would become obese increased by 37%. By the way, those effects were not seen among neighbors.

If social networks are so influential in the spread of obesity, then this may actually explain another well-known observation. Individuals in weight loss programs or after weight loss (bariatric) surgery, who attend regular support group activities, that modify the person's social network, are more successful than those that do not.

This is a great study that will certainly be quoted over and over in the future.

(1) The Framingham Heart Study is an ambitious project that was initiated in 1948, when 5209 people were enrolled in the original cohort. The Framingham Offspring Study began in 1971, when most of the children of members of the original cohort and their spouses were enrolled in the offspring cohort. In 2002, the third-generation cohort, consisting of 4095 children of the offspring cohort, was initiated. All participants undergo physical examinations (including measurements of height and weight) and complete written questionnaires at regular intervals.


Source:

Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med. 2007 Jul 26;357(4):370-9. [PMID: 17652652]

Hungry, Satisfied, or Full?

For the sake of simplicity and to make points clearer, I will use definitions that may be different from the standard broad dictionary definitions:

Hunger: The unpleasant feeling that accompanies a real physical need for nourishment or food.
Fullness: The feeling that maximum capacity to eat has been reached.
Satiety: A state of satisfaction that can be reached when not hungry, but before feeling full.

When we are hungry, we know it. Of course we need to eat. The trick is either not let yourself get really very hungry, so that you can avoid over-eating, or simply develop the habit of recognizing a point of satiety, or satisfaction, before actually feeling full. Remind you, I am using the definitions outlined above. So, how to recognize that point of satisfaction? Well, that point can be appreciated by allowing your brain to recognize that you are not hungry anymore. The signal will come up, but you have to give it time to reach up there. What that means? Don't eat too fast. Do not enter in your mouth one large bite at a time. Once in your mouth, take your time chewing your food. Enjoy the taste of the food. Chew 20 times before actually swallowing. After swallowing the well-chewed bite, wait a little bit before you get the next bite into your mouth.

If you are using portion control (for example, after weight loss surgery, or as a part of dieting), put on your plate only the portion that you are supposed to eat. If there is more on your plate, do not clear your plate. Eat slowly as described above, till you have almost completed your portion, then STOP. Even if you are not satisfied, stop. Distract yourself. Do something. Then ask yourself in 10 minutes or so: "Am I still hungry? Or do I want to eat just because? If you are not truly hungry, and if you reached the portion size that you have decided, you have probably reached the point of satisfaction and hopefully the above techniques gave your brain enough time to appreciate that signal. Remember, feeling full (using the definition that I wrote above) is not a good signal to stop eating. It is too late. And if you had Lap Band, gastric bypass, or a sleeve gastrectomy, you are probably setting yourself up for a stretch of the pouch. In case of an adjustable gastric band in particular (like the Lap Band), stretching the pouch may be a factor in slippage (prolapse). So, be careful, and stay healthy!

The Paradox

Restaurant (A) presents food items that are advertised as being healthy choices, and has even caused some people to lose serious weight. Restaurant (B) was the topic of an entire movie (Supersize Me) which focused on unhealthy eating. Could someone possibly think that eating huge portions at restaurant (A), and picking up choices that were not advertised in their health menu, would still be healthier than eating anything at Restaurant B? Aha, it is the branding thing, again. You remember, we touched on that once before. And here is a very elegant study, actually four studies in one report, that is an eye opener. The article title is “The Biasing Health Halos of Fast-Food Restaurant Health Claims: Lower Calorie Estimates and Higher Side-Dish Consumption Intentions”, that appeared in the October issue of the Journal of Consumer Research.

Study 1: “Calorie Estimations by Subway and McDonald’s Diners” concluded that branding Subway as the healthier choice leads people to believe that Subway meals contain 21.3% fewer calories than same-calorie McDonald’s meals.

Study 2: found that even consumers who are "familiar" with both restaurants estimate that Subway sandwiches contain much less calories than McDonald’s sandwiches containing the “same” number of calories.

Study 3 is the real kicker. Participants were given Subway sandwiches that contained 50% “more” calories than the “unhealthy” Big Mac. In addition to a serious underestimate of the calories in the Subway sandwich, participants who ate the Subway sandwiches ended up ordering higher-calorie drinks and cookies. It is as if those who thought that they ate healthier main-dishes, tended to reward themselves by eating higher calorie side-dishes or drinking more calorie-rich drinks. As you can imagine, they consumed many more calories because of the double mistake (underestimating the main meal calories, and taking richer side orders)

Study 4 actually proved the influence of marketing and branding. When consumers were presented with arguments contradicting the health claims, the “halo effects” mentioned above tended to disappear.

What a fascinating research, and no doubt one that will become a classic. The series of studies were designed to help finding an answer to a question, as stated by the authors: Why is America a land of low-calorie food claims, yet high-calorie food intake?

