Eatwell plate advice doesn’t reduce cardiovascular disease



Adapted from  BMJ 27 Jan 2018 from a study reported in PLOS Med

The UK Food Standards Agency uses a scoring system of their own devising to determine whether a food is “healthy” or not.  Fruit, vegetables, fibre and protein get top marks and saturated fat, sugar and salt get a fail.

When 25 thousand participants in the European Prospective Investigation of Cancer study completed a seven day food diary at the start of the study, and their food choices were marked on perceived health benefits, there was no difference in the incidence of cardiovascular disease over the next 16 years.

Time to lay the Eatwell Plate advice in the bin?


Kris Kresser: Should you skip breakfast to lose weight?

Does Skipping Breakfast Help with Weight Loss?
on May 9, 2017 by Chris Kresser 

Is breakfast really the most important meal of the day? Researchers have been trying to answer that question for years, particularly as it relates to achieving a healthy weight. Read on to learn what the latest randomized clinical trials are telling us, and whether intermittent fasting is really an effective weight loss strategy.
While intermittent fasting has been lauded for its health benefits, including promoting cellular maintenance and protecting against aging and neurodegenerative diseases, popular wisdom maintains that skipping breakfast is bad for you. Often labeled as the most important meal of the day, breakfast is said to “boost metabolism” and reduce hunger. But is this really true? Mounting evidence suggests that eating three meals a day may not be important for weight loss.

In this article, we’ll explore the evidence for and against eating breakfast with all its nuances, including an ancestral approach, the problems with association studies, a review of the biochemistry of intermittent fasting, and relevant results from randomized controlled trials.
Did our ancestors eat breakfast?

The truth is, it’s hard to know for sure, but it’s thought that most hunter–gatherers ate intermittently depending upon food availability. (2, 3) Loren Cordain, founder of the Paleo diet, writes:
“The most consistent daily eating pattern that is beginning to emerge from the ethnographic literature in hunter–gatherers is that of a large single meal which was consumed in the late afternoon or evening. A midday meal or lunch was rarely or never consumed and a small breakfast (consisting of the remainders of the previous evening meal) was sometimes eaten. Some snacking may have occurred during daily gathering, however the bulk of the daily calories were taken in the late afternoon or evening.” (4)
It appears that the three-meals-a-day paradigm was not adopted until the Agricultural Revolution around 10,000 years ago. Frankly, the fact that we eat three times a day is somewhat arbitrary and seems to be based on when it was most convenient to eat during farm work and harvest. (5)

Most studies regarding breakfast consumption and obesity are association studies. And while there is undeniably an association between a lean body type and breakfast consumption, correlation does not imply causation, and many of these association studies have been inappropriately used to shape recommendations for weight loss.
Because “eat breakfast” is such popular health advice, people who are committed to their health are more likely to eat breakfast. They are also likely to avoid smoking, manage stress, and eat more fruits and vegetables, all things associated with a healthier weight. Breakfast eaters tend to be leaner, but this doesn’t mean that they are lean because they eat breakfast.

Luckily, in the last few years, several research groups have sought to use randomized controlled trials (RCTs) to answer the question “does eating breakfast cause weight loss?” Let’s take a closer look at the studies and what they found.
In one of the first RCTs in 1992, researchers separated 52 moderately obese adult women based on their normal breakfast habit (whether they ate or skipped breakfast regularly) and then randomly assigned half of each category to a breakfast group and half to a no-breakfast group. In their results, they reported a trend suggesting that women who had to make the most substantial changes to their initial eating habits achieved more weight loss. Essentially, habitual breakfast skippers tended to do a bit better when they had to eat breakfast, and habitual breakfast eaters tended to do better when they had to skip breakfast. (10) Unfortunately, when this result was cited by other studies and the media, it was widely misconstrued. First, the researchers only observed a trend for this interaction effect, meaning that it did not reach the level of statistical significance (p < 0.06, for those familiar with statistics). Second, the study was widely reported in the scientific literature as having shown that eating breakfast led to weight loss, even though the authors never concluded anything of the sort. Unfortunately, poor reporting of this study shaped scientific and popular opinion for several decades.
The belief that breakfast is important for weight loss prevailed, despite a few smaller studies that found that skipping breakfast had no effect or even a potential beneficial effect on weight loss.

