Childhood Obesity: Time to Target Pediatricians

Posted: April 9, 2012 in Evidence Based Medicine, Fructose, low-carbohydrate diet, Lustig, USDA Dietary Guidelines
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“I do not think I ever met Mr. Hyde?” asked Utterson.

“O, dear no, sir.  He never dines here,” replied the butler. “Indeed we see very little of him on this side of the house; he mostly comes and goes by the laboratory.”

“Well, good-night, Poole.”

“Good-night, Mr. Utterson.” And the lawyer set out homeward with a very heavy heart. “Poor Harry Jekyll,” he thought, “my mind misgives me he is in deep waters!”

                             – Robert Louis Stevenson, Dr. Jekyll and Mr. Hyde.

First off, some of my best friends are pediatricians. No kidding.  But the title of the paper in the International Journal of Obesity caught my eye: “Preventing and treating childhood obesity: time to target fathers.”  Target fathers?  Blaming the patient, at least in the abstract, is standard.  The USDA made it clear that we have perfectly good recommendations and that the fault is in ourselves that we are underachievers. And if you are one of the “diet gurus” (as JAMA refers to us), who think that dietary carbohydrate restriction has promise, you get used to a certain amount of abuse. Still, one is not happy with the family angle.

The Abstract from the University of Newcastle, New South Wales was modest enough: “Children with overweight or obese fathers are at a higher risk of becoming obese…. interventions are urgently required to test the efficacy of treating overweight fathers….” It sounds like a genetic or at least epigenetic problem and, with no evidence that getting the father to lose weight will affect the child — and the fact that we are still not sure on exactly how to get people to control overweight — it is not obvious what intervention, beyond euthanasia, is in the offing.

It’s not the details. It’s “targeting.”  Not help fathers.  Not educate fathers. Target fathers.  Very odd. We expect a certain friendliness in our pediatricians. Of course, it’s tough with kids.  My own pediatrician, Dr. Kanof was a kindly man and a widely respected physician. It was not his fault that he had a large build and that, to a 10 year old, even his name was evocative of Boris Karloff.  In the end, though, I understood that he did not invent the idea of giving injections and I now think on him with appropriate good feelings.

So what’s happened here? Where is the caring pediatrician?  Time to target fathers? Rob Lustig wants your kid to be carded if they are so weak-willed that they want to buy a Snickers® bar. What about “Call for parents to lose custody?”  That was the headline on ABC News’s take on David Ludwig’s proposal for dealing with obesity.  Although he assures us that taking obese kids from their parents would only be a last resort — I am sure he is willing to be the one who decides — the requirement is likely to be less stringent than malnutrition or behavior that constitutes child abuse, cases already covered by existing statutes. Where did this hostility come from? One guy wants to tax your food and the next guy wants to take your kid away.

If the principle is a good one, that is, if aversive stimulation will improve people’s behavior, it seems reasonable to apply the idea to doctors themselves. After all, these guys are frustrated by their inability to deal with childhood obesity. Maybe it is just the absence of aversive stimulation.  Shouldn’t we pay Lustig and other pediatricians if and only if they can really help patients lose weight.  The pediatrician’s bill is a kind of  “tax” on the patient and even my co-pay is probably more than the anticipated tax on soda would be.  Removing it would implement negative reinforcement for the doctor.  And one justification for a punitive approach is that the revenue stream will be used for obesity programs.  So, since these programs clearly fail, shouldn’t we stop paying for them.  It’s simple: pediatricians only get paid for success. More important, academic pediatricians should lose custody of their federal grants if they cannot demonstrate that they are really experts.

Avoiding ad hominem is tough. Lustig’s Nature paper contains the single stupidest line in the history of the journal —  in suggesting that fructose has the same toxic effect on the liver as alcohol he says “This is no surprise, because alcohol is derived from the fermentation of sugar” — but nobody would suggest that Lustig is stupid. Also, whereas the lipophobes, as Michael Pollan calls them, are able to dish it out, they are quick to take offense.  On the other hand, once you step out of the science arena into public policy and especially when you want to bear down on my family, the rules are different.  Anyway, names are hard to resist.  Did we not win World War II because we had General Eisenhower (Ger. Iron cutter) while even the German general staff at the time used to refer to General Keitel as Lakeitel because he was Hitler’s lackey?  April Smith says that I am only allowed to make fun of somebody’s name if they are male, over 50 and make more than $ 150, 000 a year. Until they institute my “taxation” plan on pediatricians, I am probably on target with David Ludwig.

