Posts Tagged ‘insulin’

Stone-walling low-carbohydrate diets. Attack of the self-proclaimed ICQC

Posted: December 1, 2015 in Crisis in Nutrition, glucose, glycemic index, low-carbohydrate diet, misuse of statistics, Research Integrity
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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.

Targeting insulin inhibition as a metabolic therapy in advanced cancer. Part 2. The hypothesis.

Posted: November 30, 2012 in Cancer, Cell Signaling, evolution, ketogenic diet, low-carbohydrate diet
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Guest post: Dr. Eugene J. Fine

Last time I discussed our pilot study showing the effects of carbohydrate (CHO) restriction & insulin inhibition (INSINH) in patients with advanced cancers.  We described how the molecular effects of INSINH plus systemic (total body) effects like ketosis might inhibit cancer growth. My goal now is to present the underlying hypothesis behind the idea with the goal of understanding how patients with cancers might respond if we inhibited insulin’s actions? Should all patients respond? If not, why not? Might some patients get worse? These ideas were described briefly in our publication describing our pilot protocol. (more…)

Suddenly last summer. Part II

Posted: October 2, 2012 in Cancer, Cell Signaling, low-carbohydrate diet
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In the last post, I had proclaimed a victory for dietary carbohydrate restriction or, more precisely, recognition of its explicit connection with cell signaling. I had anointed the BMC Washington meeting as the historic site for this grand synthesis. It may have been a matter of perception — many researchers in carbohydrate restriction entered the field precisely because it came from the basic biochemistry where the idea was that the key player was the hormone insulin and glucose was the major stimulus for pancreatic secretion of insulin. We had largely ignored the hook-up with cell-biology because of the emphasis on calorie restriction, and it may have only needed getting everybody in the same room to see that the role of insulin in cancer was not separate from its role in carbohydrate restriction. (more…)

Intro to Fatty Acids and Triglycerides

Posted: October 20, 2011 in lipid metabolism, low-carbohydrate diet, Protein, triglycerides
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The following question was posted on Facebook:

I had thought that free fatty acids were triglycerides. But I am reading a study that measured both. Can someone enlighten me on free fatty acids? … please.

 I think I can help.  The good news is that, contrary to the college myth, organic chemistry is easy — it is freshman chemistry that is hard because it has more physics and mathematics.  Now, jumping into lipid metabolism is a little bit of starting in the middle of things but the reason organic chemistry is easy is that it has only a few assumptions and basic principles and the basic theory, at least, is logical and you can get pretty far deducing things from simple principles, so with a few basic ideas we may have a shot. I have two YouTube videos that are short, relatively easy and might be a background.  The take home message from the videos, the one big idea in organic, is that organic compounds have two parts: A hydrocarbon backbone and a non-hydrocarbon part that contains the chemically reactive part of the molecule, the functional groups. The assumption is that all compounds with the same functional group have similar chemistry.  So, for example, all carboxylic acids have the carboxyl (-COOH) functional group. In many ways, even a simple acid like acetic acid has chemical properties that are similar to a complicated acid, like the fatty acids.  You may need the YouTube to appreciate this: chemistry is about structure, that is, it is visual.

Bottom line on fatty acids and Triglycerides

All dietary and body fats and oils are triglycerides (TG) or, more correctly, triacylglycerols (TAG).  The term “acyl” (pr. A-sill) is the adjective form of acid (i.e. There are three acids).

Fats have a roughly E-shaped structure. The arms of the E are the fatty acids and there are three of them. The fatty acids provide the real fuel in fats.  The three fatty acids are attached to the compound glycerol which is the vertical stroke of the E.  The chemical bond that attaches the fatty acid  to the glycerol is called an ester bond.  You only need to know the term ester because when the fatty acids are found alone, especially in blood, they are referred to either as free fatty acids (FFA) or, because they are no longer attached to the glycerol by the ester bonds, as non-esterified fatty acids (NEFA): FFA and NEFA are the same thing.

Metabolism: the fatty acid-TAG cycle.

The digestion of fat in the intestine involves the progressive removal of the fatty acids from the first and last position of the glycerol.  The process is called lipolysis and the enzyme that catalyzes the reaction is called a lipase. What remains is called 2-monoacylglycerol, or 2-MAG  (fatty acid still attached at the center carbon of glycerol) and  2-MAG and the free fatty acids from digestion are absorbed into the intestinal cells.  Within these cells they are re-formed into TAG which is exported together with cholesterol and other components in particles called chylomicrons.  Chylomicrons, in turn, represent one type of complex structure known as lipoproteins. The lipoproteins transport lipids and some of these are familiar, e.g., LDL (low density lipoprotein), HDL. Triglycerides in the blood are carried in these particles. So this is probably the triglycerides you read about.

