Salt hides everywhere

When I talk to patients about their "sodium" intake, the routine assumption is that I am referring to table salt. Almost every patient says, "I never add salt to my food" and assumes that this is an adequate strategy to reduce sodium intake. The problem is that table salt, or sodium chloride, is but one of numerous foods that add sodium to your diet. Look at the ingredient list and nutritional information for macaroni and cheese. 540 mg of sodium, or 23% of your recommended daily intake, comes in a serving that is 1/6th of a box of macaroni. In the ingredients, we see both sodium phospate and sodium tripolyphosphate as additional sources of sodium. This amount of sodium is a common finding in grocery items that are boxed and processed.

Other hidden sources of sodium? Bread is a big one, and the focus of the news article that prompted this post. the CDC reported data from a 2007-2008 survey of diets and found that nearly half (44%) of the daily sodium intake comes from just ten sources of sodium.

1. Bread, 7.4%
2. Cold cuts, 5.1%
3. Pizza, 4.9%
4. Poultry, 4.5%
5. Soup, 4.3%
6. Cheeseburgers and sandwiches, 4.0%
7. Cheese, 3.8%
8. Pasta, 3.3%
9. Mixed meat dishes (meatloaf), 3.2%
10. Savory snacks (chips and pretzels), 3.1%

So, potato chips made the list, but just barely, and they were outclassed by lots of other foods, few of which you might think have lots of sodium.

For one other illustration, NPR posted a calculation of the sodium in a simple turkey sandwich, up to 1500 milligrams! Going low sodium on everything cut that nearly in half to about 800. 

A balanced review of "heart healthy" foods

The media seems to love the numerous studies about diets and foods, each hoping and promising to be the simple solution to your ailments. If you find all the conflicting reports confusing, you might enjoy this article from the Washington Post, which is actually reprinted from a book by Robert Davis called "Coffee is Good for You". Anyway, it succinctly summarizes the current data on several foods at just how healthy they are for you including: coffee, coca, olive oil, fish oil, nuts, and more. For background, Davis is a PhD at Emory. He has blogged over at the HuffPo in January on food label tricks to avoid and he runs a website called everwell.com.

Another diet study, frying is okay?

The BMJ has published a paper of 40,000 Spanish patients followed for 12 years. They compared people who ate the most fried food versus those who ate the least and concluded no increase in the risk of heart attack. The wrinkle is that the foods were fried in olive or sunflower oil. Before you celebrate, MedPage Today points out a couple of limitations. First, frying foods increases the calorie content, which could be bad for your health. Deep frying versus pan frying may have an effect and so could the number of re-uses of the oil.

As with the vast majority of these studies, this is observational, ie: someone tracked their habits and then ran the statistics to guess about risks. This is different from the scientific "gold standard", a randomized trial, but you can imagine how hard it would be to randomly assign some people to eat olive oil fried foods and others to eat, say, peanut oil fried foods. Besides, no one eats the same thing every day.

My take home point would be: if you are going to fry, use a healthy oil, but try to avoid it and bake or broil the majority of your food.

See the accompanying editorial for more opinion on the study.

Cook your own food

Last Fall, I spoke at a local church group with the intended topic being general "heart health". After I completed the talking points that I had brought and wanted to cover, I spent an additional hour or so answering questions which strayed far, far away from heart health. At one point I ended up explaining why you might get a tingle in your legs from sitting on the toilet for an extended period of time. Another major topic of questions was diet and how to find and eat the right foods. Since my wife and I cook all the time and we eat pretty healthy, it was easy for me to provide practical advice.

I was reminded about this experience when I came across an article in American Medical News discussing a collaboration between Harvard and the Culinary Institute of America. Together, they sponsor conferences, some of which are aimed at getting doctors to better understand how one goes about actually "making" food. So, while few of my patients want or need to take classes from a culinary institute, it certainly makes sense for doctors to have practical cooking advice so they can tell patients how to eat more healthy and cook at home for themselves. The reason this is so important is that by cooking at home, at least you know what you are putting in your food, you have more control over the contents, and you can depend on yourself to reduce sodium or added sugars and fats. (FYI, a quick Google search yielded a survey done by Whole Foods in 2009 that found about 1 in 5 Americans rarely or never cook at home.)

