First New Weight-Loss Drug in a Decade: Lorcaserin Hydrochloride

Posted on June 27, 2012 | 1 comment

The U.S. Food and Drug Administration today approved lorcaserin hydrochloride as a weight-loss drug, according to MedPage Today.

The drug, to be sold as Belviq in the U.S., is an activator of the serotonin C2 receptor in the brain.  This may reduce food consumption by producing early satiety at mealtime.

According to the FDA’s press release, “the most common side effects of Belviq in non-diabetic patients are headache, dizziness, fatigue, nausea, dry mouth, and constipation, and in diabetic patients are low blood sugar (hypoglycemia), headache, back pain, cough, and fatigue.”

I rarely prescribe weight-loss drugs for my patients.  They’re expensive.  They have side effects.  They’re not very effective.  And when you stop the drug, the fat returns.

Steve Parker, M.D.

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Huge Study Confirms Health and Longevity Benefits of Mediterranean Diet

Posted on June 27, 2012 | Comments Off on Huge Study Confirms Health and Longevity Benefits of Mediterranean Diet

Italian researchers reported in the September 11, 2008, online issue of the British Medical Journal what is already known:

“Greater adherence to a Mediterranean diet is associated with a significant improvement in health status, as seen by a significant reduction in overall mortality (9%), mortality from cardiovascular diseases (9%), incidence of or mortality from cancer (6%), and incidence of Parkinsons’s disease and Alzheimer’s disease (13%).  These results seem to be clinically relevant for public health, in particular for encouraging a Mediterranean-like dietary pattern for primary prevention of major chronic diseases.”

Methodology

Researchers, mostly at the University of Florence, performed a meta-analysis of 12 other published studies that looked at the effects of a Mediterranean-style eating pattern on health and longevity.  [Meta-analyses are popular, in part, because they are cheap.  This study required no specific funding.]

Most, if not all, of these 12 studies were observational, and involved 1,574,299 participants.  Six of the 12 studies were in Mediterranean countries, the others were in the U.S., northern Europe, and Australia.  Study participants were followed between 3.7 and 18 years.

The researchers devised their very own Mediterranean diet scale based on study participants’ intake of various foods.  Participants were given a point if they had higher than average intake of vegetables, fruits, legumes, cereals, fish, and red wine during meals.  They were given a point if they had lower than average intake of red meat, processed meats, and dairy products.  Due to differences among the 12 studies, “the total adherence scores…varied from a minimum of 0 points indicating low adherence to a maximum of 7-9 points reflecting high adherence to a Mediterranean diet.”

(This version of a Mediterranean diet score is problematic.  Curiously, olive oil – the predominant source of fat in the traditional Mediterranean – is not in the score.  Olive oil is a key characteristic of the Mediterranean diet.  Furthermore, the study authors also state that dairy products are “presumed not to form part of a Mediterranean diet.”  Most experts would argue that cheese and yogurt are a significant part of the Mediterranean diet, if only in low amounts.  I also doubt that participants in the 12 original studies  were surveyed whether they drank red wine – as contrasted with white – and whether it was with meals or not.  I admit I did not read each of the 12 component studies.  The underlying cause of this idiosyncratic definition of the Mediterranean diet is that the 12 original studies themselves used different definitions of the Mediterranean diet.  The meta-analysts had to pigeonhole the data.  There are a handful of respected Mediterranean diet scores in existence, but the authors of this study couldn’t apply them across the board due to database inconsistency or inadequacy.)

Results

“The cumulative analysis of 12 cohort studies shows that a two point increase [emphasis added] in the score for adherence to a Mediterranean diet determines a 9% reduction, in overall mortality, a 9% reduction in mortality from cardiovascular diseases, a 6% reduction in incidence of or mortality from neoplasm [cancer], and 13% reduction in incidence of Parkinson’s disease and Alzheimer’s disease.”

The only one of the 12 original studies focused on Alzheimer’s disease, and it showed a 17% reduction in participants with high adherence to the Mediterranean diet.  The two studies that focused on Parkinson’s disease revealed a 7% reduction in men, and 15% reduction in women.  These reduced incidence figures, again, apply to a two-point increase in Mediterranean diet adherence score.

