Monkeying Around With Longevity

The search to extend human longevity spans the ages. More recently, scientists have repeatedly shown that restricting the intake of calories while continuing to supply essential nutrients extends the lifespan of flies and yeast by as much as 40 percent. An additional research vector that captured much attention were animal studies with rodents that suggested similar benefits from caloric restriction. 

Although positive results were not seen with all strains of rodents, some rodents were shown to live significantly longer when their calories were limited.  As with all animal studies, scientists wanted to know if these benefits extended to more complex creatures that more closely resemble humans--such as primates--better known as monkeys.

When the National Institute of Aging (NIA) completed their studies with monkeys in 2012, the NIA's conclusion was that that caloric restriction made no difference. This hardly put the controversy to bed, but it did seem to dampen some enthusiasm for this approach to extending human longevity.

This past week, a new study from the University of Wisconsin stirs up new hope for reconsidering this strategy. Over 25 years, Wisconsin researchers studying rhesus monkeys, considered by some the best proxies for humans, found a significant reduction in mortality and in age-associated diseases among those monkeys fed calorie-restricted diets. The study, begun at the University of Wisconsin-Madison in 1989, is one of two ongoing, long-term U.S. efforts to examine the effects of a reduced-calorie diet on nonhuman primates.

The study of 76 rhesus monkeys, reported Monday in Nature Communications, was performed at the Wisconsin National Primate Research Center in Madison. When the monkeys were 7 to 14 years of age, they began eating a diet reduced in calories by 30 percent. The comparison monkeys, or the control group, which ate as much as they wanted, had an increased risk of disease 2.9 times that of the calorie-restricted group, and a threefold increased risk of death.

So which study is correct?  According to the Wisconsin researchers the reason for the discrepant results is that the NIA monkeys that were in the control group versus the intervention group were actually already on calorie restricted diets and that's why no difference was found in longevity between the two groups. Also, the NIA monkeys were consistently slimmer (and presumably healthier) that the Wisconsin monkeys, who were allowed to eat what they wanted. (I guess even monkeys, particularly captive ones, overeat when enabled to do so.) The NIA was apparently more careful with all their monkeys to limit their food intake regardless of the study.

How did the Wisconsin researchers reach this conclusion? Through their own experience in monkey research, and by reference to an online database recording the weight of thousands of research monkeys, the Wisconsin researchers concluded that the NIA controls were actually on caloric restriction as well. “At all the time points that have been published by NIA, their control monkeys weigh less than ours, and in most cases, significantly so” stated Ricki Colman, a senior scientist at the Wisconsin Primate Center, who presently co-leads the project.

More importantly, the NIA control group monkeys were also found to live longer on average that most other monkeys, and the Wisconsin researchers theorized that this was due to even a small reduction of calories. The big conclusion was that it seems that the small caloric restriction in the NIA control animals had its own benefits, suggesting that a reduction of as little as 10 percent could meaningfully retard aging.

As these studies were very expensive to conduct and will therefore not be repeated any time soon, the question remains do primates benefit from calorie restriction as long as they get all essential nutrients? The Wisconsin study would suggest that for rhesus monkeys, the answer is yes.

So what does that mean for us humans?

According to the Wisconsin researchers, they were“not studying [caloric restriction]...so people can go out and do it, but [rather] to delve into the underlying causes of age-related disease susceptibility...It’s a research tool, not a lifestyle recommendation."

Although the helpful mechanism of why caloric restriction may be beneficial has not been fully identified, it is believed to have something to do with the "reprogramming of the metabolism. In all species where it has been shown to delay aging and the diseases of aging, [calories restriction]... affects the regulation of energy and the ability of cells and the organism to respond to changes in the environment as they age.”

One of the first break-downs in metabolism results in diabetes, which can be seen as “an inability to properly respond to nutrients.” Diabetes damages a whole range of human capabilities including the functioning of muscle, fat and blood vessels. "The Wisconsin scientists began to see diabetes among the control animals while they were still in the prime of life, within six months after beginning their study. The contrast with the restricted animals could not have been more dramatic" Colman said. “Until two years ago, we did not have evidence of diabetes in any caloric-restriction animal, but we had a significant number of diabetes, or pre-diabetes, metabolic syndrome, in the control animals.”

Although it is generally accepted that very few people can tolerate a 30 percent reduction in calories, the study does merit consideration.  Primarily because “the basic biology of caloric restriction in rodents, worms, flies and yeast seems to carry over to primates," it appears worthwhile to identify the underlying mechanism for this result in order to better understand the potential benefit to human primates who are genetically so closely related to rhesus monkeys.

The bottom line here is that as long as they all get their essential nutrients it would appear across multiple species, from simple worms to far more complex primates, that eating less is better than eating more. It's not a large stretch to extend that logic to homo sapiens. Accordingly, even cutting back on 10% of your calories may have a huge effect on your longevity--adding years of healthy living to your life.  And that's not something to monkey around with.

Stop The Weight Loss Madness

This past week, I saw no less than ten patients who wanted to lose weight. Each described in their own unique way how the extra weight was contributing to some perceived problem they had with the weight's effect on their image, energy level, health, etc.

To each patient, I said the same thing. Stop focusing on losing weight and start focusing on what you can and cannot do to your body to help it function at its optimal level.  To each, I conveyed how the human body was developed over millions of years, with its most latest form, homo sapiens being around two hundred thousand years old. Over this period of time, human biology has evolved a full host of protective mechanisms to ward off disease. Of course, we all know these mechanisms sometimes fail miserably. It is very unfortunate when it does, and my heart goes out to those who suffer seemingly happenstance illness. Nevertheless, these mechanisms work for most and that is why the human body can usually protect itself fairly well against poor eating, lack of exercise, inadequate sleep, mounting stress, etc. for at least the first five or six decades of life.  It's not that damage isn't being done, it's just that the damage isn't always so obvious until later.

I often share with patients the story of the my growing up in Brooklyn, NY and how one day the red lights turned on in on the dashboard of my father's old car.  I share how my father drove it to a nearby gas station and spoke to the attendant and asked if he could help with the red light, to which he replied, "yes, I can disconnect it."  Now even to a young boy that was a ridiculous statement. Little did I realize that during medical school and my residency, my teachers and mentors would primarily educate me on how to turn off patients' red lights. As doctors have become successful in eliminating symptoms without addressing the underlying problem, akin to turning off a red light warning of problems, patients have been confused into thinking they don't really have a problem. A case in point is a patient this week telling me that he was very healthy with normal blood sugar despite the fact that he was a diabetic on high blood sugar medication and nearly morbidly obese.

