Posts Tagged ‘nutrition’

Our 2015 paper, Low-carbohydrate diets as the first approach in the treatment of diabetes. Review and evidence-base, summarized the clinical experience and the research results of the 26 authors. Meant to be a kind of manifesto on theory and practice, the first version of the manuscript was submitted to a couple of major journals under the title “The 15 Theses on…” harking back to Martin Luther’s 95 Theses. A critique of Church practices, particularly indulgences — for a few bucks, we get you or your loved ones out of purgatory — the Theses were supposed to have been nailed by Luther to the door of a church in Wittenberg. Our MS was rejected by BMJ and New England Journal although, like the original 95, it did not seem particularly radical — The American Diabetes Association (ADA) acknowledges that dietary carbohydrate is the major source of high blood glucose and most of our points of evidence were based on pretty solid fact.  Anyway, somebody suggested that we were, in effect, trying to nail our low-carbohydrate paper to the door of the ADA and, in the end, we changed the name to “evidence base” and it was ultimately published.

Until recently, I had not noticed the extensive parallels of the current low-carbohydrate revolution with the Protestant Reformation. The recent imperious and rather savage actions of professional organizations, notably two in Australia, the DAA (Dietitian’s Association of Australia) and AHPRA (Australian Health Practitioner Regulation Agency) in clamping down on their own members for deviation from orthodoxy brought out the similarities. Unlike Luther, who felt that the church really needed his help in getting abuses straightened out, Jennifer Elliott, a dietitian with an established practice of 30 years and Gary Fettke an orthopedic surgeon, thought that they were just doing their job and that, however, non-standard, the low-carbohydrate diets that they recommended for people with diabetes, was far from heresy. Because of the ties between government health agencies, Jennifer ultimately lost her job and Gary is under the bizarre order not to recommend diets to his patients because, as an orthopedic surgeon, there is “nothing associated with your medical training or education that makes you an expert or authority in the field of nutrition, diabetes or cancer.” (Those of us who are actively trying to upgrade the medical curriculum would question which part of the medical profession has such expertise or authority). Dr. Fettke’s training does, however, allow him to perform amputations which have diabetes as its greatest cause, second only to accidents. In any case, offering low-carbohydrate diets to patients has long been perceived as a threat by establishment medicine.  While their claims to control the epidemics of obesity and diabetes has been at the level of offering reduction of time in purgatory, the medical establishment has largely responded to criticism by delaying or preventing publication and refusing to fund research. The direct attacks on practitioners is new. There are several instances but the Australian cases distinctly represent desperation.


Luther at the Diet of Worms.

History of religion remains one of the gaps in my undergraduate liberal education and I was unfamiliar with the dramatic events surrounding Luther’s mission. The sixteenth century was a brutish time and I should have guessed how violent and oppressive would have been the response of the Catholic Church to Luther’s suggestions for improvement. After all, if you insisted on the word of the Bible rather than the word of priests, indeed, if you wanted direct access to a Bible in your own language rather than in Latin, then everybody could be their own savior. Being burnt at the stake was standard punishment for such heresy. We all know about Galileo’s brutal treatment and his being forced to recant his heliocentric theories, although at some point, he supposedly muttered, under his breath, “eppur se muove.” (It (the earth) does move anyway). That was almost a century after Luther’s protest and the danger was even greater in 1521. Luther, however, was a madman and refused to recant. Ultimately, he faced a trial at the Diet of Worms. (Contrary to popular opinion, “Diet” is an English word and means assembly; the German is Reichstag; Worms is in Germany, about 60 kilometres from Frankfurt-am-Main, and is pronounced “Vorms,” to rhyme with “norms,” but the joke is widely made, even by Shakespeare: see end of this post). At The Diet, Luther got off because a unanimous vote was required for conviction. He had an inside man, Frederick the Wise, the elector (as local political leaders were known) in his province.  Frederick seems to have thought that Luther was good for tourism (and probably helped get the Church off his back). Of course,“not guilty,” doesn’t mean innocent and, as for sex-offenders in our day, you could get killed in the street anyway and the authorities would understand. Frederick had him “kidnapped,” disguised him as an aristocrat with the alias Junker Jörg and he went to the mattresses in a Castle in Wartburg for a year until it all blew over. Lucas Cranach the Elder painted a portrait of Jörg, possibly to let followers know that Luther was still alive.

