Traditional Okinawan Diet: Sweet Potatoes

This is incredible. Almost 70% of the calories in the traditional Okinawan diet came from sweet potatoes. That according to an extensive investigation of six decades of archived population data published in 2007.¹ And that wasn't the only carbohydrate they ate. Rice and beans also played prominent roles at mealtimes. Theirs must have been the mother of all high-carb diets.

I've been reading about the people from Okinawa, a series of little islands right smack in the middle of the East China Sea. The islands belong to Japan (Okinawans are Japanese), but are geographically close to Taiwan and mainland China.

Okinawans are known for their long lives. Not only do they enjoy some of the longest life expectancies in the world, but they also have one of the highest number of centenarians - people who have lived 100 years or more - about 50 centenarians per 100,000 people, compared to 20 per 100,000 here in the US.

They live long, and they do so with exceptional vigor. Okinawans have low rates of many of the chronic diseases Americans bear: diabetes, heart disease, cancer, and dementia. Or at least they used to. Changes in lifestyle from the 1950s - food choices, caloric intake, and physical activity - have eroded their mortality advantage.

So what did a traditional pre-1960 Okinawan diet look like? Here's how Willcox et al. summarized it. (Click to enlarge.):



When 85% of your calories are coming from carbohydrates, it leaves very little for the other 2 macronutrients, fat and protein. Indeed, a diet that gets about 10% of its calories from fat, a la Dean Ornish, would have been considered lavish here. This diet racked up a mere 6% of calories from fat.

Fish, which I assumed would have constituted a fair portion of their diet, didn't. At 1% of total calories, it's about one 3-ounce serving of fish a week. And meat (including poultry) was considerably less, perhaps one small serving a month. One egg every 2 months.

Added oils, at 2% of total calories, works out to about 36 calories. That's less than a teaspoon a day.

The bulk of the diet came from those 849 grams of sweet potatoes, about 4.5 cups a day! Rice (the article mentioned that Japanese rice half a century ago was not polished and likely included bran and germ) was consumed at about 1 cup/day. That was considerably less than the rest of Japan at the time.

Theirs was a very low-fat, low-protein, just about vegan, diet with very few processed grains and oils.

This isn't saying that the foods Okinawans ate were the primary factor in their longevity. But they certainly didn't impede long life.
________¹Caloric Restriction, The Traditional Okinawan Diet, And Healthy Aging: The Diet Of The World’s Longest-Lived People And Its Potential Impact On Morbidity And Life Span, Annals of the New York Academy of Sciences, 2007

Photos of Okinawans from National Geographic.
(Interestingly, the video from where these photos were taken said that Okinawa now has the highest rate of obesity in all of Japan.)

Undiagnosed Diabetes

I usually write about the technical aspects of diabetes. Here's a personal story.

Gail Wellings, seen in the photo, cut her toe and ended up having her lower leg amputated. She had undiagnosed diabetes for several years, not learning of it until after her amputation.

"Sometimes there are no signs, as Gail Wellings discovered, when she fell on a kerb, cutting the big toe on her right foot.

Although she wasn't in pain, the toe became increasingly red and the cut failed to heel.

After three weeks, she decided to see her doctor. 'I'll never forget the expression on his face,' says Gail. 'He took one look at my toe and said: "Oh no, Gail, you are going to lose your foot." I couldn't believe it.'

Gail, a secretary from High Wycombe, Bucks, was sent to A&E where, after a day of blood tests and X-rays, she was a told that even though it was just her toe that had been injured, she had no circulation in her lower leg and before long those tissues would become gangrenous, too.

There was no real choice but for her to have a below- knee amputation.

'It was a nightmare,' she says. 'One moment it was my foot. Now it was my lower leg. I was absolutely stunned because everything happened so quickly.

'I kept thinking, my life is over, I won't be able to play tennis, to run, to get around. But what amazed me was that when I came round from the operation I was told the cause was Type 2 diabetes.'