Mad Ludwig of Boston

The famous castle Neuschwanstein, on travel posters for Germany and the inspiration for the Castle in Disneyland, is not medieval but rather the nineteenth century creation of Mad Ludwig of Bavaria.  Ludwig II was quite reclusive but, beyond an obsession with Wagnerian opera, it is not clear that he was really mad.  According to Wikipedia,  the castle was paid for out of the King’s pocket, contrary to the myth that he used public funds and was forced from office by his constituency’s perception of their tax dollars at work. He was, however, removed from power by his cabinet ministers, possibly over requests for money, and the excuse, as in the former Soviet Union, was that he was clinically insane. My own take on Neuschwanstein is that it is generally considered that Ludwig was gay and because it was not acceptable, in those days, to come out of the closet, he built a castle with 5, 000 closets.

What castle is David Ludwig building?  It certainly rests on the ABC article cited above. So what’s with these guys? They are frustrated by childhood obesity.  Pediatrics, like all of modern medicine is remarkably powerful — not just the technology but the medical training and we take for granted the things that can be diagnosed and cured. When things don’t work, then, it must be somebody else’s fault. The power of modern medicine does not guarantee, however, that doctors have any ability outside their area of specialty. Biochemistry and nutrition and, most of all, motivating people to eat less are not major parts of the medical curriculum. But if you think you are an expert you will take it out on somebody: fat kids and their parents are a good target.  Childhood obesity is scary and carries a xenophobia that is hard to quell no matter how professional you are.  Human nature tends towards punishment and aversive stimulation under conditions of frustration.  It’s human. All too human.  But the real reason that it is time to target pediatricians is their refusal to investigate a method that might give them good results.

Does carbohydrate restriction help kids?

Here’s a picture from Jim Bailes’s book “No More Fat Kids.”  Fred Hahn has described similar good results in “Strong Kids, Healthy Kids,” and several practitioners of carbohydrate restriction have had similar good success.  That this is completely ignored by pediatricians is what makes this all so sad.  Especially odd, in Ludwig’s case is that, like Neuschwanstein itself, his fame is built on the site of an older castle.

Ludwig’s Castles.

David Ludwig’s earlier fame was built on the glycemic index although, unlike the Bavarian keep, it was paid for by NIH funds, that is, our tax dollars. The glycemic index was a great idea. It was about the data, rather than simply guessing: what kind of carbohydrate had what effect on blood glucose?  As such, it was the same principle as carbohydrate restriction and could have been seen as a politically correct version of the Atkins principle. In practice, however, it was touted as an alternative to carbohydrate restriction.

Ludwig’s 1999 paper showed, for example, that “consumption of high-GI foods induces hormonal and metabolic changes that… lead to overeating in obese subjects.”  Table I shows you what people ate.  You will notice that, as the paper admits, “the low-GI vegetable omelet … contained more protein, more fat, and less carbohydrate than did the high-GI instant oatmeal” (my italics).

In other words, Ludwig was able to implement a low-GI diet by making it low-carbohydrate. We are supposed to accept that “the observed differences …can be primarily attributed to differences in the GI itself,” because it is the main player in cases where carbohydrate is the same.

Ludwig’s patient.

In the same issue as George Bray’s article on macronutrients, the Clinical Corner Section of JAMA has an article by David Ludwig: “Weight Loss Strategies for Adolescents. A 14-Year-Old Struggling to Lose Weight,” the story of

“… an obese 14-year-old girl who is struggling with weight loss. She lives in the greater metropolitan Boston area. Ms K began to gain excess weight at age 8 years. Over the past 7 years, her weight has increased by 20 to 30 lb annually . Her peak weight is 256 lb, giving her a body mass index of 40.”