One reason why eating veggies might help you lose weight

From Graphjam.com

Common grocery store labels and what they really mean

Aside from the fruits and vegetables at the periphery of the grocery store, it can be very difficult to know what (if anything) might actually be healthy. Since most food product manufacturers take liberty with splashing all sorts of quasi-health claims on their products, it is worth knowing what labels mean and who is in charge of granting a label. For example, did you know that "zero calorie" actually means up to 5 calories (or that "zero calorie" soda might not actually be healthy at all) What about "certified organic"? What does that mean and Who is doing the certifying? Thorin from Lifehacker has a great post on a lot of these labels that is certainly worth a read. Also, one of the first commenters made a point that I am always quick to make: if it comes in a box, you probably should not be eating it. I would add, if you are not cooking it yourself (warming and microwaving does not count), it is not real food.

Run for 50 minutes or drink a soda?

Given the choice, would you rather run for 50 minutes, or drink a sugared soda? Obviously, I would choose the run, but an interesting new study in the American Public Health Association (H/T NPR and Gawker) tested this question using signs posted in a Baltimore neighborhood. The researchers posted one of three different signs on the soda coolers to educate people prior to their purchase. The signs would inform them that 1) each soda had 250 calories, 2) each soda accounted for 11% of their total diet of calories for the day, or 3) each soda requires 50 minutes of running to burn off the calories. They also performed a control with no sign. Guess which one resulted in the biggest drop in soda purchases?

All reduced sales, but only one was statistically significant, which was the warning about running, dropping sales by 50%. The percent calorie allowance and the sign with the number of calories dropped sales by 40% (neither statistically significant). The same authors (S Bleich Pubmed references) have done other work regarding increasing public awareness about caloric content and the effect on caloric intake. They found that the public wants to know more about calories at restaurants, and it seems like it might be a useful strategy to get people to moderate their diets, although, not all the science finds this strategy effective.

Diet and cholesterol

I posted a comment over at Nutraingredients.com where Shane Starling asserts that a new study shows that diet and olive oil are superior to drugs for heart disease. Read the study for yourself and see what you think.

 The authors of this study assert that a mediterranean diet reduces atherosclerosis more than drugs.

Unfortunately, that is not what they tested.

Their study compared the effects of three diets. They did not control for the use of lipid-lowering drugs, the rates of which were different between the groups. Further the authors did not report statistical tests of these differences.

Their primary outcome was not atherosclerosis, nor heart disease (such as heart attack or death). Their primary outcome was the level of apolipoprotein in the blood.

An accurate title for this article would be: "Olive oil and nuts reduces one part of your cholesterol more than a low-fat diet."

Healthy eating, not again!

Fiber. Part of a good diet, and as it turns out, makes you less likely to die. A study of over a half a million people found you were about 20% less likely to die if you eat a diet rich in fiber. So while the general rule is that boxed foods are not very healthy for you, perhaps eating the box is!

The caloric content of restaurant food

A few years ago, New York City required that food service chains to post calorie count on their menu boards. Similar requirements are part of the Affordable Care Act and are growing in popularity. There is a debate as to whether such information does or does not make any notable effect on people's food choices. A study in the July 20 issue of JAMA addresses a different, but very important aspect of the debate. Can you even believe the calorie counts that are posted?

To study this, the researchers went to several sit-down and counter-service chain restaurants (not named) and purchased a variety of entrees, desserts, and side dishes for which there was posted caloric information. They purchased food from three different parts of the country, then freeze dried them and directly measured the caloric content using a bomb calorimeter.

At this point, it might be worth mentioning exactly what a "calorie" is. A calorie is a unit of energy, specifically heat energy. When we talk about calories as laypeople, they are kcals (kilocalories or 1000 calories). A calorie, then, is the amount of energy required to heart one gram of water by one degree (since the density of water = 1, this is also the same as one cubic centimeter or milliliter of water). A bomb calorimeter then is a device for burning a substance to see how much it energy it contains that is released when burned.

For the most part, the research suggests that yes, the calorie content is fairly accurate (within -15 to +54 kcals of the amount stated on the menus). However, they found that about 19% of the products underreported the measured caloric content by at least 100 kcals. There were some other interesting trends I noticed. For example, sit-down restaurant entrees actually were significantly LOWER in calories than reported, and that the more calories an entree reportedly had, the more likely it was being overestimated on the menu. Fruits a vegetables had one of the lowest amount of discrepancy, while salads, soups, carb-rich foods, and desserts had the highest underestimation of reported calories.

