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Tag: obesity

  • Lose Weight by Eating More in the Morning  | NutritionFacts.org

    Lose Weight by Eating More in the Morning  | NutritionFacts.org

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    A calorie is not a calorie. It isn’t only what you eat, but when you eat.

    Mice are nocturnal creatures. They eat during the night and sleep during the day. However, if you only feed mice during the day, they gain more weight than if they were fed a similar amount of calories at night. Same food and about the same amount of food, but different weight outcomes, as you can see in the graph below and at 0:18 in my video Eat More Calories in the Morning to Lose Weight, suggesting that eating at the “wrong” time may lead to disproportionate weight gain. In humans, the wrong time would presumably mean eating at night. 

    Recommendations for weight management often include advice to limit nighttime food consumption, but this was largely anecdotal until it was first studied experimentally in 2013. Researchers instructed a group of young men not to eat after 7:00 pm for two weeks. Compared to a control period during which they continued their regular habits, they ended up about two pounds lighter after the night-eating restriction. This is not surprising, given that dietary records show the study participants inadvertently ate fewer calories during that time. To see if timing has metabolic effects beyond just foreclosing eating opportunities, you’d have to force people to eat the same amount of the same food, but at different times of the day. The U.S. Army stepped forward to carry out just such an investigation.

    In their first set of experiments, Army researchers had people eat a single meal a day either as breakfast or dinner. The results clearly showed the breakfast group lost more weight, as you can see in the graph below and at 1:35 in my video. When study participants ate only once a day at dinner, their weight didn’t change much, but when they ate once a day at breakfast, they lost about two pounds a week. 

    Similar to the night-eating restriction study, this is to be expected, given that people tend to be hungrier in the evening. Think about it. If you went nine hours without eating during the day, you’d be famished, but people go nine hours without eating overnight all the time and don’t wake up ravenous. There is a natural circadian rhythm to hunger that peaks around 8:00 pm and drops to its lowest level around 8:00 am, as you can see in the graph below and at 2:09 in my video. That may be why breakfast is typically the smallest meal of the day. 

    The circadian rhythm of our appetite isn’t just behavioral, but biological, too. It’s not just that we’re hungrier in the evening because we’ve been running around all day. If you stayed up all night and slept all day, you’d still be hungriest when you woke up that evening. To untangle the factors, scientists used what’s called a “forced desynchrony” protocol. Study participants stayed in a room without windows in constant, unchanging, dim light and slept in staggered 20-hour cycles to totally scramble them up. This went on for more than a week, so the subjects ended up eating and sleeping at different times throughout all phases of the day. Then, the researchers could see if cyclical phenomena are truly based on internal clocks or just a consequence of what you happen to be doing at the time.  

    For instance, there is a daily swing in our core body temperature, blood pressure, hormone production, digestion, immune activity, and almost everything else, but let’s use temperature as an example. As you can see in the graph below and at 3:21 in my video, our body temperature usually bottoms out around 4:00 am, dropping from 98.6°F (37°C) down to more like 97.6°F (36.4°C). Is this just because our body cools down as we sleep? No. By keeping people awake and busy for 24 hours straight, it can be shown experimentally that it happens at about the same time no matter what. It’s part of our circadian rhythm, just like our appetite. It makes sense, then, if you are only eating one meal per day and want to lose weight, you’d want to eat in the morning when your hunger hormones are at their lowest level. 

    Sounds reasonable, but it starts to get weird.

    The Army scientists repeated the experiment, but this time, they had the participants eat exactly 2,000 calories either as breakfast or as dinner, taking appetite out of the picture. The subjects weren’t allowed to exercise either. Same number of calories, so the same change in weight, right? No. As you can see in the graph below and at 4:18 in my video, the breakfast-only group still lost about two pounds a week compared to the dinner-only group. Two pounds of weight loss eating the same number of calories. That’s why this concept of chronobiology, meal timing—when to eat—is so important. 

    Isn’t that wild? Two pounds of weight loss a week eating the same number of calories! That was a pretty extreme study, though. What about just shifting a greater percentage of calories to earlier in the day? That’s the subject of my next video: Breakfast Like a King, Lunch Like a Prince, Dinner Like a Pauper. First, let’s take a break from chronobiology to look at the Benefits of Garlic for Fighting Cancer and the Common Cold. Then, we’ll resume checking other videos in the related posts below.

    If you missed the first three videos in this extended series, also check out related posts below. 

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    Michael Greger M.D. FACLM

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  • Milk Hormones and Female Infertility  | NutritionFacts.org

    Milk Hormones and Female Infertility  | NutritionFacts.org

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    Dairy consumption is associated with years of advanced ovarian aging, thought to be due to the steroid hormones or endocrine-disrupting chemicals in cow’s milk.
     
    When it comes to the amount of steroid hormones we are exposed to in the food supply, dairy “milk products supply about 60–80% of ingested female sex steroids.” I’ve talked about the effects of these estrogens and progesterone in men and prepubescent children, and how milk intake can spike estrogen levels within hours of consumption. You can see graphs illustrating these points from 0:25 in my video The Effects of Hormones in Milk on Infertility in Women. In terms of effects on women, I’ve discussed the increased endometrial cancer risk in postmenopausal women. What about reproductive-age women? Might dairy hormones affect reproduction? 
     
    We’ve known that “dairy food intake has been associated with infertility; however, little is known with regard to associations with reproductive hormones or anovulation.” How might dairy do it? By affecting how the uterus prepares, or by affecting the ovary itself? Researchers found that women who ate yogurt or cream had about twice the risk of sporadic anovulation, meaning failure of ovulation, so some months there was no egg to fertilize at all. Now, we know most yogurt is packed with sugar these days. Even plain Greek yogurt can have more sugar than a double chocolate glazed cake donut, but the researchers controlled for that and the results remained after adjusting for the sugar content, “which suggests that the risk of anovulation was independent of the sugar content included in many flavored yogurt products.” We don’t know if this was just a fluke or exactly what the mechanism might be, but if women skip ovulation here and there throughout their lives, might they end up with a larger ovarian reserve of eggs? 
     
    Women are starting to have their first baby later in life. As you can see in the graph below and at 2:02 in my video, there’s been a rise in women having babies when they’re in their late 30s and 40s.

    We used to think that women’s ovarian reserve of eggs stayed relatively stable until a rapid decline at about age 37, but now we know it appears to be more of a gradual loss of eggs over time. The graph below and at 2:22 in my video charts a steady loss starting at peak fertility in one’s 20s.

    This measures “antral follicle count,” which is an ultrasound test where you can count the number of “next batter up” eggs in the ovaries, as you can see below and at 2:31 in my video. It is probably the best reflection of true reproductive age. It’s a measure of ovarian reserve—how many eggs a woman has left.

    What does this have to do with diet? Researchers at Harvard looked at the association of various protein intakes with ovarian antral follicle counts among women having trouble getting pregnant. “Even though diminished ovarian reserve is one of the major causes of female infertility, the process leading to reproductive senescence [deterioration with age] currently is poorly understood. In light of emerging population trends towards delayed pregnancy, the identification of reversible factors (including diet) that affect the individual rates of reproductive decline might be of significant clinical value.”

    The researchers performed ultrasounds on all the women, studied their diets, and concluded that higher intake of dairy protein was associated with lower antral follicle counts—in other words, accelerated ovarian aging. The graph below and at 3:39 in my video shows what counts look like in nonsmokers: Significantly lower ovarian reserve (12.7 antral follicle counts) at the highest dairy intake, which would be like three ounces of cheese a day, compared to the lowest dairy intake (16.9 antral follicle counts).

    What do these numbers mean in terms of biological age? Is 16.9 down to 12.7 really that much of a difference? As you can see below and at 3:58 in my video, when you look at women with really robust ovaries, a follicle count of 16.9 is what you might see in a 36- or 37-year-old, whereas 12.7, which is what you can see in women eating the most dairy, is what you might see in a really fertile 50-year-old. So, we’re talking year’s worth of ovarian aging between the highest and lowest dairy consumers.

    While it wasn’t possible for the researchers to “identify the underlying mechanism linking higher dairy protein intake to lower AFC,” antral follicle count, they had educated guesses. (1) It could be the steroid hormones and growth factors or (2) “the contamination of milk products by pesticides and endocrine disrupting chemicals that may negatively impact” the development of these ovarian follicles and egg competence.

    “Regarding the former [the hormones], studies suggest that commercial milk (derived from both pregnant and non-pregnant animals) contains large amounts of estrogens, progesterone, and other placental hormones that are eventually released into the human food chain, with dairy intake accounting for 60–80% of the estrogens consumed. Dairy estrogens overcome [survive] processing, appear in raw whole cow’s and commercial milk products, are found in substantially higher concentrations with increasing amounts of milk fat, with no apparent difference between organic and conventional dairy products…” Hormones are just naturally in cows’ bodies, so they aren’t just in the ones injected with growth hormones. And, once these bovine hormones are inside the human body, they get converted to estrone and estradiol, the main active human estrogens. Following absorption, bovine steroids may then affect reproductive outcomes.

    The researchers asserted that further studies are needed and that “it is imperative that these findings are reproduced in prospective studies designed to clarify the biology underlying the observed associations. The latter might be crucial given that consumption of another species’ milk by humans is an evolutionary novel dietary behavior that has the potential to alter reproductive parameters and may have long-term adverse health effects.”

    The video I mentioned about the effects of these estrogens and progesterone in men and prepubescent children is The Effects of Hormones in Dairy Milk on Cancer.

    I talk about the effect of dairy estrogen on male fertility in Dairy Estrogen and Male Fertility.

    How else might diet affect fertility? See related posts below. 

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    Michael Greger M.D. FACLM

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  • Skip Breakfast to Lose Weight?  | NutritionFacts.org

    Skip Breakfast to Lose Weight?  | NutritionFacts.org

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    Breakthroughs in the field of chronobiology—the study of our circadian rhythms—help solve the mystery of the missing morning calories in breakfast studies.

    Where did this whole “breakfast is the most important meal of the day” concept come from? “The Father of Public Relations,” Edward Bernays, infamous for his “Torches of Freedom” campaign to get women to start smoking back in the 1920s, was paid by a bacon company to popularize the emblematic bacon-and-eggs breakfast. The role of public relations, he wrote in his book Propaganda, is the “conscious and intelligent manipulation of the organized habits and opinions of the masses….” Public relations specialists thereby “constitute an invisible government, which is the true ruling power of our country….”

    Breakfast is big business. Powerful corporate interests, such as the cereal lobby, are blamed for “perpetuating myths such as the value of consuming breakfast.” An editorial in The American Journal of Clinical Nutrition urged nutrition scientists to speak truth to power and challenge conventional wisdom when necessary “even when it looks like we are taking away motherhood and apple pie.” “Actually,” the editorial concludes, “reducing the portion size of apple pie might not be a bad idea, either.”

    So, should we “break the feast” and skip breakfast to lose weight? As I discuss in my video Is Skipping Breakfast Better for Weight Loss?, though “the advice to eliminate breakfast will surely pit…nutritional scientists…against the very strong and powerful food industry,” skipping breakfast has been described as “a straightforward and feasible strategy to reduce total daily energy [caloric] intake.” Unfortunately, it doesn’t seem to work.

    Most randomized controlled studies of breakfast skipping found no weight-loss benefit to omitting breakfast. How is that possible if skipping breakfast means skipping calories? The Bath Breakfast Project, a famous series of experiments run not out of a tub, but the University of Bath in the UK, discovered a key to the mystery. Men and women were randomized to either eat breakfast (defined as taking in at least 700 calories before 11:00 am) or fast until noon every day. As you can see in the graph below and at 2:15 in my video, as in other similar trials, the breakfast-eating group ate a little less throughout the rest of the day but still ended up with hundreds of excess daily calories over the breakfast skippers.

    Those who ate breakfast consumed more than 500 more calories a day. Over six weeks, that would add up to more than 20,000 extra calories. Yet, after six weeks, both groups ended up with the same change in body fat, as you can see below and at 2:36 in my video. How could tens of thousands of calories just effectively disappear? 

    If more calories were going in with no change in weight, then there must have been more calories going out. And, indeed, as you can see in the graph below at 2:52 and in my video, the breakfast group was found to spontaneously engage in more light-intensity physical activity in the mornings than the breakfast-skipping group. Light-intensity activities include things like casual walking or light housecleaning, not structured exercise per se, but apparently, enough extra activity to use up the bulk of those excess breakfast calories. There’s a popular misconception that our body goes into energy conservation mode when we skip breakfast by slowing our metabolic rate. However, that does not appear to be true. But, maybe our body does intuitively slow us down in other ways. When we skip breakfast, our bodies just don’t seem to want to move around as much. 

