What's wrong with the conventional wisdom on cholesterol and how it could actually be harming us

I just finished reading health blogger and podcaster, Jimmy Moore's, new book called Cholesterol Clarity: What the HDL is Wrong with My Numbers. For those interested in diving deeper into one of nutrition's most misconstrued and contentious issues, or simply want the "straight dope on cholesterol" (borrowing from the name of Peter Attia's unparalleled blog series on the issue, which I HIGHLY recommend), this is a must read book. Not only does it provide some of the latest research and thinking on the topic through a series of interviews with 28 leading experts in the field, but Moore packages the information in an accessible way for the widest possible audience, whether you're a lipid researcher or someone who just wants to stay healthy.

So, let's dive into some the main issues in the book and some of my key takeaways. 


Cholesterol is actually a good thing that plays an irreplaceable role in the body. Bottom line: if you don't have cholesterol, you die. Morbid, but true. Here are a few essential things it does or supports in the body:

• Hormone production, including estrogen, progesterone, testosterone, pregnenolone, adrenaline, cortisol, and DHEA
• The health and efficiency of cell membranes
• Nervous tissue, including the white matter in your brain
• Optimal adrenal gland function, which modulate a number of different vital hormones like adrenaline as well as kidney function
• Water and electrolyte balance
• Formation of Vitamin D
• Immune function

By far, one of the most important things influenced by cholesterol is something called coenzyme Q10, or CoQ10. Some, like Nora Gedgaudas, the author of Primal Body, Primal Mind, have called CoQ10 the "single most important nutrient for the functioning of the heart."

When cholesterol is too low, bad things can happen. Based on the important functions listed above, you can probably guess some of the negative things that can happen in the body when cholesterol is too low. For example, cholesterol actually plays a very important role in tissue repair, specifically with stem cell production. As a result, blood vessels can become stiffer - not a good combination with small, dense LDL particles. Research has also shown a close link between low cholesterol and a higher risk of infection, cancer, and a variety of mental side effects, such as depression and a higher likelihood of suicidal behavior.

In fact, research has documented that people with the lowest cholesterol levels actually had the highest rate of death from coronary heart disease and demonstrate a greater risk for some cancers. In addition, this study actually found that almost half of patients hospitalized for heart disease (80% experiencing acute symptoms), had LDL cholesterol levels less than 100 mg/dL, which is the current recommended level by the American Heart Association. As Moore argues, LDL cholesterol (and total cholesterol) are bad predictors of heart disease risk.

Dietary cholesterol doesn't really impact your numbers. The amount of cholesterol from food makes up only about 15-30 percent of your body's total cholesterol. In fact, the overwhelming majority of cholesterol our bodies use - up to 2 grams every day - is actually produced within the body itself, mostly in the liver. Cholesterol is tightly regulated by the body and as Dr. Chris Masterjohn explains in Cholesterol Clarity, "if we eat a lot of cholesterol, our bodies make less of it; if we eat less cholesterol, our bodies make more of it. In most people, the majority of cholesterol that is circulating in the blood is made by their own bodies."

All LDL isn't "bad cholesterol." There are actually two kinds, or patterns, of LDL cholesterol. Pattern A is large and fluffy, regarded by experts as generally harmless. Pattern B, on the other hand, are potentially more dangerous since they are small and dense. Many will say that this measure of particle size and number, or LDL-P, is a much better way of determining risk, than the traditional LDL-C measure that shows up on a standard lipid panel (which is actually a calculated number, not one that's directly measured - more in the next section on this).

Thankfully, there are more and more options available to test for this. One such test is called the NMR LipoProfile test made by the relatively new diagnostic testing company in North Carolina, LipoScience. The test uses NMR technology (which stands for nuclear magnetic resonance and is regarded as one of the best technologies on the market) to actually measure the number of LDL particles in a blood sample.

Of course, certain dietary choices can influence the ratio of Pattern A and Pattern B LDL in the blood, which Moore also flags as quite concerning. He particularly focuses in on the relatively recent trends towards promoting polyunsaturated fats, mostly in the form of vegetable oils (things like canola oil, soybean oil, etc). It is true that there is a fair bit of research showing the effectiveness of polyunsaturated fats (PUFAs) at lowering LDL in the blood. The problem is that PUFAs help achieve this reduction in LDL primarily through decreasing the number of good Pattern A LDL particles, leaving mostly Pattern B. You can see how this can be extremely concerning for heart disease and atherosclerosis risk. One of the best ways to increase the number of good Pattern A particles and decrease the number of Pattern B particles is by eating quality saturated fats from things like coconut, and grass-fed beef and butter.