For some reason, Americans seem to disassociate the reasons they gained the weight with the effects such reasons have on their health beyond the number on a weight scale.  They gain weight because they ate too much, they ate the wrong food, they barely moved, they slept poorly and were always hungry, etc. That is why I tell people to stop worrying about the numbers on the scale and to start paying close attention to the details of their lives. Although there is no perfect plan for staying healthy as the old Yiddish saying goes, mensch tracht un Got laft, men plan and G-d laughs, it still pays to plan. Therefore, by focusing on those elements of your life that you do have control over, you can shift the odds of staying and getting healthy in your favor. By doing so, one of the benefits is usually weight loss.

I have always believed that for virtually all problems, there are solutions.  Over the past three years, by investing the time and listening carefully to what patients are telling me, in partnership with them, I have helped them identify such problems and come up with workable solutions.  It has been a three year whirlwind and I am so grateful that I had the opportunity to so positively effect so many lives.  However, as clinically successful and emotionally rewarding this endeavor has been, the time has come for me to move on to my next challenge. I will always be grateful for all that my patients have taught me and the wonderful personal stories they shared.

I know that those who embraced my philosophy about taking care of the one body they had by eating healthy foods in moderation, avoiding unhealthy foods altogether to the extent possible, physically staying  active over the course of a day as much as possible beyond simply going to a gym for a specified work-out, improving sleeping habits, managing stress more effectively with good meditation and relaxation techniques, nurturing relationships and being grateful for the good things in life, have and will continue to reap great benefits from developing such good health habits.

To the rest of you I say, while good health is never guaranteed, a healthy lifestyle can shift the odds in your favor. Choices do have consequences so please choose wisely. Stop chasing weight loss like a lost puppy and focus on what really matters--your overall well-being.

To Lose Weight, Get Your Head Into the Game

Altogether now. "If your head is not in the game, the game is over before you start."

Last evening, I came across an article about a new analysis of a study called the Look AHEAD (Action For Health in Diabetes) trial that purported to show that lifestyle intervention had no (yes, I meant no) benefit in reducing heart disease for type two diabetics. The study was a randomized study in which one group, the control group, received up to three yearly educational sessions dealing with their diabetes, while the second group, the study group, received regular counseling about reducing their calories and exercising more.

This may surprise you, but I wasn't surprised by the results.

About fifteen years ago, a study was done called the Adverse Childhood Experiences (ACE) study. The  ACE study showed a direct link between adverse child events and unhealthy behaviors. The number of adverse child experiences, which include physical and sexual abuse, the death of a parent, living with an alcoholic parent, etc.correlated almost perfectly with the number of unhealthy behaviors demonstrated during later adult life.  The landmark study showed the absolute relationship between mind and body, psychology and physiology, what's going on in your head, and your overall health.

When I rook a close look at the Look AHEAD study, it was very clear that although a psychologist was suppose to be part of the team at each medical center that participated in the trial that involved over 5,000 patients, psychological counseling and behavioral modification was not an intrinsic part of the study.

Most health conscious people know that simple caloric reduction does not guarantee weight loss, let alone good health because the source of the calories is as important as the number of calories. Case in point. A recent medical case revealed a woman who drank only soda for a number of years and became deathly sick. Another example is the Atkins Diet which proves that calories derived mostly from meat does produce weight loss, but at the cost of heart health.

The lesson here should be clear. Simply telling people to restrict their calories is a failed experiment in the making. Getting them to exercise more without concomitant changes in other aspects of their lifestyle provides marginal benefits at best.

Having now counseled hundreds of patients about their weight and the lifestyle changes they need to make to get healthier and lose weight, I can tell you with almost absolute certainty that simply telling patients what to do does not work.  Virtually every human being has a story unique to him or her. Understanding that story, identifying rationales for the decisions made, exposing motivations to make change, and acknowledging the challenges faced to modify behaviors are equally important to helping a person make changes.

In the Look AHEAD trial, it should have come to no surprise to any of the researchers that many of the participants either regained or were regaining the weight they earlier had lost as the trial progressed. Why? They had followed directions, not made fundamental changes to their mind-body connections. Their relationship to food had not changed. They had simply denied themselves calories for an extended period of time and eventually resumed bad habits. Nothing had really changed and the weight came back. Their hearts were essentially no better off than before the trial began.

Back in March, I wrote a blog titled "The Main Reason You Can't Lose Weight is EXACTLY What You Think!," which can be found at http://mdprevent.blogspot.com/2013/03/the-main-cause-of-weight-gain-is-exacty.html.

I think the Look AHEAD study does an admirable, if clearly not intended, job of proving the point that lifestyle interventions that don't include psychosocial counseling are often doomed to fail.

Discussing the mind-body connection is more than new age mumble-jumble. It is the key to good health and those who ignore the connection do so at their own peril.  If you are one of those people who has tried everything possible to lose weight through the mouth and you just can't seem to get a handle on it, maybe it's time to switch your focus to whats going on in your mind. It may change everything.

The Main Reason You Can't Lose Weight is EXACTLY What You Think!

Most businesses hope for repeat customers; weight loss businesses bank on it. Following New Year's, every single year, thousands of resolutions to lose weight are made and broken. If you have dieted once, chances are you have done it many times. You've tried the programs, read the books, watched the shows, took the pills, had the injections, and maybe even spoke to your doctor about your desire to lose weight.

Perhaps, you've even enjoyed some success, only to find yourself slipping again. But despite your best efforts, every time you look in the mirror or get out of a chair, you know you are carrying around more weight than is good for you. You are probably ready to throw your hands up in disgust and give up. Or maybe you will keep watching Dr. Oz hoping that one of his far flung schemes or pill of the day may actually work for you. Don't! The problem of losing weight and keeping it off is clearly a challenging one and difficult predicaments need good solutions. So what's a person to do?

From the inception of MDPrevent, I have believed that psycho-social issues are at the forefront of most people's inability to lose weight and keep it off. Some eat too much or choose the wrong foods because of stress, poor sleep, anxiety, depression, comfort, loneliness, etc. There are many reasons, and sometimes they even combine. Either way, if you don't deal with them, they keep plaguing you.