These are the transporters of lipids.  TAG, in particular is brought into cells by another lipase (lipoprotein lipase or LPL) on the cell surface that removes the fatty acids.  In other words, to be absorbed the TAG is broken down into fatty acids again.  Once absorbed, the fatty acids can be oxidized for fuel or, once again can be re-synthesized, step-wise: → MAG → diacylglycerol (DAG)  → TAG.  Here’s the summary figure:

Bottom line:

Fat (TAG) is continually broken down and re-synthesized.  The breakdown process is called lipolysis and the lipolysis-synthesis cycle goes on in different places in the body but notably in fat cells.  An interesting thing about fat cells is the way they carry out the cycle. Lipolysis is a simple process but synthesis is complicated.  Speaking in energy terms, it is easy to break down nutrients. It requires energy to put them back together.  To make TAG, either the glycerol or the fatty acid has to be “activated”: so the actual reactive form is a molecule called fatty acyl-coenzyme A or fatty acyl-CoA (pr. Co-A).

Biochemical reactions almost never run by themselves even if energetically favorable but are rather controlled by catalysts, that is, enzymes.  The enzyme that catalyzes the first step in the reaction, a transferase, will not work with glycerol itself.  The enzyme requires a particular form of glycerol, glycerol-phosphate.  The special characteristic of the fat cell is that the required glycerol-phosphate cannot be made directly from glycerol as it can, for example, in the liver which also has an active fatty acid-TAG cycle.  In order to make glycerol phosphate, fat cells require glucose. In the absence of glucose, as in starvation or a low carbohydrate diet, fat synthesis is repressed.  At the same time the enzyme that catalyzes breakdown, hormone-sensitive lipase, is enhanced because it is turned on by glucagon and turned offby insulin (these are the hormones in the term “hormone-sensitive lipase”).  This was the original rationalization for the apparent advantage in a low-carbohydrate diet: without carbohydrate the adipocyte would not be able to supply glycerol-phosphate and the fatty acid-TAG cycle would go largely in one direction: breakdown to produce fatty acids and this is undoubtedly one of the major effects.

It turns out, however, that the fat cells protect stores of energy in fat by other methods. We now understand that cells run a process called glyceroneogenesis which is a truncated form of gluconeogenesis, the process whereby glucose is synthesized from other nutrients, mostly protein, that is, the process supplies an intermediate in the synthesis of glucose and this can be converted to glycerol-phosphate. Generally, especially if the diet is hypocaloric, the net effect is to break down fat and supply fatty acids as a fuel for other cells.  Fatty acids circulate in the blood bound to a protein called albumin. Under conditions where there is higher carbohydrate, however, and the fatty acids are not being used for fuel, they can stimulate insulin resistance. So, fatty acids in the blood are a good thing if you are breaking down fat to supply energy.  They are not so good if you are over-consuming energy or carbohydrates because, in the presence of insulin, they can lead to insulin resistance.

Summary: triglycerides are made of three fatty acids.  There is a continual fatty acid-TAG cycle that goes on all the time in different cells.  Triglycerides in the blood are carried in lipoprotein particles, chylomicrons, LDL, HDL.  Fatty acids in the blood are carried by the protein albumin.

Wait a Minute, Lustig. The Threat of Fructophobia. And the Opportunity.

Posted: July 29, 2011 in low-carbohydrate diet
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“The truth?  If I wanted the truth, I would have called Sixty Minutes.”

— Spiros Focás in Jewel of the Nile.

Sugar is an easy target. These days, if you say “sugar” people think of Pop-Tarts® or Twinkies®, rather than pears in red wine or tamagoyaki the traditional sweet omelet that is a staple in Bento Boxes.  Pop-Tarts® and Twinkies® are especially good targets because, in addition to sugar (or high fructose corn syrup (HFCS), they also have what is now called solid fat (the USDA thinks that “saturated” is too big a word for the average American ) and the American Heart Association and other health agencies are still down on solid fat.  Here’s a question, though: if you look on the ingredients list for Twinkies®, what is the first ingredient, the one in largest amount?  (Answer at the end of this post).