LDL is actually a calculated number on your standard lipid panel. If there is one number from the standard lipid panel that doctors focus on, along with total cholesterol, it's LDL. The entire statin-prescribing system, argues Moore, has been built upon artificially defining a certain threshold for LDL and total cholesterol (which isn't really rooted in any solid evidence as mentioned above) and teaching physicians (very well) to automatically prescribe the drug once your numbers exceed these thresholds. Usually any conversation about diet is secondary or nonexistent. This is essentially how Lipitor and other statin drugs have become some of the most commonly prescribed medication on Earth.

Among some alternatives, like testing for LDL particle size and number, there is also pretty strong consensus that your ratio of HDL cholesterol to triglycerides is a better gauge of current heart health. Both numbers are on the standard lipid panel, which makes them a bit more accessible. The easiest prescription to maximize HDL while minimizing triglycerides is by avoiding carbohydrates and eating more fats.

Keeping total cholesterol low, as guidelines recommend, is 100% counter-intuitive. The prevailing guidelines by a variety of public health authorities focus exclusively on total cholesterol and LDL, and specifically keeping these two numbers low. In the case of total cholesterol, guidelines suggest this number should be kept under 200. But the irony of all of this is that if you're trying to keep total cholesterol low, you're assuming all components that make up the total should be kept to a minimum.

Most people know this is hardly the case. As I mentioned, having a lot of large, fluffy Pattern A LDL particles is not nearly as harmful as having a lot of Pattern B. Also, when it comes to HDL cholesterol, or the so-called "good" kind, every leading health authority suggests we need to keep this number as high as possible. This seems like a big contradiction to say keep some cholesterol particles, like HDL, high, while applying an arbitrary cap to total cholesterol.

Statins do a lot more harm than good. Though statins do lower LDL cholesterol (which I hope I've already convinced you is not necessarily a good thing), here are a few examples of the documented negative consequences of taking statins:

• This 2013 article found a 21% increased risk of death among women with breast cancer who took statins compared to those who didn't. Other studies have documented the link between statin use and musculoskeletal diseases and joint pain.
• Compared to people who did not use statins, statin users had had a 50% increased risk for any musculoskeletal pain, a 59% increased risk for lower back pain, and a 50% increased risk for lower extremity pain.
• This review article documents the ample evidence showing increased risk of cardiovascular disease in women among statin users, including a three-fold increase in risk of coronary artery and aortic artery calcification.
• Statin use has been shown to hinder the positive effects of exercise among overweight and obese individuals. 

It's all about inflammation. If there is one thing to worry about instead of cholesterol, Moore argues, we should be much more concerned about inflammation in the body and the things that cause it. This is the true cause of atherosclerosis. In his words, "without inflammation, cholesterol can't harm you." It's really all about cholesterol oxidation, which is nearly a two-fold better predictor of heart disease risk than simply looking at cholesterol alone. So, we should be focusing more on things that cause chronic inflammation in the body, which results from poor diet, smoking, lack of sleep, infrequent exercise, elevated stress, and a compromised gut, just to name a few that Moore references. One of the best blood markers for determining the amount of chronic inflammation in the body is something called high-sensitivity C-reactive protein, or hs-CRP. Many experts have argued that hs-CRP is a much better biomarker to track because it's a much better predictor of heart disease and health complications than total cholesterol or LDL.  

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This book is definitely for everyone. I thoroughly enjoyed the balance struck between offering practical guidance while underpinning it all with sound science. If you're trying to cut through all the noise out there on cholesterol or you're interested in tracking your own health and wellness, this is definitely worth the read. My only critique - but this is coming from a researcher who loves evidence - is the lack of citations in the book. Moore does provide some suggested references for additional reading, but I personally could've really benefited from the book to a greater degree with citations, particularly for many of the chapters discussing the science.

Nonetheless, I highly recommend taking a look at this book. It'll definitely challenge (and maybe even change) the way you think about cholesterol.

Note: I was not compensated in anyway for writing this posting. Views are my own.

Should we really substitute saturated fat?

Remember all those years people were saying to stay clear of saturated fat? Remember being told to use margarine instead of butter? Remember hearing you should use vegetable oil? Remember being told to watch saturated fat intake, and use polyunsaturated fats (like margarine and vegetable oils) as a substitute if you were going to eat fat?