575707-1449742854         Junker Jörg aka Martin Luther.

Heresy down under

So what had the Australian health professionals done to arouse the wrath of the “Church”? Not much. Jennifer Elliott has more than 30 years of experience and is the author of the excellent book, Baby Boomers, Bellies & Blood Sugars  which is distinguished by its straight-forward practical approach and does not seem to tweak anybody’s beard. In fact, she was not really accused of any specific thing although the message was clear: low-carbohydrate high fat (LCHF) diets are forbidden. Trying to help out, I sent an email message to Claire Hewat, head of DAA. I attached the twelve-points of evidence paper and I explained our position. I pointed out that “Ms. Elliott seems quite upset and genuinely puzzled since carbohydrate restriction has been a treatment for diabetes more or less forever, certainly going back to Elliott Joslin (early twentieth century physician and authority on diabetes).”

hewat_claire11474634995-300x224        Claire Hewat, head of DAA.

I mentioned an interview with a reporter from the New York Times who could not understand the resistance to an established, successful and ultimately obvious therapy, — you don’t give carbohydrates to people with a disease of carbohydrate intolerance — and I made the case that the burden of proof should be on anyone who didn’t approve. I suggested a discussion, “perhaps an online webinar, in which all sides present their case. I and/or my colleagues would be glad to participate.” Claire’s answer was that I was “obviously not in possession of all the facts in this matter, nor can I apprise you of them as this is part of a confidential complaints process …nor is DAA afraid of debate but this is not the place for it.”

Not to digress too much, I loved the idea that I did not have the facts right but the facts were not available because they were confidential. It reminded me of watching a scene in one of the old Basil Rathbone Sherlock Holmes movies. Holmes is playing the violin and his arch-enemy, Professor Morality suddenly appears in the doorway:

Moriarity: “Holmes, I’ve come to….Well, I am sure that you can deduce why I’ve come.”

Holmes: “Yes. And I’m sure you can deduce my answer.”

Moriarity: “So that’s final?”

Holmes: “I’m afraid so.”

Most distressing remains the fact that DAA constitutes a professional dietitians’ organization which should, as in Macbeth, “against his murderer shut the door, / Not bear the knife myself.” (Is this a DAAger I see before me?)

The details of Jennifer’s case are buried in evasive legal double-talk but were obviously caused by her recommending low-carbohydrate diets to her patients with diabetes. Claire Hewat’s defense against the obvious lack of due process was that Jennifer was invited to appear before an inquiry, obviously set up along the lines of the Diet of Worm, but she refused to appear. In fact, it would have been worse than the Diet in that there were no formal charges and even Luther was afforded legal representation. There would certainly be no defenders, as Luther had in Frederick, the Wise. Most important, recanting was not an option — if it wasn’t about anything real, there was nothing to recant. (Like Luther, she probably would not have felt able to recant anyway). Jennifer declined to attend telling Claire that it appeared to be “an invitation to a beheading.” The net effect is that she lost her job and and legal recourse would likely be exorbitant.

The words

In the reformation, heresy might have meant simply owning a Bible in your native language, or really owning any Bible at all. The Church held onto the Latin versions which you did not get to see directly. Somewhat like governmental nutritional guidelines, it was not in your native language, and required an “expert” priest to tell you what’s what. The first English translation was accomplished by John Wycliffe. During the English Reformation, several people were actually executed for owning a Wycliffe Bible. I found it somewhat analogous to the persistent hatred of Dr. Atkins so long after his death, that, at some point, the Church in England had Wycliffe’s body exhumed and burnt at the stake.

