The Nutrition Debate #147: AMA: Obesity is a Disease (for billing purposes)

The New York Times article begins, “The American Medical Association has officially designated obesity as a disease…” I know, this is ‘old news,’ but with all the coverage I thought it needed a little time to cool off. Besides, it ties in nicely now with the last two columns, #146 “Medicare to Pay for Obesity Counseling” and #145, “Gastric Bypass vs. Medical Therapy for Metabolic Syndrome,” and the next column, #148, “Obesity, a Condition of Genetic Susceptibility?”

The AMA call was a tough one for a variety of reasons not least of which is that there is no general agreement in the scientific community on the definition of disease. The Times piece explains, “Those arguing against it [the designation of obesity as a disease] say that there are no specific symptoms associated with it and that it is more of a risk factor for other conditions than a disease in its own right.” In fact, in making the designation, the AMA delegates at their annual convention overrode a recommendation against doing so by a committee that had studied the matter for a year.

The committee said that “obesity should not be considered a disease mainly because the measure usually used to define obesity, the body mass index, is simplistic and flawed,” according to The Times. The committee argued that “some people with a B.M.I. above the level that usually defines obesity are perfectly healthy while others below it can have dangerous levels of body fat and metabolic problems associated with obesity.” The committee wrote, “Given the existing limitations on B.M.I. to diagnose obesity in clinical practice, it is unclear that recognizing obesity as a disease, as opposed to a ‘condition’ or ‘disorder,’ will result in improved health outcomes.”

See The Nutrition Debate #142, “I'm Sorry... Confessions of a Weight Loss Consultant” to see how, when and by whom obesity was redefined, and read #141, “...the Ultimate Oxymoron: Diet Food” to see why it was and who benefits.

The AMA finessed the B.M.I business by “simply defining obesity as an excess of body fat sufficiently large to cause reduced health and longevity,” according to a long piece in Forbes by Chris Conover. According to Conover, “they answered the question of ‘should we consider obesity a disease’ largely on utilitarian grounds that the social benefits of doing so will outweigh the costs.” Conover then goes on to totally and brilliantly demolish that argument.

Besides, Conover says, “the AMA is (late) to the party.” He notes that the National Institutes of Health declared in 1985 that “obesity is a serious health condition that leads to increased morbidity and mortality.” And The National Heart, Lung and Blood Institute commented in 1995 that “obesity is a multifactorial chronic disease developing from multiple interactive influences of numerous factors.” He cites the Surgeon General’s 2001 Call to Action to Prevent and Decrease Overweight and Obesity, and Michelle Obama’s 2009 Taskforce on Childhood Obesity. Even the IRS more than a decade ago considered obesity to be a disease, and Medicaid jumped on the bandwagon in 2010. Medicare has too for counseling and surgery, but not for reimbursement for weight loss drugs.  What then could the AMA’s motive be in defining obesity as a disease now?

The Times gives us a clue (if we needed one) to a pecuniary motive for the AMA action. One advocate commented, “I think you will probably see from this physicians taking obesity more seriously, counseling their patients about it.” And, The Times noted, “…it could help improve reimbursement for obesity drugs, surgery and counseling.” They note, “Two new obesity drugs – Qsymia…and Belviq…have entered the market in the last year,” and “Qsymia has not sold well for a variety of reasons, including poor reimbursement…” At the Huffington Post, self-described policy wonk and blogger Larry Cohen enthusiastically huffed, “After the AMA announcement, some members of Congress introduced a bill to expand Medicare reimbursements for weight-loss drugs and weight-reduction treatment.” The Washington lobbyists jumped in exaltation.

