Update on Tubby Theory from Topeka 2008 to 2016

8 years later

A friend asks me:

"You have been talking about Coronary Calcium Score for a long time. Were you ahead of your colleagues, or in step? Is the Ultra Sound of ..."
07:52 AM - 29 Apr 16



I wrote the book The Tubby Theory from Topeka after I passed the lipid boards and Tim Russert died.
No one in NLA spoke on National media that his non-HDLc was not treated to goal.

I guess they were afraid of being sued.
I thus wrote a book about treating patients in my practice aggressively.
I used the teachings of my mentors at NLA.
I quote them (my mentors) throughout my book.

My only originality was to call non-HDLc the Tubby Factor because patients and physicians could not remember "non-HDL cholesterol" nor how to calculate it. 
I called it the Tubby factor because non-HDLc is usually discordant with LDLc in patients with metabolic syndrome.

Since my book in 2008 I have been gratified to see that CAC and CIMT have proven themselves as significant and independent risk predictors for CVD.
New AHA/ACA guidelines in 2013 by Stone use CAC or CIMT in low risk patients to determine if statins should be started or not.
Niacin is under attack as being a dangerous drug which I believe is just silly.  If low dose wax matrix niacin 1,000 mg/d is used with low dose lipitor 20 mg/d early in the disease of sub-clinical atherosclerosis for long term treatment I believe we can prevent most CVD.

I am very proud of my book and still stand by it. 
Even the low fat diet I suggest might be suitable for some folks who are insulin sensitive and hyper-absorbers of cholesterol.

Important Look Ahead trial

   

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)."  (2.5% difference)

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.”
Many in control group had excellent weight loss link

Tribute to the Pelican

My pet pelican in Jensen Beach had a birthday so I made him a classic gin martini, stirred not shaken.
I then recited this famous limerick in his honor:
A rare old bird is the Pelican
His beak can hold more than his bellycan.
Though I am damned if I know
How the hell he can.

Any ideas what his name should be?
I believe he is the team bird for NOLA basketball?
There are quite a few of these down here.
They fly by my window all the time.

How strong is evidence for exercise for weight loss and lipids?

Above is from NLA Guidelines Part 2 on Lifestyle changes

Above slide from Paul Maclean report from Innovative Research to Improve Maintenance of Weight Loss.

 

Paul MacLean, Ph.d presented the above three slides at Fall Obesity Summit Plenary Sessions 2015
The NLA guideline chart does not specifically address exercise advice for maintaining weight loss. 

Exercise to lower cholesterol? Which type of cholesterol? What type of exercise?

Having passed the American Board of Obesity Medicine in Dec. 2015,  I am now studying for re-certification of my boards in Lipidology.

I do this to prepare myself to go back to the practice of medicine in June 2016.
I plan to open a Obesity/Lipid Clinic.

Statements from NLA Self Assessment Program Critique Book:

Above slide from Dr Horn lecture in Washington DC 2015

Below documents from NLA Guidelines Part 2      2015

Few controlled trials done with dyslipidemia and exercise:

 Exercise with weight loss will lower LDLc:

Leaving exercise and addressing weight loss and lipid change

Weight loss maintained in very few patients.

Ref 75:  Bays HE, Toth PP, Kris-Etherton PM, Abate N, Aronne LJ, Brown WV, Gonzalez-Campoy

JM, Jones SR, Kumar R, La Forge R, Samuel VT.

Obesity, adiposity, and dyslipidemia: a consensus statement from the National Lipid Association. J Clin Lipidol. 2013;7:304-83. 

I find the last sentence in the above paragraph made without any reference to the Look Ahead trial which had favorable changes in risk factors but was a negative trial. Gary Foster on Look Ahead trial




NLA Guidelines Part 2 in chart below summarized:

My question after comparing what NLA wrote in 2013 and in it's guidelines in 2015 is: 

Where is the apoB data mentioned in the NLA self-assessment program critique book that I posted at the start of this blog? 

Seems as if NLA guidelines Part 2 is going backward rather than forward.

Other blog links 

My review of exercise guidelines from studying for ABOM exam Dec 2015 


The NLA guidelines Part 2 on lifestyle made me sad


8 year weight loss maintenance of 5% failed to improve CV outcomes  


Look Ahead: 39% maintained greater than 10% weight loss for eight years.  

However, then you look at the control results (DSE) in Look Ahead.
24% of the control group lost more than 10% of weight after 8 years.  WOW! 


 

Ketogenic diets better at weight loss?

1-Eric Westman trial

Conclusion

Dietary modification led to improvements in glycemic control and medication reduction/elimination in motivated volunteers with type 2 diabetes. The diet lower in carbohydrate led to greater improvements in glycemic control, and more frequent medication reduction/elimination than the low glycemic index diet. Lifestyle modification using low carbohydrate interventions is effective for improving and reversing type 2 diabetes.

2- Veech RL1 2004 abstract 

"Current ketogenic diets are all characterized by elevations of free fatty acids, which may lead to metabolic inefficiency by activation of the PPAR system and its associated uncoupling mitochondrial uncoupling proteins. "

3- Diet and Syndrome X. Reaven GM1. 2000

4- Etiology of peripheral insulin resistance. Zammit VA1.

5- Very-low-carbohydrate diets and preservation of muscle mass Anssi H Manninencorresponding author

"a VLCARB is, if anything, protective against muscle protein catabolism during energy restriction, provided that it contains adequate amounts of protein."

6-  Composition of weight lost during short-term weight reduction.

"Composition of weight lost (percentage) during the ketogenic diet was water 61.2, fat 35.0, protein 3.8. During the mixed diet, composition of loss was water 37.1, fat 59.5, protein 3.4... "

7- Eric Westman article 2008 

"The diet lower in carbohydrate led to greater improvements in glycemic control, and more frequent medication reduction/elimination than the low glycemic index diet"

8- Ketosis and appetite-mediating nutrients and hormones after weight loss. Sumithran P1 

"The circulating concentrations of several hormones and nutrients which influence appetite were altered after weight loss induced by a ketogenic diet, compared with after refeeding. The increase in circulating ghrelin and subjective appetite which accompany dietary weight reduction were mitigated when weight-reduced participants were ketotic."

 9- The effects of high protein diets on thermogenesis, satiety and weight loss

"There is convincing evidence that a higher protein intake increases thermogenesis and satiety compared to diets of lower protein content."

10- Effects of a high-protein ketogenic diet on hunger, appetite, and weight loss in obese men feeding ad libitum.

"In the short term, high-protein, low-carbohydrate ketogenic diets reduce hunger and lower food intake significantly more than do high-protein, medium-carbohydrate nonketogenic diets."

I found these reference from the March 2016 article The Ketogenic Diet 

I myself am on a ketogenic diet as I follow LCHF diet.  

However, I am still not convinced that it is superior to other diets.  It works for me but recently I lost weight not because I am in nutritional ketosis but because I ate less on a  

diet medication, Qsymia.