Body Building information: 2008

Thursday, October 2, 2008

I'll be back Thursday

So, you know how it goes - you think your schedule is such that you'll have plenty of time to get everything done. Except it doesn't always go that way. This week is no exception - we're leaving on vacation tomorrow, so I'll be traveling and unable to post.

UPDATE 01/27/08: I'll return to posting on January 31, 2008...thank you for your patience!

Poor Math Skills Leading to Weight Gain?

What if Willpower Matters Little in the Long-Term for Weight? provoked quite a discussion in the comments and led me to consider my own beliefs about the role of willpower in both weight loss and weight maintenance for the long-term after losing weight.

What got me thinking about the role of willpower is our collective belief that one must exert their will over their desire for food in order to overcome the strong desire to eat, often what amounts to too much food.

We're repeatedly told that we suffer mindless eating habits, a toxic food environment, and a host of other influences which lead us to overeat; all of which can be overcome if we simply set our minds to choosing foods wisely, strictly rationing our intake with portion control methods, and sticking to recommended intakes of each food group to target particular ratios of calories from carbohydrates, proteins and fats.

When doing these things fails to produce long-term weight management, the individual is often the target of blame - they failed by failing to follow the recommendations. They failed to have adequate willpower to continue as directed. They failed to restrict calories sufficiently enough for the long-term to maintain weight effectively.

Rather than challenge the concept - consciously restricting food intake - we instead accept that such is normal and focus on the failure as an execution problem by the individual, often stated many different ways, but always boiling down to calories in exceeding calories out if the individual could only get it right then all would be well.

This makes weight loss and management a math problem.

In order to lose and maintain weight one must then be good at math in order to be able to constantly be vigilant in counting their calories in each day to keep consumption within target outputs.

So, maybe it isn't willpower, but poor math skills leading to long-term failure to maintain weight loss?

No, I don't really believe that...but, it does open the door to consider the idea that weight isn't simply a math problem that is easily solved by changing inputs and outputs of numbers; that in the long-term exerting will to restrict calories over desire to eat is not really all there is to successful weight management.

If weight is not a math problem, then what is the problem?

If we look at the issue differently - set aside the idea that in the long-term one must exert willpower to maintain a calorie balance and seek to understand what truly drives our appetite, we find that weight is not a math problem, but a chemistry problem!

Weight is chemistry.

Chemistry thus influences obligate requirements for nutrients and energy, as well as our ability to exert our will over our desire.

Willpower then depends upon chemistry.

What does the data say about that concept? We'll take a look in upcoming posts - in the meantime, your comments and thoughts are welcome!

Bill Introduced to Mandate Restaurants Deny the Obese Service

MISSISSIPPI; HOUSE BILL NO. 282
An act to prohibit certain food establishments from serving food to any person who is obese, based on criteria prescribed by the state department of health; to direct the department to prepare written materials that describe and explain the criteria for determining whether a person is obese and to provide those materials to the food establishments; to direct the department to monitor the food establishments for compliance with the provisions of this act; and for related purposes.

Be it enacted by the legislature of the state of Mississippi:
SECTION 1.
(1) The provisions of this section shall apply to any food establishment that is required to obtain a permit from the State Department of Health under Section 41-3-15(4)(f), that operates primarily in an enclosed facility and that has five (5) or more seats for customers.

(2) Any food establishment to which this section applies shall not be allowed to serve food to any person who is obese, based on criteria prescribed by the State Department of Health after consultation with the Mississippi Council on Obesity Prevention and Management established under Section 41-101-1 or its successor. The State Department of Health shall prepare written materials that describe and explain the criteria for determining whether a person is obese, and shall provide those materials to all food establishments to which this section applies. A food establishment shall be entitled to rely on the criteria for obesity in those written materials when determining whether or not it is allowed to serve food to any person.

(3) The State Department of Health shall monitor the food establishments to which this section applies for compliance with the provisions of this section, and may revoke the permit of any food establishment that repeatedly violates the provisions of this section.

SECTION 2.
This act shall take effect and be in force from and after July 1, 2008.

Estimated 10% of Teens in US Have Metabolic Syndrome!

The February issue of the Journal of Pediatrics reports a recent study finding an alarming increase in the prevalence of Metabolic Syndrome (MetS) in teens in the United States.

First, let's look at the definition of MetS for teens used to determine how many teens are estimated to have the condition:

a waist circumference at or above the 90th percentile for age and sex;
blood pressure at or above the 90th percentile;
a high triglyceride level at or above 10 mg/dL;
a low HDL cholesterol level at or above 40 mg/dL;
and an impaired glucose metabolism at or above 100 mg/dL (pre-diabtes)

Using data from the National Health and Nutrition Examination Survey (NHANES) from 1999-2002, the researchers found that an estimated 9.4% of teens meet the definition MetS; and that 33% of obese teens, classified by BMI, fall within the definition.

This is pretty disturbing when we consider the last time such data was reviewed, back in 2003 (using earlier-years NHANES data), it was found that 4% of teens met the difinition of MetS above.

To be fair, some quibble that the definition for teens is less stringent than adults, and that if the adult definition is used, then 5.8% of teens meet the adult definition of MetS and 25% of obese teens meet the adult definition.

The bottomline is that no matter how you slice and dice the data, there is a rising prevalence of metabolic syndrome among teens in the United States.

Back on October 2006 I wrote about the increasing prevalence of hyperinsulinemia in the adult population in the United States. At the time, I wrote, "[l]ike the canaries in the mine, slowly dying in the presence of odorless but harmful gases, we're slowly dying in the presence of seemingly logical yet harmful dietary recommendations. All the researchers can keep repeating is eat less and move more; while encoraging us to eat more more whole grains, more fruits and vegetables, more skim milk and non-fat dairy, more beans, more soy and limit saturated fat by eating less meat."

Now today, we're seeing an alarming rise in the incidence and prevalence of metabolic syndrome in our teens - tomorrow's adults - and being spoon-fed the pab that "that the increased prevalence is driven by the rise in obesity."

As the Editor's Perspective noted in the journal, "The obesity epidemic in children is out of control. Our children are living in an obesiogenic environment that fosters all of the components of the metabolic syndrome, regardless of the definition used. It is very likely that a high proportion of youth today who have all the components of the metabolic syndrome will go on to develop cardiovascular disease and type 2 diabetes in adulthood. Clinicians must continue to increase their awareness of the existence of the syndrome and begin to treat it before it becomes even more of a health hazard for our youth."

Here's the big, glaring problem - the elephant in the room if you will - it isn't weight gain per se that is driving up the incidence of metabolic syndrome in our young population - it is the diet they're consuming that's driving up their blood glucose and insulin; and that is causing elevated triglycerides, suppression of HDL, hypertension, visceral fat accumulation and impaired glucose metabolism in a state of chronic hyperinsulinemia!

This is happening despite improvements to school lunches, greater awareness about limiting sweetened beverages, increasing activity in and out of school, and consistent messages about healthful "low-fat" eating inundating our kids today; this is happening because they're still being encouraged to consume a diet rich with carbohydrate, the message now being whole grains are better than refined grains.

It's excessive carbohydrate driving the bus here and until we're able to, as a population, wrap our head around the idea that we cannot continue to feed our children a diet rich with excessive carbohydrate - whole grain or otherwise - that is also concurrently deficient in micronutrients and essential fatty acids and amino acids, we will not see these trends reverse.

Tweaking the Don't Feed the Obese Bill

Many will recall the bill introduced in Mississippi that would ban restaurants from serving obese people.

Now it seems some recognize that such a law would be unworkable, so they're trying to tweak it along to be more palatable for passage.

A press release today touts the ideas of public interest law professor John Banzhaf, who suggests "Focusing your bill on protecting children rather than adults would remove the major objection to it, and provide a strong argument for it - one likely to be echoed by many groups concerned about child health and welfare."

BELOW IS A DRAFT OF THE MAIN PROVISIONS OF THE REVISED BILL BANZHAF PROPOSES:

No employee of a fast food chain outlet shall serve to any child who appears, to a reasonable person, to be under the age of 16 and to be obese, any single food item reported by the company to contain more than 500 calories, nor any meal where the calories in all of the food items in the meal (including any drinks, but not including sauces not provided at the counter) as reported by the company exceed 1000 calories.

However, all such food items may be served if the child is accompanied by a parent or guardian, or if the child presents a letter or note on the letterhead of a physician, hospital, or other health care entity certifying that he is not obese or that for medical reasons he should be served such food items, or if he or she provides such proof in a form or manner approved by the State Department of Health, including but not necessarily limited to, a wallet-sized card from any of the above sources or from the school which the child attends.

Oy!

Read the full press release here.

Tuesday, August 12, 2008

ADA Revises Nutrition Recommendation for those with Diabetes Bodybuilding tips

I'm still reading through the just released Nutrition Recommendations and Interventions for Diabetes - the 2008 position statement from the American Diabetes Association regarding dietary recommendations for those at risk for or diagnosed with diabetes.

While I finish reading the actual documents and write up what I think of the paper, here are links to what others are saying today:

Jimmy Moore - New 2008 ADA Recommendations Partially Acknowledge Low-Carb Diets

Adam Campbell - Apparently Hell Just Froze Over

Dr. Mary Vernon - HAS THE AMERICAN DIABETES ASSOCIATION SPARKED YET ANOTHER ATKINS REVOLUTION?