In 2013, Cornell researchers performed a randomized crossover study in 24 undergraduate students and found that skipping a meal did not result in energy compensation at later meals and that it might even be an effective means to reduce energy intake in some people. (11)

In 2015, researchers in the UK performed a similar study with a week-long intervention in 37 participants and concluded that “there is little evidence from this study for a metabolic-based mechanism to explain lower BMIs in breakfast eaters.” (12) However, these studies were both relatively short-term compared to the 1992 study and didn’t receive as much attention.
In 2014, as part of the Bath Breakfast Project in the UK, 33 obese adults were randomly assigned to a breakfast group or no-breakfast group for six weeks. (13) The breakfast group ate slightly more calories but was also a bit more physically active. The no-breakfast group ate fewer calories over the entire day but was also slightly less active and had slightly more variable glucose levels in the afternoon and evening at the end of the trial. Body mass and fat mass did not differ between the two treatments, and neither did indexes of cardiovascular health. Contrary to the popular notion that breakfast “boosts metabolism,” resting metabolic rate did not differ between the groups. Breakfast also did not provide any significant suppression of energy intake later in the day. It seemed like the evidence was mounting against popular belief.
Finally, in the largest long-term, multisite clinical trial to date, researchers attempted to settle the debate once and for all. They randomized 309 obese adult participants to a breakfast group or no-breakfast group for 16 weeks. They reported in the American Journal of Clinical Nutrition:
“A recommendation to eat or skip breakfast for weight loss was effective at changing self-reported breakfast eating habits, but contrary to widely espoused views this had no discernable effect on weight loss in free-living adults who were attempting to lose weight.” (14)
Over 92 percent of subjects complied with the recommendation they were given, but it had no impact on weight loss. They also separated individuals based on their baseline breakfast habit and found no interaction between initial breakfast habit and success of the intervention. This is directly contrary to the near-significant interaction found by Schlundt and colleagues in 1992 and was a much larger study.

But wait, does a bowl of cereal and toast with jam have the same effect as an egg omelette, greens, and a sweet potato? Food quality matters more than food quantity, right? Yep. When “breakfast” is lumped into one big category, there’s not conclusive evidence for or against it, (15) as we saw in the previous section. But researchers have looked at different types of breakfast and weight loss as well, with some intriguing results.
In 2015, a study in China found that obese teenagers ate less at lunchtime if they had an egg breakfast compared to a bread breakfast. The egg breakfast was reported to increase levels of satiety hormones, keeping them full for longer. The egg breakfast group also had significantly more weight loss. (16) Sounds pretty good to me! Unfortunately, there wasn’t a “no-breakfast” group in this study, so it’s hard to know how the egg breakfast would have compared to intermittent fasting.
Researchers in Missouri performed a randomized trial in 2015 with three different groups. They randomly assigned 57 breakfast-skipping teens to a cereal-based breakfast (13g protein), an “egg-and-beef rich” breakfast (35g protein), or to continue skipping breakfast. They found that the egg-and-beef breakfast led to voluntary reductions in daily food intake and reduced reported daily hunger. It also prevented fat mass gains over the 12-week study. (17)
The truth is, most of the studies above (that found no effect of breakfast) were likely based on a typical high-carbohydrate breakfast, a la the Standard American Diet. It would be very interesting to see the metabolic response to breakfast omission in a group of healthy individuals eating a nutrient-dense, evolutionarily appropriate diet.

What about fasting in relation to exercise for weight loss? In the fed and fasted states, we preferentially oxidize (“burn”) different substrates to produce energy. Could exercising in one state or the other provide benefits for weight loss? In 2012, researchers in London performed a crossover study, monitoring food intake and energy expenditure in 49 participants during one week with breakfast and one week skipping breakfast. They found that total energy intake, energy expenditure, and activity levels did not differ between conditions. (18)
A study in Japan in 2014 used a randomized crossover design with eight male subjects, all of whom were habitual breakfast eaters. The subjects were instructed to eat or skip breakfast, and the researchers measured their energy expenditure during the day. Interestingly, they found that breakfast skipping did not affect energy expenditure, fat oxidation, or the thermic effect of food if you looked at the entire 24-hour period (similar to the previous study), but it did change the rhythm over the course of the day.