Ultimately, Luther succeeded because of Gutenberg and the invention of movable type. Now you did not have to make copies by hand. Now Luther could get the word out. And he wrote the word. During his period of lying low in Wartburg, he translated the Bible into German.  And he published it. It was a big hit although the German population recognized that they had been swindled — financially as well as theologically — and history records a Peasant’s Revolt put down with great brutality. This is where we really are in the establishment’s determination to repress LCHF diets. And everybody recognizes the analog of Gutenberg’s press.

Unser Gutenberg  and the Fettke case

Our Gutenberg is, of course, the internet where technical and scientific writings, once the province of specialists, can now be viewed by many and where they can be discussed widely. Publishers of many journals try to maintain pay-walls in keeping with somebody’s observation that publishers’ function used to be to make new information available while now they work to make information unavailable.  (Many simultaneously cash in on open access which charges the authors outrageous fees). Whether the availability of scientific facts is out-weighed by proliferation of alternative facts is open to question but, on balance, we have a view, not only of the science, but of the inner workings of the health agencies that might otherwise be visible to only a few. And that’s how we have extensive access to the Fettke case and an associated Diet convened by the Australian Senate.

As reported by Marika Sboros, Fettke “cannot tell patients not to eat sugar. Why not? Because the country’s medical regulatory body, Australian Health Practitioners Regulatory Authority (AHPRA), says so….It has been investigating Fettke for more than two years now. That was after the first anonymous complaint from a DAA dietitian in 2014. Earlier this year,  AHPRA told Fettke to stop talking about nutrition until it had decided on a suitable sanction.” and — I’m not making this up — “informed Fettke that it was investigating him for ‘inappropriately reversing (a patient’s) type 2 diabetes…’”

Dr. Gary Fettke testified at an Australian Senate Inquiry on November 1. and just “by coincidence,” a few hours later, AHPRA’s 2 1/2 year investigation came to an end and Fettke was told that he would be constrained from giving nutritional advice.  In the end, this did not sit well with the Senate which undertook further hearing interrogating Martin Fletcher, the CEO of APHRA.

“Haven’t you got better things to do?”

You can see Martin Fletcher trying to defend AHPRA’s actions.  on Youtube. At 31:25, one of the Senators asked “…if a health practitionerr is advising a patient to go on a … sensible, medically-accepted diet program, why would you risk-assess that and have all guns blazing? Haven’t you got better things to do?”

One of life’s great disappointments is that when you finally corner the bad guys, they turn out to be pathetic like Saddam Hussein. They don’t break down on the stand as in the old Perry Mason episodes. It is sad but it is also hard to feel much sympathy.


Martin Fletcher, CEO of AHPRA trying to juggle the truth at the Senate hearing.

“Bread thou art…”

It was a trip to Rome, intended to deepen his faith, that ultimately contributed to Luther’s transformation. What he saw was corruption on a grand scale. The thing that really freaked him out was that the corruption and vice were coupled with a cynical disregard for religious practice: a priest going through the motions of giving the elements in the sacrament  muttered to himself “Bread thou art, and bread thou shalt remain; wine thou art, and wine thou shalt remain.”

That becomes the most distressing feature of this analogy. The quotation above, “There is nothing associated with your medical training or education that makes you an expert or authority in the field of nutrition, diabetes or cancer,” was in a letter to Dr. Fettke that continued “Even if, in the future, your views on the benefits of the LCHF lifestyle become the accepted best medical practice, this does not change the fundamental fact that you are not suitably trained or educated as a medical practitioner to be providing advice or recommendations on this topic as a medical practitioner.”

This statement that treating disease is less important than loyalty to political power stands as the greatest exposition of the need for Reformation in Medicine.

Appendix. Shakespeare on the Diet of Worms.

Hamlet has been charged by his father’s Ghost with avenging the father’s murder by Claudius, the current king. Hamlet has put on an “antic disposition” to hide his motives. At one point, mistaking him for the King, Hamlet kills Polonius, a pompous court official, who is hiding behind a wall-hanging. The king hears about it and is pissed and wants to know where the body is (Act 4,Scene 3):

CLAUDIUS: Where’s Polonius?