Low-Carb Ketogenic Diet - Greater Weight Loss and More... Bodybuilding tips

A neat little study was published in the January 2008 American Journal of Clinical Nutrition - Effects of a high-protein ketogenic diet on hunger, appetite, and weight loss in obese men feeding ad libitum.

In the study, researchers followed seventeen obese men, confined to a metabolic ward, for a month while they consumed either a low-carb ketogenic diet or a moderate carbohydrate diet on an ad libitum basis (eat as much as desired from foods allowed).

Over the course of the study, the protein intake of both dietary regiments was fixed to provide 30% of calories; carbohydrate was restricted to 4% of total calories in the men consuming the low-carb diet and 22% in the men consuming the moderate carbohydrate diet; and fat intake rounded out the calories in each diet with no specific limitation on fat consumption in either.

All meals were prepared and provided as requested by the men and they were allowed to eat whatever they wanted of the allowed foods in each meal with no restrictions other than on their carbohydrate options. The men on the low-carb diet consumed less calories each day on their own and reported higher feelings of satiety while on the diet.

On average, the difference in carbohydrate intake was great - the men on the low-carb diet consumed just 22g of carbohydrate each day, while those on the moderate carbohydrate diet consumed 170g each day. Both levels of intake were significant reductions from baseline, where the men averaged 396g of carbohydrate each day.

Weight loss was greater for the men following the low-carb diet, who averaged a weight loss of 6.34kg (13.95-pounds) compared to the moderate carb diet averaging a loss of 4.35kg (9.57-pounds). Calorie differences between the two groups do not fully explain the greater weight loss in the men consuming the low-carb diet since they ate about 1731-calories a day compared to the men consuming the moderate carb diet consuming about 1898-calories a day. This difference - about 167-calories a day - translates to a month long difference of 5016-calories, or 1.43-pounds....yet the difference between the two groups was 4.38-pounds greater weight loss in those on the low-carb diet.

Digging deeper into the published data we also find that the men on the low-carb diet experienced statistically significant improvements in blood glucose, insulin and HOMA-IR, as well as favorable improvements in their cholesterol levels with a reduction in total cholesterol and LDL, an increase in HDL and a significant reduction in triglycerides.

All of these favorable changes occured while the men consumed a dietary fat intake similar to that at baseline. Where at baseline they consumed an average of 126g of total fat with 43.8g of saturated fat, their dietary intake while following low-carb didn't change much - they averaged 129g of total fat on the low-carb diet and 46.3g of saturated fat. This basically highlights that modifying one's diet to be low-carb does not mean one suddenly increases dietary fat consumption significantly - in this trial, dietary fat was pretty much the same compared to baseline.

So, with this study, we have one more to add to the pile that supports carbohydrate restriction for satiety, ad libitum-spontaneous calorie reduction, weight loss, improvements to glucose, insulin and insulin resistance, along with favorable improvements (although not statistically different from the moderate carbohydrate diet) to lipids.

Low-GI Diet for 1-year Suggests Improvements for T2DM? Bodybuilding tipsM?

As I was browsing through the January issue of the American Journal of Clinical Nutrition this weekend, a perspective written by John Miles caught my attention. In his article, A role for the glycemic index in preventing or treating diabetes, he wrote, "Elsewhere in this issue of the Journal, Wolever et al (7) report the results of the Canadian Trial of Carbohydrates in Diabetes (CCD). Patients with well-controlled type 2 diabetes who were treated with diet alone were randomly assigned to receive either a high-GI diet, a low-GI diet, or a low-carbohydrate, high-monounsaturated fat diet for 1 y.

The study was carefully conducted and of longer duration than many earlier trials. The investigators found no weight loss and a small increase in glycated hemoglobin (HbA1c) in all 3 groups. This increase in HbA1c is what one would expect with no intervention (8). The fact that glucose concentrations 2 h after an oral glucose challenge were significantly lower in persons who had followed the low-GI diet for 1 y than in those who followed the other 2 diets for 1 y suggests improvement in either insulin sensitivity or insulin secretion (or improvements in both)."

Sounds like a compelling study, so intrigued, I clicked open the study mentioned, The Canadian Trial of Carbohydrates in Diabetes (CCD), a 1-y controlled trial of low-glycemic-index dietary carbohydrate in type 2 diabetes: no effect on glycated hemoglobin but reduction in C-reactive protein, and read the abstract.

In it, researchers concluded "In subjects with T2DM managed by diet alone with optimal glycemic control, long-term HbA1c was not affected by altering the GI or the amount of dietary carbohydrate. Differences in total:HDL cholesterol among diets had disappeared by 6 mo. However, because of sustained reductions in postprandial glucose and CRP, a low-GI diet may be preferred for the dietary management of T2DM."

Here I was even more intrigued - a study trial comparing three different dietary approaches, and one low-carb for a year?

But I wondered, how was it that the low-carb diet didn't do as well as other studies would suggest it should have?

Wanting to know this, I opened the full-text to understand how it was possible that greater improvement was not found in the "low-carbohydrate" subjects and why HbA1c didn't remain stable or improve in the course of one year with either low-GI or low-carbohydrate diets. Previous study data published by others would suggest that HbA1c would at least remain stable with low-carb, no?

Well, it took no more than five minutes to fully see why things turned out as they did - the "low-carbohydrate" diet was not a low-carbohydrate diet afterall - at baseline the subjects assigned the low-carb diet ate an average of 210g of carbohydrate each day and during the low-carb diet consumed an average of 199g of carbohydrate each day.

Hello? In whose fantasy world is 199g of carbohydrate each day a low-carb diet?

Ah, but I digress...

While the researchers took pains to measure many risk factors, at the end of the year, the subjects in every group experienced progression of their diabetes risk factors - there simply was no improvement to laud in this trial, no matter how you twist the data.

What's absolutely disappointing in how the findings are presented is that the researchers honed in on two measures of improvement - CRP and post-prandial glucose - to the exclusion of significant declines in other measures that are critically important for those with type II diabetes.

Where do I even begin?

Weight remained fairly stable in all three groups, with only the low-GI group actually gaining some weight, despite no meaningful difference in calorie intake from baseline through one year on the low-GI diet.

Worse though is the lack of critical thought around the marked and significant increase in waist circumference in all three diet groups.

The high-GI group started with a waist circumference of 99.1cm - it increased over the year to 103.1cm (+1.6 inches) - this despite stable weight on the scale (84.4kg at baseline; 84.3kg after 1-year on the diet).
The low-GI group started with a waist circumference of 98.3cm - it increase over the course of the year to 104.9cm (+2.6 inches). They also experienced a weight gain, going from 81.1kg at baseline to 83.9kg at the end of the study (+6.2-pounds gained).
The supposed "low-carbohydrate" group - eating 199g carbohydrate on average - started with a waist circumference of 98.6cm - it increased over the study period to 103.1cm (+1.8-inches) - like the high-GI group, this increase was despite a stable scale weight...they started at 84.7kg and ended the year at 84.3kg.

If that wasn't bad enough - all three groups experienced increases in their HbA1c too.

Those consuming a high-GI diet saw a rise from 6.2 to 6.34; low-GI saw a rise from 6.2 to 6.34; and those on the supposed low-carb diet rose from 6.1 to 6.35.

Over time the researchers reported that this rise was statistically significant - and I'd say clinically significant too!

Now with just these risk measures, you'd think there was enough to maybe, just maybe, inspire the researchers to challenge the efficacy of any of the above diets for those with type II diabetes. Maybe even say that perhaps the level of carbohydrate - despite quality or glycemic index or load improvements - matters; that simply modifying the type of carbohydrate in the diet does NOTHING for glycemic control and if carbohydrate is consumed habitually at levels seen in this study, perhaps someone with type II diabetes should expect a continued progression of their disease?

But, ya know what? They didn't even consider that. And the above problems were not all they reported either.

Let's see what else was reported in the data:

Total cholesterol didn't do much in any of the groups; LDL didn't change significantly in any group....HDL however declined in the low-GI group, but rose in the high-GI and supposed low-carb groups.

Triglycerides fell slightly in the high-GI and supposed low-carb groups, but rose in the low-GI group.

Two more markers of potential health risks found to be problematic in the low-GI diet over a year - and the researchers even noted it in the full-text - "With the low-GI diet, mean triacylglycerol was 12% higher, HDL was 4% lower, and the ratio of apoB to apoA was 4% higher than with the low-CHO diet

But a 12% increase in triglycerides and a 4% drop in HDL didn't set off any alarm bells either.

Neither did the fact the low-GI group saw an increase in their fasting plasma glucose over the year, which was also noted and basically disregarded.

With regards to the main focus in the abstract, C-Reactive Protein, the researchers did find a significant difference between the low-GI diet and the high-GI diet, but also noted that between the low-GI diet and the supposed "low-carb" diet there was no significant difference.

Yet, they chose to focus on the low-GI diet as better for a type II diabetic, despite the fact it led to

weight gain
waist circumference increase
increase in HbA1c
increase in fasting plasma glucose
a marked rise in triglycerides
and a decline in HDL

The conclusion here speaks volumes when taken in context to the carbohydrate intake in each group, "In subjects with T2DM managed by diet alone with optimal glycemic control, long-term HbA1c was not affected by altering the GI or the amount of dietary carbohydrate."

Better stated might be, with no meaningful change in absolute carbohydrate consumption, even with improvement in quality of carbohydrate - it is likely a type II diabetic will experience progressive decline in glycemic control along with other declines in risk factors over a year.

The data is published right in the full-text - the glycemic index as a means to reverse or prevent diabetes is no solution.