When people skipped breakfast, energy expenditure was lower during the morning but higher during the evening and sleep than those who ate breakfast. Breakfast skipping increased fat oxidation and reduced carbohydrate oxidation in the morning relative to breakfast eating and increased carbohydrate oxidation during the evening. (19)
Following up on this study, a crossover study in Korea in 2015 tracked 10 obese male college students. For one week, they ate before their morning workout. The second week, they ate breakfast after their morning workout. Their results? The fasted workout caused the men to burn more body fat, but it also increased levels of the stress hormone cortisol after exercise relative to the fed workout. (20)

While burning body fat is beneficial to weight loss, large rises in cortisol are not. It should be noted that these participants were not adapted to fasted exercise and that “fat-adapted” people might have a smaller cortisol response to fasting.
What do these studies tell us? Well first, the thermic effect of food in the morning, a common argument for why we should eat breakfast and “boost our metabolism,” is a myth. Over the total course of a day, total energy expenditure does not change. They also suggest that morning fasting might be a great time for a fat-burning workout, as long as it’s not too stressful on your body.

When you eat, the hormone insulin is released from your pancreas to the bloodstream and shuttles glucose (carbohydrate) into muscles and other tissues, where it is used for energy production. Excess glucose is converted to fat and stored in the adipose tissue. When you fast, the hormones glucagon and cortisol stimulate the release of these fatty acids from adipose tissue into the bloodstream. The fatty acids are taken up by the muscles and other tissues and broken down (oxidized) to produce cellular energy. In this concerted manner, the body switches from utilizing carbohydrates to fats as its primary fuel and ensures a constant source of energy to the body.
This is all good and rosy, as long as the body can actually make this metabolic switch. In the scientific literature, this is called “metabolic flexibility,” (21) though you may be familiar with it as “fat-adapted.” People who are “fat-adapted” are more accurately “metabolically flexible,” meaning that they can easily switch from oxidizing carbohydrates in the fed state to oxidizing fat in the fasted state, and vice versa.

On the other hand, people who are said to be “carb-adapted” are “metabolically inflexible,” meaning that they are constantly burning carbohydrates and have trouble switching to fat oxidation. These people still release fatty acids from adipose tissue to the bloodstream but have lost the capacity to oxidize fatty acids in the muscle and other tissues. The accumulation of lipids due to reduced fatty acid oxidation has been hypothesized to cause insulin resistance, (21) and a low ratio of fat to carbohydrate oxidation has been identified to be a good predictor of weight gain. (22)
The phenomenon of metabolic inflexibility may explain some of the results of breakfast studies. Most of the participants in these studies were individuals eating an evolutionarily inappropriate Standard American Diet with large amounts of refined carbohydrates three times a day. If, all of a sudden, you instruct these “carb-adapted” people to skip breakfast, you’re asking for a blood glucose crash and insatiable hunger by lunchtime. In reality, most people who want to try intermittent fasting transition do so gradually by slowly increasing the time between meals, allowing the body to adapt and restore metabolic flexibility.
This may explain why prior breakfast habits have an effect in some studies. Researchers at the University of Colorado studying 18 overweight women found that the adverse effects of skipping breakfast were restricted to habitual breakfast eaters. While habitual breakfast eaters who skipped breakfast had increased blood lipids, insulin, and free fatty acid responses at lunchtime, habitual breakfast skippers who skipped breakfast had none of these effects. The authors concluded that meal skipping may have enhanced effects in habitual breakfast eaters due to entrainment of metabolic regulatory systems. (23)
So, skipping breakfast might not cause weight loss in the short term, but if over the long term it allows your body to “reset” and restore metabolic flexibility and insulin sensitivity, you may ultimately see some weight loss benefit. This is especially true if you’re also improving the overall quality of your diet. A low-fat diet reduces your body’s ability to release fatty acids from adipose tissue and oxidize them in the muscle, (24) while a high-fat diet increases the ability to use fat for energy in muscle and thus improves metabolic flexibility. (25, 26)
Summing it up: should you fast, or break-fast?
If you’re overwhelmed by this quantity of research, you’re not alone. Researchers have been struggling to find consensus on this topic for decades. If you glazed over some of it, here are the major takeaways from this article:
Hunter–gatherers probably only ate one large meal later in the day.
You cannot trust association studies. Correlation does not equal causation!
When all breakfast is lumped together, skipping or eating breakfast has no apparent effect on weight loss.
If you separate out different types of breakfasts, a protein-rich, fiber-rich breakfast seems to confer the most benefits.
Eat before or after exercising depending on your health status and goals. Skipping breakfast will optimize fat metabolism during your morning workout, but it may also spike your cortisol levels.
Most of the individuals in these studies were “carb-adapted” individuals eating a Standard American Diet. It would be interesting to see how the results might differ in “fat-adapted,” metabolically flexible individuals eating a nutrient-dense Paleo diet.
And that’s it!

