Tuesday, July 31, 2012

The 14-percent advantage of eating little and then a lot: Putting it in practice

In my previous post I argued that the human body may react to “eating big” as it would to overfeeding, increasing energy expenditure by a certain amount. That increase seems to lead to a reduction in the caloric value of the meals during overfeeding; a reduction that seems to gravitate around 14 percent of the overfed amount.

And what is the overfed amount? Let us assume that your daily calorie intake to maintain your current body weight is 2,000 calories. However, one day you consume 1,000 calories, and the next 3,000 – adding up to 4,000 calories in 2 days. This amounts to 2,000 calories per day on average, the weight maintenance amount; but the extra 1,000 on the second day is perceived by your body as overfeeding. So 140 calories are “lost”.

The mechanisms by which this could happen are not entirely clear. Some studies contain clues; one example is the 2002 study conducted with mice by Anson and colleagues (), from which the graphs below were taken.

In the graphs above AL refers to ad libitum feeding, LDF to limited daily feeding (40 percent less than AL), IF to intermittent (alternate-day) fasting, and PF to pair-fed mice that were provided daily with a food allotment equal to the average daily intake of mice in the IF group. PF was added a control condition; in practice, the 2-day food consumption was about the same in AL, IF and PF.

After a 20-week period, intermittent fasting was associated with the lowest blood glucose and insulin concentrations (graphs a and b), and the highest concentrations of insulin growth factor 1 and ketones (graphs c and d). These seem to be fairly positive outcomes. In humans, they would normally be associated with metabolic improvements and body fat loss.

Let us go back to the 14 percent advantage of eating little and then a lot; a pattern of eating that can be implemented though intermittent fasting, as well as other approaches.

So, as we have seen in the previous post (), it seems that if you consume the same number of calories, but you do that while alternating between underfeeding and overfeeding, you actually “absorb” 14 percent fewer calories – with that percentage applied to the extra calorie intake above the amount needed for weight maintenance.

And here is a critical point, which I already hinted at in the previous post (): energy expenditure is not significantly reduced by underfeeding, as long as it is short-term underfeeding – e.g., about 24 h or less. So you don’t “gain back” the calories due to a possible reduction in energy expenditure in the (relatively short) underfeeding period.

What do 140 calories mean in terms of fat loss? Just divide that amount by 9 to get an estimate; about 15 g of fat lost. This is about 1 lb per month, and 12 lbs per year. Does one lose muscle due to this, in addition to body fat? A period of underfeeding of about 24 h or less should not be enough to lead to loss of muscle, as long as one doesn’t do glycogen-depleting exercise during that period ().

Sounds good? It actually gets better. Underfeeding tends to increase the body’s receptivity to both micronutrients and macronutrients. This applies to protein, carbohydrates, vitamins etc. For example, the activity of liver and muscle glycogen synthase is significantly increased by underfeeding (the scientific term is “phosphorylation”), particularly carbohydrate underfeeding, effectively raising the insulin sensitivity of those tissues.

The same happens, in general terms, with a host of other tissues and nutrients; often mediated by enzymes. This means that after a short period of underfeeding your body is primed to absorb micronutrients and macronutrients more effectively, even as it uses up some extra calories – leading to a 14 percent increase in energy expenditure.

There are many ways in which this can be achieved. Intermittent fasting is one of them; with 16-h to 24-h fasts, for example. Intermittent calorie restriction is another; e.g., with a 1/3 and 2/3 calorie consumption pattern across two-day periods. Yet another is intermittent carbohydrate restriction, with other macronutrients kept more or less constant.

If the same amount of food is consumed, there is evidence suggesting that such practices would lead to body weight preservation with improved body composition – same body weight, but reduced fat mass. This is what the study by Anson and colleagues, mentioned earlier, suggested ().

A 2005 study by Heilbronn and colleagues on alternate day fasting by humans suggested a small decrease in body weight (); although the loss was clearly mostly of fat mass. Interestingly, this study with nonobese humans suggested a massive decrease in fasting insulin, much like the mice study by Anson and colleagues.

Having said all of the above, there are several people who gain body fat by alternating between eating little and a lot. Why is that? The most likely reason is that when they eat a lot their caloric intake exceeds the increased energy expenditure.

Sunday, July 29, 2012

BRAVO NHS, BRAVO Pussy Riot and BRAVO Dr Malcolm Rigler...

What a week! I shall keep heroically quiet in the face of Olympic fever, only to say what a wonderful distraction Danny Boyle provided us with in times of swingeing austerity. Bravo, you volunteer dancing nurses. Was that art and health - was that Big Society in action, and do you have jobs to waltz back to? I had a funny feeling watching the opening ceremony - near emotional...in fact, it reminded me of how I was almost washed along in something similar after the people’s princess died: a rare coming together of people, in that case through a media-induced shared pseudo-grief, in this case, through a desperate clinging on to our fractured identity. Come to think of it, hasn’t D who shall not be named, been conspicuous in her absence from all things jubilant and olympic? All hail the puppet master - all hail our transient moments of civic delusion.

