Posts Tagged ‘insulin’

Pancreatic Cancer

October 19, 2013

 Pancreatic Cancer 

Andrew Siegel, M.D.  Blog #124

The pancreas is a vitally important organ that serves dual roles: as an endocrine organ that produces hormones including insulin and glucagon and as an exocrine organ that secretes digestive enzymes that help the process of fat, protein and carbohydrate breakdown and digestion.  It is located deep within the upper abdomen and is divided into a head, body and tail.  The head lies within the concavity of the duodenum (the first part of the intestine).  The body runs behind the stomach and the tail touches the spleen.  The fact that it is such a deep-seated organ makes it virtually impossible to examine on a physical exam (unlike superficial organs such as the breasts or testicles) and pathological problems of the pancreas are identifiable only on sophisticated imaging studies of the abdomen.

Cancer of the pancreas is an incredibly lethal malignant tumor.  Approximately 45,000 Americans will be diagnosed with pancreatic cancer in 2013 and more than 38,000 will die from the disease, with a five-year survival rate of only about 5%.   The greatest challenge is that there are no early detection tests and, unfortunately, most patients who have early and localized disease have no recognizable symptoms such that most are not diagnosed until late in the disease—after the cancer has spread (metastasized).

In spite of the dismal prognosis, there has been recent progress in pancreatic cancer with surgery becoming safer and less invasive, the availability of new drug combinations that have been shown to improve survival, and advances in radiation that have resulted in less side effects. Significant strides forward have been made in the understanding of the genetics of pancreatic cancer, and unlocking the molecular basis of this horrific disease hopefully will translate into better treatment options.

The most common form of pancreatic cancer is invasive ductal adenocarcinoma.  The second most common type is a pancreatic neuroendocrine tumor; this is less aggressive than the ductal carcinomas, but still has a 10-year survival rate of only 45%. Some of the neuroendocrine tumors manufacture hormones such as insulin that produce clinical syndromes.

A combination of inherited and environmental factors contributes to the development of pancreatic cancer. The most common environmental risk factor is tobacco; smokers having a more than double the risk of pancreatic cancer as compared to non-smokers.  The good news is that smoking cessation will substantially reduce the risk.  Other risk factors are long-standing type II diabetes, increased body mass index, heavy alcohol consumption, and chronic pancreatitis.   A strong family history of pancreatic cancer puts an individual at significant risk.  BRCA2 gene mutations also increase the risk. Additionally, patients who have hereditary pancreatitis have a 60-fold increased risk; this is so substantial that some patients with this disease opt for a prophylactic removal of the pancreas.

Now for Molecular Biology 101:  Genes are inherited bits of information that code for proteins.  When genes become mutated, the proteins that the genes code for become dysfunctional.  One can think of genes as the written recipe for a particular meal and their product as the meal itself—when the recipe is changed (mutated) the resultant meal is defective.  In the case of the human body, the altered genes code for altered proteins that damage cellular function and replication in such a way as to alter the normal orderly process of cellular reproduction, resulting in unrestrained, disorderly cell replication, aka cancer.  Scientists have identified numerous genetic mutations responsible for cancers and they are named with bizarre combinations of letters and numbers—do not be daunted by their names as follow.

So, on a molecular level, cancer is caused by inherited and acquired mutations in genes. The sequencing of the genetic material of the pancreatic ductal adenocarcinomas has demonstrated that four specific genes are each altered in more than 50% of these cancers.  KRAS, an oncogene (a gene with the potential to cause cancer), becomes activated in 95% of pancreatic cancers—the protein coded for by this gene plays an important role in cell signaling, a complex system of communication that governs basic cellular activities and coordinates cell actions. The p16/CDKN2A gene, a tumor suppressor gene (a gene that protects a cell from cancer that, when mutated, would allow the cell to progress to cancer), becomes inactivated in 95% of pancreatic cancers.  The protein product of this gene plays an important role in the regulation of the cell cycle and its loss promotes unrestricted cell growth. The TP53 tumor suppressor gene is inactivated in 75% of pancreatic cancers. Loss of its function through mutation promotes pancreatic cancer through the loss of a number of critical cell functions.  The SMAD4 tumor suppressor gene has a protein product in the cell signaling pathway that when interfered with is associated with a very poor prognosis and widely metastatic disease. In addition to these 4 major genes, there are numerous other genes that are mutated in pancreatic cancer at lower frequencies.

Unfortunately, most pancreatic cancers do not cause specific symptoms and are not diagnosed in a timely manner. Typical non-specific symptoms include upper abdominal pain radiating to the back; unexplained weight loss; nausea; jaundice; clay colored stools; and in a small percentage of people, migratory thrombophlebitis (multiple blood clots appearing in a variety of veins). At times, it can present with diabetes, symptoms of pancreatitis, or depression. Diagnosis is predicated upon imaging tests including CT, MRI, and endoscopic ultrasound.  Standard cancer staging is stage I through stage IV, with stages I an II being localized, III being locally advanced, and IV being metastatic. In the absence of metastatic disease, the ability to surgically remove the cancer is predicated on the relationship of the tumor to the adjacent major blood vessels.

Pancreatic cancer is a complex disease and is best treated by a multidisciplinary team including a surgeon, medical oncologist, and radiation oncologist. In general, patients with stage I/II disease should undergo surgery followed by adjuvant therapy (chemotherapy and/or radiation).  Patients with stage III locally advanced disease should be treated with chemotherapy and/or chemo-radiation.  Patients with stage IV and good performance status may receive systemic therapy and those with poor health should be given supportive therapy.

The best chance of long-term survival of a patient with localized pancreatic cancer is surgical removal. However, because pancreatic cancer is often beyond the confines of the pancreas at presentation and due to the potentially negative impact of surgery on quality of life as well as the low chance of long-term survival, surgery is often non-curative. Certainly, the risk of local and systemic recurrence after surgery is very high.

Bottom Line: Pancreatic cancer is a wickedly lethal cancer.  In terms of minimizing one’s risk, avoid tobacco, obesity and heavy alcohol consumption. So, don’t smoke, eat a healthy diet, maintain a good weight, and be moderate with alcohol.  Despite the dismal prognosis, there have been recent advances on many fronts, particularly in terms of the genetics of the cancer, wherein the key to treating this miserable cancer most likely lies.

“Sometimes life hits you in the head with a brick. Don’t lose faith. I’m convinced that the only thing that kept me going was that I loved what I did. You’ve got to find what you love. And that is as true for your work as it is for your lovers. Your work is going to fill a large part of your life, and the only way to be truly satisfied is to do what you believe is great work. And the only way to do great work is to love what you do. If you haven’t found it yet, keep looking. Don’t settle. As with all matters of the heart, you’ll know when you find it. And, like any great relationship, it just gets better and better as the years roll on. So keep looking until you find it. Don’t settle.” 

Steve Jobs, who died of neuroendocrine cancer of the pancreas

Reference: Recent Progress in Pancreatic Cancer, Wolfgang, Herman, Laheru, Klein, Erdek, Fishman and Hruban

CA CANCER J CLIN 2013;63:318-348 September/October 2013

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health; in press and available in e-book and paperback formats in January 2014.

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe and receive notifications of new posts in your inbox.  Please feel free to avail yourself of these educational materials and share them with your friends and family.

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Not So Sweet on Sugar

September 14, 2013

Andrew Siegel  Blog #119

Nature is ever so clever—look at our human species—brilliantly evolved and adapted not only to survive, but also to thrive on this planet, breathing the air in the atmosphere, drinking the water and eating the bounty from the soils of the fertile earth.

Whenever clever nature provides us with a nutrient that is potentially unhealthy, it protects us by limiting our access to that nutrient.  Take, for example, sugar—also known as sucrose or, alternatively, 50% glucose/50% fructose—clearly unhealthy and a key contributor to the obesity epidemic.  The major sources are sugar cane and sugar beets.  If you ever tried to extract the sugar out of a sugar cane or sugar beet plant you would quickly find that they are fibrous and unyielding. If you want to derive calories from them, it requires great effort and you will likely end up quite frustrated.  It’s not unlike chewing on a stick of bamboo and trying to suck the sugar out—at best we will only get a few calories out of the whole endeavor and probably burn more calories than taken in with the effort.

