Is Fat the new Thin?

JAMA just published a meta-analysis that the media has been reporting with headlines like "Thin is In, but Fat is Better."  I hate how the media treats meta-analyses as "proof" of something.  To me, a meta-analysis can cue us in on something that needs more study, but not prove that a slightly high BMI offers some sort of protective effect.

The study authors analyzed nearly 100 studies that included more than 2.8 million people. The researchers found that obese people (particularly when BMI was over 35) had a higher all cause incidence of death than normal weight people. However, slightly overweight people (with a BMI of 25 to 30) had a lower risk of dying than people of normal weight.

The idea of body mass index and prediction of mortality risks has been tossed around medicine forever.  It's commonly told to new interns and medical students that thin patients do worse after surgery, for example, than those that are slightly overweight.  I remember being told in rounds that seniors who are slightly overweight live longer than normal weight ones, as if it were a fact.  Intuitively, that makes sense.  If you have extra weight, you have more reserves when you get sick than someone who doesn't.  Oftentimes, thin seniors are malnourished and not physically active.  Those factors lead to increased mortality, and complications.


It's also true that overweight people tend to get more tests and check-ups than thin people.  Even doctors sometimes look at thin people and assume they're healthy, whereas the overweight person would probably get panels of blood tests and an EKG.  That would catch things earlier. The overweight  person with high blood pressure and cholesterol might be on life prolonging-drugs before the normal weight person with the same problems.

JAMA has an interesting commentary about the article that says that it used to be assumed that lifespan was the longest when body weight was maintained at the same level as a 25-year old with similar height and frame size.  Should we compare ourselves to our 25-year old selves?  If you've always been larger, does it confer you with some sort of protective effect?  Are some people's metabolism setup to be healthier at a larger size?  Would losing weight actually increase mortality in some?

I don't think the JAMA article answers any of these questions, but it does question the current dogma that the ultimate goal for our health is to be thin.  What I really think needs to be said is that extremes of anything are bad.  Being "thin" can be just as bad as being "fat" if you take it to extremes.  Exercising too much can be just as bad as not exercising at all.  Eating too little can be just as bad as eating too much.

People make snap judgements based on weight.  That heavy person must sit on their butt all day and eat chips and ice cream.  That thin person must be hitting the gym everyday and living clean.    These assumptions, that thin is fit and fat is not, are not always true.  If only obesity were that easy to cure. Unfortunately, the human body is complex and I don't even think we really understand all the elements that lead to obesity, health and fitness yet.  That slightly overweight person might be the one hitting the gym everyday and eating healthy, whole foods.  The thin one could be living off mountain dew and pop-tarts. You really never know.

Is it Possible to Eat Out Healthily?

Panera Bread

Today, my mom wanted to go out to eat.  She wanted to go have Mexican food.  I don't like to be jailed by my diet, so I decided to go and try to eat as low carb as possible.  She agreed that we'd just have one "good" thing.  Her favorite food is cheese enchiladas.  We looked at the nutritional info for the place we wanted to go.  They aren't too bad.  They're about 20 carbs each.  Rice is about 50 carbs and beans are 30 carbs.  We both decided to forgo the rice and beans and have a salad (the house salad was 20 carbs).  She had two enchiladas and I had 2 soft veggie tacos (they were 80 carbs, ridiculous.  The carb count was mostly from the tortillas).  We also decided to have a few chips, but not eat the whole bowl like we normally do when we go out.  Overall I think we did well. 

It's almost impossible to be vegetarian and eat out healthy in a normal restaurant.  Most of the vegetarian choices are pasta, bread or rice dishes.  Most of those have almost no protein in them.  Most of the servings are so big, they are probably 2 days worth of carbs.

I used to eat at Panera Bread a lot, because a sandwich seemed healthy.  It's not really much better than my Mexican meal.  What I normally eat at a Mexican restaurant would be the two tacos, rice and beans: 160 carbs.  At Panera, I used to get soup (instead of chips) and a sandwich. The mozzarella and tomato ciabatta is one of my faves: 96 carbs.  A small bowl of the low fat garden vegetable soup is 10 carbs.  Together, that's 106 carbs.  There's a big difference between 106 and 160, but both are way too high (my mom's Mexican dinner would be only 120 with beans and rice).  Panera's chips are 23 grams of carbs, by the way. Soup is a smart sub.  I should have just eaten the soup.

