Wednesday, June 28, 2006

Enough is Enough

Earlier this week, the American Heart Association updated its dietary guidelines with a number of notable improvements, but one glaring flaw - a recommendation to reduce intake of saturated fat to less than 7% of calories. A number of researchers and scientistist are wondering "where is the evidence?" to support such a recommendation on a population-wide basis.

Today, Dr. Gil Wilshire, shares his thoughts with us in this space in a guest editorial.

Gil Wilshire, MD, FACOG

As I get older and a bit wiser, I have learned to let emotions simmer down a bit before putting thoughts to paper. Restraint of tongue and pen is a true virtue. Suffice it to say that the recent AHA recommendation to further reduce dietary saturated fat consumption has left me angry, dumbfounded, and very frustrated. Now that I have had a chance to absorb this news, I believe I can now calmly formulate an intelligent response.

My thoughts gelled last night as I read the Skeptic column in this month's Scientific American magazine. The author of this monthly piece, Michael Shermer, quotes Francis Bacon thusly:

The human understanding when it has once adopted an opinion (either as being the received opinion or as being agreeable to itself) draws all things else to support and agree with it. And though there be a greater number and weight of instances to be found on the other side, yet these it either neglects and despises, or else by some distinction sets aside and rejects, in order that by this great and pernicious predetermination the authority of its former conclusions may remain inviolate. (Novum Organum, 1620)

Clearly, what was true in 1620 remains true today. Once people's minds are made up, they see what they want to see, and they gather information in a selective way.

Low-fat dietary recommendations were born in the late 1950's out of the work of Ancel Keys. Although we can now see that these studies were fatally flawed by selection bias and confounding variables, the "conclusions," which were actually inferences, were widely accepted. In the past, this phenomenon of acceptance of an authority opinion was common at this time. Healthcare workers and policy makers were generally unaware of the concept of evidence-based medicine, let alone the rigor of Level 1 evidence; that is prospective, randomized human studies.

Now it is 2006, and the low-fat and cholesterol dietary recommendations of Keys remain essentially unchanged, except for the fact that the extremists are now becoming ever more so. We are now experiencing the full onslaught of what Bacon so aptly described as "pernicious predetermination."

What I find so alarming and disturbing is the fact that in the past half century NOT ONE SMIDGEN OF LEVEL 1 EVIDENCE HAS BEEN GENERATED TO SUPPORT THESE RECOMMENDATIONS. I don't know how to say it any louder or clearer.

Virtually everything I do in my medical practice must have rigorous scientific validation before I use it on a patient. Why should public dietary advice be an exception?

My levels of alarm and frustration are very high. If people can convince themselves to drink cyanide-laced Kool-aid, I consider that to be their choice and their problem; but in this analogy, the powers that be want all the rest of us to drink it too! The low-fat proponents consider their position to be so obvious that it does not need any scientific validation. I'm sure they believe their position much the same way when people believed the sun revolves around the earth. It's just obvious, no?

I now live and work in my newly adopted state of Missouri. They have a great motto around these parts: "Show Me." Please somebody, anybody, show me a body of Level 1 (or well-done Level 2) evidence that supports low fat and low cholesterol dietary recommendations for the population at large! Show me some high-quality data. Show me that someone has bothered to properly test the 50 year-old hypothesis.

In the absence of this information, I would like to make the following recommendation:


Sanity in this field will only come out of a complete overhaul. We need to tear down the current edifice of confusion to its most basic foundations, and rebuild it from the bedrock up.

As a side note, I am not blind to the ramifications of my statements. The thought of six billion or so apex predators (which we are) returning to a diet we evolved to eat is a very scary proposition. The current ravages of the bush meat trade in Africa would be trivial in comparison to the carnage wrought by billions of hunters on a global landscape. It is likely that Homo erectus has caused numerous mass extinctions of prey species in the past from uncontrolled hunting. Numerous animals and large fish are currently undergoing decimation.

I also wish nothing ill upon our grain farmers. I now live in the Heartland, and one would be hard-pressed to find a more honorable and hard-working bunch of people anywhere in the world. I understand the economic implications of a shift back to meat-based protein food sources would be profound.

Nevertheless, if a grain-heavy food pyramid is being promoted because it is in our country's best economic interests, then just tell me and also communicate this to the American public. I'm actually OK with that. I am willing to put environmental stewardship ahead of my personal interests, just don't call it good nutrition, evidence-based, a balanced diet or healthful eating and expect me to buy it or promote it to patients with chronic disease.

We are in a health crisis in the United States. Surely, with all of our accumulated knowledge and wisdom, we can find a workable solution that is supported by evidence, is economically feasible and returns our population to good health.

Tuesday, June 27, 2006

Demand Accountability from the AHA

Over the last few days, since posting my challenge, to anyone out in cyber-space, to create a menu within the new 2006 American Heart Association (AHA) Diet & Lifestyle Guidelines and meet all essential nutrients as established by the Institute of Medicine, I've received more than a dozen menus. All within the calorie level (1956-calories for a female, age 30, BMI 24.99, light active) and also within the limit of less than 7% saturated fat. Those submitting a menu are finding however, their attempt to meet all essential nutrients is impossible within the restriction of saturated fat.

The AHA remains silent on an individuals ability to follow their guideline. They have not provided the public with a sample menu as a guide, have not detailed what types of foods are required to meet their guideline and have not even offered a single-day menu as proof it can even be done.

For the American public - the target of this new guideline - this should be a wake-up call to demand accountability from the AHA. When an organization, held in high esteem as the AHA is, recommends a particular dietary approach, the public deserves to know what it takes to follow the guideline, what is the scientific basis of the guideline, and what is the real risk, the real potential consequence to health, if one doesn't follow the guideline.

Without this vital information, the public is left with no real help to modify their diet for the better and is set up for failure.

Without this important information, the public is left helpless to help themselves.

Which begs the question, is that the point?

The AHA has a responsibility to each and every person in the United States when it issues a population-wide dietary recommendation; it has an obligation to detail how to follow the guideline and meet nutritional requirements; it has a duty to provide the public with access to the scientific evidence it analyzed to reach its guideline; and it holds the burden of proof to show the public that their recommendation not only reduces health risks when followed, but leads to improved long-term health outcomes.

At present, the AHA is not providing the public with any useful information to follow their guideline and has not established there is a scientific basis for limit on saturated fat that supports its recommendation on a population-wide basis.

You know what I call that? A population-wide experiement without consent.

The public must start to demand evidence, demand accountability and demand workable solutions to our national health crisis. Don't leave the AHA the option, in years to come, to opine "if only the public would follow the guidelines..."

It's time to demand they show us how to follow the guideline, provide a real example of how to eat according to the guideline and meet all nutrient requirements, and provide quality evidence that following it for the rest of our life will reduce risk and improve long-term health outcomes!

Monday, June 26, 2006

Personal Responsibility & Health

An article in - Obesity debate: personal responsibility needed - caught my attention last week with the opening sentence, "Scientists wish to bring some 'common sense' to the debate on obesity: no need to demonise sugar or any other food as a culprit for obesity - the problem remains imbalance of energy intake and consumption."

Last week EU and US scientists gathered at an event titled "Managing Sweetness" and developed a consensus statement defending the role of sugar in a balanced diet. They argued for bringing personal responsibility back to the core of public health policy and called on the EU and the member states to take the lead in shaping strategies to help individuals learn to manage their diets.