If anything is clear from this consortium of research, it is the need for individualized nutrition. I’ve written several articles and spoken on my podcast previously about why intermittent fasting (IF) may not work for everyone. If IF works for some people (they lose weight) and is detrimental to others (they gain weight), and these people are all lumped together, we’ll see a net zero change in weight.
So how do you know if intermittent fasting is right for you? Try an n=1 experiment: eat or skip breakfast for a period of time, and notice how it affects your weight, mood, productivity, gut function, and other factors. Transition slowly if necessary, by eating your first meal of the day later and later each morning. There are some predictors of success with fasting, but only you can really know if IF works well for you.

Yummy Lummy’s Low-Carb Chicken Casserole

This post belongs to Yummy Lummy – I cook, photograph and eat food with the occasional restaurant review!. Whisky flavoured chicken blue cheese casserole Whisky flavoured chicken and blue cheese casserole may sound weird but the taste is amazing, especially with some nice Danish blue cheese melted throughout the chicken and vegetable mix. 34 more…

via Whisky flavoured chicken blue cheese casserole — Yummy Lummy

Hilda’s fit to serve: Berry Pie

Still looking for a low-carb dessert for your Christmas? Try this one…

Low Carb Nut-Free Crust
1 cup (2 sticks of butter melted and cooled)
4 large eggs
½ teaspoon sea salt
1 ½ cups coconut flour
¼ baking powder
1 tablespoon of water
Crust Instructions
1. Mix all the ingredients of the low carb crust just until dough forms.
2. Divide dough in half to make the top and bottom of the pie crust.
3. Roll out with between two sheets of parchment paper. Set aside.
4. Transfer one crust into a 9-inch pie pan. Being careful to smooth out any cracks.
5. Once you add the filling to the pie and the top crust.
Filling Ingredients
1 ½ cups of berries (I used mulberries)
2 tablespoons of sugar substitute (I used Swerve)
1 8 ounce package of room temperature neufchâtel cream cheese or regular cream cheese

Many people miss such items as apple pie after going low carb. Hilda shows you here what she does with the mulberries from her mum’s tree in the garden.  In Scotland you can use brambles in the autumn that you can pick for nothing. Now you know the secret of the pie crust you can experiment. I wouldn’t use mincemeat as in our Christmas pies though as that is too sugary for a low carb diet. 











Pie Instructions
Pre-heat oven to 350
1. Place half the rolled low carb dough into a 9-inch pie pan.
2. Spread the cream cheese to the bottom of the crust.
3. Add the berries that have been mixed with the 2 tablespoons of sugar substitute over the cream cheese layer.
4. Top the pie with the other half of the rolled-out dough. Make sure to add vents to the top of the crust.
5. Bake for 25 minutes until the topping is lightly brown.
6. Allow to cool before slicing.
7. Store in the refrigerator.


The Pulse of Life!

Diabetes and how you cope with it is an ongoing exploration. Recently, I’ve been experimenting with pulses such as lentils, and beans (kidney and butter) and even (shock, horror) whole grains such as barley.

I find their effect on my blood sugar minimal, and I love the variety they add to my diet. I was vegetarian for a long time, and lentils were a favourite food – lentil curries, patties and stews, all delicious.

Keto proponents don’t approve of lentils and beans because such diets promote extremely low carb intakes as sub 50g, but if you aim for a more moderate carbohydrate intake, such as 90-150g a day, you can easily add in pulses and beans. Remember too, that they have a high fibre content and you’ll probably be able to subtract that from the carbohydrate total when you work out how much insulin you need to cover a meal.

Apart from adding variety to my diet, I’ve also gone back to pulses and beans because of their fibre content. A lot of nutritional research these days points towards the importance of fibre, and it’s difficult to get much fibre on an extremely low-carb diet.

My body seems like the pulses and beans, and my blood sugar results confirm this. If your diet opens up and allows you more variety, this is always a good thing.

So, to celebrate here’s my recipe for hummus. Hummus is high in fibre and relatively low-carb. Used as a dip or sauce, you’ll only be adding minimal carbs to your diet.

