As the nutrition world implodes, there are a lot of accusations about ulterior motives and personal gain. (A little odd, that in this period of unbelievable greed — CEO’s ripping off public companies for hundreds of millions of dollars, congress trying to give tax breaks to billionaires — book authors are upbraided for trying to make money). So let me declare that I am not embarrassed to be an author for the money — although the profits from my book do go to research, it is my own research and the research of my colleagues. So beyond general excellence (not yet reviewed by David Katz), I think “World Turned Upside Down” does give you some scientific information about red meat and cancer that you can’t get from the WHO report on the subject.

The WHO report has not yet released the evidence to support their claim that red meat will give you cancer but it is worth going back to one of the previous attacks.  Chapters 18 and 19 discussed a paper by Sinha et al, entitled “Meat Intake and Mortality.”    The Abstract says “Conclusion: Red and processed meat intakes were associated with modest increases in total mortality, cancer mortality, and cardiovascular disease mortality,” I had previously written a blogpost about the study indicating how weak the association was. In that post, I had used the data on men but when I incorporated the information into the book, I went back to Sinha’s paper and analyzed the original data. For some reason, I also checked the data on women. That turned out to be pretty surprising:


I described on Page 286: “The population was again broken up into five groups or quintiles. The lower numbered quintiles are for the lowest consumption of red meat. Looking at all cause mortality, there were 5,314 deaths [in lowest quintile] and when you go up to quintile 05, highest red meat consumption, there are 3,752 deaths. What? The more red meat, the lower the death rate? Isn’t that the opposite of the conclusion of the paper? And the next line has [calculated] relative risk which now goes the other way: higher risk with higher meat consumption. What’s going on? As near as one can guess, “correcting” for the confounders changed the direction….” They do not show most of the data or calculations but I take this to be equivalent to a multivariate analysis, that is, red meat + other things gives you risk. If they had broken up the population by quintiles of smoking, you would see that that was the real contributor. That’s how I interpreted it but, in any case, their conclusion is about meat and it is opposite to what the data say.

So how much do you gain from eating red meat? “A useful way to look at this data is from the standpoint of conditional probability. We ask: what is the probability of dying in this experiment if you are a big meat‑eater? The answer is simply the number of people who both died during the experiment and were big meat‑eaters …. = 0.0839 or about 8%. If you are not a big meat‑eater, your risk is …. = 0.109 or about 11%.” Absolute gain is only 3 %. But that’s good enough for me.

Me, at Jubilat, the Polish butcher in the neighborhood: “The Boczak Wedzony (smoked bacon). I’ll take the whole piece.”


Boczak Wedzony from Jubilat Provisions

Rashmi Sinha is a Senior Investigator and Deputy Branch Chief and Senior at the NIH. She is a member of the WHO panel, the one who says red meat will give you cancer (although they don’t say “if you have the right confounders.”)

So, buy my book: AmazonAlibris, or

Direct:  Personalized, autographed copy $ 20.00 free shipping USA only.  Use coupon code: SEPT16


…what metaphysics is to physics. The old joke came to mind when a reporter asked me yesterday to comment on a paper published in the BMJ. “Intake of saturated and trans unsaturated fatty acids and risk of all cause mortality, cardiovascular disease, and type 2 diabetes: systematic review and meta-analysis of observational studies” by de Souza, et al.

Now the title ““Intake of saturated and trans unsaturated fatty acids…” tells you right off that this is not good news; lumping together saturated fat and trans-fat is an indication of bias. A stand-by of Atkins-bashers, it is a way of vilifying saturated fat when the data won’t fit.  In the study that the reporter asked about, the BMJ provided a summary:

“There was no association between saturated fats and health outcomes in studies where saturated fat generally replaced refined carbohydrates, but there was a positive association between total trans fatty acids and health outcomes Dietary guidelines for saturated and trans fatty acids must carefully consider the effect of replacement nutrients.”