Some background, the Managing Sweetness event is the second one hosted by Oldways Preservation Trust - the first was held in Mexico City, October 21-23, 2004. That conference also led to the creation of and publication of a consensus statement regarding sugars in the diet. Interestingly, the Oldways website has no information about the current conference on their website - nothing, not even the date or location. But with the article above, we know the event took place and that it was hosted again by the Oldways Preservation Trust.

So what are we to make of this new - still unreleased - consensus statement?

We have a good idea of what's to come - managing weight is all about personal responsibility for consumption of sugars and total calories in the diet. Everything, including sugars, in moderation is just fine and dandy. Don't ask for a definition of "moderation" - that's part of the personal responsibility required of anyone taking responsibility for what goes in their mouth.

Which begs the question, how many times are we going down this path before we take a long hard look at the metabolic consequence of excessive carbohydrate in the diet and its direct influence on hunger and appetite?

How much longer are we going to capitulate to the politics that are beneath the surface in this type of consensus statement?

How much longer are we going to appease the food industry and put the financial health of food manufacturers ahead of the health of our adults and our children?

The idea that many "experts" still continue to hold the opinion that it's just a matter of willpower to simply eat less calories, that if one just takes "personal responsibility" and eats "everything in moderation" they'll lose weight...well, it just mystifys me how, after decades of this idea making the rounds while at the same time not working for millions of people, we're still stuck on it.

Of course personal responsibility does come into play - we each choose what we will eat each time we're hungry. However, the influence a food has on our metabolic response is tied to a number of things - calories, weight of food and beverages consumed, macronutrients in food consumed, micronutrients delivered in food consumed, etc. Basically, once we've made a conscious decision about what to eat, our metabolism then takes over and we are no longer consciously "in control" of what happens next. When hunger is triggered a few hours after eating, there is only so long a person can and will ignore the very real, very physical signals the body is sending to urge consumption of more food.

Now the experts, backed by the food industry, are counting on you to eat everything in moderation, even if the very things triggering your hunger are making it difficult to eat less. When you can't, when your hunger is too intense, it's your own fault. It's not the excessive sugars, it's not the food you're eating - it's your fault, your lack of personal responsibility and will power.

Personally, I don't buy it.

As I said, there is a level of personal responsibility involved, but where is the integrity of these experts to tell you how different foods are affecting your metabolism, affecting your hunger triggers, affecting your level of satiety? Where is their personal responsibility to communicate the science honestly to you, the consumer?

Why do these esteemed professionals not communicate about the satiety value of quality protein? Oh, if they did, you'd consume less calories, less food and may even feel better. But, you'd also be eating less processed food, less added sugars and spending less money on the very foods your body no longer hungers for.

Why do these experts not communicate the various data from studies that finds if you consume less carbohydrate, you're more likely to spontaneously - without specifically being told to do so - lower calorie intake? Could it be that you'd again be eating less food, less processed foods and less of the very things that trigger your hunger to eat more?

So while the experts are continuing to push this idea of personal responsibility, isn't it time they took some themselves and told the truth? The truth that what you eat now has a powerful effect on when you'll be hungry again and what you'll be likely to choose to eat later?

Sunday, June 25, 2006

The Challenge Continues...

The first menu received, just hours after posting my $1,000 Challenge, was created by a VP of Nutrition with one of the major online diet sites:

Breakfast: Oatmeal (regular), Walnuts, Skim Milk and Blueberries

Lunch: Turkey breast, Salad Greens, Tomatoes, Broccoli Florets, Olive Oil & Vinegar

Dinner: Red Wine, Baked Salmon, Sweet Potatoes, Carrots, Spinach, Hummus, Cantaloupe

Snacks: Yogurt, Orange, Almonds & Raisins

With 1950-calories and less than 7% saturated fat the above menu met the AHA Diet and Lifestyle Guidelines. However, it failed to meet the DRI for Vitamin D, so I didn't analyze further for other essential vitamins, minerals, trace elements, EAA or EFA levels.

Please note, I am not including the quantity of food to eat in the menus I'm posting. The reason - the challenge must be fair. Those seeking to prove a menu can be created with less than 7% saturated fat and provide all essential nutrients must do it themself without starting with someone else's failing menu!

So, the challenge remains open - no menu has been received that meets the new AHA guideline and provides all essential nutrients!

Thursday, June 22, 2006

New AHA Diet & Lifestyle Recommendations: The $1000 Challenge

This week, the American Heart Association (AHA) revised it's 2000 Dietary Guidelines with a new title and updated recommendations. The 2006 American Heart Association Diet and Lifestyle Recommendations include the following major changes:

  • including "lifestyle" in the title to emphasis the importance of diet and lifestyle
  • minimizing the intake of food and beverages with added sugars;
  • emphasizing physical activity and weight control;
  • eating a diet rich in vegetables, fruits and whole-grain foods;
  • avoiding use of and exposure to tobacco products;
  • achieving and maintaining healthy cholesterol, blood pressure and blood glucose levels; and
  • further reducing saturated and trans fatty acids in the diet

The media has focused its attention on the stricter limit for trans-fats to less than 1% of total calories in the diet. None in the mainstream media seem to be asking about the new stricter guideline for saturated fat - the new recommendation is to limit saturated fat intake to less than 7% of total calories. And let's be clear, it's not 7% or less saturated fat - it's a very clear recommendation to consume less than 7% of energy from saturated fat. The omission of the little "equal sign" under the "less than" sign makes this a "less than" recommendation, not an "equal to or less than" proposition.

To achive this, one must strictly limit consumption of animal foods and regular dairy. There is no way around it when we consider that every liquid oil provides some saturated fatty acids along with the monounsaturated and polyunsatured fats. Basically, this particular guideline is establishing a population-wide recommendation to move to a vegetarian diet without stating it as such.

What's very troubling with the recommendation is that there is no clear, convincing evidence that reducing saturated fat intake to less than 7% of daily energy will prevent chronic disease, improve quality of life in the long-term or increase life expectancy.

After pondering how to communicate how the new stricter limit on saturated fat is dangerous, I concluded I could write, write, write and bore you to death with statistics, data and decades of research findings - or - I could get to the point very quickly with some basic, public information and add a simple challenge to readers.

First some basic information:

On average, as the statistics from 1970-2000 highlight, we've increased our consumption of carbohydrates - significantly - along with our intake of overall calories; our intake of fat, saturated fat and protein has remained more or less stable. In fact, men actually reduced both fat and saturated fat as percentage of their daily calories and in absolute grams eaten each day.

As a nation, our dietary modifications have made us fatter, more have developed Type II Diabetes, and significantly more are taking one or more prescription drugs each day (in 2000, 44% of the population), and an alarming number require three or more prescription medications each day (in 2000, 17% of the population).

We have to ask, what will happen if we do manage to convince the population to reduce saturated fat even more?

Based on studies that have investigated the role of saturated fats in our metabolism, we must ready ourselves for larger numbers of people with nutrient deficiencies, especially the fat soluable vitamins; growing numbers suffering with obesity and insulin resistance, leading to more people with Type II Diabetes; a greater reliance on prescription medication to alleviate the chronic conditions caused by our diet; and more foods touting the benefits of their "low-fatness" to convince you to eat more of it instead of eating animal foods that have saturated fat.

The fact is, limiting saturated fat to less than 7% of calories will directly reduce intake of critical essential micronutrients, fatty acids and amino acids; reduce the absorption of essential fat soluble vitamins; and inhibit the absorption of important minerals. We know this - it's found in numerous studies and surveys. Data from nutritional surveys of people in the US continue to show nutrient deficiencies.

