It is estimated that at any given time, as many as a third of people with overweight and obesity are on a restrictive diet (in addition to an unknown number of normal weight people, who follow diets in the hope that they are healthier and may prevent weight gain).

As most of the popular diets consist of restricting overall caloric intake (despite often misleading claims to the contrary) and amounts of certain foods, the question arises whether or not there may be any potential drawbacks to being on such diets.

This question is of particular importance as many people with overweight and obesity often have nutrient deficiencies to start with - a situation that can potentially become worse as total food consumption decreases.

In a paper published online in the Journal of the International Society of Sports Nutrition, Jayson Calton, from North Venice, FL, who holds a PhD in holistic medicine, examines the potential of micronutrient deficiencies with popular diet plans.

Micronutrients include vitamins and minerals, crucial nutrients that are required in very low concentrations but are essential for maintaining proper health.

Calton analysed suggested daily menus from four popular diet plans (Atkins for Life diet, The South Beach Diet, the DASH diet, The Best Life Diet) to determine if they met the USDA recommended dietary intake (RDI) for 27 micronutrients.

According to Calton’s analysis, none of these four popular diet plans provided minimum RDI sufficiency for all 27 micronutrients analyzed.

In fact, the four diet plans, which provided an average daily caloric intake of around 1750 KCal/day, were found to be RDI sufficient in only 12% of the 27 micronutrients examined.

Further analysis of the four diets found that an average calorie intake of 27,000 calories of these diet would be needed to achieve sufficiency in all 27 micronutrients.

Six micronutrients (vitamin B7, vitamin D, vitamin E, chromium, iodine and molybdenum) were identified as consistently low or nonexistent in all four diet plans.

When these six micronutrients were removed from the sufficiency requirement one would still have to eat an about 3500 calories of these diets every day to reach 100% sufficiency in the remaining 21 micronutrients.

As Calton concludes:

“These findings are significant and indicate that an individual following a popular diet plan as suggested, with food alone, has a high likelihood of becoming micronutrient deficient“

It may thus be not such a bad thing that the vast majority of people fail to stick with such diets over any significant periods of time after all.

Those who do, may likely benefit from taking additional micronutrient supplements while on these diets.

AMS
Edmonton, Alberta

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Calton JB (2010). Prevalence of micronutrient deficiency in popular diet plans. Journal of the International Society of Sports Nutrition, 7 (1) PMID: 20537171

One of the unwanted complications of gaining a lot of weight and then losing it, is the sometimes grotesque amounts of unwanted skin that patients are left with. This excess skin can be both aethetically distressing but also cause functional and dermatological problems.

With the advent of bariatric surgery, a parallel discipline of plastic surgery specialising in the aesthetic correction and removal of excess skin has emerged. As this surgery is generally performed on various parts of the body including the trunk, buttocks, thighs, arms and breasts, the more general term “body-contouring surgery” is often used to describe these procedures.

Often patients need multiple surgical procedures with extensive incisions posing important challenges to these patients with regard to wound healing and risk for infections.

One of the most important determinants of adequate wound healing and optimal immune function is proper nutrition, often a challenge in post-bariatric surgery populations.

This issue was now examined by Siamak Agha-Mohammadi and Dennis Hurwitz, New Port, California, in a series of studies published in Aesthetic and Plastic Surgery.

In a first study the surgeons examined the preoperative nutritional parameters of 90 body-contouring patients, both with surgical and non-surgical weight loss. Of the 48 post-bariatric surgical patients, 38% had low prealbumin, 33% had vitamin A deficiency, 32.6% had low hemoglobin, 16.3% had iron deficiency, 9.5% had vitamin B12 deficiency, and 12% had hyperhomocystinemia.

In contrast, only 10% of the 42 non-surgical patients had low prealbumin and only 11.5% had vitamin A deficiency.

In a subsequent study, the investigators examined the complications of body-contouring surgery in patients with non-surgical and surgical weight loss, whereby some patients in the latter group also received a nutritional supplement.

In this cohort, complications in obese non-bariatric and post-bariatric patients receiving the nutritional supplement were comparable with those of normal-weight nonbariatric patients.

This study not only highlights the common occurrence of significant nutritional deficiences in the post-bariatric surgery populations, but also shows that these deficiencies are associated with complications in body-contouring surgery.

