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!

Carbohydrate Restriction Seminar - Nashville, TN - May 5

It's a bit of short notice, but anyone interested in learning more about the science and research supporting carbohydrate restriction - register to attend the Nutrition & Metabolism Society Seminar at the 2007 Eastern Regional Obesity Course of the American Society of Bariatric Physicians in Nashville, TN, May 5, 2007.

Saturday, May 5
8-8:45 am Low GI and Very Low Carbohydrate Diets for Type 2 Diabetes
Eric C. Westman, MD, MHS

8-8:45 am Low GI and Very Low Carbohydrate Diets for Type 2 Diabetes
Eric C. Westman, MD, MHS

8:45-9:30 am Carbohydrate Restriction for Type 2 Diabetesin Clinical Practice
Mary C. Vernon, MD, FAAFP, CMD

9:30-9:45 am Break

9:45-10:30 am Using the Traditional Diet for Type 2 Diabetes in a Canadian First Nations Community
James A. Wortman, MD

10:30-11:15 am A Review of the American Diabetes Association Recommendations for Dietary Carbohydrate
Judy Wylie-Rosett, EdD

11:15am-Noon Panel Discussion of Morning Speakers

Noon-1:30 pm Lunch & NMS Award Presentation (lunch provided for Obesity Course & NMS attendees)

10:30-11:15 am A Review of the American Diabetes Association Recommendations for Dietary Carbohydrate
Judy Wylie-Rosett, EdD

10:30-11:15 am A Review of the American Diabetes Association Recommendations for Dietary Carbohydrate
Judy Wylie-Rosett, EdD

NMS ATTENDEES ONLY
1:30-2:15 pm Very Low Carbohydrate Diets and Serum Biomarkers of Cardiac Risk
Jeff S. Volek, RD, PhD

2:15-3 pm The Paradox of Fats in the Low Carb Diet
Steven D. Phinney, MD, PhD

3-3:15 pm Break

3:15-3:45 pm Biochemical Aspects of Carbohydrate Restriction
Richard D. Feinman, PhD

3:45-4:30 pm Panel Discussion of Afternoon Speakers

REGISTER HERE

Accreditation
The American Society of Bariatric Physicians (ASBP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The ASBP designates the NMS Seminar for a maximum of 6.5 credit hours in category 1 credit towards the AMA Physicians Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity. The program is eligible for AOA-CME credits under category 2-A.

Atkins Editorial Rejected

Five heathcare professionals - Dr. Stephen D. Phinney, MD; Dr. Mary C. Vernon, MD; Dr. Eric C. Westman, MD; Dr. Jay Wortman, MD; and Jacqueline A. Eberstein, RN - recently penned and submitted an editorial response to the recent media attention concerning the A to Z study published in JAMA. It was rejected by JAMA, Newsweek, Time and others. Here it is, in its entirety:

More Science and Less Zealotry, Please.

The controversy over which diet is best for all has again made headlines with the publication of the Stanford University study in the Journal of the America Medical Association March 7, 2007. Since the results are favorable to the low-carbohydrate Atkins diet, the usual criticism can be expected to follow.

Predictably, Dean Ornish has launched a tirade in which he manipulates the study findings to find fault with the low-carb approach and to deflect criticism away from his ultra low-fat diet which did not perform well in the study. Unfortunately, this is an argument based on dogma and not on science. The science speaks for itself.

As scientists and clinicians, we believe that no one dietary approach is going to be ideal for everyone. There is no doubt that, for some, an ultra-low-fat approach may be appropriate. Unlike Dr. Ornish, we recognize that there is no one-size-fits-all approach to the enormously complex problem of obesity and related conditions. Unfortunately, other authoritative sources like the US dietary guidelines also recommend a single lowered fat high-carbohydrate diet approach and have been doing so over the decades that this epidemic has grown.

Gratuitous attacks on the Atkins diet that imply it involves abandonment of wholesome vegetables and fruit for “bacon and brie” are simply wrong. Even in the most restrictive phase it meets the recommended daily guidelines for vegetables and fruits. As one advances through the phases, low-glycemic fruits, more vegetables, legumes and even whole grains are introduced based on an individual’s metabolic tolerance for these foods. One survey found that people who follow the Atkins plan over the long term eat more vegetables than they did before. Another study found that rather than increase the intake of fat and protein to compensate when carbohydrates were reduced, people simply ate less.

The unfortunate reality of today is that too many Americans are eating potato chips and fries and drinking sugar-sweetened beverages. We support the idea that wholesome foods such as meat, fish, cheese and eggs along with vegetables and low glycemic fruits constitute a healthier diet than chips and fries and sodas.

While this study examined four popular dietary approaches, what is clear is that whatever approach one takes to healthy eating, success will depend on how well you can stick to it. In this case, and in many earlier studies, it is clear that the Atkins diet is the one most people can maintain. On the other hand, the extremely low-fat diet advocated by Dr. Ornish is very difficult to follow. In this study, the subjects who were supposed to reduce their fat intake to his recommended intake of 10% could not reach that target.