Now, one thing I tried with this is the peeling the skins off thing. I’d read about this online, that if you want velvety-smooth hummus, you need to peel the chickpeas. U-huh. I wouldn’t do this every time as it’s possibly the most tedious job in the world, but for a special occasion, absolutely. You get beautifully smooth hummus.

Velvety-Smooth Hummus

  • Servings: 4-6
  • Difficulty: easy
  • Print

·         1 x 400g tin chickpeas (save two tablespoons of the water)

·         Juice of one lemon

·         1-2 cloves garlic, crushed

·         2 heaped tablespoons tahini

·         Salt to taste

Drain the chickpeas, reserving two tablespoons of the water. Peel the skins off. The easiest way to do this is to pinch each chickpea between your thumb and finger, and it should pop out of its skin. Do this above a bowl and be prepared for a few to ping across the room.

Pop into a food processor, along with the garlic and reserved water and whizz for a minute or so. You can also use a stick blender, but this is the less messy method.

Add the lemon juice and tahini and whizz again, for a couple of minutes, so you get a smooth, creamy texture.

Add salt to taste – about ½ to one teaspoon.

Use as a dip, spread on your favourite low-carb bread. It’s also lovely spread on lamb steaks.

Total carbs – 24g, minus 11g for the fibre.



Jovina cooks Italian: Carrot Cake

Italian Almond Carrot Cake (Torta di Carote)
This cake is gluten-free and made with olive oil. It is not your traditional American carrot cake.
You can also buy the carrots shredded from the supermarket.
Carrot cake
1/2 cup regular olive oil, not extra-virgin
1/4 cup pine nuts
3 cups shredded carrots
1/2 cup granulated sugar substitute
1 teaspoon vanilla extract
3 eggs
2 1/2 cups almond meal/flour
1/2 teaspoon ground nutmeg
1 lemon, zest finely grated and juiced
Mascarpone cream
1 cup mascarpone
2 tablespoons rum
Preheat the oven to 350 degrees F. Line the base of a 9 inch springform pan with a parchment paper cut to fit the bottom. Coat with olive oil spray.

Add the pine nuts to a small dry pan and toast them over low heat.
Grate the carrots in a food processor or with a coarse grater, and put them on a double layer of paper towels. Wrap the towels around the carrots to soak up the excess liquid.
Using the whisk attachment in an electric mixer, combine the sweetener and olive oil until creamy.
Whisk in the vanilla and eggs. Fold in the almond meal/flour, nutmeg, grated carrots, toasted pine nuts the lemon zest and lemon juice.

Scrape the mixture into the prepared cake pan and smooth the surface with a rubber spatula. The batter will be not be very high in the pan.
Bake the cake until the top is risen and golden and a cake tester comes almost clean, about 45 to 50 minutes.
Remove the cake from the oven and let it rest on a rack for 10 minutes before removing the sides. Let cool until ready to serve. Transfer the cake to a serving platter.
Combine the mascarpone and rum in a small bowl. Slice the cake and serve with the mascarpone cream.

BMJ: The PURE Study debunks the sat fat/heart disease hypothesis


The PURE study: Eating fat is associated with lower cardiovascular disease

From BMJ 9 Sept 17
PURE is a five continent observational study in relation to cardiovascular disease in mortality in almost 150 thousand people. It found that high carbohydrate intake was associated with a higher risk of total mortality whereas total fat and individual types of fat were related to a lower total mortality.
Total fat and types of fat were not associated with cardiovascular disease, myocardial infarction, or cardiovascular disease mortality, and the more saturated fat people ate the less strokes they had.
Like all observational studies correlation does not necessarily imply causation. The main message however is a series of negatives. There does not seem to be a connection between carbohydrate intake and cardiovascular disease, the association is with all- cause mortality. Perhaps high carbohydrate diets are simply a marker for poverty?
In contrast eating more fat, including saturated fat was associated with lower cardiovascular disease, meaning that we can abandon the saturated fat-cardiovascular disease hypothesis with some certainty.
So, what does “healthy food” look like?
A higher intake of fruit, vegetables and legumes was associated with a lower risk of non-cardiovascular and total mortality at three to four servings a day.
Great, says the author of this piece, Richard Lehman. His dream meal is cannelli beans and tuna salad with lots of olive oil, rib eye steak in butter, a salad, fruit, cheese and strawberries and cream.