Discussion

The authors indicate that their report is the first ever meta-analysis of the data associating the Mediterranean diet with reduced mortality and chronic disease in the general population.  Congratulations, guys!

The authors’ idiosyncratic Mediterranean diet score is unusual and won’t be widely adopted.  However, the 12 studies comprising the meta-analysis did have reasonable Mediterranean diet characteristics.

Combining Alzheimer’s data with Parkinson’s data doesn’t make sense to me, nor did the authors try to explain it.   You could lump them into the category of “neurodegenerative diseases,” but they aren’t the only ones by any means.  The single Alzheimer’s study, by the way, was quite small compared to the two Parkinson’s studies.

Nearly all the popular media stories reported the findings as I did in my first paragraph above, which may be  misleading.  The specific improvements in mortality and various disease rates is per two-point increase in Mediterranean diet score.  For example, consider the 9% reduction in overall mortality.  If a population increased its Mediterranean score by four points, would overall mortality be reduced by 18%?  I’ve read this study four times and cannot answer my own question.  But I suspect that the answer is “yes.”  So the news here may better than it seems at first blush.

In other words: If a population’s score goes from 5 to 7, the death rate is reduced by 9%.  If that same population then moved its score from 7 to 9, would mortality improve another 9%?  I think so, but this study as written does not make it clear.

I’m starting to see why the popular media simplified the study findings.  The reporting on this study is amazingly uniform.  They must have all gotten the same news release.

Of course, “populations” don’t die or get cancer, heart attacks, strokes, Alzheimer’s, or Parkinson’s disease.  Individuals do that.  If I as an individual had a low Mediterranean diet score, I’d try to improve my score by at least two points.  A good place to start would be a review of the Mediterranean diet.

Steve Parker, M.D.

Reference:  Sofi, Francesco, et al.  Adherence to Mediterranean diet and health status: Meta-analysis.  British Medical Journal, 337; a1344.  Published online September 11, 2008.  doi:10.1136/bmj.a1344

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Posted in Alzheimer Disease, Cancer, Coronary Heart Disease, Dementia, Heart Disease, Longevity

Quote of the Day

Posted on June 25, 2012 | Comments Off on Quote of the Day

Adult diapers outsold baby diapers in Japan last year for the first time ever.

— Morgan House in an article at The Motley Fool

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Quote of the Day

Posted on June 25, 2012 | Comments Off on Quote of the Day

A tip for guys who like to wear speedos. It helps to carry a potato in your speedo. But make sure you wear it in the front.

— Keaton (comment No.23)

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Is Exercise Important for Maintenance of Weight Loss In Women?

Posted on June 24, 2012 | Comments Off on Is Exercise Important for Maintenance of Weight Loss In Women?

This news is a bit stale, but I wanted my readers to be sure to see it.

An article in the July 28, 2008, issue of Archives of Internal Medicine teaches us the role of regular physical activity in keeping lost weight from returning to once-overweight women.

Methodology

201 overweight women (body mass index 27-40) aged 21 to 45 wanted to lose excess weight.  They were sedentary at baseline, exercising fewer than three days a week for under 20 minutes.  Sound familiar?  Depending on baseline weight, the participants were assigned to eat either 1200 or 1500 calories per day, and to exercise according to one of four different exercise programs.  Exercise recommendations were to burn a certain number of calories per week (1000 or 2000 calories) at either moderate or vigorous intensity.  There were weekly group meetings for discussion of eating and exercise for the first six months, twice monthly meetings during the next 6 months, and monthly for the next six months.  There was telephone contact for between months  19 to 24.  This is pretty intense contact.  Each participant was given a treadmill to use at home, but my impression is that other forms of exercise were permitted and discussed.

Ten subjects were excluded from follow-up analysis, mostly because they got pregnant.  Nineteen others lost interest and dropped out.

Participants self-reported their physical activity levels.

At 24 months into the study, 170 of the original 201 participants were able to provide objective weight loss data.

Findings

Of the 170 subjects available for full analysis at 24 months, 54 either gained weight or lost none.  Thirty-three lost 0 to 4.9% of initial body weight, 36 lost 5 to 9.9% initial body weight, and 47 (24.6%) lost 10% or more of initial body weight.  [Who says diets don’t work?]