An article of more than 7,000 words (about three times the length of this post), it discusses almost everything about the subject, the patient’s being teased at school and her interactions with her parents: “….Ms K was adopted at birth. Her biological father is obese. Her adoptive parents are overweight.” (Talk about punishing fathers. Are these guys in trouble, or what?).

Notably missing, however, is any mention of low-carbohydrate diets (you can search the pdf).  Perhaps not unrelated, there is really no suggestion that she can be helped.

Much of this reads like a catalog of the sequelae of an incurable disease. It is an unspeakably sad description of the failure of the medical establishment to help childhood obesity and their blind and obstinate refusal to even consider carbohydrate restriction. These are Ludwig’s “grounds for optimism:”

“Ms K’s mother’s decision to relinquish her role as ‘food police’ was an important first step and may have helped her daughter become ready to pursue a weight management program….Special emphasis should be placed on modeling healthful behaviors and maintaining a health-promoting home environment.”

The Gatekeepers

How could such a depressing revelation of the failure of medicine get published?  I have previously made the analogy between “evidence-based medicine” and evidence in a court of law, where judgement has to be made as to the admissibility of evidence. In science, the gatekeepers are supposed to be peer reviewers and editors.  My Letter to the Editor on Bray’s paper (which similarly did not cite papers on carbohydrate restriction) was rejected by JAMA and I asked the editor, Howard Bauchner, whether it was policy at the journal that authors could simply omit relevant literature at their discretion. He has so far not been interested in discussing this issue with me.  Dr. Bauchner is a pediatrician but his heart is in the right place. A few years ago, he co-authored a paper entitled “A call for outcomes research in medical education.

“…Recent calls for greater accountability in medical education and the development of outcomes research methodologies should encourage a new research effort to examine the effects of medical training upon clinical outcomes….”

Encouragement would be good.

Inborn errors of Metabolism

Pediatrics is, oddly, the area of medicine where physicians have to be familiar with basic biochemistry. The pathology of inborn errors of metabolism can best be understood with knowledge of the underlying metabolic pathways.  I warn our students that, if they go into pediatrics, the Krebs cycle will come back to haunt them when they are fellows.  When teaching one of these inborn errors in my lectures, I generally turn to my old college roommate, Karl Roth, former head of the Department of Pediatrics at Creighton University. I either call him personally or check his published works and online entries. Beyond his great expertise in inborn errors of metabolism, Karl is a compassionate fellow — unlikely to target fathers — and a highly accomplished violinist (I have never heard a better performance of the Largo from the Four Seasons).  Some of my best friends are pediatricians.  No kidding.

  1. dhackam says:

    Fascinating discussion, thanks.
    I recently contacted an expert on pediatric obesity (actually an academic pediatric cardiologist) and asked him why Atkins type diets are not more formally recognized in combatting the current epidemic of childhood obesity. He replied that they are disliked because their effects on growth and development are uncertain.

    But you and I both know that ketogenic diets have been used in the management of pediatric epilepsy for nearly a century, and in recent years have really made a comeback (they are being re-pioneered at Johns Hopkins among other places). They are especially useful in patients with intractable epilepsy that is refractory to multiple tried and tested agents. So what do pediatric neurologists (epileptologists) know that pediatric endocrinologists do not? Is this an example of the silo effect in medicine with super-sub-sub-specialization? I believe it is.

    In the meantime, I had a follow-up question for you. Are there some individuals who might be oversensitive to the effects of low carb high fat diets in that they are prone, perhaps due to genetic mutations in intestinal transporters, to hyper-absorb dietary cholesterol? I wonder how one might best manage such individuals – it seems important to retain the good effects of dietary carb restriction while not increasing a very heavy serum cholesterol load – should they be on vegan proteins instead? Note this is hypothetical and not an actual case. But I have found in my clinic that LDL cholesterol does tend to go up on the Atkins diet, although counterbalancing that there are salutary and good effects on other fractions (eg HDL, triglycerides, total:HDL ratio, CRP, blood pressure, etc). Thank you for sharing your thoughts and expertise.


