Wednesday, May 02, 2007

Diet for Diabetes Mired in Half-Truths

"A half-truth is a whole lie."
Yiddish Proverb

If you want to see a truly stupendous exercise in smoke-and-mirrors and misdirection, look no further than people like Hope Warshaw, or organizations like the American Diabetes Association -- they've practically cornered the market on rhetorical tricks and red herrings.

Of course, that's almost understandable since everything recent scientific studies have to say about their most popular punching bag, carbohydrate restricted diets, directly contradicts their doom-and-gloom predictions that no one can eat that way, or should.

Case in point, the recent Diabetes Health article penned by, none other than, Hope Warshaw, The Optimal Eating Plan for Type 2 Diabetes?

Let me first say, Ms. Warshaw is quite proud of her accomplishments and offers visitors to her website the following information in her biography detailing her direct work with "McNeil Nutritionals, LLC, a Johnson & Johnson Company; Mead Johnson Nutritionals, a division of Bristol-Myers Squibb; Roche Diagnostics and Novo-Nordisk Pharmaceuticals. She writes consumer and professional materials for brochures, newsletters and websites. Hope has worked with PR [public relations] companies on nutrition-related campaigns, such as Barkley Evergreen & Partners, Fleischman Hillard, Inc., Paine PR, Edelman, RF Binder and Hunter Public Relations."

I point this out to highlight the fact that Ms. Warshaw is well schooled in media and marketing, or should I say "spin"? Simply put, she's no novice when it comes to creative persuasion, that is how to craft a message that hits on all cylinders of your emotions.

Keep in mind as we move on, feelings do not change facts.

In her recent addition to the media fodder attempting to discredit carbohydrate restricted diets, she sets the stage quite brillantly to avoid fact by littering her piece with half-truths designed to appeal to fear.

Bottom line - statements with half-truths are deceptive; they're partly true, but not the whole truth; they present a verifiable piece of information that is true, but in context is not representative of the truth. Some might say they're lies, others might say they're stretching the truth, and still others may say that a half-truth is really just being economical with the truth.

They've been with us for generations. We find them littering food packaging and in advertisements for many different things; sometimes stated, sometimes implied, and sometimes even admitted to in the fine print no one reads. Half-truths are so prevalent in our daily lives, is it any wonder that when one appears in an article about health, no one seems to notice?

Ms. Warshaw sets the stage by setting readers minds to believe her article is the truth about the "optimal" diet for those with diabetes; and uses a number of literary tricks - rhetorical statements, imaginative prose and pursuasive words to trigger a desired response in readers. She leads with our base knowledge that dieting is hard and we should "be realistic and take a long-term perspective in this “which diet is best” debate, rather than wasting time quibbling over extremes - from low-carb to vegan."

With this one sentence she's already working hard to influence readers by bringing them into her world while employing empathy, *we all know* it's a waste of time to quibble over diet, that vegan and low-carb are *extreme* diets, and that, as the title of her article hints, *we know* the optimal diet for those with diabetes.

Forget about data, there isn't even room for debate.

Since that isn't quite enough, she then adds a message driver, a logical fallacy to drive this message home by appealing to fear, one of our strongest emotions.

Fear of being a loser, on the losing team, on the team that no one wants to be a part of anyway, the team that everyone quits because it's so bad.

"A Team’s No Good If All the Players Quit"

Think about that statement for a moment.

A Team’s No Good If All the Players Quit.

It conjures up cliches we all know - quitters never win, be a team player, teamwork works, winners never quit...and it stirs up fear - the fear of failure.

So with that in play, she then moves in with the half-truths - "A number of studies that compare low carb diets to conventional diets demonstrate early initial weight loss and improvement in other health parameters, such as blood glucose control. But studies of low carb diets that last longer than six months do not show significantly more weight loss. They do show that many study subjects drop out of the study and are unable to stick with the diet."

She cites two studies to support her assertion and show veracity of her statements:

1. Foster GD, Wyatt HR, Hill JO, McGuckin BG, Brill D, Mohammed S, Szapary PO, Rader DJ, Edman JS, Klein S.: A randomized trial of a low-carbohydrate diet for obesity. NEJM 348(21): 2082-90, 2003.

2. Bravata, DM, Sanders L, Kuang J, Krumholz HM, Olkin I, Gardner CD, Bravata D: Efficacy and safety of low-carbohydrate diets: a systematic review. JAMA 289: 1137 – 1850, 2003.

When we review these studies, we find her statements are accurate, but more accurately they are smoke and mirrors because they do not present the whole truth since the two studies are not trials specifically investigating dietary approaches for those with diabetes.

Indeed the studies she cites - one is an investigation comparing low-carb and low-fat diets for obesity, the second is a meta-analysis reviewing some of the published studies up to one year comparing low-carb and low-fat diets for obesity. So while weight loss was a key part of the studies cited, they are not the most relevant available to us to examine for those with diabetes.