That's why one of the first professionals I added to my team was a health psychologist. Patients who want to lose weight once and for all find seeing a psychologist trained in such matters to be a godsend. Why? The answer comes from the psychologists themselves.

A new survey of psychologists confirms that dieters should pay attention to the role emotions play in weight gain and loss if they hope to succeed.

According to the American Psychological Association, the survey, conducted by the Consumer Reports National Research Center, queried over 1,300 licensed psychologists about how they dealt with clients’ weight and the challenges of losing weight. The strategies psychologists cited as essential to losing weight and keeping it off, was "understanding and managing the behaviors and emotions related to weight management." The doctors believed this was essential to forty-four percent (44%) of their clients who wanted weight loss. "Survey respondents also cited “emotional eating” (43 percent) as a barrier to weight loss, and included "maintaining a regular exercise schedule" (43 percent) and "making proper food choices in general" (28 percent) as keys to shedding pounds.

In general, gaining self-control over behaviors and emotions related to eating were both key, indicating that the two go together."

Among the 306 respondents who provide weight loss treatment, 92% reported helping a client “address underlying emotional issues related to weight gain.” More than 70 percent identified cognitive therapy, problem-solving and mindfulness as "excellent" or "good" weight loss strategies. In addition, motivational strategies, keeping behavioral records and goal-setting were also important in helping clients to lose weight and keep it off, according to survey results. Cognitive therapy, one of the clinical approaches often used by psychologists, helps people identify and address negative thoughts and emotions that can lead to unhealthy behaviors. "Mindfulness allows thoughts and emotions to come and go without judging them, and instead concentrate on being aware of the moment."

The full survey results are reported in the February 2013 issue of Consumer Reports Magazine.^®

Now clearly, psychologists telling the surveyors that their efforts to ensure their clients keep losing weight is somewhat self-serving, and I would be a ‘doubting Thomas’ myself if I didn't see the difference a psychologist can make. By the way, it’s not just the psychologists with whom I work that make a difference.  I recently sat with a friend from out of state who has enjoyed over a one-hundred pound weight loss. When we sat down to discuss his formula, the secret sauce is that he has been working with a psychologist.  My only concern in listening to him was that some of the foods he was eating to lose weight are not the healthiest.  Also, he would have been better off to consult with a nutritionist or registered dietitian to make sure that he was both losing weight and eating health promoting foods. Not all weight loss is healthy and ultimately what's the point of losing weight only to get sick?

Therefore, I recommend that if you can afford to see both a registered dietitian and a psychologist to lose weight, there is no better combination. If you have Medicare, nutritional consultations for weight loss are 100% covered under a program called Intensive Behavioral Therapy for Obesity if your body mass index (BMI) is above 30.

Last year, MDPrevent was the largest provider of such services in the State of Florida. If you can get to our office in Delray Beach, I welcome you do so (561-807-2561).  If not, consult with your local primary care physician or cardiologist to identify who is offering this service near your home.  Even if you don’t have Medicare, you can still give us a call so we can let you know what your insurance company will cover.

It turns out that the key to losing weight may really be in your head and we can help you use that knowledge to unlock a healthier, higher energy, and more enjoyable life.     

So stop wasting your time and money on programs whose results usually don't last and address once and for all the real problem: your emotional health.

Dr. Oz, Dr. Block and Donuts. Can You Trust Them?

To paraphrase an old English saying, "You can trust a man by the company he keeps." If we accept this notion, then it must also be fair to say a man can be judged trustworthy by considering those in whom they implicitly trust.

On his show last week, Dr. Oz said he "implicitly" trusts Rovenia Brock, a nutritionist with a PhD from Howard University. He made these comments in response to Dr. Brock's statement that it was okay to consume a sweet for breakfast in order to lose weight. She claimed she based her statement on studies that supported her.  In fact, she offered a donut as an example of a sweet that could be consumed and Dr. Oz said he trusted her judgment. (Let's not forget this is the same Dr. Oz who says people should eat regular ice cream. See my previous blog on the topic.)

Before we tackle the question of which study or studies, if any, support this statement, let's analyze the substance of donuts for a moment.  Donuts come in different shapes, sizes, and flavors. There are glazed donuts, cream filled donuts, sugar-coated donuts, etc. Donuts are often fried.  Most donuts have somewhere between 200 and 400 calories with fat often comprising half of the calories. Dr. Brock made no distinction between the type of donut she was recommending and Dr. Oz asked for no clarification. He simply stated he trusted her.

Now let's look at the science.  In the journal Steroids, a paper was published based on research done in Israel that included 193 obese (BMI 32.2±1.0kg/m(2)), sedentary non diabetic adult men and women (47±7years) who were randomized to a low carbohydrate breakfast (LCb) or an isocaloric diet with high carbohydrate and protein breakfast (HCPb). (To read about the study, cut and paste this url: http://www.ncbi.nlm.nih.gov/pubmed/22178258 Meal timing and composition influence ghrelin levels, appetite scores and weight loss maintenance in overweight and obese adults.)

During the study, both groups of subjects consumed the same amount of total daily calories, except one group consumed more calories during breakfast than during other meals. These calories came from both proteins and carbohydrates.  This loading of mixed calories to breakfast resulted in subsequent greater weight loss than those who balanced out calories during the day.

Carbohydrates come in several forms. There are simple and complex carbohydrates and there is soluble and insoluble fiber. A whole grain cereal can be high in both carbohydrates and fiber.  Fiber can be expected to increase a sense of fullness. In fact, a previous study showed that consuming cereal for breakfast results in greater net weight loss. (To read about the study, cut and paste this url: http://www.ncbi.nlm.nih.gov/pubmed/16339127  Dietary intake of whole and refined grain breakfast cereals and weight gain in men.)

So the question is how did Dr. Brock and Dr. Oz make the leap from the Israeli study (which is the only study available to show such results) to declaring on national television that it is okay to consume a donut for breakfast if you want to lose weight.

By the way, at no time did he or she add that doing so required less calorie consumption later in the day. Rather, they implied that doing so would result in less calorie consumption during the day, a fact not supported by the study that required specific adherence to a strict calorie count. The study did show that a larger breakfast with protein and carbohydrates increased satiety for the rest of the day. Wow, imagine that. Eating a big breakfast may make you less hungry later in the day. Where's the news in that? Nevertheless, the study never said you should use fatty donuts as a source of your carbohydrates, so don't.

