Medical Nihilism

 The Worried Well



5 min video Like a Bridge Over Diagnosis



I think it was Hank Williams who sang "No one gets out alive".

Who said in Mad Magazine, "What me Worry".

My dad like to quote the British Navy saying: "You are taking youself too seriously.

"A hundred year old man said, "If I knew I was going to live this long I would have taken better care of myself."


I think the video above is great.  It has much good information. Much of it has to do with personal philosophy. 

 I have been a physician since 1973.
The most gratifying work I have done is the preventive work with medicine and cancer screening.

As an internists the plan is to prevent disease.
Vaccines are the best.
Medications during my career have become inexpensive, safe and extended life in people who are asymptomatic.

It's all about risk vs. reward.

Hypertension.
Diabetes.
High Cholesterol Particle Number
High Triglycerides.
Osteoporosis.

All have safe generic brand medicine available now.
Of course of medicine has potential side effects.
We have learned that using lower doses in combination can avoid many of the side effects.

Cancer screening.
To wait for symptoms before getting a colonoscopy is not a good plan.

Heart screening.
CIMT, CAC are inexpensive ways to find subclinical plaque early.  Rx early with low doses to eradicate the disease and avoid stents, strokes and bypasses.  100,000 sudden cardiac deaths a year with half of them having death as the first symptom.


 

New Research on Niacin 2015

           New Research on Niacin 2015 link

Conclusions—
 In statin-treated men with type 2 diabetes mellitus, Extended Release Niacin decreased plasma Lp(a) concentrations by decreasing the production of apo(a) and Lp(a)-apoB-100. 

Extended Release Niacin also decreased the concentrations of apoB-100–containing lipoproteins by decreasing VLDL production and the transport of these particles down the VLDL to LDL cascade.

 Our study provides further mechanistic insights into the lipid-regulating effects of Extended Release Niacin. 

Choose one of 3 weight loss diets used in Shai trial

The Mediterranean diet is 1500 calories a day.
The Low fat is 1500 calories a day.
The Low carbohydrate high fat diet is ad libitum,  Initially, induction with 20g/d CHO, then up to 120 g/d.

Editorial on Vegetarian diets

Non- vegetarians drink 9.8 wine.
Vegetarians drink 23 wine. 

Link to Editorial


Vegetarian diet is one of the good restrictive diets as some people are able to stick to it for the rest of their lives. 

However as this quote from the editorial states:
"Nevertheless, it is possible to eat a vegan diet that is highly processed, rich in fat and hydrogenated oils and low in fiber; this sort of diet will not provide health benefits solely because it is devoid of animal flesh."  

East Asian vegetarians have this problem with frying foods in USA and develop metabolic syndrome. 

My concern is the best diet for obese insulin resistant patients.  I think Low Carb High Fat is best for them. 

This editorial states vegetarian diets are lower Hgb A1c but the trials mostly have con-founding data of weight loss as well.  

I don't think this editorial is fair about LDLc changes with non-vegetarian diets.  I think LDLp is more important and that data is largely lacking.  

CIMT, CAC data is lacking.  I have been concerned about this for myself and thus have done yearly CIMT's.  I have had regression of plaque on 60% fat. My metrics here 

Another quote from editorial:

"Compared with non‐vegetarians, vegetarians eat diets lower in total fat, saturated fat, and cholesterol and higher in fiber.19

They also consume more grains, legumes, vegetables (green leafy and yellow), fruit, and wine."19

9.8 ± 0.5

7.0 ± 2.5

9.4 ± 3.5

23.0 ± 4.45

Non- vegetarians drink 9.8 wine.
Vegetarians drink 23 wine.  

Ref 19 What do Vegetarians eat link

This begs the question that arises with the Mediterranean diet.  How big a role does wine play? 

 

The Bon Vivant Diet vs. The Great Starvation Diet

The reduced obese need to take 
diet medications 
for the
 disease of chronic obesity



I was on the Starvation Diet and Lost 80 in the short term.  

In the long term I advise the Bon Vivant diet. 

Please read my experience at:

The Bon Vivant diet vs. The Great Starvation Diet 



Update October 28, 2019

Adding modified intermittent fasting to Bon Vivant. link

Meat causes cancer definitely?

 Population studies are what they are.

I treat individual patients. 

 Individuals need screening colonoscopies.

 Insulin resistant obese need #LCHF or Atikins diet. 

High levels of  LDLp need statins. 

To know if you are on a healthy diet get:

CIMT, CAC and LDLp

 For a good analysis of this new study read this article link

Below is a quote from the article. 

 

As Professor Phillips explains, “IARC does ‘hazard identification’, not ‘risk assessment’.