The current U.S. dietary guidelines call for people to substitute saturated fat in favor of polyunsaturated fat. The World Health Organization's new global action plan aimed at preventing chronic diseases, which is currently being developed, similarly calls for policy measures to decrease the levels of saturated fat in the diet and also eliminate trans fat, in favor of polyunsaturated fats. (The trans fat piece is a good thing).

A recent study published in the British Medical Journal provides further evidence as to why everything I just wrote is probably wrong.

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The study recovered data on 458 middle-aged men (aged 30-59 years) from a large randomized controlled trial, called the Sydney Heart Diet Study, which was conducted between 1966 and 1973.
These men who were specifically enrolled had, on average, a coronary event in the past 11 weeks. The goal of the study was to essentially evaluate the effectiveness of replacing dietary saturated fat with polyunsaturated fat in the form of safflower oil and safflower oil polyunsaturated margarine, or a similar recommendation often heard today. (Second to canola oil, safflower oil has the highest unsaturated to saturated fat ratio of many of the most common oils and fats and is also quite high in inflammatory omega-6 fatty acid content.)

The men were allocated into two groups, a control group, which was not given any specific dietary advise (though some of those in the control group had already begun substituting margarine for butter after their coronary event on advice from their doctor), and saturated fat intake remained about 15% of total dietary calories throughout the study. The intervention group was instructed to increase their polyunsaturated fat intake to about 15%, reduce their intake of saturated fat and to less than 10% and reduce their dietary cholesterol to 300 mg per day. To achieve these targets men in the intervention group were provided with liquid safflower oil and safflower oil polyunsaturated margarine (high polyunsaturated fat group). The overall diet for both groups consisted of about 40% fat, 40% carbohydrate, and 15% protein, and 3-4% alcohol (doesn't add too 100% because of rounding).

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Now what did the study find? First, the study found that after 12 months the cholesterol levels of the men on the high polyunsaturated fat diet were 8.5% lower than the men on the high saturated fat diet. At first glance this may seem like a good thing - oh, cholesterol went down when eating more polyunsaturated fat. But, the study measured only total serum cholesterol, which really isn't a good predictor of poor health outcomes in the future. Just think (and this is over-simplified, I know), you have your LDL cholesterol (the bad kind) and HDL cholesterol (the good kind). There can easily be a situation where total cholesterol decreases, but it's predominantly HDL, which isn't necessarily a good thing. Not to mention, the indicator says nothing about cholesterol particle size (large and fluffy vs. small and dense), which many think is a much better predictor of adverse health events. (If you're looking for a much more in-depth explanation, I recommend reading Dr. Peter Attia's "straight dope" blog series on cholesterol over at The Eating Academy. It's well worth the time.)

The below series of graphs really tells the story.

• (Graph 1) Men who consumed the high polyunsaturated fat diet (the blue line in all three graphs) had a 62% increased risk of death compared to the men who consumed the high saturated fat diet (the dashed red line in all the graphs).
• (Graph 2) Men who consumed the high polyunsaturated fat diet had a 70% increased risk of death from cardiovascular disease compared to the men who consumed the high saturated fat diet.
• (Graph 3) Men who consumed the high polyunsaturated fat diet had a 62% increased risk of death from heart disease compared to the men who consumed the high saturated fat diet.

Source: Ramsden, et al (2013). BMJ;346:e8707

So, when it comes down to it, the study essentially shows that increasing dietary polyunsaturated fats from sources like vegetables oils (safflower, canola, sunflower, corn and soybean) and decreasing saturated fats is associated with an increase in both overall death rates and heart disease death rates.

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The study does have some limitations (the study didn't control for some healthy lifestyle changes, such as smoking cessation, and it's a correlation study, indicating nothing about causality), but I think it does add to the growing body of evidence to suggest what we commonly hear about what's good in our diet is often contrary to what the research shows (a few examples here, here, and here). It's also a clear case-in-point regarding what I've written about before: not all calories, and especially not all fats, are created equal. So, when you can, take a look at the most important part of a nutrition label on foods: the ingredients list!

Underlying Causes NOT Disease: Shifting our view of health

Cardiovascular diseases cause more deaths around the world than any other condition - more than 17 million, or about 30%. By 2030, the World Health Organization predicts these numbers to continue climbing upward, to about 25 million. And this global epidemic is not cheap. It's the principle driver of health care costs in many countries (including the U.S.), and is going to cost the global economy $47 trillion by 2030 - yes, that is trillion with a "t".