Another important aspect of this and earlier studies is the beneficial effect that reducing carbohydrates has on metabolic markers. In his criticism, Dr. Ornish states that the LDL-cholesterol level fell in response to his diet, but does not mention that none of the differences in LDL-C in this study were statistically significant. This is therefore not a scientifically valid criticism. On the other hand, it is widely recognized that elevating the HDL-C, the good cholesterol, is an important factor in reducing cardiovascular risk. In this study there was a highly significant 10% rise in HDL-C in the Atkins group but no such change among those who followed the very high-carbohydrate Ornish diet.

In the same vein, the Atkins group demonstrated a significant (both statistically and clinically) greater reduction in systolic and diastolic blood pressure than the other three diets. A difference in mean arterial pressure of 5 mm Hg is about the response we would expect to see with a first-line pharmaceutical in the clinical setting. Any objective observer would acknowledge this as a major beneficial effect of the Atkins diet.

Dr. Ornish suggests that the positive findings of research such as this that supports the Atkins diet will cause problems, and that “many people may go on a diet that harms them based on inaccurate information.” This is a wildly irresponsible statement, given the consistency with which a reduction in important metabolic and cardiovascular risks are achieved by lowering carbohydrate consumption. It is simply preposterous to suggest that an approach that leads to significant risk factor reduction is unhealthy.

The seriousness of the accelerating epidemic compels us to think outside the box to find new solutions where the status quo has failed. The only approach that will be successful is one that people can actually follow. This study adds to the mounting evidence that the Atkins diet is a healthy choice which should be supported as a viable way to lose weight and improve metabolic and cardiovascular risk factors.

The Real Atkins Lifestyle

Before there was research on the Atkins diet it was commonly criticized in the belief that it would elevate cholesterol, ruin one’s kidneys and bones and cause heart disease. None of this has been borne out by the research.

What is clear from this JAMA study, and others like it, is that cardiovascular risk factors actually improve when controlling carbs. The scientific studies of this approach have shown numerous times that a pattern of rising HDL-C and falling triglycerides is the hallmark of carb restriction and that this benefit occurs even in the absence of weight loss.

Research also shows that rising HDL-C (good cholesterol) and falling triglycerides is correlated with larger LDL-C particles which are less likely to cause heart disease. Even the much touted statin drugs do not deliver this kind of improvement in LDL-C particle size. On the other hand, the research shows that eating a high-carb diet and cutting fat intake results in small dense LDL-C particles that are linked to an increased risk of heart disease.

Importance of Fat

There are other problems associated with extremely low fat diets, as well. Cutting fat intake can lead to deficiencies in fat soluble vitamins, depletion of essential fats such as EPA and DHA, and decreases in the absorption of nutrients. Studies also show that people with cholesterol levels that are too low become prone to depression, suicide and cancer and have higher overall death rates than those who have higher cholesterol levels.

When all is said and done, it behooves us to remember that the diet debate is not a horse race where there is only one winner. We know there is a great variability in metabolic and genetic factors that will determine what dietary approach is best for each individual person. Although, in this and many other studies the Atkins diet worked better for more people, it is also evident that other dietary approaches will work for some people as well. The most important thing we have learned from dietary research is that people need to find the approach that will deliver healthy outcomes for them individually. And, just as the proof of the pudding is in the eating, the proof of a diet's effectiveness is whether it can sustain those benefits over the long haul. Hopefully, the weight of the evidence will now allow the Atkins diet to be recognized and supported as a legitimate option for people who want to improve their health through better nutrition.

On a final note, Dr. Ornish’s repugnant attempt to undermine Dr. Atkins’ credibility by perpetuating the myth that he had heart disease is unconscionable. It is unbecoming of any honorable person to make ad hominem attacks on those who are departed. Enough is enough. Dr. Atkins died of a head injury. He is no longer with us, but the line of scientific inquiry that he started continues to vindicate his dietary approach. And no amount of unfounded criticism will alter the fact that this study, and the 60 others before it, clearly demonstrate that what Dr. Atkins had been telling us all along was right.

• Jacqueline A. Eberstein, R.N. Co-author, Atkins Diabetes Revolution, President, Controlled Carbohydrate Nutrition
• Stephen D. Phinney, M.D. Ph.D Emeritus Professor, Department of Medicine, UC Davis, Elk Grove, Cal
• Mary C. Vernon, M.D., CMD, Co-author, Atkins Diabetes Revolution, President, American Society of Bariatric Physicians
• Eric C. Westman, M.D. M.H.S, Associate Professor of Medicine, Duke University Medical Center
• Jay Wortman, M.D, Department of Health Care & Epidemiology, Faculty of Medicine, University of British Columbia