House Call, MD: Health Carefully Explained

MS, RD | frankel@myhousecallmd.com

With a new diet making headlines each week it can be more than a little confusing deciding which diet will give you the results you’re looking for. Many of these diets have some good intentions but can be very stringent or not realistic to follow for more than a few days. Most fad diets cut out entire food groups, making it difficult to meet the nutrient requirements we need for our bodies to function properly. These fad diets become popular because people actually lose weight on them; many of these fad diets will reduce your caloric intake in one way or another leading to weight loss…it’s not rocket science. Last year, a nutrition professor lost weight on a diet consisting of twinkies and donuts because he simply decreased his overall calorie intake. We don’t recommend the Twinkie Diet (it is obviously lacking in several areas including fruits and vegetables), but it proves a valuable point: there’s more to a healthy diet than weight loss.  We’ll not only discuss the basic idea behind recent fad diets, but also get into the good, the bad and the ugly aspects of each.

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MD 2011 | ortega@myhousecallmd.com

The holidays are here, bringing family feasts, festive baked goods, toasty foam-topped beverages and tantalizing cocktails.  Throw 3 feet of snow in the mix along with sub-zero temperatures and you have the perfect storm for holiday weight gain.  The House Call, MD team has put together 5 tips to help you make it through December without picking up any extra holiday weight.  This way, you can have your holiday bundt cake and eat it too!

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by Rebecca Shatsky, MD 2011 | shatsky@myhousecallmd.com

According to commercials for the OneTouch glucose monitoring device, rock and roll legend B.B. King hasn’t let Type II diabetes give him the blues. In commercials, little computerized finger stick devices might even look kind of fun, a sentiment we would guess that few diabetics probably share. But, while drug companies and the popular media may try to downplay the gravity and life-altering nature of this chronic disease, few physicians see diabetes as something to be taken lightly.

If you live in America these days, chances are you know someone who either has or has been affected by Type II diabetes. The disease has ravaged the country leaving no stone unturned. Recently rising to epidemic proportions, diabetes has become the leading cause of kidney failure, amputations and blindness in the US. It is also a major contributor to the number one cause of death in the industrialized world: heart disease.

Unfortunately, even though diabetes has become exceedingly common, few doctors really take the time to explain the disease to their patients. This lack of education has led to widespread confusion amongst patients and poor compliance with treatment regimes, a vicious cycle that benefits no one. So, on that account, we want to take this opportunity to summarize things and simplify, providing the basics without all the confusing medical jargon.

What is Type II Diabetes??

Diabetes is a disease of metabolism (the breakdown of sugar for energy) so to understand diabetes, we have to first look at what normally happens in the body after we eat a meal.

Usually, when we eat a meal rich in carbohydrates (sugar), the sugar that we eat enters our blood steam and causes blood sugar levels to rise. When blood sugar levels rise, the body responds by secreting a hormone from the pancreas, called insulin, which allows the sugar floating around in the blood to be used for energy. When the pancreas releases insulin into the blood, blood sugar levels go back down to their normal pre-meal values. The picture below shows how this occurs in your body.  Simple, right?

In diabetes, however, something in this sequence of events goes haywire and the body either doesn’t respond to the insulin in your blood or doesn’t secrete enough insulin to lower blood sugar levels to a healthy range. When blood sugar levels no longer decrease appropriately in response to insulin, we call this “insulin resistance.”

The idea of insulin resistance is central to the development of Type II diabetes. Most studies suggest that in the early stages of the disease, the body’s response to insulin becomes progressively worse over time (4). With increasing insulin resistance we become more and more unresponsive to the normal (life-sustaining) effects of insulin. It’s a little bit like alcoholism, where the body needs greater and greater amounts of alcohol to get drunk; when we become insensitive to insulin, the pancreas needs to produce and release more and more insulin just to keep the body’s blood sugars in a healthy range.