The Threat

What went wrong in the obesity epidemic?  There is some agreement that by focussing on fat, the nutritional establishment gave people license to over-consume carbohydrates. The new threat is that by focusing now on fructose, the AHA and USDA and other organizations are giving implicit license to over-consume starch — almost guaranteed since these agencies are still down on fat and protein.  The additional threat is that by creating an environment of fructophobia, the only research on fructose that will be funded are studies at high levels of total carbohydrate where, because of the close interaction between glucose and fructose, deleterious effects are sure to be found. The results will be generalized to all conditions.  Like lipophobia, there will be no null hypothesis.

The latest attack on sugar and on fructose itself (sugar and HFCS are half fructose) comes from Robert Lustig, a pediatrician at University of California San Francisco. His lecture describing fructose as a virtual poison got more than a million and a half hits on YouTube.  The presentation has an eponymous style (Lustig, Ger. adj., merry, amusing, e.g. Die Lustige Witwe, The Merry Widow) and includes a discussion of the science bearing on fructose metabolism. While admitting the limitations of that science, even Gary Taubes was worried. Comments on YouTube and other sites say they liked the science but did not agree with his recommendations — it will turn out that he now wants government control of sugar consumption, especially for my kid and yours.

The presentation of the science is compelling but, while it has a number of important points, it is clearly biased and, oddly, a good deal of it is totally wrong, some of it containing elementary errors in chemistry that border on the bizarre — how hard would it have been to open an elementary organic chemistry text?  In trying to draw parallels between alcohol and fructose, Lustig says “ethanol is a carbohydrate.” Ethanol is not a carbohydrate.  A horse is not a dog. If you said that ethanol is a carbohydrate in sophomore Organic Chemistry, you would get it wrong. Period. No partial credit. Such elementary errors compromise the message and raise the question in what way Lustig is an expert in this field.  It gets worse.

It is biological function that is important and ethanol is not processed like fructose as Lustig says. There is very little chemical sense in saying that ethanol and fructose are processed biologically in similar ways.  And a metabolic pathway is shown in which glycogen is absent. Glycogen is the storage form of glucose and is generally taken as a good thing because of its relation to endurance in athletes but, like fat, glycogen is a storage form of energy and having a lot is not always a good thing.  In any case, it is not true that fructose does not give rise to glycogen.  In fact, fructose is generally better at forming glycogen than glucose is.  This is especially true when you consider the effect of exercise which is why Gatorade® may actually be a good thing if you are in a football game rather than watching one. This is the general error in Lustig’s talk.  Metabolism is not static and has evolved to deal with changing conditions of diet and environment. A metabolic chart, like any map only tells you where you can go, not whether you go there. And the notable absence in Lustig’s talk is data.

It is possible that  sugar and ethanol have behavioral effects  in common but this is not due to similarities in metabolism.  And even the behavioral effects are not settled within the psychology community; alcoholism is far different from “sugar addiction,” if there is such a thing; polishing off the whole container of Häagen-Dazs® may not technically qualify as addictive behavior.

The Threat of Policy

All of this might be okay — Lustig’s lecture was not a scientific treatise — except that he has gone to the next step.  Convinced of the correctness of his analysis, he wants government intervention to control sugar and sweeteners in some way .  There is an obvious sense of deja-vu as another expert attempts to use the American population as Guinea pigs for a massive population experiment, like the low fat fiasco under which we still suffer. It is not just that we got unintended consequences (think margarine and trans-fats) but rather that numerous people have pointed out that the science was never there for low-fat to begin with (brilliantly explained in Fat Head).  In other words leaving aside the question of when we should turn science into policy, is the science any good?

Fructose

It is important to understand that fructose is not a toxin. It is a normal metabolite. If nothing else, your body makes a certain amount of fructose.  Fructose, not music (the food of love), is the preferred fuel of sperm cells. Fructose formed in the eye can be a risk but its cause is generally very high glucose. Fructose is a carbohydrate and is metabolized in ways similar to, if different in detail, from glucose but a substantial amount (can be 60 %) of fructose is turned to glucose — that is why the glycemic index of fructose is 20 and not zero.

The extent to which fructose metabolism has a uniquely detrimental effect is strongly dependent on conditions.  Fructose may be worse than glucose under conditions of very high carbohydrate intake but its effect will change as total carbohydrate is lowered. And since carbohydrate across the board is what is understood to be the problem — Lustig states that clearly in his YouTube — policy would suggest that that is the first line of attack on health — reduce carbohydrate (emphasizing fructose if you like) but as carbohydrate and calories are reduced, any effect of fructose will be minimized.  In the extreme, if you are on a very low carbohydrate diet, any fructose you do eat is likely to be turned into glucose.