In this study, those who followed the low-GI diet had the worst overall outcome - they gained weight, increased waist circumference, saw triglycerides rise while HDL fell, and experienced a decline in glycemic control as evidenced by their increased HbA1c.

Yet you wouldn't know it from the abstract which focuses instead on "sustained reductions in postprandial glucose and CRP" and then concludes that "a low-GI diet may be preferred for the dietary management of T2DM."

And then back to the article from John Miles, who said this study "suggests improvements" in those who followed the low-GI diet for one year. Who's he kidding?

ADA Says Low-Carb Okay for Weight Loss, So What? Bodybuilding tips

An article published today in Diabetes Health, ADA Now Supports Low-Carb Diets, reminded me that I have not yet posted my thoughts on the updated guidelines for Medical Nutrition Therapy (MNT) recently issued by the American Diabetes Association (ADA). This will probably be longer than usual, so bear with me!

On December 28, 2007, the ADA issued a press release to highlight the publication of and changes within their clinical practice recommendations, better known as the Standards of Care in Diabetes.

Each year the guidelines are updated and this year was no exception - as noted in the press release, "Until now, the ADA did not recommend low carbohydrate diets because of lack of sufficient scientific evidence supporting their safety and effectiveness. The 2008 Recommendations include a statement recognizing the increasing evidence that weight-loss plans that restrict carbohydrate or fat calorie intake are equally effective for reducing weight in the short term (up to one year). The "Standards of Medical Care in Diabetes--2008" document reviews the growing evidence for the effectiveness of either approach to weight loss. In addition, there is now evidence that the most important determinant of weight loss is not the composition of the diet, but whether the person can stick with it, and that some individuals are more likely to adhere to a low carbohydrate diet while others may find a low fat calorie-restricted diet easier to follow."

There are two main issues I'll look at in the above statement today:

1. that low-carbohydrate diets are as effective as low-fat calorie restricted diets for weight loss for up to one-year

2. that composition of diet is less important than whether a person can stick with the dietary approach for weight loss.

In order to fully understand exactly what the ADA is saying with regard to the first issue, we need to return to the August 2006 issue of Diabetes Care, where an updated consensus statement was published, Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy: A consensus statement from the American Diabetes Association [ADA] and the European Association for the Study of Diabetes [EASD]

As I noted in my review of that consensus statement "Rather than question the dietary recommendations, or explore emerging data supportive of dietary interventions that are different from the recommendations, the statement instead concludes that "the limited long-term success of lifestyle programs to maintain glycemic goals in patients with type 2 diabetes suggests that a large majority of patients will require the addition of medications over the course of their diabetes."

The final sentence in the section discussing medications, which followed the section on lifestyle intervention, sets the stage for what is to come, "addition of medications is the rule, not the exception, if treatment goals are to be met over time."

In August 2006 the ADA, along with the EASD, threw up their hands and decided that dietary and lifestyle intervention was futile, therefore the only logical place to go was intensive pharmaceutical intervention at diagnosis.

The authors wrote, in the paper's conclusion, "We now understand that much of the morbidity associated with long-term complications can be substantially reduced with interventions that achieve glucose levels close to the nondiabetic range. Although new classes of medications, and numerous combinations, have been demonstrated to lower glycemia, current-day management has failed to achieve and maintain the glycemic levels most likely to provide optimal health care status for people with diabetes."

On this the ADA remains steadfast - pharmacological intervention is the first step with lifestyle intervention upon diagnosis. The freely available full-text of the Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy clearly continues with the August 2006 consensus that lifestyle intervention for those diagnosed with diabetes will not work, therefore medication must be initiated upon diagnosis.

Yet we find the ADA falling all over itself to tout its position change for weight loss - that now a low-carbohydrate diet is considered as effective as a low-fat calorie restricted diet for weight loss? And somehow we're supposed to be jumping for joy that they made this change?

If we take the entire package of documents published in the Diabetes Care Supplement, we cannot reach any conclusion other than the ADA has made up its mind and is not going to review the evidence. They may concede that a low-carbohydrate diet can help with some loss of weight, but nothing else - and even that carries the caveat that one must be intensely monitored if they do decide to follow a low-carb diet.

But, going back to the first point - the concession that low-carbohydrate diets and low-fat calorie restricted diets are both effective for weight loss over the short-term.

Quite frankly this statement by the ADA is meaningless when we consider the full context of their position because they hold that "current-day management has failed to achieve and maintain the glycemic levels most likely to provide optimal health care status for people with diabetes."

While many lauding the change as a step in the right direction for the ADA, I'm not impressed, nor convinced - if anything, the ADA only confirmed what they've already said previously.

We only need to go back to the publication of a 22-month study, in which diabetic subjects were found to have significant health improvements following a low-carbohydrate diet, to read the ADA reaction in an article at WebMD - "While agreeing that carbohydrate restriction helps people with type 2 diabetes control their blood sugar, ADA spokesman Nathaniel G. Clark, MD, tells WebMD that the ADA does not recommend very low-carb diets because patients find them too restrictive. "We want to promote a diet that people can live with long-term," says Clark, who is vice president of clinical affairs and youth strategies for the ADA. "People who go on very low carbohydrate diets generally aren't able to stick with them for long periods of time."

Which brings us to issue two above - diet composition does not matter as much as a diet one can follow, a theme the ADA has been hot and heavy on for at least two years now.

Let's review the sentence in the ADA press release carefully, "In addition, there is now evidence that the most important determinant of weight loss is not the composition of the diet, but whether the person can stick with it, and that some individuals are more likely to adhere to a low carbohydrate diet while others may find a low fat calorie-restricted diet easier to follow."

Evidence? What evidence?

The Standards of Medical Care in Diabetes 2008 includes this sentence, "Although numerous studies have attempted to identify the optimal mix of macronutrients for meal plans of people with diabetes, it is unlikely that one such combination of macronutrients exists. The best mix of carbohydrate, protein, and fat appears to vary depending on individual circumstances. For those individuals seeking guidance on macronutrient distribution in healthy adults, the Dietary Reference Intakes (DRIs) may be helpful;" referencing the IOM documents published back in 2002.

The Nutrition Recommendations and Interventions for Diabetes: A Position Statement of the American Diabetes Association 2008 includes "Nutrition counseling should be sensitive to the personal needs, willingness to change, and ability to make changes of the individual with pre-diabetes or diabetes. (E)"

Note with that the letter "E" assigned to it, classing it as "expert opinion" - so again, where is the evidence? Each study referenced dates between 1997 and 2004 - so what exactly is the new evidence alluded to in the updated documents?

Oh, that's right, there is NONE...this is simply an opinion and has already been stated numerous times before.

I've said it before, "evidence versus sophistry; with just enough opinion thrown in to ensure glycemic control remains elusive..."

The ADA refuses to acknowledge that diabetics deserve clear statements about how to achieve normal blood sugars, and instead continues headlong on this path that they somehow deserve to eat like anyone else in the population and can mediate the effects of carbohydrate-rich food with medications.

:::sigh:::

So yeah, the ADA now says one can try a low-carbohydrate diet for weight loss, for the short-term (up to 1 year) and that some will somehow manage to follow such a diet. But let's not forget, if you do decide to follow a low-carbohydrate diet, you're also going to be subjected to much more intense monitoring than your low-fat calorie restricted peer and you're left with no advice other than the same-old same-old once your year is up.

Then what?

The failed ADA diet?

Lifelong medication with continued stepped-up pharmaceutical requirements with each passing year until you're dependent upon insulin injections?

The ADA, even with this new position that a low-carbohydrate diet may be used for up to one year for weight loss, still continues to fail in their mission - to prevent and cure diabetes and to improve the lives of all people affected by diabetes - because they refuse to actually review the hard data available; and instead continue in this sophistry that dietary recommendations need to be based upon what one wants to eat rather than what one should eat based upon metabolic, hormonal and physiological facts.

Animal products are ‘whole foods,' too Bodybuilding tips

Dana Carpender's latest - I couldn't have said it better myself!

Animal products are 'whole foods,' too
Dana Carpender

The nutritional buzz phrase is 'whole foods.' This is encouraging. I've been watching the nutrition scene long enough to remember when people who insisted that whole-grain bread was more nutritious than enriched bread were scorned as 'food faddists.'

But the admonitions to eat whole foods seem to apply only to grains, fruits and vegetables. Officialdom still recommends discarding large fractions of animal foods. Yet few see these fractionated animal foods as the refined, depleted foods they are.

Take dairy. Virtually all recommendations for dairy products include the qualifiers 'low-fat' or 'fat-free.' But that's not the way it comes out of the cow. Yes, whole milk has more calories than skim. It also has far more vitamin A, because it's carried in the butterfat. (Some skim milk is fortified with vitamin A —- the equivalent of adding a few vitamins back to nutritionally depleted white flour.) Because fat aids in calcium absorption, you'll get more calcium from whole milk. Whole milk from grass-fed cows supplies CLA, a fat that increases fat-burning and reduces heart disease and cancer risk, and omega-3 fats, which reduce inflammation, and heart disease and cancer risk. It is worth paying premium prices for such milk.

And eggs. Oh, poor eggs. There they are, just about the most perfect food in the world, and what do people do? They throw away the yolks. The part with almost all the vitamins, including A, E, K and the hard-to-come-by D, not to mention brain-enhancing choline and DHA. Eggs from pastured chickens also have yolks rich in omega-3. Better to throw away the whites, not that I'd recommend that, either. Just eat whole eggs, will you?