    The extra activity didn’t completely make up for the added calories consumed by the breakfast group, though. We seem to still be missing about a hundred daily calories, suggesting there may be another factor to account for the mystery of the MIA morning calories. Recent breakthroughs in the field of chronobiology—the study of our body’s natural rhythms—have unsettled an even more sacred cow of nutrition dogma: the concept that a calorie is a calorie. It’s not just what we eat, but when we eat. Same number of calories, different weight loss, depending on meal timing.  

    Just to give you a taste: As you can see in the graph below and at 4:11 in my video, the exact same number of calories at breakfast are significantly less fattening than the same number of calories eaten at supper. Mind-blowing!

    A diet with a bigger breakfast causes more weight loss than the same diet with a bigger dinner, as shown below and at 4:23 in my video. Because of our circadian rhythms, morning calories don’t appear to count as much as evening calories. So, maybe breakfast should be the most important meal of the day after all. 

    If you missed my last video, catch up with Flashback Friday: Is Breakfast the Most Important Meal for Weight Loss or Should It Be Skipped?. 

    Did I pique your interest in chronobiology? If so, you’re in luck. See more in the related posts below. 

    For some breakfast inspiration, check out A Better Breakfast and my recipe videos for a vegetable smoothie and a grain bowl from The How Not to Die Cookbook. 

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    Michael Greger M.D. FACLM

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  • Are Branched-Chain Amino Acids Good for Us?  | NutritionFacts.org

    Are Branched-Chain Amino Acids Good for Us?  | NutritionFacts.org

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    I discuss why we may not want to exceed the recommended intake of protein.

    Diabetes isn’t just about the amount of body fat, but also the distribution of body fat. At 0:26 in my video Are BCAA (Branched-Chain Amino Acids) Healthy?, you can view cross-sections of thighs from two different patients using MRI. In the images, the fat shows up as white and the thigh muscle is black. At first glance, you might think the bottom cross-section has more fat since it’s ringed with more white. That is the subcutaneous fat, the fat under the skin. But, if you look at the top cross-section, you’ll see how the middle of the thigh muscle is more marbled with fat, like those really fatty Japanese beef steaks. That is the fat infiltrating into the muscle. In the graph below and at 0:48 in my video, the two cross sections are colored so you can see the different types of fat: the fat infiltrating the muscle in red, the fat between the muscles in green, and subcutaneous fat outside of the muscles and under the skin in yellow. If you add up all three types of fat, both of those thighs actually have the same amount of fat—just distributed differently.

    This seems to be the critical factor in terms of determining insulin resistance, the cause of type 2 diabetes. Researchers found that the subcutaneous adipose tissue, the fat right under the skin, was not associated with insulin resistance. Going back to the two cross sections, as seen below and at 1:20 in my video, it is healthier to have the bottom thigh with the thicker ring of subcutaneous fat but less fat infiltrating muscle than the top thigh with more fat present in the muscle.

    Is it possible a more plant-based diet also affects a more healthful distribution of fat?

    We now know the effect of a vegetarian diet versus a conventional diabetic diet on thigh fat distribution in patients with type 2 diabetes. Researchers took 74 people with diabetes and randomly assigned them to follow either a vegetarian diet or a conventional diabetic diet. Both diets were calorie-restricted by the same number of calories. The vegetarian diet was also egg-free, and dairy was limited to a maximum of one serving of low-fat yogurt a day. What did the researchers find? The reduction in the more benign subcutaneous fat was comparable; it was about the same in both groups. However, the more dangerous fat—the fat lodged inside the muscle itself—“was reduced only in response to a vegetarian diet.” So, even getting the same number of calories, there can be a healthier weight loss on a more plant-based diet.

    Those eating strictly plant-based also had lower levels of fat stuck inside the individual muscle fibers themselves, which may help explain why vegans in particular are often found to have the lowest odds of diabetes. It is not just because vegans are generally slimmer either. Even if you match subjects pound for pound, there is significantly less fat inside the muscle cells of vegans compared to omnivores. This is a good thing, since storing fat in muscle cells “may be one of the primary causes of insulin resistance,” which is what’s behind both prediabetes and type 2 diabetes. On the other hand, if you put someone on a high-fat diet, the fat in their muscle cells shoots up by 54 percent in just a single week.

    What about a high-protein diet? That may undermine one of the principal benefits of weight loss: eliminating the weight-loss-induced improvement in insulin resistance. Researchers put obese individuals on a calorie-restricted diet of less than 1,400 calories a day until they lost 10 percent of their body weight. Half of the participants were getting more of a regular protein intake (73 grams a day), and the other half were on a higher-protein diet (about 105 daily grams). Normally, if you lose 10 percent of your body weight, your insulin resistance improves. That’s why it is so critical for obese individuals with type 2 diabetes to lose weight. However, the beneficial effect of a 10 percent weight loss was eliminated by the high protein intake. Those extra 32 grams of protein a day abolished the weight-loss benefit. “The failure to improve…insulin sensitivity in the WL-HP [weight-loss high-protein] group is clinically important because it reflects a failure to improve a major pathophysiological [cause-and-effect] mechanism involved in the development of T2D,” type 2 diabetes. In summary, the researchers concluded that they demonstrated “the protein content of a weight loss diet can have profound effects on metabolic function.” 

    Is this true of any protein? As you can see below and at 4:19 in my video, if you split it between animal protein versus plant protein, following people over time, intake of animal protein is associated with an increased risk of diabetes in most studies.

    Intake of plant protein, however, appears to have either a neutral or even protective association with diabetes, as shown below and at 4:25 in my video. 

    Those were just observational studies, though. People who eat a lot of animal protein might have many unhealthy behaviors. However, you see the same thing in randomized, controlled, interventional trials, where you can improve blood sugar control just by replacing sources of animal protein with plant protein.

    We think it may be the branched-chain amino acids concentrated in animal protein. Higher levels in the bloodstream are associated with obesity and the development of insulin resistance. As you can see below and at 5:00 in my video, we may be able to drop our levels by sticking to plant proteins, but you don’t know if that has metabolic effects until you put it to the test. 

    Ruining the suspense, researchers titled their study: “Decreased Consumption of Branched-Chain Amino Acids Improves Metabolic Health.” They demonstrated that “a moderate reduction in total dietary protein or selected amino acids can rapidly improve metabolic health,” and this included improving blood sugar control, while also decreasing body mass index (BMI) and body fat. As you can see at 5:27 in my video, the protein-restricted group was eating hundreds more calories per day, significantly more calories than the control group, so they should have gained weight. But, no. They lost weight! After about a month and a half, they were eating more calories but lost more weight—about five more pounds than participants in the control group who were eating fewer calories, as you can see at 5:38 in my video. What’s more, this “protein restriction” had people eat the recommended amount of protein per day, about 56 daily grams. They should have been called the normal protein group or the recommended protein group instead, and the group eating more typically American protein levels and suffering because of it should have been called the excess protein group. Just sticking to the recommended protein intake doubled the levels of a pro-longevity hormone called FGF21, too, but we’ll save that for another discussion.

    To better understand the negative impact of omnivores getting too much protein relative to vegetarians, see my video Flashback Friday: Do Vegetarians Get Enough Protein?.

    I have several additional videos and blogs that may help explain some of the benefits of plant-based proteins. Check in the related posts below.

    Of course, the best way to treat type 2 diabetes is to get rid of it by treating the underlying cause, as described in my video How Not to Die from Diabetes. 

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    Michael Greger M.D. FACLM

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  • Drinking apple cider vinegar daily may be linked with weight loss, study finds

    Drinking apple cider vinegar daily may be linked with weight loss, study finds

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    Apple cider vinegar makes for a tasty salad dressing or marinade, but new research has found that it also could be useful in boosting weight loss efforts.

    Daily consumption of small amounts of apple cider vinegar — which is made from fermented apple juice and contains the active ingredient acetic acid — may aid weight management in people who are overweight or obese, according to a study published earlier this month in BMJ Nutrition, Prevention & Health. 

    The small study focused on 120 people from Lebanon, ages 12 to 25 years, who had obesity or were overweight. Some participants were randomly assigned to drink either 5, 10 or 15 milliliters of apple cider vinegar diluted in a cup of water once a day, first thing in the morning, for a period of 12 weeks. Other participants were given a placebo liquid to drink each day.

    Compared with the people given the placebo, the participants who drank the apple cider vinegar lost “significant” amounts of weight, losing an average 15 pounds over the course of the study. The apple cider vinegar drinkers also saw reductions in BMI. Those who drank the largest amount of apple cider vinegar, 15 milliliters, experienced the largest decreases in weight and BMI after 12 weeks. 

    The apple cider vinegar drinkers also saw significant reductions in waist and hip measurements and body fat ratio compared with the placebo. These reductions were similar regardless of dose, suggesting the effect didn’t depend on the quantity, the researchers say.

    There were also improvements in metabolic markers — which are used to gauge someone’s overall health — such as levels of blood glucose, triglycerides and total cholesterol.

    “These results suggest that apple cider might have potential benefits in improving metabolic parameters related to obesity and metabolic disorders in obese individuals,” the study authors said. “The results might contribute to evidence-based recommendations for the use of (apple cider vinegar) as a dietary intervention in the management of obesity.”

    The authors note that there are some limitations, including the study’s small sample size and short 12-week period, which is not enough to gauge possible longterm side effects.

    Furthermore, while apple cider vinegar has shown to have several possible health benefits — like killing harmful bacteria, managing diabetes and improving heart health — it is not necessarily a “magic pill,” registered dietitian nutritionist Michelle Routhenstein told Healthline.

    “(Apple cider vinegar) needs to be looked at in conjunction with overall diet and physical activity, as well as stress and sleep management, to have a significant long-lasting impact,” Routhenstein said.

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    Franki Rudnesky

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  • The Efficacy of Weight-Loss Supplements  | NutritionFacts.org

    The Efficacy of Weight-Loss Supplements  | NutritionFacts.org

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    Are there any safe and effective dietary supplements for weight loss?

    In a previous discussion, I noted that an investigation found that four out of five bottles of commercial herbal supplements bought at major U.S. retailers—GNC, Walgreens, Target, and Walmart—didn’t contain any of the herbs listed on their labels, instead “often containing little more than cheap fillers like powdered rice, asparagus and houseplants…”

    You might hope your supplement just contains houseplants. Weight-loss supplements are infamous for being “adulterated with prescription and over-the-counter” drugs. In a sampling of 160 weight-loss supplements that “were claimed as 100% natural,” more than half were tainted with drugs and active pharmacological ingredients, ranging from antidepressants like Prozac to erectile dysfunction medications like Viagra. Diuretic drugs are frequent contaminants, which makes sense. In my previous videos on ketogenic diets, I talk about rapid water loss being “the $33-billion diet gimmick” that has sold low-carb diets for more than a century. But why the Viagra?

    At least the spiked Viagra and Prozac are legal drugs. Researchers in Denver tested every weight-loss supplement they could find within a ten-mile radius. Alarmingly, they found that a third were adulterated with banned ingredients. The most common illegal adulterant of weight-loss supplements is sibutramine, which was sold as Meridia before it was yanked off the market back in 2010 for heart attack and stroke risk. Now, it is also blamed for cases of slimming supplement–induced psychosis.

    An analysis of weight-loss supplements bought off the internet that were advertised with claims like “purely natural products,” “harmless,” or “traditional herbal” found that a third of them contained high doses of the banned drug sibutramine and the rest had caffeine. Wouldn’t you be able to tell if caffeine was added to a supplement? Perhaps not, if it also had temazepam, a controlled substance (benzodiazepine) “downer” sedative found in half of the caffeine-tainted supplements.

    Doesn’t the FDA demand recalls of adulterated supplements? Yes, but they often just pop back up on store shelves. Twenty-seven supplements were purchased at least six months after recalls were released, and two-thirds still contained banned substances. That’s 17 out of 27 with the same pharmaceutical adulterant found originally, and 6 containing one or more additional banned ingredients. Aren’t the manufacturers penalized for noncompliance? Yes, but “the fines for violations are small compared to the profits.”