That will only be exacerbated even more if they strictly limit saturated fat to less than 7% of calories.

Now the challenge:

I contend, one simply CANNOT plan a day's menu for a eating and keep saturated fat at less than 7% of energy while at the same time meet essential nutrient-requirements for fatty acids, amino acids, vitamins, minerals and trace elements.

It can't be done.

Take a look at the AHA document, full-text this time - there is not one example of how to eat within the document. No example menu to show following their dietary recommendation will provide for all essential nutrients. No example menu to even show how to eat according to their new guidelines.


It can't be done and meet nutrient requirements.

So, my challenge is - if someone can prove me wrong - create a menu with about 2,000-calories (the IOM establishes a 30-year old female with a BMI of 24.99 who is "low-active" requires 1,956-calories per day), using common whole foods and that menu conforms to the new AHA recommendations, I'll eat my words, issue a public written apology and reward the person with $1000.00.

Yup, if someone can create a menu, I'm willing to pay to see it.

The AHA didn't think it important to take the time to show anyone reading their recommendations HOW TO DO IT, so I'm willing to here if someone creates a one-day menu and sends it to me and it's within the AHA guidelines. Sad when you think about it - the AHA has the in-house experts on hand to do so!

Heck, they even have menus in their No-Fad Diet book...oh, wait, those menus don't conform to their new guidelines and have way too much trans-fats! But, I digress...

Anyone up for the challenge?

Here are the specifics the menu must include, to conform to the AHA guidelines:

  • 1,956-calories from food and beverages detailed with quantity to consume
  • No vitamin supplements may be included to meet essential nutrient DRI's, the AHA specifically recommends foods for meeting nutritional needs
  • Essential nutrients must provide atleat 98% of DRI: Recommended Intake for Individuals based on a female, 30 years old
  • Essential nutrients not to exceed established Upper Tolerable Limits for a female, 30 years old
  • Less than 7% of calories from Saturated Fat
  • Less than 1% of calories from Trans-fats (industrial and naturally occuring)
  • Total Fat - no specific limit
  • Whole Grain foods must be included as part of grains included
  • Vegetables must be included and may be fresh, frozen or canned
  • Fruits must be included and may be fresh, frozen or canned
  • Dairy must be included
  • Nuts, Seeds, Legumes, lean meats, poultry and fish allowed in menu
  • Added Fats and Oils - depends on what you can fit in with 1,956-calories
  • Added Sugars - allowed, but keep to a minimum, especially beverages
  • Cholesterol - no more than 300mg
  • Sodium - no more than 2300mg
  • Alcohol - no more than one serving (4-oz wine, 12-oz beer, 1.5-oz hard liquor)
  • July 18, 2006: Must comply with the AHA guideline to include a wide variety of foods

You can email your submissions for review and analysis. I'll maintain this challenge online through August 31, 2006. Foods included in the menu must have a nutrient profile available in the USDA Nutrient Database for analysis. Only one submission per person (or organization) allowed.

Over the next few weeks and months I'll present menus submitted along with analysis to determine if it meets nutrient requirements and conforms to the AHA recommendations. If anyone creates a menu that conforms to the above, you'll know when I make a public written apology here on my blog and cut a check to the person who created the menu.

Good Luck!

UPDATE: July 18, 2006

The American Heart Association has placed a page on their website with a general guideline of how many servings of each food group to eat daily (or weekly) as part of a diet that complies with their new 2006 Diet and Lifestyle Recommendations issued last month. Because my challenge requires those submitting menus to comply with the AHA guidelines, the foods included in the menu must comply with this additional information. This guideline is similar to the two dietary patterns the AHA pointed to in their full-text paper previously.

Tuesday, June 20, 2006

Effect of Protein in a Low-Carb Diet - Good or Bad?

In the July issue of Current Opinons in Clinical Nutrition and Metabolic Care an interesting review was published - Effects of dietary protein on glucose homeostasis [Carbohydrates]. Within the abstract the authors write, "Recent intervention trials revealed that, in the short-term, the intake of proteins at the expense of carbohydrates increases satiety and thereby lowers intake of calories. High protein intake augments prandial insulin secretion and might thereby improve glycaemic control in type 2 diabetic patients."

Then they turn to the predictable - issue a caution and the reasons why such a diet should be avoided. "On the other hand, epidemiological studies suggest that chronic high dietary protein intake is associated with increased incidence of type 2 diabetes. Furthermore, a short-term increase in plasma amino acid concentrations has been shown to directly induce insulin resistance in skeletal muscle and stimulate endogenous glucose production."

So what is one to make of this? Does a low-carb diet offer a benefit or not?

To answer that we have to determine if the authors provide justification for their position. It's important to keep in mind when reviewing a study or review of studies that it is the obligation of the author to build an explicit arguement for their claim using appropriate data. It is our obligation as readers to determine if the claims are warranted.

The big question here is, are the studies cited to highlight potential adverse effects similar in context? Basically, is existing data about potential adverse effects from other studies transferable and thus appropriate for extrapolation?

In this case, the answer is a firm "no."

The reason is that the studies used to support the beneficial effects of low-carb diets are well-controlled clinical trials that specifically investigate a low-carb diet; those used to claim potential adverse effects are epidemiological studies and data from studies where amino acids are directly inflused into the blood stream. Neither specifically include low-carb dieters or sub-groups consuming a carbohydrate restricted diet.

This is an important point. Especially when we're mindful of the fact that it is incumbent upon the authors to articulate their position and also reference data in the right context. In this case, the context is a low-carbohydrate diet. Where data is cited for potential detriment, the findings must be in the context of a low-carbohydrate study population, or the authors must acknowledge their extrapolation is beyond the specifics studied in those references they do use and justify why using studies out-of-context is warranted in their review.

They do neither. And we find the epidemiological studies are problematic mainly due to the fact they are not in the proper context. That is, they're investigating the effect of dietary habits of a large population consuming a carbohydrate-rich diet. So, while the finding that one is at an increased risk for diabetes when they consume high amounts of red meat and processed meat applies to a population consuming a carbohydrate-rich diet, it cannot be extrapolated to apply to a population consuming a low-carbohydratre diet. It's out of context and beyond the scope of the data available.

We find similar problems with the data presented from studies where subjects were infused with amino acids directly into their blood stream. They too were consuming a typical diet before the testing. But more importantly, humans don't typically have amino acids infused into them. So the delivery of the amino acids makes the extrapolation of this data subject to suspicion as a justification to say the data should apply to those following a low-carb diet. In this case, it's not even comparing apples to oranges, it trying to compare apples to rocks.

In this study, the authors do not meet their obligation to build an explicit arguement for their claim. And, it seems, they missed the opportunity to highlight an area of research where data is slim - the metabolic effect of protein intake in the long-term while consuming a carbohydrate restricted diet.

Saturday, June 17, 2006

ADA Acknowledges Low-Carb Diets Help Control Blood Sugar

In an interesting twist this week, in an updated WedMD article, American Diabetes Association spokesman Nathaniel G. Clark, MD acknowledged in an interview that carbohydrate restricted diets help people with type II diabetes control blood sugar.

In previous articles, I've stated evidence-based medicine must be the gold standard used for making for recommendations; I've pointed to the consensus driven, dogmatic position of the ADA; and I've stated in no uncertain terms that the ADA must be held accountable for the health harming position, based on opinion not data, it takes.