Because of the collective intelligence of mankind, we are now easily able to remove the protective fiber matrix of the sugar cane or sugar beet and process the sugar into a pure, refined and powdery product.  This enables unrestricted access to the sugar and allows many “naked” calories to be easily consumed in a short time period. That is NOT the way nature intended, but humankind has prevailed over nature. Processing has allowed us to cheat nature by refining sugar, permitting consumption in immoderate and unhealthy amounts, contrary to nature’s design.  However, it is very difficult to beat nature in the long run, and though mankind may have won this battle, we are losing the war, because the consequences of excessive sugar consumption are potentially dire and grave.

Most humans love—if not crave—the taste of sugar. It activates pleasure pathways in our brain that reinforce the desire for its continued consumption and, in some of us, it behaves like addictive substances.  Even if one is extremely disciplined and rarely opens a packet or cube of sugar to sweeten their ice tea, chances are they nonetheless are consuming way too much sugar.  The typical American diet adds 25 or so teaspoons of sugar to our daily consumption.  This includes sugar from sugar cane and sugar beet sources as well as from the highly processed high fructose corn syrup (HFCS).  In one month, this inadvertent cumulative sugar consumption is equivalent to approximately 4 extra days of eating!

Sucrose—a.k.a. table sugar—is a combination of glucose and fructose.   All sugars are not the same.  After consuming glucose, it is absorbed by the small intestine and used as fuel by our cells, aided by the hormone insulin.   Any glucose that does not need to be used for immediate fuel is stored in the form of glycogen in our muscles and liver.   Fructose behaves differently than glucose. Insulin does not have an effect on fructose and after absorption it goes straight to our livers where it is mostly converted to fat.  Fructose does not cause the same amount of satiety as glucose does. Too much fructose leads to increased visceral fat and high blood lipid levels.

Fructose is the predominant sugar in many fruits, hence the term fructose. How do we explain the apparent paradox between fructose being a “bad” sugar, yet fructose being the main sugar in fruit, which is good for us? One difference between the fructose contained within fruit as opposed to that within a bottle of soda is that fruit fructose is natural and not created in a chemistry lab (i.e., high fructose corn syrup).  Additionally, the concentration of fructose in fruit is significantly less than that contained within the soft drink. Furthermore, the fructose in beverages is a source of “empty” calories—essentially liquid candy—as they do not contain health-promoting ingredients present in fruit including fiber, anti-oxidants, vitamins, minerals and other phyto-nutrients. Because of the fiber content of the apple, the sugars are slowly absorbed whereas the “naked” sugars in beverage form are rapidly absorbed, providing a “load” of fructose to the liver.  More than being just empty calories, fructose is a source of poisonous calories that promote obesity—think of fructose as fat.

Let’s do the math comparing an apple to a bottle of soda: An average-sized apple has about 80 calories: this includes 20 grams of sugar consisting of 4 grams of sucrose (equivalent to 2 grams fructose and 2 grams glucose), 5 grams of glucose, and 11 grams of fructose, for a total of 13 grams of fructose.  A 20-ounce bottle of soda has about 240 calories: this includes 60 grams of sugar all from HFCS (55% fructose / 45% glucose) for a total of about 35 grams of fructose. 

High fructose corn syrup is a gooey, liquefied sweetener that is abundant in processed foods and beverages. The typical American consumes an astonishing 50-100 pounds of HFCS per year! The derivation of HFCS is as follows: Corn is milled to cornstarch, a powdery substance that is then processed into corn syrup.  Corn syrup consists primarily of glucose. Through a complex chemical process, the glucose in the corn syrup is converted to fructose.  HFCS results from the mixing of this fructose back in with glucose in varying percentages to achieve the desired sweetness: 55% fructose/45% glucose ratio of HFCS is used to sweeten soft drinks; 42% fructose/58% glucose ratio of HFCS is used in baked processed foods.  

The processed food industry is quite enamored with HFCS for a number of reasons. First, it is cheaper than sugar because of huge corn subsidies and sugar tariffs.  Second, the liquid syrup lends itself to ready transportation in enormous storage vats within 18-wheelers, similar to how gasoline is hauled.  Third, fructose is incredibly sweet and does not crystallize or turn grainy when cold, as sugar can do.  Fourth, because HFCS is very soluble and retains moisture, it makes for softer and moister processed baked goods.  Fifth, it acts as a preservative that extends the shelf life of processed foods and helps to prevent freezer burn.  Finally, HFCS is a key ingredient in many processed junk foods, which are addictive and promote cravings and continued consumption.

There is a good reason why HFCS is so demonized: while HFCS may help “preserve” processed foods, it does not help “preserve” us!  In fact, a diet high in HFCS will help accelerate our demise. To reiterate an important fact: fructose is metabolized very differently from glucose.  Every cell in our bodies can metabolize glucose, but it is primarily the liver that metabolizes fructose. Fructose does not stimulate insulin release as does glucose, nor does it stimulate leptin (our satiety hormone).  Fructose, more readily than glucose, replenishes liver glycogen, and once the liver is saturated with glycogen, triglycerides (fats) are made and stored. So, too much HFCS and we end up with a fatty liver and body.  The bottom line is that HFCS ingestion pushes our metabolism towards fat production and fat storage, potentially leading to obesity, diabetes, elevated cholesterol, high blood pressure and cardiovascular disease.  HFCS should be thought of as a toxin, in precisely the same way that tobacco is dangerous to our health.  Unfortunately, sugar in the little packets that we use to sweeten our frappuccinos is really no better.

Bottom Line Tips: High fructose corn syrup and sugar are NOT our “friends,” so:

·      Don’t drink too many calories or sugars if possible: minimize sodas, sweetened ice tea, lemonade, fruit juices, sports drinks, etc.  Water or seltzer with lemon, lime or other fruit is so much healthier.  Go for the real fruit instead of the juice.  Easy on the alcohol because it is all carbs. Even milk has sugar in the form of lactose, (consisting of glucose and galactose, about 11-12 grams/cup.

·      Avoid processed yogurts that are laden with excessive amounts of sugar because of the processed fruit on the bottom.  You are much better off adding fresh fruit to plain yogurt.

·      Try to avoid snacking on candy, cookies, energy bars, etc., and instead munch on nuts, fiber-rich fruits and vegetables and whole grains, like popcorn.

·      Eat healthy cereals instead of those that are sugar-laden: steel-cut oats are so much healthier than Fruit Loops.

·      Beware of “alternative” sweeteners—brown sugar, honey, molasses, maple syrup are all more-or-less the same.

·      Read labels carefully since about 75% of packaged foods have sweeteners some that would surprise you, including sauces, salad dressings, breads, etc.

·      Bottom line: use sugar and alternative sweeteners in moderation

Coming soon: Artificial sweeteners

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health, in press and will be available in e-book and paperback formats in the Autumn 2013.

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.

Beach Body Season

May 11, 2013

Beach Body Season 

Andrew Siegel, M.D.   Blog #106

Michelangelo’s “David” was at one time a mere solid block of marble.  The master artist crafted this magnificent sculpture by knowing exactly what to carve away.  Antoine de Saint-Exupery (author of Le Petit Prince) wrote: “Perfection is not when there is no more to add, but when there is no more to take away.”

We all have “beach bodies” obscured beneath our perhaps winter-weighted physiques.  We may be a bit flabbier and less toned than desirable, but somewhere hidden within is a sinewy, tight, and lean figure. What can we do to bring out this inner beach body—to allow us to feel confident, svelte and shapely—since swimsuit season is right around the corner?

A great body (and more importantly, a healthy body) mandates a lifestyle encompassing a healthy diet and plentiful physical activity—this is a process incorporated into the daily existence of those who respect themselves and are committed to being stewards of their own wellness.  Realistically, this is a lifetime pursuit—major changes are not going to occur in 6 weeks of “cramming” to achieve a respectable appearance at the beach. However, all journeys start with small steps and with diligence, some real and measurable progress towards that beach body can be made even after a few weeks of effort.  Within a month or so of consistent healthy eating and exercise, we should note the pounds peeling off, better muscle tone, and increased energy levels.

Nutrition to Maximize Our Beach Body Appearance

To help sculpt our bodies to reveal the “David” or “Venus de Milo” within, we are going to need healthy fuel to serve as energy and provide the basic building blocks for the reconstructive and regenerative processes that are ongoing in our bodies.  For weight loss, we will need reduced caloric consumption—3500 calories fewer per week will result in a one-pound loss, a very realistic and reasonable goal.  As weight gain is gradual, so should weight loss be.  No fads, no gimmicks, no nonsensical, unbalanced, ridiculous diets—just a sensible reduction in calories and an effort to eat healthy, nutrient-dense, natural and unprocessed foods.