What so perplexed her was that she'd had no other symptoms. 'But now, with the benefit of hindsight I can see why I might have been a candidate for the condition,' she says. 'I was 56 at the time (the risks increase with age) and 2st (28 pounds) overweight. Doctors guessed I'd been diabetic for around four or five years, which is why the damage was so great. It was the most horrible, horrible time of my life.' "

You can read the rest of her story, and another about a man whose first symptom was swollen legs (he lost two toes), here:
Are You A Diabetes Timebomb? If You're Slightly Overweight, You Could Be One Of A Million Britons With Undiagnosed Diabetes, Daily Mail, July 27

It surprised me that diabetes was not suspected earlier in these cases. Being overweight (but you don't have to be), being thirsty, peeing a lot, and blurry vision are giveaways. The article lists other warning signs too.
________

Low-Fat Vegan Diet Outperforms Conventional ADA Diabetes Diet

Participants, all of whom had type 2 diabetes, were assigned to either a low-fat vegan diet or a conventional diabetes diet (2003 American Diabetes Association (ADA) Guidelines), which they followed for 22 weeks.¹

Here were each group's goals:

The vegan diet (~10% of energy from fat, 15% protein, and 75% carbohydrate) consisted of vegetables, fruits, grains, and legumes. Participants were asked to avoid animal products and added fats and to favor low–glycemic index foods, such as beans and green vegetables. Portion sizes, energy intake, and carbohydrate intake were unrestricted.

The conventional diabetes diet (15–20% protein, <7% saturated fat, 60–70% carbohydrate and monounsaturated fats, and cholesterol ≤200 mg/day) was individualized, based on body weight and plasma lipid concentrations.

Here's what participants ate over the course of 22 weeks (which did not quite meet their goals). Click to enlarge:*





*Not shown:
Vegan Diet: Caloric intake 1425 kcal/day, Cholesterol 24 mg/day
Diabetes Diet: Caloric intake 1392 kcal/day, Cholesterol 189 mg/day
________
What happens when people with diabetes eat a high-carb diet ... consuming 70% of their calories as carbohydrates?

Here's how each group fared (all of the following reached levels of significance):

Among participants whose diabetes medications remained unchanged:
A1C fell 1.23 points in the vegan group
A1C fell 0.38 points in the ADA group
(A1C is short for HbA1c, a measure of blood glucose over the last 3 months)

Reduction in diabetes medications:
43% (21 of 49) of the vegan group
26% (13 of 50) of the ADA group

Body weight decreased:
6.5 kg [14.3 lbs] in the vegan group
3.1 kg [6.8 lbs] in the ADA group

Among those who did not change lipid-lowering medications:
LDL cholesterol fell 21.2% in the vegan group
LDL cholesterol fell 10.7% in the ADA group

Reductions in urinary albumin:²
15.9 mg/24h in the vegan group
10.9 mg/24 h in the ADA group

In sum, those on the high-carb vegan diet had lower blood sugars (and so could reduce their meds more), lower LDL cholesterol, improved kidney function and over double the weight loss. There were also significantly greater reductions in BMI, waist circumference, and total cholesterol in the vegan group compared to the ADA group. There was no significant difference in exercise between groups, so these changes weren't because vegans were overtly spending more calories. ("Overtly" is key, since, as previously discussed, some diets lead to greater expenditure of calories from digestion and thermogenesis.)

Gary Taubes in his book, Good Calories, Bad Calories said, "Carbohydrates make us fat and ultimately cause obesity. The fewer carbohydrates we consume, the leaner we will be." He also said, "Refined carbohydrates, starches, and sugars are the dietary cause of coronary heart disease and diabetes." This study did not support his claims.

This is noteworthy ... Participants in the vegan group were allowed unrestricted consumption. They could eat as many calories and as much carbohydrate as they wanted, as long as they didn't eat from certain food groups. Participants in the conventional diet group had to limit their caloric intake, count calories, and control portion sizes. Even with unrestricted food intake and a higher calorie consumption, the vegan group lost more than twice as much weight.
________¹ A Low-Fat Vegan Diet Improves Glycemic Control And Cardiovascular Risk Factors In A Randomized Clinical Trial In Individuals With Type 2 Diabetes, Diabetes Care, August 2006
² People with diabetes suffer microvascular complications involving the kidneys that allow passage of protein into urine. The lower the amount of the protein albumin that leaks into the urine, the healthier the kidneys.