Source:

Chandon P, Wansink P. The Biasing Health Halos of Fast-Food Restaurant Health Claims: Lower Calorie Estimates and Higher Side-Dish Consumption Intentions. Journal of Consumer Research. Vol. 34 · October 2007

Pierre Chandon, Ph.D. is Associate Professor of marketing at INSEAD, France. Brian Wansink, Ph.D. is the Chair of Marketing and of Nutritional Science in the Applied Economics and Management Department, Cornell University, NY. The data in these studies were collected at the expense of the authors, and the studies were not sponsored by any outside source.

Alcohol after Gastric Bypass

A glass of wine or two. A beer. A little mixed drink. Would that be OK after a gastric bypass? Well, early after the surgery, while the stomach is healing, you really want to avoid the irritant effect of alcohol. You want your pouch to heal well. So, the answer, as far as we know, is "no". But, what about drinking, let's say 6 months, a year, or more after the surgery? A very interesting study confirmed the previous opinion, that is, alcohol levels go higher after gastric bypass than people who had no such surgery. In a study published in the September issue of the journal "Surgery for Obesity and Related Diseases" (SOARD), researchers from Stanford School of Medicine, Stanford, California, concluded that the gastric bypass patients had a greater peak alcohol level and a longer time for the alcohol level to come back down to zero than the individuals who did not have gastric bypass. A particularly interesting finding was that the gastric bypass patients did not feel that alcohol influenced them any more than the no-surgery group. Could that explain why there are reports of post-gastric bypass patients who were cited for driving under the influence (DUI) after a small social alcoholic drink? Maybe. But also remember that there are other complications related to alcohol intake. Liver disease from alcohol is well-known. To develop alcoholic liver disease on top of the known obesity-related liver disease can be particularly dangerous. Alcohol is not good for peptic ulcers, either. Alcohol calories are empty calories, which is not what gastric bypass patients want to ingest. Also alcohol drinking has been linked to vitamin B1 deficiency. Severe vitamin B1 deficiency can lead to serious nerve damage, that is, Wernicke’s encephalopathy. So far, we do not have a perfectly scientific answer to the question: Is it OK to drink, in moderation, if you are not driving, several months or years after gastric bypass? We just do not have the final answer, and prefer to err on the cautious side. Better be safe than sorry.

References:
Klockhoff H, Naslund I, Jones AW. Faster absorption of ethanol and higher peak concentration in women after gastric bypass surgery.Br J Clin Pharmacol. 2002 Dec;54(6):587-91.

Hagedorn JC, Encarnacion B, Brat GA, Morton JM. Does gastric bypass alter alcohol metabolism? SOARD. 2007 Sept;3(5):543-8. (Note: This is the study quoted above)

Can TV ads influence our kids' taste buds?

This is not exactly a bariatric surgery topic, but, nevertheless, a very interesting one. Does advertising/branding affect children's taste? Well, we know that TV ads do influence kids, who, as a consequence, keep begging and nagging for an advertised product. The pressuring will intensify, once other parents provided your kids friends with the product. What standing do you have when you stick to the hated "No", while the attractive TV ads say "yes", and peers' parents have given the sign of approval?

A very interesting study came from Stanford Prevention Research Center and Stanford University School of Medicine. It was published in the August, 2007, issue of the "Archives of Pediatrics & Adolescent Medicine." (1) Kids aged 3-5 years (yes, that young!) were entered into a food tasting game, where they were given 2 identical food items, one wrapped in a McDonald's typical wrapping, and the other wrapped in a plane white wrapping. Items included not only hamburgers, fries and chicken McNugget's, but also baby carrots, which are not even sold at McDonald's, but were placed on top of a McDonald's french fries bag and on top of a matched plain white bag. McDonald's was chosen because it is a good example of a well-branded and heavily marketed source. Guess what? There was a statistically significant higher taste preference for the foods associated with the branded wrappings. This study is remarkable for its hypothesis, and the results that came out of it.

The authors concluded that branding of foods and beverages influences young children's taste perceptions. The authors also suggested that branding may be a useful strategy for improving young children's eating behaviors.

No wonder, a report of a joint "WHO/FAO Expert Consultation" indicated that: "Heavy marketing of fast-food outlets and energy-dense, micronutrient-poor foods and beverages" is a "probable" cause of excess weight gain and obesity. There has been strong evidence of a relationships between television viewing and obesity in children. Could that be, at least partially, due to the food advertising to which they are exposed? You bet.

(1) Robinson TN, Borzekowski DL, Matheson DM, Kraemer HC. Effects of fast food branding on young children's taste preferences. Arch Pediatr Adolesc Med. 2007 Aug;161(8):792-7. PMID: 17679662