Since portion control is fundamental to the process, a really easy diet is simply to reduce portions to one-half to three-quarters of our normal size helpings.  When it comes to snacking, we should make every effort to eat wholesome fresh vegetables and fruits instead of processed junk that often contain a load of unhealthy fats, salt and carbohydrates. It is important to make smart choices and often our intuition will suffice to guide us.

Lean sources of protein such as egg whites, wild salmon (or any other wild fish that is grilled or broiled), skinless chicken, turkey breast, fat-free yogurt and soy products such as tofu and edamame are healthy and desirable.  We should be judicious with meat and dairy intake because they are rich in saturated fats and high in calories.  Vegetables are a much healthier source of fat—think nuts, avocados and olives.  High fiber foods—vegetables, fruits and legumes including lentils, peas and beans—are very filling and the fiber regulates the rate of carbohydrate absorption. Intake of a variety of brightly colored fruits and veggies will ensure getting ample doses of phyto-nutrients and anti-oxidants.   We need to attempt to minimize the rich sauces and fattening dressings put on otherwise healthy foods…if we cannot avoid them, then we need to use them in moderation.   It is important to be careful with our sodium intake as it causes fluid retention, bloating, weight gain and a number of potential medical issues.

And now a brief discussion of the science of fat: Our hormone insulin has much to do with the way our bodies store or burn fat—when insulin levels are elevated, we accumulate fat; when levels are low, we burn fat as fuel.  Our insulin levels are more-or-less determined by the carbohydrates we eat: the more carbs we eat, the sweeter they are, the easier they are to digest, the greater the insulin levels and the more that fat accumulation is driven. Insulin secretion caused by eating carb-rich foods—flour and cereal grains, starchy vegetables like potatoes, sugars and high-fructose corn syrup—makes us fat.  The sweeter the food, and the easier it is to digest, the fatter it will make us, and liquid carbs such as sodas, fruit juices and beer are probably the biggest culprits.

So, we need to try to steer clear of refined carbohydrates, substituting whole grain products for white bread, refined pasta, white rice, etc.   It is very important to minimize sugar intake since sucrose is fructose/glucose and fructose gets metabolized much differently from glucose, pushing our bodies towards fat deposition…the same thing goes for high fructose corn syrup (HFCS), which should be avoided like the plague.  Let fruits be the source of fructose for our bodies, not refined sugars and HFCS.  It is imperative that we carefully read food labels to know what we are consuming.

To repeat a very important principle: if we want a beach body we do NOT want to drink our calories—actively avoid liquid calories such as soda, juices, processed iced tea, etc.  The best drink is water or seltzer—we can spritz them up with a lemon or lime.  Lots of water will serve to keep us well hydrated, dampen our appetites, and will quell our thirsts, which are sometimes confused for hunger.  Remember that liquid calories include alcohol—a beer belly is the opposite of a beach belly.  It is best to be moderate with alcohol consumption during the beach body training period—reducing alcohol will also help us maintain our discipline, which can easily be thrown by the wayside due to the uninhibiting effects of alcohol.  Sobriety will go a long way towards molding that beach body.

Exercise to Maximize Our Beach Body Appearance

Our bodies are remarkably engineered to adapt to the stresses placed upon them with compensation, adapting to exercise with increased muscle strength and fitness.  The general rule of thumb is to think “athletics” and the “aesthetics” will follow.   The key to exercise is diligence—carving out the time—and variety—strength  (resistance) training, cardiovascular (aerobic) training and core (abdominal and torso) conditioning.  A core synergistic exercise regimen, which is a combination of the aforementioned three types of exercise, provides a great overall workout.

Muscles play a key role in our metabolism: they are extremely metabolically active.  With a sedentary existence and aging, there is a gradual loss of muscle mass and a resultant slowing in our resting metabolic rate.  By building and maintaining our muscle mass with strength training, we will raise our resting metabolic rate and burn more calories.  Additionally, exercise serves to increase the “insulin sensitivity” of muscle, which means that our muscles become more efficient at burning off carbs as fuel, before they have a chance to become stored as fat.

We can measure our maximal heart rates by doing an aerobic activity, such as swimming, running or cycling full throttle until we can’t go on, and then taking our pulses.  In our workouts, if we can achieve a heart rate of 75% of our maximum rate and sustain that for 30-60 minutes daily, it is easily conceivable to burn 600 or more calories per day.   High intensity interval training—alternating between extremely intense exertion and regular “normal” exertion—can rapidly help propel us towards the beach body within.

“Integrational” exercise—incorporating non-gym physical activities into our daily lives—is an alternative form of exercising that burns calories and gets us moving just the same.  These include gardening, house chores, vacuuming, walking the dog, chopping down trees, etc.  It has even been shown that fidgeting will do the trick.  The key is to get off the couch and get moving.

In order to feel and look your best it will take the combined efforts of diet and exercise.  A healthy diet is fundamental and will help you look great in clothes, but it is the exercise component that will help you look and feel great in a bathing suit. Maintaining good posture like a ballet dancer will help with the beach body mode—David and Venus certainly do not slouch forward with rounded shoulders.  To this end, yoga and Pilates are wonderful forms of exercise. Getting enough rest and sleep is also imperative.  Insufficient sleep makes it difficult to exercise and the fatigue eating that often ensues can often be detrimental to our goals.

Minimizing stress and negativity in our lives will help many causes, including the beach body one.  Our stress hormone—cortisol—functions to stimulate our appetites and cravings and promotes fat deposition and weight gain. Stress can be managed in a healthy fashion through exercise as opposed to the unhealthy habit of stress eating.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.

Fat: Location, Location, Location Matters

September 14, 2012

Andrew Siegel, M.D.     Blog #74

 

We all have body fat; even elite athletes have a body composition that is a svelte 5-10% fat—this translates into roughly 10-20 pounds of fat for a 180-pound athlete.  What is important is that all fat is not created equal—where the fat accumulates in our bodies dramatically effects how that fat behaves.  So, the very location where your fat takes up residence has a tremendous influence on your health.

Fat on our body surface is much less problematic than fat deep within our body. Humans have two basic types of fat: subcutaneous fat and visceral fat. Subcutaneous fat—also known as “love handles,” “spare tires,” “muffin tops,” or “middle-age spread”—is present between the skin and the abdominal wall. When present in normal amounts, it gives us nice contours and makes us look less bony and skeletal and more smooth and curvy. When present in excessive amounts, it makes us look plump, roly-poly and pear-shaped. A moderate amount of subcutaneous fat is of little danger to our health and, in fact, provides us numerous advantages including padding and insulation to conserve heat and help with temperature regulation, a means of storage of fat-soluble vitamins, and a ready source of energy. Visceral fat—also referred to as a “pot belly,” “beer belly,” or “Buddha belly”—is internal fat deep within the abdominal cavity that can make us apple-shaped.  It wraps around our internal organs including our liver, kidneys, and pancreas. Visceral fat is always unhealthy fat that can have dire metabolic consequences. In general, waist circumference is a reasonably good measure of visceral fat. (Of course, morbid obesity due to either type of fat can prove extremely  dangerous to one’s health.)

It’s kind of like real estate, the value of which is predicated on location, location, location. Think of visceral fat as prime, expensive beachfront property on the gold coast with a short walk to the ocean, the ocean of metabolic disasters.  Think of subcutaneous fat as less expensive, inland property, quite removed from this ocean of metabolic disasters.  Clearly, visceral fat is fat that behaves badly and fat that is strongly desirable to avoid.

In many ways, the distinction between subcutaneous and visceral fat parallels the distinction between good fats and bad fats in our diet.    The not unhealthy one or two inches of subcutaneous fat that you can pinch around your waistline can be thought of as a good fat such as the fat in olive oil, avocados, or nuts.   On the other hand, the unhealthy visceral fat that causes a man to have a big protuberant abdomen—creating an appearance not unlike a very pregnant female—can be thought of as bad fats such as the partially hydrogenated fats present in vegetable shortening that are commonly used in fast foods and other processed baked goods.

Visceral fat storage is not static but dynamic, meaning that there is continuous mobilization of our fat (as fatty acids) and storage (as triglycerides).  Lipolysis is the chemical reaction in which the fat is broken down into fatty acids that the body can use as energy. This can occur very readily in visceral fat. Likewise, accumulation of visceral fat can occur in a very rapid fashion. Excessive intake of calories will be rapidly stored as visceral fat, whereas under circumstances of a reduced calorie intake, the visceral fat is broken down to provide fuel for our bodies’ metabolic processes, particularly muscle contraction.