The Opportunity

Lustig makes his case against fructose in terms of fundamental biochemistry which is really how it should be.  Can biochemistry be explained to the general population?  Can the problem be explained in a simple but precise way so that we really have the sense of talking about science and not politics?  So what is needed is somebody who actually knows biochemistry.  Maybe somebody with experience in teaching biochemistry to future doctors.  Hey, that’s my job description.  In fact, I’m going to try that in the next few blogs and on YouTube. I and others have  taught courses that try to reduce the three year sequence that professional chemists follow: general chemistry-organic chemistry-biochemistry.  I will try to give everybody a window into organic chemistry, biochemistry and metabolism. In fact, that might be a good focus for government intervention. Instead of punishing the patient, how about funding for teaching biochemistry to the public. For the moment, though, let’s look at some population data.

Sweetener Consumption.

What about sweeteners?  Well, of course, consumption has gone up. Surprisingly, not as much as one would have thought.  According to the USDA about 15 %.  One question is whether this increase is disproportionately due to fructose. The figures below show that, in fact, the ratio of fructose to glucose has remained constant over the last 40 years.  (The deviation from 1:1 which would be expected for pure sucrose or HFCSA, is due to a  relatively constant 20 % or so of pure glucose that  is used in sweetening in the food industry). It is possible that, although the ratio is the same, that the absolute increase in  fructose has a worse effect than the increased glucose but, of course, you would have to prove it.  The figures suggest, however, that you will have to be careful in determining whether the effect of increased sweetener is due to fructose or glucose, or the effect of one on the other, or the effect of insulin and other hormones on both.  An unrestrained, lustige, lack of anything careful is exactly the current threat.

Answer to “puzzler:” The main ingredient in Pop-Tarts® and Twinkies® is flour. Some people say that if you add up the different forms of sugar that will be greater but like all ideas derived from Lustig, there is an advantage in looking at the data: 38 g. of carbohydrate, 17 g. of sugars.

Fair and Foul on the Diabetes Scene. Diabetes Health beats Jay Leno but the ADA takes the Cake.

Posted: July 14, 2011 in American Diabetes Association, Dietary Fiber, The Nutrition Story
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“Headlines” is one of Jay Leno’s routines on The Tonight Show. While low on production values, it provides amusing typos, odd juxtapositions of text and inappropriate couplings from real notices and newspapers. The headlines are frequently very funny since, like fiction in general, authored comedy has to be plausible. There have been many other versions of the same idea including items in the New Yorker but Jay Leno’s audience rapport adds to the impact. Expert as he is, though, Jay seemed a little off guard when nobody laughed at the headline: “The Diabetes Discussion Group will meet at 10 AM right after the pancake breakfast.” It’s probably generational. After 30 or so years having the American Diabetes Association tell you that sugar is Ok as long as you “cover it with insulin” and that diabetes, a disease of carbohydrate intolerance, is best treated by adding carbohydrate and reducing fat, who knows what anybody believes.

One of the headlines on a previous show that did get a laugh said: “To increase gas mileage, drive less.”  (If Jay only knew how much we spent to get the USDA committee to come up with the advice that if you want to lose weight, you should eat less).

“.. Have we eaten on the insane root,
That takes the reason prisoner?”
— William Shakespeare, Macbeth.

For tragic humor in the bizarre field of diabetes information, it is really hard to compete. About the same time as the headlines sequence on the Tonight Show, DiabetesHealth  an organization and website that is intended to “investigate, inform, inspire” produced an inspiring investigation from the literature. The story is entitled “Maple Syrup – A Sweet Surprise.”  You gotta’ read this:

 “Meet the latest superfood: maple syrup.  Wait a minute…maple syrup? The super-sugary stuff poured on pancakes and waffles and used to glaze hams? That maple syrup? That’s right. Researchers from the University of Rhode Island have discovered that the syrup-produced in the northeastern United States and Canada–contains numerous compounds with real health benefits.”

So how did people with diabetes fare on the maple syrup? Well, there were no people. Or animals. The researchers did not test the effect of consumed maple syrup but only chemically analyzed samples of the stuff.

“‘In our laboratory research, we found that several of these compounds possess anti-oxidant and anti-inflammatory properties, which have been shown to fight cancer, diabetes, and bacterial illnesses,’ said Navindra Seeram, an assistant professor of pharmacognosy (the study of medicines derived from natural sources) at the university and the study’s lead author”

“Pharmacognosy,” incidentally, is the only English word correctly pronounced through the nose.  The article indicates that “a paper describing their results will appear in the Journal of Functional Foods. Scientists hope that these discoveries could lead to innovative treatments as the beneficial substances are synthesized to create new kinds of medicine.”  The article, however, is nothing if not circumspect:

“You might want to pause for a moment before rushing out and buying jug after jug of Canada’s finest maple syrup, though. It still contains plenty of sugar,…” In fact, by far the major ingredient in maple syrup is sucrose which, again, only has to be “covered” with insulin. So, with all those beneficial compounds, we will need less insulin per gram of sucrose with maple syrup, right?    Would Jay Leno have gotten a laugh if the diabetes meeting followed the pancakes and maple syrup breakfast?  How about if they were whole grain pancakes?