“But?” The two statements are not really connected. In any case the message is clear: saturated fat is Ok. Trans-fat is not Ok. So, we have to be concerned about both  saturated fat and trans-fat. Sad.

And “systematic” means the system that the author wants to use. This usually means a meta-analysis. Explained by the overly optimistic “What is …?” series:


The jarring notes are “precise estimate” in combination with “combining…independent studies.” In practice, you usually only repeat an experiment exactly if you suspect that something was wrong with the original study or if the result is sufficiently outside expected values that you want to check it. Such a systematic examination involves an analysis of the experimental details. The idea underlying the meta-analysis, however, usually unstated is that the larger the number of subjects in a study, the more compelling the conclusion. One might make the argument, instead, that if you have two or more studies which are imperfect, combining them is likely to lead to greater uncertainty and more error, not less.  I am one who would make such an argument. So where did meta-analysis come from and what, if anything, is it good for?

I am trained in enzyme and protein chemistry but I have worked in a number of different  fields including invertebrate animal behavior. I never heard of meta-analysis until very recently, that is, until I started doing research in nutrition. In fact, in 1970 there weren’t any meta-analyses, at least not with that phrase in the title, or at least not as determined by my PubMed search. By 1990, there were about a 100 and by 2014, there were close to 10, 000 (Figure 1).

Meta-anal_Year_Mar9Figure 1. Logarithm of the number of papers in PubMed search with the title containing “meta-analysis” vs. Year of publication

This exponential growth suggests that the technique grew by reproducing itself. It suggests, in fact, that its origins are in spontaneous generation. In other words, it is popular because it is popular. (It does have obvious advantages; you don’t have to do any experiments). But does it give any useful information?


If you have a study that is under-powered, that is, if you only have a small number of subjects, and you find a degree of variability in the outcome, then combining the results from your experiment with another small study may point you to a consistent pattern. As such, it is a last-ditch, Hail-Mary kind of method. Applying it to large studies that have statistically meaningful results, however, doesn’t make sense, because:

  1. If all of the studies go in the same direction, you are unlikely to learn anything from combining them. In fact, if you come out with a value for the output that is different from the value from the individual studies, in science, you are usually required to explain why your analysis improved things. Just saying it is a larger n won’t cut it, especially if it is my study that you are trying to improve on.
  2. In the special case where all the studies show no effect and you come up with a number that is statistically significant, you are, in essence saying that many wrongs can make a right as described in a previous blog post on abuse of meta-analyses.  In that post, I re-iterated the statistical rule that if the 95% CI bar crosses the line for hazard ratio = 1.0 then this is taken as an indication that there is no significant difference between the two conditions that are being compared. The example that I gave was the meta-analysis by Jakobsen, et al. on the effects of SFAs or a replacement on CVD outcomes (Figure 2). Amazingly, in the list of 15 different studies that she used, all but one cross the hazard ratio = 1.0 line. In other words, only one study found that keeping SFAs in the diet provides a lower risk than replacement with carbohydrate. For all the others there was no significant difference.  The question is why an analysis was done at all.  What could we hope to find? How could 15 studies that show nothing add up to a new piece of information? Most amazing is that some of the studies are more than 20 years old. How could these have had so little impact on our opinion of saturated fat?  Why did we keep believing that it was bad?


Figure 2. Hazard ratios and 95% confidence intervals for coronary events and deaths in the different studies in a meta-analysis from Jakobsen, et al.Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies. Am J Clin Nutr 2009, 89(5):1425-1432.

3. Finally, suppose that you are doing a meta-analysis on several studies and that they have very different outcomes, showing statistically significant associations in different directions. For example, if some studies showed substituting saturated fat for carbohydrate increased risk while some showed that it decreased risk. What will you gain by averaging them? I don’t know about you but it doesn’t sound good to me. It makes me think of the old story of the emerging nation that was planning to build a railroad and didn’t know whether to use a gauge that matched the country to the north or the gauge of the country to the south. The parliament voted to use a gauge that was the average of the two.

