“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.
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.
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.
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.
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.”
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.