The take home message for me is that I do not think this study detected any systematic underreporting of calories to try and fool consumers. That said, there appears to be significant variability between reported and measured calories and it is hard to know if the menu under or over estimates the true calories. I still think the best bet is to take responsibility and make your own food so that you know what goes into it, and if you need to, you can count calories on your own.

Yet another reason to be healthy

The July 6, 2011 issue of JAMA has an article from Chiuve et al who reviewed data from the Nurses Health Study (81,722 women in the US followed from 1984 to 2010). They found that following healthy habits such as not smoking, keeping a BMI under 25, exercising 30 minutes or more a day, and a healthy (Mediterranean) diet reduced the risk of sudden death.

How reduced? Doing just one of these cut the risk in half, while doing all four reduced the risk 92%!!! This study is limited by the typical problems of cohort studies, perhaps one of the most important being selection bias. This is where people who are generally healthy and well-educated are more likely to participate in such studies. In this case the study participants were compared to each other, so that makes it more likely that the effect is real. Furthermore, based on Bayesian probability theory, there is already a profound body of evidence that healthy behaviors are, well, healthy, so I am inclined to believe it. What is astonishing to me is the magnitude of the effect.

Of course the 92% estimate is just the middle of a range of possible "true" results. This range is referred to as the 95% confidence interval. For this study, the range is a 97% to 77% reduction (reported as a relative risk of 0.03 - 0.23). Roughly that means that there is a 95% chance that the "true" effect is between 97% and 77%. So, that is the statistics lesson for the day, time to go get some exercise, eat healthy, and not smoke.

Enterotypes: your gut bacteria may affect how medicine works for you

Humans are covered in bacteria. In fact, it is estimated that we each have ten times more bacterial cells on our bodies than human cells which make up our bodies. A large portion of the masses of bacteria you drag around with you live in your gut. Some are helpful bacteria that break up foods that you otherwise cannot digest on your own. Some are pathological, such as C. dificile, a notorious and potentially deadly bacteria. Many of the bacteria in your gut are actually un-culturable. That is, we do not even know what they are because we cannot figure out how to grow them outside of the human body and have little idea of how they work. Your bacteria are different from my bacteria, are different from everyone else's bacteria, but it turns out that there are some patterns which might be of research interest.

Researchers reported in Nature on a discovery they are calling the enterotype. Bascially, they took a buch of fecal samples and measured the DNA in each of them. Even if you can not grow and culture all the bacteria, you can always cut the cells up and measure the DNA. Then you can measure parts of the DNA and guess about what you started with. It turns out that people fit into one of three basic patterns of DNA, the enterotype (entero = gut, type = category). Several aspects of this discovery are quite amazing. First, there does not appear to be a continuum of gut bacteria, but dinstinct "types". Second, enterotypes do not seem to follow geographic or cultural boundaries, and furthermore, are not associated with weight, gender, or age. It seems that regardless of your diet, upbringing, cultural and genetic heritage, your gut bacteria settle into one of three equilibira.

We do not know for sure if this phenomenon could explain health disparities, or why some people seem to respond to certain drugs while others do not. Perhaps it could shed light on why some people can easily lose weight while other struggle or never succeed. Alternatively, someone might try to make a lot of money off of it without ever publishing any meaningful research on the topic (Eat Right For Your Blood Type). Time will tell, but this is an exciting discovery.

Some level headed advice about sugar

Thanks to Adam at Lifehacker who wrote up this extensive post about sugar in its varied forms (table sugar, high fructose corn syrup, natural fruit sugars, etc.). I think he presents a balanced view and concludes the way that I would:

"Like with anything, sugar isn't all that bad for you in moderation. The problem with sugar these days is that there's a lot more of it in everything and it's in practically everything. So long as you pay attention to what you're eating and you don't overdo it, sugar can be a pleasant part of your life few to no issues. The important thing is that you know what you're consuming and make good choices as a result. The answer to this problem isn't groundbreaking, but just a matter of paying attention."

That, and encouraging healthy regular physical activity to stay lean and fit. The content for his Lifehacker post is drawn from this video by Robert H. Lustig, Professor of Pediatrics in the Division of Endocrinology at UCSF. It was given at a "Mini-Med School' series of lectures and is geared towards a general audience and is well worth a watch if you are interested in the subject. He does rely on a lot of basic science to help explain the background of what is going on with sugar and fructose, but he does back it up with some real clinical studies as well. For example, around 1:10 in the video, he describes how UCSF does its lifestyle intervention clinic to facilitate weight loss. It requires four things:

1. Remove all sugared beverages, only water and milk
2. Eat carbohydrates with fiber
3. Wait 20 minutes before getting second portions
4. Buy screen time with active time (one minute of exercise gets you one minute of TV time)

Doing these four things was highly effective at weight loss. But interestingly, one of the key reasons for failure was not removing the beverages. 