“If you can look into the seeds of time,
And say which grain will grow, and which will not…”
— William Shakespeare, Macbeth.

Not to be outdone, the American Diabetes Association website offers the lowdown on just how good grain is. Fiber, in general, is so good for you that you should be careful not to snarf it up too fast. As they point out, it is “important that you increase your fiber intake gradually, to prevent stomach irritation, and that you increase your intake of water and other liquids, to prevent constipation.” Doesn’t really sound all that healthy but foods with fiber “have a wealth of nutrition, containing many important vitamins and minerals.” Now, vitamin deficiency has always seemed to me to be the least of our nutritional problems but there’s more: “In fact,” using fact in its non-traditional meaning, fiber “may contain nutrients that haven’t even been discovered yet!” (their exclamation point). Not to belabor all the metaphors here, the ADA, long telling us that people with diabetes deserve to have their carbs, are surely offering pie in the sky.

Metabolic advantage, “a calorie is a calorie,” and why the First Law of Thermodynamics does not apply.

Posted: June 6, 2011 in low-carbohydrate diet, The Nutrition Story, thermodynamics
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The big news in the low carb world is that Consumer Reports has published, for the first time, faint praise for the Atkins diet. However, the vision one might have of CR employees testing running shoes on treadmills doesn’t really apply here. They did not put anybody on a diet, even for a day. They didn’t have to. They have the standards from the government. Conform to the USDA Guidelines and CR will give you thumbs up. It probably doesn’t matter since, these days, most people buy a food processor by checking out the reviews on the internet — there are now many reviews online of what it’s like to actually be on a low-carbohydrate diet, so rather than follow CR’s imaginings of what it’s like, you can check out what users say — Jimmy Moore, Tom Naughton and Laura Dolson together get about 1.5 million posts per month with many tests and best buy recommendations. What caught my eye, though, is the ubiquitous Dean Ornish; the ratio of words written about the Ornish diet to the number of people who actually use it is probably closing in on a googol (as it was originally spelled). The article says: “to lose weight, you have to burn up more calories than you take in, no matter what kind of diet you’re on. ‘The first law of thermodynamics still applies,’ says Dean Ornish, M.D.

That’s how I got into this field. My colleague Gene Fine, and I published our first papers in nutrition on the subject of metabolic advantage and thermodynamics and we gave ourselves credit for reducing the number of people invoking laws of thermodynamics. “Metabolic advantage” refers to the idea that you can lose more weight, calorie-for-calorie on a particular diet, usually a low-carbohydrate diet. (The term was used in a paper by Browning to mean the benefits in lipid metabolism of a low-carbohydrate diet, but in nutrition you can re-define anything you want and you don’t have to cite anybody else’s work if you don’t want to). The idea of metabolic advantage stands in opposition to the idea that “a calorie is a calorie” which is, of course, the backbone of establishment nutrition and all our woe. As in the CR article, whenever the data show that a low-carbohydrate diet is more effective for weight loss, somebody always jumps in to say that it would violate the laws of thermodynamics. Those of us who have studied or use thermodynamics recognize that it is a rather difficult subject — somebody called it the physics of partial differential equations — and we’re amazed at how many experts have popped up in the nutrition field.

Finding the right diet doesn’t require knowing much thermodynamics but it is an interesting subject and so I’ll try to explain what it is about and how it’s used in biochemistry. The physics of heat, work and energy, thermodynamics was developed in the nineteenth century in the context of the industrial revolution — how efficiently you could make a steam engine operate was a big deal.  Described by Prigogine as the first revolutionary science, it has some interesting twists and intellectual connections. The key revolutionary concept is embodied tin the second law which describes the efficiency of physical processes.  It has broad philosophical meaning.  The primary concept, the entropy, is also used in communication and  the content of messages in information theory.  The entropy of a message is, in one context, how much a message has been garbled in transmission.  The history of thermodynamics also has some very strange characters, besides me and Gene, so I will try to describe them too.