But as important as it is to diagnose a health condition like heart disease - particularly from a disease surveillance perspective - it unfortunately says little about the condition's underlying root causes. At the World Economic Forum's annual meeting in Davos last week, Dr. Mark Hyman described the issue by saying, "We have a naming problem...and we confuse the name [of disease] with the cause."

Dr. Hyman has been pioneering an approach to health called functional medicine, which is concerned more with ways to achieve health rather than treat disease. This may sound intuitive, but there are strong, built-in incentives in our health system that tend to favor doctors writing prescriptions rather than discussing strategies to prevent illness in the first place.

For those public health folks out there, this sounds quite similar to something called "social medicine," which looks at how social and economic conditions impact health (like socio-economic status, education, where someone lives), and has been recently championed by the public health physician/advocate Dr. Paul Farmer.

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As I've written in several previous posts, I strongly believe in the power of things like food, sleep, exercise, and relaxation to achieve better health (and therefore prevent illness). During his interview in Davos last week, Dr. Hyman does a wonderful job of explaining why this approach to health not only makes sense from a medical perspective, but also from a policy perspective, helping us reverse the seemingly uncontrollable costs associated with healthcare.

Let me know what you think. Leave a comment below.

Endurance Sports and Heart Health (Part II): What are the benefits?

This is the second part in a series of posts on endurance sports and heart health.

2,466,115,200. That's how many times my heart will beat if I live as long as the average American is expected to (78.2 years). (My wife says it better beat for longer.) My resting heart rate is about 60 beats per minute. That's a fascinating number to think about. For almost eight decades my heart will supply my entire body (and itself) with the oxygen it needs to survive, and never stopping. 

When it comes down to it, the heart is a relatively simple organ - essentially a four-chambered pump with some tubing going into it and coming out of it. But of course the devil is in the details. Over the course of more than 2 million beats, there is a lot of opportunity for things to go wrong, and many times these things are the result of accumulated issues over time.

As I discussed in the first part of this series, with endurance exercise, there is a fine line between performance and pathology - something referred to as the "grey area" in the scientific literature. There are risks when it comes to endurance sports. But risks can be managed and risks must also be viewed in the context of benefits (it's all about optimizing). 

In this post I discuss some of the benefits of endurance sports and regular exercise, particularly from a physiology perspective, as well as a public health standpoint. But I close with some cautions about maximizing exercise while neglecting other areas of daily life that contribute to heart disease and heart issues.

Popularity of Endurance Sports is Increasing

Endurance sports, such as half-marathons, marathons and triathlons, are becoming more and more popular. The previous post in this series showed the increasing level of participation in USAT-sanctioned triathlon events. Half-marathons and marathons held in the U.S. show a similar trend. Not only are there more races, but more people are participating. For example, according to Running USA, a non-profit that tracks trends in U.S. distance running events, the number of marathons in the U.S. more than tripled between 1985 and 2011, from 200 events to 720 events.

Active.com, an online community for sports and event registration hub for a variety of activities (including running, cycling, triathlon, and more), revealed similar increases based on race registrations between 2008 and 2010. During these three years, marathon registrations increased 203%; half marathons rose 154%, 10K events rose 155% and 5K events rose 144%.

Why is This a Good Thing from an Individual Health Perspective?

Your heart is a muscle, and like other muscles, it responds to stimuli like exercise. It can grow stronger and increase in size similar to other muscles in our body after periods of exercise. And generally (and up to a point), the more exercise, the stronger, more efficient, and sometimes larger the muscle. Endurance activities markedly improve the efficiency of your heart, increasing stroke volume (or the amount of blood pumped by the heart with each beat) and thereby decreasing the number of overall beats needed.

Other markers of heart health have also been positively linked with endurance exercise, such as lower blood pressure and increased HDL cholesterol.

There is also evidence to suggest that exercise plays a strong role is energy partitioning, or the type of energy (such as carbohydrates or fat) our body preferentially burns for fuel. One study of 55 years old women found a more than 9% increase in energy derived from fat after 12 weeks of endurance exercise training.

The weight-bearing movements of regular exercise and strength training support bone health and improve longevity, particularly as people age. Exercise is also associated with lower stress levels, higher energy levels, and overall positive mental health.

Not a bad list of benefits.

Why is This Essential from a Public Health Standpoint?

Physical inactivity is becoming a new norm and the trends don't look promising. A recent review from researchers from the University of North Carolina looked at trends of metabolic equivalent hours (just a fancy way to show the amount of exertion by your body doing different activities) from 1965 to the present, and also projected trends through 2030. Between 1965 and 2009, MET-hours per week decreased by about half (235 to 160), and they are projected to decrease to roughly 126 by 2030. You can see the trend in the graph below, which traced MET-hours in several different areas, such as physical activity during work, transport, domestic activities, and leisure time. The black line is the average hours per week of being sedentary.