Another view is that designating obesity as a disease, like alcoholism or other addictions, “would reduce the stigma of obesity that stems from the widespread perception that it is simply the result of eating too much or exercising too little.” And then The Times piece cracks the door open just a bit with, “Some doctors say that people do not have full control over their weight.” Are they hinting that obesity may be a condition of genetic susceptibility? (Again, see my next column, #148, next Wednesday.) Another naysayer would remark “that ‘medicalizing’ obesity by declaring it a disease would define one-third of American as being ill and could lead to more reliance on costly drugs and surgery rather than lifestyle changes. Some people might be overtreated because their B.M.I. was above a line designating them as having a disease, even though they were healthy.”  I agree. Besides, if the treatment is merely treating a symptom (obesity), rather than the underlying disease, doesn’t that solidify in the medical protocols a wrong treatment modality for a non-existent disease? The AMA finessed that too in their final resolution by saying that obesity was a “multimetabolic and hormonal disease state” (thus avoiding using “disease” as a noun) that leads to unfavorable outcomes like type 2 diabetes and cardiovascular disease.”

What might the underlying disease be? Obviously, neither The Times nor the AMA subscribes to Gary Taubes’s Alternative Hypothesis that insulin resistance, the metabolic disregulation that characterizes type 2 diabetes, is what leads to fat accumulation (obesity). The Times later posted that the article now “correctly noted” (NOT) that “obesity can lead to type 2 diabetes.” As Taubes (and others) have pointed out, The Times together with most of the “old school” medical establishment has got the “cause and effect” of obesity exactly backwards. Oh well, it’s still a long road back to sanity.

The Nutrition Debate #146: Medicare to Pay for Obesity Counseling

DiabetesinControl.com is a website with “news and information for medical professionals.” Last November it trumpeted, “Medicare to Pay for Obesity Prevention in the Name of Prevention.” What a boon (boondoggle?) for physicians! And what an incomplete and mixed blessing for their patients! Medicare has finally recognized that obesity prevention in the form of counseling, as public health policy, might be as efficacious as costly gastric bypass surgery. Reducing obesity through “intensive medical nutrition therapy…could produce similar results,” it concluded. But only if your primary care physician “supervised” its administration. It sounds to me like it’s all about billing.

One of the reasons offered is that “It’s almost impossible for physicians to take care of everything. They don’t have the expertise [how true!] or the time,” according to the piece. “Seventy-two percent of primary care physicians surveyed…said nobody in their practices had been trained to deal with weight-loss issues.” Yet they say (and to me, the irony here is very heavy), “unfortunately, those best prepared to provide obesity counseling will not be able to bill directly to do so.” Under the rules, “those with expertise in the field, such as registered dietitians, are not eligible to bill directly.” Medicare, with perhaps just a little lobbying from the American Medical Association, “has limited who is able to bill for those services to primary care physicians, including nurse practitioners, clinical nurse specialists and physician assistants. Medicare will cover services from ‘auxiliary’ providers only if the service is provided in a physician’s office suite and the physician is immediately available to provide assistance and direction,” it added. Yep, it is all about the billing.

The decision about registered dietitians is, of course, for me, good news. Registered dietitians and CDE’s, if they follow the training required for certification, are the least qualified persons to provide obesity training, at least to the pre-diabetic and Type 2 community. This has been my personal experience from attending group counseling for diabetics provided by a CDE/RN at a local health care facility, and years ago with a registered dietitian and much more recently with a CDE.

Years ago, my doctor employed a registered dietitian in his “office suite” (her “office” was in a closet!). This carbohydrate intolerant Type 2 diabetic remembers her advice “Eat a ‘balanced’ diet,” she said, “and exercise.” The truth is that she was as ignorant as my doc about the effect on a Type 2 diabetic of eating from 40% to 60% of calories in the form of carbohydrates. My meter provided plenty of feedback, all of it negative.

Forty-five to sixty-five percent carbohydrates is the amount recommended by the Institute of Medicine for everyone in the latest Dietary Guidelines for Americans, 2010 (Table 2-4, pg. 15). The USDA’s Nutrition Facts panel on processed food packaging is likewise a one-size-fits-all formula. Carbohydrates are 1,200 (60%) of the 2,000 calories in the Standard American Diet (SAD,) for a woman. It’s 1,320 of 2,200 kcal for a man! And that’s why Type 2 diabetes is a “progressive” disease, folks! To be clear, I know that both my doctor and his dietitian had in mind a good health outcome for me. They both wanted me to lose weight. But their dietary advice for me, a Type 2 diabetic, was bad advice as it ignored the implacable fact of carbohydrate intolerance. The outcome could only result in my disease continuing to be progressive. Progressive disease and complications are, however, not inexorable. And if you need to lose weight, you do have a better alternative.