First, we can settle the question of metabolic advantage, or more precisely, energy inefficiency. The question is whether all of the calories in food are available for weight gain or loss (or exercise) regardless of the composition of the diet. Right off, metabolic advantage is an inherent property of higher protein diets and low carbohydrate diets. In the first case, the thermic effect of feeding (TEF) is a measure of how many of the calories in food are wasted in the process of digestion, absorption, low-level chemical transformation, etc. TEF (old name: specific dynamic action) is well known and well studied. Nobody disputes that the TEF can be substantial for protein, typically 20 % of calories. It is much less for carbohydrate and still less for fat. So, substituting any protein for either of the other macronutrients will lead to energy inefficiency (the calories will be wasted as heat). A second unambiguous point is that in the case of low-carbohydrate diets, in order to maintain blood glucose, the process of gluconeogenesis is required. You learn in biochemistry courses that it requires a good deal of energy to convert protein (the major source for gluconeogenesis) into glucose.

So, right off, metabolic advantage or energy inefficiency is known and measurable. Critics of carb restriction as a strategy admit that it occurs but say that it is too small in a practical sense to be worth considering when you are trying to lose weight. These are usually the same people who tell you that the best way to lose weight is through accumulation of small changes in daily weight loss by reducing 100 kcal a day or something like that. In any case, there is a big difference between things that are not practical or have only small effects and things that are theoretically impossible. If metabolic advantage were really impossible theoretically, that would be it. We could stop looking for the best diet and only calories would count. Since we know energy inefficiency is possible and measurable, shouldn’t we be trying to maximize it.  But what is the story on thermodynamics? What is it? Why do people think that metabolic advantage violates thermodynamics? What is their mistake? More specifically, doesn’t the first law of thermodynamics say that calories are conserved? Well, there is more than one law of thermodynamics and even the first law has to be applied correctly. Let me explain. (Note in passing that the dietary calorie is a physical kilocalorie (kcal; 1000 calories).

There are four laws of thermodynamics. Two are technical. The zeroth law says, in essence, that if two bodies have the same temperature as a third, they have the same temperature as each other. This sounds obvious but, in fact, it is an observational law — it always turns out that way. The law is necessary to make sure everything else is for real. If anybody ever finds an experimental case where it is not true, the whole business will come crashing down. The third law describes what happens at the special condition known as the absolute zero of temperature. In essence, the zeroth and third laws, allow everything else to be calculated and practical thermodynamics like bioenergetics pretty much assumes it in the background.

The second law is what thermodynamics is really about — it was actually formulated before the first law — but since the first law is usually invoked in nutrition, let’s consider this first. The first law is the conservation of energy law. Here’s how it works: thermodynamics considers systems and surroundings. The thing that you are interested in — living system, a single cell, a machine, whatever, is called the system — everything outside is the surroundings or environment. The first law says that any energy lost by the system must be gained by the environment and any energy taken up by the system must have come from the environment. Its application to chemical systems, which is what applies to nutrition, is that we can attribute to chemical systems, a so-called internal energy, usually written with symbol U (so as not to confuse it with the electrical potential, E). In thermodynamics, you usually look at changes, and the first law says that you can calculate ΔU, the change in U of a system, by adding up the changes in heat added to the system and work done by the system (you can see the roots of thermo in heat machines: we add heat and get work). In chemical systems, the energy can also change due to chemical reactions. Still, if you add up all the changes in the system plus the environment, all the heat, work and chemical changes, the energy is neither created nor destroyed. It is conserved.

Now, why doesn’t the first law apply to nutrition the way Ornish thinks it does? To understand this, you have to know what is done in chemical thermodynamics and bioenergetics, (thermo applied to living systems). If you want to. In nutrition, you can make up your own stuff. But, if you want to do what is done in chemical thermodynamics, you focus on the system itself, not the system plus the environment. So, from the standpoint of chemical thermodynamics, the calories in food represent the heat generated by complete oxidation of food in a calorimeter.