Now the excuse from the ADA is that they do not recommend controlling carbohydrate because patients find them too restrictive. "We want to promote a diet that people can live with long-term," says Clark, who is vice president of clinical affairs and youth strategies for the ADA. "People who go on very low carbohydrate diets generally aren't able to stick with them for long periods of time."

The WebMD update was prompted by the publication of Low-carbohydrate diet in type 2 diabetes. Stable improvement of bodyweight and glycemic control during 22 months follow-up, in the peer-reviewed journal, Nutrition & Metabolism.

The study started as a six month study to compare the effect of a low-carb or low-fat diet in those with type II diabetes. The original study data was published in 2005. In the present study, the researchers wanted to determine to what degree the changes among the 16 patients in the low-carbohydrate diet group at 6-months were preserved or changed 22 months after start, even without close follow-up. They also noted that 2/3 of the original low-fat group modified their diet after the study term and also showed improvement after making the dietary change. At the 22-month mark it was concluded that the improvements found at six months had a lasting effect on both body weight and glycemic control.

Noteworthy is that this is the first "long-term" study - one that didn't even include intensive follow-up and tracking for compliance - at almost two years. Without dietary counseling those who experienced the dramatic improvements stuck with the diet - even the majority of those subjected to the low-fat diet saw the results in the group following the low-carb diet and jumped at the chance to follow a low-carb diet and experienced the improvements too in the period between six months and twenty-two months.

So, it's now difficult for the ADA to say there's no data. What they're doing now is changing their tune - patients don't want to follow the diet, it's too hard.

Again we see the ADA purposely avoiding evidence-based medicine standards.

Quite frankly, it doesn't matter if a patient can or will follow the dietary protocol the evidence shows is superior to the current recommendations. Evidence-based medicine demands these findings be not just acknowledged in an interview, but presented to the patient as a line of defense in their management of the disease.

It's nothing but pure arrogance for the ADA to arbitrarily decide that it will not fully disclose the benefits of a carbohydrate restricted diet, as shown by the evidence, to patients because it feels patients won't want to follow the diet.

Since when does the ADA or any other medical organization decide what a patient wants?

Those with type II diabetes, those with pre-diabetes, and those at risk for developing insulin resistance which will lead to diabetes must be given all the facts so they can make a decision based on the full data available - anything less fails the standard of informed consent.

This study shows that individuals, when given an opportunity to experience the health changing effects of carbohydrate restriction, stick with it for the long-term. And who wouldn't? Just imagine what their health would be today if they never enrolled in the study and never were given the information about how to properly follow a carbohydrate restricted diet - they'd be progressively deteriorating!

Instead, their improvements are persisting - because they chose to continue eating a carbohydrate restricted diet.

It's time the ADA takes the evidence-based approach seriously and abandons this notion they know what a patient wants.

At the end of the day, you'll be hard pressed to find a majority of those with diabetes willingly opting for more medication and progressive deterioration rather than just give up the bread, pasta, rice and potatoes!

Tuesday, June 13, 2006

Study: Trans-Fats Increase Fatness, Insulin Resistance, Risk of Diabetes

For years now the warning bells have sounded about the health risks associated with consuming industrial trans-fats (partially hydrogenated oil) found in margarine, processed foods and fast food. This heart-damaging fat is in the majority of packaged foods in the grocery store - from breads to cake mix and frosting, margarine to cookies, and frozen french fries to prepared convenience foods.

As of January this year, manufacturers were required to disclose the level of trans-fats on nutrition labels, with an exception allowed for servings that contain 0.5g or less of trans-fat. So, even if a label states "zero trans-fats" on the front of the package, the consumer must read the ingredients to determine if small amounts are still present.

With the dangers known, no research can be conducted to investigate the damaging effects in humans in controlled-feeding trials. It would simply be unethical to feed humans large amounts of industrial trans-fats purposely to see what happens. We already know enough to know that such a trial will damage long-term health.

Six years ago, however, researchers at Wake Forest University Baptist Medical Center in Winston-Salem, North Carolina began what would be a ground-breaking study in monkeys. The findings, presented at the 66th Scientific Sessions of the American Diabetes Association this weekend were, in a word, shocking.

Trans Fat Diet Induces Insulin Resistance in Monkeys was part of the presentations made in the Nutritional Conundrums - What Nutrient Mixes are the Best? program.

In her presentation, Dr. Kylie Kavanagh detailed how her team fed one group of monkeys a diet with 8% of their calories from trans-fats (partially hydrogenated soybean oil) and the other group the same diet sans the trans-fat. At the end of six years, Kavanagh scanned the monkey's arteries, but the thing that really stood out was their bellies. The trans-fat eating monkeys had gained around 7% in weight, while their healthier counterparts had put on just 2%. They also had about a third more flab around their abdomen. "You can see white globs of fat in these guys," Kavanagh said at the meeting.

The trans-fat fed monkeys gained more weight on the same calories as their trans-fat free counterparts!More important - the trans-fat fed monkeys had higher blood glucose levels and were more insulin resistant than the trans-fat free monkeys.

Bottom line - the monkeys fed the trans-fats were well on the road to developing diabetes!

Not only did they gain more weight - they gained more fat and were experiencing insulin resistance.With that higher blood glucose and insulin resistance comes a higher risk for cardiovascular disease too.

Hmmm - will this research help the American Heart Association recall it's book The No-Fad Diet where trans-fat rich foods are included in the sample menus? Will the AHA insist that any food with industrial trans-fats remove its logo from the package?

Will this research finally eliminate the mentality that "everything in moderation" is a good dietary principle?

And lastly, will this research serve as a catalyst for the American Diabetes Association to stop it's promotion that all foods are acceptable for someone with pre-diabetes or diabetes?

Where Are Her Parents?

In New York Magazine this month, a feature titled The New York Diet - What Five of us Ate in a Week, details not only what five New Yorkers ate, but when and where they ate their various meals. As the article highlights early, "Most important: Food is everywhere. It happens not just around the table but in the street, at the office, in front of the television, even on the subway."

As part of a peek into the food habits of New Yorkers, five were asked to keep a record of everything they ate for a week in May. They also detailed where they ate and at what time in the day. Before getting into the details of each participant, the authors sum up the findings (non-scientific, of course) with "Look quickly, and you’ll see more differences than similarities here. Some of us are scarfing Sour Patch Kids in class, while others dine on lamb shanks and grapefruit Bellinis at the Modern. But look closely and you’ll see that really, we’re all the same: hungry."

No person in the group ate what I'd considered good food each day - and heck, none managed to even eat well for just one day. Sadly, the bunch ate horribly, and while not a representative sample of Americans, I think their eating habits reveal that there is something wrong with our thinking about food in the United States. Each person in the article is a testament to the power of marketing and placement of junk foods, and the prevalence of ready-to-eat meals.

The worst eating habits came from a young girl, a teen - her daily menu consisted largely of candy, sweet beverages and fast food. Where is this 15-year-old's parents? How was she allowed to eat this on Monday?

8:00 A.M. HOME Stick of gum
8:10 Stick of gum
10:05 SCHOOL 6 Oreos 12:30 3/4 pack of M&M’s
1:40 P.M. POPEYES Buttermilk biscuit
1:45 MCDONALD’S Half a chicken strip
6:40 DOMINO’S Slice of pizza
7:15 HOME Bag of Puffin’ Corn
11:50 11/2 glasses of banana milk shake

Good grief!
Calories = 1673
Fat = 33% (60g)
Carbohydrate = 58% (247g)
Fiber = 7g
Protein = 9% (just 38g)

This child is STARVING for essential nutrients!