Furthermore, the researchers did not study what results would be obtained if the breakfast only included protein without carbohydrate. A recent study done in England and published in the European Journal of Nutrition showed that, in fact, consuming protein for breakfast offered more satiety than carbohydrates (in the form of a croissant and orange juice), with ingesting the protein alone resulting in lower subsequent calorie consumption during lunch and dinner. (To read about the study, cut and paste this url: http://www.ncbi.nlm.nih.gov/pubmed/22948783 Variation in the effects of three different breakfast meals on subjective satiety and subsequent intake of energy at lunch and evening meal.)

So why did Dr. Brock and Dr. Oz use donuts as an example.  In my opinion, it's TV ratings, pure and simply.  If they had said you should eat more whole grain cereal as a source of carbohydrate, no one would notice. But say you can eat a donut for breakfast to lose weight and that becomes newsworthy and sensationalistic; people take note.

One can only wonder how many Dr. Oz disciples hastened to follow the show's advice and will now add a donut to their breakfast routine. Poor, misguided souls.

So to answer the question posed in the title, should you trust Dr. Oz and Dr. Brock, I say no. You cannot trust their advice on donuts, and once you can't trust one thing they say, you make the decision regarding what you can trust.

If you want to include carbohydrates in your breakfast meal and want to satisfy your sweet tooth, then include a naturally sweetened, healthy, non-preservative muesli and leave the donuts to mortals foolish enough to take advice from doctors who have sold out to celebrity and TV ratings.

Vitamin D Blood Tests May Be Unreliable--Particularly In Overweight People

As the Vitamin D debate rages on, it seems that practically every day a new related study emerges.

Vitamin D, the reigning health topic du jour, has been linked to cancer, diabetes, obesity, the autism spectrum, unhealthy aging, and a myriad of other health issues--basically everything. (the more illnesses it is linked to, the more pills marketers can sell).

There are many dubious pundits claiming that there is an epidemic of vitamin D deficiency, with some proclaiming that as many as 75% of all people are deficient, and therefore, everyone should be supplementing with Vitamin D tablets, particularly those who get little sun exposure and the elderly.

I don't agree with the statistics regarding the number of people with deficiency because I think the blood tests don't tell the whole story, and a recent study involving obese and non-obese people makes me think I am right. Notice the emphasis on think, not know. (By the way, another recent study revealed that two out of three of the main pieces of equipment used by blood labs to measure Vitamin D often report artificially low numbers.)

Before I get to the main study, here's what everybody seems to agree on in regards to Vitamin D:

1. Vitamin D is a group of fat soluble substance most call a vitamin. (There is some disagreement if it's really a vitamin as the body can produce it on its own, unlike all other vitamins which must be derived from external sources. However, Vitamin D is often called the "sunshine vitamin" because the body can produce it from cholesterol after your skin is exposed to sun.)

2. Human beings can consume two forms of Vitamin D: cholecalciferol (vitamin D₃) or ergocalciferol (vitamin D₂). The liver apparently converts Vitamin D to calcidiol and the kidney converts some of it to the active form called calcitriol. Blood tests measure only calcidiol.

3. Vitamin D deficiency can cause osteomalacia (rickets in children), a disease related to softening of the bones due to problems with bone mineralization.

4. There is more vitamin D stored in fat or adipose tissue than typically circulates in the blood. That makes sense because it is fat-soluble. (There is some disagreement if they are positively or negatively correlated, eg. whether they increase and decrease together.) What is known for sure is that generally the more fat you have, the more Vitamin D is stored in such fat.

5. Routine Vitamin D blood tests only measure circulating Vitamin D (calcidiol) and not fat stored Vitamin D. (There are ways, such as liquid chromatography, to measure fat-stored vitamin D, but they are not part of normal testing.)

6. Obese people have lower levels of circulating and higher levels of fat-stored Vitamin D than non-obese people.  Basically, the more fat you have, the more of your Vitamin D is stored in it and the less you have circulating and easily measurable. (This could explain why some scientists claim there is more Vitamin D deficiency today than ever before. It could be a result of an increasing weight among Americans with 2 out of 3 now deemed overweight and 36% purported to be obese.)

7. Vitamin D blood levels increase with weight loss. (It is not clear what happens to the total amount of fat-stored Vitamin D with weight loss, but presumably it decreases.)

8. Wild fish such as salmon are still a great source of Vitamin D.


Here are the questions whose answers have less agreement, if not outright disagreement.

1. What levels of blood circulating Vitamin D define deficiency and inadequacy?

2. Can the body tap into fat-stored Vitamin D when needed?

3. Why do vitamin D blood levels increase with weight loss?

4. Why do obese people have lower levels of circulating blood Vitamin D?

5. When and how much supplementation is necessary and appropriate for different levels of deficiency or inadequacy.

6. In the absence of deficiency or inadequacy, does extra Vitamin D offer any special protection against cancer, diabetes, heart disease, diabetes, etc.?

The recent study about Vitamin D, I referenced above, showed that in comparing obese young men to normal weight young men, the obese young men when exposed to tanning radiation akin to sun exposure actually seemed to produce 57% less Vitamin D than the non-overweight young men exposed to the same radiation. The results suggest that the obese get less Vitamin D from sun exposure that the non-obese. 

The authors of the study contend that the reason for this result is that the fat or adipose tissue in the obese men may absorb the additional Vitamin D produced.  The authors also put forth the supposition that obese people have less Vitamin D to start with because they spend less time in the sun.

This study triggered an exhaustive research effort by me to better understand the science of how vitamin D moves in and out of fat storage. More specifically, I wondered if one has a high level of Vitamin D in fat storage and a low level in blood circulation, would the Vitamin D come out of storage before a clinically evident deficiency develops. In other words, can you depend on your fat-stored Vitamin D to play a helpful role and prevent deficiency? If your fat-stored vitamin D provides the body with necessary Vitamin D, then we can dispense with all the blood tests for circulating Vitamin D because they would be unreliable indicators of deficiency and inadequacy.

The study, among others, seemed to suggest that the more obese you are, the more of your Vitamin D would go into fat storage and therefore there would be less in blood circulation. This means that the more obese you are, the more Vitamin D deficient you would be on blood measurement. If this would be a true deficency, one would expect to see cases of osteomalcia among the morbidly obese.