In a calorimeter, the food is placed in a small container with oxygen under pressure and ignited. The heat generated is determined from the increase in temperature of the water bath. (Before the food measurement, we determine the heat capacity of the water bath, that is, how much heat it takes to raise the temperature). The heat is how we define the calories in the food. The box around the sample in the figure shows that we are measuring the heat produced by the system, not the system plus the environment, that is, not applying the first law. If you applied the first law, the calories associated with the food would be zero, because any heat lost in combustion of the food would show up in the water bath of the calorimeter. The calories per gram of carbohydrate would be 0 instead of 4, the calories per gram of fat would be 0 not 9, etc. So, in studying reactions in chemical thermodynamics, energy is not conserved, it is dissipated. When systems dissipate energy, the change is indicated with a minus sign, so for oxidation of food, generally: ΔU < 0. So, no, the first law does not apply. That’s one of the reasons that “a calorie is not a calorie.”
There is an additional point that we assumed in passing. In chemical thermodynamics, the energy goes with the reaction, not with the food. It is not like particle physics where we give the mass of a particle in electron-volts, a measure of energy, because of E=mc2. What this means, practically, is that the 4 kcal per gram of carbohydrate is for the reaction of complete oxidation. Do anything else, make DNA, make protein and all bets are off.
The bottom line is that, contrary to what is usually said, thermodynamics does not predict energy balance and we should not be surprised when one diet is more or less efficient than another. In fact, the question to be answered is why energy balance is ever found. “A calories is a calorie” is frequently what is observed (although there is always a question as to how we make the measurement). The answer is that insofar as there is energy balance, it is a question of the unique behavior of living systems, not physical laws. Two similar subjects of similar age and genetic make-up may, under the right conditions, respond to different diets so that most of what they do is oxidize food and the contributions of DNA or protein synthesis, growth, etc. may be similar and may cancel out so that the major contribution to energy exchange is the heat of combustion.
But thermodynamics is really not about the first law which, while its history is a little odd, it is not revolutionary. Intellectually, the first law is related to conservation of matter. Thermodynamics is about the second law. The second law says that there is a physical parameter, called the entropy, almost always written S, and the change in entropy, ΔS, in any real process, always increases. In ideal, theoretical processes, ΔS may be zero, but it never goes down. In other words, looking at the universe, (any system and its surroundings), energy is conserved but entropy increases. The first law is a conservation law but the second law is a dissipation law. We identify the entropy with the organization, order or information in a system. Systems proceed naturally to the most probable state. In one of the best popular introductions to the subjects, von Baeyer’s Warmth Disperses and Time Passes, entropy is described in terms of the evolution of the organization of his teenage daughter’s room.  To finish up on calorimeters, though, there is Lavoisier’s whole animal calorimeter.



One of Lavoisier’s great contributions was to show that combustion was due to a combination with oxygen rather than the release of a substance, then known as the phlogiston. Lavoisier had the insight that in an animal, the combination of oxygen with food to produce carbon dioxide was the same kind of process. The whole animal calorimeter was a clever way to show this. The animal is placed in the basket compartment f. The inner jacket, b, is packed with ice. The outer jacket, a, is also packed with ice to keep the inner jacket, cold. The heat generated by the animal melts the ice in the inner jacket which is collected in container, Fig 8. Lavoisier showed that the amount of carbon dioxide formed was proportional to the heat generated as it would be if an animal were carrying out the same chemical reactions that occur, for example, in burning of charcoal. “La vie est donc une combustion.” His collaborator in this experiment was the famous mathematician Laplace and people sometimes wonder how he got a serious mathematician like Laplace to work on what is, well, nutrition. It seems likely that it was because Laplace owed him a lot of money.

From A Future History of Diabetes:

Posted: January 5, 2011 in American Diabetes Association, Evidence Based Medicine, The Nutrition Story
Tags: , , , , , , ,
6

I don’t believe in time travel, of course, so when somebody sent me the following article that was supposed to be a chapter from a Study of the History of Diabetes published in 2018, I didn’t think about it much.  Then I read an article about a woman who had been charged with neglect in the death of her son from complications due to diabetes.  It seems she “was trying to live by faith and felt like God would heal him.”

For some reason, that made me think of the Future History, so here is a chapter from the History.

Chapter IV.  ACCORD to The Court

We have seen how, early in the history of medicine, diabetes was recognized as a disease of carbohydrate intolerance and how, until the discovery of insulin, removing carbohydrate from the diet became the major treatment (Chapters I and II).  We chronicled the shift away from this medical practice under the influence of low fat recommendations and the ascendancy of pharmacology that followed the discovery of insulin.  Nonetheless, it persisted in the popular mind that you don’t give candy to people with diabetes, even as health agencies seemed to encourage sucrose (sugar) consumption.

The rather sudden reappearance of carbohydrate restriction, the so-called modern era in diabetes treatment, is usually dated to 2008, the precipitating event, publication of the ACCORD study in which a group undergoing  “intensive treatment” to lower blood glucose showed unexpected deaths [1].  ACCORD concluded that “These findings identify a previously unrecognized harm of intensive glucose lowering in high-risk patients with type 2 diabetes.” The intensive treatment turned out to be intensive pharmacologic therapy and this flawed logic lead to a popular uprising of sorts, a growing number of patients claiming that they had been hurt by intensive drug treatment and typically that they had only been able to get control of their diabetes by adherence to low carbohydrate diets. Blogs compared the ACCORD conclusion to an idea that alleviating headaches with intensive aspirin led to bleeding and we should therefore not treat headaches.