Then there's chicken. When did 'chicken' become synonymous with 'boneless, skinless chicken breast?' Chicken breast is a good food, but the whole chicken is better. Dark and white meats both have nutritional strengths. They are not identical in vitamin and mineral content. Chicken skin is a good source of vitamin A, again because it's fatty. I wrote recently about liver's nutritional bonanza, and hearts are nutrient-rich as well, making giblet gravy a great idea. Simmering the leftover chicken bones yields flavorsome broth rich in highly absorbable calcium and joint-building gelatin. (I save my steak bones, too, for beef broth.)

Our ancestors, ever mindful of where their next meal was coming from, relished every edible part of every animal they killed. Indeed, paleoanthropologists assert that hunter-gatherers ate the rich, fatty organ meats first, preferring them to muscle meats, and smashed bones to eat the marrow. As recently as a century ago, marrow was such a popular food that special spoons were made for scooping it out of bones. I love the stuff. I've been sucking the marrow out of lamb-chop bones since I was a tyke. A 1997 article in the journal Nature asserts that human brain capacity decreased at the dawn of agriculture 10,000 years ago, very likely because of a reduction in animal-fat consumption. Whole animal foods are part of our nutritional heritage.

My low-carbohydrate eating habits are often referred to as a 'fad.' Whatever. If it was good enough for my hunter-gatherer ancestors, it's good enough for me. Do you want to know what's really a fad? Removing the fat from milk and the yolks from eggs, and discarding three- quarters of the chicken, all organ meats and most bones. There's not a culture in the world where our narrow, refined, low-fat, flavorless versions of animal foods are part of the traditional diet.

Continuing reading for recipe included in original article!

Two-Fold Reduction in Triglycerides! How? Low-Carb! Bodybuilding tips

In a recent study - Metabolic Effects of Weight Loss on a Very-Low-Carbohydrate Diet Compared With an Isocaloric High-Carbohydrate Diet in Abdominally Obese Subjects, published in the Journal of the American College of Cardiology, researchers reported favorable results for obese adults randomly assigned a low-carbohydrate diet for 24-weeks (six months).

As reported in heartWire, "After six months, isocaloric energy-restricted very-low-carbohydrate, high-fat and high-carbohydrate, low-fat diets produced similar weight loss and substantial reductions in a number of cardiovascular disease risk markers," write Jeannie Tay (Flinders University, Adelaide, Australia) and colleagues in the January 1, 2008 issue of the Journal of the American College of Cardiology.

"Neither diet displayed adverse effects, suggesting diverse dietary patterns, including very-low-carbohydrate, high-fat diets, may be tailored to an individual's metabolic profile and dietary preference for weight management."

The investigators note that while the traditional diet reduced LDL-cholesterol levels, the low-carbohydrate, high-fat diet resulted in greater increases in HDL cholesterol and singificantly larger reductions in triacylglycerol levels (a two-fold greater reduction compared to the traditional low-fat diet).

In fact, if we go to the full-text, we find the researchers went so far as to write "consistent with other recent studies, the VLCHF (very-low-carb high-fat) diet produced greater reductions in TAG and increases in HDL-C than the HCLF (high-carbohydrate low-fat) diet. This suggests that the VLCHF diet as a weight loss strategy may confer the greatest clinical benefits in patients who present with hypertriglyceridemia, low HDL levels, abdominal adiposity, and insulin resistance"

Did you catch that - "greatest clinical benefits" - part?

In the paper we learn that subjects were randomly assigned to either of the moderately energy-restricted diet plans for 24 weeks. For those assigned to the very-low-carbohydrate, high-fat diet, 4% of total calories were obtained from carbohydrates, 35% from protein, and 61% from fat, including 20% of total calories from saturated fat. Subjects randomized to the high-carbohydrate, low-fat diet followed a more traditional macronutrient profile, with 46% of calories obtained from carbohydrates and 30% from fat, including <8% from saturated fat.

Now we all know the American Heart Association insists we must keep saturated fat at less than 7% of our calories because intakes higher than that will kill us (eye roll) - yet here we have stunning improvements with saturated fat intake at/above 20% daily for six months! If you haven't read it yet, Dr. Richard Feinman wrote a good article about saturated fat recently.

So, what gives? It seems the subjects in this study significantly reduced their carbohydrate, and that carbohydrate does matter. Also, this study confirms previous data published that found similar improvements in those restricting carbohydrate.

Slowly but surely more data is coming forward that validates carbohydrate restriction for not only weight loss, but health improvements!

Insulin Resistance and Cardiomyopathy Bodybuilding tips

An interesting abstract was published in the recent issue of the Journal of the American College of Cardiology - Insulin-Resistant Cardiomyopathy, Clinical Evidence, Mechanisms, and Treatment Options.

Increasing evidence points to insulin resistance as a primary etiologic factor in the development of nonischemic heart failure (HF). The myocardium normally responds to injury by altering substrate metabolism to increase energy efficiency. Insulin resistance prevents this adaptive response and can lead to further injury by contributing to lipotoxicity, sympathetic up-regulation, inflammation, oxidative stress, and fibrosis.

Animal models have repeatedly demonstrated the existence of an insulin-resistant cardiomyopathy, one that is characterized by inefficient energy metabolism and is reversible by improving energy use. Clinical studies in humans strongly support the link between insulin resistance and nonischemic HF.

Insulin resistance is highly prevalent in the nonischemic HF population, predates the development of HF, independently defines a worse prognosis, and predicts response to antiadrenergic therapy.

Potential options for treatment include metabolic-modulating agents and antidiabetic drugs. This article reviews the basic science evidence, animal experiments, and human clinical data supporting the existence of an "insulin-resistant cardiomyopathy" and proposes specific potential therapeutic approaches.

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Too bad the researchers didn't include a carbohydrate restricted diet in their list of potential treatment options!

Friday, August 8, 2008

Protein Provides Satiety Through PYY Bodybuilding tips

In our strange world, we have researchers now promoting the idea that a pharmaceutical version of the gut hormone PYY may offer a solution to help individuals lose weight.

In the MSN article, Natural Gut Hormones May Provide a Treatment for Obesity, we learn that researchers are seeking to develop a pill to provide the satiety hormone PYY.

"The advantage of developing weight loss medications based on gut-derived satiety hormones is that they enhance a process that occurs naturally. It is expected, therefore, that side effects will be minimal," says Dr Sainsbury-Salis.

Folks, we're not PYY deficient; in fact, I'd argue we're not eating the foods that stimulate PYY to effectively sate appetite naturally.

As I noted in a previous blog post about research investigating PYY, "A high protein diet led to spontaneous calorie reduction as PYY increased. The phenomenon was consistent with both the animal model using mice and in human studies used to validate the mice model. Over a longer term, the higher protein diet stimulated weight loss and enhanced PYY synthesis and secretion in mice."

As I noted in that post, the study I wrote about included quite specific detail about how diet influences the release of PYY in humans - "The ready availability of carbohydrate-rich grains and cereals has been a recent development in human nutrition with the onset of organized agriculture. Many of the physiological systems that regulate food intake were probably established and may function better under lower-carbohydrate and higher-protein dietary conditions."

Those were not my words, but the words of the researchers!

And now we have researchers looking to design a pill to provide what we already have naturally - if we eat adequate protein and fat. But, let's not go there and discuss diet, let's just pop a pill and continue along with the supposed "healthy diet" that obviously is not sating out appetite!

Calorie Counting: A Hard Sell Bodybuilding tips

The results of a survey conducted by the International Food Information Council were presented at the American Farm Bureau Federation's annual conference. The highlights and findings were discussed in an article in the Voice of Agriculture, in which we learn "42 percent of survey respondents feel that the food and health information they receive from various sources is contradictory. Slightly more than 30 percent said it was inconsistent."

Rachel Cheatham, Director of Science and Health Communications for the IFIC says "This really is the issue, [t]here is an overload of information. How do we package this information so that people understand it and know what to do with it?”

The survey results found that "very few people understand or apply the concept of energy balance, in which calories consumed and calories used are treated as an equation that results in weight maintenance, or depending on the individual’s goals, weight loss or gain. Almost half of the survey respondents said they don’t balance the calories they take in with the calories they use, while 16 percent said they do increase their exercise to compensate for eating more than usual."

I have to say I'm not surprised - it's simply not natural for us to be so calorie obessed, to the point where we are ever aware of the calories were eating each day - so it's no wonder that most people don't make it a point to "balance" calories in and calories out each day!

The article however makes this an issue of selling the concept to consumers rather than questioning its validity; "calorie counting is a hard sell."

For some reason we are stuck in this thinking that the problem isn't the concept, but the execution. If it were only that easy. If it were only a matter that people don't get it and more education would lead to better compliance. If it were only a matter of calories in and calories out, and just following a recipe to eat x-servings of this and y-servings of that each day to remain within prescribed calorie intake.

I've said it many times before - the flaw is in the recommendations, not in those trying to follow them! It's more than just calories, and rather than try to sell consumers on an unnatural way of eating each day, perhaps time is better spent understanding how modification of the macronutrients (carbohydrate, protein and fat) can lead to spontaneous reduction of calorie intake without counting calories.

Until the powers that be begin to address the role of nutrients and micronutrients on hunger and satiety, on nutritional status, and on health and well-being, little is going to change.

Afterall, the thinking goes that it remains the fault of the individual to not follow the recommendations rather than the recommendations failing to live up to expectations and provide the necessary nutrients and satiety to be followed long-term successfully.