With the very generous contribution of our NHS staff entertaining us in mind, it is with thanks to a friend in New York, that I can share news of an event in Kingston (just north of NYC) in October. The O+ Festival brings health workers and artists together to exchange practice - bartering the art of medicine for the medicine of art. Admittedly this is from a country where many people can’t afford health care insurance, but the premiss is excellent and well worth exploring. 

Did you know that across the NHS at the moment, there are over 100 different tools for monitoring your vital signs? In other words, the ways in which vital signs such as blood pressure and temperature are monitored in hospitals needs to be standardised across the NHS. Lack of a standardised process is causing confusion and sometimes delays in patients getting help. To find out more about this, click on the happy and valued nurse below. The excellent writer and surgeon, Dr Atul Gawande has written extensively on this in his fascinating book, The Checklist Manifesto. Just imagine for a moment, if airline pilots didn’t rigorously follow a systematic safety checklist before they took you off on your summer holidays! Well, imagine too, if the team preparing you for surgery hadn’t gathered your health information in a systematic and universally understood manner.

And following on from the opening ceremony of our ultimate national wellbeing campaign, it was with great honour, that I accepted the invitation to speak alongside Dr Malcolm Rigler at the Faculty of Public Health’s Annual Conference, rather suitably held at the Royal Welsh College of Music and Drama in Cardiff. Dr Rigler isn’t one to blow his own trumpet, but without hesitation, he can safely be described as one of the founding fathers of this thing we call arts and health. As a GP, he has never been shy in coming forward to expound the potential of the arts, and artists to influence both medical practice and civic society. He’s been supporting the ideas of the Peckham Experiment for many years and commissioned some of the arts/health greats from his GP Practice at Withymoor Village Surgery. Think Ali Jones (now Clough), John Angus and Mike White. Rigler ploughed this furrow, before others were brave enough to question the way in which medicine is delivered. The conference was packed to the roof with delegates, and although our hour session was very much quieter than the other parallels which focused on leadership, we were proud to have had the input and enthusiastic support from real innovators and giants from the field of medicine and public health. I extend my thanks to all of you that attended and particularly to John Wyn Owen, Prof John Ashton and the very inspirational Mark Gamsu. Dr Rigler and I will be writing an article that takes our thoughts further, entitled Imagination in 21st Century Public Health.

It seems that since we first broadcast the plight of Pussy Riot in February 2012, the band have gained much in the way of celebrity support. Lets hope that the growing media attention puts pressure on the Russian authorities, to release them, and listen to their voices. For an exclusive interview with three members of the collective, click on the video below. 

It would be easy to smirk at Pussy Riot from a safe distance, but performing songs like, Putin Pissed Himself in front of the Kremlin is both courageous and dangerous. Ekaterina Degot, Russian art critic comments, "What you were doing was incredible. That it's going to change Russian history. That there is no question that what you are doing is art and that no Russian artist has brought about this much change, ever." Powerful stuff.

Finally, another pioneer of arts in health in Manchester: Chris Agnew, has died on 3 July after a long and courageous battle with cancer. Chris established puppetry and performance at Manchester's St Mary's Hospital in 1979, helped initiate arts activities at the Christie cancer hospital, developed performance work with elderly patients at Withington Hospital and, with textile artist Adrienne Brown, was joint coordinator of Stockport Arts and Health (SAH). For a fuller appreciation of Chris Agnew by her friend and colleague Langley Brown, please click on the image below. 

‘To create a healthier nation we must start by encouraging inclusive and harmonious relationships in a society where so many find themselves socially excluded. The principal killers are not cancer and heart disease but lack of social support, poor education and stagnant economies.’ Dr Malcolm Rigler

Tuesday, July 24, 2012

How Happy Are You? Let the government tell you...

First ONS Annual Experimental Subjective Well-being Results

David Cameron's attempts to chart the nation's happiness alongside economic data gas been published today by the Office of National Statistics. The data, gathered between April 2011 and March 2012, compares happiness and anxiety levels by sex, age, ethnicity and other demographic factors. It reveals that people aged 16-19 and 65-79 recorded satisfaction levels considerably higher than the British average of 7.4 out of 10. Analysis of responses according to ethnicity, revealed the Indian population recorded the highest levels of satisfaction – 7.5 out of 10 – and the black population the lowest, at just 6.7. Anxiety ratings were highest among the Arab population, among whom the average response was 3.7, compared with a national average of 3.1. When asked about day-to-day emotions, 10.9 per cent of people in the UK rated their ‘happiness yesterday’ as less than 5 out of 10 (indicating lower happiness). For the ‘anxious yesterday’ question, 21.8 per cent reported a rating of more than 5 (indicating higher anxiety)
To go directly to the report, just click on our happy first minister above.