Importantly, however, the study also shows that these nutritional deficiencies can be corrected, and that with correction, the complications rates of post-bariatric surgery patients can be reduced to levels comparable to non-bariatric patients.

AMS
Edmonton, Alberta

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Agha-Mohammadi S, & Hurwitz DJ (2010). Enhanced Recovery After Body-Contouring Surgery: Reducing Surgical Complication Rates by Optimizing Nutrition. Aesthetic plastic surgery PMID: 20464396

Chocolate, prepared from the seed of the tropical Theobroma cacao tree, contain alkaloids such as theobromine and phenethylamine, which have physiological effects on the body that include elevating serotonin levels in the brain.

Low levels of serotonin are linked to mood disorders and one of the primary action of antidepressants is to raise brain serotonin levels, thereby alleviating the signs and symptoms of depression.

It is therefore not unreasonable to ask the question whether some people who like to eat chocolate are really using it to self-medicate their depression.

This question was now addressed by Natalie Rose and colleagues from the University of California in a paper just published in the Archives of Internal Medicine.

In this paper, the researchers examined the relationship between chocolate consumption and depressed mood in 1018 adults (694 men and 324 women).

Participants who screened positive for possible depression had significantly more chocolate consumption (8.4 servings per month) than those not screening positive (5.4 servings per month) for depression.

In fact, those with the highest depression scores reported even higher chocolate consumption (11.8 servings per month).

Although the authors are very careful in pointing out that this correlation by no means implies causality, it is clearly consistent with the hypothesis that people with mood disorders are more likely to consume chocolate than those with no signs of depression.

This finding certainly corroborates my own, albeit anecdotal, experience that proper management of mood disorders often alleviates chocolate cravings in many of my patients.

As chocolates are one of the densest forms of energy commonly consumed (a single ounce of milk chocolate can contain 150 KCal), using chocolate to treat your depression is certainly a bad idea if you happen to also have a weight problem.

Tip to all clinicians: it may not be a bad idea to screen all patients reporting a particular liking for or excessive consumption of chocolate for an underlying mood disorder.

AMS
Edmonton, Alberta

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Rose N, Koperski S, & Golomb BA (2010). Mood food: chocolate and depressive symptoms in a cross-sectional analysis. Archives of internal medicine, 170 (8), 699-703 PMID: 20421555

Was Gandhi older or younger than nine when he died?

This is obviously a stupid question. Of course you know that Gandhi must have been older than nine when he lead India to independence.

So what has this question to do with anything?

Yesterday, on my way to Whitehorse in the Yukon, where I am advising my Yukon colleagues on better managing their obese patients, I picked up “Risk”, a book by the Ottawa journalist Dan Gardner, which deals with the issue of why we fear things we shouldn’t.

Much of what’s in the book has to do with basic human psychology and how we process and respond to bits of information with our guts rather than our heads.

The Gandhi question comes from an example in Gardner’s book. Of course we all know that Gandhi did not die before the age of nine, so seriously, guess how old he really could have been when he was assassinated?

It turns out that in carefully conducted experiments by the German psychologists Fritz Strak and Thomas Mussweiler, in which people were first asked the nonsense “nine” question and then asked to try and guess how old they thought Gandhi really was when he died, their average guess was around 50.

Strak and Mussweiler then asked another set of volunteers the “nonsense” question, but this time it was whether they thought that Gandhi died before or after age 140. Then after agreeing that this was indeed nonsense, the participants were asked to seriously think about how old he might have been – this time around, their answer was 67.

So simply by throwing a ridiculously low number out there, the researchers apparently made people guess a lower age than by throwing out a ridiculously high number, despite the fact that in both cases the first number could obviously not have been true.

This experiment, as do many others in the psychology literature, illustrate a phenomenon Gardner refers to as the ‘Anchoring Rule’. This rule describes our natural tendency to be influenced in our judgment by numbers even when we fully know they are ridiculous or even have absolutely nothing to do with the issue at hand.

Of course we know Gandhi could not have been nine when he died, so he must have been older – and we quickly try to recall images of him and all the stuff he did and try to make a reasonable guess – namely perhaps around 50 or so? So we are making adjustments for what we know to be wrong and come up with a number that we think is more likely.

When we start with 140, we know this is ridiculously high and of course Gandhi must have been much younger when he died and immediately, we call up exactly the same mental image of Gandhi and think of all he accomplished and in the end estimate that he could well have been, say, in his late sixties when he died.