While her calorie intake was questionable as "adequate" for her age, her nutrient profile was nothing short of a disaster - and this particular day was not an anomoly, it was her typical eating pattern!Not only did she totally rob her body of essential amino acids with a deficient protein intake, and completely miss out on essential fatty acids - she also missed almost every important micronutrient - Potassium, Vitamins A, C, D, E, B-6, B-12, K along with Folate, Niacin, Calcium, Magnesium, Zinc and Selenium!

This young woman is a metabolic timebomb - a dietary disaster walking, that at some point will catch up with her in the most certain of health terms.

The rest of her week was no better - everything from a wide assortment of candy, chips, fast foods and empty calories. There's no easy way to say this, but she's slowly starving her body for nutrition and at some point her health is going to be the price for this diet.

Where are her parents?

Friday, June 09, 2006

Low-Carb Research Featured at ADA 66th Scientific Sessions

Today the American Diabetes Association opens the 66th Scientific Sessions in Washington, DC with some intriguing presentations. Unlike previous years, I'm not able to attend this year's sessions, but am carefully following the program line-up and hope to write about as much of the latest research findings as possible in the days to follow.

Today two presentations of interest are found in the session, Conundrum - A Diverse Mix of Approaches to Nutrition and Diabetes Education, scheduled for 4:15PM.

In the first, Efficacy and Safety of Carbohydrate Restriction Diets in Obese Type 2 Diabetes, researchers evaluated the efficacy and safety of carbohydrate restricted diets compared with the conventional prescribed dietary approach for those with type II diabetes. They conclude "Carbohydrate restriction is an effective means of weight loss in type 2 diabetes over 6mths, associated with reduced waist circumference. Furthermore it was not associated with any deleterious effect on glycaemic control, other risk factors or renal safety over a 6mth period."

Within this study group, there were two statistically significant findings between the diets - weight loss and reduction of waist circumference. In all other measures, the differences did not reach significance, but were greater in those following the low-carb diet.In the second study, A Randomized, Controlled Trial of a Low-Glycemic Index vs. a Low-Carbohydrate, Ketogenic Diet for Type 2 Diabetes, researchers evaluated differences between a very low-carb diet (ketogenic) and a low glycemic index diet (good carb). Again, the better approach was a low-carb diet. The researchers conclude, "Both lifestyle interventions led to medication reduction, weight loss, and improved glycemic control, but the LCKD led to a greater reduction in HgbA1c after 3 months."

It's important to note that 79% of those assigned the low-carb diet either reduced or eliminated their medications within the three month trial. This is a finding consistent with numerous other studies evaluating a low-carb diet - reduction or elimination of medication in a relatively short period of time.

In previous years similar findings such as these have been presented at the annual Scientific Sessions. Yet, they remain ignored by the ADA and those considered "expert" in the management and treatment of diabetes within the organization. I personally find this dismissal of evidence not only contrary to the standards of evidence-based medicine, but also a major breach of trust between the leading diabetes organization, healthcare professionals on the frontlines of an epidemic of diabetes and the public.

I've previously written some scathing words here about the ADA:

I remain of the opinion that the ADA must accept the evidence as it stands - evidence that for decades has found the dietary recommendation they advance is inferior to other approaches - specifically carbohydrate restricted diets. Millions of people in the United States - MILLIONS - are already living with type II diabetes, millions more are already pre-diabetic. If the ADA does not rethink their standards of care, I fear that number will only continue to rise in both our youth and adults in the United States.

I've said it before, and I'll say it again - we have the evidence, we have the hard data, we have thousands already off diabetic medication following a low-carb diet...when will we accept it and finally take an evidence-based approach and actually run with it to reverse this epidemic?

When will the ADA be held accountable to the millions already diagnoised with diabetes and the millions more on the road to diabetes?

Thursday, June 08, 2006

Re-thinking Calories - The Cost Per Ounce

In the June issue of the American Journal of Clinical Nutrition a study, Dietary energy density is associated with energy intake and weight status in US adults, researchers concluded "Adults consuming a low-energy-dense diet are likely to consume more food (by weight) but to have a lower energy intake than do those consuming a higher-energy-dense diet."

The researchers based energy density on foods eaten and did not include beverages in the calculation to avoid dilution - they explained their reasons with "Although several studies in the literature have found lower dietary energy density values to be associated with a more favorable body weight, other studies have not supported such a relation. One potential explanation for the inconsistent findings may be that different schemes for including beverages in the calculation of energy density were used in these studies. Beverages tend to have a lower energy density than do most foods and may disproportionately influence dietary energy density values."

In their discussion the researchers stated, "Although it is important to understand the relation between energy density and food intake, it is also critical to explore the relation between energy density and body weight. In the present study, those who were obese consumed diets higher in energy density than did those who were not obese."

Guess what? That was true!

However, a huge opportunity was missed in the discussion of the findings which clearly showed a strong association between non-water beverage consumption and obesity. You see, at the end of the day, those consuming diets with the lowest energy density and those consuming diets with the highest energy density - they both consumed similar total weight of food and beverages. Beverages clearly displaced food consumption and added more calories too!

The men eating a diet classed as "low energy density" consumed about 94.7-ounces total food and beverage a day; those in the middle range, about 94.6-ounces a day; and those in the "high energy density" group consumed about 93.1-ounces a day total. The women had similar eating patterns - those eating a diet classed as "low energy density" consumed about 69.5-ounces total a day; those in the mid-range, about 63-ounces a day; and those in the "high energy density" group ate about 64.9-ounces a day total.

Quite frankly the differences appear significant when we look at how much of that total is from beverages in each group! The weight from beverages for the men (from low to high energy density) was 49-ounces, 55-ounces and 61-ounces; for the women (from low to high energy density) the weight of the beverages was 36-ounces, 39-ounces and 42-ounces. As consumption of beverages (other than water) increased, so too did calories and the weight of food eaten. The beverages were providing weight and thus displacing food in the diets of these subjects!

Also noteworthy was the fact this study was designed to be a representative sample of US adults. The data clearly shows that the vast majority of people either cannot or will not reduce fat intake to below 30% of total calories - for whatever reason, a full 72% of those in the study ate a diet that provided 30% or more of their daily calories from fat.

Interestingly - and not discussed in the paper - is the prevalance of obesity was cut in half in those consuming a diet defined as "high fat" when fruit and vegetable intake exceeded nine-servings a day! You read that right - a 50% less chance of being obese when you eat nine or more servings of fruits and vegetables, even when you're consuming a diet that's considered "high fat."

In fact - regardless of dietary fat intake - there was no real difference between those eating a high-fat diet with less than 5-servings a day of fruits and vegetables and those that ate between 5-and-9 servings a day - the group that consumed the least, obesity affected 18% of the subjects, the group that ate 5-9-servings, obesity affected 17% of the subjects.

But, those that ate more than nine servings a day - just 9% were obese.

And what type of a diet do you eat if you're eating a diet that's "high fat" and rich with fruits and vegetables? You guessed it - one that is low-carb or controlled-carb! The reason is simple - you cannot eat excessive grains and added sugars if you're eating more than nine servings of fruits and vegetables a day!

Nine servings sounds like a lot, I know - but guess what? Even if you're following a low-carb diet, it's very easy to consume that much - five-to-nine-cups - in a day.