During the disease development period, the body’s blood sugar levels are normal or mildly elevated before meals and then high directly after. If you are screened for diabetes at this stage, blood glucose levels will be higher than normal, but not quite high enough to be classified as “diabetes.” We call this stage “prediabetes.” Clever, we know (we are a bunch of nerdy doctors after all).

Eventually, the pancreas can no longer produce enough insulin to keep up with your body’s increasing insulin requirements. When this happens blood sugar levels soar out of control, both before and after meals. Blood sugar levels that remain high first thing in the morning (after not eating for hours!) are a true indication that diabetes has developed and that treatment is necessary.  The diagram to the right compares the blood sugar levels of a healthy individual with that of an individual with diabetes after having a drink containing 75g of glucose (called a Glucose Tolerance Test).  As you can see, the blood glucose levels soar out of control in the individual with diabetes.

What’s wrong with a little extra sugar?

While it might not sound so bad to have a little extra sugar floating around in your blood, having poorly controlled blood sugar is actually incredibly damaging to your organs, especially your blood vessels. When the cells in your blood are exposed to high levels of sugar for long periods of time, the sugar attaches to the blood cells making them sticky and less flexible. We can measure the percentage of blood cells that have been affected by high sugar levels with a blood test called the hemoglobin A1C level. The hemoglobin A1C level gives doctors a good estimate of how high blood sugar levels have been for the past three months and can be useful in predicting how much damage may be occurring to various tissues in the body.

The best way to explain the complications of diabetes is to look at the different parts of the body the disease affects. The most pervasive and significant complication of diabetes is damage to blood vessels. Damage to large blood vessel results in an increased risk of heart attack and stroke in diabetics, while injury to small blood vessels damages the kidneys (causing kidney failure) and the eyes (leading to blindness). Damage to small blood vessels can also affect the peripheral nervous system (i.e. all nerves not in your brain or spine) and may cause pain, tingling and numbness in your arms and legs, particularly the feet. Finally diabetes has some dangerous effects on the immune system, which puts diabetics at increased risk of infection and increases the time it takes to heal from injuries and surgeries (4). While some of these adverse effects may occur in all diabetics, it is important to remember that the severity of complications is directly related to the length of time a person has had the disease as well as how well blood sugars are controlled.

Who gets diabetes and why?

There are many different theories as to why things go haywire with the body’s insulin response, but what we do know is that the greatest contributing factors to the development of the disease are obesity, physical inactivity and genetics (1).

The importance of obesity in the development of type II diabetes is demonstrated by the tremendous increase in children and adolescents diagnosed with type II diabetes (2).  Once upon a time, Type II diabetes was unheard of in children; so much so that we used to called it “Adult Onset Diabetes.” However, since the obesity crisis swept the nation, the number of children diagnosed with Type II diabetes has increased dramatically and virtually all childhood cases occur in children who are overweight or overtly obese.

The role of genetics in diabetes is well documented but still poorly understood. Certain ethnic populations are at increased risk for Type II diabetes. Those at highest risk include African Americans, Latinos and American Indians (2). We also now know that having a family history of Type II diabetes markedly increases your risk of developing the disease (so if Grandma Mildred had Type II diabetes, you are at an increased risk of developing it). The exact extent to which having a family history of diabetes increases your risk is still hard to predict since the disease is caused by both environmental factors(obesity), as well as genetics. The take home message: If you do have a family history, it’s essential to tell your doctor so they can screen you sooner rather than later.

What does this mean for me?

The most important thing to keep in mind with diabetes, whether the disease has affected you or your loved ones, is that aggressive treatment makes a difference. The surge in Type II diabetes that has occurred over the past 20 years is, without a doubt, intimately related to the obesity epidemic. And, just like obesity, the first weapon in our arsenal against diabetes is diet and exercise. If diet and exercise are not enough, then the key to staving off complications is strict blood sugar control. We cannot emphasize this point enough. It is absolutely essential to take prescribed diabetes medications every single day and to check and record blood sugar levels on a regular basis. If the medications you are taking aren’t doing the trick, make an appointment to see your doctor so that you can find the right combination of medications for you.

