Posts Tagged ‘carbohydrate’

The attack was quite sudden although it appeared to have been planned for many years. The paper was published last week (Augustin LS, Kendall CW, Jenkins DJ, Willett WC, Astrup A, Barclay AW, Bjorck I, Brand-Miller JC, Brighenti F, Buyken AE et al: Glycemic index, glycemic load and glycemic response: An International Scientific Consensus Summit from the International Carbohydrate Quality Consortium (ICQC). Nutr Metab Cardiovasc Dis 2015, 25(9):795-815.

Augustin_Stresa+Nov_27

As indicated by the title, responsibility was taken by the self-proclaimed ICQC.  It turned out to be a continuation of the long-standing attempt to use the glycemic index to co-opt the obvious benefits in control of the glucose-insulin axis while simultaneously attacking real low-carbohydrate diets. The authors participated in training in Stresa, Italy.

The operation was largely passive aggressive. While admitting the importance of dietary carbohydrate in controlling post-prandial glycemic,  low-carbohydrate diets were ignored. Well, not exactly. The authors actually had a strong attack.  The Abstract of the paper said (my emphasis):

Background and aims: The positive and negative health effects of dietary carbohydrates are of interest to both researchers and consumers.”

Methods: International experts on carbohydrate research held a scientific summit in Stresa, Italy, in June 2013 to discuss controversies surrounding the utility of the glycemic index (GI), glycemic load (GL) and glycemic response (GR).”

So, for the record, the paper is about dietary carbohydrate and about controversies.

The Results in Augustin, et al were simply

“The outcome was a scientific consensus statement which recognized the importance of postprandial glycemia in overall health, and the GI as a valid and reproducible method of classifying carbohydrate foods for this purpose…. Diets of low GI and GL were considered particularly important in individuals with insulin resistance.”

A definition is always a reproducible way of classifying things, and the conclusion is not controversial: glycemia is important.  Low-GI diets are a weak form of low-carbohydrate diet and they are frequently described as a politically correct form of carbohydrate restriction. It is at least a subset of carbohydrate restriction and one of the “controversies” cited in the Abstract is sensibly whether it is better or worse than total carbohydrate restriction. Astoundingly, this part of the controversy was ignored by the authors.  Our recent review of carbohydrate restriction in diabetes had this comparison:

 

 

15_Th_Westman_Jenkins_Mar25-2

A question of research integrity.

It is considered normal scientific protocol that, in a scientific field, especially one that is controversial, that you consider and cite alternative or competing points of view. So how do the authors see low-carbohydrate diets fitting in? If you search the pdf of Augustin, et al on “low-carbohydrate” or “low carbohydrate,” there are only two in the text:

“Very low carbohydrate-high protein diets also have beneficial effects on weight control and some cardiovascular risk factors (not LDL-cholesterol) in the short term, but are associated with increased mortality in long term cohort studies [156],”

and

“The lowest level of postprandial glycemia is achieved using very low carbohydrate-high protein diets, but these cannot be recommended for long term use.”

There are no references for the second statement but very low carbohydrate diets can be and frequently are recommended for long term use and have good results. I am not aware of “increased mortality in long term cohort studies” as in the first statement. In fact, low-carbohydrate diets are frequently criticized for not being subjected to long-term studies. So it was important to check out the studie(s) in reference 156:

[156] Pagona L, Sven S, Marie L, Dimitrios T, Hans-Olov A, Elisabete W. Low carbohydrate-high protein diet and incidence of cardiovascular diseases in Swedish women: prospective cohort study. BMJ 2012;344.

Documenting increased mortality.

The paper is not about mortality but rather about cardiovascular disease and, oddly, the authors are listed by their first names. (Actual reference: Lagiou P, Sandin S, Lof M, Trichopoulos D, Adami HO, Weiderpass E: . BMJ 2012, 344:e4026). This minor error probably reflects the close-knit “old boys” circle that functions on a first name basis although it may also indicate that the reference was not actually read so it was not discovered what the reference was really about.

Anyway, even though it is about cardiovascular disease, it is worth checking out. Who wants increased risk of anything. So what does Lagiou, et al say?

The Abstract of Lagiou says (my emphasis) “Main outcome measures: Association of incident cardiovascular diseases … with decreasing carbohydrate intake (in tenths), increasing protein intake (in tenths), and an additive combination of these variables (low carbohydrate-high protein score, from 2 to 20), adjusted for intake of energy, intake of saturated and unsaturated fat, and several non-dietary variables.”

Low-carbohydrate score? There were no low-carbohydrate diets. There were no diets at all. This was an analysis of “43, 396 Swedish women, aged 30-49 years at baseline, [who] completed an extensive dietary questionnaire and were followed-up for an average of 15.7 years.” The outcome variable, however, was only the “score” which the authors made up and which, as you might guess, was not seen and certainly not approved, by anybody with actual experience with low-carbohydrate diets. And, it turns out that “Among the women studied, carbohydrate intake at the low extreme of the distribution was higher and protein intake at the high extreme of the distribution was lower than the respective intakes prescribed by many weight control diets.” (In social media, this is called “face-palm”).

Whatever the method, though, I wanted to know how bad it was? The 12 years or so that I have been continuously on a low-carbohydrate diet might be considered pretty long term. What is my risk of CVD?