“That sounds quite technical, but what it means is that IARC isn’t in the business of telling us how potent something is in causing cancer – only whether it does so or not”, he says.

To take an analogy, think of banana skins. They definitely can cause accidents, explains Phillips, but in practice this doesn’t happen very often (unless you work in a banana factory). And the sort of harm you can come to from slipping on a banana skin isn’t generally as severe as, say, being in a car accident.

But under a hazard identification system like IARC’s, ‘banana skins’ and ‘cars’ would come under the same category – they both definitely do cause accidents.

Confusion about compliance with weight loss diets.

There is confusion about compliance with weight loss diets.

Few people can maintain weight loss after hitting the plateau. 
(See National Weight Control Registry here for how 10,000 people have done it.)


 Here is why most people can't maintain their diet and exercise after hitting the plateau  

Atkins Meta-Analysis of Low Carb vs. Low fat diet

Sackner-Bernstein article 2015

"In conclusion, this trial-level meta-analysis of 17 randomized controlled trials shows that both LoCHO and LoFAT diets are effective in reducing weight. 
However, LoCHO diet appears to achieve greater weight loss and reduction in predicted risk of ASCVD events compared with LoFAT diet. 
On the basis of these results, we suggest that dietary recommendations for weight loss should be revisited to consider this additional evidence of the benefits of LoCHO diets." from original article above

Larry Husten News Article about trial
excerpts below:


"The study, published in PLoS ONE, was funded by Atkins Nutritionals. A unique feature of the paper is that it contains both a classical frequentist and a Bayesian meta-analysis."

"Seven trials showed a significant weight reduction in the low-carb group, but no trials found a significant benefit for the low-fat diets."

"The low-fat group had a larger beneficial effect on LDL cholesterol, while the low-carb group had a better effect on HDL cholesterol, triglycerides, and systolic blood pressure:

• LDL fell by 1.8 mg/dL with low-carb versus 10.9 mg/dL with low-fat
• HDL rose by 4.4 mg/dL on low-carb but fell 1 mg/dL with low-fat
• Triglycerides declined 41.1 mg/dL with low-carb versus 11.3 mg/dL with low fat
• Systolic blood pressure dropped 6.7 mm Hg versus 4.4 mm Hg"

"Both diets were associated with significant reductions in the 10-year cardiovascular risk score, but the reduction in risk was significantly greater in the low-carb group."

"He (a physician) also questioned the role of Atkins in the study. In the paper, the authors state that the company "had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

Ghrelin was hot in 2002, Bile Acid is hot in 2014

Ghrelin levels after Gastric Bypass Surgery are low for 6-9 mos?

 

The bottom line shows the very low level of Ghrelin post Gastric Bypass Surgery. 

The middle line is matched obese controls who have lower Ghrelin levels than non-obese.

The top line are the non-obese controls with the highest levels of Ghrelin. 

INTERESTINGLY THE OBESE HAVE LOWER GHRELIN BECAUSE THEY HAVE HIGHER LEPTIN THAN NON-OBESE.

HOWEVER IN 2014 THE REST OF THE STORY IS BILE ACID:

1- FRANK GREENWAY REVIEW

2- FXR IS A MOLECULAR TARGET FOR THE EFFECTS OF VERTICAL SLEEVE GASTRECTOMY  NATURE 13135 RYAN ET AL.

3- BILE DIVERSION TO THE DISTAL SMALL INTESTINE HAS COMPARABLE  METABOLIC EFFECTS TO BARIATRIC SURGERY NATURE COMMUNICATIONS8715 FLYNN ET AL

What is more important: weight loss or lower saturated fats? Look Ahead DATA #2

Slide from Nathan Lazarus at OMA meeting in Washington D.C, 2015


I went to the NLA Pittsburgh meeting 2 weeks before this Obesity meeting.  I was surprised the NLA PART lifestyle guidelines advised a diet with saturated fat less that 10% and cholesterol less than 200 mg/d. 

I found out that Look Ahead advised its lifestyle arm to eat less than 30% of calories from fat, with < 10% from saturated fat. 
Below are 3 graphs showing 10 years of data.  
The red circles are the control data.  
There was no difference in outcome data making this a negative trial.  
What does this say about lifestyle changes of saturated fat less 10% and low fat diet in the lifestyle change group?   

Another Look at Look Ahead #1

This is a recent slide from OMA that Ethan Lazarus presented. 

This is a negative outcome lifestyle trial. 
39% maintained greater than 10% weight loss for eight years.  Excellent result.  People who achieved this goal at one year increase exercised to 200 minutes a week to maintain weight loss.
14% gained 5% weight after eight years. 