For those of you thinking the panini press adds carbs, another favorite of mine is a plain sandwich: Mediterranean veggie on tomato basil bread.  It's also 96 carbs.  Seems that's the only number they know for vegetarians.

The Olive Garden, famous for being high calorie and artery clogging, isn't much worse for your diet than Panera Bread.  If you got the lunch portion of fettuccine Alfredo (and skipped the bread, salad, etc. Yeah right), it would only be 125 carbs.  Remember the sandwich? It's 96 carbs.  That's not really that much of a difference.  My two tacos were 80 carbs, and not nearly as filling as a whole serving of fettuccine.

The worst item on the Mexican food menu was a chicken burrito: 173 grams of carbs (without the beans and rice).  I imagine that's a massive burrito.  The item they claimed to be the healthiest on their menu was also chicken, it was "only" 60 grams of carbs for the entire meal.  It's not served with beans and rice, just steamed vegetables.   Panera's healthiest sandwiches are 64 grams of carbs each: Turkey on three cheese bread and Asiago Roast Beef on Asiago cheese bread.

Most of the time, vegetarians are stuck with a salad.  The Mexican place had a range from 23 grams of carbs for a fajita salad to 80 grams of carbs for a taco salad (and the house salad was the only vegetarian salad at 20 grams).  The fajita salad is not a bad choice for meat eaters.  Panera ranged from 11 grams of carbs for a chicken cobb salad to 50 grams of carbs for a BBQ chopped chicken salad.  Not bad.  A couple of vegetarian salads are in the 12-14 range.

My point isn't that we should never eat out, though maybe it should be.  If you're vegetarian trying to keep your carb count down, you're probably going to be stuck munching on a salad  Our carnivore friends have just as much trouble if sticking to the menu.  At a Mexican place, ordering fajitas or tacos without the tortilla and skipping the chips would cut you carbs down.  You could order a sandwich without the bread or just stick with a soup at the deli.

What I'm really trying to say is that I think we've all gotten a perverse sense of what is "healthy."  I used to eat Panera everyday in school, because I figured it was the healthiest thing in the food court, if I avoided the pastry.  My mom even mentioned maybe going to a deli because it's "healthier" today.    It's really not.  Fries (33 grams per serving and McDs) and mozzarella sticks (40 grams per serving at Sonic) would have been just as healthy as a deli meal. 

I'm being a little facetious.  If you've read any of my earlier posts, you know I believe there is more to food than just carbs and just chasing the "low carb" meal as the answer is a bit misleading.  It's hard for me to seriously claim that over-processed, over salted fries are better than a tomato sandwich.  On the other hand, I can't claim the sandwich is "healthy" either.  It has better ingredients.  It actually has a real live vegetable in it and their bread is often more toothsome than McDonald's buns, but that's about the end of it's praise.

Why haven't we vilified the deli sandwich like we have the burger and fries?  I've avoided fettuccine Alfredo most of my life because of the "heart attack on a plate" moniker, yet I'd happily eat fettuccine noodles and marinara (and deli sandwiches for lunch).  I'm sure I'm not the only one.

What this country needs is not more of the "eat less, move more" rhetoric, but a sea change in deciding what is healthy and what isn't.  That's the only way to combat the obesity epidemic.   It really says something that I'm often still surprised when I read a label, even after I've studied nutrition in  courses aimed at MDs, PharmDs and nutritionists, after I read all the nutritional studies and even the pop science I can about why and how we eat.  I'm still surprised at how often sugar and high-fructose corn syrup are slipped into things.

I bought some frozen sweet potatoes fries the other day. Sweet potatoes are great for you.  They're naturally sweet, but full of vitamins, minerals and fiber.  You know what?  They put sugar and high fructose corn syrup in the sweet potatoes. Why?!  It just always astonishes me.

My mantra (which I think is partially stolen from Michael Pollen): Whole food.  Nothing from a box.  Eat at home more often than you eat out.