Sunday, July 22, 2012

Laughing our way through a double-dip recession...

Across history and cultures, if you are seen as ‘different’ or perhaps question the status quo, the prescribed method of the state has been to tell you to shut up, or else lock you up. Religion has played no small part in this too. Just think witchcraft - think sexuality - think gender. Incarceration and execution. Homosexuality as a mortal sin: and then post-enlightenment, as a diagnosable illness that only this year, the psychiatrist Dr Robert Spitzer recanted his theory that if you were gay, you could be ‘cured’. Widely seen as one of the architects of the Diagnostic and Statistical Manual of Mental Disorders (DSM) which is the ‘bible’ of the the American Psychiatric Association, and in which for years homosexuality was categorised as a disease, the DSM isn’t without it’s detractors, who argue it perpetuates the beliefs of a small number of powerful psychiatrists and by proxy, the pharmaceutical industry.
Psychotherapists like Gary Greenberg in his book Manufacturing Depression, suggest that the pathologising of human nature is pernicious, and it could be that ‘the depression epidemic is not so much the discovery of a long unrecognised disease, but a reconstitution of a broad swath of human experience as illness.’

It was with Greenberg’s comments in mind, around the pathologising of human discontent as disease, that I read with some disquiet, economist Lord Layard’s comments that, ‘If you go back 30 or 40 years, people said you couldn't measure depression. But eventually the measurement of depression became uncontroversial.’ 
With the first set of results on happiness for the governments national happiness/wellbeing index due this week from the Office for National Statistics - and with Layard something of a happiness tzar: the assertion that depression is all neat, measurable and uncontroversial is divorced from reality. Yes, we all know that treatments have, by and large improved, as has general understanding of mental ill health, but the assumption that human nature can be weighed out, compared and categorised still dominates, and in turn the relationship between those manufacturing the ‘cures’ and those diagnosing the ‘disease’ still exists. Earlier this month, I shared the story of the GlaxoSmithKline $3billion payout for ‘bribing doctors and encouraging the prescription of unsuitable antidepressants (Paxil) for children’, and having ‘paid for articles on its drugs to appear in medical journals...’ Therefore, it’s relevant that of the ‘authors who were selected and who defined the DSM-IV psychiatric disorders, roughly half had had financial relationships with the pharmaceutical industry at one time.’

So no, the measurement of depression is not clear cut Lord Layard and subjective happiness - on a scale of 1 to 10? I’m a sceptic, a cynic - no a pessimist, and I’m told that this is unhealthy, after all, our government aspires to be the next Bhutan! Happiness by government target? Well judging by our ranking in all the global measurements of wellbeing, we’re not doing too well. Still with the right medication, we can passively laugh our way through our double-dip recession.
Greenberg again, gets it right: ‘To think of pessimism as the symptom of an illness and then turn our discontents over to the medical industry is to surrender perhaps the most important portion of our autonomy: the ability to look around and say, This is outrageous. Something must be done.’

Talking of being incarcerated for expressing dissent or opinion in the face of an oppressive  state/church, lets remind ourselves of the non-violent protest of Pussy Riot back in February 2012. The Independent reports that, the three members of a feminist punk band arrested for singing a protest song in Moscow's main Orthodox church must remain in custody.
The trio, part of a collective called Pussy Riot, were told they would be kept in detention for a further six months, until at least 12 January. The case involving Maria Alyokhina, 24, Nadezhda Tolokonnikova, 22, and Ekaterina Samutsevich, 29, has split Russian society. The women have been in prison since they were arrested in February for performing an impromptu rendition of a song "Blessed Virgin, Mother Mary, Drive Putin Out!". They sang the "punk prayer" at the altar of the Cathedral of Christ the Saviour two weeks before the presidential election that returned Mr Putin to the Kremlin. They could be jailed for seven years if they are convicted of "hooliganism motivated by religious hatred".

Five women took part in the prank, dressed in the trademark coloured balaclavas worn by the Pussy Riot collective. Ms Tolokonnikova, Ms Alekhina and Ms Samutsevich were arrested a fortnight later after a video of the stunt went viral on YouTube. On Thursday, a lawyer for one of the cathedral guards, who claims to have been a "victim" of the women's alleged hooliganism, accused Pussy Riot of being supported by the same "Satanic forces" that carried out the 11 September terrorist attack in New York in 2001. Read more by clicking on the very satanic image of the three incarcerated women who used music to comment on politics, below.