My experience with a CDE (employed by a doctor) was the result of a silent auction for a non-profit a few years ago. The bidding started at $20, so I placed the first bid, and it was the only bid. At this point I had been eating Very Low Carb for about 10 years. I had lost 170 pounds and had eliminated virtually all my oral diabetes meds. My blood glucose was normal, my blood pressure (on the same meds) had dropped dramatically, and my blood lipids (both HDL and triglycerides) had totally turned around. I no longer had Metabolic Syndrome or detectible hypertension (with meds) or Type 2 diabetes as long as I refrained from eating carbohydrates. Okay, those conditional statements are caveats, but that is a price I was and am willing to pay for the complete abatement of my symptoms. In doing so I am now at much lower risk of all the Diseases of Civilization to which I was exposed before I began this Way of Eating. It was a rough session for the CDE, but she toughed it out. In retrospect, the whole episode wasn’t a very nice thing for me to do, but she needed to hear my story. That’s why I write this blog, to get the word out.

So “save your money,” so to speak, if counseling is voluntary as with Medicare, or just ignore the advice if obesity counseling, also at government expense, is required by the NHS. Your health will be better served if you listen to your meter and avoid “one size fits all” diets (and clothes!). My next column will address another recent milestone discovery. More “old” news: Obesity is a Disease (for billing purposes).

Postscript:

“The Power of Sugar,” published two days ago in The Atlantic, is an interesting read for two reasons: 1) the charts, and 2) it is from an economist’s perspective. Unfortunately, it contains an egregious editing error: The headline on the first shaded box reads, “Fructose and Glucose are Essentially Same.” That is wrong, as the text of the shaded box (and science) makes clear. What the headline meant to say was, “HFCS and Sucrose are Essentially Same,” which is basically true. It is ironic that the editor unknowingly demonstrates the point the writer makes, that the “recent focus -- medical, media and regulatory – has converged…” All three (the editor, if not the writer, in the case of the media) perpetuate the ignorance in this headline.

The Nutrition Debate #145: Gastric Bypass vs. Medical Therapy for Metabolic Syndrome

Recently, my Medscape alert brought me this write-up by Albert B. Lowenfels, MD: “Gastric Bypass vs. Conventional Medical Therapy for Metabolic Syndrome.” I read it, and the full paper  in JAMA, and my reaction was that it would be funny if it weren’t so very sad. This study uses a “2-group unblinded randomized trial” and is a perfect example of how bloody blinkered the medical community is to the treatment of Metabolic Syndrome and its associated co-morbidities.

This narrow mindedness is best exemplified by the first bold heading in the abstract, quoted here: “IMPORTANCE: Controlling glycemia, blood pressure, and cholesterol is important for patients with diabetes. How best to achieve this goal is unknown.” Unknown!!! Let’s face it. This “innocent” statement is just a set-up to obfuscate and camouflage the true purpose of the entire enterprise, which is to promote gastric-bypass surgery in “mild to moderately obese patients with type 2 diabetes.” Gastric bypass is generally reserved for the morbidly obese patient (BMIs ≥ 35). The growing number of gastric bypass surgeons, however, necessitates that there be more “eligible” patients. And the sooner the better, before the unfortunate side effects such as “dumping episodes” and a higher suicide rate are better known.  

Controlling glycemia, blood pressure, and cholesterol is certainly important for patients with diabetes. How best to achieve these multiple goals (collectively known as Metabolic Syndrome), is certainly, however, NOT UNKNOWN. It is well documented innumerable times in countless papers published in peer reviewed medical literature, including JAMA. Here is just one recent paper and if you want to know more about this, “The Art and Science of Low Carbohydrate Living,” by Jeff Volek and Stephen Phinney is a great read.  The problem is that control is NOT achieved with “medications for hyperglycemia, hypertension and dyslipidemia (that) were prescribed according to protocol” nor with “surgical techniques that were standardized,” to quote from the specific “interventions” utilized in this trial. Control is achieved by people who change what type of food they eat.