    One of the ways supplement makers can skirt the law is by labeling them as “not intended for human consumption because it shifts the responsibility from the seller to the user”—for example, labeling the fatal fat-burner DNP as “an industrial- or research chemical.” This is how designer street drugs can be sold openly at gas stations and convenience stores as “bath salts.” Another way is to claim synthetic stimulants added to slimming supplements are actually natural food constituents, like listing the designer drug dimethylamylamine (DMAA) as “geranium oil extract.” The FDA banned it in 2012 after it was determined that DMAA “was not found in geraniums.” Who eats geraniums anyway? Despite being tentatively tied to cases of sudden death and associated with hemorrhagic stroke, DMAA has continued to be found in weight-loss supplements with innocuous names like Simply Skinny Pollen made by Bee Fit with Trish.

    There is little doubt that certain banned supplements, like ephedra, could help people lose weight. “There’s only one problem, and it’s a big one: This supplement may kill you,” wrote a founding member of the American Board of Integrative Medicine.

    Are there any safe and effective dietary supplements for weight loss? As I discuss in my video Friday Favorites: Are Weight-Loss Supplements Safe and Effective?, when popular slimming supplements were put to the test in a randomized placebo-controlled trial, not a single one could beat out placebo sugar pills. “A systematic review of systematic reviews” of diet pills came to a similar conclusion: None appears to generate appreciable impacts “on body weight without undue risks.” That was the conclusion reached in a similar review out of the Weight Management Center at Johns Hopkins, which ended with: “In closing, it is fitting to highlight that perhaps the most general and safest alternative/herbal approach to weight control is to substitute low-energy density [low-calorie] foods for high-energy density and processed foods, thereby reducing total energy intake.” In other words, eat more whole plant foods and fewer animal foods and junk. “By taking advantage of the low-energy density [low-calorie] and health-promoting effects of plant-based foods, one may be able to achieve weight loss, or at least assist weight maintenance without cutting” down on the volume of food consumed or compromising its nutrient value.

    Learn more about the risks of supplements in my video Are Weight Loss Supplements Safe?.

    I referred to a keto diet video I did, check out the related posts below the links to other videos and blogs in that series.

    Learn more about optimal weight loss in my book, How Not to Diet. 

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    Michael Greger M.D. FACLM

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  • The Safety of Weight-Loss Supplements  | NutritionFacts.org

    The Safety of Weight-Loss Supplements  | NutritionFacts.org

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    Only 2 out of 12 supplement companies were found to have weight-loss products that were even accurately labeled.

    According to a national survey, one-third of adults who have made serious attempts at weight loss have tried using dietary supplements, for which Americans spend billions of dollars every year. Most people mistakenly thought that over-the-counter appetite suppressants, herbal products, and weight-loss supplements had to be approved for safety by a governmental agency, like the U.S. Food and Drug Administration (FDA), before being sold to the public or at least include some kind of warning on the label about potential side effects. Nearly half even thought they had to demonstrate some sort of effectiveness. None of that is true.

    As I discuss in my video Friday Favorites: Are Weight Loss Supplements Safe and Effective?, the “FDA has estimated that dietary supplements cause 50,000 adverse events annually,” most commonly liver and kidney damage. Of course, prescription drugs don’t just have adverse effects; they kill more than 100,000 Americans every year. But, you at least notionally have the opportunity to parse out the risks versus benefits of prescription drugs, thanks to testing and monitoring requirements typically involving thousands of individuals.

    When the manufacturer of Metabolife 356, a supplement containing ephedrine, had it tested on 35 people, only minor side effects were found, such as dry mouth, headache, and insomnia. However, once unleashed on a broad population, nearly 15,000 adverse effects were reported, including heart attacks, strokes, seizures, and deaths, before it was pulled from the market.

    Given the lack of government oversight, there is no guarantee that what’s on the label is even in the bottle, as you can see in the graph below and at 1:55 in my video. FDA inspectors have found that 70 percent of supplement manufacturers violated so-called Good Manufacturing Practices, which are considered the minimum quality standards. This includes things like basic sanitation and ingredient identification. Not 7 percent in violation, but 70 percent.

    DNA testing of herbal supplements across North America found that most could not be authenticated. In a significant percentage of the supplements tested, the main labeled ingredient was missing completely and substituted with something else. For example, a so-called St. John’s wort supplement contained nothing but senna, a laxative that can cause anal blistering. Only 2 out of 12 supplement companies had products that were accurately labeled.

    This problem isn’t limited to fly-by-night phonies in some dark corner of the internet either. The New York State Attorney General commissioned DNA testing of 78 bottles of commercial herbal supplements sold by Walgreens, Walmart, Target, and GNC “and found that four out of five…did not contain any of the herbs on their labels.” Instead, the capsules “often contained little more than cheap fillers like powdered rice, asparagus and houseplants…”

    What about weight-loss medications? See Are Weight Loss Pills Safe? and Are Weight Loss Pills Effective?. Also, see related posts below.

    Take a deep dive into the best way to lose weight with my book How Not to Diet. 

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    Michael Greger M.D. FACLM

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  • The Ozempic Revolution Is Stuck

    The Ozempic Revolution Is Stuck

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    Millions more Americans are now eligible for obesity drugs. But the injections remain maddeningly hard to find.

    Illustration by The Atlantic. Source: Getty.

    The irony undergirding the new wave of obesity drugs is that they initially weren’t created for obesity at all. The weight loss spurred by Ozempic, a diabetes drug in the class of so-called GLP-1 agonists, gave way to Wegovy—the same drug, repackaged for obesity. Zepbound, another medication, soon followed. Now these drugs have a new purpose: heart health.

    On Friday, the FDA approved the use of Wegovy for reducing the risk of heart attack, stroke, and death in adults who are overweight and have cardiovascular disease. The move had been anticipated since the publication of a landmark trial in the fall, which showed the drug’s profound effects on cardiovascular  health. The decision could usher in a new era where GLP-1 drugs become mainstream, opening up access to millions of Americans who previously didn’t qualify for Wegovy.

    Some of the obstacles stopping people from getting the drug may also begin to crumble. Insurance companies commonly deny coverage of Wegovy because obesity is seen as a cosmetic concern rather than a medical one, but that argument may not hold up for cardiovascular disease. “This new FDA indication is HUGE,” Katherine Saunders, an obesity-medicine physician at Weill Cornell Medicine, told me in an email. Wegovy may soon be within reach for many more Americans—that is, if they can find it.

    In practice, Wegovy is maddeningly hard to get hold of. Shortages of injectable semaglutide, the active ingredient in Wegovy and Ozempic, have been ongoing since March 2022; currently, most doses of Wegovy are in limited supply. As the popularity of semaglutide has skyrocketed, demand has completely outstripped the capacity of its manufacturer, Novo Nordisk. The drug comes in injection pens containing a glass vial; “these are not easy products to make,” Lars Fruergaard Jørgensen, the CEO of Novo Nordisk, said in August. In response to the shortages, the company withheld its supply of lower Wegovy doses last year. Because treatment on the medication must begin in low doses, this meant that new patients who wanted to start on Wegovy functionally couldn’t. In January, the company began “more than doubling the amount of the lower-dose strengths” of the drug, a Novo Nordisk spokesperson told me, and it plans to gradually increase overall supply throughout the rest of the year.

    The ongoing shortages have left providers and patients feeling stuck. “It is devastating to prescribe a lifesaving medication for a patient and then find out it’s not covered or we can’t locate supply,” Saunders said. Doctors are scrambling to make do with what’s available. Ivania Rizo, an endocrinologist at Boston Medical Center, told me she has had to turn to older GLP-1 drugs such as Saxenda to “bridge” patients to higher doses of Wegovy, although now that is in shortage too. Patients can spend each day calling pharmacy after pharmacy in search of one with Wegovy in stock, Rizo said. In desperation, some have turned to versions of the drug that are custom-made by compounding pharmacies with little oversight, despite the FDA expressing concerns about them. The shots are supposed to be taken weekly, but others have attempted to stretch their doses beyond that.

    That the new FDA approval could very mainstream obesity drugs may create long-needed pressure to help resolve these shortages. It makes clear that Wegovy is a lifesaving medication not only for people with obesity but also for those with cardiovascular disease—the leading cause of death in the U.S.—putting the impetus on Novo Nordisk to ramp up production. But in the short term, the access issues may persist. “The new approval is very likely to worsen shortages, because the demand for Wegovy will continue to climb—now at an even faster pace,” Saunders said.

    If patients think they’re stuck now, they’re about to feel entrenched. Wegovy is the only obesity drug that has been approved to reduce the risk of heart attacks, but none of its competitors is easily available either. Supplies of certain dosages of Eli Lilly’s Mounjaro, a diabetes drug whose active ingredient is sold for obesity as Zepbound, are limited, and shortages are expected later this year. “We need supply to increase dramatically,” Saunders said. Both Novo Nordisk and Eli Lilly have invested heavily in expanding production capacity, but some of the new plants won’t open until 2029.

    For all of its advantages, the FDA approval has a sobering effect on the unrelenting hype around GLP-1s. So much of the excitement around obesity drugs has focused on the future, as dozens of pharmaceutical companies develop more powerful drugs, and commentators imagine a world without obesity. In the process, the issues of the present have gone overlooked. More drugs won’t make much of a difference if the drugs themselves are out of reach.

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    Yasmin Tayag

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  • 7 habits that can help you lose weight—and keep it off—according to experts

    7 habits that can help you lose weight—and keep it off—according to experts

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    Nearly 75% of Americans are overweight or obese, despite a $225 billion dollar weight loss and management industry focused on tools, programs, and products for shedding pounds and keeping them off. But if there are so many solutions available, why aren’t more people successful at their weight loss efforts?  

    “What we’re largely taught—in society, in the weight loss field, in diet books—is if you just find the right diet, the right guru, the right pill, then it’ll solve all your problems,” says Dr. Scott Kahan, MPH, director of the National Center for Weight and Wellness in Washington, D.C. “You lose the weight, and you’ll live happily ever after. And that’s pretty much never, ever the case.”

    Dr. Lydia Alexander, obesity medicine specialist and president-elect of the Obesity Medicine Association says that when experts approach weight loss and weight management, they don’t use a single-strategy method, but instead approach it with a comprehensive care model based on four pillars: nutritional therapy, physical activity, behavioral modification, and medical interventions.

    “It gets us away from the fixed mindset that there’s one way to do this,” says Alexander. “It requires understanding it as not a cosmetic issue, but as a medical condition that’s treatable.”

    Here are a few tried-and-true tenets that Kahan and Alexander say can help move you toward a healthier weight.

    Track your progress

    Self-monitoring is a proven strategy for both weight loss and weight maintenance. You might think keeping records means “counting calories,” but any kind of check-in can work to help you build a new habit.

    You can keep a record of your weight over time to get an idea of how things are trending, your steps to see how sedentary you are in a day, or the types of foods you’re eating to get an overall picture of your nutrition, such as how many vegetables you eat in a day, says Kahan.

    “Generally tracking behaviors is very helpful for people, because it helps keep focus on a change you’re intending to make and be mindful toward working at it,” he says.

    Keep a realistic perspective

    Reducing your weight and keeping it off is primarily a process that involves small, consistent changes over time. Even if your goal is to lose 100 pounds, you have to start with just a few. 

    “This is something that doesn’t have to be—and realistically can’t be—automatically solved,” says Kahan. ‘It’s something that happens, sometimes slowly and sometimes a little quicker, but modest steps and modest goals can both lead to meaningful weight loss and weight loss that is reasonably sustainable.”

    What’s more, even a small amount of weight loss can lead to significant health improvements, such as improving or preventing diabetes, better mobility and physical functioning, and healthier cholesterol levels. Remembering the big picture instead of focusing solely on the number on the scale and how quickly it’s falling can bolster your spirits as you stay the course. 

    Have two separate goals: Lose weight. Maintain it

    Most of weight management messaging is about losing weight, but maintaining weight takes the same amount of intentionality—or even more, says Alexander.

    “A popular misconception is that once you’ve lost the weight, you’re done, and so you can move on,” she says. “A better strategy is to change the mental mindset of your timeline by thinking, ‘OK, I’ve lost the weight, and that was the first piece. The second piece now is keeping my weight at that spot.’ That requires the same type of active involvement as the first piece did. It’s a marathon, not a sprint.”

    Build a support system

    Kahan says one of the most consistent predictors of long-term progress with weight management is having support and interaction. “That could be meeting with a specialist like myself, it could be meeting with a dietitian, it could be meeting with a trainer, or it could be meeting in an ongoing group session,” he says.

    Even just choosing a close friend to check in with can increase your chances of success. Studies show people who keep themselves accountable with a partner as they work toward a weight loss goal may lose 50%–60% more weight than those who don’t.