However, then you look at the control results (DSE).
24% of the control group lost more than 10% of weight after 8 years.  WOW!
Take note:  This shows typical WATERFALL results of all diet trials
I would like to see this type of chart for the control group. 
I would also like to see the results extended out to the full 9.6 years.
Amazingly, only 4% were lost to follow up.  Intention to treat analysis was done. 

Quote from the NEJM paper:
"Weight loss was greater in the intervention group than the control group throughout
 (8.6% vs. 0.7% at 1 year; 6.0% vs. 3.5% at study end)."




Below is a quote from the NEJM study supplement:

“ILI participants were given a calorie goal

of 1200-1500 kcal/day for those who weighed less than 114 kg (250 lbs) and

1500 to 1800 kcal/day for those over 114 kg.

They were encouraged to consume

30% of total calories from fat and at least 15% of calories from protein.”

“Meal replacement products were provided at no cost to help participants adhere to their dietary goals.

During weeks 3 to 19 of the program, individuals were encouraged to replace two meals each day with a liquid shake and one snack with a bar.

The other meal (typically dinner) consisted of conventional foods;

fruits and vegetables were added to reach the calorie goal.

From week 20 on, meal replacements were typically used for one meal per day with conventional foods consumed at the other times.”

“To maximize weight loss, a tool box of additional strategies was available for use with participants after month 6 if the individual had not achieved the 10% weight loss. The tool box included orlistat, a weight loss medication. However, since minimal weight loss benefit was observed with orlistat, the use of this medication was discontinued in 2008.”

The Two Phases of Weight Loss : calories needed to lose pound of weight changes

Time to Correctly Predict the Amount of Weight Loss with Dieting Diana M. Thomas

 Quote from above link:

"When a subject in weight equilibrium reduces energy intake without changing voluntary energy expenditure (e.g., by increasing or decreasing physical activity), a period of negative energy balance follows that draws upon energy stores.

Assuming the subject is ingesting a low calorie macronutrient-balanced diet, weight loss will proceed in two distinct phases; a rapid weight loss phase during the first few days or weeks followed by a slower weight loss phase lasting up to two years7,8.

Lost Weight ≠ 3500 kcal/lb and Energy Output is Not Constant

The early weight reduction phase lasting several days or weeks7,8 is characterized by relatively rapid loss in body mass consisting of a small carbohydrate (glycogen) pool, protein, and to a less extent fat as sources of energy.

Water balance is also negative during this period as carbohydrate and protein coupled with associated water are released with their oxidation and fluid balance readjusts with changes in dietary sodium intake.

Water is also a byproduct of carbohydrate and protein oxidation.

The high fluid content and low proportion of weight loss as fat during the evolving early weight loss phase is accompanied by an energy content of weight change that is thus not constant and substantially less than 3500 kcal/lb7,8.

As a contemporary example, men and women participants in the Comprehensive Assessment of Long-term Effects of Reducing Intake of Energy (CALERIE I) Study at Pennington Biomedical Research Center prescribed low (25% below baseline energy requirements) and very-low (890 kcal/d for three months followed by weight maintenance) calorie diets had intensive monitoring of actual energy intake with doubly-labeled water and dual energy X-ray absorptiometry body composition measurements over the 24-week weight loss phase8,9.

At week 4 the measured energy content of weight change was (X±SEM) 4858±388 kcal/kg (2208 kcal/lb), far lower than Wishnofsky’s value of 7700 kcal/kg (3500 kcal/lb).

Although the timing of metabolic adaptations with low calorie dieting is not exactly clear with respect to the early phase of weight loss, there develops over time hormonal and neural regulatory mechanisms that trigger reductions in resting energy expenditure, protein turnover, and other metabolic processes10, 11.

A reduced energy intake also leads to a lowering of the thermic effects of feeding and perhaps to levels of non-exercise activity thermogenesis10.

Taken collectively, exhaustion of the available glycogen pool and metabolic adaptations reduce the rates of protein catabolism and energy expenditure with a shift to increasing levels of fat oxidation7.

The combined effects of these processes slows the rate of weight loss and leads into the second slower weight loss phase.

The second weight loss phase extends for months or years, although very few supervised studies go beyond six months to one year that can be used to critically evaluate theoretically derived energy balance relations7.

Since glycogen is largely depleted, oxidized carbohydrate comes mainly from the diet and glucogenic amino acids in protein.

Nitrogen (i.e., protein) balance approaches zero, the steady-state level depending on energy and protein intake12.

Adipose tissue triglycerides constitute the main energy source during this period with the rate of weight loss substantially reduced from the early diet period.

By 24 weeks the measured energy content of weight change observed in CALERIE I Study participants had increased from the mean 4-week value (4858±388 kcal/kg) to 6569±272 kcal/kg (2986 kcal/lb)8,9."