You see, the two studies above, while they included subjects who were obese, they were not diabetic subjects; and the second was not a research study, but a meta-analysis review of studies that included the first study cited.

But a casual reader wouldn't know that - they only see two references which lends credibility to her statements and makes them appear to be important in determining dietary recommendations for those with diabetes.

Now consider this - how would her statement need to change if she included Beneficial effects of ketogenic diet in obese diabetic subjects?

In this study, subjects with and without diabetes, were grouped by blood sugar levels and the study lasted 56-weeks (one year, one month) and there were no drop outs - that is all who started the study completed it. With across the board improvements in total cholesterol, HDL, LDL, triglycerides, and fasting blood sugar in both groups, along with significant weight loss over the period of a year (a 54-pound average weight loss for both groups!) is it any wonder she didn't cite this one?

Or how about Low-carbohydrate diet in type 2 diabetes. Stable improvement of bodyweight and glycemic control during 22 months follow-up, a study over a period of almost two years that compared a low-fat diet to a low-carb diet in those with diabetes; and at six months, those following the low-fat diet abandon it when they saw the results of those following the low-carb diet? Oh, yeah, there were also significant improvements to risk factors including blood sugars (with elimination of medications) and weight loss and weight maintenance.

Two longer term studies, both ignored for this particular article. But a casual reader doesn't know they exist and Ms. Warshaw isn't going to tell.

So she moves on to the statement "Low-carbohydrate diets are not recommended by the American Diabetes Association for two key reasons. First, avoiding carbohydrate, as some low carb diets suggest, does not entirely return blood glucose levels to the normal range after meals. Second, an adequate amount of carbohydrate is an important component of a healthy eating plan, providing essential fuel, vitamins, minerals, and fiber;" and offers two more citations to support her words, both references are ADA statements.

So again we find half-truth, but not the whole truth.

This is because Warshaw sees the world though the prism of ADA truth making it impossible to take her seriously on any level.

Does she really believe someone with diabetes will not, or more accurately, can not give up consuming sugar or excessive carbohydrate that she feels it necessary to portray the dietary approach as one where "avoiding carbohydrate" is a problem rather than the solution?

Many, if not all, carbohydrate controlled plans restrict total carbohydrate each day, but no plan says you must avoid all carbohydrate or eliminate it completely. Maybe she has a problem with a diabetic avoiding sugar and foods that quickly raise blood glucose?

Second, her statement that avoiding carbohydrate..."does not entirely return blood glucose levels to the normal range after meals" implies that what she's going to present to readers will do just that - just ignore the smoke, just ignore the mirrors, as she continues with "an adequate amount of carbohydrate is an important component of a healthy eating plan, providing essential fuel, vitamins, minerals, and fiber."

Ignore the fact that all carbohydrate restricted plans include and encourage a high intake of non-starchy vegetables (rich with nutrients, fiber and minerals); no the message by now is clear - low-carbohydrate diets are for losers, they're unhealthy, nutrient deficient, make you avoid something with no reward for the effort (normal blood sugars after meals) and you're not going to lose weight with a low-carb diet anyway, move along now and don't pay to much attention to the fact she opened with two "extremes" low-carb and vegan but only attempts to discredit one.

Afterall we can't have anyone consider a low-carb diet, because "diets that force people to dramatically change their eating style are not maintained over the long haul. These diets require too dramatic change compared to the common, albeit not healthy, eating habits of the 21st century."

Take a good look at the last sentence - it's too big a change from the "unhealthy" eating habits we have, but by golly, a person with diabetes deserves to eat whatever they want and they can continue on with their common ways!

What she is saying is that no person with diabetes is willing to change their unhealthy ways, so why bother.

She then has the nerve to present to readers more rubbish - "Research from numerous studies, including the Diabetes Prevention Program and the National Weight Control Registry, show that people can lose weight and keep it off successfully for three years and five years, respectively, by reducing dietary fat and total calories."

Two is not "numerous" it's a couple.

And one is from subjects at risk for diabetes, the other a self-selected group of dieters who are followed in a national database because they lost weight not because they have diabetes and are in good glycemic control and maintaining weight loss!

Ms. Warshaw is pretty confident you won't check or think critically, and that you'll take her half-truths and believe a low-carb diet is impossible to follow for the long-term.

She's so sure of this in fact, she has no worry saying you can't diet on your own anyway - you need help, "you need knowledge and skills to make lifestyle changes, as well as help in setting behavioral goals, not to mention ongoing and long-term support...Ask your health care provider to refer you to a diabetes education program."

Her writing is chock-full of manufactured criticism, dead-wrong assumptions, half-truth evidence, and child-like ignorance of the emotional universe inhabited by men and women with diabetes.

She hopes no one notices that what is more important is the quality of pertinent research published, not the crafty presentation.

She relies heavily on logical fallacies - appeal to authority (the ADA) and appeal to fear - to grab and hold readers' attention, then offers clever cliches to play emotions without presenting pertinent facts to help an individual with diabetes understand the hard data.