Following up from chapters in The World Turned Upside Down, I will try to provide a guide to getting through the medical literature. I will talk about relative risk first with an excerpt from the book and a quick way to get a feel for what relative risk really is.

It has been frequently pointed out that to succeed at major league baseball all you have to do is screw up no more than 70 % of the time. In fact ,it is almost 75 years since someone was able to come up with a failure rate as low as 60 %. (Ted Williams hit .406 in 1941). The point is that statistics is about interpretation. It is how you describe things. As in Paulos’s Once Upon a Number, mathematics and especially statistics is a story, and how you tell it.  The potential for being misled is obviously great. The idea that statistics is a cut-and-dried standard set of manipulations into which you pour your data and from which you are automatically given significance, importance and truth, is one of the major components in the failure of the medical nutrition literature. Read the rest of this entry »

In  The World Turned Upside Down. The Second Low-Carbohydrate Revolution, I add my voice to the critiques of the low-fat hypothesis and the sorry state of nutritional science. I also provide specific strategies on how to analyze reports in the literature to find out whether the main point of the paper is valid or not. The deconstructions of traditional nutrition, the “also bought” on the Amazon page, are numerous and continuing to proliferate as more and more people become aware of how bad things are. To me, the “surprise” in Nina Teicholz’s “Big Fat Surprise” is that, after all the previous exposés and my own research, there were deceptive practices and poor science that even I didn’t know about.

Even establishment voices are beginning to perceive how bad things are. So, with all these smoking guns why doesn’t anybody do anything? Why doesn’t somebody blow the whistle on them? It’s not like we are dealing with military intelligence.  What are they going to do? Not fund my grant? Not publish my paper? Ha.


“When you go to work today, imagine having a tape recorder attached to your body, a second one in your briefcase, and a third one in a special notebook, knowing that you will be secretly taping your supervisors, coworkers, and in some cases, your friends.” These are the opening lines of Mark Whitacre’s remarkable confession/essay/exposé (later a movie with Matt Damon) describing his blowing the whistle on Archer Daniels Midland (ADM) one of the largest food companies in the world; their motto at the time “ADM. Supermarket to the world.”

informant_lMatt Damon in The Informant!

It turned out that ADM had been colluding with its competitors to fix prices, in particular on the amino acid, lysine. Whitacre’s story is fascinating in detail.  Although relatively young, he was high up in the company, a division manager (“I lived in a huge home, which had an eight car garage filled with eight cars, and indoor horse-riding stables for my children”). He travelled around the world to big corporate meetings. At some point, encouraged by his wife whose ethical standards were quite a bit higher than his own, he became an FBI informant. Accompanying him in his business trips was a green lamp, housing a video feed. ”It is a good thing that all of the co- conspirators were men. A woman would have immediately noticed that this green lamp did not match the five star décor of some of the finest hotels, such as the Four Seasons in Chicago.” Ultimately, the lysine trial resulted in fines and three-year prison sentences for three of the executives of ADM as well as criminal fine for foreign companies worth $105 million, a record at the time. At the trial, things really went down-hill for the company when Whitacre produced a tape recording of the President of ADM telling executives that the company’s competitors were their friends and their customers were the enemy. Wits at the time suggested a new motto “ADM. Super mark-up to the world.” In the end, in a remarkable twist in the story, Whitacre’s whistle-blowing was compromised by the fact that he was on the take himself.

“I concluded that I would steal my own severance pay, and decided upon $9.5 million, which amounted to several years of my total compensation. …And I also considered what would happen if ADM learned of this theft. If they accused me, I thought that I had the perfect answer. How can you prosecute me for stealing $9.5 million when you are stealing hundreds of millions of dollars each year in the price fixing scheme? …. I decided to submit several bogus invoices to ADM, until I accumulated $9.5 million, which was meant to be my family’s financial security when I would be fired at a future date for being a whistleblower.”