    • rdfeinman says:

      “He replied that they are disliked because their effects on growth and development are uncertain.” Translation: “I don’t have any information and have never talked to anybody who has had experience with Atkins type diets, so I prefer to believe what my residents say in the cafeteria, or what I hear on CBS News, that they are extreme, and therefore are probably dangerous.”

      As for “oversensitive to the effects of low carb high fat diets in that they are prone, perhaps due to genetic mutations in intestinal transporters, to hyper-absorb dietary cholesterol?,” low-carbohydrae diets are not necessarily high fat especially since they tend to be hypocaloric in practice. There are also many kind of carbohydrate-resricted diets. Most important, however, there is the unspoken assumption that there exists some standard diet which is well-defined diet that has been tested in any kind of comparative trial and has been shown to have good success at treating or preventing disease but there is no such thing. It is what is known in computers as vapor-ware. Dr. Sue Kirkman of the American Diabetes Association said that my criticism that the ADA was strong on what it didn’t like but not so strong on what it recommended, that that was a fair criticism. As for LDL, try to get somebody at the AHA to honestly and convincingly tell which is the best indicator of CVD risk. Good luck on that.

  2. Marilyn says:

    Vivaldi. 🙂

    And to think, there was once a time when a patent medicine bottle would boast, “Makes children fat as pigs.”

    There are so many things about this childhood obesity thing that make me cringe. It is, first and foremost, a giant experiment on a powerless and unwilling group of people. It is hugely unethical, IMHO, to try any drastic measures to cause a child/youth to lose weight before a proper low carbohydrate diet — or other diet shown to be equally effective — has been tried. It is hugely unethical to subject children/youth to studies, authority-enforced diets, kidnapping from parents, bariatric surgery, etc., before it is established beyond all doubt that the emotional and physical damage from all this is of less consequence than going through life fat. So far, I think that’s just an assumption.

    Keep these posts coming!

  3. Sidereal says:

    Excellent post – well said.

    I would only add that recently I was engaged in a discussion on another LC blog about Lustig and was quite taken aback by the Lustig lovefest coming from people who have successfully reversed their obesity using ketogenic VLC diets. Lustig’s recommendations are not actually LC and his own intervention for treating paediatric obesity is actually completely ineffective. While it is slightly less insulin-spiking and tissue-destroying than the official guidelines, it’s still firmly in the politically-correct lipophobic camp. It’s not clear to me where his total conviction and pompously high self-esteem originate from – not to mention his audacity to advocate all these extreme policy measures – given his total failure as a doctor treating this problem. There is no evidence that cutting out fructose is uniquely beneficial and will somehow reverse established obesity in the absence of true carb restriction. None.

    I dug up this paper of his on PubMed:

    This was a retrospective chart review of all non-pharmacologically-treated paediatric patients passing through UCSF’s fat clinic. “The WATCH clinic lifestyle intervention is modeled after a low glycemic load diet as developed by Ludwig and colleagues […]” I think we can guess where this is going. The patients were told to stop drinking soda and other sugared beverages, eat “healthy whole grains”, “lean protein”, low-fat dairy, fruit and vegetables. The kids also couldn’t watch as much TV, were told to exercise, and there was talk of “portion control” which is just Newspeak for self-control. In other words, they were told to do exactly what the government has been telling us to eat for decades now, with devastating consequences.

    Mean baseline BMI = 36.4 kg/m^2
    Mean change in BMI from baseline to first follow-up (median time to first follow-up was 3.2 months): -0.2 [-0.4, 0.0]
    Mean change in BMI from baseline to last follow-up: -0.4 [-0.8, 0.1]

    In other words, the Ludwig/Lustig diet, I mean, “lifestyle intervention” causes no decrease in obese children’s BMI.

    For some reason, in medicine no one bats an eyelid at the publication of this sort of abject failure. Failure to treat patients adequately is not considered abnormal or even worthy of attention and one can enjoy primetime media appearances and op-ed pieces in Nature while not providing adequate care to one’s patients. I honestly don’t think Lustig is “on our side”. If he were, he wouldn’t be telling his patients to eat grain and low fat. Contrary to Ludwig’s hand-wringing JAMA piece you quoted, effective treatment for obesity DOES exist and it isn’t all that difficult to implement. If Lustig just implemented his buddy Gary Taubes’ advice, his patients would actually lose weight. Why doesn’t he?