Visceral fat is not just a bland collection of fatty tissue sitting inertly within your belly causing an oversized appearance to your abdomen.  It is an extremely metabolically active endocrine organ with a life of its own.  Fat is the largest endocrine organ in our bodies and it releases a myriad of pro-inflammatory factors, hormones and immune cells that can affect metabolism and other bodily functions. Fat has an abundance of the hormone aromatase, which converts testosterone to the female hormone estrogen.  One consequence of too much fat in men is excessive conversion of testosterone to estrogen. Men with plentiful visceral fat often will bear the consequences of lower testosterone and higher estrogen levels, including sexual issues and breast development as well as numerous other negative consequences of insufficient levels of testosterone.

Visceral fat is intimately connected to the inflammatory process and can result in insulin resistance, metabolic syndrome, cardiovascular disease and an entire array of negative health ramifications, including chronic diseases such as arthritis and cancer.  This is in contradistinction to subcutaneous fat, which produces far less inflammatory chemicals. Since men have a tendency towards visceral fat collection whereas women have a tendency towards subcutaneous fat collection, this might explain why women are less susceptible to cardiovascular disease then men are.

Insulin is the principal regulator of fat metabolism. After a sugar and carbohydrate load, insulin is released to get the fuel into our cells. When we go without food, as happens when we sleep, insulin levels decrease and fat is released to be used as fuel.  Insulin levels are determined primarily in response to our carbohydrate intake in order to keep our blood sugar regulated. Insulin has much to do with the way our bodies store or burn fat. You can think of insulin as our fat hormone—when insulin levels are elevated, we accumulate fat; when levels are low, we burn fat for fuel.  So if you have a substantial collection of visceral fat, it becomes highly desirable to reduce sugar and refined carbohydrate intake to decrease insulin and burn away that bad, pro-inflammatory fat as fuel. The good news is that by losing abdominal fat, the potentially bad health repercussions can be reversed. The dangerous visceral fat submits relatively easily to diet and exercise whereas the less harmful subcutaneous fat at the waist is more stubborn and resistant to reversal measures.

How To Burn Fat:

  • Eat in accordance with nature’s design—meaning whole foods.  Avoid processed foods.  The best diet is an “anti-processed-atarian” diet.
  • Avoid “naked” calories (stripped of fiber), so restrict sugar, simple white carbohydrates, and liquid calories. Specifically avoidsugared drinks, white pasta, white rice, white bread, doughnuts, bagels, potatoes, etc.  Aggressively steer clear of high fructose corn syrup.
  •  Eat high-quality, whole-grain, high-fiber carbohydrates (whole grain pasta, brown rice, whole grain breads, legumes, whole fruits and vegetables), lean protein sources (easy on meat and dairy) and healthy fats (vegetable and seafood-origin).
  • Avoid giant meals in which the caloric load will be stored as fat; substitute with multiple smaller meals in which the calories will be used for immediate energy.
  • Limit after dinner snacking since unnecessary calories at a time of minimal physical activity will be stored as fat.
  • You must incorporate exercise into your lifestyle, achieving balance between aerobic, resistance and core workouts.  Aerobic exercise has great potential in burning fat for fuel and interval training seems to really rev up our fat-burning capabilities.
  • Portion control is the name of the game: in order to burn fat, energy intake must be less than energy output.  Even if you eat only the healthiest of foods, if calories in exceed calories out, you will not burn fat for fuel.
  • Minimize stress; if you can’t eliminate it, work to manage it.
  • Get adequate amounts of quality sleep.  See my previous blog entitled “Sleep To Slim” to find details: https://healthdoc13.wordpress.com/2012/07/20/sleep-to-slim/

The bottom line is that while body fat in any excessive amount is unhealthy and unattractive, it becomes a potentially life-threatening issue depending on its location in our bodies.  An enormously protuberant belly can lead to processes that result in disease—and even death.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

www.PromiscuousEating.com

Now available on Amazon Kindle

 

Eat It Raw

August 11, 2012

Blog # 70   Andrew Siegel, M.D.

 

There are numerous health advantages to eating raw produce.  As a general premise, the less our food is processed, the healthier it is—and cooking is certainly a form of processing.  There is often some degree of nutrient loss as a vegetable or fruit is cooked.   If weight loss is a concern, raw is particularly good because one expends more calories just to break down raw food as opposed to cooked food, which is essentially “pre-digested.”   Also, since raw foods are less calorie-dense because of increased water content, they not only are more filling, but also require more energy to heat the increased water content to body temperature.  The need to use additional calories to burn calories is called the thermogenic effect.  For example, eating raw broccoli has a strong thermogenic effect; drinking soda has very little thermogenic effect.

Clearly, raw food is less digestible and more bulky and filling than its cooked brethren. Raw foods require more chewing and thus more exercise of our masseter muscles of the jaw—hence more calories burned. This increased requirement for chewing—think raw carrots vs. cooked—forces us to eat more slowly and increases our satiety.  The high fiber content of raw fruit and vegetables slows digestion and minimizes glucose fluctuations, modulating insulin spikes and thus helping to prevent fat deposition and weight gain, in addition to its beneficial effect on bowel regularity.

Forget about all of the potential benefits for health and vitality for a moment.  On a more primal level, there is nothing like the delight derived from a piece of ripe, juicy, aromatic summer fruit bursting with sweetness and intense flavor. The vibrant color appeals to our vision, the sweet scent is alluring, the feel in our hands and mouth is pleasing, in addition to being downright delicious and a reminder of the beauty of the simple and natural things that life has to offer.

By no means am I recommending a totally raw produce diet, but it is reasonable to shake it up and consume some vegetables and fruits in their natural state.  Most people eat some raw vegetables in the form of salads, and raw fruit is often the norm for most of us.   But many of us would be well served to increase the amount and variety of raw veggies in our diet.   Think of a nice crudité platter as opposed to mushy cooked vegetables. Keep in mind a beautiful red delicious apple vs. a baked apple or applesauce.

Advice of the day: Eat a salad with crunchy vegetables before a meal to help decrease caloric consumption during the meal.  Throw in some strong flavored veggies like radicchio, scallions, radishes or arugula because their intensity is so stimulating that they can induce satiety, allowing us to eat less. Alternatively, a piece of fruit before a meal will achieve the same endpoint.  Experiment with how you use raw fruits and vegetables—the results can be a delightful change for your palate, and a slimmer waistline.

Andrew L. Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

www.PromiscuousEating.com

Available on Amazon Kindle

Diabetes and the Urologist

April 21, 2012

Andrew Siegel, M.D.   Blog #55

“Let food be your medicine and medicine be your food.”

Hippocrates

Many diseases and disabilities are related to the quantity and quality of the foods we eat and the amount of exercise we get or don’t get.  The most prevalent form of diabetes, Type 2, is a classic example of an avoidable disease that occurs because of lifestyle indiscretions. Type 2 diabetes is now occurring in epidemic proportions and, sadly, can have catastrophic consequences including: heart disease, strokes, blindness, kidney failure requiring dialysis and vascular disease resulting in amputations.  This disease has the capability of dramatically decreasing the quantity and quality of our lives.

There are over 25 million diabetics in the USA, and the incidence is rapidly spiraling upwards, particularly because of poor dietary choices and insufficient exercise.  Diabetes causes elevated blood glucose (i.e., sugar) and occurs on the basis of a defect in the body’s ability to produce the pancreatic hormone insulin or use the insulin (insulin resistance). The function of insulin is to regulate glucose and move it  into our cells so that it can be used for energy and metabolism.  When insulin is unavailable or the body has developed resistance to its effect, blood glucose levels rise uncontrollably with potential dire health complications.

Common presenting symptoms of diabetes are frequent urination, thirst, extreme hunger, weight loss, fatigue and irritability, recurrent infections, blurry vision, cuts that are slow to heal, and tingling or numbness in the hands or feet.  However, the most common symptom may unfortunately be…no symptom at all.

There are two distinct types of diabetes.  These were formally called juvenile diabetes and adult-onset diabetes, but because of the increasing incidence of obesity in children (such that children are now developing adult-onset diabetes), they have been renamed Type 1 and Type 2.  Type 1diabetes is not linked to obesity and is responsible for about 5% of diabetes.   It is an autoimmune condition in which the body’s immune system destroys its own insulin-producing cells, thus severely limiting or completely terminating all insulin production, and is often inherited. It is managed by insulin injections or an insulin pump. 95% of diabetes in the USA is Type 2 diabetes, also known as diabesity (diabetes caused by obesity). This form of diabetes is typically on the basis of insulin resistance, due predominantly to environmental factors including overeating and sedentary living.  Unlike Type 1, Type 2 diabetics produce plenty of insulin, but their bodies cannot process the insulin and are resistant to its actions. Anybody who has excessive abdominal fat is on the pathway from insulin resistance towards diabetes.