Lastly, although discussion of the prevention and treatment of diabetes could be an entire article in itself, it’s important to be aware of the various resources out there available to diabetics. Most insurance plans have good coverage for diabetes medications and many give out free or low cost glucose monitoring devices. The American Diabetes Association is a great resource for information. There are even health care professionals called “diabetes educators” specifically trained to help diabetics learn to live with their disease and make specific lifestyle changes to decrease their risk of complications (nobody wants to go blind as a result of poor glucose control). Ultimately, the best way to manage this disease is to be proactive and take charge of your own health. Successful control of diabetes isn’t just luck, it’s all about lifestyle.

Questions? E-mail the Author: shatsky@myhousecallmd.com

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References:

1. Braunstein, Glenn D. “Diabetes Mellitus.” Andreoli and Carpenter’s Cecil Essentials of Medicine. By Philip S. Barnett. Philadelphia: Saunders, 2007. 676-95. Print.

2. “Diabetes Research and Statistics.” Centers for Disease Control and Prevention. Web. 18 June 2010. .

3. Ligaray, Kenneth Patrick L., and William L. Isley10. “Diabetes Mellitus, Type 2: EMedicine Endocrinology.” EMedicine – Medical Reference. 10 June 2010. Web. 18 June 2010. .

4 .Powers Alvin C, “Chapter 338. Diabetes Mellitus” (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison’s Principles of Internal Medicine, 17e: http://www.accessmedicine.com/content.aspx?aID=2891108.

5. Steppan, CM, ST Bailey, EJ Brown, RR Banerjee, and CM Wright. “The Hormone Resistin Links Obesity to Diabetes.” Nature 409.6818 (2001): 307-12. Print.

by G. John Mullen, DPT 2011 | mullen@myhousecallmd.com

The United States is the most obese nation in the world. Awesome…well done, America. 30.6% of Americans are believed to be obese, 6% higher than the next country, ironically, our Americanized neighbor… Mexico (3)! It is estimated 50% of Hispanics born since 2000 will become diabetic. Mississippi currently holds the crown as the fattest state in the fattest union and has been for the past 5 years, with obesity estimated at 32.5%3. Mississippi also holds the award for fattest children at 44.4% of 10-17 year olds (3). Five states have a current adult obesity percentage over 30%3. To top it off, obesity rates have more than tripled in the past 30 years! These obesity rates are out of control and are a huge weight on the United States budget. On the other end of the spectrum, Colorado is the thinnest state in the union with an obesity rate of 18.9% and is the only state with an obesity rate under 20% (3).  The take home message: America has a weight problem.

Where is all this weight coming from?

The cause of obesity is relatively simple: weight gain occurs when caloric intake exceeds caloric expenditure. Despite the simplistic nature of obesity, weight maintenance and loss are thought of as difficult or impossible tasks. Roughly 25% of American adults report no leisure time activity and 60% report activity levels less than the value shown to reduce their risk of disease (5). No wonder we’re overweight! To add insult to injury, overweight individuals are more inclined to be inactive, with 33% of men and 41% of women reporting inactivity (5). At the same time, roughly 50% of women set a New Year’s resolution to lose weight2. We, as a society, acknowledge the problem and are committing to fixing it each January 1st but seem to fail over the course of the year.

What does it take to lose weight?

Federal guidelines suggest a minimum of 150 minutes a week of moderate-intensity exercise to obtain “substantial health benefits” (4). These health benefits are not associated with weight management, but rather with lowering rates of chronic disease. A recent publication in the Journal of American Medical Association followed 34,079 healthy US women from 1992-2007 studying their activity level and associated weight gains/losses. This study concluded that (amongst women consuming a “normal” diet) physical activity was associated with less weight gain (5 lbs) in women with a BMI lower than 25. The “activity level” was defined as 60 minutes of daily moderate-intensity activity for the duration of the study (4). However, only 45% of women in America are estimated to have a BMI of 25 or less. This study does a great job looking at activity level for weight management, but does not tell us about the volume of exercise necessary for weight loss.