This study had a “lifestyle modification” component modeled on recent “successful clinical trials, particularly the Diabetes Prevention Program and the Look AHEAD Protocol.” Note, the Diabetes Prevention Program did show a benefit from intensive lifestyle interventions for people with Metabolic Syndrome and impaired glucose tolerance, but not type 2 diabetes. The interventions were to lose 7% of body weight and to exercising 150 minutes a week. The Look AHEAD Protocol examined whether weight loss reduced the risk of heart attacks and strokes in obese Type 2 diabetics. It did not.

Maybe, just maybe, (Is my sarcasm too thick?) the problem with these studies is what they have in common- a “healthy low-calorie, low-fat diet” that fails to lower blood glucose enough to reduce the risk of diabetic complications, including heart disease.  The Gastric Bypass study called for “Portion controlled diets using meal replacements, structured menus, and calorie counting were encouraged to help participants stay within calorie limits,” according to the study document. “Both groups [the gastric bypass group and the conventional medical therapy group] met regularly with a trained interventionist to discuss strategies for facilitating weight management and increasing physical activity, including self-monitoring, stimulus control, problem solving, social support, cognitive behavior modification, recipe modification, eating away from home, and relapse prevention.”

“Counseling sessions comprised 24 weekly meetings over the first 6 months, biweekly meetings between months 7 and 9, and monthly meetings between months 10 and 12. The lifestyle intervention protocol was similar for participants in both treatment groups. Patients in to the gastric bypass group, however, delayed initiation of the lifestyle intervention until they could tolerate solid foods (typically 3 to 4 months after surgery), did not have calorie ceilings during the period of rapid weight loss, and received additional instruction regarding food volume and adequate protein intake.” (Very important post-surgical issues)

Maybe I am being too hard on these gastric bypass surgeons. Study participants were a “failed” cohort. Participants had diabetes for an average of 9.0 years, had a mean BMI of 34.6, and a mean A1c of 9.6%, in spite of medications to control glycemia (high blood glucose) and cardiovascular disease risk factors (statins). Perhaps I should ignore the fact that the PI (Principal Investigator), who led the study concept and design, drafting of the manuscript, study supervision, and funding, was also receiving funding from Covidien, a leading manufacturer of medical devices, as well as serving on the medical advisory boards of Novo Nordisk, USGI, and Medica. Eight other co-authors, all doctors and support staff, also reported receiving grant support from Covidien, including one who received salary support for what, in small print, on the last page, is now called, unabashedly and aptly, “The Diabetes Surgery Study.” 

I can ignore these funding facts, just as they ignore the simplicity of carbohydrate intolerance. Your meter will tell you if you are eating too many carbs. To achieve control, eat fewer carbs. Your triglyceride levels will also tell you if you are eating too many carbs. Your blood pressure readings will improve too, as you lose weight. Your diet is under your control.

The Nutrition Debate #144: Diabetes and Dementia

I have been contemplating a whole series on the subject of diabetes and dementia for some time, but this one just begs to be written now. This article in Diabetes in Control, a digest for medical doctors, was reprinted on 8/31/13 from a piece that originally appeared in issue 692 of Neurology. It in turn was based on an abstract published in The Lancet: Diabetes and Endocrinology on August 20, 2013 here. All these articles deal with the risk of type 2 diabetics developing dementia.

The Background in the Abstract of The Lancet piece states: “Although patients with type 2 diabetes are twice as likely to develop dementia as those without this disease, prediction of who has the highest future risk is difficult. We therefore created and validated a practical summary risk score that can be used to provide an estimate of the 10 year dementia risk for individuals with type 2 diabetes.” Have I got your attention yet? Well, it gets much scarier.