The truth is modifying your diet is difficult, losing weight may be hard, and maintaining weight after it's lost can be a challenge; having diabetes is also a challenge and managing everything that comes with a diagnosis is no small endeavor - everything from blood glucose levels to HbA1c to cholesterol to body weight is monitored, tracked and managed; not for a week or a month, but for the rest of your life.

Ms. Warshaw contends that modifying diet too is too much to ask, too much for a person to do, too much for anyone to have to do over the long-term.

She offers the status quo - the ADA position that one deserves to be able to eat normally (even though she admits this "normal" is unhealthy); afterall a low-carb diet requires "too dramatic change" in eating habits.

Notice she hasn't said a word about the dramatic change one must make to include their medication each day; self-monitor blood sugar levels; keep doctor, opthamologist and podiatrist appointments; adjust medications as complications arise; injecting insulin each day; careful wound care; and more.

Notice she hasn't said a word about what dietary modification is necessary with the ADA recommendations.

Notice she presents no evidence to support the implication that normal blood sugars are achieved when one follows this "optimal diet."

That's because normal blood sugars do not happen when one follows the dietary recommendations of the ADA.

In fact, the ADA position is that medication is the first line defense upon diagnosis because their dietary approach fails over the long-term.

Oh, Ms. Warshaw didn't include that, did she?

No, she's done a run-around the evidence, fully aware the casual reader won't know the published data well enough to spot her half-truths or question the depth of her statements.

She stays on the surface rather than digging deep and offering a compelling look at the truth.

The truth is, those with diabetes deserve to know they have options.

They deserve a full disclosure of the data to allow them to make an educated decision about what they can and cannot do with diet; what they will and will not do to manage their diabetes.

They deserve to know that not only do blood sugars normalize in many with diabetes who adhere to a carbohydrate restricted diet, but medication is often eliminated or reduced.

They deserve to know a dietary approach is available that may indeed provide normal blood sugars!

They deserve no less than full patient autonomy, something Ms. Warshaw seems to know nothing about.

They deserve the whole truth!


  1. Anonymous11:07 AM

    Regina, what is your educational background? I ask because, even leaving aside expertise in nutrition, this column is an excellent example of rhetorical analysis. I'm very impressed! In fact, I would like to ask your permission to use parts of it as an example for a rhetoric class I'm teaching ... the kind of essay I'd like my students to aspire to. May I?


  2. Thanks Rachel!

    ....feel free to use it in your class - gosh, I only touched on the glaring logical fallacies and didn't even get into the others...which I'm sure you see too! Hope it helps your students develop a critical eye!

  3. Excellant post!

  4. Once again, excellent post.

    I've been trying all morning to access Ms. Warshaw's article, but the page won't load....wonder if it's been pulled?

    I've given up thinking that the ADA, AHA, or any other "expert" group is going to start recommending low carb....I mean, can you imagine the lawsuits???

  5. Anonymous8:14 PM

    It's an amazing oversight by some diet researchers not to distinguish subjects who do and do not have significant insulin resistance, since this has such a large impact on the weight loss and blood chemistry effects associated with lower-carb dieting.

  6. Great blog with great information I hope you can visit my website that has links to Weight Loss Programs
    best regards John

  7. A wonderful article! I'd like to see it printed up and put into the waiting room of every doctor who deals with diabetics; to see it made into leaflets and dropped from airplanes; and made required reading at medical schools.

    The sad part of it all is that the very same diabetics who, seeing articles like Hope's, will also never do the research and will most certainly never see your blog. I suspect that the majority of your readers are proactive diabetics.

    We need press! We need some famous person to take up OUR cause and talk about it on TV. Or is it impossible for our diabetic Davids to fight the Goliath of the ADA?

    What do you do when a business (because I don't consider the ADA a medical group) offers diabetics a diet that guarantees diabetic complications later in life? How does this work with the concept of "first, do no harm"?


  8. Hello...just found your blog while doing a Google search. Love this entry...and you "get it"! Too bad the ADA (and the majority of the medical establishement) does not "get it".

    I suppose one other reason is: Legal liability!

    Can you imagine what might happen if the ADA would end up having to admit they were wrong but, simply to preserve their income stream, they continued to "push" a therapeutic diet which is, more and more, proving to be the exact opposite of the one they should have been? And it could be established that they could or should have known that this was the case?

    Uhhh...The "sharks" (lawyers) would have a field day! And not just with litigation against the ADA:

    What about all the other entities who supported the ADA and/or passed on the same lousy advice? Advice that, in turn, THEY had reason to know or should have known was faulty based on science and/or practical experience.

    Therefore the actions of the ADA (and those associated with the ADA and its policy makers) may well have risen to a level of negligence that has or will cause injury to diabetics.

    In other words, if the ADA were to admit they gave into "urban legend" and political pressure (mainly)to preserve their funding instead of relying on truly sound science to make their dietary treatment recommendations? IMHO, that would almost certainly create a domino effect in the courts with subsequent litigation that would make Enron look like a piggy-bank raid in comparison.