    • rdfeinman says:

      Excellent comments. You should send this to the primetime media,op-ed pieces and to the NIH which is probably, at his minute, planning to fund Lustig’s research which will certainly produce ever new failures. In general we need to engage the lipophobes, the government agencies and, at least document their resistance.

      On “in medicine no one bats an eyelid at the publication of this sort of abject failure,” however, this is a good thing. Clinical trials are mandated to reveal outcomes and derives from things like the Framingham study where the failure was buried for years. Of course, you can interpret the results any way you want. As “Fat Throat,” the author of the merger article put it “The Women’s Health Initiative, which showed no benefit in weight loss, risk of cardiovascular disease or diabetes after 8 years of a low-fat diet is generally credited with having instituted an entirely new field of scientific study known as Excuseanomics.”

      One possible area of moving forward is resisting the Dietetic Association or whatever they call themselves from getting a monopoly on giving nutritional advice.

      Better than Taubes, Jim Bailes actually has success as in the picture in the post.

    • greensleeves says:

      “If Lustig just implemented his buddy Gary Taubes’ advice, his patients would actually lose weight. Why doesn’t he?”

      Because Lustig needs government funding for himself and UCSF. And if he goes the Taubes’ path, he’ll never get another dime. Then UCSF will find a way to let him go. It’s really that simple.

      • rdfeinman says:

        He could do better than that. He could follow the advice of physicians who already have success with low-carb diets like Eric Westman. I would not presume to guess what his motives are but something about what you say rings a bell.

  4. davebrown9 says:

    Pediatricians may not understand the childhood obesity issue but this Australian mom does.

  5. George Henderson says:

    It seems to me, from my little reading in genomics, that the epigenetic argument in obesity is becoming a red herring.
    – parental epigentics influence offspring’s weight. This mainly means that children of starved (not overfed) parents gain weight more efficiently; common sense short-term adaptation.
    – epigenetics is gene expression; changes in dietary composition also alter gene expression. Thus, a relatively short course of carbohydrate restriction can rewrite the above; because there is a present dietary reality to adapt to, which trumps a potential reality.
    – gene expression of young can only stay constant so long as THEIR DIET IS SUBSTANTIALLY THE SAME AS THEIR PARENTS. All epigentic dietary experiments so far feed young on same dietary ratios as their parents.
    – supplementation of methylating agents during pregnancy prevents epigentic obesity, again showing that epigentic effects are not set in concrete.

    Epigentics may become another selling point of VLC diets – once better understood by diet researchers.
    But I am not holding my breath.

  6. George Henderson says:

    Low carb diet not necessarily higher-fat:

    from Anne Stock with the great John Yudkin, 1970

  7. George Henderson says:

    In the days when diets were reasonably high in fat and protein anyway, all you had to to lose weight was pull out the carbs.

  8. Galina L. says:

    There are so many potential benefits of ketogenic diet besides just a weight loss. I control with it the frequency and severity of my migraines. Sure, I lost some weight (over 30 lb), but health benefits of the diet include normalization of moods, disappearing need for asthma medications,diminishing of allergies, inability to catch any flue or infection (I used to be treated very regularly for urinary tract infections) since the beginning of the LC diet 4.5 years ago, and it is more. I don’t offer to make it the default diet for all children, but the children who are prescribed potent drugs or a gastric surgery with known side-effects should try a LC diet first. I think about such diagnosis as ADD, mood and psychiatric disorders, asthma, epilepsy and, of course, the obesity. The illusive danger of raised cholesterol should pale when it is compared with some side-effects of drugs for epilepsy, for example. Inhaler with steroids doesn’t look good for me as well. I think the main problem with the diet approach is the inability to acsept a diet as a strong and potent remedy. In the minds of most people their diet is something being taken very lightly, unlike drugs . Any diet which consists of veggies, meats, dairy will look as a high fat if analysed mostly because plants are very not-dense nutritionally, and normally people don’t eat a lot of proteins whatever diet they follow.

