Shortly after recommending approval of Qnexa (Phentermine / Topiramate), the FDA advisory panel this week also voted to approve Arena Pharmaceuticals weight loss drug, Lorgess (Lorcacerin).  This medication has been in clinical trials over the past several years and works through the 5HT2c sub-type Seratonin receptor in the brain.

Why is this important?  What is 5HT2c?  Well, Lorgess is a seratonin agonist – that means it triggers the release of seratonin.  Sound familiar?  The big hit weight loss drug of the 90′s, Fenfluramine worked as a seratonin agonist as well.  That was when it was discovered that we had seratonin receptors in lots of places, not just our brains.  In fact, we have a seratonin receptor in heart valves.  That’s why Fenfluramine caused heart valve damage.

Fast forward to 2012.  We now have the technology to target specific seratonin receptors.  By targeting the 5HT2c receptor, Arena Pharmaceuticals has been able to develop a medication that targets only the brain, with little to no activity in the heart.  They have done careful safety studies, and have proven that their new obesity drug is both safe and effective.

The FDA panel is scheduled to vote on Qnexa on July 17th, and on Lorgess on June 27th, but they are under no obligations to follow their advisory panel’s advice.

So, will 2012 be the first year in 13 years that we get a new obesity treatment?  Stay tuned…

Weight loss and weight gain have many obstacles.   Our bodies produce a  hormone called leptin and it is a key element in the body weight regulation system. Leptin and other chemicals trigger the area in the brain to let you know you are full. If your system is malfunctioning, you don’t feel full even if you have consumed an adequate amount of food.

Dopamine is a neurotransmitter that motivates us to eat and is involved in other rewarding behaviors. It also is involved in “wanting” more than “liking” which could be why we feel addicted to foods. So different levels of dopamine could be one problem causing obesity.

Weight issues are often rooted in biology, not just “will-power”.  Here are some strategies to help with weight loss and to help with maintenance:

1) EAT BREAKFAST-make sure you have lean protein like 3/4 cup to 1 cup of egg whites with low-fat cheese plus Fat-Free yogurt and fresh fruit.

2)Eat ‘Filling Foods ‘such as: skinless poultry, fresh fruit, vegetables, lentils and beans

3)Exercise!  Cardio and Weights….aim for 150 minutes weekly

4)Self-weighing or how clothes feel should be evaluated weekly or daily-whichever is most motivating individually.

5)Journal food, exercise and water.  Stay mindful of your eating and concentrate on slow eating. Try either writing down food consumed or use apps such as Myfitnesspal and endomondo

6)Water-drink plenty and  increase water intake with exercise;  Every 15min. of exercise add another 8 oz. cup

7)Positive Self Talk-don’t get mad at yourself but think of being overweight as a health problem and needing treatment. Healthy eating habits and lifestyle behaviors are essential to success….don”t give up!  Our clinic is here to keep you HEALTHY!!!

-By Mary Ellen  Doukakis, RD

Another hot topic at this year’s American Society of Bariatric Physicians meetings here in Denver, CO this year was the Mediterranean Diet.  Dr. Scott Rigden gave a very interesting review.

Interest in this style of diet was really sparked in 1999 by the Lyon Diet Heart Study.  In this study, participants were asked to either follow a Mediterranean Diet, or to follow an American Heart Association (AHA) style diet.  After 5 years, the study was stopped early due to excess mortality in one group.

Which group?  The AHA diet group.  In fact, comparing the 2 groups, those following the Mediterranean Diet experienced a drop in Total Mortality (death rate) by an astounding 72%, and a drop in death rates from Cardiovascular events of 47%.

We’ve now had 13 years to ponder these results.  Even though there was no significant change in blood cholesterol, blood pressure or weight between the 2 groups, the answer seems to be inflammation.  Because the Mediterranean style of eating incorporates a much higher intake of nutrients known to decrease inflammation (like Omega 3, Gamma Tocopherol, Flavenoids, Coumarins and Anthrocyanins) and excludes many nutrients known to increase inflammation (Omega-6, linoleate and arachidonate, iron, trans fats, and alpha tocopherol), it results in marked decrease in inflammatory mediators in the body (c-reactive protein, interleukin 6, and white blood cell count).

It appears to have benefits for a variety of conditions including:

• Obesity
• Diabetes
• High Blood Pressure
• Metabolic Syndrome (Insulin Resistance)
• Cardiovascular Disease
• Inflammation
• Alzheimers Dementia / Parkinsons
• Depression
• Certain Cancers
• Sexual Function

So, what is the Mediterranean Diet?  There are actually several styles of Mediterranean Diet and several good books on the topic, but in short:

1. Eat Large Quantities of minimally processed plant based foods including fruits, vegetables, whole grains, legumes, seeds and nuts.
2. Olive oil is the principal source of dietary fat.
3. Low consumption of red meat and dairy products (some authors suggest moderate intake of low-fat dairy).
4. Wine in low to moderate amounts with meals.
5. Eat fish and healthy fats.
6. Engage in regular physical activity.