We've got some explaining to do: patient knowledge of cardiovascular risk factors

Results from a survey of 2,200 patients in Western Massachusetts were published in the American Journal of Cardiology in May. Sartak et al found that of these patients, just over one third could correctly identify the seven factors which the American Heart Association promotes as ways to reduce your risk of heart attack:

1. Do not smoke (ever)
2. Exercise regularly (30 minutes a day)
3. Eat a healthy diet (plant based)
4. Maintain low BMI (under 25)
5. Treat high cholesterol
6. Treat high blood pressure
7. Treat high blood sugar

Now, it might be a stretch to say that you need to know all seven to be healthy. For example, as long as you are seeing a doctor who is helping you to manage you blood pressure, sugar, and cholesterol, perhaps that is enough. In my experience though, patients who are aware of the goals they need to meet are much more likely to meet them. Furthermore, this was a survey of people already in a clinic, seeing a doctor. Evidence shows that for the general population, not only is knowledge worse, but adherence is abysmal. For example, this study from 2005 which showed only that only 7% of Americans with heart disease successfully 1) do not smoke, 2) eat fruits and vegetables, and 3) exercise regularly.

Fast Food Capitals of the US

The Daily Beast posted on February 8 an article that they put together a list of the Top 40 US Cities based on density of fast food chains, along with help from a couple of independent research firms. You have to read through the gallery to get the list, but Consumerist has summarized it and guess what, Florida has three in the top ten, woohoo!

Number One? Orlando, FL with 463 restaurants and 196.3 per 100,000 residents. Also on the list is Miami with 123.5 per 100,000 and Tampa with 100 per 100,000.

Two things I found especially interesting about this list. First, there is a huge disparity among the top cities. Orlando has almost triple the density that #10 (Birmingham, AL) has. Second, guess what the most common fast food chain was? Not McDonalds, but Subway.

Interesting, but is Subway 'fast food' the same as the golden arches or the Whopper? Subway has done a lot to try and promote themselves as 'healthy' for 'fast-food'. For me, when I am out traveling and have no choice, I would certainly rather have a turkey sub than a Big Mac. Then, of course, there is Jared Fogle who lost hundreds of pounds eating Subway subs and even ran the NYC Marathon last year. Of course the trick is to not get a meatball sub, or slather you sammich in mayo and creamy sauces they offer. The sodium content is probably not that healthy, but I have to imagine it is no worse than a super-size french fries and at least the fat content of a sub is way lower.

Benefits of green tea in a variety of diseases

I got a notification in my email today about a newly published study showing that people who drink green tea had a lower risk of developing coronary artery disease (CAD). This was contrasted to black tea, which did not reduce the risk of CAD. The study was a meta-analysis, which is a type of super-analysis where the results of several trials were pooled. This methodology generates larger numbers of patients, giving it more power to detect effects, but since each trial uses different criteria to enroll patients, the method can make the results a meaningless jumble of mixed messages.

It is important to remember that nearly all studies of food consumption and risk of diseases have many significant limitations. They are almost never randomized trials, but observational. They are limited by what people remember. Do you remember the last time you drank green tea? Unless you drink it every day, you might have a hard time remembering. Let's say you do drink green tea every day, do you drink the same amount every day? Sometimes you have one cup, sometimes four. Now, tell me the average number that you drink every day over the last five years. After all, you will almost certainly see no significant benefit from a single cup of tea. Observational studies are also limited by the fact that there could be differences between tea drinkers and non-drinkers that you cannot control for. Think about tea drinkers you know, are they healthier than other people in other ways? Do they tend to be vegetarian? Are they nonsmokers? Do they exercise more than other people? You can imagine how this could get confusing.

Despite the limitations of observational studies and meta-analyses, green tea does seem to have some beneficial effects. After checking out the first study, I clicked on the top four related results, all of which were analyses of green tea for other diseases, like breast cancer, (green tea beneficial) lung cancer, (green tea beneficial, black not) stomach cancer, (mixed results) and stroke (green and black beneficial). Furthermore, there is some plausible science behind the idea that green tea could be healthy. Tea does contain antioxidants, catechins, and myriad organic compounds of unknown effect on humans. The difference between this and quackery, though, is that someone has taken the time to review the literature and find all the pertinent studies on green tea for several diseases and analyze them to find the effect. It is not enough to say A) green tea has antioxidants and B) it is therefore good for you. Some effort needs to be made in actually measuring effects to see if they are repeatedly observed.