François Matarasso
Echoing many of my blog comments on worries about understanding the value of the arts in terms of reductionist methods, I hope you’ll find this new paper from François of great interest. A Different Heartbeat is an account of a residency by musician Patrick Dineen at the Kidney Dialysis Unit, Royal Liverpool University Hospital, in spring 2011, with drawings by Mik Godley. A Different Heartbeat describes an intimate, small scale arts in health project, and places it into a wider context of questions about chronic illness, well being and the nature of benefits. It is an essay by François Matarasso and is a reflection on particular experience, and so about as far from a randomized controlled trial as it could be. But perhaps in that difference is something of value also.

Clore Duffield Poetry awards
The Clore Poetry and Literature Awards fund poetry and literature initiatives for children and young people, under the age of 19, across the UK. The Foundation has created these Awards with the aim of providing children and young people with opportunities to experience poetry and literature in exciting and compelling ways, in and out of school. The Awards are worth a total of £1m over five years, 2011 to 2015, with individual awards ranging from £1,000 to £10,000.
For more information click on le ciel below... 

Think you can run public services better than they are being run now?
The Government has announced a new £11.5m financial support scheme that will help voluntary organisations take over the running of public services in their communities. Communities with good ideas for how they can run local public services and want to use the Community Right to Challenge, can access advice and support to develop their skills to be able to bid for and run excellent local services.The grants programme will open in mid-July and more information on criteria and applications will be available then. Read more at: http://www.thesocialinvestmentbusiness.org/our-funds/communityrights/
Comic Relief UK Grants Programme (UK)
Comic Relief has announced that the final funding round as part of the current UK grants strategy will open for applications on the 13th August 2012. Under the UK grants programme voluntary and community groups can apply for funding for projects in the areas of:
  • Young people and mental health
  • Sexually exploited and trafficked young people
  • Domestic and sexual abuse
  • Mental health
  • Young people and alcohol
  • Refugee and asylum-seeking women
Comic Relief provides both capital and revenue and can pay for up to 100% of projects costs but they encourage applicants to get some of their funding from other sources. On average grants of between £25,000 and £40,000 are available.  The closing date for applications will be 12 noon on the 19th October 2012. Read more at: http://www.comicrelief.com/apply-for-a-grant/apply-for-a-uk-grant

£2.6 Million to Help Disabled People Become MP's (UK)
The Government has announced a new £2.6 million fund designed to help disabled people overcome barriers to becoming councillors, police and crime commissioners or MPs.  The money will help meet the additional costs a disabled candidate may face in standing for election.  The fund will be open for applications until the end of March 2014. It will help disabled candidates meet the additional costs they may face compared to a non-disabled person whether these are related to transport, communication, technology or support.  In addition to the fund, a new online training package went live today, tailored to disabled people who are interested in a political career.  Grants available will range from £250 - £10,000. Read more by clicking on the anarchist symbol above.

The British Film Institute – Film Fund (UK)
The British Film Institute has announced that its Film Fund is open to applications.   Through the fund a total of £18 million a year is available for filmmakers in the UK who are emerging or world class and capable of creating distinctive and entertaining work.  The funding is available for the development, production and completion of feature films.  The British Film Institute welcome applications for all kinds of film – from commercial mainstream to experimental, from genre movies to personal stories, from documentaries to animation to live-action fiction.  Applications can be submitted at any time. Read more at: http://www.bfi.org.uk/film-industry/lottery-funding-filmmaking

The Art of Good Health and Wellbeing, 
Fremantle 2012
4th Annual International Arts and Health Conference
The Art of Good Health and Wellbeing
26 - 29 November 2012
The University of Notre Dame Australia, Fremantle WA
The Art of Good Health and Wellbeing, 4th Annual International Arts and Health Conference, will present best practice and innovative arts and health programs, effective health promotion and prevention campaigns, methods of project evaluation and scientific research. Get full details of the conference by clicking on the image above.

an absence 

Monday, July 16, 2012

Hirst, Burgers, Evidence and Basting...

Following on from last weeks news that the Biggest, Fattest McDonalds in the world has opened up in the shadow of the Olympic Stadium....and yes, its an Eco version - sustainable, in that after the Olympics, they're going to bulldoze it after the games - here are some more facts. It will serve up to 1,200 customers an hour and sell £3million of fast food during the Games.  Altogether they will serve 1.75 million ‘meals’ in 29 days, with Britons accounting for an estimated 85 per cent of customers. Not to be outdone though, Burger King have had a whopping donation from none other than Damien (I’ve got an exhibition on at the moment) Hirst! Great stuff eh? But Damien, wouldn’t half a cow be better?