Want to see how easy?
  • 1/2-cup canteloupe, breakfast (1 serving)
  • 2-cups salad greens, lunch (1 serving)
  • 1-cup sliced cucumber, red cabbage, cherry tomatoes and shredded carrots (2 servings)
  • 1/2-cup blueberries, snack (1 serving)
  • 1-cup spinach, cooked, dinner (2 servings)
  • 1-cup mixed salad greens, dinner (1 serving)
  • 1/2-cup assorted salad fixings (cucumber, red cabbage, etc.) (1 serving)
  • 1/2-cup peppers and onions, dinner (1 serving)

Ten servings - 210 calories - 7-cups of fruits and vegetables - and just 30g net carbs!

Better still, the above provides almost 27-ounces of food by weight. If the average man consumes 94-ounces, the above just filled 28% of the total weight eaten in a day; if the average woman consumes 66-ounces a day, the above just filled 41% of the total weight eaten in a day.

Once you add proteins (meats, fish, poultry, eggs), some fats and an assortment of other good foods like nuts and seeds, there is little more you could eat if you tried - seven cups of fruits and vegetables is a large amount of food to eat in a day! Eating that much makes it difficult to overindulge in other, less nutritious food or consume large quantities of non-water beveages!

The data in this study clearly points to consuming fruits and vegetables as the best defense to protect against obesity. Regardless of fat intake - low-fat, high-fat - didn't matter, the overall rate of obesity was just 7.5% for those who consumed more than nine-servings of fruits and vegetables a day - half the 15.5% prevalance of obesity in those consuming nine or less servings a day!

That's right - in both the low-fat and high-fat groups, the prevalance of obesity doubled when fruit and vegetable consumption was at or less than nine servings a day!

What this tells me is that the foundation of eating well is fruits and vegetables - today, the vast majority of Americans eat less than five servings a day (and that's even if we include french fries, potato chips and fruit juice in the accounting)!

Our obesity epidemic isn't being driven because Americans are eating too much fat or not enough whole grains or too many animal foods - we're not eating enough fruits and vegetables (and I place stronger emphasis on vegetables) and that leaves us at risk of consuming excessive amounts of sugary beverages, processed foods, grains and junk food in general to provide us with the daily weight of food and beverages we're used to eating each day.

Remember, this study showed that overall consumption at the end of the day, by weight, was similar across all groups.

What differed was consumption of non-water beverages that provided for weight but added too many calories.

We have to get back to basics - and to put it simply, you get the most nutritional bang-for-the-calorie from non-starchy vegetables, followed by non-starchy root vegetables and fruits, followed by starchy vegetables.

We have to stop recommending people base their menus on a foundation of grains - these foods provide less nutrients and cost more calories to eat by the ounce because they have less moisture (water) packed in them.

A good example - a cup of cooked spinach has 57-calories and weighs 7-ounces. So, each ounce costs about 8-calories to eat. Compare that to a cup of cooked regular oatmeal (no fat added) - it weighs 8-ounces and has 145-calories in the serving, costing you 18-calories an ounce to eat.

Bottom line - we have to better communicate to the public not only the nutritional benefits of eating more fruits and vegetables, but also communicate the advantages in terms everyone seems focused on - calories.

But not just overall calories - let's begin to talk about the cost of calories per ounce....if we talk in these terms, who doesn't want to take advantage of the "savings" one gets when they eat fruits and vegetables?

Wednesday, June 07, 2006

Childhood Obesity - Back to the Future

There is an old adage that says "for all complex problems there is a simple solution -- and it never works."

For decades must we have endured the message that eating less fat, specifically less saturated fat, is the panacea for weight management and health. Over the same period of time this message was preached, two out of every three adults have grown overweight or obese; our children are now being affected - not only are they too growing overweight and obese, they're now suffering from cardiovascular disease, type II diabetes, metabolic syndrome, high cholesterol, arthritis and a host of other obesity related illness.

Our "obesity crisis" is now a national obession with the spotlight on childhood obesity - how do we save the children?

The World Health Organization has revised its growth curves for infants and toddlers - taking acceptable weight down a notch in the hope that "the new charts give public-health officials, pediatricians and families the opportunity to redefine normal growth in infancy and rethink the social norm in which parents boast about 95th percentiles for their babies."

Robert Whitaker, a senior fellow at Mathematica Policy Research, stated "The prevalence of obesity is increasing and affecting children at younger and younger ages. If we talk about healthy weight earlier, it may be a good opportunity to start obesity prevention early."

Former President Clinton recently crusaded against childhood obesity and is partly responsible for the school soda ban, working with major vendors to voluntarily remove the sweetened beverages. He's also on an anti-fat campaign and has pledged to work with food companies and food vendors to reduce the amounts of all forms of dietary fat in the items kids love to eat, including French fries and pizza.

School districts across the country have either mandated BMI screening or are considering similar policies to weigh and measure children and include the findings in report cards sent home to parents. In addition, school boards are revising nutrition policies to ban whole milk and high-fat snacks (replaced, of course, with low-fat versions of the same junk food).

Last year the 2005 Dietary Guidelines for Americans launched with a section specifically targeting young children with interactive games to teach them that healthy eating is eating a diet low in fat that limits saturated fat. The site even includes classroom materials teachers can use to get the message across to the kids in their classes.

Don't get me wrong - I totally agree we have a problem in the United States - there is a continued trend of problematic increases in overweight and obesity amongst our children. Our children are now at significant risk of having a shorter life expectancy than we adults do. Scary!

Albert Einstein is credited with saying that insanity was doing the same thing over and over again and expecting different results.

When the government decided to modify dietary policy and recommend all Americans reduce their intake of fat, they were warned of unintended consequences. Dr. Phil Handler, in 1980 during testimony before Congress asked ''What right has the federal government to propose that the American people conduct a vast nutritional experiment, with themselves as subjects, on the strength of so very little evidence that it will do them any good?''

Now, some thirty odd years later, we're witnessing the effects of that population-wide nutritional experiment, yet the experts remain blinded by the gospel of low-fat dogma.

It doesn't take an Einstein to go through the literature and find the diet our children eat is significantly different today than it was in 1977-79.

Did you know that parents way back then were feeding their 2-5 year-olds an average of 36.2% of their daily calories from fat, with 14.3% from saturated fat. The average preschooler ate just 4-servings of grains a day, about 3-servings of fruits and vegetables, about 2-servings of dairy and consumed about 12-teaspoons of added sugar from all sources (food and beverages) in their diet.

Good grief, how did any of us survive?

For the record, we didn't just survive - in the period of 1977-79, only 4-6% of children were overweight or obese. Today more than 15% are overweight or obese, and that number continues to climb each year.

Rather than step back and ask "what were we doing right thirty years ago?," we're intent on the idea that a low-fat diet is better for us and our children.

Within the literature we find a very comprehensive review that was published in the American Journal of Public Health in 2004 - Changes in Diet Quality of American Preschoolers Between 1977 and 1998 - in which researchers concluded that diet quality had improved over the 21-year period investigated.

The data in that study shows, as the researchers stated, that added sugars "increased strongly" in the diet of preschoolers, and that children were eating more calories. What did the researchers say was the cause of the higher calorie intake? Dietary fat! They put it this way - consumption of dietary fat also "contributed to higher energy intakes" - a wholly inaccurate statement if one simply does the math!

This is what happens when one is already convinced dietary fat is the culprit in the obesity epidemic!

I took the time to crunch the numbers from the published data and guess what? Dietary fat intake increased by 0.1g on average - put into reality, fat intake contributed just a hair less than one-calorie more per day in 1998 than in 1977. One calorie?