I've said before, "The failure of the dietary recommendations are no small matter, various agencies go to great pains to explain away the long-term failure and wind up making the issue one of personal failure rather than admit the flaw is in the recommendations."

If you'd like to read more on the issue of our flawed recommendations, two previous articles provide greater depth on the subject:

Fatally Flawed Health & Risk Paradigms
Fatally Flawed Health & Risk Paradigms 2

What if Willpower Matters Little in the Long-Term for Weight? Bodybuilding tips

In my last post I noted that the idea of counting calories to maintain a balance between calories in and calories out is an unnatural state of being. Yet is it exactly what is promoted, has been promoted for decades, and increasingly is being promoted in what could be considered a 'cradle to grave' approach, where even children are being subjected to messages designed to make them ever aware of calories in, calories out - if they gain weight, it's obviously their fault that they didn't get it right.

As I said in my previous post, "For some reason we are stuck in this thinking that the problem isn't the concept, but the execution."

Some lively discussion in the comments followed, as well as a good number of emails - with most boiling down to four main themes - any type of restriction is difficult, counting carbohydrates is as unnatural as counting calories, most people won't eat just whole, natural foods and most people won't do what it takes anyway.

How depressing!

But I definitely understand the points made, and think at least opening a discussion on the issue has value for the future.

Afterall, we can safely say, based on the evidence available, almost every weight loss diet dreamed up in the last century works - data clearly shows that calorie restriction, dietary fat reduction, carbohydrate restriction, increasing protein, manipulating glycemic index or glycemic load, using shakes and meal replacements, fasting approaches, and even weight loss surgery all enable an individual to lose weight.

The diet or medical intervention one utilizes does not matter all that much - they all work for weight loss - so to say one approach is better than the other for weight loss truly has little value for long-term success to maintain weight loss.

Weight loss isn't the problem - keeping the weight off afterward is the really critical issue that we continue to fail to address in a meaningful way to actually see long-term results.

Oh, don't get me wrong, the diet industry, along with the medical and research communities talk a good story, point to data from those few who manage to maintain their weight loss in a national registry, and repeat again and again that failure comes down to lack of willpower in the individual. If only a person would continue, for the long-term, the dietary principles they utilized to lose the weight, they would not gain back the weight lost.

As Sandy Szwarc said in a Junkfood Science post early last year, "Only long-term results, after weights have stabilized, are relevant when evaluating any diet and, more importantly, any actual impact on health outcomes."

While I don't always agree with Sandy's take on things, or her conclusions, she is well known for taking an evidence-based approach in her writing and on this issue I agree 100% - not because everything she wrote in the above linked article was spot-on, but because she stated something so obviously ignored in the current urgency to do something about the "obesity epidemic" that seems to have no workable long-term solution.

The rising incidence of obesity in the United States is not new - for decades now we've watched as each year more and more of our population is classified as overweight or obese; and it does not appear to be reversing, despite the continuous messages to eat less and move more, be aware of calories in and calories out, just do it and stick to it.

Oddly it seems, the louder the messages get, the fatter the population grows.

Yet, while it's acknowledged that in the long-term dieting doesn't seem to result in long-term weight stabilization and maintenance, few are asking why.

Instead we're left with the idea that all these tens of millions of people who lose weight on a diet lack the willpower and resolve to maintain a healthy-balanced diet in the long-term.

It's the failure of the individual not the dietary principles they're told work - as I said before, the failure is not the concept, but the execution.

Every single year, tens of millions of people set out to lose weight and the vast majority do lose weight - they celebrate, buy new clothes, enjoy high self-esteem, are empowered by their success and feel great.....and then are just too damn weak, so they eat themselves back to where they started?

Is this not where the idea that it's a lack of willpower takes us?

If it's not willpower, then what does enable successful weight loss followed my maintenance and improved health outcomes in the long-term?

Before embarking on an exploration of this issue next week, I'd like to hear from readers about their experiences - success and failure - and what ultimately you've learned over the years? If you had to give advice on how to maintain weight loss for the long-term, what would you suggest based on your experiences?

Message in the Dryer: Lose Weight Bodybuilding tips

The Ad Council and the U.S. Department of Health and Human Services are placing tiny T-shirts in dryers throughout New York City, urging laundry-doers to “Shrink a few sizes.”

Ouch!

The campaign, done pro bono by McCann Erickson, sends the presumed to be overweight or obese to HHS’s Smallstep site, where they are further encouraged to “shed those holiday pounds, reduce their risk for obesity and lead a healthy lifestyle,” according to the press materials.

So now the government thinks shaming people is going to make them lose weight?

I'll be back Thursday Bodybuilding tips

Poor Math Skills Leading to Weight Gain? Bodybuilding tips

Wednesday, August 6, 2008

Bill Introduced to Mandate Restaurants Deny the Obese Service Bodybuilding tips

Estimated 10% of Teens in US Have Metabolic Syndrome! Bodybuilding tips

a waist circumference at or above the 90th percentile for age and sex;
blood pressure at or above the 90th percentile;
a high triglyceride level at or above 10 mg/dL;
a low HDL cholesterol level at or above 40 mg/dL;
and an impaired glucose metabolism at or above 100 mg/dL (pre-diabtes)

This is pretty disturbing when we consider the last time such data was reviewed, back in 2003 (using earlier-years NHANES data), it was found that 4% of teens met the difinition of MetS above.

The bottomline is that no matter how you slice and dice the data, there is a rising prevalence of metabolic syndrome among teens in the United States.

Tweaking the Don't Feed the Obese Bill Bodybuilding tips

PETA in the Ring to Deny Obese Food (unless it's vegan) Bodybuilding tips

February 5, 2008

Jackson, Miss. - A provocative bill introduced by state representative W.T. Mayhall Jr. that would bar Mississippi restaurants from serving obese people has captured PETA's attention, but the group is suggesting an amendment. The animal rights group thinks it can do HB282 one better: instead of refusing to serve overweight people altogether--something that would raise the ire of restaurants and patrons alike if the bill were actually passed and implemented--PETA is proposing that restaurants be required to serve only healthy vegan meals to consumers who are struggling with their weight.

Citing research studies that show that vegans and vegetarians are much thinner on average than their meat-eating counterparts, PETA points out that most vegan foods are naturally high in fiber (there is none in meat and dairy products), and low in fat and contain zero cholesterol (which is only found in animal products).

"There's no reason to starve fat people--they just need to pile their plates with healthy, vegan food," says PETA Vice President Bruce Friedrich. "Vegan meals like hearty vegetable casseroles, bean burritos, and pasta with mushrooms, tomatoes, and green peppers not only are satisfying but will slim you right down too."

PETA's letter to Rep. Mayhall follows:

February 5, 2008

The Honorable W.T. Mayhall Jr.
Mississippi House of Representatives

Dear Representative Mayhall:

On behalf of PETA's more than 1.8 million members and supporters, I am writing to commend you for your creative effort to combat the obesity epidemic in Mississippi. I'd also like to suggest a change to HB282 that we think would make it truly effective.

Changing the bill slightly would not just make a point--it could actually address (and even solve) Mississippi's obesity epidemic rather than simply generating a discussion about it.

Instead of refusing to serve obese people, restaurants could be required to serve them only vegan dishes. Vegan food is not only delicious and satisfying, but overwhelming scientific evidence shows that vegans and vegetarians are far less likely to be overweight than meat-eaters. Vegans are also far more likely to be in better overall health because, among other things, vegan foods contain no cholesterol and lots of fiber, the complete opposite of meat- and dairy-based meals. The American Dietetic Association--the nation's largest group of nutrition professionals--reviewed hundreds of studies and concluded that vegetarians have lower rates of obesity, heart disease, diabetes, and certain types of cancer than people who eat meat.

A U.S. government review of studies on weight loss found that two-thirds of dieters gain back all the weight they've lost within a year, and a whopping 97 percent gain it all back within five years. The only weight-loss plan that has been proved to take weight off--and keep it off--for more than a year is a vegan diet. Most vegan foods are naturally low in fat, so quantity and calorie restrictions are often unnecessary. Obese people can still eat the portions that they're used to while watching pounds slip away and good health return!

Please contact me at 757-622-7382 if you have any questions. Thank you for your consideration. Please accept PETA's best wishes for good health (and trim waistlines) for all Mississippi residents.

Sincerely,

ACCORD Trial Mess Bodybuilding tips

...a major federal study of more than 10,000 middle-aged and older people with Type 2 diabetes has found that lowering blood sugar actually increased their risk of death, researchers reported Wednesday.

It's hard to make heads or tails of what happened as the actual data has not been released - we're left to read through press reports and information provided by the NIH to try to determine what went wrong in the trial. Everyone seems to be bending over backward to get the message across that the intensive drug therapy - a large number of pharamaceuticals taken together - had nothing to do with the higher incidence of death in the trial.

But one must really wonder!

Speculation abounds, but that hasn't stopped some from foisting out the idea that it is the lowering of blood sugars to normal ranges that was the problem, not the means utilized to do it.

Dr. Irl Hirsch, a diabetes researcher at the University of Washington, said the study’s results would be hard to explain to some patients who have spent years and made an enormous effort, through diet and medication, getting and keeping their blood sugar down.

They will not want to relax their vigilance, he said.“It will be similar to what many women felt when they heard the news about estrogen,” Dr. Hirsch said. “Telling these patients to get their blood sugar up will be very difficult.”

Call me crazy, but didn't this study throw every pharmacuetical intervention at these folks?

Perhaps the problem wasn't the lowered blood sugars, but toxicity and side-effects from massive drug therapy to acheive a lower blood sugar level?