HAMLET: At supper.

CLAUDIUS: At supper where?

HAMLET: Not where he eats, but where he is eaten. A certain convocation of politic worms are e’en [now] at him. Your worm is your only emperor for diet. We fat all creatures else to fat us, and we fat ourselves for maggots. Your fat king and your lean beggar is but variable service—two dishes, but to one table. That’s the end.

CLAUDIUS: Alas, alas!

HAMLET: A man may fish with the worm that hath eat of a king, and eat of the fish that hath fed of that worm.

CLAUDIUS: What dost thou mean by this?

HAMLET: Nothing but to show you how a king may go a progress through the guts of a beggar.

CLAUDIUS: Where is Polonius?

HAMLET: In heaven. Send hither to see. If your messenger find him not there, seek him i’ th’ other place yourself. But if indeed you find him not within this month, you shall nose him as you go up the stairs into the lobby.

CLAUDIUS (to attendants) Go seek him there.

(Exeunt some attendants)

HAMLET: He will stay till ye come.

This series of posts is a followup to the project that Dr. Eugene Fine and I described in our campaign at as follow-up to Dr. Fine’s pilot study of ten advanced cancer patients on ketogenic diets and the in vitro projects that we are carrying out in parallel.

The last post described the two major processes in energy metabolism, (anaerobic) glycolysis and respiration. Pyruvate is the product of glycolysis and has many fates. (Remember pyruvate and pyruvic acid refer to the same chemical). For cells that rely largely on glycolysis, pyruvate is converted to several final products like ethanol, lactic acid and a bunch of other stuff that microorganisms make in the fermentation of glucose. (The unique smell of butter, e.g., is due to acetoin and other condensation products of pyruvate). Rapidly exercising muscles also produce lactic acid.

The sudden interest in the metabolic approach to cancer stems from the work of Otto Warburg whose lab in the 1930’s was a center for the study of metabolism. (Hans Krebs was an Assistant Professor in the lab). Warburg’s landmark observation was that cells from cancer tissue showed a higher ratio of lactate to CO2 than normal cells, that is, the cancerous tissue was metabolizing glucose via glycolysis to a greater degree than normal even though oxygen was present. The Coris (Carl and Gerty of the Cori cycle) demonstrated what is now called the Warburg effect in a whole animal. Ultimately, Warburg refined the result by comparing the ratio of lactate:CO2 in a cannulated artery to that in the vein for a normal forearm muscle. He compared that to the ratio in the forearm of the same patient  that contained a tumor. Warburg claimed that this greater dependence on glycolysis was a general feature of all cancers and for a long time it was assumed that there was a defect in the mitochondrion in cancer cells. These are both exaggerations but aerobic glycolysis appears as a feature of many cancers and defects in mitochondria, where they exist, are more subtle than gross structural damage. The figure shows current understanding of the Warburg Effect.


What about this mechanism makes us think that  ketone bodies are going to be effective against cancer? We need one more step in biochemical background to explain what we think is going on. In normal aerobic cells, pyruvate is converted to the compound acetyl-CoA.  Acetyl-CoA represents another big player in metabolism and functions as the real substrate for aerobic metabolism. If you have taken general chemistry, you will recognize acetyl-CoA as a a derivative of acetic acid.