The rising trend from 2010 to 2030 represents one of the major public health challenges we face. 

 

What These Trends Don't Tell Us  

Even though registration and participation levels in endurance activities, such as triathlon and marathon, are increasing for a range of age groups, a couple things to remember.

First, this is still a relatively small proportion of the overall U.S. population, which is almost 315 million. From a sports, competition, and individual health perspective, increasing participation is a great thing. For people like myself, it provides a great opportunity to continue competing, setting and working towards new individual goals, staying in good overall health (though my third point mentions another counter-argument to this), and traveling to new and interesting places. However, one must keep this all in perspective that we're still talking about a fairly exclusive cohort of people.

Second, inequalities, particularly in regards to access, are major issues. Opportunities to participate in physical activity pay huge dividends with individual physical and mental health, population health, and create millions of dollars of health care cost savings annually. But, not everyone can afford a gym membership; or can safely walk to a park; or can spare the $120 marathon registration or the extra 30 minutes a day to train. The challenge is to celebrate record numbers of people taking on the endurance challenges of running, triathlon, cycling, etc, but to also ensure environments are conducive to regular physical activity for everyone.

Third, all the effort put into exercising everyday could be for naught if you spend hours sitting for the rest of the day. A recent review examining the link between sedentary time and diabetes, cardiovascular disease and cardiovascular and all-cause mortality in adults older than 18 years of age found that "higher levels of sedentary behavior are associated with a 112% increase in the RR of diabetes, 147% increase in the risk of cardiovascular disease, 90% increase in the risk of cardiovascular mortality and 49% increase in the risk of all cause mortality." Even more frightening are the results from a recent National Health and Nutrition Examination Survey. The study looked at almost 5,000 adults 20 years of age or older and found "Independent of potential confounders, including moderate-to-vigorous exercise, detrimental linear associations of sedentary time with waist circumference, HDL-cholesterol, C-reactive protein, triglycerides, insulin, HOMA-%B, and HOMA-%S were observed." (emphasis added) This essentially is saying that even if someone exercises in the morning, and the rest of the day is spent sitting, this could have a detrimental effects on risk factors - high levels of triglycerides, higher inflammation, higher waist circumference (a fairly good measure for dangerous visceral fat), etc - for heart disease and other chronic diseases.

So, I come back to this theme of optimizing. Sure there are a lot of health benefits to exercise and endurance training. But at the same time, if you're trying to maximize in this area of your life, and neglect other things (such as diet, stress, amount of time sitting during the day, etc), are you really optimizing for better overall health?

Let me know your thoughts and post a comment below.

Flawed from the start? NIH study of diabetics cut short after failing to show effect on heart disease risk

The objective of the 11-year, $220 million NIH funded study made sense – entitled the Look AHEAD trial - to see if an “intensive lifestyle intervention program” focused on improved diet and increased physical activity would lower heart risks, such as fatal and non-fatal stroke and heart attack, among more than 5,000 diabetics. There were of course high expectations, and researchers offered several reasons for the study’s perceived failings, which was recently halted. The National Institutes of Health released this statement on Friday, October 19, 2012.

But, was the study destined to fail from the start?

There is broad recognition about the close association between being overweight or obese, and risk for developing diabetes and heart disease. So, the study’s design went after this association, but did so by focusing exclusively on calories for the diet portion of the intervention and strictly followed dietary composition guidance by groups like the American Diabetes Association and the National Cholesterol Education, which advises a diet of 65% carbohydrate, 15% protein, and 30% fat (with a maximum of 10% of total calories from saturated fat). 

Yes, caloric intake is important to manage weight – the study called for “1200-1800 kcal/day depending on the individual’s baseline weight.” However, the study’s protocol also called for  “commercially available liquid meal replacements that will replace two meals and snacks each day” and a “frozen entrée” for an evening meal. This begs the question, is it surprising there was no effect observed on heart disease risk (even though weight loss was achieved, albeit a much greater percentage in the first year than over the entire timeframe of the study) when people were encouraged to each pre-packed frozen dinners and liquid meal drinks like Ensure.

