A Healthy Diet

What is a healthy diet? The question assumes more and more importance as evidence points to a deterioration in the overall American diet and also points more and more strongly towards diet as a potentially modifiable risk factor for depression.

We have recently updated this page to add information from the PURE study (see below).

Bad Fat

We need to cut down on hydrogenated fats that are found in many of the fast foods that we love so much. Hydrogenated fats and (perhaps) saturated fats are strongly associated with heart and circulatory diseases that can lead to early dementia and strokes. A recent study has called into question the long-standing recommendation to reduce saturated fat intake ( see Mahshid Dehghan, et al, in references)

Good Fat

The good news is that we can eat more monounsaturated fats (olive oil, canola, walnut, soybean and, especially, flax seed oil), and we definitely need to eat more omega-3 fatty acids (see below). In fact, the largest study to date on the relationship between diet and mortality suggests that increasing fat intake (as compared with carbohydrate intake) may be helpful for some people. The researchers found those in the highest quintile of carbohydrate intake had higher total-mortality risks than those in the lowest. Conversely, those with the highest total fat intakes showed lower mortality risks than those in the lowest quintile.

What to Do About Cholesterol

A lot of the concern about saturated fat has focused on effects on cholesterol and, as a result, the effects of a diet high in saturated fat on heart disease. While not, strictly speaking, relevant to the topic of weight loss, we thought we would provide you a link to information about an effective and natural approach to lowering cholesterol through diet. For more information.

Simple Carbohydrates

Refined sugar and refined flour seem to be linked to weight gain. The Atkins diet focuses on reducing carbohydrates and is quite effective at inducing weight loss (less effective at maintaining it).

Complex Carbohydrates

On the other hand, whole grains (except for whole wheat, which isn’t much better than plain flour) are not only healthy but a good source of fiber and B vitamins. You can eat more rye, brown rice, bulgur and other whole grains.

Eat Your Fruits and Vegetables

Mom was right. Fruits and vegetables are the foundation of a healthy diet. They are the most important natural source of agents that combat the damage of oxidation. A healthy diet should be a colorful diet, if you eat red, green and orange or yellow fruits and vegetables every day you are likely to get plenty of natural anti-oxidants that will reduce your risk of heart disease and cancer. Moreover, since these foods are high in fiber, they tend to make you feel full even when you haven’t eaten many calories. Finally, the largest epidemiological study of diet, as reported by Miller, et al, argues that increasing raw vegetable intake is the most effective way of improving overall mortality.

The Mediterranean Diet

A recent study from Greece, the country that originally provided the strongest evidence for the benefits of the Mediterranean diet has highlighted the value of such a diet and clarified what the essential components of that diet are. Researchers followed more than 22,000 healthy Greeks for an average of 4 years and found that those eating the traditional Mediterranean diet were not only 33% less likely to die from coronary artery disease than Greeks eating other foods, but also 24% less likely to die from cancer. Overall they had a 25% lower death rate. The main elements of the diet: an abundance of plant foods such as fruits, vegetables, whole grains, nuts and beans, olive oil as the main fat, instead of butter, small to moderate amounts of fish and poultry and little red meat, and moderate consumption of wine. No one part of the diet was responsible for the effect, it was the combination of all of the elements that seemed to make the difference.

Drink Your Milk

A promising set of studies suggest that calcium, especially calcium from milk products, may be associated with weight loss success, or with keeping weight off after you have lost it. These studies were conducted at Purdue University and found that higher calcium intake was associated with significantly greater weight loss in those on weight loss diets (4 pounds more on average). The studies found benefits from 1,000 to 1,500 mg daily, which is what we get in a balanced diet that includes three servings of dairy products or calcium-fortified foods a day. Obviously, dairy products need to be low or non-fat if they are going to have this effect. For information about supplements.