For those of us who attended the evening networking event with Anne Basting here at MMU, I think its safe to say, that we were all blown away by her imagination, passion and vision for the potential of people affected by dementia.  Anne had come to the UK to speak at a conference at Keele University and kindly offered to talk to members of the North West Arts and Health Network - and what a great evening it was! She shared her work on Time Slips; the Penelope Project and some of her new developments around Shipwrecked. She emphasized the liminal nature of our work, existing between disciplines, investing social capital in people who are largely marginalised to the extreme.  For me, what Anne did, was up the ante, and for those of you who couldn’t come to the event, but who read this, two things to ponder - part of her work with people affected by dementia involves not only getting to grips with Homer’s The Odyssey,  but also learning passages of ancient Greek. Forget the status quo, this is aspirational stuff.  Thank you Anne. These links will take you to some of her work

Last week in a comment on GlaxoSmithKlein I mentioned Ziggy Stardust as research, and I got a few interesting emails - to which - thank you.  As a counter-blast to the reductionist model, I’d like to hear from you about art and popular culture that might be construed as evidence of impact, or a research methodology - particularly as an unintended outcome, or intention. I’m thinking much in the same vein as Bowies claims - the mainstream and the popular. Please get in touch.

GRUNDTVIG and Arts for Health
I am thrilled to be working with Mark Prest and Portraits of Recovery over the next two years. Alongside partners in Italy, Turkey and Lithuania we will be developing work that explores different cultural experiences of recovery and addiction through the arts. This will include informal learning and the development of culturally relevant arts and health strategy with a range of European partners.
More details soon.

Public Art, Cultural Well-Being and the 
National Planning Policy Framework (NPPF) 
ixia is organising three briefing events on how the provision of public art will be influenced by the prominent inclusion of cultural well-being within the NPPF. The events will be led by the planning barrister, Ian Dove QC of No5 Chambers, and the cultural commentator, John Holden.
The topics covered will include: the purpose and status of the NPPF and how it relates to the planning system at a local level, including the Community Infrastructure Levy (CIL); the relationship between cultural well-being and public art; the justification and inclusion of cultural well-being and public art within local planning documents. The briefing events are for arts officers, public art officers, planners, artists, curators, developers and arts funders.
The dates and locations of the events are:
22nd October 2012 - London;
5th November 2012 - Birmingham;
12th November 2012 - Manchester or Leeds.

The Intima is an electronic journal founded in 2011 to stimulate thought, reflection, and conversation about the intersecting worlds of medicine, humanities and art, in the context of individual clinical experiences across the spectrum of health and illness. Narrative Medicine thrives on dialogue..
Mission: The Intima is an electronic journal dedicated to promoting the theory and practice of Narrative Medicine, an interdisciplinary field aiming to enhance health care through the development of effective communication and understanding between caregivers and their patients.
Vision: By providing an online venue for the expression of personal experience within the medical arena, The Intima creates space for caregivers, professionals, patients, and families to share their narratives in a format that fosters empathy, reflection, and deeper understanding of the diversity inherent in effective delivery of care.
Submission Guidelines: We have a rolling admissions policy for the Fall 2012 edition, expected to be published in September The final deadline is August 1st. Please consult http://www.theintima.org/guidelines.html for more information and feel free to contact editor@theintima.org with any questions.
Submissions can include:
  • Scholarly essays or articles geared towards educating a general audience about Narrative Medicine
  • Non-Fiction, personal narratives or perspective pieces
  • Fiction, Short Fiction
  • Field Notes, reflections on working in the field
  • Poetry
  • Studio Art, in any medium such as paintings, photographs, or prints
  • Audio or Visual Multimedia

Healthful Dancing Retreat: with Small Things Dance Collective, Miranda Tufnell and Joe Moran.
10th September 2012, Edge Hill University, Ormskirk.
For more details, by clicking on Anne Widdecombe.

Funding to Support to Voluntary Projects in Health and Social Care (England)

The Government has announced that applications are invited to the 2013-14 Innovation, Excellence and Strategic Development Fund that supports the voluntary sector in developing innovation across health and social care.  The fund is open to third sector health and social care organisations in England that provide a service similar to a service provided by the National Health Service or by Local Authority social services and whose activities support the Department of Health’s priorities. Applications must be made under one of the three Funding Strands, which are Innovation, Excellence and Strategic Development.  To be eligible, projects must have a national impact.  This can include local projects that can be replicated nationally.  There is no minimum or maximum amount that organisations can apply for. In the last funding round grants awarded ranged from £15,865 to £239,669 (for the first year allocations).  YouthNet is one organisation that has benefited from the fund, allowing it to redevelop its confidential online question and answer service. Through askTheSite young people are able to access confidential expert advice on any issue that is affecting their lives.
The closing date for applications is the 21st September 2012. Read more at: http://www.dh.gov.uk/health/2012/06/iesd-2013-14-2/

The 14-percent advantage of eating little and then a lot: Is it real?