    Make calories count

    Nutritional therapy isn’t a simplistic “eat less” paradigm, it’s a shift toward understanding the quality of what you’re eating. For example, whole, fresh food decreases inflammation in your body and can reverse some of the internal malfunction that causes weight gain, says Alexander. That’s why your body feels very differently when you eat empty, processed calories than when you fill up with same amount of calories from whole foods rich in vitamins and nutrients.

    “Your body will fight against you more when it’s not getting the nutrition it needs,” says Alexander. “So, you keep on wanting to eat more food as opposed to feeling satiated.”

    Move your body regularly (anything goes!)

    Physical activity isn’t just for burning calories, it has much deeper benefits specifically tied to weight loss. Walking, one of the simplest forms of exercise, decreases your resistance to insulin, and makes you less hungry. Strength training increases your muscle mass, which aids metabolism, sustaining your calorie balance.

    When you move your body during the day, you sleep better. Lack of sleep makes you more likely to reach for fatty and carb-heavy snacks. Your stress levels improve with regular exercise, too. Chronic stress increases cortisol, which increases hunger, which increases blood sugar, in a vicious cycle.

    You don’t have to do your exercise all at once, says Alexander. And what you do doesn’t matter. The “right” kind of movement to do is any movement you enjoy.

    “Choose the activity you like,” she says. “If you love pickleball, great. If you love walking, wonderful. Pace while you talk on the phone or put away your laundry one sock at a time. If it gets you to move, then that’s your solution.”

    See an obesity medicine specialist

    Just like you’d go see an orthopedist for a knee problem or an OB/GYN for reproductive system issues, seek out a physician who specializes in weight management for help with your weight loss issues. They can assess whether you may benefit from medications or procedures—or whether you may have a medical reason underlying your weight gain such as a medication side effect or sleep apnea.

    “Some people have more significant physiologic challenges that make weight management tougher, some people have more behavioral challenges that will make weight management tougher,” says Kahan. This doesn’t mean weight loss strategies won’t work for you, it just means you have unique barriers that need to be addressed, and a specialist can help with that.”

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    Rachel Reiff Ellis

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  • The Pros of Early Time-Restricted Eating  | NutritionFacts.org

    The Pros of Early Time-Restricted Eating  | NutritionFacts.org

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    Calories eaten in the morning count less than calories eaten in the evening, and they’re healthier, too.
     
    Time-restricted feeding, where you limit the same amount of eating to a narrow evening window, has benefits compared to eating in the evening and earlier in the day, but it also has adverse effects because you’re eating so much, so late, as you can see below and at 0:12 my video The Benefits of Early Time-Restricted Eating. 

    The best of both worlds was demonstrated in 2018 when researchers put time-restricted feeding into a narrow window earlier in the day. As you can see below and at 0:28 in my video, individuals who were randomized to eat the same food, but only during an 8:00 a.m. to 3:00 p.m. eating window, experienced a drop in blood pressure, oxidative stress, and insulin resistance, even when all of the study subjects were maintained at the same weight. Same food, same weight, but with different results. The drops in blood pressure were extraordinary, from 123/82 down to 112/72 in five weeks, and that is comparable to the effectiveness of potent blood-pressure drugs.


    The longest study to date on time-restricted feeding only lasted for 16 weeks. It was a pilot study without a control group that involved only eight people, but the results are still worth noting. Overweight individuals, who, like most of us, had been eating for more than 14 hours a day, were instructed to stick to a consistent 10- to 12-hour feeding window of their own choosing, as you can see below and at 1:17 in my video. On average, they were able to successfully reduce their daily eating duration by about four and a half hours and had lost seven pounds within 16 weeks. 

    They also reported feeling more energetic and sleeping better, as seen in the graph below and at 1:32 in my video. This may help explain why “all participants voluntarily expressed an interest in continuing unsupervised with the 10-11 hr time-restricted eating regimen after the conclusion of the 16-week supervised intervention.” You don’t often see that after weight-loss studies. 

    Even more remarkably, eight months later and even one year post-study, they had retained their improved energy and sleep (see in the graph below and 1:55 in my video), as well as retained their weight loss (see in the graph below and 1:58 in my video)—all from one of the simplest of interventions: sticking to a consistent 10- to 12-hour feeding window of their own choosing. 
    How did it work? Even though the study “participants were not overtly asked to change nutrition quality or quantity,” they appeared to unintentionally eat hundreds of fewer calories a day. With self-selected time frames for eating, you wouldn’t necessarily think to expect circadian benefits, but because they had been asked to keep the eating window consistent throughout the week, “metabolic jet lag could be minimized.” The thinking is that because people tend to start their days later on weekends, they disrupt their own circadian rhythm. And, indeed, it is as if they had flown a few time zones west on Friday evening, then flew back east on Monday morning, as you can see in the graph below and at 2:40 in my video. So, some of the metabolic advantages may have been due to maintaining a more regular eating schedule. 


    Early or mid-day time-restricted feeding may have other benefits as well. Prolonged nightly fasting with reduced evening food intake has been associated with lower levels of inflammation and has also been linked to better blood sugar control, both of which might be expected to lower the risk of diseases, such as breast cancer. So, data were collected on thousands of breast cancer survivors to see if nightly fasting duration made a difference. Those who couldn’t go more than 13 hours every night without eating had a 36 percent higher risk of cancer recurrence. These findings have led to the suggestion that efforts to “avoid eating after 8 pm and fast for 13 h or more overnight may be a beneficial consideration for those patients looking to decrease cancer risk and recurrence,” though we would need a randomized controlled trial to know for sure. 
     
    Early time-restricted feeding may even play a role in the health of perhaps the longest-living population in the world, the Seventh-day Adventist Blue Zone in California. As you can see in the graph below and at 3:55 in my video, slim, vegetarian, nut-eating, exercising, non-smoking Adventists live about a decade longer than the general population. 

    Their greater life expectancy has been ascribed to these healthy lifestyle behaviors, but there’s one lesser-known component that may also be playing a role. Historically, eating two large meals a day, breakfast and lunch, with a prolonged overnight fast, was a part of Adventist teachings. Today, only about one in ten Adventists surveyed were eating just two meals a day. However, most of them, more than 60 percent of them, reported that breakfast or lunch was their largest meal of the day, as you can see below and at 4:26 in my video. Though this has yet to be studied concerning longevity, frontloading one’s calories earlier in the day with a prolonged nightly fast has been associated with significant weight loss over time. This led the researchers to conclude: “Eating breakfast and lunch 5–6 h apart and making the overnight fast last 18–19 h may be a useful practical strategy” for weight control. The weight may be worth the wait. 


    For more on fasting, click here. 
     
    My big takeaway from all of the intermittent fasting research I looked at is, whenever possible, eat earlier in the day. At the very least, avoid late-night eating whenever you can. Eating breakfast like a king and lunch like a prince, with or without an early dinner for a pauper, would probably be best. 
     
    For more on fasting, fasting for disease reversal, and fasting and cancer, check the related videos below.  

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    Michael Greger M.D. FACLM

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  • What the Science Says About Time-Restricted Eating  | NutritionFacts.org

    What the Science Says About Time-Restricted Eating  | NutritionFacts.org

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    Are there benefits to giving yourself a bigger daily break from eating? 
     
    The reason many blood tests are taken after an overnight fast is that meals can tip our system out of balance, bumping up certain biomarkers for disease, such as blood sugars, insulin, cholesterol, and triglycerides. Yet, as you can see in the graph below and at 0:20 in my video Time-Restricted Eating Put to the Test, fewer than one in ten Americans may even make it 12 hours without eating. As evolutionarily unnatural as getting three meals a day is, most of us are eating even more than that. One study used a smartphone app to record more than 25,000 eating events and found that people tended to eat about every three hours over an average span of about 15 hours a day. Might it be beneficial to give our bodies a bigger break? 

    Time-restricted feeding is “defined as fasting for periods of at least 12 hours but less than 24 hours,” and this involves trying to confine caloric intake to a set window of time, typically ranging from 3 to 4 hours, 7 to 9 hours, or 10 to 12 hours a day, which results in a daily fast lasting 12 to 21 hours. When mice are restricted to a daily feeding window, they gain less weight even when fed the same amount as mice “with ad-lib access.” Rodents have such high metabolisms, though, that a single day of fasting can starve away as much as 15 percent of their lean body mass. This makes it difficult to extrapolate from mouse models. You don’t know what happens in humans until you put it to the test. 
     
    The drop-out rates in time-restricted feeding trials certainly appear lower than most prolonged forms of intermittent fasting, suggesting it’s more easily tolerable, but does it work? Researchers found that when people stopped eating from 7:00 p.m. to 6:00 a.m. for two weeks, they lost about a pound each week compared to no time restriction. Note that “there were no additional instructions or recommendations on the amount or type of food consumed,” and no gadgets, calorie counting, or record-keeping either. The study participants were just told to limit their food intake to the hours of 6:00 a.m. and 7:00 p.m., a simple intervention that’s easy to understand and put into practice. 
     
    The next logical step? Put it to the test for months instead of just weeks. Obese men and women were asked to restrict eating to the eight-hour window between 10:00 a.m. and 6:00 p.m. Twelve weeks later, they had lost nearly seven pounds, as you can see in the graph below and at 2:18 in my video. This deceptively simple intervention may be operating from several different angles. People not only tend to eat more food later in the day, but eat higher fat foods later in the day. By eliminating eating in the late-evening hours, one removes prime-time snacking on the couch, a high-risk time for overeating. And, indeed, during the no-eating-after-7:00-p.m. study, the subjects were inadvertently eating about 250 fewer calories a day. Then, there are also the chronobiological benefits of avoiding late-night eating. 

    I did a whole series of videos about the role our circadian rhythms have in the obesity epidemic, how the timing of meals can be critical, and how we can match meal timing to our body clocks. Just to give you a taste: Did you know that calories eaten at dinner are significantly more fattening than the same number of calories eaten at breakfast? See the table below and at 3:08 in my video. 

    Calories consumed in the morning cause less weight gain than the same calories eaten in the evening. A diet with a bigger breakfast causes more weight loss than the same exact diet with a bigger dinner, as you can see in the graph below and at 3:21 in my video, and nighttime snacks are more fattening than the same snacks if eaten in the daytime. Thanks to our circadian rhythms, metabolic slowing, hunger, carbohydrate intolerance, triglycerides, and a propensity for weight gain are all things that go bump in the night.  


    What about the fasting component of time-restricted feeding? There’s already the double benefit of getting fewer calories and avoiding night-time eating. Does the fact that you’re fasting for 11 or 16 hours a day play any role, considering the average person may only make it about 9 hours a day without eating? How would you design an experiment to test that? What if you randomized people into two groups and had both groups eat the same number of calories a day and also eat late into the evening, but one group fasted even longer, for 20 hours? That’s exactly what researchers at the USDA and National Institute of Aging did. 
     
    Men and women were randomized to eat three meals a day or fit all of those same calories into a four-hour window between 5:00 p.m. and 9:00 p.m., then fast the rest of the day. If the weight-loss benefits from the other two time-restricted feeding studies were due to the passive calorie restriction or avoidance of late-night eating, then, presumably, both of these groups should end up the same because they’re both eating the same amount and they’re both eating late. That’s not what happened, though. As you can see below and at 4:49 in my video, after eight weeks, the time-restricted feeding group ended up with less body fat, nearly five pounds less. They got about the same number of calories, but they lost more weight. 

    As seen below and at 5:00 in my video, a similar study with an eight-hour eating window resulted in three more pounds of fat loss. So, there does seem to be something to giving your body daily breaks from eating around the clock.


    Because that four-hour eating window in the study was at night, though, the participants suffered the chronobiological consequences—significant elevations in blood pressure and cholesterol levels—despite the weight loss, as you can see below and at 5:13 in my video. The best of both worlds was demonstrated in 2018: early time-restricted feeding, eating with a narrow window earlier in the day, which I covered in my video The Benefits of Early Time-Restricted Eating. 


    Isn’t that mind-blowing about the circadian rhythm business? Calories in the morning count less and are healthier than calories in the evening. So, if you’re going to skip a meal to widen your daily fasting window, skip dinner instead of breakfast. 

    If you missed any of the other videos in this fasting series, check out the related videos below. 

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    Michael Greger M.D. FACLM

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  • A Look at the 5:2 Diet and the Fasting-Mimicking Diet  | NutritionFacts.org

    A Look at the 5:2 Diet and the Fasting-Mimicking Diet  | NutritionFacts.org

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    What are the effects of eating only five days a week or following a fasting-mimicking diet five days a month? 
     