While Type 1 diabetes is treated primarily with insulin replacement, diet and exercise are also necessary for its management. With Type 2 diabetes, it is imperative to pursue a lifestyle modification, including dietary changes that avoid certain diabetic-promoting foods and replacement with healthier foods.  Diabetics should refrain from high glycemic index foods (those that are rapidly absorbed) including sugars and refined white carbohydrates and instead should consume high-fiber vegetables, fresh fruits, and whole-grain products.   Regular exercise is equally as important as good dietary habits, and the combination of healthy eating, physical activity, and weight loss can often adequately address Type 2 diabetes.  When lifestyle measures cannot be successfully implemented, there are different classes of medication that can be used to manage the diabetes, although lifestyle modification should always be the initial approach, since lifestyle (in large part) caused the problem and is capable of improving/reversing it.   At times, when diet, exercise and drugs have not been able to control the diabetes, bariatric (weight loss) surgery might be needed to control and even potentially eliminate the diabetes.

As a urologist (a urinary tract specialist), it is not uncommon for me to make the initial diagnosis of diabetes.  This is because diabetes often presents with urinary frequency, a symptom typically treated by urologists.  Sleep-disruptive nighttime frequency is a particularly disturbing symptom and is often a major complaint that brings patients into my office.  Because diabetes causes high levels of blood glucose, this results in glucose in the urine, which causes a diuretic effect (lots of urine production).  In fact, earlier this week a patient came in complaining of new onset of significant urinary frequency; his urinalysis on dipstick showed glucose (normally there should be no glucose in the urine) and his serum glucose was over 400 (normally < 100).  He was promptly sent to his internist for management of Type 2 diabetes.

Additionally, many uncircumcised men who present to my office with foreskin problems have diabetes.  In fact, when a man has foreskin issues such as the foreskin being stuck down over the head of the penis and is not able to be pulled back (phimosis), the first thing I do is to dipstick the urine for glucose.

Aside from urologists having the occasion to make the initial diagnosis of diabetes, we also have ample opportunity to treat many diabetic patients because of the urological problems that can occur as a result of the diabetes, including urinary infections, bladder conditions, and sexual problems such as erectile dysfunction. Additionally, recent studies have indicated that diabetes greatly increases the risk of kidney stones. Although many of these symptoms are common with the aging process in the absence of diabetes, the presence of diabetes hastens them, causing earlier onset and increased severity of these issues.

In general terms, the complications of diabetes occur because of damage to blood vessels and nerves.  Diabetes accelerates atherosclerosis, a condition in which fatty plaques get deposited within the walls of arteries, compromising blood flow and the vital delivery of oxygen and nutrients to tissues. Diabetic “small blood vessel” disease can lead to retinopathy (visual problems leading to blindness), nephropathy (kidney damage leading to dialysis), and neuropathy (nerve damage causing loss of sensation in the hands and feet). Diabetic “large vessel disease” can cause coronary artery disease, stroke, and peripheral vascular disease.  Diabetes increases the risk of infections because of poor blood flow and impaired function of the infection-fighting white blood cells.  It is important to know that diabetic control can lower the chances of the early onset and severity of the aforementioned problems.

Many diabetics have urological problems on the basis of neuropathy that affects the bladder.  These issues include impaired sensation in which the bladder becomes “numb” and the patient gets no signal to urinate and impaired bladder contractility in which the bladder muscle does not function properly, causing inability to empty the bladder completely.  Other diabetics develop involuntary bladder contractions (overactive bladder), causing such symptoms as urgency, frequency and incontinence.  The good news here is that there are effective, non-invasive means of managing diabetic voiding dysfunction.

Diabetics have many more urinary tract infections than the general population because of many factors including improper functioning of the infection-fighting white blood cells, glucose in the urine (a delightful treat for bacteria) and compromised blood flow to the kidneys and bladder.  Diabetics have a greater risk of asymptomatic bacteruria and pyuria (the presence of white cells and bacteria in the urine without a frank infection), cystitis (bladder infections), and pyelonephritis (kidney infections).  Impaired bladder emptying further complicates the potential for infections.  Diabetics have more serious complications of pyelonephritis including kidney abscess, emphysematous pyelonephritis (infection with gas-forming bacteria), and urosepsis (a very serious systemic infection originating in the urinary tract requiring hospitalization and intravenous antibiotics).  Fournier’s gangrene (necrotizing fasciitis) is a soft tissue infection of the male genitals that often requires emergency surgery (that can be very disfiguring) and has a very high mortality rate.  Over 90% of patients with Fournier’s gangrene are diabetic.  Diabetic patients also have an increased prevalence of infections with surgical procedures, particularly those involving prosthetic implants, such as penile implants, artificial urinary sphincters, and mesh implants for pelvic organ prolapse.

Satisfactory sexual functioning is predicated upon good blood flow and an intact nerve supply to the genitals and pelvis.  Diabetics often develop sexual problems because of the combination of neuropathy and blood vessel disease.  Men commonly have a reduced sex drive and have difficulty achieving and maintaining erections.  Diabetes has clearly been linked with testosterone deficiency that can worsen libido and sexual function.  Because of the neuropathy, many diabetic males have retrograde ejaculation, a situation in which semen goes backwards into the bladder and not out the urethra.  Female diabetics are not spared from sexual problems either and commonly have reduced desire, decreased arousal, and vaginal lubrication issues.

In summary, diabetes is a serious chronic illness with potentially devastating complications. Type 1 diabetes is relatively rare and unavoidable, but is eminently manageable with insulin replacement. Type 2 diabetes is now epidemic and its prevalence has increased dramatically coincident with the expanding American waistline. Type 2 is avoidable and can be improved/reversed through integration of healthy eating habits, weight management, and exercise.

Many people—myself included—do not relish seeing doctors, because such visits can be frightening, invasive, and sometimes uncomfortable.  It is a simple fact that healthy people do not need to consult doctors very often, aside from routine “wellness” visits.  The corollary is if you don’t want to see doctors very often, stay healthy.  To stay healthy you need the right lifestyle—avoiding tobacco, maintaining a satisfactory weight, eating healthy foods and drinking in moderation, avoiding stress, and getting plenty of exercise as well as adequate sleep. If your lifestyle is not up to par, remember that it is never too late to change. Your health is ultimately your own responsibility, but as doctors, it is our responsibility to help educate you and guide you towards the pathway of healthy habits and lifestyle—there is simply no magic bullet other than this.  Lifestyle modifications can be amazingly restorative to your health and overall well being.  And simply put, there is absolutely nothing else that transcends being healthy.

A special thank you to diabetes specialist Joseph Giangola, M.D. for reviewing and editing this blog entry.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

www.PromiscuousEating.com

Now available on Amazon Kindle

Refined Foods: Not So Fine For Us

February 11, 2012

 

Blog # 45   Andrew Siegel, M.D.=

 

 

Nature is ever so clever—look at our human species—amazingly engineered, evolved and adapted not only to survive, but also to thrive on this planet.

Whenever nature provides us with a nutrient that is potentially unhealthy, it protects us does by limiting our access to that nutrient.  Take, for example, sugar—also known as sucrose or alternatively, 50% glucose/50% fructose—clearly unhealthy and a key contributor to the obesity epidemic.  The major sources are sugar cane and sugar beets.  Did you ever try to get the sugar out of a sugar cane or sugar beet plant?  They are fibrous and unyielding and if we want to derive calories from these, it will require great effort and we will likely end up frustrated.  It’s like chewing on a stick of bamboo!

However, because of the collective intelligence of mankind—standing on the shoulders of giants, if you will—we are now able to easily remove the protective fiber matrix and process the sugar cane or sugar beet into a pure, refined and powdery product.   This process enables unrestricted access to the sugar and allows many “naked” calories to be easily consumed in a short time period. That is NOT the way nature intended, but humankind has prevailed over nature. Processing has allowed us to cheat nature by refining sugar, permitting consumption in immoderate and unhealthy amounts, contrary to nature’s design.

Now lets move on to a discussion about the processing of grains—specifically wheat, since these amber waves of grain are one of the staples of the American diet. However, this same line of thought is relevant to other grains including rice, corn, rye, oats, barley, etc.  The bottom line is that processing leaves us with a very refined product—not unlike sugar—again cheating nature’s “natural” protective mechanisms.  Unfortunately, when we cheat nature, we ultimately cheat ourselves.