When you look at the literature on overfeeding, you see a number over and over again – 14 percent. That is approximately the increase in energy expenditure you get when you overfeed people; that is, when you feed people more calories that they need to maintain their current weight.

This phenomenon is related to another interesting one: the nonlinear increase in body weight and fat mass following overfeeding after a period starvation, illustrated by the top graph below from an article by Kevin Hall (). The data for the squares on the top graph is from the Minnesota Starvation Experiment (). The graph at the bottom is based mostly on the results of a simulation, and doesn’t clearly reflect the phenomenon.

Due to the significant amount of weight lost in what is called above the semistarvation stage (SS), the controlled refeeding period (CR) actually involved significant overfeeding. Nevertheless, weight was not gained right away, due to a sharp increase in energy expenditure. That is illustrated by the U-curve shape of the weight gain in response to overfeeding. Initially the gain is minimal, increasing over time, and continuing through the ad libitum refeeding stage (ALR).

Interestingly, overfeeding leads to increased energy expenditure almost immediately after it starts happening. It seems that even one single unusually big meal will significantly increase energy expenditure. Also, the 14 percent is usually associated with meals with a balanced amount of macronutrients. That percentage seems to go down if the balance is significantly shifted toward dietary fat (), probably because the metabolic “cost” of converting dietary fat into body fat is low. In other words, large meals with a lot of fat in them tend to cause a reduced increase in energy expenditure – less than 14 percent. Shifting the balance to protein appears to have the opposite effect, increasing energy expenditure even more, probably because protein is the jack-of-all-trades among macronutrients ().

The calorie surplus used in experiments where the 14 percent increase in energy expenditure is observed is normally around 1,000 calories, but the percentage seems to hold steady when people are overfed to different degrees () (). Let us assume that one is overfed 1,000 calories. What happens? About 140 calories are “lost” due to overfeeding.

What does this have to do with eating little, and then a lot, in an alternate way? It allows for some reasonable speculation, based on a simple pattern: when you alternate between underfeeding and overfeeding, you reduce food consumption for short period of time (usually less than 24 h), and then eat big, because you are hungry.

It is reasonable to assume, based on the empirical evidence on what happens during overfeeding, that the body reacts to “eating big” as it would to overfeeding, increasing energy expenditure by a certain amount. That increase leads to a reduction in the caloric value of the meals during overfeeding; a reduction of about 14 percent of the overfed amount.

But the body does not seem to significantly decrease energy expenditure if one reduces food consumption for a short period of time, such as 24 h. So you have the potential here for some steady fat loss without a reduction in caloric intake. Keeping a calorie intake up above a certain point is more important than many people think, because a calorie intake that is too low may lead to nutrient deficiencies (). This is possibly one of the reasons why carrying a bit of extra weight is associated with increased longevity in relatively sedentary populations ().

Is this 14-percent effect real, or just another mirage? If yes, what does it possibly translate into in terms of fat loss? More on these issues is coming in the next post.

Saturday, July 7, 2012

Sievenpiper: Fructose should not "worry" in diabetes

As the fructose debate rages on, one serious concern has been what the message should be for people who have diabetes. There's no question that the alarming media headlines, articles, and YouTube videos have confused many with prediabetes and both type 1 and type 2 diabetes.

Even health professionals and organizations like the American Diabetes Association have taken a cautious approach by recommending avoidance of fructose as a sweetening agent. That is, for fear it may raise plasma lipids. They stop short of recommending people avoid fructose from fruit.

There is also the extreme arguments of Internet marketers like Joe Mercola blasting out articles about the supposed danger of fructose including that of which comes from fruit. (I've had more questions than I can count about Mercola's unreasonably scary headlines and viral copy. He makes baseless recommendations that those with diabetes should cut fructose from all sources to amounts of less than 15g per day.)

In my prior interview with John Sievenpiper, M.D., of St. Michael's Hospital, University of Toronto,  we talked of the controversies surrounding fructose, as well as rhetoric used by scientists like Dr. Robert Lustig and others, which he said could lead people to reduce intake of fruits. "That's the danger," Dr. Sievenpiper said, "that people will say that fruit is a source of fructose and won't consume fruit because it may induce obesity, metabolic syndrome, and so on. It's not just the lay public that may take this message to heart, but health professionals."

As the lead author of three systematic reviews and meta-analyses evaluating fructose's effects in randomized controlled feeding trials, Dr. Sievenpiper offered some perspective to the metabolic fate of this simple sugar in humans (versus animals). In short, these analyses found fructose had no significant effect on body weight or blood pressure in humans (as it does in rats, for example). In fact, fructose in amounts similar to that found in fruit improved glycemic control in humans.