The researchers were from the University Medical Center Utrecht, Netherlands, the University of Chicago, the University of Washington, and Kaiser Permanente. Kaiser Permanente is the largest managed care organization in the U. S. It has almost 9 million health plan members, 15k doctors, 170k employees, and $50 billion in annual revenues. Funding for the study included Kaiser Permanente Community Benefit, the National Institute of Health, and Fulbright.

The researchers used data from two cohorts of patients with type 2 diabetes, aged ≥60 years, with 10 years of follow-up. The risk factors in their statistical analysis that were “most strongly predictive of dementia” were “microvascular disease, diabetic foot, cerebrovascular disease, cardiovascular disease, acute metabolic events, depression, age, and education.”

And what was the outcome of their risk analysis? “The prediction of 10 year dementia risk in patients with type 2 diabetes mellitus“shows a 5.3% risk for the lowest score and 73.3% for the highest score. The Diabetes in Control piece states, “According to the authors of this study, those in the higher risk category were 37 times more likely to develop dementia than those in the lowest risk category.”

How do they plan to use this information? You’ll love this. They say, “The risk score can be used to increase vigilance for cognitive deterioration and for selection of high-risk patients for participation in clinical trials.” And that’s it! In other words, they watch for (“be vigilant”), i.e. observe, as you develop dementia, and then perhaps suggest that you sign up for a clinical trial to test another pharmaceutical product(s) to treat your cognitive deterioration. Isn’t that just dandy!

Of course, there is another way. Remember, the researchers who created and tested this risk analysis prediction tool used “data from approximately 30,000 type 2 diabetic patients aged 60 and greater over a 10-year interval.” These diabetics were presumably being advised to eat a “one-size-fits-all” low-fat, high-carb, restricted-calorie dietary regimen, with lots of “healthy fruits and vegetables” (all carbohydrates) with minimum saturated fat and dietary cholesterol. They were probably being medicated for “high cholesterol,” hypertension (high blood pressure), and high triglycerides and low HDL-cholesterol symptoms of metabolic syndrome); and with other drugs for various neuropathies and co-morbidities associated with type 2 diabetes.

Further, the treatment standard that the clinicians were using was undoubtedly the one “supported by the current ‘Standards of Medical Care in Diabetes’ published every January in Diabetes Care, the Journal of the American Diabetes Association:” http://care.diabetesjournals.org/content/36/Supplement_1/S11.full That means that your physician will be content, or at least safe-guarded from medical liability, to simply advise you that your type 2 diabetes is “under control.” He will not inform you that your elevated blood glucose levels (as allowed by this standard) are progressively damaging your blood vessels, organs and endocrine system.

If you leave the care of your type 2 diabetes in the hands of your physician, this is what will happen to you: As he observes your A1c rise, he or she will prescribe more of the same medication, and when you are maxed out on that, he or she will write a script for another, and then possibly a third (before switching you to injected insulin). Repeat for your elevated cholesterol and high blood pressure. And when you are unable to lose weight and keep it off on a low-fat, high carb diet, you will be reminded again to “eat less and exercise more,” as he makes a note in your file that the “patient was non-compliant.”

I would like to suggest an alternative: Don’t be a member of this treatment cohort. Take charge of your own health. Do not accept an A1c of 6.5% as “in control.” At this level, your heart attack risk is doubled. Eat a diet that is low in carbohydrates; better yet, very low. Don’t sweat the saturated fat and dietary cholesterol. Your body will love it. And so will your doctor. He will be perplexed at how wondrous your lab results are. He will likely have to lower your meds, and he will tell you to “just keep on doing what you’re doing.” And if he perchance asks you how you did it, you might tell him. It’s time doctors took off their blinders and used current best evidence in making decisions about the care of individual patients. Your individual results, like mine, could be very impressive indeed.