In both cases we are starting with numbers we know are definitely wrong and are correcting them to something we consider more reasonable. Once we’ve heard the number ‘nine’ we underestimate the possible age of death. In contrast, once we’ve heard the number ‘140’, our guesstimate is much higher.

So how does this relate to testimonials and weight loss expectations?

We’ve all seen the commercials with testimonials from people who have lost an incredible amount of weight (say 250 lbs), often in a ridiculously short amount of time (say 3 months), with virtually no effort (say just by taking the super-expensive ‘all-natural’ supplements).

Ok, so we all know that this, even if remotely true, is probably the best result ever and because we know that the company wants to sell us their product or service, they are probably presenting their best case (in fact they’ll will happily state on their ad that this result may not be typical).

So we make adjustments – yeah, maybe if I join I’ll not lose 250 lbs (because I know that’s ridiculous) but, hey, maybe I’ll lose 60 or maybe even only 40 lbs. And of course I know that 3 months is an unrealistic time frame, so I mentally readjust this number to, let’s say, 6 months. And yes, of course, it’s not just taking the pills that’ll make this happen, sure, I’ll probably also have to make some lifestyle changes like eat healthier and perhaps do a few minutes of exercise everyday, because of course I know there’s so such thing as ‘magical’ supplements.

But you know what – 40 lbs in 6 months with healthy eating and a bit of exercise, that sounds reasonable and if the supplements can help me do that, then maybe $199 a month (first month free!) is perhaps not such a bad deal – so, now that I have seen through the ad and have reasonably adjusted my expectations, where can I order this stuff?

This is exactly how the Anchoring Rule works – despite being very cautious and reasonable, it works every time – even in the smartest and most cautious people!

Indeed, the power of testimonials is so compellingly effective and misleading, that it is in fact illegal for doctors in Canada to use patient testimonials to promote their services, even if these testimonials are completely honest and true!

This is why, by law, I am prohibited from posting any of the many comments that I receive from former patients who have successfully managed their weight problem and want to personally thank me by posting their success stories on my blog.

But of course, what applies to me as a regulated health professional, does not apply to any of the commercial weight loss programs that can bombard you with all kinds of success stories and testimonials, the more unrealistic and wildly atypical, the better for their sales.

Thanks to the Anchoring Rule, even the most ridiculous success story, after reasonable adjustment, will still sound convincing enough to make you risk spending a few bucks.

So, the next time you read a wildly enthusiastic weight loss testimonial and consider signing up, simply ask yourself – could Gandhi really have died before he turned nine?

AMS
Whitehorse, Yukon

Yesterday, I attended a Research in Progress lecture at the Alberta Diabetes Institute by Catherine Chan, Professor of Physiology and Nutrition Science here at the University of Alberta with the catchy title, “Give Peas a Chance“.

The talk focussed on the putative benefits of locally produced dried peas, some of which are surprisingly rich in antioxidants.

While the results of Dr. Chan’s animal feeding experiments showing beneficial effects on glucose metabolism and perhaps even pancreatic islet function may still be in their early stages, her presentation did very much remind me of the importance of doing careful experiments before jumping to conclusions about the putative beneficial effects of that or the other natural product.

Thus, as Chan presented, not all peas are made equal and substantial differences exist between the antioxidative effects of different types of peas (in her presentation she specifically focussed on a dried pea variety with yellow coats versus those with while coats - as she showed - very different properties indeed).

This ongoing work on peas is actually part of a much larger project ongoing at the University of Alberta called PANDA (Physical Activity and Nutrition for Diabetes in Alberta), a multidisciplinary, multi-sectoral research project focussing on a wide range of projects aimed at developing a practical ‘toolbox’ of physical activity and diet to help better prevent and treat Type 2 Diabetes.

The peas project was part of work that aims to develop a prototype Alberta Diet to be developed around Alberta crops and foodstuffs. Apart from testing local crops (i.e. legumes, peas, berries, canola oil, etc.) for their effect on chronic disease, the researchers are also looking at innovative modifications in crop production and processing methods to increase these beneficial effects.

Ultimately, rural economists working in the PANDA project will ascertain the economic viability of adopting the Alberta Diet with a careful look at both the financial and health benefits of adopting such a diet for the prevention and treatment of type 2 diabetes.

The multi-year project is funded through a variety of sources including Alberta Innovates and other public and private organisations.

AMS
Edmonton, Alberta