Guess what? After reviewing every published study available on pubmed, it was startling that there was not a single case or study reported that demonstrated bone related problems with rising obesity. In fact, it doesn't even seem to lead to osteoporosis, another bone related disease, and in fact, scientists have long believed that obesity protects against osteoporosis.  (Some recent studies out of China that differentiate between obesity based on body mass index versus actual body fat composition suggest that obesity based on high fat composition may not be preventive of osteoporosis.)

Furthermore, the only studies linking osteomalacia to obesity involve obese patients who undergo a surgical procedure to lose weight called the jejunal-ileal bypass. This procedure can sometimes lead to malabsorption, a condition in which the body can't absorb certain nutrients, in which case all kinds of problems and deficiencies become more likely.

This knowledge raises a serious question regarding the validity of the widely used Vitamin D blood test. If the test does not correlate to clinical symptoms, of what value is the test?  When the test shows a low level, is it because it is actually absent throughout the body or because much of it is stored in the fat, thereby undetectable by the blood test?

Although the study postulated, and other studies have also shown, that Vitamin D levels increase with weight loss, allegedly due to more outside exercise and therefore more sun exposure, I offer an alternative theory.  I say theory because I can't support what I suspect is the case because I couldn't find a single study that has considered this issue. Like all theories, it needs to be tested.

I postulate that as body fat shrinks, stored Vitamin D is released into circulation. What I don't know if having more blood circulating versus fat-stored Vitamin D actually makes a health difference? The answer to this question is imperative to know definitively before we compel so many people, particularly the overweight and obese to unnecessarily supplement with Vitamin D for the sole purpose of increasing circulating levels of Vitamin D.

Until the role of fat-stored Vitamin D is elucidated, I think most of the rest of the studies on Vitamin D will be essentially meaningless because you aren't measuring all the Vitamin D in the body.

For example, another study showed that there is an increased incidence of developing metabolic syndrome and a larger waist circumference after five years in patients with low blood Vitamin D.

My questions, which this study did not fully answer, are did they really have low total body Vitamin D or was it low in the blood because most of it was stored in fat. Also, did the low Vitamin D levels put them at greater risk because they were already overweight and/or pre-diabetic or because they had low sun exposure and poor dietary intake?  Finally, does low Vitamin D cause problems or indicate they already exist?

Perhaps it is not the Vitamin D blood level that matters but the presence of excess fat? Perhaps it is the excess Vitamin D that is stored in the fat that is causing the problems? We must know more about the role and activity of the fat-stored Vitamin D to answer these questions.

Maybe Vitamin D is a proxy for something else. It won't be the first time in medicine that we discovered that something was not what we thought it was. For example, we thought ulcers were caused by stress and it turned out to be mostly bacteria infections. We thought homocysteine controlled heart disease and it turned out to be only a bio-marker. We thought taking beta-carotene would prevent cancer, but it turned out that to be just the opposite. We thought statins were great for us...wait, many, but fewer still think that but maybe that will change some day as well.

From my perspective, I will no longer be recommending, in the absence of symptoms, Vitamin D supplementation for levels above 25 in overweight and obese patients. I will however, continue to strongly recommend (and offer extensive support to) overweight people to help them lose weight, not only for the sake of increasing their Vitamin D levels, but also for all the other health benefits such weight loss confers.

Also, for those without history of skin cancer, I continue to advocate for at least 15 minutes per day of sun exposure to extremities or belly, as long as reddening of the skin is avoided. Based on my current knowledge, this appears to beat supplementation almost every time, even in the elderly.

Vitamin D is obviously a complicated issue that begs for real clarity. Major studies are underway which may offer some real answers.  However, if they don't consider the role of fat-stored Vitamin D, they may actually be of little value. Let's hope for the some good answers and in the interim, try to stay healthy the old fashioned way- get up, get out, and move around.  Of course, watch what you eat because it is still the single most important determinant of health.

A Vitamin D Study Worth Ignoring and Good News at MDPrevent

It seems like everyone wants in on the Vitamin D hoopla. A study published in Mongolia (not sure if it's Outer Mongolia-the place many often refer to as a wasteland) shows that children who increase their Vitamin D levels suffer fewer cold symptoms. The only problem is that it only works with children who are Vitamin D deficient due to lack of sun during their winter (maybe it is Outer Mongolia).

There is no one, including me, that will argue that the body needs Vitamin D and without an ample supply your body will not function properly. And by not function, that includes an immune system incapable of warding off even the simple and ubiquitous cold virus. But the real debate is what defines a clinical relevant deficiency and what's the best way to treat it. I vote sun, wild Salmon, and almond milk in that order over supplements. Nevertheless, while the question of deficiency still begs an answer, with all the studies now underway, I hope the question won't stay unanswered for long. For the moment, I encourage patients to consciously raise their levels if it is below 30.

On another note, it's turned out to be an unexpectedly busy summer. Without warning, MDPrevent is suddenly inundated with patients wanting access to our medical care, particularly our weight loss and diabetes education services. Word of mouth has generated excitement about our drug-free, fully paid for by Medicare approach to successful weight loss. Even doctors such as cardiologists and endocrinologists we've never met are now referring patients to us because they are witnessing first-hand the weight loss success their other patients are enjoying.  It's both exhilarating and exhausting at the same time. It's actually getting tough to schedule new patients.

Why is it working? What have we discovered that seems to elude others? The answer is simple. Teamwork. Our program combines the skills of a physician, a registered dietitian, and a clinical psychologist. Each of us works in unison to guide, encourage, and cheer each patient on. The result is that patients are steadily losing weight, lowering cholesterol, and starting to enjoy their former selves again.

For those of you who have referred friends, relatives, and neighbors, we say thank you. I suspect so do the people you referred.

Finally, someone asked me the other day if I enjoy what I do. I said of course because what can be more gratifying than seeing people turn their lives around and feel in control again for the first time in many years!  It really does feel good to do good!

I hope you all have a wonderful and relaxing Labor Day weekend.
 

The Only Thing I Know For Sure Is That We Need To Keep Learning

About 30 years ago, I read an article about agriculture that had a profound impact on my thinking. The article was about soil erosion and basically stated that what had long been considered an incontrovertible truth about how to avoid soil erosion turned out to be the exact opposite. The idea that something held as an absolute truth could prove to be absolutely wrong has given me pause to think about such 'truths' to this day.