The Nutrition Debate #143: Fruit Consumption & Diabetes – a Theater of the Absurd Construct

No sooner had I posted column #138, “Fruit, the 3^rd Rail for Prospective Low Carb Dieters,” when my Medscape Alert brought me this absurdist piece: “Consumption of Certain Fruits Linked to Lower Diabetes Risk.” It knocked me back on my heels. How could the consumption of any food, including all fruit, whose principal macronutrient is just simple sugars, “lower diabetes risk”? Am I living in an incomprehensively illogical world? A world without meaning? Has the respected research community abandoned rational thinking, I asked? I had to read the piece.

The report was from the Department of Nutrition, Harvard School of Public Health, and appeared in an online article in BMJ, the British Medical Journal. The Medscape write-up was authored by Joe Barber, Jr. PhD, who wrote, “Increasing fruit consumption has been recommended for the primary prevention of many chronic diseases, including type 2 diabetes, although epidemiologic studies have generated somewhat mixed results regarding the link with risk of type 2 diabetes.”

But here, in my opinion, is where the study author’s logic went awry. “The inconsistency among these studies may be explained by differences in types of fruits consumed in different study populations as well as difference in participants' characteristics, study design, and assessment methods, although a meta-analysis did not show that the associations differed by sex, study design, or location." Okay, all epidemiological studies inherently have many confounding factors and biases, but the hypothesis proposed to address these factors is, IMHO, also inherently flawed. Just because “differences in types of fruits consumed” was not previously studied, does not lead to the conclusion that the types of fruit consumed are differentiating, even if only associative, criteria. True, the authors cache the hypothesis carefully in the word “may,” but that did not similarly constrain the report’s conclusions, or the gushing headlines.

The authors’ conclusion: "Overall, these results support recommendations on increasing consumption of a variety of whole fruits, especially blueberries, grapes, and apples, as a measure for diabetes prevention." Utterly unbelievable!

The article received funding from the National Institutes of Health and was published on August 29^th. It immediately was picked up and ‘broadcast’ in such places as The Guardian, Science Daily, Medical News Today, The Huffington Post, the Daily News, today.com and FoxNews.com. The lede in the e! Science News piece was, “Eating more whole fruits, particularly blueberries, grapes, and apples, was significantly associated with a lower risk of type 2 diabetes, according to a new study led by Harvard School of Public Health (HSPH) researchers.” How can a humble blogger compete with a headline like that?

The only redeeming message in the “study” was the lede in a few more circumspectly edited pieces:  “Greater consumption of fruit juices was associated with a higher risk of type 2 diabetes.” However, other studies, including this study of European adults in PubMed.com, incredulously show no link between fruit juice and diabetes risk. But, sadly and invariably, the headline and the lede is all that the mass media market will pick up: Eat more fruit to lower your risk of diabetes. I feel at times like a character in an absurdist plot, “facing the chaos of a world that science and logic have abandoned,” to borrow from a Wikipedia passage describing Theatre of the Absurd.

The absurdity is further confounded by the inherent contradiction of the perfunctory conflicts of interest disclaimer: “The study received funding from the National Institutes of Health. The authors have disclosed no relevant financial relationships.” In other words, fruit growers didn’t pay them to say that “eating more whole fruits...was significantly associated with lower risk of type 2 diabetes.” But the National Institutes of Health did! No conflict of interest there! We taxpayers paid, in part, the costs of this observational report in furtherance of the government’s stated goals, to promote the consumption of “healthy” fruits and vegetables and avoid animal-based nutrition with its attendant “unhealthy” saturated fats and dietary cholesterol.

Since this nuance will be lost on all but the most informed readers, note also that the authors were careful to say that the results were “linked” to the outcomes. The conclusions of all such “studies” show only an association, not a causal relationship, and quite a weak one at that. These confounding factors, including multiple biases assumed, are expressly discussed near the end in the full text of such “studies,” inevitably making the conclusions subjective. In this study, the confounding factors include: “In all three cohorts, total whole fruit consumption was positively correlated with age, physical activity, multivitamin use, total energy intake, fruit juice consumption, and the modified alternate health eating index score, and was inversely associated with body mass index and current smoking.” 