The reaction acetyl-CoA ➛ 2CO2 is the main transformation from which we get energy. Acetyl-CoA provides the building block for fatty acids and for ketone bodies. Conversely, fatty acids are a fuel for cells because they can be broken down to acetyl-CoA. Under conditions of starvation, or a low-carbohydrate diet, the liver assembles 2 acetyl-CoA’s to ketone bodies (β-hydroxy butyrate and acetoacetyl-CoA). The ketone bodies are transported to other cells where they are disassembled back to acetyl-CoA and are processed in the cell for energy. The liver is a kind of metabolic command center and ketone bodies are a way for the liver to deliver acetyl-CoA to other cells.kdforca_blog-iii_dec_4

Now we are at the point of asking how a cell knows what to do when presented with a choice of fuels? In particular, how does the input from fat dial down glycolysis so that pyruvate, which could be used for something else (in starvation or low-carb, it will be substrate for gluconeogenesis), is not used to make acetyl-CoA.  It turns out that acetylCoA (that is, fat or ketone bodies) regulate their own use by feeding back and directly or indirectly turning off glycolysis (in other words: don’t process pyruvate to acetyl-CoA because we already have a lot). The feedback system is known as the Randle cycle and appears (roughly) as the dotted line in our expanded metabolic scheme.

robin_map_2012-2Where we are going. In our earlier work Dr. Fine and I and our assistant, Anna Miller, found that if we grow cancer cells in culture, acetoacetate (one of the ketone bodies) will inhibit their growth and will reduce the amount of ATP that they can generate. Normal cells, however, are not inhibited by ketone bodies and the cells may even be using them. Our working explanation is that the ketone bodies are inhibiting the cancer cell through the Randle cycle. Now, normal cells can maintain energy, that is compensate for the Randle cycle, by running the TCA cycle (in fact, that is the purpose of the Randle cycle: to switch fuel sources). The cancer cells, however, have some kind of  defect in aerobic metabolism and can’t compensate.  How does this happen? That’s what we’re trying to find out but we have a good guess. (A good guess in science means that when we find out it’s wrong we’ll probably see a better idea). We find that our cancer cells in culture over-express a protein called uncoupling protein-2 (UCP2). We think that’s a player. To be discussed in Part IV.

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.”


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

Bernard (more…)


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.


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…)

Doctor:    Therein the patient

  Must minister to himself.

Macbeth: Throw physic [medicine] to the dogs; I’ll none of it.

— William Shakespeare, Macbeth

The quality of nutrition papers even in the major scientific and medical journals is so variable and the lack of restraint in the popular media is so great that it is hard to see how the general public or even scientists can find out anything at all. Editors and reviewers are the traditional gate-keepers in science but in an area where rigid dogma has reached Galilean proportions, it is questionable that any meaningful judgement was made: it is easy to publish papers that conform to the party line (“Because of the deleterious effects of dietary fructose, we hypothesized that…”) and hard to publish others: when JAMA published George Bray’s “calorie-is-a-calorie” paper and I pointed out that the study more accurately supported the importance of carbohydrate as a controlling variable, the editor declined to publish my letter.  In this, the blogs have performed a valuable service in providing an alternative POV but if the unreliability is a problem in the scientific literature, that problem is multiplied in internet sources. In the end, the consumer may feel that they are pretty much out there on their own. I will try to help.  The following was posted on FatHead’s Facebook page:

 How does one know if a study is ‘flawed’? I see a lot of posts on here that say a lot of major studies are flawed. How? Why? What’s the difference if I am gullible and believe all the flawed studies, or if I (am hopefully not a sucker) believe what the Fat Heads are saying and not to believe the flawed studies — eat bacon.

Where are the true studies that are NOT flawed…. and how do I differentiate? : /

 My comment was that it was a great question and that it would be in the next post so I will try to give some of the principles that reviewers should adhere to.  Here’s a couple of guides to get started. More in future posts:

 1“Healthy” (or “healthful”) is not a scientific term. If a study describes a diet as “healthy,” it is almost guaranteed to be a flawed study.  If we knew which diets were “healthy,” we wouldn’t have an obesity epidemic. A good example is the paper by Appel, et al. (2005). “Effects of protein, monounsaturated fat, and carbohydrate intake on blood pressure and serum lipids: results of the OmniHeart randomized trial,” whose conclusion is:

“In the setting of a healthful diet, partial substitution of carbohydrate with either protein or monounsaturated fat can further lower blood pressure, improve lipid levels, and reduce estimated cardiovascular risk.”