Best Head to Head Trial ? Shai NEJM 2008

2 yr trial n=322 

Results: 

Low Carb High Fat in Blue:  Best increase HDLc.  
                                                 Best decrease in triglycerides. 
                                                 Best TC/HDL ratio change.

Med diet in Orange: Best decrease LDLc

Low Fat in Red: Has the worse results in biomarkers

"a. Low-carbohydrate and Mediterranean diets had greater weight loss than low-fat.

b. Lipid profile improved the best in the low-carbohydrate diet.

c. The inflammatory marker increased CRP decreased by more than 20% only in the low-carbohydrate diet and Mediterranean diet.

d. Only the Mediterranean diet decreased plasma glucose levels in a subgroup of diabetics."

N Engl J Med 2008;359:229–41

Dubnov-Raz& Berry p. 941 and p. 942

Obesity

LeRoith and Karnieli

Medical Clinics of North America

September 2011, volume 95, number 5


Another good head to head trial discussed by Dr. Vasselli video 

American Diabetic Association Guideline (ADA) on diets

How are these diets the same and how are they different?

 The ADA suggests to the Doctor to consider personal preferences and metabolic goals when choosing one of them.

Dr. Lazarus tells us which diet for which circumstance at this link


I would like to point out that the DASH is high in fruits and is not for weight reduction.  It is good for reducing blood pressure. 

A VLCD or Very Low Calorie Diet is not on the ADA list.  It's too expensive and people only stay on it for a year at most. 

I am not sure why a low fat diet is on the list other than the list is from 2013.   Low fat diets have not proven to be healthy.

On the other hand a higher fat diet, like the Mediterranean diet, in Spain has reduced CV events.  Is it the olive oil, some red meat, nuts, or really the wine?   ADA says MED diet has low to moderate
 diary, eggs, red meat and wine (with meals).  A very nice diet but perhaps not a weight loss diet?


It is nice to see Low carbohydrate, high protein, high fat  diet listed on the ADA guidelines. 
Atkins or Low Carb High Fat (LCHF) is a diet that satiates with a low calorie ad libitum diet.
 See this link for a head to head trial showing this


















]

When should diabetics go on a statin?

This is a slide of Dr. Jeffrey Sicat from OMA lecture 2015


Lifetime risk of Diabetic for cardiovascular event is often 50%.

CAC of zero reduces the likelihood of CV event in 10 years
 but with LDLc higher than 100 the patient will continue to lay down atheroma.  
This can be prevented with low dose statin that is inexpensive with few side effects.

Lifetime vs. 10 year risk of heart attack or stroke link

Why does Bariatiric Surgery Fail: Denis Halmi gives 11 reasons in 2 slides

Surgeon Denis Halmi said in his OMA lecture in 2015 Washington DC that:

30% of patients regain the lost weight by 10 years post bariatric surgery.

Dr Denis Halmi in his lecture, Recidivism after Bariatric Surgery, states: 
There are few large studies on revisional surgery results. 
They are less effective than the primary surgery. 
Some patients lose little weight. 
Except:
Lap Band conversion to gastric bypass or sleeve gastrectomy has good results because of new hormonal effects.

Is GLP-1 increase the main reason Gastric Bypass works so well?

                         This is Jeffrey Sicat's slide from OMA lecture in Washington DC 2015

 Quote from Frank Greenway Review 
May 2015

"Following gastric bypass surgery, levels of ghrelin are extremely low,39 while GLP-1 and PYY are elevated,46 which should attenuate appetite.

These findings raise the possibility that the gastric bypass procedure reduces weight, at least in part, by altering the production and/or release of these mediators of appetite.

Interestingly, among individuals who underwent gastric bypass, plasma ghrelin levels did not oscillate in relation to meals and were much lower than those of normal-weight controls and matched obese controls, after substantial weight loss resulting from a 6-month dietary programme.39 

However, recent studies in rodents have indicated that weight loss following sleeve gastrectomy is not mediated by changes in ghrelin or GLP-1, or through the melanocortin (MC)-4 receptor in the hypothalamus.47, 48, 49

  Instead, as shown by a knockout mouse study, the mechanism of weight loss in sleeve gastrectomy appears to involve the nuclear bile acid receptor, farnesoid X receptor.50

Note that the observation that gut hormones such as ghrelin and GLP-1 are not involved in the mechanism of weight loss with sleeve gastrectomy does not mean that they are not important mediators of body weight. 

Indeed, a rationally designed monomeric peptide has been shown to reduce body weight and diabetic complications in rodents by acting as an agonist at three metabolically related peptide hormone receptors: the GLP-1, gastric inhibitory polypeptide and glucagon receptors.51"

New Peptide in Rodents?