The final paragraph of such full “studies” then invariably acknowledges that the conclusions are inconclusive and require “further study,” preparing the ground in the name of “science” for another grant application to pay the direct salaries and specific expenses of another round of so-called “research.” Call me cynical, if you want, but to me this ongoing charade is phantasmagorical and surreal, if not downright Machiavellian.

Oh, well. At least you can be comforted to know that this “reporter” (your humble blogger) is not paid for his opinions.

The Nutrition Debate #142: “I’m Sorry…” Confessions of a Former Weight Loss Consultant

Recently, I came across a blog at HuffPost Women with a title that piqued my interest. The title was “An Open Apology to All of My Weight Loss Clients.” The apology was originally posted on Your Fairy Angel, the website of Iris Higgins, a “certified hypnotherapist, past life regression specialist, and women’s health coach.” Her mission now: “helping women to rediscover the magic in their lives.” That sounds pretty good to me.

Ms Higgins opens her confession with, “I worked at a popular weight loss company for three years…” She continues, “I’m sorry that I put you on a 1,200 calorie diet and told you that was healthy.” Now she really had my attention. I personally eat a 1,200 calorie a day diet, and I weigh probably twice what she and most of her past and present clients do, and I’m very healthy (besides being a type 2 diabetic for 27 years). Is she going to tell her former clients that that is an unhealthy practice? Well, she does, but as my readers know, a calorie is not just a calorie.

 As we’ve said often here, all calories are not alike. The body metabolizes the calories of different foods differently, according to their macronutrient composition. A carbohydrate calorie is not processed (digested and used) the same as a protein calorie or a fat calorie. If you are not clear on this yet, watch this new video or read my earlier expositions on the subject. A list of my columns can be seen in the upper right hand corner of my blogs.

Higgins’ confession, though, is sincere, if also motivated to promote her current occupational endeavors. That’s okay, and I agree with her premise: “that you’ve been played.” “And that’s why I’m sorry,” she says, “because I’ve been played for years…” “And it wasn’t just the company [her employer] feeding them [lies] to me. It was the doctors and registered dietitians on the medical advisory board. It was the media and magazines confirming what I was telling my clients.”

She sold her clients food that helped them “lose weight and then gain it back, so that you thought we were the solution and you were the failure,” she wrote. “You became a repeat client, and we kept you in the game.” Hmmm… Sounds like what I described in #141 here and what Jacques Peretti wrote in The Guardian here (thanks Beth Mazur at Weight Maven) and that the BBC has chronicled in their compelling new series beginning here, also brought to my attention by Beth.

Ms Higgins’ main thrust is that most of her clients were not really overweight. This is one of the main points that Peretti makes: obesity was redefined by the World Health Organization some years ago with the result that many of her clients obsessed over losing a few pounds to satisfy their mothers or some other societal pressure to conform to an artificially created norm of what is considered a “healthy” weight. Amen to that! BMI be damned, I say.

Anyway, my main disappointment with this blog by Ms Higgins came when she failed to recognize the cause for the eating patterns and yo-yo weight swings of her clients. “When,” she asks, “did we become ‘professional dieters.’”? “I’m sorry because I get it now,” she says (wrongly). “If you’re trying to starve your body because you’re eating fewer calories than it needs, of course it’s going to fight back” (my emphasis).

Calories are not the problem, I say. The macronutrient composition of the diet is. What your body does with the calories that you eat – burn them or store them – is the issue. The quality of the calories you eat is the issue; by this I mean the degree of processing and the nutrient density. And the quantity of low-quality processed carbohydrate “foods” that we eat is the problem. Avoiding these processed and manufactured “foods” is the solution. And here, at the end of her “confession,” is where Ms Higgins finally gets in right. She concludes, “Just eat food. Eat real food, be active, and live your life. Forget all the diet and weight loss nonsense. It’s really just that. Nonsense.”  That’s really good advice.

