Defining the Enemy

I think it's safe to say we all agree that when it comes to public health issues there exist a number of enemies - obesity, cardiovascular disease, diabetes, cancer - to name a few. We are indeed in a public health crisis, with many of our health issues tied directly to our rising rates of obesity in the United States. Obesity, in my mind is public enemy number one at this time.

With that said, as the year comes to an end, it is imperative that we review where we are as a nation and define the direction we must travel if we are to address this health menace. As 2005 nears an end, we begin 2006 with some staggering realities:

• two out of every three adults in the US are overweight with one of the two obese
• 22 million adults in the US have Diabetes (diagnoised and undiagnoised)
• 75 million adults have features of Metabolic Syndrome (25% adult estimate)
• 460,000+ will die from a heart attack
• 700,000 will have a stroke, 165,000+ will die from a stroke
• 300,000+ will die from obesity
• 225,000+ will die from diabetes
• 350,400+ will die from the seven most common cancers

These are sobering statistics and each number represents a real, living breathing person alive today who will not be with us as we see 2006 near its end next year.

This is something we often lose sight of in the presentation of statistics - the numbers seem like just numbers and when they are presented in terms like "X per 100,000" or "X per million" the sense of the individuals these numbers represent is lost along with the reality that we may be among the statistics ourselves in the coming year.

So, it was the Annual Review of Public Health article, Competing dietary claims for weight loss: finding the forest through truculent trees, from Dr. David Katz an Associate Professor Adjunct in Public Health Practice at the Yale School of Public Health, that caught my attention this morning.

The abstract is short and can only be described as a less than objective review of evidence.

In response to an accelerating obesity pandemic, competing weight-loss diets have propagated; those touting carbohydrate restriction are currently most in vogue. Evidence that sustainable weight loss is enhanced by means other than caloric restriction, however, is lacking. Whereas short-term weight loss is consistently achieved by any dietary approach to the restriction of choice and thereby calories, lasting weight control is not. Competing dietary claims imply that fundamental knowledge of dietary pattern and human health is lacking; an extensive literature belies this notion. The same dietary and lifestyle pattern conducive to health promotion is consistently associated with weight control. A bird's eye view of the literature on diet and weight reveals a forest otherwise difficult to discern through the trees. Competing diet claims are diverting attention and resources from what is actually and urgently needed: a dedicated and concerted effort to make the basic dietary pattern known to support both health and weight control more accessible to all.

Sadly, the last sentence speaks volumes - Katz is of the opinion that research investigating dietary approaches outside the accepted dogma (high-carbohydrate, low-fat) are a waste of precious resources and divert attention from useful efforts to educate the public about weight control and health.

In a review of the full publication, something pops out almost immediately - Katz seems to be of the opinion that the enemy here is not obesity and disease, but rather, the research conducted to investigate alternative approaches to weight loss and health.

I kid you not!

Perennially reinventing our destination for weight control in the form of the “hot” diet du jour is a discredit to our common sense, a digression from our cultural imperatives about confronting challenges, an indictment of our collective judgment, and a neglect of a robust base of evidence characterizing the effects of dietary pattern on the health of human beings across the life span. But it is something far worse. It is a bona fide public health threat in and of itself.

A public health threat?

Oh, and he doesn't stop there...

One cannot offer ironclad evidence that fad diets are harmful in the long-term, simply because such long-term studies have not been conducted. They may never be conducted. The onus of proof lies with those suggesting radical departures from patterns of behavior known to support human health; the community of nutrition experts is not obligated to prove the harmfulness of every new diet proposed.

In this instance, intellectual honesty would have been nice - an acknowledgement that there does not exist any long-term, random, controlled, prospective trial that supports low-fat diets for the general population. Not one.

Not one study has ever been conducted to investigate the dietary recommendations made to the general population day in day out! Go look for yourself if you don't believe me - PubMed, MedScape, Cochrane Library.

His recommendation for the future? Stop researching useless alternatives and everyone work together in a consensus that the 55-60% carbohydrate, up to 20% protein and 20-30% fat is the path that will lead to population-wide health and weight control!

The challenge before us is determining how best to get where we need to go, not deciding where that is. The sooner we accept that we know where we should be going, the sooner we may actually hope to advance toward that destination. Stated differently- we will need to espouse a common vision of the forest through the trees before we can hope to get out of the woods.

Hello? Haven't we been taking this very road for the last thirty years?

The enemy here is not the research and certainly not those investigating the alternatives.

No, today we face another enemy - the closed mind that believes that we already know everything we need to know about the correct macronutrient composition in an ideal diet and that anything else is flawed (or outright wrong), a waste of time to investigate and is simply just diverting attention from the "truth" we should all just accept, without question - afterall, just leaving the door open to the idea of alternative options is a public health threat!

I readily admit that a controlled-carb approach is not suitable for everyone and that low-fat diets formulated within the accepted dogma 55-60:15:25-30 ratios (carb:protein:fat) do work for some and may even be the "best" dietary approach for some health problems.

What I cannot and will not accept is this notion that continuing research that investigates alternate dietary approaches is a waste of our time, resources and effort.

The literature continues to grow and evidence continues to mount that controlled-carb approaches (from 20g net per day to 40% of calories) are an appropriate, scientifically supported alternative for a number of individuals in our population who are obese, overweight and/or suffering from any number of medical problems.

To shut the door to continued reasearch of any dietary approach that is outside the current dogma is to shut the door for those individuals who have failed on traditional low-fat approaches, have yo-yo'ed up and down with a low-fat diet, or continue to have poor health despite compliance with a low-fat diet. Such a mindset continues the notion that "if only they'd eat less and exercise more" they would be normal weight and experience good health.

What we need going into 2006 isn't for the scientific and medical communities to slam the door shut to future research but to systematically work together to tease out the critical information needed to determine who is a candidate for a controlled-carb diet, what testing needs to be done while one is following a controlled-carb approach to monitor health, and what measurements can be used to track the health of the individual in the short and long term?

What we need are clinical guidelines healthcare professionals can use to guide their patients and monitor health as we continue to research the long-term effects of controlled-carb diets! And, hey, if this idea of mine is a threat to public health, so be it!