If you are interested to learn more, be sure to talk to your Clinical Nutrition Center Dietitian to learn how to incorporate these principals in to your eating plan.

Walking

We all fall into routines.  Routines are a normal, and usually positive pattern.  But sometimes it’s nice to shake things up, set goals and break out of normalcy.  The spring and summer in Colorado are packed with hundreds of organized races, walks, bike rides and hikes.  Often times having an organized event to look forward to can motivate us to keep on track.  I have posted below a sampling of the many activities you can choose from in May.  (This is a very small sampling of the available events!)  I challenge you to pick 1 or 2 each month between now and September.  Then set a training goal and make time for fitness 3 times a week.   If you have never participated in an organized race event before, don’t worry!  Almost every race has “walker waves”, beginning waves and/or later start times for the less competitive participants.    Bonus points for finding a friend or family member to join you.

It doesn’t matter if you finish quickly ….just that you finish!  You will find that many races support a cause, so you can pick one that is near and dear to your heart.  Or maybe you want to pick one in a new part of town that you haven’t been to before.    Once you have signed up, you can get excited about training for your chosen event.

RUNNING/WALKING EVENTS:

May 19th, 2012 Colfax Marathon – 5k and kids run http://www.coloradocolfaxmarathon.org/

May 19th, 2012 The gift of life and breath 5k http://www.thegiftoflifeandbreath.com/

May 20, 2012 Miles for Smiles 5k http://www.active.com/running/broomfield-co/miles-for-smiles-5k-2012

May 22nd, 2012 Dash n Dine in Boulder http://www.withoutlimits.co/dash-n-dine-5k-series

May 28th, 2012 Bolder Boulder http://www.bolderboulder.com/

June 10, 2012 Denver Triathlon (Run, Bike & Swim)  http://www.active.com/triathlon/denver-co/denver-triathlon-2012-no796

BIKING EVENTS:

May 19th, 2012 Battle the Bear Bike Ride http://www.active.com/cycling/lakewood-co/battle-the-bear-bike-ride-2012

May 20th, 2012 Community Class Bike Tour  http://www.mckeefoundation.com

HIKING EVENTS:

May 25, 2012 Nature Hike in Commerce City http://www.active.com/outdoors-class/commerce-city-co/nature-hike-5-25-2012-pa101

May 31, 2012 Rocky Mountain Park Hiking Trip http://www.active.com/outdoors-class/evergreen-co/rocky-mountain-national-park-hiking-trip—may-31-2012

Hundreds of additional events can be found at active.com , runcolo.com and more.  Google the type of activity you want to do combined with your city name and find your perfect event(s)!  Enjoy your event and feel free to post events you are participating in on our Facebook page …. maybe other patients would like to join you.

I hope you enjoy walking, running, biking & hiking in May!

-Aimee Lazarus

Sleep Off Those Pounds!

Another exciting topic at this year’s American Society of Bariatric Physicians conference examined the link between sleep and obesity.  In fact, this is one of the few lectures that kept me awake

Did you know that we actually burn calories while we sleep?  Sleep is divided into 5 stages, conveniently labeled stage 1 through 5.  Unsurprisingly, we progress through the stages in numerical order, with Stage 1 and 2 sleep being Light Sleep, 3 & 4 are Deep Sleep, and stage 5 is the “REM” sleep (standing for rapid eye movement).  Most people go through about 5 sleep cycles each night.  However, the early part of the night there is a lot more Stage 1 and 2 sleep, while most of the REM sleep occurs in the final 1/3rd of the night.

In Stage 3 & 4 sleep, we physically restore our bodies.  In fact, during this stage we have the largest production of growth hormone, which is responsible for cellular repair and tissue regeneration.  Further, we restore our immune system, reduce risk of osteoporosis, and restore skin elasticity.

In Stage 5 or REM sleep, we mentally restore ourselves.  This large increase in brain activity also leads to a large increase in calories being burned.  We move the information from our short-term to our long-term memories.  In fact, in REM sleep, we burn 118 calories per hour.  Since most individuals I meet have been gaining weight slowly (1-2 pounds per month, or 100-200 calories per day), 1 extra hour of REM sleep might be enough to prevent weight gain.

Unfortunately when an individual does not get as much sleep as his or her body needs, we curtail the most important part of our sleep.  Waking up just 1 hour too early results in a loss of most of this enormously valuable REM sleep.  Further, not getting enough sleep has been associated with having an unfavorable effect on our body’s hunger hormones, resulting in a drop in Leptin (a satiating hormone) and a large increase in Grehlin (one of the strongest hunger hormones).