Too Much of a Good Thing

Many of us are trying to lose weight. There is now evidence that weight gain for depressed patients may be not only a psychological but also a biological factor worsening depression. However, that doesn’t really answer the question: what do we do? Most of us already knew that we should lose weight, and more guilt doesn’t help.

One very interesting approach is to try to bring some order to our eating, which alternates between indulgence and starvation. Geneen Roth, in her book, Why Weight? A Guide to Ending Compulsive Eating , argues that we can sanely and carefully lose weight if we pay attention to how we eat. She has seven rules that are worth attending to carefully:

  1. Eat when you are hungry
  2. Eat sitting in a calm environment
  3. Eat without distractions
  4. Eat only what you want
  5. Eat until you are satisfied
  6. Eat with the intention of being in full view of others
  7. Eat with enjoyment, pleasure and gusto.

Frankly, we like her psychological approach to the problems of over-eating. A lot of why we overeat is learned behavior. However, if you are more inclined to think about traditional approaches, we find that it is helpful to divide this topic into two parts: losing weight, and keeping the weight off.

Losing Weight

You won’t be surprised to hear that losing the weight is the easier part. There are many ways of losing weight that are effective. Many people now report that the Atkins diet, or something like it (low simple carbohydrates, higher protein, relatively liberal fat intake) is effective. This may be because it induces a state called ketosis, which is a state of starvation that tends not to be associated with too much hunger. One recent study comparing the Atkins, Ornish (very low fat), Weight Watchers (restricted calorie) and Zone (macronutrient balance and low glycemic load) diets found that all four were effective in reducing heart disease and causing weight loss. The most important issue was how well and how long people stayed on the diet… thus it may make sense to try different approaches to find the one that seems the most sustainable.

Another study looked at the comparison of a low fat diet (like the Ornish), a low carbohydrate diet (like the Atkins) and the traditional diet of people living in the Mediterranean (which we will describe a bit more below ). This study followed a large number of people for two years and is one of the best studies comparing diets. It found that all three diets were effective. The low carbohydrate diet showed the most early weight loss, but also had the most regained weight (which is consistent with other studies and our experience). The low fat diet had the least overall weight loss. The low carbohydrate and Mediterranean diets ended up being the most effective.

In our clinic, we particularly like the South Beach Diet and the Mediterranean Diet, because they are less extreme than the Atkins and we find them more sustainable. But Weight Watchers and Jenny Craig are also useful, especially if you participate in their counseling sessions, which help maintain motivation.

There are also some interesting new medications that may be helpful in weight loss and weight maintenance. One thing to consider about any medication is that it will only work while you take it, so you may be talking about adding a medication to your life on a long term basis. Also, some of the medications have not been studied long term for this purpose, so they should only be used if the need to lose weight is great. At the Mood Disorders Clinic we have had good experience using sibutramine ( Meridia ), orlistat ( Xenical ), topirimate ( Topamax ), and other medications. We are also interested in studies that show that zonisamide (Zonegran) may also be useful as a medication to help with weight loss. More information on medications and what to do if diet and exercise aren’t working is here.

Keeping Weight Off

Although some weight lost and regained is better than no weight lost at all, weight cycling can lead to frustration, low self-esteem and self-worth, with an ultimate return to poor eating habits and permanent overweight or obesity.

So, after weight has been lost, the most difficult question is how to maintain that loss. Researchers at Brown University Medical School created the National Weight Control Registry, a “club” of successful losers (people who maintained a weight loss of at least 30 pounds for at least one year). With responses from over 4,000 people these researchers were able to precisely describe the strategies that successful weight losers used. Interestingly, they found that methods used to lose weight initially varied significantly from person to person, however, there was much less variation in the methods used to maintain successful weight loss.