“Many were taking four or five shots of insulin a day,” he said. “Some were using insulin pumps. Some were monitoring their blood sugar seven or eight times a day.”

They also took pills to lower their blood sugar, in addition to the pills they took for other medical conditions and to lower their blood pressure and cholesterol. They also came to a medical clinic every two months and had frequent telephone conversations with clinic staff.

What this trial lacked was a control group utilizing an effective, non-pharmaceutical approach - a carbohydrate restricted diet - to lower blood sugars and A1c, which would have resulted in less medication, not more to achieve glycemic control.

If and when the data is published, I'll update - but for now think it highly irresponsible of anyone to speculate that it was simply the lowering of blood sugars that caused the problem given the wide variety and large number of medications used to intensively reduce blood sugars; and worse is to suggest that those with type 2 raise their blood glucose levels!

More Weight Gained Over 6-Years on Low-Fat Diet Bodybuilding tips

Last week I posted about our collective belief, as a nation, that weight loss and maintenance is a problem solved by simple math - balance the "in" with the "out" columns of the calorie ledger and weight will be lost when the "out" exceeds the "in" and will be maintained when the two are equal.

Or so we're told.

I threw out the idea that weight isn't simply about math, but about chemistry.

The latest issue of the American Journal of Clinical Nutrition is out, and within is a very intriguing study where this very issue was central to the research conducted. It's one piece of the "weight is chemistry" equation, so let's take a look.

In the study, A novel interaction between dietary composition and insulin secretion: effects on weight gain in the Quebec Family Study, researchers followed subjects for six years to see what effect, if any, levels of insulin secretion had on weight.

The objective was to "determine whether physiologic differences in insulin secretion explain differences in weight gain among individuals consuming low- and high-fat diets."

This interest to investigate such was born from clinical trials where subjects consumed low-fat diets where results often revealed that there are huge variations between individuals consuming similar dietary ratios of macronutrients and reported calories; these differences are often chalked up to psychological and behavioral factors - motivation, compliance with diet, under-reporting of foods consumed, etc., ignoring the possibility that there is a physiological variation that may be at work.

In this study, the researchers noted the findings of Dansinger et al who compared four dietary approaches (Atkins, Ornish, LEARN and Zone), noting that "Of those assigned to the Ornish very-low-fat diet, mean weight loss was again small, 2 kg, but individual weight change ranged from almost –30 kg to >10 kg. This interindividual variation is commonly attributed to differences in motivation and compliance, but biological factors may also be contributory."

Thus the researchers in this study considered the the following for a test hypothesis: Low-fat diets are inherently high in carbohydrate because, for most people, the third major nutrient, protein, remains within a fairly narrow range. Carbohydrate has the most potent effect on insulin secretion of the major nutrients. Therefore, individuals with high insulin secretion consuming a low-fat diet might be especially susceptible to weight gain.

To investigate this, they "examined the associations between insulin concentration at 30 min (insulin-30) during an oral-glucose-tolerance test (OGTT) and change in body weight or waist circumference in the Quebec Family Study (QFS)" over a period of six years."

The findings were very interesting.

The primary findings of this study are that a proxy measure of insulin secretion strongly predicted weight gain and change in waist circumference over 6 y in adult whites, especially among those consuming lower-fat diets.

...our results and those involving GI suggest the existence of a unique physiologic phenotype that responds poorly to high insulin-stimulating diets, regardless of whether these diets are high in carbohydrate or have a high GI. Moreover, the combination of a high-carbohydrate and high-GI diet—that is, a diet high in glycemic load (GL)—may produce especially great weight gain among individuals with this phenotype.

While the researchers reached the conclusion that these findings suggest there exists a "unique physiological phenotype that responds poorly to high insulin-stimulating diets" - such assumes we're supposed to consume a low-fat, high carbohydrate diet; if we're not responding well to such a diet, it's because some have a unique physiological phenotype rather than consuming a diet that is at odds with human physiology.

I'd counter that it's just as likely it has nothing to do with a "unique phenotype" among us, but rather the expected results of a modern diet at odds with our physiology. Minor quibble.

Nonetheless, the finding is important as it points directly to individual metabolic factors playing a role within the context of the diet - low fat verus high fat - not just calories. In this study, it was insulin secretion. It mattered, especially in those consuming a low-fat diet.

What Would You Do? Bodybuilding tips

When the prevailing message fails to achieve its intended aims or achieves the wrong ends, the solution is to...?

And the Answer is... Bodybuilding tips

Steven H. Woolf, MD, MPH, from Virginia Commonwealth University and Marion Nestle, PhD, MPH, of New York University:

"When the prevailing message fails to achieve its intended aims or achieves the wrong ends, the solution is not to abandon the enterprise but to reshape the message to achieve desired outcomes."

There are none so blind as those who will not see Bodybuilding tips

An article in Yahoo News, Fast-food binge harms liver, but boosts good cholesterol: study, caught my attention yesterday. Within the article, which provided details from the findings of a neat little study in Sweden, was an intriguing quote from the lead researcher, Dr. Frederik Nystrom:

"That signs of liver damage were linked to carbohydrates was another key finding, he said.

"It was not the fat in the hamburgers, it was rather the sugar in the coke," he said."

The study?

A sort of duplication of Morgan Spurlock's Supersize Me - Fast food based hyper-alimentation can induce rapid and profound elevation of serum alanine aminotransferase in healthy subjects - in which subjects were to consume two meals a day from fast food restaurants and cease any daily exercise for a month.

Eat a-plenty they did! Where their baseline calorie intake was an average 2273-calories each day, during the study they consumed 5753-calories a day! Not only did they gain weight (as expected), they also experienced an increase in their waist circumference and BMI, their HOMA-IR (insulin resistance score) increased, and their liver panel indicated development of Non-Alcoholic Fatty Liver Disease (NAFLD) to boot!

The underlying culprit was simply calories, or even an increase in dietary fat - but the significant increase in both sugar and total carbohydrate in the diet.

Now take a look at what's being reported in the media, as picked up by Conditioning Research:

It is interesting to see how this has been reported elsewhere:

MedPage today says: Explain to interested patients that this small study suggested that overdoing it on high-fat foods, even during a short holiday period, for instance, and a failure to exercise can cause liver damage.

eh? the researchers said it was the sugar not the fat

NHS Choices says: The study does provide a further reason to avoid overeating (especially food high in saturated fat) if one is needed.

er...the researcher said that "The study showed that the increase in saturated fat correlated with the increase in healthy cholesterol"

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Then there is the CBS article, "The study, published in the advance online edition of Gut, doesn't show which was more damaging - bingeing on fatty food or being sedentary."

ABC News, "The extra fat is the big enchilada here..."

My take? There are none so blind as those who will not see.

Additional Blog Takes:

John Briffa - Why Carbs Can Turn Your Liver into Foie Gras
Hyperlipid - French Paradox in Sweden

Getting Creative with Seven Little Words Bodybuilding tips

In January, the New York Times Tara Parker Pope held a little contest on her blog, based on Michael Pollan's seven little words:

Eat food. Not too much. Mostly plants.

She asked readers "of the Well Blog to submit their own 2-3-2 word sequences sharing advice for the rest of us. Submit as many entries are you want. Here are the rules:

Dispense wisdom. Don't be gross. No profanity."

The winner?

Ate plants. A big heap. Still hungry.

Next week I'll review Pollan's newest book, In Defense of Food: An Eaters Manifesto - in the meantime, you can add your own 2-3-2 creation in the comments here!

Normal Blood Sugars; Type 1 Teens Bodybuilding tips

Stan De Loach, Ph.D., CDE Certified Diabetes Educator and Clinical Psychologist in independent practice México, Distrito Federal, México

ABSTRACT
Objective
For children and adolescents with recent-onset DM1 to learn to quickly and safely achieve normoglycemia (71—99 mg/dl) and glycemic stability (MAGE score £ 95), using self-directed learning methods, insulin analogues, reduced concentration of dietary CHO, and ad libitum physical activity and SMBG, during an educational camp.

Methods
A 5-person international multidisciplinary team managed time, task, territory, technique, and technology boundaries, while responding to the educational and emotional needs of 9 Campers (8—17 years of age [11.8 ± 2.6]), with average diabetes duration of 1.62 years (± .88), during a residential 57-hour (3-day/2-night) diabetes camp.

Campers chose foods from meal buffets, calculated lispro insulin doses, and exercised and monitored BG at will. SMBG values documented in each Camper's combined glucose/ketone monitor furnished statistical data.

Results
Mean arrival and departure BG was 209 mg/dl (± 101.5) and 87 mg/dl (± 23), respectively [P less than .0025].

Mean 3-day BG (95 mg/dl ± 21) and MAGE score (66 ± 27) validated stable euglycemia.

Conclusions
Integrating self-directed diabetologic education, basal/preprandial insulin therapy with analogues, elective physical activity and SMBG, and reduced concentration of dietary CHO rapidly and safely established routinely normal mean daily glycemic levels and stability in this sample.

More ACCORD Bodybuilding tips

Laura Dolson, at About.com, recently posted about the ACCORD Trial mess in a Tale of Two Diabetes Studies. To get you started:

Many people who follow low-carb diets do it to achieve greater blood glucose control. Therefore, it was disconcerting when ten days ago the news was full of a large study of diabetics ("ACCORD") which was halted when it was found that patients in the more aggressive treatment group, who had lower blood glucose as a result, had more deaths than the patients with higher levels of blood glucose.