Now, Dr. Sievenpiper and his colleagues -- including Dr. David Jenkins (who first introduced the concept of a low-glycemic index) -- has released yet another meta-analysis and systematic review to evaluate the effect on fructose on long-term glycemic control in diabetes.

The new study, published in Diabetes Care, included 18 controlled feeding trials that included 209 individuals with type 1 and type 2 diabetes. The study's results: The isocaloric exchange of fructose improves long-term glycemic control as determined by significantly reduced glycated proteins, namely hemoglobin (HbA1c) and glycated albumin.

Moreover, the isocaloric exchange of fructose reduced HbA1c by an average of 0.53 percent, which is the equivalent to taking a hypoglycemic or anti-hyperglycemic agent like glucophage (Metformin). The fructose also didn't significantly affect fasting glucose or insulin.

When I asked Dr. Sievenpiper what people with diabetes should take away from the results of the study, what they should make of fructose's contribution to total carbohydrates, and its use as a substitute for other carbohydrates in the diet, he wrote:
In the context of a healthy, nutritionally balanced, weight-maintaining diet, people with type 2 diabetes do not need to worry about avoiding sources of fructose.  
Provided weight management goals are being met, no one dietary pattern has shown itself to be best for the nutritional management of diabetes. A number of dietary patterns have shown benefit in people with diabetes. These include a low-glycemic index, Mediterranean, or vegetarian dietary patterns, as well as those which emphasize specific foods such as dietary pulses or nuts or allow for a range of macronutrient distributions. The range of possibilities allows for the individualization of diets based on treatment goals and the values and preferences of the individual. 
Within this context, using small to moderate amounts of fructose in place of other sugars and starch may offer added benefit. This would be expected to be especially true where the sources are low-glycemic index fruits and cereal grain products, both of which have shown metabolic benefit.  
That being said, we need larger, longer, and higher quality trials to clarify the benefit of fructose in people with diabetes. We are currently planning such trials. 
Fructose, far from being "toxic," may be a uniquely beneficial carbohydrate in diabetes when given in amounts equivalent to what's found in fruits, according to the evidence. Once again, the study drives home the point further that dose matters, as it does with most nutrients and bioactive compounds, and that fructose can be healthy when eating as part of a well-balanced diet.

With the virtues of a low-glycemic diet extolled recently in the media for healthy weight loss (mainly after Dr. David Ludwig and colleagues published an impressive three-way crossover study in the Journal of American Medical Association evaluating low-fat, low-glycemic index, and very low-carb diets) it's odd that more attention hasn't been given to the value of fructose as a source of low-glycemic carbohydrate.

The most likely reason, perhaps, as addressed in my previous posts, is the continuing fears people have about high-fructose corn syrup. Despite the fact that it's chemical makeup being almost identical to plain sucrose, the ingredient is still often singled out as somehow uniquely problematic. Greater intake of all foods, especially all carbohydrate sources, is what is most likely what has led us down the road of the obesity epidemic.

Bottom line? Fruit is still healthy. Fructose is most likely good for folks in amounts equivalent to what's found in fruit. Moderation in the diet needs to be the key message as it comes to any nutrient. Plus, more focus could be put on the intake of low-glycemic carbohydrates along with balanced amounts of proteins and good fats as part of a reduced-calorie diet for weight management.


Cozma AI et al. Effect of Fructose on Glycemic Control in Diabetes: A Systematic Review and Meta-analysis of Controlled Feeding Trials. Diabetes Care 2012;35:1-10.doi: 10.2337/dc12-0073

Friday, July 6, 2012

$3 billion GlaxoSmithKline and the IMPACT AWARDS

This week I received my flyers for the GlaxoSmithKline IMPACT Awards 2013, which offer a range of awards ranging from one of £40k, to ten of £30k to reward charities’ excellent work to improve people’s health. There’s absolutely bucket loads of cash and the closing date for applications is the 21st September. The awards are offered in partnership with the King’s Fund and I’ve seen a number of arts/health projects proudly emblazoned with their award winning GSK logos over the years. Great opportunity in a time of austerity eh? But hold fire for a second, because haven’t GlaxoSmithKline been in the news for things other than philanthropy this week?
That’s right: as well as being fined $3 billion ‘after admitting bribing doctors and encouraging the prescription of unsuitable antidepressants (Paxil) for children’, they’re also expected to admit failing to report safety problems with the diabetes drug Avandia! GSK also ‘paid for articles on its drugs to appear in medical journals...’ 