Charts: Bix. Data from study.

The Sugar Diet

Sugar being processed at the Louisiana Sugar Cooperative mill in St. Martinville, La.

"The third shift that underpinned Britain's Industrial Revolution was a far greater reliance on food imports. Just as it used coal from underground to power its new steam engines, Britain used food from overseas to provide energy for its workers. From its possessions in the West Indies, it brought in vast quantities of sugar, which provided an astonishing proportion of Britain's caloric intake during the nineteenth century, increasing from 4 percent of all calories consumed in 1800 to 22 percent by 1900."
- Tom Standage, An Edible History Of Humanity

That is astonishing. For a person consuming about 2000 calories a day:

• 4% is 80 calories, between 5 and 6 teaspoons of sugar a day.
• 22% is 440 calories, between 29 and 30 teaspoons/day.

The sugar was used either to sweeten tea (another import), or to make jam, which was eaten on bread throughout the day. I'm not sure if those figures accounted for rum (another sugar derivative) consumption.

If a high-carb diet causes weight gain (Gary Taubes in his book Good Calories, Bad Calories said, "Carbohydrates make us fat and ultimately cause obesity."), why didn't the potato-sugar-wheat diet in the UK in the 19th century lead to obesity?

For comparison, the USDA lists US refined cane and beet sugar consumption in 2009 at 13.4 teaspoons/day, down from 21.4 teaspoons in 1970. (Although we've found other ways to sweeten our tea.)
________ Photo from New York Times, Seeing Sugar's Future In Fuel. Caption: "Sugar being processed at the Louisiana Sugar Cooperative mill in St. Martinville, La."

Sleep Apnea? Meat And Cheese May Not Be Your Friends

You go to bed, fall asleep, and wake up. You visit the loo and return to bed, fall asleep, and wake up. Another trip to the bathroom? Frequent nighttime urination is one indication of sleep apnea. It may not be the need to urinate that's waking you, but the need to breathe.

Sleep apnea, episodes of shallow or absent breathing while asleep, is not uncommon. About 1 in 5 adults have it to some degree (a minimum of 5 episodes an hour); most don't know it's occurring.¹ If you are overweight, you are likely in that 20% prevalence rate. (About half of people with diabetes experience it.²)

It's serious. The decreased blood oxygen (from inadequate air flow to the lungs) tells your brain to wake you up so you can breathe better. The cycle of falling asleep, disturbed air flow, and waking up, over and over, increases levels of stress hormones that raise heart rate and blood pressure. Hypertension is an almost guaranteed fallout of sleep apnea, as are behavioral problems. Heart disease and other elements of the metabolic syndrome (insulin resistance and blood glucose abnormalities) are also linked.

One of the first studies to examine the diets of people with sleep disordered breathing (SDB), including sleep apnea found:³

"The results indicated that even after adjusting for BMI, age, and daytime sleepiness, subjects with very severe and extremely severe SDB (RDI ≥ 50*) consumed a diet that was higher in cholesterol, protein, total fat, and total saturated fatty acids. These findings were most evident among women."

*RDI is Respiratory Disturbance Index. Individuals with an RDI ≥ 10 events/hour were considered to have obstructive sleep apnea.

Although obesity is a risk factor for sleep apnea, this study found that - apart from being overweight - a high-fat, high-protein diet led to disordered nighttime breathing. Cholesterol and protein, nutrients typically found in foods of animal origin, were especially strong indicators. Trans fats, total fat, and saturated fat followed close.

It's hard to know if you have apnea without an outside judge, be it the person who bears witness to the characteristic snoring or a doc. Daytime sleepiness is a giveaway. So is a dry, scratchy throat (from snoring). Irritability, mood swings, and aggression are all related to sleep apnea. So is hunger...