Wheat needs to be processed to make it available and accessible to us. Threshing is the means whereby the chaff  (the wheat husk) is separated from the wheat kernel, the diamond of wheat.  Highly efficient milling enables the wheat kernel to be separated into the following three components—the bran: the outer covering of the wheat kernel; the germ: the embryo or sprouting section; and the endosperm: the source of the white flour that contains starch and protein.

White flour has the bran and germ removed, resulting in a pure, highly refined powder as opposed to whole-wheat flour that contains the bran and germ. By removing the fiber-rich bran and germ, the resulting product has a longer shelf life and makes for lighter and fluffier breads, as opposed to the darker, coarser, heavier breads made from the whole-grain wheat.

The removed bran and germ—the wholesome and healthy components of the wheat kernel—are often used to produce animal and poultry feed.   Interestingly, the farm animals are fed the wholesome, slow-digesting grain components and us humans end up with the refined and unhealthy component!  Go figure!  In fact, the nutritionally depleted and deficient processed white flour needs to be fortified with vitamins and minerals to replace those that were lost with refining, hence the term “enriched” wheat flour.

What is the problem with enriched wheat flour?  Simply, wheat grain that is hulled and stripped of the bran and germ results in a pulverized, super-fine, silky-white powder. This highly refined substance is very similar in appearance to cocaine or heroin. This pre-chewed, pre-digested, melts-in-your-mouth, adult baby food equivalent is absorbed extremely rapidly and is promptly transformed into glucose; it is not unlike getting an injection of intravenous glucose into one’s bloodstream.  Insulin levels (remember that insulin is our “fat” hormone) surge in response and any glucose that does not need to be immediately used as fuel gets stored as glycogen in our muscles and liver and when that is maximized, any excess glucose gets stored as fat.

This quick fix of sugar is not particularly filling because of the absence of fiber; it is a short-lived satisfaction that begs for more consumption, establishing a vicious cycle. The result is a push in the direction of weight gain, insulin-resistance, obesity, diabetes and heart disease. Furthermore, the refined product does not induce the “thermic effect” that many more substantive foods do, in which the body’s metabolism increases because of the energy expenditure it takes to digest a wholesome, fiber-rich product.

In contrast to the refined, enriched wheat flour product, whole-wheat flour is made by grinding up the entire wheat kernel. “Whole” refers to all three grain components used—bran, germ, and endosperm.  Whole-wheat flour is brown in color and textured, as opposed to the silky-white enriched wheat product. Whole wheat is very nutritious because the bran and germ components contain abundant fiber, protein, calcium, iron and other minerals. Because of the fiber, absorption and glucose transformation occur in a slow, gradual and well-regulated fashion. Whole wheat is filling, satisfying and substantive and literally sticks to your ribs.  Whole-wheat adds heaviness to breads or to whatever recipe it is used for and requires more flour to obtain the same volume of bread as white flour. Whole-wheat has a shorter shelf life than white flour because of its higher oil content—the source of the oil being the wheat bran, and the oil being a healthy one.  Products containing oil will go rancid faster than products that do not contain oil.  Whole-wheat flour is more expensive than white or enriched wheat flour.  It is easy to understand why the Industrial Food Complex is enamored with enriched wheat flour.

Now let’s go way beyond mere processing and separation of a natural product into its components and get into a real chemistry experiment—high fructose corn syrup (HFCS).  HFCSis a sugar substitute that is derived from corn via a complicated chemical process. Corn is milled to produce cornstarch, a powdery derivative. The cornstarch is processed into corn syrup, which contains glucose. Glucose is converted to fructose by using a process developed in the 1970’s by food scientists in Japan. Glucose is then added back in differing percentages to the fructose to achieve the desired sweetness. 55% fructose HFCS is used to sweeten soft drinks and a 42% fructose HFCS is used in baked goods. HFCS is abundant in processed foods and drinks.

Why does the Industrial Food Complex adore HFCS?  It is less costly than sugar because of corn subsidies and sugar tariffs. It is easy to transport as the viscous syrup lends itself to huge storage vats within trucks.  Fructose is the sweetest of all naturally occurring carbohydrates and does not crystallize or turn grainy when cold, as sugar can do in cold drinks such as iced tea. Because HFCS is highly soluble, its use makes for softer products and its ability to retain moisture allows for moister and better textured baked goods. Finally, it acts as a preservative to help prevent freezer burn as well as maintain the freshness and extend the shelf life of processed foods.

While HFCS may help preserve processed foods, it does not help preserve us; in fact, I would describe HFCS as killer sweetener.  It’s not just about the “naked” calories of the refined, fiber-less carbohydrate but is all about the fructose, which can be thought of as “poisonous” carbohydrate that has unique and distinct properties.  Fructose is remarkably similar to a carbohydrate that is very familiar to all of us—ethanol, a fermented sugar that is an acute toxin to the brain. However, fructose can only be metabolized by the liver and not by the brain, so in the words of Dr. Robert Lustig, fructose is “alcohol without the buzz.”   While ethanol is an acute toxin, fructose can be thought of as a chronic toxin. The “beer belly” from alcohol is not unlike the “soda belly” seen in those who overindulge in products containing HFCS.

Fructose is metabolized entirely differently from the way glucose is.  Every cell in our body can metabolize glucose, but only the liver can metabolize fructose. Fructose does not stimulate insulin release, as does glucose.  Fructose does not stimulate thesecretion of our satiety hormone leptin, nor suppress our hunger hormone ghrelin, so that foods containing fructose, unless couched in fiber, do not fill us up and curb our appetites. Fructose much more readily than glucose replenishes liver glycogen, and once the liver is saturated with glycogen, triglycerides (fats) are made and stored. Thus, HFCS ingestion can readily lead to obesity, elevated cholesterol, fatty liver, hypertension, insulin resistance and metabolic syndrome. The bottom line is that excessive HFCS ingestion pushes our metabolism towards fat production, and it doesn’t take eating that much processed food to cross the excessive HFCS threshold.

Fructose is the predominant sugar in many fruits, hence the name fructose. The difference between this sugar contained within a piece of fruit as opposed to that within a bottle of cola is that fruit fructose is natural (not created in a chemistry lab) and the amount is significantly less than the load contained within the soft drink. Additionally, the fruit fructose is accompanied by a substantial amount of fiber, anti-oxidants, and other phyto-nutrients, all health-promoting ingredients not present in the cola.

 

Bottom line:  Resonate with nature and literally think “outside the box,” can, package, bottle, etc., by eating whole, natural foods and not their refined by-products. Whole and real foods do not require a label because what you see is what you get. Leave the chemistry experiments to the chemistry lab and not for our consumption. Processing is a necessity to make some foods accessible to us, so read food and nutritional labels as carefully as you would read the ingredients in a medication, because when it comes down to it, food is medicine. The best diet is the “anti-processed-atarian” diet.  Your body will thank you.

 

 

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

www.PromiscuousEating.com

Where’s Your 6-Pack?

January 28, 2012

Blog # 43 written by Andrew Siegel, M.D.

 

I posed this question to my nurse friend Jen and she replied “in the fridge.”  She made me laugh with that reply, but in reality she has a pretty hard body, especially for a woman who has given birth to several children.  However, if your answer to the question truly is “in the fridge,” then you might just want to read on!

If you would like the short version, skip to the end of this blog where you can read “10 pearls to help your washboard abdomen emerge”—itprovides nuggets of information that if heeded, will allow your to firm up your abdomen and start the process of unveiling the 2-pack, 4-pack or 6-pack that lies obscured within.  Read the full blog if you would like to know the more detailed science.  Although vanity may be an important driving force for wanting to develop that 6-pack, it’s really about living a healthy lifestyle—in brief, the aesthetics will follow a healthy existence and our internal health often mirrors our external physiques.

Sporting a six-pack is a badge of honor emblematic of one’s discipline, restraint and tenacity.   A “hard core” can only be earned through the combined efforts of healthy eating and vigorous exercise.  Chances are if you’re wearing a 6-pack, then you are fit and healthy and that in all probability you have rejected the Western diet of processed foods, lots of added fats, sugars and loads of refined grains and instead have chosen a healthy diet consisting of real food that comes from nature, rather than from a chemistry lab.