Note that none of the researchers said that the lower blood sugar itself caused the result -- it could have been the more agressive drug therapy that these patients were on, or some other factor. Nor are they clear on what caused the extra deaths at this point. And no one was recommending that treatment programs or goals be changed based on this preliminary data. In fact, the American Diabetes Association recommended not changing anything. However, this did not stop the media from producing headlines such as, "Diabetes Study Shows Lowering Blood Sugar Increases Death Risk" and "Diabetes Study Upends Another Long-held Belief". In my opinion, these kinds of headlines are blatantly irresponsible, and I also wonder what is to be gained by blasting this story everywhere before we have a decent analysis of what was going on in the study.

The findings in the ACCCORD study prompted researchers in Austalia to peek into a similar study in progress there called ADVANCE. Were the results the same? No, not at all! Their data did not show increased deaths in the lower blood glucose group, despite the fact that twice as much data has been collected so far in the ADVANCE study. So the interim advice is to wait until the results of both studies, plus one additional similar one, are available.

What are we to think?

Dr. Jamie Bailes: The Fat-Free Fallacy Bodybuilding tips

Dr. Jamie Bailes, a pediatrician at Marshall Unieristy in Huntington, WV, recently penned an article for Diabetes Health - The Fat-Free Fallacy: Is it Obesity's Great Enabler?

Obesity in the United States is increasing in epidemic proportions. This is true in children as well as adults. It's estimated that the healthcare costs associated with obesity and its related complications will exceed $130 billion this year.

If something is not done to stem this burgeoning tide of obesity, then the healthcare system that we know will soon crumble.

Why are we seeing this dramatic increase in childhood obesity?

It is certainly true that children are not as active as they were 30 or 40 years ago. Television, video games and computers can entertain kids 24 hours a day. Parents are often relying on technology to babysit their children and are not spending as much time outdoors with them exercising or just playing.

Is this the only reason for the surge in obesity? As a pediatrician who specializes in childhood obesity, I see many children who are very active but they are also massively overweight. What about these children? I believe many of these children are victims of what I like to call the "fat-free fallacy."

Scapegoating Fat Backfires

In 1977 the U.S. Department of Public Health issued a statement encouraging Americans to eat less fat. In 1988 the U.S. Surgeon General recommended that we restrict our consumption of dietary fat. The assumption was that as we eat less fat the thinner we would become. The multi-billion-dollar food industry was quick to jump on the bandwagon. The race was on to produce fat-free everything. If food didn't have fat then it was OK to eat as much as you wanted.
Americans consumed more fat-free foods in the 90's than the previous three decades combined. This fat-free philosophy is exactly why we are becoming so obese as a society. Obviously if fat were the problem, then obesity would have decreased during this time. Instead, obesity did not decrease but skyrocketed to unprecedented levels.

But fat is not bad for you. Being fat is. The two are not related! Fat actually helps to satisfy our appetites and keeps us from eating too much or too often. Fat is also an important flavoring for food.

I, too, was a victim of this fat-free fallacy. I had been taught (brainwashed) that in order to lose weight we must eat less fat. I was a huge proponent of cutting back fat intake and watching total calories. I recommended at least 30 to 45 minutes of vigorous exercise daily.

I knew that it was very hard to lose weight. I didn't push overweight children to lose weight, thinking that if they could just maintain their current weight as they grew that would be significant progress. I felt like I was doing a good job. I believed whole-heartedly that I was explaining to these children the correct way to lose weight.

An Eye-Opening Study

In the late 1990's, a first-year pediatric resident physician at Marshall University did a required research project in which he looked at about 100 children whom I had counseled about weight loss. The results were astonishing to me. Not only did these children not lose weight or even slow down their weight gain, most gained weight at the same rate and some even faster.
The results did not lie. All of this time and energy that I had been spending to help children lose weight had been a waste of time. It just didn't work. A low-fat diet only worked for about one out of every 25 patients. Was this the best we could do?

I was determined to succeed. I began to look at other ways to lose weight. A third-year medical student at the time asked me about using a high-protein, carbohydrate-restricted diet for weight loss. At the time I knew very little about approach. This was not something that was taught in medical school. I couldn't believe that this would be successful or that it could be good for you, so I was very skeptical. How could eating high-fat foods not be bad for you? This is what I learned in textbooks from professors in medical school.

However, I still could not ignore the facts. We had cut back our fat intake and yet we were becoming fatter as a nation.

Low Carbs Make a Case

I researched and relearned the physiology and biochemistry behind low-carb diets. As I began to take a closer look, my findings were not what I expected. It all came back to insulin. Insulin is what causes fat storage. Insulin is what drives weight gain. Insulin is what is secreted when we eat carbohydrates. Insulin is one of the most powerful and efficient substances that our body uses to control the use, distribution and storage of energy. Insulin is essential for life. Without insulin, we would quickly waste away and perish. Just ask the teenager with type I diabetes who has been hospitalized for diabetic ketoacidosis because of not taking his or her insulin.

Let's look at what happens after a meal that is high in carbohydrates. Carbohydrates are broken down into thousands of molecules of glucose that are quickly absorbed through our small intestines into our bloodstream. Our body has the ability to monitor this rapid rise in blood sugar and quickly secretes insulin to counterbalance this. This is true if we do not have diabetes. Our nervous system keeps our blood glucose levels very steady no matter what we eat. These values almost never get above 120 or less then 70mg/dl. This is true whether we eat a meal that consists of pure sugar, a meal loaded with complex carbohydrates, a meal consisting of only protein or fat, or when we have fasted for two or three days. Almost all of our cells use glucose for energy.

Our bodies are extremely efficient energy machines. Only a small part of what we eat is actually used or needed by the muscles or other cells for energy. If these energy-using cells do not need any extra energy what happens to the majority of the glucose that we ingest? Insulin converts a portion of that glucose to another starch, called glycogen. Glycogen is stored in the liver and can maintain our blood sugar levels in the normal range for several hours after a meal. This is why we do not have to eat continuously. Glycogen can quickly be converted to glucose whenever glucose is not readily available in the bloodstream.

Why Low-Fat Diets Don't Work

What about the rest of the glucose? Where does it go after a meal? Herein lies the answer to why most low-fat diets do not work. The extra glucose is converted to fat. Fat is our main storage area for energy. Let me say this again: insulin promotes the production and storage of fat. That's right, even without eating fat our body produces fat from sugar.

Insulin is an extremely efficient hormone. It is the master hormone of our metabolic system. Its most important function may be the control and maintenance of our blood sugar, but insulin performs a myriad of other activities. In the appropriate amount, insulin keeps the metabolic system running smoothly and everything in balance.

However, in great excess it becomes a dangerous hormone wreaking havoc through the body. Mountains of scientific evidence implicate insulin as the primary cause or significant risk factor for high blood pressure, heart disease, arteriosclerosis and high cholesterol. It may also have a causative role in type 2 diabetes.

With type 2 diabetes our body needs extra insulin to help to maintain our blood sugar. The insulin that is available just does not work as well and we become resistant to its effects.
With type 1 diabetes we have a little different story. Our body can no longer make the insulin that we need therefore we have to take manufactured insulin to maintain our blood sugar. More carbs equals more insulin.

Teenage girls with diabetes know that insulin causes them to gain weight. Many recent studies have shown that in order to keep from gaining weight a very high percentage of teenagers with diabetes omit their insulin. We cannot continue to allow this to happen. This leads to uncontrolled diabetes and horrible long-term complications.

More Protein = Greater Insulin Control

So, how can we control our insulin requirements? The key to good blood sugar control, the key to weight loss and the key to lowering our insulin secretion is very simple. Eat fewer carbohydrates and eat more protein.

Protein keeps us from being hungry. A meal high in protein stays with us a lot longer than a meal high in carbohydrate content, which is quickly absorbed and does not satisfy our appetite as long. When we eat protein our body does not need as much insulin. Our blood sugar values are much steadier and we do not have the wide fluctuations that we see with high carbohydrate foods. This dietary approach works whether you have diabetes or not. It is perfect for anyone who is overweight or has type 2 diabetes. Type 1 people with diabetes can benefit by improved blood sugar values and lower insulin requirements.

I have seen hundreds of children actually lose weight with our plan. Eight and nine year old kids have lost 40 to 50 pounds. Obviously, the health benefits are tremendous, but the greatest improvement is what we see with self-esteem. Children's energy and blood pressure improve, and their lipid profiles universally improve. Before-and-after pictures of these successful children can be viewed on our website http://www.nomorefatkids.com/.

In general, the fewer carbohydrates we eat the better. However, we should get a minimum of 30 grams of carbohydrates per day. The standard approach of 60 to 75 grams of carbohydrates per meal and 30 grams per snack is way too much. If you do not want to restrict carbs to 30 grams per day, then somewhere between 60 to 100 grams per day will still allow for weight loss if it is combined with exercise.

Remember: Eat all the protein you desire. Do not worry about where the protein comes from or how it is prepared. People who eat more protein end up eating fewer total calories. Protein keeps us from being hungry and satisfies our appetite more than any other macronutrient. This is the key for successful weight loss. It is hard to lose weight if you are hungry all the time

Comment Moderation Update Bodybuilding tips

Just a quick reminder about comment moderation - the reasons a comment may be rejected include:

Trying to sell something to others via the comments
Personal attacks on another commentor
Comment has absolutely no relevance to the subject matter of the post nor any other comment on the thread of comments for the post
Attempting to re-direct traffic to a site selling products/services contrary to this blogs message
Profane and/or vulgar comments

All are absolutely free to disagree, challenge anything I've written and/or comment about their experience (with a product or service)....but the above guidelines are a reminder that I do moderate comments, and while I'm reluctant to reject a comment, occasionally I find myself having to. If a comment of yours is rejected (doesn't appear) and you have a question about why, you can always email me and ask why.