 It’s hard to know how healthful the original diet, a “carbohydrate-rich diet used in the DASH trials … currently advocated in several scientific reports” really is if removing carbohydrate improved everything.

Generally, understatement  is good.  One of the more famous is from Watson & Cricks’s 1953 paper in which they proposed the DNA double helix structure. They said “It has not escaped our notice that the specific pairing we have postulated immediately suggests a possible copying mechanism for the genetic material.”  A study with the word “healthy” is an infomercial.

2. Look for the pictures (figures).  Presentation in graphic form usually means the author wants to explain things to you, rather than snow you.  This is part of the Golden Rule of Statistics that I mentioned in my blogpost “The Seventh Egg”  which discusses a very flawed study from Harvard on egg consumption. The rule comes from the book PDQ Statistics:

“The important point…is that the onus is on the author to convey to the reader an accurate impression of what the data look like, using graphs or standard measures, before beginning the statistical shenanigans.  Any paper that doesn’t do this should be viewed from the outset with considerable suspicion.”

The Watson-Crick  paper cited above had the diagram of the double-helix  which essentially became the symbol of modern biology.  It was drawn by Odile, Francis’s wife, who is described as being famous for her nudes, only one of which I could find on the internet.

Krauss, et. al. Separate effects of reduced carbohydrate intake and weight loss on atherogenic dyslipidemia.

The absence of a figure may indicate that the authors are not giving you a chance to actually see the results, that is, the experiment may not be flawed but the interpretation may be misleading, intentionally or otherwise.  An important illustration of the principle is a paper published by Krauss. It is worth looking at this paper in detail because the experimental work is very good and the paper directly — or almost directly — confronts a big question in diet studies: when you reduce calories by cutting out carbohydrate, is the effect due simply  to lowering calories or is there a specific effect of carbohydrate restriction.  The problem is important since many studies compare low-carbohydrate and low-fat diets where calories are reduced on both. Because the low-carbohydrate diet generally has the better weight loss and better improvement in HDL and triglycerides, it is said that it was the weight loss that caused the lipid improvements.

So Krauss compared the effects of carbohydrate restriction and weight loss on the collection of lipid markers known collectively as atherogenic dyslipidemia.  The markers of atherogenic dyslipidemia, which are assumed to predispose to cardiovascular disease, include high triglycerides (triacylglycerol), low HDL and high concentrations of the small dense LDL.

Here is how the experiment was set up: subjects first consumed a baseline diet of  54% of energy as carbohydrate, for 1 week. They were then assigned to one of four groups.  Either they continued the baseline diet, or they kept calories constant but reduced carbohydrate by putting fat in its place.  The three lower carbohydrate diets had 39 % or 26 % carbohydrate or 26 % carbohydrate with higher saturated fat.  After 3 weeks on constant calories but reduced carbohydrate, calories were decreased by 1000 kcal/d for 5 week and, finally, energy was stabilized for 4 weeks and the features of atherogenic dyslidemia were measured at week 13.  The protocol is shown in the figure from Krauss’s paper:

The Abstract of the paper describes the outcomes and the authors’ conclusions.

Results: The 26%-carbohydrate, low-saturated-fat diet reduced [atherogenic dylipidemia]. These changes were significantly different from those with the 54%-carbohydrate diet. After subsequent weight loss, the changes in all these variables were significantly greater…(my italics)

 Conclusions: Moderate carbohydrate restriction and weight loss provide equivalent but non-additive approaches to improving atherogenic dyslipidemia. Moreover, beneficial lipid changes resulting from a reduced carbohydrate intake were not significant after weight loss.