So where were the kids getting the additional calories from?

Added sugar accounted for 13.9% of calories in 1977 - about 198-calories; by 1998 added sugar accounted for 15.7% of calories - or about 245-calories a day.

Children also added more grains to their diet - in 1977, on average, children consumed four servings of grains - by 1998 their consumption increased to six servings. And who says parents don't listen to government recommendations?

Fruits and vegetables also increased - in 1977, on average, children consumed about 3 servings of fruits and vegetables each day - by 1998 they were consuming about 4.6-servings. Again, who says parents don't list to government recommendations?

As a proportion of their diet, fat did decrease - from 36.2% of total calories to 32.3% of calories. In absolute terms, fat intake remained flat - an additional calorie each day DID NOT contribute to their increase in calories in any significant way. It was the additional sugar, too much juice (also increased from 1.2-ounces of excess juice in 1977 to 5.4-ounces of excess juice in 1998) and additional grains that had the major caloric impacts!

The message in the last 30-years has been clear - eat more grains, added sugar is harmless and juice counts as a fruit. Guess what? Parents heeded that message, fed their kids more grains, more sugars and more juice and we're seeing the results - childhood obesity, children with type II diabetes, kids stricken by cardiovascular disease, our future generation already in poor health!

And what are we doing about it?

Preaching the same message - lower the fat, increase the grains!

The exact definition of insanity!

Friday, June 02, 2006

It's Your Heath - What are you Going to Do About It?

With the recently published estimate that one in three Americans either have diabetes or impaired fasting glucose (pre-diabetes) the alarms are sounding that we must modify our lifestyle or face the consequences. The oft-repeated recommendations include losing weight, eating less calories, eating less fat and increasing physical activity. To be clear, losing weight can and will improve health. Eating fewer calories does result in weight loss and increased activity does have a positive effect on glycemic control.

To convince you that complying with the recommendations will prevent or delay the onset of diabetes if you eat less fat as part of your calorie reduction isn't necessary even though a number of studies are being referenced as "proof" such a dietary modification works best.

Some background - the American Diabetes Association (ADA) sets the standard for evaluating test results and diagnosis of pre-diabetes or type II diabetes. Since October 2003, the ADA maintains that normal fasting blood sugar is 100mg/dL or lower; pre-diabetes is greater than 100mg/dL but less than 126mg/dL; and diabetes is a reading greater than 126mg/dL. They also maintain a series of values for testing of glucose tolerance - when levels of blood sugar remain at or below 140mg/dL after an oral glucose challenge, the person is said to have a normal glucose response; blood sugars greater than 140mg/dL but less than 200mg/dL indicate impaired glucose tolerance (pre-diabetes); and blood sugars higher than 200mg/dL indicate diabetes is present.

With these numbers in mind, let's take a look at the evidence from the studies the ADA references to see how well the recommendations are at preventing progression of impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). Heck, let's even see if the dietary recommendations can reverse IFG or IGT!

Let's really see if the ADA's claim that "Research has also shown that if you take action to manage your blood glucose when you have pre-diabetes, you can delay or prevent type 2 diabetes from ever developing;" and that, "People with pre-diabetes can expect to benefit from much of the same advice for good nutrition and physical activity. The links on this page are cornerstones of successful management of pre-diabetes."

The ADA states that the Diabetes Prevention Program study "conclusively showed that people with pre-diabetes can prevent the development of type 2 diabetes by making changes in their diet and increasing their level of physical activity. They may even be able to return their blood glucose levels to the normal range." [emphasis mine]

How about we take a look?

The study was published in the New England Journal of Medicine in 2001. It provides an interesting look at how three different approaches may influence the development of diabetes in those with pre-diabetes. The researchers recruited 3,234 individuals to participate and randomly assigned them to three groups - 1,082 were in the placebo group (control); 1,073 were in the Metformin group; and 1,079 were in the lifestyle intervention group - instructed to increase activity to 150-minutes per week and modify diet as per ADA recommendations and lose 7% of their body weight.

There were indeed differences at the end of the study - 28.9% of the control group progressed to a diagnosis of diabetes; 21.7% of the Metformin group progressed to a diagnosis of diabetes; and 14.4% of the lifestyle intervention group progressed to a diagnosis of diabetes. Basically, those individuals who followed the lifestyle intervention had a 58% less chance of developing diabetes than those who did nothing.

Impressive, isn't it?

The researchers concluded "Lifestyle changes and treatment with metformin both reduced the incidence of diabetes in persons at high risk. The lifestyle intervention was more effective than metformin."

Something important to keep an eye on - the lifestyle intervention did not prevent diabetes in everyone who followed the recommendations. In fact, the researchers point out that to prevent one case of diabetes, seven individuals would have to follow the intervention program in three years. "To prevent one case of diabetes during a period of three years, 6.9 persons would have to participate in the lifestyle-intervention program."

So, while statistically there was a risk reduction of 58% in those following the lifestyle intervention, the program worked for one in seven individuals over the three year period.

Tuck that number away in your head - one in seven over three-years - for later.

More importantly though - did the lifestyle intervention have a positive effect on fasting blood sugars and HbA1C over the study period? Those in the study all started with impaired glucose tolerance, which we'll address in a moment. Did the FBG and HbA1C improve over time with lifestyle modifications?

Initially, at the six-month and one-year follow-ups there were dramatic changes for those who modified their lifestyle - impressive improvements in fasting blood glucose (FBG). At baseline those in the lifestyle intervention group had an average FBG of 106.3mg/dL which declined over the first year to just a hair above 100mg/dL. After the first year, their fasting blood glucose levels rebounded however, so for the first year the diet and exercise did have a positive effect - but that was lost over time as fasting blood glucose did a rebound and ended higher at the conclusion of the study than at baseline. So, after three years of the lifestyle intervention, while they weren't diabetic, those in the intervention group experienced an overall negative effect on fasting blood glucose - it worsened over time.

The same disturbing trend is seen with regard to the HbA1c levels. Initially HbA1c improved only to rebound over time with the follow-up levels higher than baseline - HbA1C worsened over time.

So, what about glucose tolerance - the measure of how well an individual metabolizes glucose when given an oral challenge?

At the start of the study, every person participating had impaired glucose tolerance. During the one-year follow-up a considerable percentage - about 50% - had GTT test results which showed normal glucose tolerance. However, much like the rebound experienced with fasting blood glucose and HbA1c levels, we find a similar decline over time with glucose tolerance.

While the ADA likes to cite this study as definitive, "conclusive" proof that lifestyle modification will prevent diabetes - the reality is that this study shows you'll probably experience some significant improvements initially, but with rebound trends evidenced in the data, progression toward diabetes is being delayed not stopped. Yes, that's better than uninterrupted progression - but shouldn't we be looking for a way to reverse what we now call "pre-diabetes" so that the risk of diabetes isn't just reduced, but eliminated?

As I said before, a number of studies are cited to convince you to follow the ADA recommendations if your fasting blood glucose or glucose tolerance tests show "pre-diabetic" values.

The newest one to hit the media is the one I already wrote about - High-fibre, low-fat diet predicts long-term weight loss and decreased type 2 diabetes risk: the Finnish Diabetes Prevention Study. While my previous article didn't explore the findings relative to glucose testing, let's take some time today to review that data.

Like the Diabetes Prevention Program study, the Finnish Diabetes Prevention study also recruited individuals with impaired glucose tolerance. This trial was a bit longer than the ADA study, an average follow-up of 4-years. Of the 500 individuals who completed the study term, 114 were diagnoised with diabetes along the way (one in five). Where the data is interesting is the difference in baseline values of those who developed diabetes and those who did not.