The disturbed sleep increases levels of an appetite-stimulating hormone (ghrelin), and decreases levels of an appetite-suppressing hormone (leptin). It also increases the appetite-stimulating neuropeptide Y. This all leads to food cravings and more eating during the day ... which can lead to weight gain ... which can worsen the apnea.

You don't have to be overweight to have sleep apnea, but if you are, losing weight seems to lessen it. From the looks of this study, eating a lower fat, plant-based diet may also help.
________¹Epidemiology Of Obstructive Sleep Apnea, American Journal of Respiratory and Critical Care Medicine, 2002
² Prevalence Of Sleep Apnea In A Population Of Adults With Type 2 Diabetes Mellitus, Endocrine Practice, 2007
³ Associations Of Dietary Intake And Physical Activity With Sleep Disordered Breathing In The Apnea Positive Pressure Long-term Efficacy Study (APPLES), Journal of Clinical Sleep Medicine, 2008

The man in the photo is wearing a continuous positive airway pressure (CPAP) machine. It maintains blood oxygen levels by keeping airways open via pressure. You still have to do the breathing. If you use one, I'm curious what you think of it.

Embrace

The pea plants are taking off. They're growing odd hairy extensions. Overnight these two found each other and embraced.


________Photo: Bix

Paying People To Take Their Medicine

For Forgetful, Cash Helps the Medicine Go Down, New York Times, June 13 2010

I think this is a great idea, for some people and some medications. From my experience with low income people, those who take anti-psychotic drugs and some people on insulin or warfarin are good candidates, as are addicts. But for incentive programs to be effective, and not turn into laughing stocks, as I gleaned from the comments, it would be a good idea to involve case workers or other impartial advocates.

It looks like, from this excerpt, doctors may not always be impartial advocates. Or there is something more to this than meets the eye:

"Aetna has begun paying doctors bonuses for prescribing medication likely to prevent problems: beta blockers to prevent heart attacks, statins for diabetes sufferers. Currently, 93,000 doctors are in Aetna’s “pay for performance” program; bonuses average three percent to five percent of a practice’s base income."

What do you get when you pay docs to prescribe meds? You get docs prescribing meds. Does that seem odd to you? Paying docs to prescribe meds? Isn't that their job?

Statins for prevention are controversial¹. I think statin makers would like to see docs prescribing them though. I would sure hope, if I dug a little, that I did not find statin makers, or any other drug maker, in any way sponsoring Aetna's program.

So when you go to the doctor, know that in the back of her mind she may be thinking how much more money she'll make by writing a prescription instead of a referrel for a dietitian, a disease education class, or a fitness center (all of which insurance companies should rightfully cover since lifestyle intervention has been shown to be more effective than drug intervention²).

________¹ Statins And All-Cause Mortality In High-Risk Primary Prevention, Archives of Internal Medicine (an AMA journal), June 28 2010. Which concluded:
"This literature-based meta-analysis did not find evidence for the benefit of statin therapy on all-cause mortality in a high-risk primary prevention set-up."
² One example: Reduction In The Incidence Of Type 2 Diabetes With Lifestyle Intervention Or Metformin, New England Journal of Medicine, 2002. Which concluded:
"Lifestyle intervention was more effective than metformin."

The Journalistic Bully-Coward

"When I was in college I worked on a project for Ralph Nader, long before his days as a presidential candidate. One evening he gave me his own graybeard lecture, from his venerable position as a man who had reached his mid-30s. He said that a really unattractive personality type was the journalistic bully-coward. That is, the person who breathes absolute fire when sitting at the keyboard, but skulks away nervously if he catches sight of someone he'd so fearlessly denounced from the writer's chair."
- James Fallows, Lessons From Nader: How Not To Be A Bully Coward, The Atlantic, June 30 2010

That's a lot of wherewithal for someone in their mid-30s.