    Instead of eating every other day, what if you ate five days a week and fasted for the other two? As I discuss in my video The 5:2 Diet and the Fasting-Mimicking Diet Put to the Test, the available data are similar to that of alternate-day fasting: About a dozen pounds of weight loss was reported in overweight men and also reported in overweight women over six months, with no difference found between participants on the 5:2 intermittent fasting regimen and those on a continuous 500-calories-a-day restriction. The largest trial to date found an 18-pound weight loss within six months in the 5:2 group, which isn’t significantly different from the 20 pounds lost in the continuous calorie restriction group. Weight maintenance over the subsequent six months was also found to be no different.
     
    Though feelings of hunger may be more pronounced on the 5:2 pattern than on an equivalent level of daily calorie cutting, it does not seem to lead to overeating on non-fasting days. One might expect going two days without food may negatively impact mood, but no such adverse impact was noted for those fully fasting on zero calories or sticking to just two packets of oatmeal on each of the “fasting” days. (The oatmeal provides about 500 calories a day.) Like alternate-day fasting, the 5:2 fasting pattern appeared to have inconsistent effects on cognition and on preserving lean mass, and it also failed to live up to the “popular notion” that intermittent fasting would be “easier” to adhere to than daily calorie restriction. 
     
    Compared to those in the continuous-restriction control group, fewer subjects in the 5:2 pattern group expressed interest in continuing their diet after the study was over. This was attributed to quality-of-life issues, with 5:2 fasting participants citing headaches, lack of energy, and difficulty fitting the fasting days into their weekly routine. However, as you can see below and at 1:53 in my video, there has yet to be a single 5:2 diet study showing elevated LDL cholesterol compared with continuous calorie restriction at six months. Nor has it been shown for a year. This offers a potential advantage over alternate-day regimens. 

    Instead of 5:2, what about 25:5, spending five consecutive days a month on a “fasting-mimicking diet” (FMD)? Longevity researcher Valter Longo designed a five-day meal plan to try to simulate the metabolic effects of fasting by being low in protein, sugars, and calories with zero animal protein and zero animal fat. By making the diet plant-based, he hoped to lower the level of the cancer-promoting growth hormone IGF-1. He indeed accomplished this goal, along with a drop in markers of inflammation, after three cycles of his five-days-a-month program, as you can see below and at 2:33 in my video. 

    One hundred men and women were randomized to consume his fasting-mimicking diet for five consecutive days per month or maintain their regular diet the whole time. As you can see in the graph below and at 2:47 in my video, after three months, the FMD group was down about six pounds compared to the control group, with significant drops in body fat and waist circumference, accompanied by a drop in blood pressure. 

    Those who were the worst off accrued the most dramatic benefits, as seen in the graph below and at 3:04 in my video. What’s even wilder is that three further months after completion, some of the benefits appeared to persist, suggesting the effects “may last for several months.” It’s unclear, though, if those randomized to the FMD group used it as an opportunity to make positive lifestyle changes that helped maintain some of the weight loss. 


    Dr. Longo created a company to market his meal plan commercially, but, to his credit, says “he does not receive a salary or a consulting fee from the company…and will donate 100% of his shares to charity.” The whole diet appears to be mostly dehydrated soup mixes, herbal teas like hibiscus and chamomile, kale chips, nut-based energy bars, an algae-based DHA supplement, and a multivitamin dusted with vegetable powder. Why spend 50 dollars a day on a few processed snacks when you could instead eat a few hundred calories a day of real vegetables? 
     
    How interesting was that? All-you-can-eat above-ground vegetables for five days would have the same low amount of protein, sugars, and calories with zero animal protein or animal fat. But we’ll probably never know if it works as well, better, or worse because it’s hard to imagine such a study ever getting done without the financial incentive. 

    To learn more about IGF-1, see my video Flashback Friday: Animal Protein Compared to Cigarette Smoking.
     
    In this series on fasting, I’ve covered several topics, including the basics of calories and weight loss, water-only fasting, and the types of alternate-day fasting, see them all in the related videos below. 
     
    I close out the series with videos on time-restricted eating: Time-Restricted Eating Put to the Test and The Benefits of Early Time-Restricted Eating. 
     
    If you want all of the videos in one place, I’ve done three webinars on fasting—Intermittent Fasting, Fasting for Disease Reversal, and Fasting and Cancer—and they’re all available for download now. 

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    Michael Greger M.D. FACLM

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  • Is Our Life Expectancy Extended by Intermittent Fasting?  | NutritionFacts.org

    Is Our Life Expectancy Extended by Intermittent Fasting?  | NutritionFacts.org

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    Alternate-day modified fasting is put to the test for lifespan extension. 

    Is it true that alternate-day calorie restriction prolongs life? Doctors have anecdotally attributed improvements in a variety of disease states to alternate-day fasting, including asthma; seasonal allergies; autoimmune diseases, such as rheumatoid arthritis and osteoarthritis; infectious diseases, such as toenail fungus, periodontal disease, and viral upper respiratory tract infections; neurological conditions, such as Tourette’s syndrome and Meniere’s disease; atrial fibrillation; and menopause-related hot flashes. The actual effect on chronic disease, however, remains unclear, as I discuss in my video Does Intermittent Fasting Increase Human Life Expectancy?. 
     
    Alternate-day fasting has been put to the test for asthma in overweight adults, and researchers found that asthma-related symptoms and control significantly improved, as did the patients’ quality of life, including objective measurements of lung function and inflammation. As you can see in the graphs below and at 0:56 in my video, there were significant improvements in peak airflow, mood, and energy. Their weight also improved—about a 19-pound drop in eight weeks—so it’s hard to tease out the effects specific to the fasting beyond the benefits we might expect from weight loss by any means. 

    For the most remarkable study on alternate-day fasting, you have to go back more than a half-century. Though the 2017 cholesterol findings were the most concerning data I could find on alternate-day fasting, the most enticing was published in Spain in 1956. The title of the study translates as “The Hunger Diet on Alternate Days in the Nutrition of the Aged.” Inspired by the data being published on life extension with caloric restriction on lab rats, researchers split 120 residents of a nursing home in Madrid into two groups. Sixty residents continued to eat their regular diet, and the other half were put on an alternate-day modified fast. On the odd days of the month, they ate a regular 2,300-calorie diet; on the even days, they were given only a pound of fresh fruits and a liter of milk, estimated to add up to about 900 calories. This continued for three years. So, what happened? 
     
    As you can see below and at 2:16 in my video, throughout the study, 13 participants died in the control group, compared to only 6 in the intermittent fasting group, but those numbers were too small to be statistically significant. 

    What was highly significant, though, was the number of days spent hospitalized: Residents in the control group spent a total of 219 days in the infirmary, whereas the alternate-day fasting group only chalked up 123 days, as you can see below and at 2:38 in my video. 


    This is held up as solid evidence that alternate-day fasting may improve one’s healthspan and potentially even one’s lifespan, but a few caveats must be considered. It’s not clear how the residents were allocated to their respective groups. If, instead of being randomized, healthier individuals were inadvertently placed in the intermittent fasting group, that could skew the results in their favor. As well, it appears the director of the study was also in charge of medical decisions at the nursing home. In that role, he could have unconsciously been biased toward hospitalizing more folks in the control group. Given the progress that has been made in regulating human experimentation, it’s hard to imagine such a trial being run today, so we may never know if such impressive findings can be replicated. 

    Well, that was interesting! I had never even heard of that study until I started digging into the topic.  

    Check out my fasting series and popular videos on the subject here.  

    For more on longevity, see related videos below.



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    Michael Greger M.D. FACLM

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  • How Safe Is Alternate-Day Intermittent Fasting?  | NutritionFacts.org

    How Safe Is Alternate-Day Intermittent Fasting?  | NutritionFacts.org

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    Eating every other day can raise your cholesterol. 
     
    Are there any downsides to fasting every other day? For example, might go all day without eating impair your ability to think clearly? Surprisingly, as I discuss in my video Is Alternate-Day Intermittent Fasting Safe?, the results appear to be “equivocal.” Some studies show no measurable effects and the ones that do fail to agree on which cognitive domains are affected. Might the cycles of fasting and feasting cause eating disorder–type behaviors, like bingeing? So far, no harmful psychological effects have been found. In fact, there may be some benefit. However, the studies that have put it to the test specifically excluded those with a documented history of eating disorders, for whom the effects may differ. 
     
    What about bone health? No change in bone mineral density was noted after six months of alternate-day fasting despite about 16 pounds of weight loss, which would typically result in a dip in bone mass. However, the researchers did not note any skeletal changes in the control group either, and they lost a similar amount of weight using continuous caloric restriction. They suggested this is because both groups tended to be “more physically active than the average obese American,” getting about 1,000 to 2,000 more steps a day. 
     
    Proponents of intermittent fasting suggest it can better protect lean body mass, but most of the intermittent trials have employed less accurate methods of body composition analysis, whereas the majority of continuous caloric restriction trials used “vastly more accurate techniques.” So, to date, it is not clear if there’s a difference in lean mass preservation. 
     
    Improvements in blood pressure and triglycerides have been noted on intermittent fasting regimens, though this is presumed to be due to the reduction in body fat since the effect appears to be “dependent on the amount of weight lost.” Alternate-day fasting can improve artery function, too, as you can see in the graph below and at 1:55 in my video, though it does depend on what you’re eating on the non-fasting day. For study participants randomized to an alternate-day diet high in saturated fat, their artery function worsened despite a ten-pound weight loss, whereas it improved, as expected, in the lower-fat group. The decline in artery function was presumed to be because of the pro-inflammatory nature of saturated fat. 

    A concern has been raised about the effects of alternate-day fasting on cholesterol. After 24 hours without food, LDL cholesterol may temporarily bump up, but this is presumably because so much fat is being released into the system by the fast. As you can see in the graph below and at 2:33 in my video, an immediate negative effect on carbohydrate tolerance may stem from the same phenomenon—the repeated elevations of free fat floating around in the bloodstream. After a few weeks, though, LDL levels start to drop as the weight comes off. However, results from the largest and longest trial of alternate-day fasting have given me pause. 


    A hundred obese men and women were randomized into one of three groups: alternate-day modified fasting (25 percent of their baseline calories on fasting days and 125 percent calories on eating days), continuous, daily caloric restriction (75 percent of baseline), or a control group instructed to maintain their regular diet. So, for those going into the trial eating 2,000 calories a day, they would continue to eat 2,000 calories a day in the control group. The calorie-restriction group would get 1,500 calories every day, and the intermittent-restriction group would alternate between 500 calories a day and 2,500 calories the next. 
     
    As you can see in the graph below and at 3:32 in my video, with the same overall, average, prescribed calorie cutting in the two weight-loss groups, they both lost about the same amount of weight, but, surprisingly, the cholesterol effects were different. In the continuous calorie-restriction group, the LDL levels dropped as expected compared to the control group as the pounds came off. 

    But, in the alternate-day modified fasting group, they didn’t, as you can see below, and at 3:55 in my video. At the end of the year, the LDL cholesterol in the intermittent fasting group ended up being 10 percent higher than in the constant calorie-restriction group—despite the same loss of body fat. Given that LDL cholesterol is a prime causal risk factor for heart disease, our number one killer—or is even the prime risk factor—this strikes a significant blow against alternate-day fasting. If you want to try it anyway, I would advise you to have your cholesterol monitored to make sure it comes down with your weight. 


    If you’re diabetic, you must talk with your physician about medication adjustment for any changes in diet, including fasting of any duration. Even with proactive medication reduction, advice to immediately break the fast should sugars drop too low, and weekly medical supervision, people with type 2 diabetes who fasted for even just two days a week were twice as likely to suffer from hypoglycemic episodes compared to an unfasted control group. We still don’t know the best way to tweak blood sugar medications to prevent blood sugar from dropping too low on fasting days. 
     
    Even fasting for just one day can significantly slow the clearance of some drugs (like the blood-thinning drug Coumadin) or increase the clearance of others (like caffeine). Fasting for 36 hours can cut your caffeine buzz by 20 percent. So, consultation with your medical professional before fasting is an especially good idea for anyone on any kind of medication. 

    If you missed it, check out Alternate-Day Intermittent Fasting Put to the Test. 
     
    So, with ambiguous cognitive, lean mass, and bone effects, plus these cholesterol findings, I wouldn’t suggest alternate-day fasting for weight loss, but dropping pounds isn’t the only thing this way of eating is purported to do. Check out Does Intermittent Fasting Increase Human Life Expectancy?. 
     
    For other types of intermittent fasting, total fasting, and more on fasting, check out the related videos below. 