People who lost 10% or more of initial body weight at 24 months reported performing more physical activity – 275 minutes a week – compared with those who lost less than 10% of initial body weight.  This amount of exercise equates to 55 minutes of exercise on five days per week above the baseline level of activity, which was sedentary as you recall.  Whether they were assigned to “moderate” or “vigorous” exercise intensity didn’t seem to matter.  Whether they actually performed at the assigned level is unclear.

These women who sustained a weight loss of 10% or more of initial body weight at 24 months were burning 1835 calories a week in physical activity.

Women who lost less than 10% of initial body weight, or lost no weight, exercised an average of 34 minutes a day on five days a week.

By 24 months, participants on average had regained about half of the weight they had lost during the first six months  [which is typical].

Take-Home Points

After six months of dieting, many people start to regain half of what they lost.  We saw this phenomenon in the Israeli study of low-fat vs low-carb vs Mediterranean diet (DIRECT trial).

If you have a lot of excess fat to lose, you have to wonder if it would make sense to start a different diet program every six months, until you reach your weight goal.  Maybe there’s something about the novelty and excitement of a new diet program that keeps you motivated and disciplined for six months.

The authors note there are few similar long-term studies examining the amount and intensity of physical activity needed to improve weight loss success.  So this is important information.

In using exercise to help prevent weight regain, it may not matter whether the exercise is moderate or intense.

The authors write:

…the inability to sustain weight loss appears to mirror the inability to sustain physical activity.

Long-term sustained weight loss is possible for a significant portion of overweight women.  Although most women won’t do it, success is enhanced by exercising for 55 minutes on five days a week.  Most men won’t exercise that much either.  Which camp do you fall into?

[For physical activity instruction and information, visit Shape Up America!, Physical Activity for Everyone, or Growing Stronger: Strength Training for Older Adults.]

Steve Parker, M.D.

Reference:  Jakicic, John M., et al.  Effect of Exercise on 24-Month Weight Loss Maintenance in Overweight Women.  Archives of Internal Medicine, 168 (2008): 1,550-1,559.  

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Posted in Exercise, Uncategorized, Weight Loss, Weight Regain

Are We Fat Because We Eat Too Much, Or Lack Physical Activity?

Posted on June 22, 2012 | Comments Off on Are We Fat Because We Eat Too Much, Or Lack Physical Activity?

Are we fat because we eat too much, or lack physical activity?

Most people would say, “It’s both.” Most people would be wrong, at least in terms of populations rather than individuals.

Obesity results from a protracted imbalance between energy intake (calories we eat) and energy expenditure (physical activity and resting metabolism).

Overweight and obesity have increased significantly over the last 25 years in most of the developed world. Is it because we started eating more, or that we have so many energy-saving devices that we now expend less energy on physical activity? If we are less active due to technologic advances, yet keep eating as much as in the past, we will gain weight as the excess calories are stored as fat.

Technologic advances over the last 150 years have allowed us to transform from a labor-intensive agrarian economy to one based on services and information. Computers, in particular, have made it much less labor-intensive to get our jobs done. For example, when I was a hospital intern 30 years ago, I made multiple daily trips from the patient care floors downstairs to Radiology to look at x-ray films. Now, the “films” are at my fingertips on computers close to the bedside.

Have trends in technology over the last 25 years continued to reduced the energy expenditure needed to get through our days? Alternatively, are we exercising less? Either explanation would lead to weight gain if caloric intake remained the same.

Researchers in 2008 studied populations in Europe and North America, examining trends in physical activity energy expenditure over time, since the 1980s. Energy expenditure was evaluated with a highly accurate method called “doubly labelled water.” They found that physical activity energy expenditure actually increased over time, although not by much. They conclude that the ballooning waistlines in the study populations are likely to reflect excessive intake of calories.

(All I have is the abstract of the article. I’ll try to get the full article and report back here if anything additional is interesting.)

So according to Westerterp and Speakman, the problem has not been lack of physical activity. We’re simply eating too much.

On the other hand, a 2011 study found that daily work-related energy expenditure decreased by over 100 calories in the U.S. over the last 50 years.  That could certainly contribute to our expanding waistlines.

Steve Parker, M.D.