It reminds me of the excellent work done by the Institute for Quality and Efficiency in Healthcare, (IQWiG) which I reported in my paper, A Brightly Coloured Bell-Jar and that showed Pfizer’s anti-depressant, reboxetine was no more effective than placebo,  and was "significantly less" effective, and was less acceptable, than the other drugs in treating the acute-phase treatment of adults with unipolar major depression. Yet, the published data on reboxetine overestimated the benefit of reboxetine versus placebo by up to 115% and also underestimated harm, concluding that reboxetine was an ineffective and potentially harmful antidepressant. The study also showed that nearly three quarters of the data on patients who took part in trials of reboxetine were not published by Pfizer until after they had been exposed by the IQWiG...
And yet, still many of us in the arts/health world talk, (with dewy eyes) about the gold-standard, randomized controlled trial, and the impartiality of the scientific journal. Let’s remember this: GSK have pleaded guilty to promoting drugs for improper use - and Pfizer were hiding the evidence that their medication was ineffective and potentially harmful. Both used scientific journals to promote their products and in the case of GSK, paid doctors to actively promote their products.

Why do we let ourselves be blindly pulled into the myth of the commercially driven scientific journals ‘objectivity’? That said, I’m sure the research of the majority of scientists is driven by a desire for clinical advance, but its the dominance of the pharmaceuticals that clearly muddy the waters. It’s worth noting that whilst GSK have been fined $3 billion, the profits on Paxil are already over $11.6 billion and from Avandia are $10.4 billion! So their offer of around £340k Impact Awards to charities, suddenly seems paltry in the face of their grotesque profit and potential harm, both to health and wellbeing - and on the ethics of clinical research and its dissemination.

Footnote: This week I saw the 1974 Alan Yentob documentary on David Bowie called, Cracked Actor, in which Bowie (apparently out of his mind much of the time on cocaine), talked eloquently about his Ziggy Stardust period, and how this work was research on how people surround celebrities, pushing them further and further, and plying them with drugs to produce more and more (Hendrix, Joplin et al). It set my mind racing on the cult of drugs, both prescribed and illegal. Which are more immoral? Then I read the GSK apology and received its offer of cash for excellence. 
For a far more eloquent account of the pharmaceutical dominance withn research, go to, one-time editor of the BMJ Dr Richard Smith. Always excellent.  

...and moving away from medication for a moment:

Start2 is an online creative wellbeing service, free to use. Start2 contains over 80 exercises that boost wellbeing and help us to live more creatively. Whether for personal or professional use, Start2 is aimed at anyone who wants to explore wellbeing through creative outlooks and activities. Visit them by clicking on the image below: www.start2.co.uk 

Case Studies Needed: 
National Alliance for Arts, Health and Wellbeing (England)
For the past couple of years, the North West Arts and Health Network has been working with partners across the country to develop a national voice for arts and health. This is due to launch in the autumn and a dedicated media campaign is being planned to coincide with this aiming to demonstrate leading arts and health projects and their impact on patients and the public.
The campaign, funded with the support of the King’s Fund and run by media agency SKV is looking for case studies which showcase the best in the field of arts health and wellbeing. We are looking to create a body of case studies which can be drawn on by SKV for press opportunities in different contexts and this means we need a variety of stories on a range of different subjects, demonstrating different points. With press attention in mind we are looking for examples which stand out, offer something new in context, demonstrate high quality work or offer real personal stories and insights which demonstrate the impact of the work. Because we will either have to be very responsive or be looking to demonstrate particular points, we cannot guarantee to use every case study we receive but we hope you will be happy to contribute to this important resource.
To let us know you would like your organisation or project to be included and for details on what to include in your case study submission, email artsforhealth@mmu.ac.uk 

RNCM Music for Health Programme
The Central Manchester University Hospitals Concert Series
Fri 13 July Royal Eye Hospital Atrium 7.30pm – 8.45pm
Ordsall Acapella Singers A four-part community choir whose programme will include songs as diverse as Imagine, Wonderful World and Nellie the Elephant!!
Sneak preview by clicking on the photograph below. 

PhD Opportunity in Nottingham 
There is an opportunity for three year full-time PhD funding from the NIHR. We are looking for a potential PhD student to collaborate with us on a research project looking at the effectiveness of singing with people with dementia. The project is at a late stage of development and you will be supported throughout the application process. We need an applicant who is 100% committed to do doing a full-time PhD in Nottingham over three years. The prospective candidate needs to be a registered health professional i.e. Nursing and Midwifery Council (NMC) or the Health Professionals Council (HPC) (at the time the award is granted - this includes arts therapists). Naturally we are also looking for somebody experienced in singing with older people. The ideal person will probably have a good science/arts balance and already have a Masters degree (or first class Bachelors with evidence of ongoing study). Contact theo.stickley@nottingham.ac.uk 

...and returning to another kind of medication:

The fast food chain McDonalds unveils its first sustainable restaurant in the Olympic Park, Stratford. It's the largest in the world and during the Games, will be the busiest in the world. Mmmm, the opiate of the massives (sp)

...thank you as ever...C.P.