  9. Low carb diet may work for some. But it doesn’t seem to offer a clear advantage over other means. At least, if this new randomized trial is to be trusted

    • rdfeinman says:

      Isn’t Bonnie Brehm the one who told Gary Taubes that she was afraid that her grant wouldn’t be renewed if she accurately reported the results of her study showing that that low carb diets were good? This group has long been known to try to find some way to trash low-carb diets. Adherence is not solely a function of the diet but rather the earnestness of the health provider to encourage the patient. Also, any study that does an intention-to-treat analysis is intellectually bankrupt.

      But hell, we all know that we don’t need low-carb diets. The standard PC diet (portion control (or is it political correct?)) diet works great. There is no epidemic of diabetes. There is no childhood obesity. Let’s pour more money into the same old labs that have done so well with the obesity epidemic. Most of all, let’s not try to get cooperation. This new randomized trial is to be trusted to be really annoying to read.

  10. P. Winter. says:

    Dear Sir.
    Have you seen any obituaries to Dr. Leila Denmark who died aged 114, The Daily Telegraph had one, & included :-
    Leila Denmark practised medicine in Atlanta for 73 years, building up a devoted following a local parents and their children. She recalled that, when she first began to practise, the air in the city was so thick with smoke “by 10 o’clock you had a moustache”; meanwhile, as there was no tinned baby food, mothers would chew meals for their children. Even so, she felt that children were healthier then than they were when she retired. “When I was a child, there was no such thing as a baby doctor on Earth. We had very little medicine, very little surgery, no immunisations and no baby food,” she told an interviewer. “Yet the children weren’t sick like they are today because their mothers fed them right … Today, 85 per cent of children in the United States go to day care, and they are sick all the time. I’m not one to say let’s go back to the past, but there is something to be learned from that.”

    Her no-nonsense approach to child-rearing gained a wider audience through her 1971 book Every Child Should Have a Chance, and through Dr Denmark Said It, a compilation of her pearls of wisdom by Madia Bowman. Some of her advice was controversial. While she believed women should have the same opportunities as men in the workplace, she argued that they should not contract out child care to others. “Women have been brainwashed into believing don’t mess around with a child, let someone else do it and go out and be lawyers, teachers, preachers, anything,” she said. “And we’ve never had more sick children than we have today.”

    Staying at home and rearing children she regarded as “the most important work on Earth”. Meanwhile, babies should be put on a consistent schedule of feeding and sleeping; and after they are weaned, they should not be given anything to drink but water — no milk, no fruit juice. Dummies, she said, were “dirty things” — “a mother who gives one to a child isn’t caring for that child, she just wants to shut him up”.

    Yours Faithfully,

    P. Winter.

  11. Marilyn says:

    “This new randomized trial is to be trusted to be really annoying to read.”

    If the link posted by pronutritionist is all there is, I’d say it was another why-bother event. There was nothing there about the level of carbohydrate used—20 grams/day? 120 grams? who knows? I’m sure the LC drop-out rate represented a self-fulfilled prophecy, especially since everyone received “weekly counseling.” The whole thing only lasted 3 months, so how can they say anything about long-term compliance?

    • rdfeinman says:

      What was posted was only an abstract but nothing in there makes me want to read the paper. But, who knows? I could be wrong but I would guess the full paper does not ask the question as to how it is that the ones who did stay on the diet, or the ones who stayed better on the diet in other studies were able to do so. In short, I am guessing the tit is not looking to low carbohydrate diets for an opportunity. But, I could be wrong. Maybe it’s a great paper.

    • George Henderson says:

      What the Kirk-Brehme paper suggests is, that dieting children, as opposed to adults, are targetted by friends and family who think they “need” carbs.
      Who can say no to a loving grandma’s homebaking?
      Only the hardhearted can lose weight. A fat kid is going to have a sweet tooth and may need special support that an adult wouldn’t to restrict carbs.
      Do we really expect children to have the same degree of self-control and ability to self-discipline as adults? If the child is going to school, there’s another big reason for poor compliance right there.