Thirty years later, a new study about exercise emerges that reminds me of what we consider absolute truths may not be so. For as long as I can remember, exercise has been associated with increasing your metabolism. It's been widely believed that exercise contributes to weight loss by burning calories and increasing your metabolism, which is believed to keep revving and burning calories even during the cool down phase.  While certain people argued that exercise was not an effective way to lose weight because they were unsuccessful losing weight despite much exercise, it was still a tenet of the weight loss movement. For example, Weight Watchers allows you to add extra "points" based on the amount of exercise you do.

The new study, which is a wonderful study, titled Hunter-Gatherer Energetics and Human Obesity, (http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0040503) studied the Hadza tribe of hunter-gatherers in Tanzania. Strapping members of the tribe with a GPS device and having them swallow so-called doubly labeled water, a liquid in which the normal hydrogen and oxygen molecules have been replaced with versions containing tracers, researchers were able to quantify their levels of physical activity, energy expenditures and metabolic rates. What they discovered is groundbreaking!

The study showed that contrary to popular belief, exercise slows down one's metabolic rate so that calories burned are actually far less than expected.  What's amazing is that this is intuitive and yet for so long everyone believed otherwise. Think about it for a moment. If your body doesn't eat for several hours, we think (I'm now officially afraid to say anything for certain any more; well, maybe some things) your metabolic rate slows down as your body tries to conserve energy, as it doesn't know when energy will be replenished. Applying that same principle to exercise, when the body senses a loss of energy consumed by increased activity, it makes sense that it will slow down its burn rate to conserve energy.

This doesn't mean that you aren't burning calories and you can't lose weight by exercising. It simply means that you burn less than you think, which means don't think you can eat a lot more because you had a good exercise session.

By now you couch potatoes are turning to your spouses or friends and smugly telling them you were right all along about exercise. Well not so fast.  Exercise is still critical to good heart and brain health. Exercise keeps the heart functioning well and exercise has been shown to be as effective as anti-depressants in treating many cases of mild to moderate depression. But that's not all. Two new studies published online in the Archives of Internal Medicine support the tremendous impact of exercise on lowering the risk of death among diabetic patients, and that weight training may reduce the risk for the disease even without aerobic activity.

Quoting medpagetoday.com, "In a large prospective trial, moderately active patients with diabetes had a lower risk of total mortality compared with those who were completely inactive...according to Diewertje Sluik, MSc, of the German Institute of Human Nutrition in Potsdam, and colleagues. And in a separate prospective study, men who did weight training only at least 150 minutes per week had a 34% lower risk of developing diabetes to begin with ...according to Frank Hu, MD, PhD, of the Harvard School of Public Health in Boston, and colleagues."

I also previously wrote about a study that shows that exercise can return the inflexible blood vessels of pre-diabetics to normal as well.

So while exercise is not the great weight loss panacea it was once thought to be, it is still a critical component of a healthy lifestyle. Keep exercising, but more importantly, if you want to stay slim or lose weight avoid the four whites--white sugar, white flour, white pasta, and white rice. If you watched 60 Minutes this past Sunday, you now know that some scientists view sugar as toxic and cancer causing. Just another good reason to choose whole foods like fruits, vegetables, nuts, beans, and whole grains. And of course, don't forget my favorite, Wild Salmon.  Bon appetite!

What A Difference A Day Makes

Over the past few months, the big health related news was the Institute of Medicine's report regarding the increasing percentage of obese Americans. The expected increased girth of the nation raised alarms because of all the other medical problems that are likely to ensue.  Unfortunately, we will not have to wait because a new medical report by Virginia Fried and colleagues was just released by the U.S. National Center for Health Statistics, part of the U.S. Centers for Disease Control and Prevention. The report titled, NCHS Data Brief, "Multiple Chronic Conditions Among Adults Aged 45 and Over: Trends Over the Past 10 Years," is truly frightening. 

According to new research, between 1999-2000 and 2009-2010, the number of Americans aged 45 and older with two or more chronic conditions has grown, with senior citizens especially at risk of developing both diabetes and high blood pressure. The study reveals that the percentage of Americans in the 45 to 64 year age group with two or more of the conditions grew from 16 percent to 21 percent and in the 65 and older age group, the percentage increased from 37 percent to 45 percent.

The report also revealed that 23 percent of adults aged 45 to 64 with at least two chronic conditions -- out of the list of nine -- either didn't receive necessary medical care or delayed it because of cost. That's up from 17 percent a decade earlier. The percentage of people in that group who didn't get necessary prescription drugs due to cost also grew from 14 percent to 22 percent over the period. Isolating individual conditions in people aged 45 or older, high blood pressure grew from 35 percent to 41 percent, diabetes from 10 percent to 15 percent, and cancer from 9 percent to 11 percent.

The most troubling part is that these numbers are expected to get even worse.  But I have reason for hope because of someone I spent time with today.

I met with a patient of MDPrevent today who has been participating in our LEAN Weight Loss program.  Prior to starting the program, her cholesterol was about 230, her fasting blood sugar was around 120, and her body mass index (BMI) was over 30. In the span of a few months, she has shed 16 pounds, dropped her BMI to 27.5, dropped her cholesterol to the 160s, and her fasting blood sugar to around 105. She accomplished this without any medications, surgery or supplements. She did it simply by changing the way she eats based on what she learned in our program. The best news is that her program was covered 100% by Medicare so it didn't cost her a penny.

Starting a new practice over the past couple of years has had its challenges. However, today it all came together when I witnessed first-hand again what a profound effect a change in lifestyle can have on someone's health. I am so proud to be part of such an effort and take great satisfaction in knowing that our team of Preventioneers are truly making a difference one life at a time. The best news is that our program is covered 100% by Medicare for those who qualify.

Is Obesity A Problem?

You probably think you know the answer to this question. From a medical perspective, your answer probably evolves around the fact that obesity leads to the development of chronic diseases such as diabetes, heart disease, cancer, dementia, arthritis, etc. These diseases lead to costly medical care which still leads to premature death. That sounds like a problem.

Well, based on a new study from the University of California Davis published in the Journal of the American Board of Family Medicine, you may be wrong. The study, which tracked 50,994 Americans between the ages of 19 and 90 for a total of six years, suggests that obesity itself may not be a harbinger of impending death; rather, hypertension and type 2 diabetes, which are often associated with obesity, are what leads to an early meeting with the grim reaper.

You may ask isn't that a question of semantics? Aren't obesity, diabetes, and hypertension so closely related that they may be considered one and the same? Isn't diabesity, as some call it, the right name for it? The answer may surprise you.