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    Michael Greger M.D. FACLM

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  • Older Americans Are About to Lose a Lot of Weight

    Older Americans Are About to Lose a Lot of Weight

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    Imagine an older man goes in to see his doctor. He’s 72 years old and moderately overweight: 5-foot-10, 190 pounds. His blood tests show high levels of triglycerides. Given his BMI—27.3—the man qualifies for taking semaglutide or tirzepatide, two of the wildly popular injectable drugs for diabetes and obesity that have produced dramatic weight loss in clinical trials. So he asks for a prescription, because his 50th college reunion is approaching and he’d like to get back to his freshman-year weight.

    He certainly could use these drugs to lose weight, says Thomas Wadden, a clinical psychologist and obesity researcher at the University of Pennsylvania, who recently laid out this hypothetical in an academic paper. But should he? And what about the tens of millions of Americans 65 and older who aren’t simply trying to slim down for a cocktail party, but live with diagnosable obesity? Should they be on Wegovy or Zepbound?

    Already, seniors make up 26.6 percent of the people who have been prescribed these and other GLP-1 agonists, including Ozempic, since 2018, according to a report from Truveta, which draws data from a large network of health-care systems. In the coming years, that proportion could rise even higher: The bipartisan Treat and Reduce Obesity Act, introduced in Congress last July, would allow Medicare to cover drug treatments for obesity among its roughly 50 million Part D enrollees above the age of 65; in principle, about two-fifths of that number would qualify as patients. Even if this law doesn’t pass (and it’s been introduced half a dozen times since 2012), America’s retirees will continue to be prescribed these drugs for diabetes in enormous numbers, and they’ll be losing weight on them as well. One way or another, the Boomers will be giving shape to our Ozempic Age.

    Economists say the cost to Medicare of giving new drugs for obesity to just a fraction of this aging generation would be staggering—$13.6 billion a year, according to an estimate published in The New England Journal of Medicine last March. But the health effects of such a program might also be unsettling. Until recently, the very notion of prescribing any form of weight loss whatsoever to an elderly patient—i.e., someone 65 or older—was considered suspect, even dangerous. “Advising weight loss in obese older adults is still shunned in the medical community,” the geriatric endocrinologist Dennis Villareal and his co-authors wrote in a 2013 “review of the controversy” for a medical journal. More than a decade later, clinicians are still struggling to reach consensus on safety, Villareal told me.

    Ample research shows that interventions for seniors with obesity can resolve associated complications. Wadden helped run a years-long, randomized trial of dramatic calorie reduction—using liquid meal replacements, in part—and stringent exercise advice for thousands of overweight adults with type 2 diabetes. “Clearly the people who were older did have benefits in terms of improved glycemic control and blood-pressure control,” he told me. Other, smaller studies led by Villareal find that older people who succeed at losing weight through diet and exercise end up feeling more robust.

    Such outcomes are significant on their own terms, says John Batsis, who treats and studies geriatric obesity at the UNC School of Medicine. “When we talk about older adults, we really need to be thinking about what’s important to older adults,” he told me. “It’s for them to be able to get on the floor and play with their grandchildren, or to be able to walk down the hallway without being completely exhausted.” But weight loss can also have adverse effects. When a person addresses their obesity through dieting alone, as much as 25 percent of the weight they lose derives from loss of muscle, bone, and other fat-free tissue. For seniors who, through natural aging, are already near the threshold of developing a functional impairment, a sudden drop like this could be enfeebling. Wadden’s trial found that, among the people who were on the weight-loss program for more than a decade, their risk of fracture to the hip, shoulder, upper arm, or pelvis increased by 39 percent. An analogous increase has turned up in studies of patients who undergo bariatric surgery, Batsis told me.

    Read: Ozempic makes you lose more than fat

    The effect of dieting on muscle and bone can be attenuated, but not prevented, through resistance training. And obesity itself—which is associated with higher bone density, but perhaps also reduced bone quality—may pose its own fracture risks, Batsis said. But even when a weight-loss treatment benefits an older patient, what happens when it ends? People tend to regain fat, but they don’t recover bone and muscle, Debra Waters, the director of gerontology research at the University of Otago, in New Zealand, told me. That makes the long-term effects of these interventions for older adults very murky. “What happens when they’re 80? Are they going to have really poor bone quality, and be at higher risk of fracture? We don’t know,” Waters said. “It’s a pretty big gamble to take, in my opinion.”

    Villareal told me that doctors should apply “the general principle of starting slow and going slow” when their older patients are trying to lose weight. But that approach doesn’t necessarily square with the rapid and remarkable weight loss seen in patients who are taking semaglutide or tirzepatide, which may produce a greater proportional loss of muscle and bone. (For semaglutide, it appears to be about 40 percent.)

    Then again, when given to laboratory animals, GLP-1 drugs seem to tamp down inflammation in the brain; and they’re now in clinical trials to see whether they might slow the progression of Alzheimer’s disease and dementia. Their multiple established benefits could also help seniors address several chronic problems—diabetes, obesity, fatty liver disease, and kidney disease, for instance—all at once. “Such a ‘one-stop shop’ approach can lead to reduction of medication burden, adverse drug events, hypoglycemic episodes, medication costs, and treatment nonadherence,” one team of geriatricians proposed in 2019.

    Overall, Batsis remains optimistic. “As a clinician, I’m very excited about these medications,” he told me. As a scientist, though, he’s inclined to wait and see. It’s surely true that some degree of weight loss is a great idea for some older patients. “But the million-dollar question is: What’s the sweet spot? How much weight is really enough? Is it 5 to 10 percent? Or is it 25 percent? We don’t know.” Waters said that if Medicare is going to pay for people’s Wegovy, then it should also cover scans of their body composition, to help predict how weight loss might affect their muscles and bones. Wadden said he thinks that treatments should be limited to people who have specific, weight-related complications. For everyone else—as for the hypothetical 72-year-old man who is prepping for his college reunion—he counsels prudence.

    To some extent, such advice is beside the point. Older people are already on Ozempic, and they’re already on Trulicity, and some of them are already taking GLP-1 drugs as a treatment for obesity. Truveta reported that the patients in its member health-care systems who are over 65 have received 281,000 prescriptions for GLP-1 drugs across the past five years. Given the network’s size, one can assume that at least 1 million seniors, overall, have already tried these medications. Millions more will try them in the years to come. If we still have questions about their use, mass experience will start providing answers.

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    Daniel Engber

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  • Putting Alternate-Day Intermittent Fasting to the Test  | NutritionFacts.org

    Putting Alternate-Day Intermittent Fasting to the Test  | NutritionFacts.org

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    Does eating every other day prevent the metabolic slowing that accompanies weight loss, or does it improve compliance over constant, day-to-day caloric restriction? 

    Rather than cutting calories day in and day out, what if you instead ate as much as you wanted every other day or for only a few hours a day? Or, what if you fasted two days a week or five days a month? These are all examples of intermittent fasting regimens, as you can see below and at 0:10 in my video Alternate-Day Intermittent Fasting Put to the Test, and that may even be how we were built. Three meals a day may be a relatively novel behavior for our species. For millennia, “our ancestors could not eat three meals every day. They consumed meals much less frequently, and often consumed one large meal per day or went for several days without food.” 

    Intermittent fasting is often presented as a means of stressing your body—in a good way. There is a concept in biology called hormesis, which can be thought of as the “that which doesn’t kill you makes you stronger” principle. Exercise is the classic example: You put stress on your heart and muscles, and as long as there is sufficient recovery time, you are all the healthier for it. Is that the case with intermittent fasting? Mark Twain thought so: “A little starvation can really do more for the average sick man than can the best medicines and the best doctors. I do not mean a restricted diet, I mean total abstention from food for one or two days.” 
     
    But, Twain also said, “Many a small thing has been made large by the right kind of advertising.” Is the craze over intermittent fasting just hype? Many diet fads have their roots “in legitimate science,” but over time, facts can get distorted, benefits exaggerated, and risks downplayed. In other words, “science takes a back seat to marketing.” At the same time, you don’t want to lose out on any potential benefit by dismissing something out of hand based on the absurdist claims of overzealous promoters. You don’t want to throw the baby out with the baby fat. 
     
    Religious fasting is the most studied form of intermittent fasting, specifically Ramadan, a month-long period in which “Muslims abstain from food and drink from sunrise until sunset.” The effects are complicated by a change in sleeping patterns and also thirst. The same dehydration issue arises with Yom Kippur when observant Jews stop eating and drinking for about 25 hours. The most studied form of intermittent fasting that deals only with food restriction is alternate-day fasting, which involves eating every other day, alternating with days consuming little or no calories. 
     
    At rest, we burn about a 50:50 mix of carbohydrates and fat, but we usually run out of glycogen—our carbohydrate stores—within 12 to 36 hours of stopping eating. At that point, our body has to shift to rely more on our fat stores. This metabolic switch may help explain why the greatest rate of breakdown and burning of fat over a three-day fast happens between hours 18 and 24 of the 72 hours. The hope is to reap some of the benefits of taking a break from eating without the risks of prolonged fasting. 
     
    One of the potential benefits of alternate-day fasting over chronic calorie restriction is that you get regular breaks from feeling constant hunger. But might people become so famished on their fasting day that they turn the next into a feasting day? After your fasting day, if you ate more than twice as much as you normally would, that presumably would defeat the whole point of alternate-day fasting. Mice fed every other day don’t lose weight. They just eat roughly twice as much food in one day as non-fasted mice would regularly eat in two days. That is not, however, what happens in people. 
     
    Study participants were randomized to fast for a day and a half—from 8:00 p.m. to 8:00 a.m. the second morning after beginning. Fasting for 36 hours only led to people eating an average of 20 percent more the day after they broke the fast, compared to a control group who didn’t fast at all. That would leave the fasters with a large calorie deficit, equivalent to a daily caloric restriction of nearly a thousand calories a day. This particular study involved lean men and women, but similar results have been found amongst overweight or obese subjects. Researchers typically found only about a 10 to 25 percent compensatory increase in calorie intake over baseline on non-fasting days, and this seems to be the case whether the fasting day was a true zero-calorie fast or a modified fast day of a few hundred calories, which may lead to better compliance. 
     
    Some studies have found that participants appeared to eat no more, or even eat less, on days after a day-long mini-fast. Even within studies, great variability is reported. In a 24-hour fasting study where individuals ate an early dinner and then had a late dinner the next day after skipping breakfast and lunch, the degree of compensation at the second dinner ranged from 7 percent to 110 percent, as you can see in the graph below and at 4:40 in my video. This means that some of the participants got so hungry by the time supper rolled around that they ate more than 24 hours’ worth of calories in a single meal. The researchers suggested that perhaps people first try “test fasts” to see how much their hunger and subsequent intake ramp up before considering an intermittent fasting regimen. Hunger levels can change over time, though, dissipating as your body habituates to the new normal. 


    In an eight-week study in which obese subjects were restricted to about 500 calories every other day, after approximately two weeks, they reportedly started feeling very little hunger on their slashed calorie days. This no doubt helped them lose about a dozen pounds on average over the duration of the study, but there was no control group with whom to compare. A similar study that did have a control group found a similar amount of weight loss—about ten pounds—over 12 weeks in a group of “normal weight” individuals, which means overweight on average. For these modified regimens where people are prescribed 500 calories on their “fasting” days, researchers found that, from a weight-loss perspective, it did not appear to matter whether those calories are divided up throughout the day or eaten in a single meal. 
     
    Instead of prescribing a set number of calories on “fasting” days, which many people find difficult to calculate outside of a study setting, a pair of Iranian researchers came upon a brilliant idea of unlimited above-ground vegetables. Starchy root vegetables are relatively calorie-dense compared to other vegetables. Veggies that grow above the ground include stem vegetables (like celery and rhubarb), flowering vegetables (like cauliflower), leafy vegetables (like, well, leafy vegetables), and all of the fruits we tend to think of as vegetables (like tomatoes, peppers, okra, eggplant, string beans, summer squash, and zucchini). So, instead of prescribing a certain number of calories for “fasting” days, researchers had subjects alternate between their regular diet and helping themselves to an all-you-can-eat, above-ground vegetable feast (along with naturally non-caloric beverages, like green tea or black coffee) every other day. After eight weeks, the subjects lost an average of 13 pounds and two inches off their waist, as you can see below and at 6:59 in my video. 