If you’re curious, take a look at the nutrition labels and ingredients in products like Ensure:

In one bottle:

• ·      250 calories

• ·      40g of carbohydrate, with 22g from sugar (64% of total calories)

• ·      9g of protein (14.4% of total calories)

• ·      6g of total fat, with 1g of saturated fat (21.6% of total calories)

Ingredients: Water, Salt, Corn Syrup, Corn Maltodextrin, Milk Protein Concentrate, Soy Oil, Soy Protein Concentrate, Cocoa Powder (Processed with Alkali), Canola Oil. Less than 0.5% of the Following: Corn Oil, Potassium Citrate, Magnesium Phosphate, Magnesium Chloride, Calcium Phosphate, Soy Lecithin, Sodium Citrate, Sugar, Carrageenan, Choline Chloride, Ascorbic Acid, Natural & Artificial Flavor, Potassium Chloride, dl-Alpha-Tocopheryl Acetate, Ferric Phosphate, Zinc Sulfate, Niacinamide, Manganese Sulfate, Calcium Pantothenate, Cupric Sulfate, Vitamin A Palmitate, Thiamine Chloride Hydrochloride, Pyridoxine Hydrochloride, Riboflavin, Folic Acid, Chromium Chloride, Biotin, Sodium Molybdate, Sodium Selenate, Potassium Iodide, Cyanocobalamin, Phylloquinone, and Vitamin D3.

But a quick glance at the first five ingredients – of which there are 40 total – you will see corn syrup and corn maltodextrin as the third and fourth respectively. Basically, a bottle of lots of sugar with some added vitamins and minerals.

A similar glance at some of the popular frozen meal brands, like Lean Cuisine, shows a similar story of consuming many of the ingredients that undermine health rather than protect against heart disease, like sugar, carbohydrates, and vegetable oils. Here is an example of the beloved Chicken Parmesan dish:

• ·      300 calories

• ·      39g of carbohydrate, with 10g from sugar (52% of total calories)

• ·      18g of protein (24% of total calories)

• ·      8g of total fat (24% of total calories)

Ingredients: TOMATOES, BLANCHED SPAGHETTI (WATER, SEMOLINA), COOKED BREADED WHITE CHICKEN MEAT, GROUND AND FORMED (WHITE CHICKEN MEAT, WATER, SEASONING (MODIFIED FOOD STARCH, SUGAR, POTASSIUM CHLORIDE, YEAST EXTRACT, DEXTROSE, SPICE, ONION POWDER, GARLIC POWDER, PAPRIKA), ISOLATED SOY PROTEIN, SODIUM PHOSPHATE, SALT. BREADED WITH: ENRICHED BLEACHED WHEAT FLOUR (NIACIN, REDUCED IRON, THIAMINE MONONITRATE, RIBOFLAVIN, FOLIC ACID), DEXTROSE, SALT, MALTODEXTRIN, PARMESAN CHEESE (PARTIALLY SKIM MILK, CULTURES, SALT, ENZYMES), WHEY, ENZYME MODIFIED PARMESAN CHEESE (PARMESAN CHEESE {MILK, STARTER CULTURE, SALT, ENZYMES}, CREAM, NATURAL FLAVOR), SPICE, ONION POWDER, GARLIC POWDER, PARSLEY, CARAMEL COLOR, SOYBEAN OIL, EXTRACTIVES OF PAPRIKA. BREADING SET IN VEGETABLE OIL), TOMATO PUREE (WATER, TOMATO PASTE), PART SKIM MOZZARELLA CHEESE (CULTURED MILK, SALT, ENZYMES), ONIONS, 2% OR LESS OF WATER, SUGAR, SOYBEAN OIL, BASIL, MODIFIED CORNSTARCH, GARLIC PUREE, SALT, POTASSIUM CHLORIDE, SPICES, SKIM MILK, XANTHAN GUM, FLAVORS. 

Take Away 

So, was this study flawed? How can you make any impact on preventing heart disease – even in the presence of weight loss – when meals are loaded with sugar and carbohydrate? Diets high in both have been linked to worse predictors of heart disease risk and certainly aren’t doing much to help manage diabetes. Chronic and high levels of sugar and carbohydrate consumption require a matched insulin release, the hormone you’re precisely trying to control to prevent and/or manage diabetes.

Diet composition and quality of food matters. This study seems to be another example of how an exclusive focus on caloric consumption has its limitations with respect to overall and long-term health goals. I wonder if different results would have been achieved had all of the intervention group ate fewer calories, a lower composition of carbohydrates/sugars, and foods were all from real, quality sources, like fresh vegetables, meat, fish, fruit, and nuts?

Let me know what you think. Please post a comment.