The study showed that obese people without these conditions were no more likely to die than non-obese people, and non-obese people with these conditions were more likely to die than obese people without them. So it's not weight per se that kills you, but the diseases that often, but not always, accompany excess weight.

In fact, in my practice I have seen many people who did not suffer from a weight problem, but were still struggling with diabetes. Well, that seems to make sense because weight itself is not the main factor in the development of diabetes and some people who are naturally heavier than others, still seem to enjoy good health.  (I remember many years ago when I worked in a summer sleep-away camp that there was a rather heavy young man that was an incredible athlete. He moved faster and stronger than most of his leaner peers. One would be hard pressed to say that he was unhealthy.) 

Nonetheless, this California study is consistent with a new movement that advocates HAES, which stands for Healthy At Every Size. The HAES camp believes that your health is more important than your size or body mass index (BMI) and I agree.

From the inception of MDPrevent, I have been telling patients not to focus on their weight loss; rather, I have been teaching, begging, exhorting, cajoling, and a number of other words ending in 'ing' to improve their health by eating certain foods and avoiding others, by staying more physically active all day long, by taking steps to ensure a good night's rest, and by developing strategies to manage stress effectively. My lectures often also focus on the need for a strong social network, the benefits of engagement and purpose, and the value of surrounding yourself with like-minded individuals. So, yes, one study doesn't prove anything, but it's not the first study to show the wisdom of focusing on your health and not your weight.

So now you may be thinking that obesity is not a problem, but you would be wrong. Obesity is still often associated with the predominance of chronic disease development. Even in the Albert Einstein College of Medicine study that identified Eastern European Jews who seem to have a longevity gene and who claimed to eat whatever they want, the results showed that those who survived into their 90s were almost always lean. Perhaps they had a genetic predisposition to being lean, but again, lean won almost every time.

I think the most serious reason obesity is a problem is because we don't as a society really seem to understand it. Quite frankly, my head is spinning from reading all the studies and books that purport to have defined, if not offered the perfect solution, to the problem. The list is almost endless.

Here's my abridged version of solutions offered (not saying they work or don't work; just listing to make a point):

Don't eat processed foods that contain white sugar and flour, avoid almost all carbs even the complex ones in fruits, eat more proteins, be a Vegan, eat more meat, drink more dairy, avoid saturated fats, avoid gluten, drink more water, balance your energy intake and output, don't live near fast food restaurants, eat more smaller meals, snack, don't snack, use small plates, eat breakfast within 30 minutes of waking up, don't eat breakfast until after you exercise, don't eat past seven at night, take dietary supplements that speed up metabolism, avoid anything other natural foods, stay physically active all day, go to Weight Watchers, follow the Adkin's diet, the South Beach Diet, the Zone Diet, the Cookie Diet, the grapefruit diet and countless other diets, take HCG and other appetite suppressants, take medications like Orlistat or Tenuate, have lap-band or stomach bypass surgery, etc.

Yes, there are quite a number of pundits that feel they have the solution, and that's a huge problem. Given so many choices, analysis paralysis sets in and we end up doing nothing or a little of this and a little of that, and that my friend is what I think is the biggest problem with obesity.

At this point, after reading countless books, articles, and studies, watching documentaries, attending conferences,  speaking to thought leaders, and working with patients, my solution is simple. Pick something that you think you can live with that has at least some decent science supporting it and STICK WITH IT. Getting healthy and losing weight takes time to do it right. It takes effort and concentration and it doesn't happen overnight. For many it will be a life-long struggle. Sacrifices will have to be made. Favorite foods may need to be given up perhaps forever. Trade-offs will be made and battle-lines drawn. That's the reality of the situation for most and I challenge anyone to prove otherwise.

If you need support, get it. If you are a do-it-on-your-own type of person, that's fine, but have a plan and follow it religiously.

If you are looking for some direction and/or insight, here's my suggestions: avoid processed foods, stay active during as much of the day as possible, drink fluids to keep your urine a pale yellow, don't take any pills you don't absolutely need to take, make fruits, vegetables, beans, nuts, and whole grains the bulk of your diet, eat some wild salmon at least 2-3 times a week, get at least 7 hours sleep a night, learn how to manage stress better, nurture relationships, and find something that gives you pleasure to engage in consistently both physically and mentally.

If you follow this advice, I can't promise what weight, if any, you will lose, but I'm pretty sure you will be healthier than you are now. In the final analysis, I hope you agree that being healthy is the most important goal.

Busting Myths: Does Dr. Oz Have A Monopoly?

Yesterday, I wrote about Dr. Oz's suggestion to snack with up to 200 calories two hours before eating your dinner in order to lose weight. There seemed to be no good logic to doing so. Imagine my surprise when today I get an email from RealAge.com, which is at least partially owned by Dr. Oz (see http://www.realage.com/press-release-sharecare) with the headline, "3 New Weight Loss Myths Busted."

Here is my favorite myth the article clams to bust.

"Myth 1: Eat five mini meals throughout the day.
The initial idea was to eat small, healthy amounts of food every couple of hours to keep blood sugar levels steady and energy high. The trouble is, many people end up eating what amounts to five full meals. "I find that people do much better when they sit down and have three balanced meals a day with two small snacks in between," says nutrition counselor Katherine Tallmadge, MA, RD. "Real meals stave off hunger. If you eat tiny bits throughout the day, you're hungry all the time."

This is diametrically opposed and mutually exclusive to Dr. Oz's concept of eating a small meal, which he calls a 200 calorie snack, two hours before dinner. Which is it? He probably doesn't even know, but busting myths seems to be one of his favorite concepts on his show. It's as if he has a monopoly on doing so. However, I never thought that in the span of one week, I would see him connected to both creating and busting a myth.

Here is another myth supposedly debunked by the article.

Myth 2: Eat less by using small plates. Studies have shown that large plates lead to more eating because they make portions look smaller, but the small-plates idea only works if there's a limited amount of food to put on the plate. In a recent diet study at Texas Christian University in Fort Worth, Texas, 10 overweight and 10 normal-weight women were randomly assigned a large or small plate for eating lunch on two different days, then allowed to serve themselves. The result? The ladies ate until they were full, regardless of plate size. "Make what you need, or measure the amount before putting it on a plate, then put things away," recommends Tallmadge, who was not involved in the study. "It's having easy access to food that keeps you eating more."