Arguably, the organization that is the best at doing these sorts of analyses is the Cochrane Collaboration, and the PubMed search I mentioned before also included the Cochrane review of the effect of green tea on cancer. This review looked at 51 studies with 1.6 million patients and found that there is "insufficient and conflicting" evidence on the subject (yes, even with 1.6 million patients, we do not know for sure). Further, the vast majority of studies came from one area of the world (Asia), which does not mean that the studies are biased, but if green tea really works, it should work regardless of where it is studied. They do also conclude, however, that green tea does not appear to be harmful and therefore if you desire, moderate habitual use, drinking 3 to 5 cups a day would be reasonable.

Secrets of Longevity, what we can learn from "blue zones"

On the blog Get Rich Slowly, April Dykman recently posted about the oldest-old in the world and how they got that way. Spurned on by an article about Sardinia, she read about how National Geographic refers to Sardinia and a handful of other places around the world as "blue zones". These zones are areas of the world that have a disproportionately large number of people over 100 years old.

Now, I've never heard this term "blue zone" before, and I'm still not quite sure where it came from. Wikipedia does have an entry on the subject and cites this scientific article as the first reference in the scientific literature. The wikipedia content, however, is eerily similar to both the post on Get Rich Slowly and another website Quest.bluezones.com which appears to promote travel and learning about these areas but has a seriously commerical feel to it.

The "blue zones" they mention are:

• Loma Linda, CA
• Sardinia, Italy
• Okinawa, Japan
• Nicoya Peninsula, Costa Rica (from GRS)
• Icaria, Greece (from GRS)

Anyway, what I found most interesting about these blue zones is the Venn diagram which appears to have originated on the Quest website, but is posted in Wikipedia, and is adapted in text on Get Rich Slowly. Bottom line is that the things held in common by all the areas are:

1. Family (ie: good family history but also good social support)
2. Absence of smoking
3. Diet based on legumes and plants
4. Moderate physical activity

Other population-based observations that some (but not all) of the "blue zones" have include:

• Polyphenols in wine
• Turmeric
• Nuts
• Abstinence from alcohol
• Whole grains
• Faith
• Gardening
• Empowered women
• Low stress
• Soy

At some point, I have heard evidence (of varying quality and consistency) for pretty much all these things in promoting health and increasing longevity. The evidence is not necessarily that strong, however. Take for example the observation of "wine" and "alcohol abstinence" as both being linked to health and longevity. This may reflect the fact that while alcohol can reduce risk of some diseases (such as cardiovascular disease) it increases the risk of others (such as liver disease and even just the likelihood of accidental death).

As such, my guess would be that there is not likely anything special about "blue zones", perhaps it is just that they happen to be areas where a lot of these healthy activities and behaviors are commonplace and encouraged socially (as opposed to the poor diet and inactivity that is promoted by elements of Western culture). I feel pretty confident in saying that if all of America just had the first four (unfortunately, you can't choose your parents), we would certainly be a much healthier nation and who knows we might all live to 100.

Sleep well to stay thin?

In the Annals of Internal Medicine, researchers took 10 overweight adults, put them on a moderate calorie restricted diet and then forced them to sleep only 5.5 hours, or permitted them to sleep 8.5 hours a night. This is obviously a very small study, but since they kept the subjects in their sleep lab for 2 week blocks of time, the quality of the data is excellent, making this worth talking about. Furthermore, they gave the subjects two days up front of the same 7 hours of sleep and then did a crossover. This is where they gave the subjects a break for a few months and did the experiment again, but now the 5.5 hour group was given 8.5 hours and vice versa. This way, each person was compared to themselves.

They found that everyone lost weight (remember they were all restricted on calories). But, those given 8.5 hours of sleep lost more weight from fat loss, and the 5.5 hours of sleep resulted in more weight loss from non-fat (ie: muscle) sources. They measured this through body composition, but they also measured blood tests which confirmed that those with more sleep were burning fat, not muscle as they lost weight.

This is one of those studies that proves a concept, that sleep is an important part of your health, even when it comes to things like weight loss. Clearly, this is a small group followed for a short period of time and we cannot draw long-term conclusions about these findings, but it is an interesting observation and perhaps something to consider if you are trying to lose weight (just remember that everyone was still eating a calorie restricted diet).