We all have 6-packs hidden beneath our winter-weighted physiques.  We may be flabbier and less toned than desirable, but somewhere within is a sinewy, tight, and lean torso.  The question is: what can we do to bring out this svelte body?  How do we reduce our shapeless stockpile of stored energy that is shrouding our underlying sculpted physique?

Michelangelo’s “David” was at one time a mere solid block of marble.  The master artist crafted this magnificent sculpture by knowing exactly what to carve away—what did not belong. In the words of Antoine de Saint-Exupery (author of Le Petit Prince): “Perfection is not when there is no more to add, but when there is no more to take away.”  The late Steve Jobs was a grand master at removing the unnecessary and superfluous to reveal the elegant simplicity that remains. In the words that follow, I will offer sound advice on how to peel away the nonessential to reveal your own magnficence that lies obscured.

Having some fat on our bodies is not a bad thing, as long as it is not excessive. Fat actually serves a number of useful purposes.  It functions to cushion our internal organs and as insulation to conserve heat.  Fat provides a means of storing energy and fat-soluble vitamins.  During periods of decreased caloric intake, fat reserves are broken down to release energy.  Fats are important parts of the structure of the brain and cell membranes and are used in the manufacture of several important hormones.  Fat has more than twice as many calories per gram than carbohydrates or protein.   Anybody who has barbecued any kind of meat with a high fat content and has witnessed their would-be dinner engulfed in flames realizes what a concentrated form of fuel that fats are.

As we age, many of us tend to slowly and insidiously gain weight.  A collection of fat often becomes apparent on our abdomens, particularly around our waistlines.  An accumulation of fat in our midsections not only is unattractive from a cosmetic standpoint, but also can have dire metabolic consequences.  It is important to distinguish between visceral fat and subcutaneous fat.  Visceral fat—also referred to as a “pot belly,” “beer belly,” or “Buddha belly”—is internal fat deep within the abdominal cavity.  Subcutaneous fat—also known as “love handles,” “spare tires,” “muffin top,” or “middle-age spread”—is present between the skin and the abdominal wall.  Although neither type is pretty, visceral fat is much more hazardous than subcutaneous fat since it increases the risk of diabetes, cardiac issues, and metabolic disturbances.  Subcutaneous fat is inactive and relatively harmless and does not contribute to the health problems that visceral fat does.

The good news is that by losing abdominal fat, the potentially bad health repercussions can be reversed and the six-pack within can become more unveiled.  The dangerous visceral fat submits relatively easily to diet and exercise whereas the less harmful subcutaneous fat at the waist is more stubborn and resistant to reversal measures.  It is this accumulation of belly fat that masks the underlying rectus abdominis muscle that is our 6-pack muscle.

And now a few necessary paragraphs on metabolism: Dietary carbohydrates are broken down to the simple sugar glucose, which is the “energy of life” and the fuel source of every cell in our body. When it is not used immediately for energy, it is stored as glycogen. The pancreatic hormone insulin is responsible for converting glucose into glycogen. Glycogen is present in our liver and muscles; when a state of saturation has been achieved and no more glycogen can be stored in our liver and muscles, the excess glucose is converted to fat.  There is a finite limit to the amount of carbohydrate stored in the muscles and liver—it amounts to about 1600-1800 calories.

When talking metabolism, it is helpful to think of our glycogen as our “small fuel tank.”  Once the fuel in the liver and muscles is exhausted, our “large fuel tank”—our fat—needs to be tapped to provide energy.  In contrast to the limited carbohydrate storage in our liver and muscles, our bodies abundantly store fat.  Depending on how much fat we have, many days to weeks of energy can be provided.  To reveal your 6-pack, you need to have as small a “large fuel tank” as possible, since it is these stored energy reserves that are obscuring the glorious sculpted abdominal musculature that lies beneath.

There are a few important facts that are fundamental to our understanding of the science of fat. First off, our fat stores are not static, but are dynamic.  In other words, there is continuous mobilization of our fat (as fatty acids) and storage (as triglycerides).  Secondly, fat storage is largely under hormonal control.  Hormones are chemical messengers that cause specific actions in our body.  The hormones involved in fat metabolism are insulin, cortisol, estrogen, and testosterone.  Thirdly, fat is not just fat—it is a metabolically active endocrine organ that does not just protrude from our abdomens in an inert state, but has a life of its own.  Fat produces pro-inflammatory factors, hormones and immune cells.  Fat has an abundance of the hormone aromatase, which converts testosterone to the female hormone estrogen.  One consequence of too much fat in men is excessive conversion of testosterone to estrogen, creating the potential for male breast enlargement.

Insulin is the principal regulator of fat metabolism. After a sugar and carbohydrate load, insulin is released to get the fuel into our cells. When we go without food, as happens when we sleep, insulin levels decrease and fat is released to be used as fuel.  Insulin levels are determined primarily in response to our carbohydrate intake in order to keep our blood sugar regulated.

Insulin has much to do with the way our bodies store or burn fat. You can think of insulin as our fat hormone. When insulin levels are elevated, we accumulate fat; when levels are low, we burn fat for fuel.  Insulin is all about increasing fat storage and decreasing fat burning—this is why diabetics on insulin injections typically get fat.  If we have a substantial amount of belly fat, then by definition we have insulin-resistance, a condition in which our pancreas works overtime to make more and more insulin to get fuel into our cells.  This is a precursor to diabetes, cardiovascular disease and all the havoc they can wreak.

Our insulin levels are determined by the carbohydrates we eat—the more carbs we eat, the sweeter they are, the easier they are to digest, the greater the insulin levels and the more that fat accumulation is driven.  Insulin secretion caused by eating carb-rich foods—flour and cereal grains, starchy vegetables like potatoes and rice, sugars and high-fructose corn syrup—is what makes us fat.  The sweeter the food, and the easier it is to digest, the fatter it will make us, and liquid carbs such as sodas, fruit juices and beer are the biggest culprits.

If we want to get leaner and reveal the 6-pack within, we must lower our insulin levels.   To lower our insulin levels requires carbohydrate restriction, meaning decreased consumption of sweets and starchy carbs.  Even if we don’t reduce our quantity of carb intake, we can improve the quality of our carb intake by eating healthier carbs—whole grains, fruits, vegetables, legumes, etc.  Aside from shrinking our waistlines, there are numerous other health benefits that accrue from a lower carb diet.  If we replace a high carb diet with a diet lower in carbs and higher in healthy protein and healthy fat, the consequences are the following: weight loss; HDL (good) cholesterol rises; triglycerides decrease; glucose levels stabilize; blood pressure decreases; heart disease risk decreases; body fat reduces; energy levels surge.

The adrenal gland hormone cortisol—releasedin response to stress—can stimulate our appetites and cravings for sugar, causing fat storage and promoting weight gain and obesity. This is the very reason people on corticosteroid medications tend to have enormous appetites, gain weight and have a central distribution of body fat known as centripetal obesity, even if they were very thin prior to starting on the cortisol.  Chronic stress literally can make us soft and flabby and sabotage our efforts to achieve that chiseled 6-pack.  So what can we do about stress, because we all have it, and it’s not going away anytime soon?  Stress busters include exercise, yoga, meditation, massages, getting into a Jacuzzi, aromatherapy, chamomile or other herbal teas, sex, etc.  Sounds nice…relax to help bring forth that 6-pack!

The sex hormones estrogen and testosterone play a key role in fat regulation. One of the key reasons that women have a different physical appearance and body fat distribution than men is because of the different levels of these two hormones in each gender.  Around the time of menopause, when the ovaries stop producing estrogen, central fat deposition is promoted and many women start packing on pounds in their mid-section.  Similarly, as men age, testosterone levels often drop, contributing to a loss of muscle mass and an increase in body fat. Low testosterone is present in about half of obese men.

Believe it or not, a good night’s sleep will help us on our mission for that elusive 6-pack.  When we sleep poorly and become sleep-deprived, we are often driven to eat. Sleep deprivation results in decreased levels of leptin, our chemical appetite suppressant, and increased levels of ghrelin, our appetite stimulant, in addition to increased levels of the stress hormone cortisol.  Furthermore, being exhausted can sabotage our exercise regimen.

Six-pack diet

Lean sources of protein including egg whites, wild salmon (or any other wild fish that is grilled or broiled), skinless chicken, turkey breast, fat-free yogurt and soy products such as tofu and edamame are money.  We need to be sparing with meat and dairy intake since they are rich in saturated fats and high in calories.  Vegetables—including nuts, avocados and olives—are a much healthier source of fat.