In those who remained free of an official diagnosis of diabetes (based on testing results), their baseline fasting blood glucose averaged 108mg/dL and their GTT results averaged 158.4mg/dL. They did have impaired glucose tolerance, and if we were to use today's accepted standard for impaired fasting glucose (100mg/dL or higher) they also had impaired fasting glucose. This study used the older standard of 110mg/dL so those participating were not considered having impaired fasting glucose.At the end of the study period, their fasting blood sugars remained at 108mg/dL - so there was no improvement there; their glucose tolerance did improve somewhat, to 145.8mg/dL - but they remained pre-diabetic with impaired glucose tolerance. Impaired glucose tolerance is impaired glucose tolerance - the intervention did not reverse this state.

They differed from those who did develop diabetes - specifically their blood test levels were lower than those who developed diabetes during the study. At baseline, those who went on to develop diabetes started with higher average fasting blood glucose levels averaging 117mg/dL - over time that rose to 127.8mg/dL; their initial baseline glucose tolerance was poorer also. At baseline those who developed diabetes averaged 169.2mg/dL readings after a glucose challenge which rose to 208.8mg/dL over time.

So while this study is being offered up as proof that consumption of dietary fat and fiber are significant predictors of progression of developing diabetes, let's not forget that those that did not develop diabetes continued to have impaired glucose tolerance. They actually started the study with better odds - their fasting blood sugars and glucose tolerance were lower at baseline than those that progressed to diabetes! The researchers don't discuss this in their paper though.

From these two studies we clearly see that a lifestyle modification, as per the ADA recommendations, can delay onset of diabetes - but that's just slowing it down, not preventing or stopping it from developing. Don't get me wrong - delaying is better than nothing....but, are we looking at all avenues available - perhaps one that doesn't just delay onset of type II diabetes, but reverses the pre-diabetic state so the individual has normal readings when tested.

Should we just forget the long-term consequences of elevated fasting blood sugar or impaired glucose tolerance? Remember neither of the above studies changed the state of impaired glucose tolerance or improved fasting blood sugars or lowered HbA1C levels.

Should we ignore that study after study points to the increased risks associated with impaired fasting glucose and impaired glucose tolerance - insulin resistance, dyslipidaemia, hypertension, abdominal obesity, microalbuminuria, endothelial dysfunction, and markers of inflammation, hypercoagulability and increased risk for heart disease and stroke! Isn't reversing the pre-diabetic state the goal we should be after rather than simply maintaining such a health-damaging state?

Are we willing to admit defeat?

Are we going to continue to ignore evidence that we can reverse the pre-diabetic state?

Are we goiong to contine to dismiss evidence that we can offer individuals diagnoised with type II diabtes an option which may not just stop progression of the disease, but reverse it?

Is there any evidence we can really do this? Or am I just speculating here?

Well, we have dozens of studies that have investigated diets that restrict carbohydrate while allowing either higher intake of protein or fat. We have data that consistently shows following such a diet improves cholesterol (specifically increasing HDL and dramatically reducing triglycerides), enables weight loss with greater satiety and spontaneous calorie reduction, improves blood pressure and increases insulin sensitivity. The data we're lacking is the effect such a dietary approach has on fasting blood glucose and glucose tolerance because few researchers have included these parameters in their study design or haven't specifically followed individuals with pre-diabetes.

The evidence we do have shows much promise. Recently, Dashti et al published Long Term Effects of Ketogenic Diet in Obese Subjects with High Cholesterol Level - in the April 2006 issue of Molecular Cell Biology. In their 56-week study following obese subjects, they found glucose levels decreased significantly (p=0.0001) from a baseline to end-of-study. In fact, after following the diet for one year, glucose levels were within normal range!

As I said though, there just isn't much data out there to really give us a clear picture about how a carbohydrate controlled diet affects those classified as "pre-diabetic." What we do have is data from studies investigating a controlled-carb or low-carb diet's effect in those with type II diabetes though.

Yancy et al published a small, short-term study in 2005, A low-carbohydrate, ketogenic diet to treat type 2 diabetes, that found statistically significant improvement in fasting glucose in those individuals following a low-carb diet. Over sixteen weeks, 28 individuals with diabetes were recruited to follow a low-carb diet. At baseline the group had an average fasting blood glucose of 163.4mg/dL - after sixteen weeks their fasting blood glucose declined to 136.26mg/dL - still, as a group diabetic.

But, if we dig into the paper, we find that of the 28-individuals in the group, 7 discontinued all medication for diabetes, 10 reduced medication and only 4 required medication at the same level as they did at baseline. Folks, that's one-in-four who improved fasting glucose levels to the point where diabetic medication was no longer needed, and another one-third had to reduce their medication during the diet.

One in four had their diabetes medications stopped during the study. Isn't that better than one in seven maintaining a pre-diabetic state, even though they did not progress to diabetes?

Too bad the study here was only 16-weeks - what would have happened if those in the study were followed for six months? One year? Three years?

But honestly, this isn't "new" information. In fact, back in 1994, JAMA published Effects of varying carbohydrate content of diet in patients with non-insulin-dependent diabetes mellitus, in which the researchers concluded that "In NIDDM patients, high-carbohydrate diets compared with high-monounsaturated-fat diets caused persistent deterioration of glycemic control and accentuation of hyperinsulinemia, as well as increased plasma triglyceride and very-low-density lipoprotein cholesterol levels, which may not be desirable."

Sixteen years ago researchers stated bluntly that a diet high in carbohydrate caused persistent deterioration of glycemic control, and yet it remains the diet of record from the ADA for those who are pre-diabetic or diagnoised with diabetes!

But I digress...

In 2004, Stern et al published a one-year study in the New England Journal of Medicine - The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial, and concluded that "Participants on a low-carbohydrate diet had more favorable overall outcomes at 1 year than did those on a conventional diet. Weight loss was similar between groups, but effects on atherogenic dyslipidemia and glycemic control were still more favorable with a low-carbohydrate diet after adjustment for differences in weight loss."

In those who had diabetes at baseline, the results for those following a low-carb diet were in stark contrast to those following the conventional, low-fat diet. The low-carb group experienced a normalization of their fasting blood sugar levels. At baseline their fasting blood glucose was reported as 9.21mmol/l - by the end of the study, their fasting blood glucose was just 3.66mmol/l. Not only did their fasting blood sugars improve, their HbA1c reading also improved moreso than those following the conventional diet - declining from 7.4 to 6.6 in the low-carb group, but only going from 7.3 to 7.2 in the convential diet group.

With these studies in mind - how do you think they compare with the studies the ADA touts as "conclusive" evidence that a low-fat diet is the gold-standard for pre-diabetes and even those with type II diabetes?

Isn't it time the ADA is called to task and asked why they're dismissing the data from studies showing superior results from alternative dietary approaches?

The data doesn't lie - it is what it is - and it consistently shows that reducing carbohydrate improves glycemic control. Carbohydrate restricted diets don't just have a similar or comparable effect when compared to low-fat diets - the differences are statistically significant - controlled-carb diets result in greater improvement in glycemic control!

With one-in-three adults in the United States at risk or already diagnoised with diabetes, isn't it time we take serious the idea of an evidence-based approach and actually do something to reverse the current trends? Or do we just keep marching down the same path that the data clearly shows will not stop diabetes?