A sampling of dietary science

Doctors and scientists are frequently lambasted by the public and the press for changing our minds about what is healthy and what is not. One day we say eggs are good for you and another they are bad. Fat is bad for you unless you are doing Atkins. Carbs are bad for you unless they are whole grains. And so on. I share the frustration, but want to explore one reason for this phenomenon and then go over a couple of recent diet studies.

Research can be hard enough to conduct even when you have strict control over all the variables. Therefore research becomes that much more complex when you are trying to measure the effect of variables that are moving targets such as "diet". I put this term in quotes because it can and does have a variety of meanings. In this case I intend it to mean what a subject eats on a day to day basis. Think for a moment about what you ate yesterday and the day before. Was it the same? Were any two meals the same? Now extrapolate that variability over the years and years it takes for someone's "diet" to impact their health. How can you really compare one diet to another? Well, we have to try to do it anyway and hope that people's diets with average out and give us some ideas about what is healthy and what is not.

So, getting to the science I wanted to share:

First, from Circulation is a paper by Micha et al which looked at red meat vs. processed meat in the risk of diabetes, stroke, and heart disease. The authors reviewed results from 20 studies totaling 1.2 million people. They found that while processed meats increased the risk of diabetes by 19% and heart disease by 42%, red meat did not increase either risk. Neither type of meat increased the risk of stroke. One important take home point I took from this however, is that the "dose" of meat they studied was 100 grams, or 3.5 ounces. If you did not know, the recommended portion of meat at a given meal is only four ounces and NOT the 18 oz Porterhouse you might find at your local steakhouse. So while beef jerky might be worse for you than a hamburger, everything should be taken in moderation.

Second, Sun et al published their findings in the Archives of Internal Medicine from a cohort study of nearly 200,000 people comparing consumption of brown rice with white rice and the risk of diabetes. They found that replacing 50g/d of white rice with brown reduced the risk of diabetes by 16%. While some people say that carbs are carbs, I tend to disagree, as this research would suggest.

Third and lastly, some science that is a little more robust. This time we have a randomized trial where, for two years, 307 received either a low-carb or low-fat diet and were followed for weight loss, as reported by Foster et al. As with many such trials, subjects were motivated at first but the dropout rate was high. An initial weight loss of 11 kg was similar in both groups, but then weight returned to be down only 7 kg after 2 years. To me, the take home message here is that weight loss can be accomplished in a variety of "diets", especially in the short term, but the effects are not likely to last unless crucial changes to overall lifestyle accompany the diet. I recently heard someone say that you should never go on a diet you don't want to follow for the rest of your life, and I would agree because otherwise you are almost certain to revert to the prior behaviors which resulted in weight gain in the first place.

It's the Calories!

Two pretty reliable facts about weight loss: it is challenging and there are plenty of people who claim to have the magic solution. I was able to, several years ago, but it took great willpower and counting calories. For me, no high fat, low fat, balanced carbs, good carbs, macronutrient, high fiber, whole grain or other diets, just calorie counting and exercise. In the spirit of that effort, we now have...

The Twinkie Diet?

Mark Haub, a professor of nutrition at Kansas State who tested the hypothesis that it's the calories that matter over the type of food eaten. He devised a 1800 calorie diet based on a protein shake, a multivitamin, and all the junk food he could fit in under the limit. Twinkies, Doritos, Hostess, Little Debbie, and Oreos. He kept up with his previous moderate exercise, no changes there. Admittedly, he did cheat a little by having some celery and green beans, but the results?

He lost 27 lbs in 2 months. Furthermore, his "bad" LDL cholesterol dropped and his "good" HDL cholesterol increased by 20% each. 

Another interesting tidbit is that he had been on what he considered a relatively "healthy" diet before, of fruits, veggies, whole grains, etc. He did not lose any weight eating on that diet, which he postulates was due to making healthy choices, but still eating too much.

For the record he does not condone the food choices (and neither do I), but he pretty strikingly illustrated the point about what matters when it comes to weight loss, it's the calories!

CNN: http://www.cnn.com/2010/HEALTH/11/08/twinkie.diet.professor/

Dr. Haub's twitter account: http://twitter.com/themarkhaubdiet

K State news: http://www.kstatecollegian.com/news/little-debbie-diet-may-not-be-so-sweet-1.2323537