    The same variability discovered for calorie compensation has also been found for weight loss, as seen in the graph below and at 7:10 in my video. In a 12-month trial in which subjects were instructed to eat only one-quarter of their caloric needs every other day, weight changes varied from a loss of about 37 pounds to a gain of about 8 pounds. The biggest factor differentiating the low-weight-loss group from the high-weight-loss group appeared to be not how much they feasted on their regular diet days, but how much they were able to comply with the calorie restriction on their fast days. 

     
    Overall, ten out of ten alternate-day fasting studies showed significant reductions in body fat. Small short-term studies show about a 4 to 8 percent drop in body weight after 3 to 12 weeks. How does that compare with continuous calorie restriction? Researchers compared zero-calorie, alternate-day fasting head-to-head to a daily 400-calorie restriction for eight weeks. Both groups lost the same amount of weight, about 17 pounds, and, in the follow-up check-in six months later after the trial had ended, both groups had maintained a similar degree of weight loss; both were still down about a dozen pounds, as you can see below and at 8:10 in my video. 


    The hope that intermittent fasting would somehow avoid the metabolic adaptations that slow weight loss or improve compliance doesn’t seem to have materialized. The same compensatory reactions in terms of increased appetite and a slower metabolism plague both continuous and intermittent caloric restriction. The longest trial of alternate-day fasting found that “alternate-day fasting may be less sustainable” than more traditional approaches. By the end of the year, the drop-out rate of the alternate-day fasting group was 38 percent, compared to 29 percent in the continuous calorie-restriction group.  

    Although alternate-day fasting regimens haven’t been shown to produce superior weight loss to date, for individuals who may prefer this pattern of calorie restriction, are there any downsides? Find out in my video Is Alternate-Day Intermittent Fasting Safe?. 
     
    I packed a lot into this one. Bottom line: Fasting doesn’t appear to provide an edge over traditional calorie cutting, but if you prefer it, why not give fasting a try? Before you do, first check out Is Alternate-Day Intermittent Fasting Safe?.  

    What about total fasting? For that and even more, check out the related videos below.

    I have a whole chapter on intermittent fasting in my book How Not to Diet—order now! (All proceeds I receive from my books are donated to charity.) 



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    Michael Greger M.D. FACLM

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  • The Safety of Fasting to Lose Weight  | NutritionFacts.org

    The Safety of Fasting to Lose Weight  | NutritionFacts.org

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    Why should fasts lasting longer than 24 hours and particularly for three or more days only be done under the supervision of a health professional and preferably in a live-in clinic? 
     
    Fasting for a week or two can actually interfere with the loss of body fat, as shown at the start of my video Is Fasting for Weight Loss Safe?. But, eventually, after the third week of fasting, fat loss starts to overtake the loss of lean body mass in obese individuals, as seen in the graph below and at 0:14 in my video. Is it safe to go that long without food? 

    Proponents speak of fasting as a cleansing process, but some of what is being purged from our bodies are essential vitamins and minerals. People who are heavy enough can fast up to 382 days without calories, but no one can go even a fraction of that long without vitamins. Scurvy, for example, can be diagnosed within as few as four weeks without any vitamin C. Beriberi, deficiency of thiamine (vitamin B1), may start even earlier in fasting patients. And, once it manifests, it can result in brain damage within days, which can eventually become irreversible.  
     
    Even though fasting patients report problems such as nausea and indigestion after taking supplements, all of the months-long fasting cases I’ve discussed previously were given daily multivitamins and mineral supplementation as necessary. Without supplementation, hunger strikers and those undergoing prolonged fasts for therapeutic or religious purposes (like the Baptist pastor hoping “to enhance his spiritual powers for exorcism”) have ended up paralyzed, become comatose, or worse. 
     
    Nutrient deficiencies aren’t the only risk. After reading about all of the successful reports of massive weight loss from prolonged fasting in the medical literature, one doctor decided to give it a try with his patients. Of the first dozen he tried it on, two died. In retrospect, the two patients who died had started out with heart failure and had been on diuretics. Fasting itself produces pronounced diuresis, meaning loss of water and electrolytes through the urine, so it was the combination of fasting on top of the water pills that likely depleted their potassium and triggered their fatal heart rhythms. The doctor went out of his way to point out that both of the people who died started out “in severe heart failure, complicated by gross obesity; but both had improved greatly whilst undergoing starvation therapy.” That seems like a small consolation since they were both dead within a matter of weeks. 
     
    Not all therapeutic fasting fatalities were complicated by concurrent medication use, though. One researcher writes: “At first he did very well and experienced the usual euphoria…His pulse, blood pressure, and electrolytes remained satisfactory, but in the middle of the third week of treatment, he suddenly collapsed and died. This line of treatment is certainly tempting because it does produce weight loss and the patient feels so much better, but the report of case-fatalities”—the whole part about killing people—“must make it a very suspect line of management.” 
     
    Contrary to the popular notion that the heart muscle is specially spared during fasting, the heart appears to experience similar muscle wasting. This was “described in the victims of the Warsaw ghetto” during World War II in a remarkable series of detailed studies carried out by the ghetto physicians before they themselves succumbed. In a case entitled “Gross Fragmentation of Cardiac Fiber After Therapeutic Starvation for Obesity,” a 20-year-old woman successfully “achieved her ideal weight” after losing 128 pounds by fasting for 30 weeks. “After a breakfast of one egg,” she had a heart attack and died. On autopsy, as you can see below and at 3:44 in my video, the muscle fibers in her heart showed evidence of widespread disintegration. The pathologists suggested that fasting regimens “should no longer be recommended as a safe means of weight reduction.” 
    Breaking the fast appears to be the most dangerous part. After World War II, as many as one out of five starved Japanese prisoners of war tragically died following liberation. Now known as “refeeding syndrome,” multiorgan system failure can result from resuming a regular diet too quickly. This is because there are critical nutrients such as thiamine and phosphorus that are used to metabolize food. Therefore, in the critical refeeding window, if too much food is taken before these nutrients can be replenished, demand may exceed supply. Whatever residual stores you still carry can be driven down even further, with potentially fatal consequences. This is why rescue workers are taught to always give thiamine before food to victims who have been trapped or otherwise unable to eat. Thiamine is responsible for the yellow color of “banana bags,” a term you might have heard used in medical dramas to describe an IV fluid concoction often given to malnourished alcoholics to prevent a similar reaction. (You can see a photo of them below and at 4:53 in my video.) Anyone “with negligible food intake for more than five days” may be at risk of developing refeeding problems. 
    Medically-supervised fasting has gotten much safer now that there are proper refeeding protocols. We now know what warning signs to look for and who shouldn’t be fasting in the first place, such as those who have advanced liver or kidney failure, porphyria, uncontrolled hyperthyroidism, and pregnant and breastfeeding women. The most comprehensive safety analysis of medically supervised, water-only fasting was recently published by the TrueNorth Health Center in California. Out of 768 visits to its facility for fasts up to 41 days, were there any adverse events? There were 5,961 of them! Most of these were mild, known reactions to fasting, such as fatigue, nausea, insomnia, headache, dizziness, upset stomach, and back pain. Only two serious events were reported, and no fatalities. You can see the chart below and at 5:58 in my video. 
    “Fasting periods lasting longer than 24 hr, and particularly those lasting 3 or more days, should be done under the supervision of a physician and preferably in a [live-in] clinic.” In other words, don’t try this at home! This is not just legalistic mumbo-jumbo. For example, normally, your kidneys dive into sodium conservation mode during fasting, but should that response break down, you could rapidly develop an electrolyte abnormality that may only manifest with non-specific symptoms, like fatigue or dizziness, which could easily be dismissed until it’s too late. 
     
    The risks of any therapy must be premised on the severity of the disease. The consequences of obesity are considered so serious that effective therapies could have “considerable acceptable toxicity.” For example, many consider major surgery for obesity to be a justifiable risk, but the keyword is effective. 
     
    Therapeutic fasting for obesity has largely been abandoned by the medical community not only because of its uncertain safety profile but its questionable short- and long-term efficacy. Remember, for a fast that only lasts a week or two, you might be able to lose as much body fat or even more on a low-calorie diet than a no-calorie diet. 
     
    Fasting for a week or two can actually interfere with the loss of body fat. For more background on this, see Is Fasting Beneficial for Weight Loss? and Benefits of Fasting for Weight Loss Put to the Test.
     
    If you’re wondering what the best way to lose weight is, I wrote a whole book about it! Check out How Not to Diet. 
     
    Interested in learning more about fasting? See related videos below. 

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    Michael Greger M.D. FACLM

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  • Does Fasting Benefit Weight Loss?  | NutritionFacts.org

    Does Fasting Benefit Weight Loss?  | NutritionFacts.org

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    Like the keto diet, fasting for one or two weeks can actually slow the loss of body fat rather than accelerate it.

    Fasting obviously causes consistent, dramatic weight loss, as shown in the graph below and at 0:09 in my video Is Fasting Beneficial for Weight Loss?, but how do fasted individuals do long-term? Some research groups reported “extremely disappointing long-term effects,” as you can see in the graph below and at 0:19 in my video. 

    Average subjects started at about 270 pounds and, in the six months before the fast, continued to gain weight as obese persons tend to do. After 24 days of “inpatient starvation,” they experienced a dramatic 27-pound weight loss. Then, what do you think happened?

    They gained it all back and more, though one could argue if they had not fasted, they might have weighed even more at that point, as seen in the graph below and at 0:45 in my video. 
    In another study with follow-ups ranging up to 50 months, only 4 out of 25 “superobese” patients achieved even partial sustained success. Based on these kinds of data, some investigators “concluded that complete starvation is of no value in the long-term treatment of obese patients.” 
     
    Other research teams reported better outcomes. One series with about 100 individuals found that 60 percent retained at least some weight loss at follow-up or even continued losing. The follow-up periods varied from 1 to 32 months with no breakdown as to who fasted and for how long, though, making the data hard to interpret. In another study, 62 patients were down an average of 16 pounds after fasting for 10 days. After one year, 40 percent of the group had retained at least 7 pounds of that weight loss. 
     
    As you can see below and at 1:37 in my video, when you put together six such studies, hundreds of obese subjects fasted for an average of 44 days and lost an average of 52 pounds. And, around one or two years later, 40 percent retained at least some of that weight loss. So, most gained back all of the weight they had lost, but 40 percent is extraordinary for a weight-loss study. 

    Following a hundred obese individuals getting treated at a weight-loss clinic with a standard low-calorie diet, researchers found that only one out of a hundred lost more than 40 pounds and only about one in ten lost even 20 pounds, with overall successful weight maintenance at only two patients over two years, as seen below and at 2:08 in my video. That’s why having a control group is so important. What may look like a general failure may actually be a relative success compared to more traditional weight-loss techniques. 

    Researchers new to the field may find it “clearly disappointing” that the “overall results of follow-up for 12 months or more” found that “two-thirds of the patients were ‘failures’ and more than one-third actually regained all the weight lost.” But, 12 percent were labeled successes, maintaining 59 pounds of weight loss two years later. As you can see in the graph below and at 2:42 in my video, the subjects lost massive amounts of excess weight and kept it off. 

    In a direct comparison of different weight-loss approaches at the same clinic, five years after initiating a conventional low-calorie approach, only about one in five was down 20 pounds compared to nearly half in the group who instead had undergone a few weeks of fasting years previously. By year seven, as you can see in the graph below and at 3:03 in my video, most of those instructed on daily caloric restriction were back up to their original weight or had even exceeded it, but that was only true for about one in ten in the fasted group. In an influential paper in the New England Journal of Medicine on seven myths about obesity, fallacy number three was identified as: “Large, rapid weight loss is associated with poorer long-term weight-loss outcomes, as compared with slow, gradual weight loss.” In reality, the opposite is true. The hare may end up skinnier than the turtle.  

    As shown in the graph below and at 3:39 in my video, researchers set up a study comparing the sustainability of weight loss at three different speeds: six days of fasting, three weeks on a very-low-calorie diet of 600 calories a day, or six weeks on a low-calorie diet of 1,200 calories a day. 

    The question is: What happened a year later? At one year, the fasting group was the only one that sustained a significant loss of weight, as you can see below and at 3:55 in my video. 