As it turned out, a number of food and beverage companies, who had won hundreds of millions in settlements against ADM  were the ones who actually provided financial security for his family while Mark Whitacre spent nine years in prison.

Whistle blowing and imperial deshabillement

If it is not hidden, is it whistle-blowing? Did the kid “blow the whistle on the emperor’s new clothes?” If it is right out in the open, what is the scandal?  Well, there is open and there is open. Leaving out information may be a sign of a cover-up. I described, in my book, the case of the paper by Foster, et al., the conclusion of which was that “neither dietary fat nor carbohydrate intake influenced weight loss.”  I admitted, in the book, that:

“I had not read Foster’s paper very carefully before making the pronouncement that it was not very good. I was upbraided by a student for such a rush to judgment. I explained that that is what I do for a living. I explained that I usually don’t have to spend a lot of time on a paper to see the general drift…. but I was probably not totally convincing. So I read the paper, which is quite a bit longer than usual. The main thing that I was looking for was information on the nutrients that were actually consumed since it was their lack of effect that was the main point of the paper.…

In a diet experiment, the food consumed should be right up front but I couldn’t find it at all…. The data weren’t there. I was going to write to the authors when I found out…that this paper had been covered in a story in the Los Angeles Times. As reported by Bob Kaplan: ‘Of the 307 participants enrolled in the study, not one had their food intake recorded or analyzed by investigators. The authors did not monitor, chronicle or report any of the subjects’ diets. No meals were administered by the authors; no meals were eaten in front of investigators. There were no self‑reports, no questionnaires. The lead authors, Gary Foster and James Hill, explained in separate e-mails that self‑reported data are unreliable and therefore they didn’t collect or analyze any.’

I confess to feeling a bit shocked. I don’t like getting scientific information from the LA Times.  How can you say “neither dietary fat nor carbohydrate intake influenced weight loss” if you haven’t measured fat or carbohydrate? …. in fact, the whole nutrition field runs on self‑reported data. Is all that stuff from the Harvard School of Public Health, all those epidemiology studies that rely on food records, to be chucked out?”

So was this a breach of research integrity? It might be considered simply an error of omission. If you didn’t measure food consumed, you might think that you don’t necessarily have to put it in the methods. Was it just dumb not to realize that if you write a study of a diet comparison, you can’t leave out what people ate or at least admit that you didn’t measure what they ate. So can you blow the whistle on them for not telling the whole truth?  The authors were all well-known researchers, if party-liners.

The Office of Research Integrity is set up to police serious infractions in federally funded grants but it usually has to be clear cut and, sometimes, there is a whistle-blower. The Baltimore case is one of the better known if somewhat embarrassing cases for the agency — there was nothing to the whistle-blower’s allegations. In any case, there is a big gray area. If you falsify your data on a government research grant, you can go to jail.  If you make a dumb interpretation, however, if you say the data mean X when they show not-X, well, research is about unknowns, and you may have slipped up. Even Einstein admitted to the need to offer “sacrifices at the altar of Stupidity.” The NIH is supposed to not fund stuff like that. Editors and reviewers are supposed to see through the omission. What if they fell down on the job too? What if you have a field like nutrition where the NIH study sections are on the same wavelength as the researchers. There is, however, the question of the total impact. A lot of stuff is never cited and never does any harm. I enquired with the ORI, in a general way, about Foster’s paper. They said that if it is widely quoted, it could be an infraction. It has, in fact, been cited as evidence against low-carb diets. So am I going to be a whistle-blower? I don’t think so.

The problem is that only an insider can blow the whistle and although cooperation and collegiality remain very weak in the nutrition field, it is still our own nest and whistle-blowing makes everybody look bad. The “long blue line” does not form because the police think that corruption is okay. The problem is not just that there can be retribution, as in Serpico, but that it makes everybody look bad. It is simply that it reflects poorly on the whole police force. And while it is probable that, as Mark Whitacre said, “almost all of their 30,000 employees went to work each day doing the right thing morally and ethically,” the statement that “ADM was not a bad company” does not ring true. If we call attention to what is tolerated in medical nutrition, we are all looking like fools. And, of course, Foster’s paper is one of the more egregious but there is a lot of competition for worst. And it reflects badly on all of us in the field. “Is that what you do when you go to work?”