The conflict culminated in the large judgment for the plaintiff in Banting v. American Diabetes Association (ADA) in 2017, affirmed by the Supreme Court in 2018.  Dalton Banting, coincidentally a distant relative of the discoverer of insulin, was an adolescent with diabetes who took prescribed medications and followed a diet consistent with ADA recommendations.  He experienced worsening of his symptoms and ultimately had a foot amputated. At this point his parents found a physician who recommended a low carbohydrate diet which led to rapid and sustained improvement.  The parents claimed their son should have been offered carbohydrate-restriction as an option.  The case was unusual in that Banting had a mild obsessive-compulsive condition, expressed as a tendency to follow exactly any instructions from his parents or other authority figures.  Banting’s lawyers insisted that, as a consequence, one could rely on his having complied with the ADA’s recommendations.  Disputed by the defense, this was one of several issues that made Banting famous for vituperative courtroom interactions between academics.

Banting was a person with type 2 diabetes.  Unlike people with type 1 diabetes, he was able to produce insulin in response to dietary (or systemic) glucose but his pancreas was progressively dysfunctional and his body did not respond normally, that is, he was insulin-resistant.  Although most people with type 2 diabetes are at least slightly overweight, Banting was not, although he began gaining weight when treated with insulin.

The phrase “covered with insulin…” rocked the court: the president of the ADA, H. Himsworth, Jr., was asked to  read from the 2008 guidelines [2], never rescinded: “Sucrose-containing foods can be substituted for other carbohydrates in the meal plan or, if added to the meal plan, covered with insulin or other glucose lowering medications.”

Jaggers (attorney for Banting): “Are there other diseases where patients are counseled to make things worse so that they can take more drugs.”

Himsworth: “We only say ‘can be.’  We don’t necessarily recommend it.  We do say that ‘Care should be taken to avoid excess energy intake.’”

It soon became apparent that Himsworth was in trouble.  He was asked to read from the passage explaining the ADA’s opposition to low carbohydrate diets:

“Low-carbohydrate diets might seem to be a logical approach to lowering postprandial glucose. However, foods that contain carbohydrate are important sources of energy, fiber, vitamins, and minerals and are important in dietary palatability.”

Jaggers: “Important sources of energy?  I thought we wanted to avoid excess energy,” and “would you say that taking a vitamin pill is in the same category as injecting insulin?”

Finally,

Jaggers: “Dr. Himsworth, as an expert on palatability, could you explain the difference between Bordelaise sauce and Béarnaise sauce?” [laughter]

Damaging as this testimony was, the tipping point in the trial is generally considered to have been the glucometer demonstration.  Banting consumed a meal typical of that recommended by the ADA  and glucometer readings were projected on a screen for the jury, showing, on this day, so-called “spikes” in blood glucose.  The following day, Banting consumed a low carbohydrate meal and the improved glucometer readings were again projected for the jury.  Defense argued that one meal did not prove anything and that one had to look at the whole history of the lifestyle intervention but was unable to show any evidence of harm from continued maintenance of low blood sugar despite testimony of several expert witnesses.  In the end, the jury agreed that common sense overrides expert testimony and that Banting should have been offered the choice of a carbohydrate-restricted diet.

Banting was held in New York State which adheres to the Frye standard: in essence, the idea that scientific evidence is determined by “general acceptance.” The explicit inclusion of common sense was, in fact, a legal precedent [3].   The Supreme Court ultimately concurred and held that the more comprehensive standards derived from Daubert v. Merrill-Dow, could sensibly be seen to encompass common sense.

The final decision in Banting lead to numerous law suits.  The ADA and other agencies changed their tactics claiming that they never were opposed to low carbohydrate diets and, in fact, had been recommending them all along [4].  This is discussed in the next chapter.

References

1. Gerstein, H. C. et al., Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 358 (24), 2545 (2008).

2. American Diabetes Association, Nutrition Recommendations and Interventions for Diabetes–2008. Diabetes Care 31 (Suppl 1), S61 (2008).

3. Berger, M, Expert Testimony: The Supreme Court’s Rules Issues in Science and Technology (2000).

4. American Diabetes Association, Nutrition Recommendations and Interventions for Diabetes–2018. Diabetes Care 40 (Suppl 1), S12 (2018).