    What happened nine years later? “Therapeutic Fasting in Morbid Obesity” is the largest, longest follow-up study I could find. At least some of the fast-induced weight losses were maintained a year later by the great majority. After one year, 90 percent remained lighter than they had started, but after two years, three years, four years, and seven years, fewer and fewer patients maintained their weight loss. By nine years later, that number dropped to fewer than one in ten. By then, almost everyone had regained the weight they had initially fasted away, as you can see in the graph below and at 4:17 in my video. “Many patients thought that the temporary loss was worth the effort,” though. As a group, they had lost an average of about 60 pounds. They described improved health and quality of life and claimed that “reemployment was facilitated and earnings increased” during that period of time. But the fasting didn’t appear to result in any permanent change in eating habits for the vast majority. 
    The small minority for whom fasting led to sustainable weight loss “all admit to a radical change in previous eating habits”; indeed, fasting only works long-term if it can act as a jumpstart to a healthier diet. In a retrospective long-term comparison of weight reduction after an inpatient stay at a naturopathic center, those who fasted lost more weight at the time, but they were back to the same weight at around seven years, as you can see in the graph below and at 5:14 in my video. 

    It’s no surprise since most reported returning to the same diet they had been on before. However, those who were placed instead on a healthier, more whole food, plant-based diet were more likely to make persistent changes in their eating and, seven years later, were lighter than when they started, as you can see in the graph below and at 5:36 in my video. 

    Why can’t you have it both ways, though? Use fasting to kickstart a big drop, then start a healthier diet. The problem is that the big drop is largely illusory, as you can see in the graph below and at 5:48 in my video. 

    Fasting for a week or two can cause more weight loss than caloric restriction, but, paradoxically, it may actually lead to less loss of body fat. How can eating fewer calories lead to less fat loss? Because during fasting, your body starts cannibalizing itself and burning more of your own protein for fuel. Emperor penguins, elephant seals, and hibernating bears can survive by just burning fat without dipping into their muscles, but our voracious big brains appear to need at least a trickle of blood sugar. If we aren’t eating any carbohydrates, our body is forced to start turning our protein into sugar to burn. Even getting just a few grams of carbs—from adding honey to water when fasting, for instance—can cut protein loss up to 50 percent.  

    What about adding exercise to prevent the loss of lean tissues during a fast? That may make it worse! At rest, most of your heart and muscle energy needs can be met with fat, but if you start exercising, some of the blood sugar meant for your brain starts getting snatched up and your body may have to break down even more protein. 
     
    As you can see in the graph below and at 7:00 in my video, less than half of the weight loss during the first few weeks of fasting ends up coming from your fat stores. So, even if you double your daily weight loss on a fast, you may be actually losing less body fat. 

    In an NIH-funded study, obese individuals were placed on an 800-calorie-a-day diet for two weeks and steadily lost about a pound of body fat a day. They were then switched to about two weeks of zero calories and started losing more protein and water. On average, though, they only lost a few ounces of fat daily. When they were subsequently switched back to the initial 800-calories-a-day diet for a week, they rapidly replaced the protein and water, so the scale registered their weight as going up, but their body fat loss accelerated back to the approximate pound a day. The scale made it look as though they were doing better when they were completely fasting, but the reality is they were doing worse. So, during the five-week experiment, they would have lost even more body fat had they stuck with their calorie-restricted diet rather than completely stopping eating in the middle. They would have lost more body fat by eating more calories. Fasting for a week or two can interfere with the loss of body fat, rather than accelerate it. You can see a series of graphs depicting this from 7:13 in my video, including the one below. 

    This is the follow-up to Benefits of Fasting for Weight Loss Put to the Test. It seems fasting may only work long-term if it can act as a jumpstart to a healthier diet, and just fasting for a week or two can be counterproductive, like the keto diet. Is it even safe to fast longer than that? Find out in Is Fasting for Weight Loss Safe?. 
     
    For more on the keto story and more on fasting for weight loss, see related videos below. 
     
    I’ve done my third live webinar on fasting, Fasting and Cancer. Those videos are also on NutritionFacts.org. 

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    Michael Greger M.D. FACLM

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  • Putting the Benefits of Fasting for Weight Loss to the Test  | NutritionFacts.org

    Putting the Benefits of Fasting for Weight Loss to the Test  | NutritionFacts.org

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    For more than a century, fasting has been used as a weight-loss treatment.

    I’ve talked about the benefits of caloric restriction. Well, the greatest caloric restriction is getting no calories at all. Fasting has been branded “the next big weight loss fad,” but it has a long history throughout various spiritual traditions, practiced by Moses, Jesus, Muhammed, and Buddha. In 1732, a noted physician wrote, “He that eats till he is sick must fast till he is well.” About one in seven American adults today report taking that advice, “using fasting as a means to control body weight,” as I discuss in my video Benefits of Fasting for Weight Loss Put to the Test. 
     
    Case reports of the treatment of obesity through fasting date back more than a century in the medical literature. In 1915, two Harvard doctors indelicately described “two extraordinarily fat women,” one of whom “was a veritable pork barrel.” Their success led them to conclude that “successive moderate periods of starvation constitute a perfectly safe, harmless, and effective method for reducing the weight of those suffering from obesity.” 
     
    The longest-recorded fast, published in 1973, made it into the Guinness Book of World Records. To reach his ideal body weight, a 27-year-old man fasted for 382 days straight, losing 276 pounds, and managed to keep nearly all of it off. He was given vitamin and mineral supplements so he wouldn’t die, but no calories for more than a year. In the researchers’ acknowledgments, they thanked him “for his cheerful co-operation and steadfast application to the task of achieving a normal physique.” 
     
    In a U.S. Air Force study, more than 20 individuals at least 100 pounds overweight and most “unable to lose weight on previous diets” were fasted for as long as 84 days. Nine dropped out of the study, but the 16 who remained “were unequivocally successful” at losing 40 to 100 pounds. In the first four days, the subjects were noted as losing as much as four pounds a day, which “probably represents mostly fluid,” mostly water weight as the body starts to adapt. But, after a few weeks, they were steadily losing about a pound a day of mostly straight fat. The investigator described the starvation program as “a dramatic and exciting treatment for obesity.” 
     
    Of course, the single most successful diet for weight loss—namely no diet at all—is also the single least sustainable. What other diet can cure morbid obesity in a matter of months but practically be guaranteed to kill you within a year if you stick with it? The reason diets don’t work, almost by definition, is that people go on them, then they go off of them. Permanent weight loss is only achieved through permanent lifestyle change. So, what’s the point of fasting if you’re just going to go back to your regular diet and gain right back all of that lost weight? 
     
    Fasting proponents cite the psychological benefit of realigning people’s perceptions and motivation. Some individuals have resigned themselves to the belief that weight loss for them is somehow impossible. They may think “that they are ‘made differently’ from those of normal weight” in some way, and no matter what they do, the pounds don’t come off. But the rapid, unequivocal weight loss during fasting demonstrates to them that with a large enough change in eating habits, it’s not just possible, but inevitable. This morale boost may then embolden them to make better food choices once they resume eating. 
     
    The break from food may allow some an opportunity “to pause and reflect” on the role food is playing in their lives—not only the power it has over them but the power they have over it. In a fasting study entitled “Correction and Control of Intractable Obesity,” a patient’s personality was described as changing “from one of desperation, with abandonment of hope, to that of an eager extravert full of plans for a promising future.” She realized that her weight was within her own power to control. The researchers concluded: “This highly intellectual social worker has been returned to a full degree of exceptional usefulness.” 
     
    After a fast, newfound commitment to more healthful eating may be facilitated by a reduction in overall appetite reported post-fast, compared to pre-fast, at least temporarily. Even during a fast, hunger may start to dissipate within the first 36 hours. So, challenging people’s delusions about their exceptionality to the laws of physics—thinking they are “made differently”—with “short periods of total fasting may seem barbaric. In reality, this method of weight reduction is remarkably well tolerated by obese patients.” That seems to be a recurring theme in these published series of cases. In the influential paper “Treatment of Obesity by Total Fasting for up to 249 Days,” the researchers remarked that the “most surprising aspect of this study was the ease with which the prolonged fast was tolerated.” All of their patients “spontaneously commented on their increased sense of well-being, and in some, this amounted to frank euphoria.” They continued that, although “treatment by total fasting must only be prescribed under close medical supervision,” they “are convinced that it is the treatment of choice, certainly in cases of gross obesity.” 
     
    Fasting for a day can make people irritable and feel moody and distracted, but after a few days of fasting, many report feeling clear, elated, and alert—even euphoric. This may be in part due to the significant rise in endorphins that accompanies fasting, as you can see in the graph below and at 5:48 in my video. Mood enhancement during fasting is thought to perhaps represent an adaptive survival mechanism to motivate the food search. This positive outlook towards the future may then facilitate the behavioral change necessary to lock in some of the weight-loss benefits. 

    Is that what happens, though? Is fasting actually effective over the long term? There are articles with titles like “Death During Therapeutic Starvation for Obesity.” Is fasting even safe? We’ll find out next. 
     
    This is the sixth in a 14-part series on fasting for weight loss. In case you missed any of the others, see the related videos below. 

    My book How Not to Diet is all about weight loss. You can learn more about it and order it here. 

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    Michael Greger M.D. FACLM

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  • Any Pitfalls with Restricting Calories?  | NutritionFacts.org

    Any Pitfalls with Restricting Calories?  | NutritionFacts.org

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    How may we preserve bone and mass on a low-calorie diet? 
     
    One of the most consistent benefits of calorie restriction is that blood pressure improves in as little as one or two weeks. Blood pressure may even be normalized in a matter of weeks and blood pressure pills discontinued. Unfortunately, this can work a little too well and cause orthostatic intolerance, which can manifest as lightheadedness or dizziness upon standing and, in severe cases, may cause fainting, though staying hydrated can help. 
     
    What about loss of muscle mass? In the CALERIE trial, which I profile in my video Potential Pitfalls of Calorie Restriction, 70 percent of the body weight the subjects lost was fat and 30 percent was lean body mass. So, they ended up with an improved body composition of about 72 percent lean mass compared to 66 percent in the control group, as you can see at 0:51 in my video. And, even though leg muscle mass and strength declined in absolute terms, relative to their new body size, they generally got stronger. 

    Is there any way to preserve even more lean mass, particularly among older individuals who naturally tend to lose muscle mass with age? Increased protein intakes are commonly suggested, but most studies fail to find a beneficial effect on preserving muscle strength or function whether you’re young or old, active or sedentary. For example, during a 25 percent calorie restriction, researchers randomized overweight older men and women to either a normal-protein diet with 4 grams for every ten pounds of body weight or a high-protein diet with about 8 grams per ten pounds. That doubling of protein intake had no discernible effect on lean body mass, muscle strength, or physical performance. As you can see below and at 1:48 in my video, most such studies found the same lack of benefit, but when they’re all put together, one can tease out a small advantage of about one or two pounds of lean mass over an average of six months. 

    Unfortunately, high protein intake during weight loss has also been found to have “profound” negative metabolic effects, including undermining the benefits of weight loss on insulin sensitivity. As you can see in the graph below and at 2:14 in my video, if you lose 20 pounds, you can dramatically improve your body’s ability to handle blood sugars, compared to subjects in a control group who maintained their weight. But, if you lose the exact same amount of weight on a high-protein diet, getting about an extra 30 grams a day, it’s like you never lost any weight at all. 


    Though you can always bulk back up after weight loss, the best way to preserve muscle mass during weight loss is to exercise. The CALERIE study had no structured exercise component, and, similar to bariatric surgery, about 30 percent of the weight loss was lean mass. In contrast, that proportion was only about 16 percent of The Biggest Loser contestants, chalked up to their “vigorous exercise program.” Resistance training even just three times a week can prevent more than 90 percent of lean body mass loss during calorie restriction. 
     
    The same may be true of bone loss. Lose weight through calorie restriction alone, and you experience a decline in bone mineral density in fracture risk sites, such as the hip and spine. In the same study, though, those randomized to lose weight with exercise did not suffer any bone loss. The researchers concluded: “Our results suggest that regular EX [exercise] should be included as part of a comprehensive weight loss program to offset the adverse effects of CR [caloric restriction] on bone.” 
     
    It’s hard to argue with calls for increased physical activity, but even without an exercise regimen, the “very small” drop in bone mineral density in the CALERIE trial might only increase a ten-year risk of osteoporotic fracture by about 0.2 percent. The benefits of calorie restriction revealed by the study included improvements in blood pressure and cholesterol, as you can see in the graph below and at 3:54 in my video, as well as improved mood, libido, and sleep. These would seem to far outweigh any potential risks. The fact that a reduction in calories seemed to have such wide-ranging benefits on quality of life led commentators in the AMA’s internal medicine journal to write: “The findings of this well-designed study suggest that intake of excess calories is not only a burden to our physical homeostasis [or equilibrium], but also on our psychological well-being.” 
     


    Check out my other videos on calorie restriction, fasting, intermittent fasting, and time-restricted eating in the related videos below. 

     

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    Michael Greger M.D. FACLM

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