Weight Loss vs. Weight Management

The Harvard study discussed above looked at women with an average age of 54.2 years with no medical complications (cardiovascular disease, cancer, etc.) (4). Women with a BMI of 25 were able to maintain their weight within 5 pounds of their weight at the beginning of the study if they exercised with moderate-intensity activity for 60 minutes a day throughout the study. Moderate-intensity exercise includes bicycling, callisthenics and fast walking (~3.0 MPH or 55-69% of maximal heart rate). However, these same protocols were not successful for weight management in females over a BMI of 25, which constitutes more than half of Americans! This research suggests that overweight or obese women need to change one of the two variables associated with weight management: decrease caloric consumption or increase caloric expenditure. The most important piece of a weight management program is consistency. As stated, many New Year’s resolutions include weight loss goals (fitness centers see an exponential membership increase during January), but the volume of people in the gym returns to normal within a month. The intent is correct but the execution falls short. There are many theories for this. We believe that lack of interest and enjoyment plays a huge role in the gym attrition rate between January and March. If someone does not like riding a stationary while bike watching CNN report another Earthquake in a third world country or another vandalism case by their neighborhood, then it is highly unlikely they will exercise consistently. If we don’t like it and we don’t have to do it, we don’t do it. It’s called human volition. The American view of exercise needs to shift dramatically from a chore to a hobby. The Harvard study used METS (metabolic equivalent) to assess activity level and determined a total of 14 MET hours per week or 3 MET hours a day was sufficient in weight management for women with a BMI of 25 or less. As stated, activities with a 3 MET or higher rating include biking, fast walking, etc. 3+ MET activities also includes various hobbies not typically viewed as exercise: canoeing/kayaking, dancing, ice/roller skating, hiking, gardening and racquetball to name a few (full list of activities with their MET ratings). If you perform these activities at a more rapid pace (really start cruising with that paddle!) these activities can reach the upper echelon of METS. The take home message: Make exercise fun. If you don’t, you’ll quit. If you do, you can potentially burn more calories than you would boring yourself to death on a stationary bike watching Larry King.

Weight loss is a tougher nut to crack and is often person-dependent. Common sense makes it sound as simple as increasing caloric expenditure, but exercising greater than one hour a day is unrealistic for many and leads to failed goals and the aforementioned NYE resolution abandonment. Often times, physical activity is not sufficient in weight loss due to the multivariable nature and complexity of the problem. Many of these issues are related to diet.

Diet is the number one contributor to weight loss. Here are a few simple tips for those trying to lose weight (be sure to stay tuned for more from our staff dietitian):

• Do not limit yourself to strict caloric restriction diets. The math is complicated and the stress at each meal is unnerving. This approach is hard to consistently maintain leading to failed goals and disappointment. Strict diets can decrease metabolism making the body more likely to gain weight once the diet is discontinued. Instead, monitor diet and decrease consumption of high caloric foods. For example, you can eat four bananas or one McDonald’s double cheeseburger…they have the same number of calories. We guarantee that eating four bananas will be just as filling as a double cheeseburger and the four bananas cost less and have more vitamins than the McDonald’s double cheeseburger.

• Monitor drink consumption. Energy drinks, frappuccinos, etc. contain high quantities of unfilling calories. Replace these high calorie, high cost options with….water! Simple and effective.

• Prepare your own food and eat foods that require some work. When was the last time you ate an uncooked carrot? It takes a while to consume and requires a lot of chewing. Increasing the amount of chewing can trick the mind regarding the amount of food being consumed, decreasing hunger.

These three tips are easy to perform and are, most importantly, cost efficient. Some additional factors affecting your ability to lose weight include:

• Sleep: Inadequate sleep impairs hormones (ghrelin and leptin) that regulate hunger and satisfaction following food consumption. One study found people who slept less than 8 hours a night had lower levels of leptin (controlling satisfication) and higher levels of ghrelin (controlling hunger) AND higher levels of body fat (1).