High fiber foods—vegetables, fruits, legumes (lentils, peas and beans) and whole-grain cereals and breads—are very filling and the fiber regulates the rate of carbohydrate absorption. Intake of a variety of brightly colored fruits and vegetables will ensure getting ample doses of phyto-nutrients and anti-oxidants. Dietary fiber (roughage) refers to the indigestible part of a carbohydrate.  Insoluble fiber, e.g., cellulose from plant foods, serves as plants’ armor against predatory pests and serves as humans protection against obesity.  Since we do not have the enzymes necessary to dissolve insoluble fiber, it increases stool bulk, decreases intestinal transit time, increases our satiety, reduces the rate of carbohydrate absorption and the conversion of complex carbohydrates to simple sugars, and decreases the absorption of some fats.  Soluble fiber binds cholesterol in the intestinal tract; for example, oatmeal can help lower serum cholesterol levels.

It is very important to minimize refined carbohydrates, substituting whole grain products for white bread, white pasta, white rice, etc.  Curtailing sugar intake is equally important since sucrose is a 50% fructose/50% glucose combination and fructose gets metabolized completely differently from glucose, pushing our bodies towards fat deposition.  The same is especially true for high fructose corn syrup (HFCS), that gooey liquefied sweetener abundant in processed foods and beverages in a 55% fructose/45% glucose ratio. Every cell in our body can metabolize glucose, but it is primarily the liver that metabolizes fructose. Fructose, more readily than glucose, replenishes liver glycogen, and once the liver is saturated with glycogen, fats are made and stored. So, HFCS gives us a fatty liver, a fatty body and a masked 6-pack.  Fructose does not suppress ghrelin (our hunger hormone), does not stimulate insulin, and is truly a toxin to our body in immoderate doses. Let fruits be the source of fructose for our bodies, not refined sugars and HFCS.

Nature is very clever—whenever it provides us with a nutrient that is potentially bad for our health, it limits access to that nutrient by adding lots of fiber to it.  So when nature has given us fructose, it has also included the antidote.  Did you ever try to get the sugar out of a sugar cane plant?  It is literally like gnawing on a piece of bamboo stick—you can’t chew it and have to suck it out!  Processing has allowed us to cheat nature by refining sugar, permitting consumption in unrestrained, unhealthy amounts, contrary to nature’s design.  For example, it is very easy to drink 12 ounces of orange juice, to the tune of about 170 calories of fiber-free sugar.  To get that kind of caloric load from nature’s whole product—the orange—you would have to eat almost 3 of them.  Can you imagine sitting down and eating three oranges?  I sure can’t.  So go easy on anything that comes in a bottle, box, carton or can…think whole foods that resonate with nature, not refined foods that are unfaithful to nature.

While at the dinner table the other evening, I found myself staring at a colorful salad on my left and a basketful of white Italian bread (not whole grain) on the right.  I pondered the “order” of eating in terms of insulin release—would there any difference if I had salad first followed by bread vs. bread first followed by salad, vs. eating them together and would the order of eating play a role in the way calories are burned or stored?

Salad first followed by bread (bulky, fiber-rich carbs then fiber-less carbs): This gives us a gradual, low-level insulin spike followed by rapid, high-level insulin spike.  It is likely that the bolus of salad slowly digesting in the gut will modulate (regulate) the insulin spike from the bread’s fiber-less carbs, resulting in less of a tendency for fat deposition.

Bread first followed by salad: (fiber-less carbs then fiber-rich carbs):  This gives us a rapid, intense insulin spike followed by gradual, lower-level insulin spike.  It is likely that this order will result in fat deposition, since by the time the salad gets to the gut, the bread has already been digested and absorbed.

Together: The salad mixing in the gut with the bread will modulate the insulin spike from the fiber-less carbohydrate load of the bread, resulting in less of a tendency for fat deposition.

Bottom line: If you are going to eat white carbs, you can minimize the intensity of the insulin spike and thus the tendency for fat deposition by mixing in some fiber-rich foods; better yet is to ditch the white carbs completely and eat the whole-grain product. If you are going to use the strategy of using the powers of fiber-rich food like salad to lessen the “damage” from fiber-less white carbs, be sure to go easy on the croutons, cheese and excessive amounts of salad dressing that can sabotage the strategy.

A very important principle in the acquisition of a 6-pack is not to drink calories, so avoid liquid calories such as soda, juices, processed iced tea, lemonade, etc.  These are particularly bad since they are essentially pre-digested, fiber-less carbohydrates that get “mainlined” into our bodies causing a massive insulin spike and caloric storage as fat.  A “beer belly” resulting from the carbohydrate alcohol and a “soda belly” resulting from the carbohydrate fructose are substantially equivalent. The best drink is water or seltzer—it can be jazzed up with a squeeze of lemon or lime.  Water keeps us well hydrated, dampens our appetite and will quell our thirst that is sometimes confused for hunger.

It is important to be careful not to overdo sodium intake as it can cause fluid retention, high blood pressure, bloating, weight gain and a number of potential cardiac issues, aside from thwarting the emergence of our 6-packs.

Six-pack exercise regimen:

A general rule of thumb is to think “athletics” and the “aesthetics” will follow.   The key to exercise is diligence—carving out the time—and variety—strength  (resistance) training, cardiovascular (aerobic) training and core (abdominal and torso) conditioning, and perseverance.  A core synergistic exercise regimen, which is a combination of the aforementioned three types of exercise, provides a terrific overall workout. Pilates, yoga, and martial arts are three great means of obtaining a hard core, although there are many other effective exercises as well.  Pilates, in particular, is an awesome means of developing core strength.  I have been taking Pilates lessons weekly for over a year from an amazing instructor, Catherine Byron, who has been instrumental in helping me achieve a toned abdomen, core strength, better balance, posture and muscle symmetry (www.cbperformancepilates.com).  My friend and yoga instructor Ben Wisch, has also helped whip my core into shape (www.homeyogaexperience.com).  I  enjoy and have derived great benefit from home exercise DVDs from beachbody.com:  the P90x “ab ripper,” “core synergistic,” and “yoga” workouts and the P90x plus “abs-core” workout can’t be beat.

Muscles play a key role in our metabolism: they are extremely metabolically active, each pound of lean muscle burning about 50 calories/day.  With a sedentary existence and aging, there is a gradual loss of muscle mass and a resultant slowing in our resting metabolism.  By building and maintaining our muscle mass with strength training, we will raise our resting metabolic rate and burn more calories.  Additionally, exercise serves to increase the “insulin sensitivity” of muscle, which means that are muscles become more efficient at burning off carbohydrates as fuel. Exercise is also our endogenous stress reducer, lowering cortisol levels, suppressing our appetites and helping us burn carbs before they have a chance to be stored to fats.

We can measure our maximal heart rates by doing an aerobic activity, such as swimming, running or cycling full throttle until we can’t go on, and then taking our pulses.  In our workouts, if we can achieve a heart rate of 75% of our maximum rate and sustain that for 30-60 minutes daily, it is easily conceivable to burn 600 or more calories per day.   High intensity interval training—alternating between extremely intense exertion and regular “normal” exertion—can rapidly help propel us towards that sculpted body that lies within.
10 pearls to help your washboard abdomen emerge:

 1.    If you want a hard waist, you must incorporate exercise into your lifestyle, achieving balance between aerobic, resistance and core workouts.

2.    Eat high-quality, whole-grain, high-fiber carbs, lean protein sources (easy on meat and dairy) and healthy fats (vegetable and seafood-origin).

3.    Eat in accordance with nature’s design—meaning whole foods.  Avoid processed foods.  The best diet is an “anti-processed-atarian” diet.

4.    If you want to look good naked, don’t eat “naked” calories (stripped of fiber), so restrict sugar, simple white carbs, and liquid calories.  Aggressively steer clear of high fructose corn syrup.

5.    Soft foods (sugared drinks, white pasta, white rice, white bread, doughnuts, bagels, potatoes, etc., will earn you a soft core; hard foods (whole grain pasta, brown rice, whole grain breads, legumes, whole fruits and vegetables) will help earn you a hard core.

6.    Avoid giant meals in which the caloric load will be stored as fat; substitute with multiple smaller meals in which the calories will be used for immediate energy.

7.    Limit after dinner snacking since unnecessary calories at a time of minimal physical activity will be stored as fat.  If you restrict your evening snacking to one piece of fruit, you will wake up in the morning with less to pinch on your waistline.

8.    Drink plenty of water; use salt sparingly.

9.    Minimize stress; if you can’t eliminate it, manage it.

10. Get adequate amounts of quality sleep.

 

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

www.PromiscuousEating.com