Results: A one tenth decrease in carbohydrate intake or increase in protein intake or a 2 unit increase in the low carbohydrate-high protein score were all statistically significantly associated with increasing incidence of cardiovascular disease overall (n=1270)—incidence rate ratio estimates 1.04 (95% confidence interval 1.00 to 1.08), 1.04 (1.02 to 1.06), and 1.05 (1.02 to 1.08).”

Rate ratio 1.04? And that’s an estimate.  That’s odds of 51:49.  That’s what I am supposed to be worried about. But that’s the relative risk. What about the absolute risk? There were 43 396 women in the study with 1270 incidents, or 2.9 % incidence overall.  So the absolute difference is about 1.48-1.42% = 0.06 % or less than 1/10 of 1 %.

Can such low numbers be meaningful? The usual answers is that if we scale them up to the whole population, we will save thousands of lives. Can we do that? Well, you can if the data are strong, that is, if we are really sure of the reliability of the independent variable. The relative risk in the Salk vaccine polio trial, for example, was in this ballpark but scaling up obviously paid off. In the Salk vaccine trial, however, we knew who got the vaccine and who didn’t. In distinction, food questionnaire’s have a bad reputation. Here is Lagiou’s description (you don’t really have to read this):

“We estimated the energy adjusted intakes of protein and carbohydrates for each woman, using the ‘residual method.’ This method allows evaluation of the “effect” of an energy generating nutrient, controlling for the energy generated by this nutrient, by using a simple regression of that nutrient on energy intake.…” and so on. I am not sure what it means but it certainly sounds like an estimate. So is the data itself any good? Well,

“After controlling for energy intake, however, distinguishing the effects of a specific energy generating nutrient is all but impossible, as a decrease in the intake of one is unavoidably linked to an increase in the intake of one or several of the others. Nevertheless, in this context, a low carbohydrate-high protein score allows the assessment of most low carbohydrate diets, which are generally high protein diets, because it integrates opposite changes of two nutrients with equivalent energy values.”

And “The long interval between exposure and outcome is a source of concern, because certain participants may change their dietary habits during the intervening period.”

Translation: we don’t really know what we did here.

In the end, Lagiou, et al admit “Our results do not answer questions concerning possible beneficial short term effects of low carbohydrate or high protein diets in the control of body weight or insulin resistance. Instead, they draw attention to the potential for considerable adverse effects on cardiovascular health of these diets….” Instead? I thought insulin resistance has an effect on CVD but if less than 1/10 of 1 % is “considerable adverse effects” what would something “almost zero” be.?

Coming back to the original paper by Augustin, et al, what about the comparison between low-GI diets and low-carbohydrate diets. The comparison in the figure above comes from Eric Westman’s lab. What do they have to say about that?

Augustin_

They missed this paper. Note: a comment I received suggested that I should have searched on “Eric” instead of “Westman.” Ha.

Overall, this is the evidence used by ICQC to tell you that low-carbohydrate diets would kill you. In the end, Augustin, et al is a hatchet-job, citing a meaningless paper at random. It is hard to understand why the journal took it. I will ask the editors to retract it.

In  The World Turned Upside Down. The Second Low-Carbohydrate Revolution, I added my voice to the critiques of the low-fat hypothesis and the sorry state of nutritional science. I also provided 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” of my book 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.

Whistleblowing

“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.

Carrot_Nation-3c

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: http://en.wikipedia.org/wiki/Carrie_Nation.

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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. (more…)

Paris. The summer of 1848. Mobs filled the streets, building barricades just like in Les Mis. If they’d had cars, they probably would have been set on fire.  In February of that year, the King, Louis-Phillipe, had abdicated in yet another French Revolution.  There was a new government, what is called the Second Republic, but whatever it tried to do, it didn’t make anybody happy and there was more unrest. At the Collège de France, faculty complained that it had “slackened the zeal for research among all of the chemists, and all of their time … is absorbed by politics.”

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 Figure 1. The Revolution of 1848. Barricades on the Rue Soufflot (Horace Vernet)

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My comments in answer to Jonny Bowden’s Huffington Post take on the sugar tax where he suggested that despite it’s flaws, “it’s all we’ve got.” I insisted that It’s not all we’ve got. We have the science and, in one afternoon, Bloomberg could convene a panel of scientists to evaluate presentations by all the players including me who believe that sugar is a smokescreen for not facing the importance of total carbohydrate restriction which you [Jonny Bowden], among others, have explained. Everybody should be heard. What I see is another rush to judgement like the low fat fiasco which we still have with us.

That you “have to do something” comes right out of Senator McGovern’s mouth as in Fat Head. And “deadly white substance that literally creates hormonal havoc and appetite dysregulation … promoting metabolic syndrome, diabetes, obesity and heart disease” is way outside of the bounds of science. I am not the only one to point out that Lustig’s population study represented the return of Ancel Keys.

We go with science or we don’t.

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Everybody has their favorite example of how averages don’t really tell you what you want to know or how they are inappropriate for some situations. Most of these are funny because they apply averages to cases where single events are important. I’ll list a couple in the text boxes in this post. From the title:

If Bill Gates walks into a bar, on average, everybody in the bar is a millionaire.

Technically speaking, averages start with the assumption that deviations are due to random error, that is, that there is a kind of “true” value if we could only control things well — if there were no wind resistance and all balls were absolutely uniform, they would always fall in the same place; any spread in values is random rather than systematic.
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