The parable of the big fish

I received an email from a physician in England. He has had consistently good results with low-carbohydrate diets.

“There is never a day when I don’t see the deleterious effects of too many carbs on those with the metabolic syndrome. And yet most doctors carry on as if it doesn’t exist !! …

Only yesterday I saw a man I have known for over 15 years. His GGT [gamma-glutamyl transferase; marker for liver disease] had always been about double normal. Embarrassingly I had assumed that he was a drinker, despite repeated denial, thinking his big belly was evidence!  He chose low carb on March 2013 and never looked back. Liver function normal now and an easy 7 Kg weight loss.”

He said that the information had been used in the production of the ABC Catalyst TV documentary from Australia, but:

“I am a very, very small fish! As smaller fish we GPs specialise in getting ideas across to ordinary folk. The Internet is democratising medicine faster than some big fish realise. I wrote my practical diabetes piece partly for the educated general public and insisted on open access.

Big fish will scoff at my small numbers (70) and lack of double blindness anyway.”

I assured him that he was making an impact, that n = 70 was fine and not to worry about the big fish. I related a story told to me by one of my colleagues in graduate school: he had gone fishing in the Gulf of Mexico and they had caught a very big fish (I no longer remember the kind) which was thrashing around on the deck and they could not contain it. There happened to be a rifle on board and somebody shot the fish. The bullet went through the bottom of the boat which sank.


I was walking on a very dark street and I assumed that the voice I heard was a guy talking on a cell phone. Apparently about a dinner party, he was saying “Remember, I don’t eat red meat.” Only a few years ago, that would have sounded strange. Of course, a few years ago a man talking to himself on the street would have been strange. He would have been assumed to be deranged, more so if he told you that he was talking on the telephone. But yesterday’s oddity pops up everywhere today. Neo-vegetarianism affects us all. It’s all described very well by Jane Kramer’s excellent review of veggie cookbooks in the April 14 New Yorker,

“…from one chili party to the next, everything changed. Seven formerly enthusiastic carnivores called to say they had stopped eating meat entirely…. Worse, on the night of that final party, four of the remaining carnivores carried their plates to the kitchen table, ignoring the cubes of beef and pancetta, smoky and fragrant in their big red bean pot, and headed for my dwindling supply of pasta. “Stop!” I cried. “That’s for the vegetarians!”

Illustration by Robin Feinman. Reference:

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The  SBU (Swedish Council on Health Technology Assessment) is charged by the Swedish government with assessing health care treatments. Their recent acceptance of low-carbohydrate diets as best for weight loss is one of the signs of big changes in nutrition policy.  I am happy to reveal the next bombshell, this time from the American Diabetes Association (ADA) which will finally recognize the importance of reducing carbohydrate as the primary therapy in type 2 diabetes and as an adjunct in type 1.  Long holding to a very reactionary policy — while there were many disclaimers, the ADA has previously held 45 – 60 % carbohydrate as some kind of standard — the agency has been making slow progress. A member of the writing committee who wishes to remain anonymous has given me a copy of the 2014 nutritional guidelines due to be released next year, an excerpt from which, I reproduce below. Read the rest of this entry »

tarnowerhermanThe only person definitely known to have died as a consequence of an association with a low-carbohydrate diet is Dr. Herman Tarnower, author of the Scarsdale diet, although, as they used to say on the old TV detective shows, the immediate cause of death was lead poisoning. His girlfriend shot him. Not that folks haven’t been looking for other victims. The Atkins diet is still the bête noire of physicians, at least those who aren’t on it — a study published a few years ago said that physicians were more likely to follow a low carbohydrate diet when trying to lose weight themselves, while recommending a low fat diets for their patients.

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