      The ability of high-fat diets to control allergies, migraines etc. was discussed in a clinical context by Richard Mackarness in “Not All in the Mind” in 1976.

      Mackarness was a highly respected UK psychiatrist and influential to this day.
      He was also a low-carb pioneer with his earlier book Eat Fat and Grow Slim
      (full text of book below)

      The comparison between the two books; low-carb diet for weight loss, paleo elimination diet for other problems, including mental illness and diet-resistant weight loss – is very interesting.

      Those who do not research the past are condemned to repeat it.

  12. George Henderson says:

    In fact, if you are prescribing a diet to a child, you are really prescribing it to both the child and their caregivers; parents, teachers, etc.
    These people, who act as gatekeepers, do not have a direct experience of the diet’s effects, and are more exposed than the child to whatever messages about the diet are doing the media rounds.
    This would seem to be a major confounder; compliance depends on people who are not the subjects of the study.

    In this page from Eat Fat to Grow Slim we have quotes from a speech John Yudkin gave in 1957

    including these words of wisdom:
    “After pointing out that even if you show a statistical relationship between two things you do not show that one causes the other, Professor Yudkin concluded that not one single dietary factor shows any clear statistical relationship with coronary thrombosis. Later he published his survey in the Lancet on July 27th, 1957, and again concluded that on the available evidence it was “difficult to support any theory which supposes a single or major dietary cause of coronary thrombosis.”

    On that point most authorities now seem to be in agreement and in the present state of our knowledge there is absolutely no justification for scaring an obese person in normal health off a high-fat diet for the treatment of his obesity. On the contrary, there is evidence to show that the loss of weight which he can easily achieve on a high-fat, high-protein, low-carbohydrate diet will lessen considerably his chances of having a heart attack and will also add years to his expected span of life.”

    John Yudkin I think did more than anyone to define the terms of today’s debate. Imagine if Lustig was careful and not prone to rash statements, you would get a book like “Pure, White and Deadly”.

    • rdfeinman says:

      Thanks for these links. Yudkin is given to a sufficient number of rash statements and I remember thinking that about him when he was popular in the fifties. I was quite ignorant of the issues and responded to the style and if he exaggerates the importance of sugar vs starch, the most rash is still out there but should probably be framed as a question: is it possible that, with the exception of well defined disease states such as familial hypercholesterolemia, there is no substantial relation between diet and risk of cardiovascular disease?

      • George Henderson says:

        I think what Yudkin was saying was, that in 1957, and probably later too, there was no epidemiological evidence to link any dietary factor at all to CVD, yet fat was being talked up because of the cholesterol link.

        Later he found a link with sugar, and Ancel Keyes declared war on him.
        Yudkin promoted a carbohydrate restricted diet as the cure for obesity, but focussed on sugar as a cause of disease for the “empty calories” reason, e. g., even white flour supplies significant protein and some vitamins and minerals.
        Thus the deleterious effects of carbohydrate will be seen more prominently with regard to sugar – it can serve as a test case. The differential metabolism of fructose was also a factor, but Yudkin was cautious about how to interpret this, given the science of the time.
        In 1985 Yudkin wrote The Penguin Encyclopaedia of Nutrition, which is a masterpiece of nutritional conservatism and scepticism. It is this tone that gives weight to his opinions about sugar; it is not the tone of Lustig. John Yudkin may well have made statements in his war with Ancel Keyes that came back to haunt him, and I believe that Keyes and his supporters didn’t hesitate to misrepresent him. But the books read like measured, cautious programmes for future research.
        Yudkin defended high-fat diets low in carbohydrate and devoid of refined carbohydrate as a useful tool.

        These articles ask, is obesity ever a good thing?

        .” Additionally, substantial body fat loss can complicate appetite control, decrease energy expenditure to a greater extent than predicted, increase the proneness to hypoglycaemia and its related risk towards depressive symptoms, increase the plasma and tissue levels of persistent organic pollutants that promote hormone disruption and metabolic complications, all of which are adaptations that can increase the risk of weight regain. In contrast, body fat gain generally provides the opposite adaptations, emphasizing that obesity may realistically be perceived as an a priori biological adaptation for most individuals. ”

  13. Daithí says:

    I am in the process of designing a research project in the area of paediatric obesity. I am a medical student and have a keen interest in nutrition.