So, get some rest!  Here are 5 helpful tips:

1.  Choose a bed time and stick with it!

Because we often have a fixed wake up time (work, kids, etc), the best way to figure out your bedtime is to start at the wake up time and count backwards by 7.5 to 8 hours.  This is your bed time – stick with it even on weekends and holidays.

2.  No caffeine after 2:00 PM

3.  No Alcohol 3 hours before bed.

4.  No exercise 4 hours before bed.

A caveat here is that for some individuals, exercise can have a calming effect.  If this is true for you, ignore #4.  Also, some individuals enjoy calming type exercise like Yoga and find this helpful for sleep – again, if you fall in to this category, ignore #4.

5.  Get at least 15 minutes of sunlight daily.

That’s it!  Enjoy your new-found energy levels, mental clarity, satiety, oh and did I mention, healthy weight?

To Eat or Not To Eat - That is the Question!

After a full week of lectures at the American Society of Bariatric Physician’s conference last week, I must say – I’ve never heard so many lectures about fat.

There was much conjecture over whether or not fat is good or bad for us to be eating.  But first, how about some history.  Back in 1980 when we received the first Food Pyramid from the U.S.D.A., it seemed clear that there was an association between fat in our diets and the development of heart disease.  Therefore, low fat became the rage.  To continue to provide Americans with highly palatable low-fat foods, the food industry responded quickly.  They realized that without the fat, food just didn’t taste as good.  Until, of course, they realized that we really like processed carbohydrates like High Fructose Corn Syrup (HFCS).

So, in coming years, we ate less and less fat, more and more refined carbohydrates.  The average American increased their carbohydrate intake by about 200 calories per day.  And our obesity rates skyrocketed.  Unfortunately, we replaced something of no known, but suspected risk with something we thought was safe.  Boy were we wrong!

As it turns out, the driving force behind the obesity epidemic is insulin resistance.  And refined carbohydrate requires a lot of insulin to digest.  These high levels quickly result in insulin resistance.  In fact, it is now thought that it is insulin resistance that is causing our weight gain.  This is in direct contrast to common thinking – that our weight gain is driving up insulin resistance and diabetes.  Let me say this again:  I believe it is the increased refined carbohydrates causing an increase in insulin resistance that is the driving force behind the obesity epidemic.  To be clear, the extra 200 gm of carbohydrates elevates insulin levels resulting in insulin resistance, then weight gain follows.

Why was it thought that fat in our diets causes heart disease?  It is actually true that fat in our circulating blood causes heart disease.  But, there was no evidence that eating fat increases fat in our circulating blood.  In fact, eating a large carbohydrate load causes increased fat in our blood!  Why?  because we can’t store or use the carbohydrates – just about a teaspoon of sugar is enough to provide our muscles with energy.  The rest gets taken up by our livers rapidly, and gets turned into triglycerides, our circulating form of fat.

Fat on the other hand does not go through this same pathway.  In fact, in a carbohydrate controlled diet, fat does not appear to elevate blood fat levels.

So, what’s the take home message?  It’s time to stop villainizing fat, and return to healthy eating styles.  It’s time to mind our carbs, avoid refined carbs, especially those in sugar sweetened beverages, and eat our fat!  In particular, if we are going to try and eat less saturated fat (a highly debatable point among conference experts), perhaps rather than replacing it with carb we should be replacing it with Polyunsaturated Fatty Acids (PUFA’s).  Or, perhaps we should stop worrying so much about Saturated Fat.

Of course, another expert suggests that we can’t take a 1-diet-fits-all approach.  Some individuals clearly have increased health risk from fat intake, some don’t.  But, for a Type II Diabetic, clearly the advantages lie in carbohydrate restriction, not fat restriction.

Guess we’ll have to wait and see what the next set of U.S.D.A. guidelines (in 2015) look like.

(Trans fats clearly have health risk – cakes, cookies, pies, shortening… – talk to your dietitian about how to optimize your fat intake).

Today the FDA announced that instead of reviewing Qnexa, the new weight loss drug by Vivus, combining Phentermine and Topiramate, they are pushing back the review date by 3 months to July 17th, 2012, to allow time to review all of the submitted data that Vivus provided the FDA.

“MOUNTAIN VIEW, Calif., April 9, 2012 (GLOBE NEWSWIRE) — The U.S. Food and Drug Administration (FDA) informed VIVUS  (Nasdaq:VVUS) of an extended Prescription Drug User Fee Act (PDUFA) date for its review of the Qnexa New Drug Application (NDA) from April 17 to July 17, 2012. The three-month extension is a standard extension period.