Fallows links the following video of a 30ish Nader at a news conference following a speech he (Nader) gave at DePauw University on September 11, 1970, "Environmental Hazards: Man-Made, Man-Remedied."

It's a short clip. I found the following bit, starting at 1:24, relevant to today. And this was 40 years ago!

"There was recently a million dollar fine imposed on Chevron for the biggest oil spill in the Gulf of Mexico. What is that? That's nothing! That's about an hour's gross revenue of the parent company. And it can be just be passed on through the cartel in the form of higher consumer prices. Unless these fines go to the culpable officials, you're not going to get law acting as deterrents to future activity.

And an oil spill is not just something that messes up beaches or kills a few seagulls. An oil spill as we now know, due to testimony before the Senate a few weeks ago, breaks down almost immediately into carcinogenic components, which are consumed by fish, and which can be passed through the food cycle. The oil spill also destroys almost every vestige of life on the seabed over an enormous area. So it's a very serious ecological disaster, one that does not repair itself in just a few months or even a few years."

In light of BP's massive oil spill from April of this year, now known to be the largest spill ever in the Gulf of Mexico, it is apparent we did not get law acting as deterent from the time Nader delivered his admonishment in 1970.


________

High-Fat High-Sugar Dietary Pattern ("Meat & Potatoes") Linked To Colon Cancer, Diabetes

Update on my post "Meat And Potatoes" Dietary Pattern And Risk For Colon Cancer.
________
What's the new direction in nutrition research? If you've been reading this blog, you know it's Dietary Pattern Analysis. Instead of investigating the effects of one food or nutrient, pattern analysis reveals effects of the whole diet.

Single nutrient analysis is still relevant. It's useful for sorting out mechanisms. But people don't eat single nutrients. Any effect one food has gets muddied in the cacophony of dietary inputs.

A study in this month's issue of The Journal of Nutrition...
Diet Index-Based and Empirically Derived Dietary Patterns Are Associated with Colorectal Cancer Risk, The Journal of Nutrition, July 2010

... employed pattern analysis to ascertain a link between diet and colon cancer.

It found that a "fruit and vegetable" pattern was beneficial; it was associated with a decreased risk for colon cancer. This pattern was characterized by intake of "fruits, vegetables, legumes, whole grains, nuts, and seeds."

"Our findings support a protective effect for both men and women of a largely plant-based dietary pattern."

It found that a "meat & potatoes" pattern was deleterious; it was associated with an increased risk for colon cancer (more so for women).

"Meat & potatoes" is just a name that describes a particular style of eating. It doesn't necessarily have to contain meat or potatoes as long as it's high in fat and sugar. (Maybe we could call it the "Wate-On Dietary Pattern.")

"This pattern, which has previously been labeled Western, meat and potatoes, or a close variant, has been characterized most often by greater intakes of red and processed meat, fried and white potatoes, fast food, pizza, high-fat dairy products, desserts, refined grain products, and other high-fat and high-sugar food items."

Other items included "sweets, salty snacks, butter, mayonnaise, and gravy."
________
Colon cancer is linked to diabetes and heart disease. Just how remains the question. From my previous post, Colon Cancer, Its Link To Diabetes, And Dietary Pattern:

As to the link between colon cancer and diabetes, the authors said, "many of the dietary risk factors associated with colon cancer may reflect the effect of hyperinsulinemia." And high insulin may, in turn, reflect a certain pattern of eating:

"... the characteristically low polyunsaturated/saturated fat ratio from a higher red meat intake contributed to insulin resistance¹, while the low intake of legumes, a food of characteristically low glycemic response, contributed to a heavier glycemic load."

________ ¹The amount of saturated fat we eat affects insulin resistance, one example: Substituting Dietary Saturated For Monounsaturated Fat Impairs Insulin Sensitivity In Healthy Men And Women: The KANWU Study, Diabetologia, 2001

Paintings by Craig Stephens. "On this blog I have posted 1000 paintings in as many days."