Reference: Westerterp, K.R., and Speakman, J.R. Physical activity energy expenditure has not declined since the 1980s and matches energy expenditures of wild mammals. International Journal of Obesity, 32 (2008): 1256-1263. Published online May 27, 2008. doi: 10.1038/ijo2008.74

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The Role of Exercise in Maintenance of Weight Loss In Women

Posted on June 21, 2012 | 2 comments

A 2008 article in Archives of Internal Medicine teaches us the role of regular physical activity in keeping lost weight from returning to once-overweight women.

Methodology

201 overweight women (body mass index 27-40) aged 21 to 45 wanted to lose excess weight. They were sedentary at baseline, exercising fewer than three days a week for under 20 minutes. Sound familiar? Depending on baseline weight, the participants were assigned to eat either 1200 or 1500 calories per day, and to exercise according to one of four different exercise programs. Exercise recommendations were to burn a certain number of calories per week (1000 or 2000 calories) at either moderate or vigorous intensity. There were weekly group meetings for discussion of eating and exercise for the first six months, twice monthly meetings during the next 6 months, and monthly for the next six months. There was telephone contact for between months 19 to 24. This is pretty intense contact. Each participant was given a treadmill to use at home, but my impression is that other forms of exercise were permitted and discussed.

Ten subjects were excluded from follow-up analysis, mostly because they got pregnant. Nineteen others lost interest and dropped out.

Participants self-reported their physical activity levels.

At 24 months into the study, 170 of the original 201 participants were able to provide objective weight loss data.

Findings

Of the 170 subjects available for full analysis at 24 months, 54 either gained weight or lost none. Thirty-three lost 0 to 4.9% of initial body weight, 36 lost 5 to 9.9% initial body weight, and 47 (24.6%) lost 10% or more of initial body weight. (Who says diets don’t work?)

People who lost 10% or more of initial body weight at 24 months reported performing more physical activity – 275 minutes a week – compared with those who lost less than 10% of initial body weight. This amount of exercise equates to 55 minutes of exercise on five days per week above the baseline level of activity, which was sedentary as you recall. Whether they were assigned to “moderate” or “vigorous” exercise intensity didn’t seem to matter. Whether they actually performed at the assigned level is unclear.

These women who sustained a weight loss of 10% or more of initial body weight at 24 months were burning 1835 calories a week in physical activity.

Women who lost less than 10% of initial body weight, or lost no weight, exercised an average of 34 minutes a day on five days a week.

By 24 months, participants on average had regained about half of the weight they had lost during the first six months [which is typical].

Take-Home Points

After six months of dieting, many people start to regain half of what they lost. We saw this phenomenon recently in the Israeli study of low-fat vs low-carb vs Mediterranean diet.

If you have a lot of excess fat to lose, you have to wonder if it would make sense to start a different diet program every six months, until you reach your weight goal. Maybe there’s something about the novelty and excitement of a new diet program that keeps you motivated and disciplined for six months.  For someone with lots of weight to lose, I wonder if they’d do better switching to a new diet every six months.

The authors note there are few similar long-term studies examining the amount and intensity of physical activity needed to improve weight loss success. So this is important new information.

In using exercise to help prevent weight regain, it may not matter whether the exercise is moderate or intense.

The authors write:

…the inability to sustain weight loss appears to mirror the inability to sustain physical activity.

Long-term sustained weight loss is possible for a significant portion of overweight women. Although most women won’t do it, success is enhanced by exercising for 55 minutes on five days a week. Most men won’t exercise that much either. Which camp do you fall into?

For physical activity instruction and information, visit Shape Up America!, Physical Activity for Everyone, or Growing Stronger: Strength Training for Older Adults.

Steve Parker, M.D.

Reference: Jakicic, John M., et al. Effect of Exercise on 24-Month Weight Loss Maintenance in Overweight Women. Archives of Internal Medicine, 168 (2008): 1,550-1,559.

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Prostate Cancer Deaths Linked to Overweight and High Insulin Levels

Posted on June 20, 2012 | Comments Off on Prostate Cancer Deaths Linked to Overweight and High Insulin Levels

Lancet Oncology in 2008 published a report associating worse prostate cancer outcomes—death, that is—with overweight, obesity, and hyperinsulinemia.