• Stress: Cortisol is a hormone produced in response to stress. Cortisol release causes insulin release resulting in increased hunger. The take home message: Relax! You can use multiple stress reduction techniques including deep breathing, meditation, visual imagery, and exercise. Take your pick.

We all know that weight management is an issue in America as obesity rates continue to rise. An undeniably effective approach to weight loss is exercise. The goals is a calorie expenditure > calorie intake. Remember that exercise should be a hobby and not a chore! Find activities you enjoy and stick with them. Set realistic goals that target three areas: appearance, health and consistency. If exercise alone does not achieve your weight goals, diet, sleep and stress can also be manipulated to make your weight goals a reality.

Questions? E-mail John: mullen@myhousecallmd.com

References:

1. Bouchez C. How Sleep Affects Your Weight. Webmd.com. 2007.

2. Losing Weight Is One Of The Most Popular New Year’s Resolutions. Medical News Today. 2005.

3. F as in Fat 2009 – Trust for America’s Health. Healthyamericans.org. 2009.

4. Lee I, Djoussé L, Sesso H, Wang L, Buring J. Physical activity and weight gain prevention. JAMA. Mar 2010;303(12):1173-1179.

5. Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Kaplan JP. The continuing epidemics of obesity and diabetes in the United States. JAMA JAM Aabbr. Journal of the American Medical Association 2001;256:1 195-1200.

by Leah Frankel, MS, RD | frankel@myhousecallmd.com

With increasing numbers of Americans now unemployed or taking salary cuts, it’s not surprising that people are trying to save money any way possible. Cutting back could mean only one double chocolate espresso ventichino per week instead of your normal five or carpooling to work instead of driving.  Many people worry that cutting back in terms of food costs may mean more trips to fast food joints and less fruits and vegetables.  In fact, there has been a boom in fast food consumption recently due to our current economic status.  We’re here to discuss tips for maintaining a healthy diet even in these hard economic times, compare a typical fast food meal to one prepared at home (looking at both price and nutritional value) and prove to you that you can continue eating healthy even if the economy has let you down!

Getting in your 5-a-Day

When cutting the cost of your grocery trips there is a concern that fruits and veggies will be the first to go, however there are a variety of ways to continue to eat fruits and vegetables without breaking the bank. In general, fresh fruits and vegetables are least expensive when they’re in season; for instance, it is best to buy asparagus and grapefruit in the spring and grapes and eggplant in the fall. Not only are foods fresher and more flavorful when they’re in season, they’re cheaper.

While fresh fruits and veggies are great, you can still get essential nutrients from frozen or canned items.  Canned and frozen items last longer than fresh items and prices won’t fluctuate seasonally as with fresh foods. When choosing frozen or canned foods, make sure there are few additives, such as sugar, salt or sauces, since these additions make the foods less healthy. For example, when buying canned fruit, choose fruit canned in its natural juice instead of in heavy syrup or frozen vegetables without added salt or sauce.

There’s no question that people are more likely to eat fruits and vegetables when they’re easily accessibly which is why many people turn to the freshly cut versions in the grocery store. Next time, instead of buying their pre-cut fruits and veggies, cut your own when you come home from the grocery store to save money.

Finally, you can always grow your own small garden with fresh herbs, veggies or fruit (depending how much space you have) and enjoy inexpensive produce right in your own backyard.  It always tastes better when you’ve grown it yourself!

How to decide what to buy

With grocery stores carrying many options, it can be overwhelming choosing healthy and cost-effective foods, but there are some easy ways to make better choices.

Shopping at warehouse stores such as Costco and Sam’s Club can save you money but only if you know what to buy there.  Depending on the size of your household, you might not benefit from buying fresh fruits or vegetables at these stores since they’ll go bad before you can eat them. However, items that can be frozen, such as meat or fish, or foods that are prepackaged in “normal” sized containers, such as pasta or cereal, may help you save money since they can be purchased at a discounted price and won’t spoil before you have a chance to eat them.