    I recently attended a local childhood obesity clinic and was not unsurprised to see that the advice being given to parents included portion reduction and referral to sports group.

    Interestingly, the parents did provide a 3-day food diary, detailing what had been consumed by their overweight children in the days prior to the appointment. Sugar and refined carbohydrates appeared frequently although the quantity of food did not stand out as being alarmingly high.

    I am keen to assess the relationship between consumption of sugar and obesity. Problem is the clinic is quite certain that their advice makes sense and should work in theory. I imagine that when the children stay obese it is of course not the doctors’ fault. Fascinated by earlier posts on paediatricians being held accountable!

    I would like to follow attendees at the obesity clinic for 4 months to see what effect the portion control/activity advice has on their fasting glucose/insulin and risk of developing T2DM. Have use of a sophisticated body composition tool.. just wondering if you have any suggestions?

    And also any advice for how I could design a research question that would not immediately undermine those people I am hoping to work with?!


    • rdfeinman says:

      I would simply ask if there is a research question here. That is, if all the kids stay fat despite following the recommendations, will that mean that they were bad recommendations, or will that mean the parents are lying. In other words, is there a null hypothesis? Is it an experiment in whether the parents are good or bad? Good luck and don’t mention my name.

  14. Bill Lagakos says:

    The School Lunch Program seems like an avenue with such enormous potential to do a lot of good. But that might require an entirely new breed of politician.

    • rdfeinman says:

      New breed of politician and a new breed of dietitian: the public school lunch program is basically locked into the USDA recommendations. The current political movement among dietitians, however, is along the lines of in-breeding.

  15. George Henderson says:

    surely the thing is to find what diets work, then work out how to improve compliance…
    here is a link to Pure, White and Deadly
    and the introduction to Yudkin’s second slimming book:

  16. Marilyn says:

    George, thanks for mentioning the Yudkin “Penguin Encyclopedia of Nutrition.” I just bought a used copy.

  17. Jim says:

    Dr. Feinman,

    Always enjoy your blog and appreciate your perspective.

    The topic of childhood obesity hits close to home. My adopted son is ADHD / Asperger and has been taking stimulant medication since the age of 6. Early in the use of medication, he actually lost weight, due to appetite suppressing effects, to the extent that his pediatrician became worried and counseled us to get calories into him by any means. He was offered high calorie foods especially in the evenings before bed, when his appetite would return. He has since developed a love for all things carbohydrate ( I should say refined carb and not whole-food carbs) and is now very much overweight at 12 years old.

    I am in a dilemma about what to do. I, myself have been maintaining a low carb eating plan and realize its merits after losing ~40lbs. I am sure that this would work for him, but am having difficulty helping him get his food choices under control. Being Asperger, he can be a very rigid thinker and instituting / accepting change is not an easy task.

    We live in the Rochester, NY area and I was wondering if you had any suggestions or recommendations regarding pediatricians that are more accepting of the low carb approach. We had seen an MD that specialized in nutrition, but her approach was really geared more towards suggesting this or that supplement and not specific food choices or how to facilitate the change in eating behavior.

    • Bruce Berry says:

      I think you would be well advised to look into GAPS (Gut and Psychology Syndrome) concepts by Dr. Campbell-McBride. There is a lot on the web about her, even some decent videos

      What you will find will be very compatible with a low-carb approach. She specifically works on techniques for kids who are very rigid in their thinking (eg autistic) and who have adopted a narrow range of preferred foods. She is strong on diet first as the core principle for treating her young patients.
      Also Nora Gedgaudas has a wonderful book “Primal Body, Primal Mind” that will help you understand some of what is going on.

  18. Wendy says:

    As Dr. Feinman suggested, I’d be happy to offer any assistance, especially since I’m semi-local (Rochester area).
    Wendy Pogozelski, SUNY Geneseo

  19. seriousstrength says:

    Nice blog doc. And thanks for the mention. We’ve helped many obese kids using a low carb diet.

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