Generally, successful weight losers:

  • Ate a low fat, low carbohydrate diet with a calorie intake of approximately 1300-1500 kcals per day.
  • Ate breakfast almost every day. This is hugely important for weight loss, as well and can help prevent overeating later in the day.
  • Self-monitored. Participants weighed themselves either weekly or daily. Either way, catching a slight weight gain early helped prevent a significant one later on. Some also continued to keep food journals to keep track of their daily intakes
  • Exercised for 60-90 minutes each day at a moderate intensity. Ninety-one percent of those who successfully maintained weight loss exercised, with walking being the most popular form.

Other strategies to consider:

  • Avoid fast food. Registry participants reduced their fast food intake to less than once per week.
  • Consider smaller, more frequent meals. On average participants ate 4-5 times each day.
  • Take the weight off slowly. Those who experienced the fastest weight loss in the beginning were less likely to maintain their weight loss.
  • Turn off the television: not only does watching television reduce time for exercise, it actually seems to have a separate weight regain effect. In other words, controlling for amount of exercise, those people who watched more television gained more weight.
  • Get support: find someone who can help sustain your enthusiasm. There are also online support resources, such as San Francisco Overeaters Anonymous . Other resources that may be very useful are some online services that provide you with diet advice, support and online support from others who are dieting.
  • Wise indulgence: We all need to have an occasional sinful pleasure. But try to avoid foods that are satisfying only in large quantity. Choose indulgences that have powerful tastes. A very good choice for many people is very, very dark chocolate (more than 70% cocoa solids).

Registry participants reported that they have tried weight loss many times before achieving success. They also found it easier to keep the weight off after 2 years. So stay encouraged and keep at it! Almost all participants note an immeasurable improvement in their quality of life.

References

  • Dansinger ML, et al. “Comparison of the Atkins, Ornish, Weight Watchers, and Zone Diets for Weight Loss and Heart Disease Risk Reduction.” JAMA. 293:43-53. In this study the authors also found that the Atkins was more effective at reducing elevated triglycerides and insulin (both associated with the “metabolic syndrome”). Whereas the Ornish was better at lowering LDL cholesterol levels, but seem to reduce HDL cholesterol levels as well.
  • Dehghan, Mahshid Diaz, R et al. “Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study.” The Lancet  2017.
  • Miller, Victoria. Diaz, R et al. “Fruit, vegetable, and legume intake, and cardiovascular disease and deaths in 18 countries (PURE): a prospective cohort study.” The Lancet. 2017
  • Shai, I, et al. “Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet.” NEJM. 359:229-241. 2008. The Mediterranean diet was the best for those concerned about blood glucose and pre-diabetes. The low-carbohydrate diet was the best in terms of cholesterol. The Mediterranean diet was also the one that more people were successful with.
    • Low-Fat Diet The low-fat, restricted-calorie diet was based on American Heart Association 20 guidelines. We aimed at an energy intake of 1500 kcal per day for women and 1800 kcal per day for men, with 30% of calories from fat, 10% of calories from saturated fat, and an intake of 300 mg of cholesterol per day. The participants were counseled to consume low-fat grains, vegetables, fruits, and legumes and to limit their consumption of additional fats, sweets, and high-fat snacks.
    • Mediterranean Diet The moderate-fat, restricted-calorie, Mediterranean diet was rich in vegetables and low in red meat, with poultry and fish replacing beef and lamb. We restricted energy intake to 1500 kcal per day for women and 1800 kcal per day for men, with a goal of no more than 35% of calories from fat; the main sources of added fat were 30 to 45 g of olive oil and a handful of nuts (five to seven nuts, <20 g) per day. The diet is based on the recommendations of Willett and Skerrett. 21
    • Low-Carbohydrate Diet The low-carbohydrate, non-restricted-calorie diet aimed to provide 20 g of carbohydrates per day for the 2-month induction phase and immediately after religious holidays, with a gradual increase to a maximum of 120 g per day to maintain the weight loss. The intakes of total calories, protein, and fat were not limited. However, the participants were counseled to choose vegetarian sources of fat and protein and to avoid trans fat. The diet was based on the Atkins diet (see Supplementary Appendix 2 ).

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