Contrary to what RealAge would have you believe, there is actually science that confirms the small plate approach to weight loss. See http://smallplatemovement.org/doc/big_portions.pdf for a review of the science. Brain Wainsink of Cornell University is one of the leading food investigators in the U.S. After reading his book, Mindless Eating, I am more inclined to trust his studies over the new study. I also know it works because it worked for me. I switched from a larger to a smaller bowl for my breakfast and never missed a beat on my way to a 20+ pound weight loss. Either way, with the conflicting study results, I hope you agree that this does not fall into the myth-busting category; however, it should fall into the sensationalistic headline one.

Here's a quote from Dr. Oz's website under the title "5 Diet Myths Making You Gain Weight" about the small plate issue:

"Dieters have been advised to eat from smaller plates in order to limit the amount they eat. Why? Because smaller plates make regular portions look larger. However, new research published in the Journal of Human Nutrition and Dietetics found that plate size had no impact on the calorie consumption of either normal weight or obese individuals. Despite these findings, Dr. Oz still recommends using small plates to help guide you in terms of how much you eat. But use them the right way – a small plate is not an excuse to pile on food vertically or go back for seconds."

So what are we expected to trust? The Dr. Oz Show or a website Dr. Oz has ownership in?


The third myth the article purports to bust is "it doesn't matter what meal plan you're on because you'll lose weight as long as you stick to it." Really, any food you eat as long as you stick to it will help you lose weight? The study the article referenced used 5 specific plans. There is definitely more than one way to lose weight, but the meal plan (and total number of calories) will always matter.

It is because of articles such as this one and the Dr. Oz Show that there is so much confusion out there that allows anyone to claim he or she is busting a myth. Besides, I caution trusting anyone that constantly claims they are a myth-buster. Wouldn't it be better if shows and websites just presented the science in layperson's terms and let intelligent people make the decision on their own. I think so. Do you agree?

Ignore Dr. Oz on Sage Leaf Tea and Alpha Lipoic Acid

Contrary to what some may think, I don’t enjoy blogging about Dr. Oz.  Why? It requires a lot of effort to identify the facts and if I don’t exert the effort, I am ultimately no better than him with his inaccurate proclamations.  Having written about the good doctor ad nauseum, I had planned to ignore his most recent show called "Snack Attack: Eat More and Weigh Less" this past Friday that originally aired February 17, 2012.   

As fate would have it, one of my guests at Friday night dinner asked me about the show and specifically about the Sage Tea he recommended to lose weight.  My short respite from analyzing the products Dr. Oz recommends was over.

So here we go again. The episode started with Dr. Oz claiming that “recent studies prove that snacking on the right foods at the right time can turn your body into a fat-burning machine.” He then went on to present that eating certain snacks of 200 calories or less two hours before dinner will result in less food consumed at dinner. One of those snacks he presented included prosciutto, a cured ham, which he recommended wrapping around 2% mozzarella cheese, and adding 2 olives, 1 cup zucchini, and 1/4 cup chickpeas.

I’d like to see a study that showed that eating prosciutto and mozzarella cheese two hours before dinner helps you lose weight. I highly doubt it. What do you think? He also states on his website in reference to this episode that “Get your metabolism going with a pre-dinner snack, 1-2 hours before your main meal. Doing so will help you stop eating once you're full, which is sometimes hard to do.” Why would snacking help you stop eating when you are full if eating non-snack food often doesn’t do that?  Enough said.

Of course, he also recommended a product—in this case a cup of Sage Leaf Tea--as a way to lose weight. After a few hours of research, including pubmed.com, Cochrane.org, naturalstandard.com, and infopoems.com, I could only find one reference to the use of Sage Tea for anything whatsoever related to weight.

It was a study titled “Antihyperlipidemic effects of Salvia officinalis L. leaf extract in patients with hyperlipidemia: a randomized double-blind placebo-controlled clinical trial.” This single study involving a whole 67 people showed that Sage Leaf may be useful in decreasing lipids. Mind you, that doesn’t mean losing weight. 

By the way, where do you think the study was done. Wait for it, here it comes—Iran.  Yes, that’s right--The People’s Republic of Iran, that bastion of scientific integrity known for its war-mongering, terrorist-supporting, Holocaust-denying oppressive government. Now that’s a source of a study I’m not sure anyone should rely upon.  There was not a single additional scientific reference to the use of Sage Leaf tea for weight loss, metabolism booster, etc. that I could find.

But Dr. Oz wasn’t done for the day pushing pills.  He then recommended 200 mg. Alpha-Lipoic Acid (ALA) as another weight loss aid.  Now here’s where it gets good. 

Like with Sage Leaf, I began an intensive search and here’s what I found--a South Korean study titled, “Effects of Alpha-Lipoic Acid on Body Weight in Obese Subjects” published in early 2011, that stated to the authors’ knowledge, “this is the first study to show that alphalipoic acid treatment led to a significant weight reduction in obese human subjects.” There appears to be no published study since, so this seems to be the first and only study of its kind. 

Second, the study initially involved 360 obese subjects (of which about 1/3 dropped out for different reasons including adverse side effects) consuming 1,800 mg (9 times the dose recommended by Dr. Oz).  

After 20 weeks of treatment with 1800 mg per day of alpha-lipoic acid, the results showed “modest but statistically significant reductions in body weight and BMI.” How much weight did they lose after 20 weeks of 9 times the dose recommended by Dr. Oz? They lost 1.8% of their weight. In a two hundred pound person that would be 3.6 pounds.  At 1,200 mg (or six times the Dr. Oz’s recommended dose) the weight loss was even less at about 2 pounds for a 200 pound person.

For full disclosure, there was another study, published in 2010, for which I could only access the abstract titled, “Alpha-lipoic acid supplementation: a tool for obesity therapy?” The conclusion of this Italian study according to the authors was “Our study indicated that LA is an ideal antioxidant candidate for the therapy of obesity related diseases. Further clinical studies should be considered to highlight the role and efficacy of LA treatment.” However, this was not a double-blind randomized controlled study and no data on caloric intake was given. By the way, they consumed 800 mg, or 4 times the dose recommended by Dr. Oz. Apparently, the South Koreans discounted this study as well based on their statement that they had performed the first study on the effects of ALA on weight loss.

Need I say more? Dr. Oz has little scientific basis (and for that matter, no business) recommending such a product at a dose that has no valid and conclusive scientific evidence to support his recommendations.

Of course, that never seems to stop him and it didn’t here.