Wate-On's Competition

If products like Wate-On and Ensure help you gain weight when consumed daily, why wouldn't products that contain the same active ingredients (Oil and Sugar) do the same? Products like... (I listed the first few ingredients for each product in the order they appear on each manufacturer's list.)

Nabisco Ritz Crackers:

• Enriched Flour
  
• Soybean Oil
  
• Sugar
  
• Partially Hydrogenated Cottonseed Oil

Nabisco Honey Maid Graham Crackers:

• Enriched Flour
  
• Sugar
  
• Graham Flour
  
• Soybean Oil and/or Partially Hydrogenated Cottonseed Oil
  
• High Fructose Corn Syrup

Wegman's Hamburger Potato Rolls:

• Enriched Flour
  
• Water
  
• Sugar
  
• Wheat Flour
  
• Soybean Oil

Kellogg's Froot Loops Cereal:

• Sugar
  
• Corn Flour, Wheat Flour, Oat Flour, Oat Fiber, Corn Fiber
  
• Partially Hydrogenated Vegetable Oil

Kellogg's Pop-Tarts, Brown Sugar Cinnamon, Unfrosted:

• Enriched Flour
  
• Brown Sugar
  
• Soybean And Palm Oil
  
• Corn Syrup
  
• Dextrose
  
• High Fructose Corn Syrup

Kellogg's Eggo Waffles, Cinnamon:

• Enriched Flour
  
• Water
  
• Sugar
  
• Vegetable Oil

Tastykake Chocolate Cupcakes:

• Sugar
  
• Water
  
• Enriched Flour
  
• Partially Hydrogenated Vegetable Shortening (Canola, Soybean, and/or Cottonseed Oils)

Dunkin Donuts Cake Donut:

• Bleached Wheat Flour
  
• Barley Malt
  
• Sugar
  
• Soybean Oil

Food markets are just crammed with products that are some amalgamation of Sugar/Fat/Flour. Really, they're all the same food with different packaging.________

Everything Old Is New Again

There are times weight gain is desirable. I often think of medical reasons; I shouldn't discount cosmetic reasons. I remember seeing these ads for Wate-On in the back of comic books when I was growing up (click to enlarge):





Here's a modern version:

"Eat well and live healthfully, and you could become 'Model of the Year!'"
- Ensure

If products like Wate-On and Ensure help you gain weight, what could this say about weight loss?

Here are the first few ingredients in Super Wate-On Liquid Strawberry Dietary Supplement:

• Hydrogenated Stabilized Soybean Oil
  
• Water
  
• Sugar
  
• Propylene Glycol
  
• Polyoxyethylene 20 Sorbitan Monolaurate
  
• Sorbitan Monostearate
  
• Xanthan Gum

Here are the first few ingredients in Ensure Strawberries & Cream Nutritional Supplement:

• Water
  
• Sugar
  
• Corn maltodextrin
  
• Milk protein concentrate
  
• Soy oil
  
• Soy protein concentrate
  
• Short-chain fructooligosaccharides
  
• Canola oil
  
• Corn oil

________
Eva Six from Myrmecos Blog.
Linda Peck from David DiDalvo of True/Slant, where I started thinking about this.
Dashing Couple from Pops Gustav's Blog, who also remembers the comic books!

What's Your Heart Rate?

The American Diabetes Association's 70th Scientific Sessions, an annual meeting that reviews the latest findings in diabetes, just wrapped up in Florida.

I've been busy digesting the presentations. It's an insidious and unfortunately common disease, but we're learning much. Diet and exercise remain key to prevention and management.

Here's a tidbit. Heart rate was found to be an independent risk factor for heart attack (in people with diabetes who had heart disease).¹

"A baseline heart rate ≥70 bpm was predictive of major cardiovascular events compared with a resting heart rate 70 bpm."

How to check your pulse, from WebMD (click pic to enlarge):



________¹ Heart Rate As A Predictor Of Cardiovascular Risk In Stable CHD Patients With Diabetes: A TNT Substudy, ADA 70th Scientific Sessions, June 2010