Grapes are an iconic Mediterranean fruit

Researchers looked at data from the respected Physicians’ Health Study, finding 2,546 men who developed prostate cancer during many years of observation. Of these men, 38.8% were overweight (body mass index 25–30) and 3.4% were obese (BMI over 30).

(For definitions of overweight and obesity, and to calculate your body mass index, click here.)

Compared with normal-weight men (BMI under 25) who developed prostate cancer, overweight men with prostate cancer were one-and-a-half times more likely to die from the cancer. Obese men with prostate cancer were two-and-a-half times more likely to die.

A blood test called C-peptide is a marker of insulin resistance and hyperinsulinemia. Obesity is often accompanied by high insulin levels and insulin resistance. Overweight, not so much. Eight hundred twenty-seven of the men with prostate cancer had C-peptide levels drawn at baseline, before diagnosed with cancer. Men with the highest C-peptide levels were almost two-and-a-half times more likely to die of prostate cancer than men with the lowest C-peptide levels.

Study participants having both excess body weight and high C-peptide levels had the worst outcome.

Prostate cancer is the most common invasive cancer in U.S. men, with about 185,000 cases diagnosed every year. It is one of the cancers that can be prevented by following the traditional Mediterranean diet for years. The other prevented cancers are breast, uterus, and colorectal. Obesity predisposes men to cancer of the prostate, colon, rectum, kidney, and esophagus.

The study at hand suggests that if you are overweight or obese and then develop prostate cancer, you have a greater risk of dying from the cancer compared with healthy-weight men. Given that prostate cancer is so common, why not cut your risk of getting it and dying from it by controlling your weight with a Mediterranean-style diet?

Steve Parker, M.D.

Reference: Ma, Jing, et al. Prediagnostic body mass index, plasma C-peptide concentration, and prostate cancer-specific mortality in men with prostate cancer: a long-term survival analysis. Lancet Oncology, online publication October 6, 2008. DOI: 10.1016/S1470-2045(08)70235-3

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22 Things To Do Before You Die

Posted on June 20, 2012 | Comments Off on 22 Things To Do Before You Die

From Staci, who died too young.

-Steve

h/t WhiteCoat

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Mediterranean Diet May Prevent Melanoma (Serious Invasive Skin Cancer)

Posted on June 18, 2012 | Comments Off on Mediterranean Diet May Prevent Melanoma (Serious Invasive Skin Cancer)

A 2008 study suggests a protective effect of the Mediterranean diet for cutaneous melanoma. This is the first study to examine melanoma’s association with the Mediterranean diet.

Melanoma is the seventh most common cancer in Americans, and the most common fatal malignancy among young adults. Lifetime risk of developing melanoma is one in 71. Incidence of melanoma in the white U.S. population has more than tripled in the last 20 years. The U.S. had 62,000 new cases of melanoma in 2008.

The researchers in Rome, Italy, used a hospital-based case-control method including 304 cases of melanoma and 305 matched controls who did not have melanoma. Information on sun exposure, skin pigmentation, smoking, medical history, and socio-demographic characteristics was collected.

The researchers report:

After careful control for several sun exposure and pigmentary characteristics, we found a protective effect for weekly consumption of fish, shellfish, fish rich in omega-3 fatty acids, daily tea drinking and high consumption of vegetables in particular carrots, cruciferous and leafy vegetables and fruits, in particular citrus fruits.

[For the sake of clarity, I have omitted odds ratios and confidence intervals. Odds ratios for many of these associations were around 0.50, meaning half the risk of developing melanoma.]

Conclusion overall: Our findings suggest that some dietary factors present in the Mediterranean diet might protect from cutaneous melanoma.

Prior studies have demonstrated lower incidence of breast, colon, prostate, and uterus cancer in people who adhere to the traditional Mediterranean diet. Note also that death rates from cancer are lower. We can probably add melanoma to the list of cancers prevented with a Mediterranean-style diet, although I would have more confidence if the current study had included more participants.

Steve Parker, M.D.

Reference: Fortes, C., et al. A protective effect of the Mediterraenan diet for cutaneous melanoma. International Journal of Epidmiology, 37 (2008): 1,018-1,029.

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