On April 4, 2012, following the FDA’s request, VIVUS submitted the Qnexa Risk Evaluation and Mitigation Strategy (REMS), which was considered a major amendment to the NDA. The submission consisted of proposed REMS materials. Since the receipt date was within three months of the user fee goal date, the FDA is extending the PDUFA date by three months to provide time for a full review of the submission.

“The Qnexa REMS submission is comprehensive, with materials based on ongoing feedback from the FDA since our advisory committee meeting in February,” stated Leland F. Wilson, chief executive officer of VIVUS. “We look forward to finalizing our REMS with the FDA while we move forward with our commercialization plans.”

The Qnexa NDA seeks approval for the treatment of obesity, including weight loss and maintenance of weight loss for obese patients (BMI ≥ 30 kg/m2), or overweight patients (BMI ≥ 27 kg/m2) with weight-related co-morbidities such as hypertension, type 2 diabetes or dyslipidemia. Obesity is the second leading cause of preventable death and directly contributes to numerous life-threatening conditions including diabetes, cardiovascular disease, hypertension and stroke.”

Perhaps you’ve noticed:  Many people in their 70s, 60s, 50s, even 40s are showing up with knee problems that require surgery.  Here’s a chart for illustration: 

One of the main reasons for the huge increase in these surgeries is the increasing weight of the US population.  Hoping NOT to become a statistic?  The US Dept. of Health and Human Services says that  losing weight will help.  Just ONE pound of lost body  weight reduces the stress on your knees by FOUR pounds.  This same one pound equals a reduction of 4800 pounds for each mile that you walk!  Word to the wise – Weight loss in ANY amount is hugely beneficial to the long term health of your knees.    Make an appointment with a Registered Dietitian and Clinical Nutrition Center today and your knees will thank you.

By Suzanne Boos, RD

When we think of crock pot meals, we are reminded of cold, winter days and comfort food.  Let’s change this thinking into using the crock pot year round with fast, easy, and nutritious meals prepared in a matter of minutes.  Here are some suggestions to get you started or add to your collection:

Chicken (4-6 frozen breasts):

-Add 1 jar red salsa or verde salsa.  Before serving, cut chicken up to allow juice to finish marinating the chicken.  Add peppers and onions for a fajita dish.  Serve over lettuce or in a bowl (like green chile) and top with white onion and cilantro.  Add 2 streamed corn tortillas or 1/2 cup pinto or black beans as a starch serving.

-Add 1 jar marinara sauce (lowfat; 1/2 cup 50 cal) with spices (red pepper flakes, basil, oregano) and veggies as desired.  Serve in bowl or on top of spaghetti squash.

Pork sirloin roast (very lean) or pork loin (lean):

-Add salsa like the chicken above and garnish.

- Add 2 Lipton onion soup packets and water.  Add carrots, celery, cabbage, or any desired vegetable.

Vegetable Soup:

-Use broth or V-8 (regular, low salt, or spicy) as your base.

-Add veggies of your choice.  There are no limitations!  Carrots, celery, leeks, cabbage, onions, zucchini, cauliflower, etc.

-Add spices (cajun, chili powder, garlic, basil, rosemary, bay leaves, red pepper flakes, etc)

-Add protein or leave as a veggie and add protein with meal (4 oz chicken, 1 cup cottage cheese) or snack (1-2 oz. cheese stick).

-This soup fills you up when you are really hungry.  I eat it as an afternoon snack to keep me full until dinner.

I hope this will inspire you to use your crock pot more often.   Set a goal to cook with it once a week and see how easy and delicious your meal can be.  Please add your own favorite recipes to share.

Enjoy!

Susan Ellis, RD

Do you have high liver enzymes? These are the ALT, AST, GGTP ALK and PHOS tests toward the bottom of your blood-work results. What do the elevation of these funny acronyms mean? Abnormal values may indicate problems with your liver,  bile duct or other bodily systems. Your liver is a key metabolic organ.  It performs many vitally important functions, filtering out toxins and waste products  It  effectively cleans your blood. Enzyme levels are often elevated when the liver has to deal with higher levels of drugs (even those over the counter) or alcohol.

Nonalcoholic Liver Disease (NALD) can occur when weight gain causes excess fat to be stored in the liver.  Untreated, it can lead to cirrhosis, diabetes and cardiovascular disease.  Gradual and sustained weight loss is the most effective treatment.  Reduced caloric intake and regular physical activity are the keys to successfully remedying this medical condition. A diet low in carbohydrate and saturated fat, and abundant in omega 3-containing foods  is the long-term treatment.  At Clinical Nutrition Center, we can help you to design and implement the program you need.   It is interesting to note that  the same diet that is used to treat and prevent liver disease is also used to prevent or ameliorate heart disease, diabetes, stroke risk and even Alzheimer’s !

By Suzanne Boos, RD