Almost every grocery store chain has its own brand of generic food items. The store’s brand is frequently less expensive than the other brands and is usually nutritionally equivalent.  We’ve found that in some instances, as with yogurt, the generic brands are higher in protein and lower in calories (and cost!) than their brand name equivalent.

Have you ever looked at a 4 lb bag of rice and tried to compare it to a 15 lb bag of rice in terms of cost?  Not an easy task without some serious arithmetic.  Next to the price of each item in the store, there is a cost per unit that helps you determine which product gives you the most bang for your buck!  Let’s look at an example, the 4 lb bag of rice may cost $0.50/ounce and the 15 lb bag of rice may cost $0.40/ounce, therefore the 15 lb bag is a better value assuming you can eat 15 lb of rice!

Lastly, and potentially most obviously, use coupons and stock up when foods are on sale. It seems like such a simple task but cutting out a piece of paper and bringing it to the store with you can save you thousands of dollars a year!  As with buying foods at Costco, the money you save by stocking up when items are on sale at your local grocery can really add up.  Remember to only buy as much as you can eat before it spoils or you’ll find yourself throwing your money straight into the trash.

Meal Time!

While all of these tips sound great, they’re really not much use if we can’t use them to create healthy meals.  Unless you’re cooking for a football team, it’s likely that your recipe will provide more than enough food for you and your family. While some people are ok eating spaghetti and meatballs all week, most of us aren’t so we need to be creative when it comes to leftovers. Depending on what you’re cooking for dinner, your leftovers can either be frozen, like a chili or meatballs, or transformed into a different meal, for instance turning baked chicken into chicken tacos or chicken salad.

Planning your meals and snacks in advance means you’ll be less likely to eat out since your kitchen will be stocked with plenty of food. Spend some time during the weekend planning out your meals for the upcoming week.  If you have kids, involve them in the planning process. Once you’ve planned your week, bring a grocery list to the store to prevent multiple trips to pick up forgotten items.  Keeping snacks readily available at home and at work will prevent snacking at the vending machine or an afternoon trip to the drive through or coffee shop.

Aside from saving money, there are many health advantages to preparing food at home.  Since you’re cooking the food yourself you can control the amount of butter or oil that’s added to your food, eliminating excess fat and calories from your diet.  You can also control the ingredients that are in each dish which is especially helpful if you or someone you are cooking for has an allergy to certain foods.  Finally, cooking at home allows you to control the portion sizes; in case you hadn’t noticed, the portion sizes at most restaurants are 2 (sometimes up to 4) times as large as they should be which can lead to overeating.

The Facts

For those of you that still don’t believe us, we’re going to prove that you can get a more nutritious meal and cost effective meal by cooking at home.  What follows is a comparison of a day of eating at fast food restaurants to a day of eating meals prepared at home.

Meals/Snacks from the grocery store:

Grocery store grand total: $10.88

Meals/snacks from fast food:

Fast food grand total: $16.74

Nutrition Facts:

We know what you’re thinking, “I only eat off the dollar menu” or “I only eat healthy fast food items.”  Let’s assume that you really do choose less expensive fast food items that also happen to be the restaurant’s healthier choices (unlikely but we’re pretending).  The problem is that many people would have ordered two 99¢ hamburgers instead of one or a large shake instead of a medium soda.  It’s hard to make consistent healthy and economic choices when eating at fast food restaurants.  When we compare breakfast we see that even items off the dollar menu are more expensive than a well-balanced meal at home.  It is possible to make healthy choices when eating out, but we’ll save those tips for another day.

Questions? E-mail Leah: frankel@myhousecallmd.com

References:

1. Nutrition facts obtained for fast food restaurants obtained from: http://www.mcdonalds.com/, http://www.in-n-out.com/, http://www.in-n-out.com/

2. Price of groceries obtained from: http://www.safeway.com/IFL/Grocery/Home

3. Nutrition assessment of grocery foods completed via: http://www.mypyramidtracker.gov/