What the World Eats Bodybuilding tips

f a picture is worth a thousand words, than the Time photo-essay What the World Eats Part I speaks volumes.

To view the pictures from around the world: What the World Eats Part I

Months ago, when Diet Blog featured this subject, I took a picture of our weekly food but then didn't have an opportunity to post it here. So, today - here's what an average week of food looks like for us:

Five Simple Rules Bodybuilding tips

PJ, over at the Divine Low-Carb!, recently issued a challenge in a post, You Choose! The March of Madness for PJ, where she asks experienced low-carbers to present a plan for her to follow throughout the month of March.

So here is a challenge for the many experienced lowcarbers out there. March is coming up in 5 days. Present a plan for me that is:

1 - LOWCARB AND SIMPLE (not 'cycling' and not 'moderate carb' and not 'atkins by the book according to OWL modified by xyz...')

2 - HAS NO MORE THAN FIVE MAIN RULES (though a given rule can have details, e.g. if supplements is one of the rules it can have a list/dosage, if fat is one of the rules it can have types/quantity)

3 - WITHIN THE PARAMETERS ABOVE (no seafood or gluten etc.)

Here's what I will do:

1. I will choose one of them and officially follow it for March, from the 3rd to the 31st, four full weeks starting on a Monday -- because that is how my weight spreadsheet is set up LOL.

2. I will track and graph my weight every day

3. AND how I feel every day

4. AND what I ingest/do every day (I use a digital gram scale for measures)

5. AND do measurements before/after,

and at the end of the month we will all see how well that given plan worked out for my body. I may not be perfect on it but I'll track what I do so it's fairly known what degrees of it I may have screwed up.

MY THEORY IS, that since I don't have ANY given goal-setting plan that inspires me enough to make a commitment to it, that instead, I will make a commitment to someone ELSE: the commitment just happens to involve a given lifestyle plan.

Can you do it?

RULE 1: NO SPECIFIC GRAM COUNTING - just eat what's allowed & simply enjoy your meals

In the current state of affairs, eating is becoming terribly complicated by an under-current that suggests we feel guilty for eating, seek to limit our desire and pleasure from good food, and contantly count calories, grams of this or that and worry about everything we place in our mouth.

No more of that - eat and enjoy what is allowed and simply pass on anything not on your list of good foods to eat.

In addition, we don't live and eat in a world of grams - it isn't even natural to have to divvy up portions by cups, ounces or any other measure. We're supposed to just simply eat, but somehow we've come to a place where that's no longer a simple affair.

Rather than fight that totally, I'm going to present information to calculate minimums for some things, that have to be included each day, ranges for others, and optional add-ins - these are to be calculated out for an individuals current weight so they're eating enough each day to avoid a state where the body conserves energy in the face of famine conditions, while also providing variety and good habits to build upon over time.

RULE 2: Eat Enough - Starvation Level of Calories Doesn't Work Long-Term

In order to eat enough, one has to know how many calories they need, at minimum, each day - over the years I've found the basal metabolic rate (BMR) to be a good minimum to use. Online calculators, like the one at Discovery Health, are accurate enough for this purpose. Once you enter your information, it will return how many calories you need each day for basic metabolic function, before any movement or physicial activity.

This is the minimum calories to target eating each day and it allows a +/- 5% range, so if you miss by 5% one day that's OK; if you're over now and then by 5%, that's OK too. Recalculate BMR with every 20-pounds of weight loss.

RULE 3: Consume Adequate Protein

Protein is, in my opinion, the most critical of foods/macronutrients to consume each day - it helps to regulate appetite, but more importantly provides the essential amino acids to repair and build within the body.

Calculating out a minimum amount of protein to be "adequate" is fairly easy - you take your body weight in pounds and multiply it by 0.40. This will allow for an adequate intake of amino acids for both essential needs, and for the production of glucose through gluconeogenesis.

But who lives in a world of grams? It's easier then to take the gram target and convert it into ounces each day - makes it easier to decide what to eat! So, to determine how many ounces each day, you simply divide the grams by 6.5 - the average amount of grams of protein per ounce in meat, cheese, eggs, poultry, fish. Now some have 7g, some have 6g - I suggest using the 6.5 as an average.

Do not count plant protein in your minimum - so you can eat whatever cuts of meat, poultry, fish, game you want, and include eggs, cheese (real, whole milk cheese only - see below). You may also boost protein with whey or egg protein powder or RTD-shakes that contain only whey protein and less than 2g carbohydrate per serving. No soy protein isolates are allowed in the shake option.

Eggs ideally will be from organic, free-range chickens; meats (ideally) should be grass-fed, pastured.

Recalculate protein requirements with every 20-pound weight loss. Each day, eating enough protein is critical, so target eating at least the calculated minimum; eating more than that is fine if you're hungry and often necessary if you're active...so if you find you are hungry, eat more protein if needed, but avoid excessive protein consumption, which is hard to define, but generally means more than 35% of calories or greater than 0.8g-1g of protein per pound of body weight (depending on level of physicial activity).

Dairy is included in your protein, but do not consume more than a combined total of 4-ounces of dairy foods each day - this includes plain whole milk yogurt, real whole milk cheese (no processed cheese allowed), heavy cream and/or half & half. Dairy must be organic.

RULE 4: Choose fats wisely

For cooking and topping vegetables, use ONLY the following fats and oils:

Olive oil, organic butter, virgin coconut oil, avocado oil, walnut oil, sesame oil, macadamia nut oil, drippings from bacon, real mayonnaise, or rendered fats from chicken or meat.

What isn't allowed is anything that contains canola, soybean oil, vegetable oil, partially (or fully) hydrogenated oils or corn oil.

Two exceptions: Salad dressing is one exception to this rule if one is using commercial dressing - canola based dressing is allowed in this case, if the carbohydrate content is 1g or less per 2-TBS serving. Real mayonnaise is the other exception if you cannot find one that is made with the acceptable fats/oils.

The meats and animal foods consumed have fat content, so added fats/oils should be used to top vegetables and salads and the amount should be individualized to meet calorie intake minimums. Adjust fats & oils as appropriate with weight loss. If you are using an online food journal to keep track of things, like FitDay.com, the percentage of calories from fat will be high - greater than 60% each day, sometimes as high as 70% or more.

RULE 5: Eat Enough Plant Foods

Plant foods - vegetables, nuts, seeds, fruits, legumes - provide variety and also are nutrient-dense. The same cannot be said for most grains, so while you're losing weight, avoid grains, but eat enough of the allowed plant-foods each day to keep things interesting.

As a rule of thumb, absolute minimum of non-starchy vegetables each day is 3-cups - choose whichever non-starchy vegetables you wish and top with whatever fats/oils you like, season however you want.~ You may include up to 6-cups of non-starchy vegetables each day if you wish. Herbs and spices may be used as desired.

OPTIONAL ITEMS:

You may also include up to 1-cup of select fruits each day - any type of berries, canteloupe, honeydew melon or tomatoes.~ The caveat with the fruit is it must be accompanied by a protein-fat food, like cheese, yogurt or meat.~ For example, if you'd like 1/2 cup of blueberries, enjoy them in a 1/4 cup of plain whole milk yogurt topped with a tablespoon of walnuts or pecans, or in 1/4 cup of heavy cream.

You may also have up to 2-ounces of any nuts/seeds each day.~ Nuts you may have include: walnuts, pecans, pine nuts, pistachios, sesame seeds, pumpkin seeds, and macadamia nuts; also nut/seed butters are an option. Two that are not allowed are peanuts (legume) and cashews. If your current body weight is greater than 300-pounds, you may include up to 4-ounces of nuts if needed to bring calories up to meet BMR.

You may include up to 15 olives in a day - green or black; and/or 1/2 an avocado; and/or 2-TBS of legumes (chickpeas, red kidney beans, navy beans, peas, etc. - but no peanuts).

Essential Nutrient Insurance

While it's definitely possible (and not all that difficult) to plan menus with 20g to 60g net carbohydrate and all the essential nutrients we need, it's not something someone new to low-carb does well without practice, and even those who have followed controlled-carb for a period of time sometimes miss hitting nutrients that are essential because they don't know which foods are best to include for nutrient-density. So, rather than write a book about this, an unofficial "rule" - it's a good idea to include some "essential nutrient insurance" in your day....two key vitamin supplements:

A. Basic multivitamin-mineral complex that is not a "mega"....choose a capsule vitamin, not the brick-hard type; it should include 100% of RDA, but not "mega" levels.

B. Cod Liver Oil and/or Fish Oil; depending upon time of year and where you live. During the winter months - mid-October through mid-April, if you're in a central or northern latitude, use cod liver oil; all others in sunny year-round locations, get sun and use fish oil instead; during mid-April to mid-October use fish oil if you're in a central or northern latitude while also getting your sunshine!

Dose is generally 1-teaspoon per 50-pounds of body weight, with a maxiumum of 1-tablespoon per day.

For those with significant weight to lose - 50+ pounds - it can also help to include:

C. Chromium picolinate (200mcg)

D. Alpha Lipolic Acid (600mg) + L-Carnitine (1g)

E. Krill oil capsules (500mg) [do not include if you have a shellfish allergy]

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