Now there is something odd about this.  It is the last line of the conclusion that is really weird. If you lose weight, the effect of carbohydrate is not significant?  As described below, Jeff Volek and I re-analyzed this paper so I have read that line a dozen times and I have no idea what it means.  In fact, the whole abstract is strange.  It will turn out that the lower (26 %) is certainly “significantly different from.. the 54%-carbohydrate diet” but it is not just different but much better. Why would you not say that?  The Abstract is generally written so that it sounds negative about low carbohydrate effects but it is already known from Krauss’s previous work and others that carbohydrate restriction has a beneficial effect on lipids and the improvements in lipid markers occur on low-carbohydrate diets whether weight is lost or not.  The last sentence doesn’t seem to make any sense at all.    For one thing, the experiment wasn’t done that way.  As set up, weight loss came after carbohydrate restriction.  So, let’s look at the data in the paper.  There are few figures in the paper and Table 2 in the paper presents the results in a totally mind-numbing layout.  Confronted with data like this, I sometimes stop reading.  After all, if the author doesn’t want to conform to the Golden Rule of Statistics, if they don’t want to really explain what they accomplished, how much impact is the paper going to have.  In this case, however, it is clear that the experiment was designed correctly and it just seems impossible from previous work that this wouldn’t support the benefits of carbohydrate restriction and the negative tone of the Abstract needs to be explained.  So we all had to slog through those tables.  Let’s just look at the triglycerides since this is one of the more telling attributes of atherogenic dyslpidemia.  Here’s the section from the Table:

Well this looks odd in that the biggest change is in the lowest carb group with high SF but it’s hard to tell what the data look like.  First it is reported as logarithms. You sometime take logs of your data in order to do a statistical determination but that doesn’t change the data and it is better to report the actual value.  In any case, it’s easy enough to take antilogs and we can plot the data.  This is what it looks like:

It’s not hard to see what the data really show: Reducing carbohydrate has an overwhelming effect on triglycerides even without weight loss.  When weight loss is introduced, the high carbohydrate diets still can’t equal the performance of the carbohydrate reduction phase.  (The dotted line in the figure are data from Volek’s earlier work which Krauss forgot to cite).

The statements in the Conclusion from the Abstract are false and totally misrepresent the data.  It is not true as it says “carbohydrate restriction and weight loss provide equivalent…” effects. The carbohydrate-reduction phase is dramatically better than the calorie restriction phase and it is not true that they are “non-additive”  Is this an oversight?  Poor writing?  Well, nobody knows what Krauss’s motivations were but Volek and I plotted all of the data from Krauss’s paper and we published a paper in Nutrition & Metabolism providing an interpretation of Krauss’s work (with pictures).  Our conclusion:

Summary Although some effort is required to disentangle the data and interpretation, the recent publication from Krauss et al. should be recognized as a breakthrough. Their findings… make it clear that the salutary effects of CR on dyslipidemia do not require weight loss, a benefit that is not a feature of strategies based on fat reduction. As such, Krauss et al.  provides one of the strongest arguments to date for CR as a fundamental approach to diet, especially for treating atherogenic dyslipidemia.

An important question in this experiment, however, is whether even in the calorie reduction phase, calories are actually the important variable.  This is a general problem in calorie restriction studies if for no other reason than that there is no identified calorie receptor.  When we published this data, Mike Eades pointed out that in the phase in which Krauss reduced calories, it was done by reducing macronutrients across the board so carbohydrate was also reduced and that might be the actual controlling variable so we plotted the TAG against carbohydrate in each phase (low, medium and high carb (LC, MC, HC) without or with weight loss (+WL) and the results are shown below

This is remarkably good agreement for a nutrition study. When you consider carbohydrates as the independent variable, you can see what’s going on.  Or can you?  After all, by changing the variables you have only made an association between carbohydrate and outcome  of an experiment. So does this imply a causal relation between carbohydrate and triglycerides or not?  It is widely said that observational studies do not imply causality, that observational studies can only provide hypothesis for future testing. It certainly seems like causality is implied here.  It will turn out that a more accurate description is that observational studies do not necessarily imply causality and I will discuss that in the next posts.  The bottom line will be that there is flaw in grand principles like “Random controlled trials are the gold standard.” “Observational studies are only good for generating hypotheses,”  “Metabolic Ward Studies are the gold standard.” Science doesn’t run on such arbitrary rules.