Of course, if you’re seriously overweight (obese or morbidly obese), and you have health issues (hypertension, ‘high cholesterol,’ elevated triglycerides or low HDL, or just creaky knees, to name just a few), you can lose weight naturally by following Ms Higgins’ advice, tweaked only to eat many fewer carbohydrates, moderate protein and high fat. By changing only the type of foods you eat, you will lose weight without stress and without hunger. The LCHF Way of Eating will achieve all of the health benefits listed above at a minimum, as well as mitigate or ameliorate other health issues. Real food, unprocessed and unmanufactured, is higher in bio-available nutrient value than the refined “foods” that dominate the boxes and bags on supermarket shelves. And they have no added sugars, and many fewer “natural sugars” or carbohydrates that break down in digestion to simple “sugars,” primarily glucose and fructose.

As I say here often, pick up a loaf of bread in a cellophane wrapper in any supermarket and read the label. I’ll wager that the 3^rd ingredient in any loaf, after flour and water, is some form of sugar (sucrose, HFCS, molasses, barley malt, etc.). I challenge you. Check out your favorite “high fiber” or “whole grain” loaf. You’ll see I’m right. Then, start reading labels.

I make no brief for or against hypnotherapy, past life regression analysis or rediscovering the magic in your life. They may indeed be good pursuits. But if you need to lose weight (only if you really need to), you might try a LCHF WOE. It’s a no-hunger way to eat 1,200 nutrient dense calories a day and be healthy. The rest of the energy your body needs will come from your fat stores. Don’t get played!

The Nutrition Debate #141: “…the ultimate oxymoron: diet food”

An article by Jacques Peretti in “The Guardian,” brought to my attention recently by Beth Mazur at Weight Maven, used this construct to describe one aspect of the symbiosis that has developed in the food industry in the last sixty years. It’s a provocative piece – well researched and well reasoned – and a worthwhile read, especially if your BMI is in the range of 25 to 27, as I’ll explain. First, I need to explicate the symbiosis. Symbiosis requires two interactive, mutually supporting parts.

Peretti describes he first part thusly: “When you walk into a supermarket, what do you see? Walls of highly calorific, intensely processed food, tweaked by chemicals for maximum "mouth feel" and "repeat appeal" (addictiveness). This is what most people in Britain actually eat. Pure science on a plate. The food, in short, that is making the planet fat.” (For more on how foods are designed to be addictive, see the NYT article, “The Extraordinary Science of Addictive Junk Food”).

 The second part follows: “And next to this? Row upon row of low-fat, light, lean, diet, zero, low-carb, low-cal, sugar-free, "healthy" options, marketed to the very people made fat by the previous aisle and now desperate to lose weight. We think of obesity and dieting as polar opposites, but in fact, there is a deep, symbiotic relationship between the two.”

Diet food then is an oxymoron because it is something you eat (to nourish your body) but which is intended for you to lose weight. How did this come about? Peretti explains: “When obesity as a global health issue first came on the radar, the food industry sat up and took notice. Some of the world's food giants opted to do something both extraordinary and stunningly obvious: they decided to make money from obesity, by buying into the diet industry.” No surprise there, is there?

In Peretti’s words, they “squared the seemingly impossible circle. And we bought it. Highly processed diet meals emerged, often with more sugar in them than the originals, but marketed for weight loss, and here is the key get-out clause, "as part of a calorie-controlled diet". You can even buy a diet Black Forest gateau if want.” How true, how true, how sad indeed it is.

We got fat by eating high calorie (high fat), highly processed (carbohydrate) food. So, what happened? The result, as we all know: “Government, health experts and, surprisingly, the food industry were brought in to consult on what was to be done. They all agreed that the blame lay with the consumer – fat people needed to go on diets and exercise. We needed to slim down by eating lower calorie (low fat), still highly processed (carbohydrate) food, but as part of a calorie-controlled (restricted-calorie, low-fat) diet. The plan didn't work. In the 21st century, people are getting fatter than ever.” How come?

Regular readers here know that what went wrong is that “government, health experts and the food industry” came up with the wrong prescription. The low fat, restricted-calorie diet of highly processed, carbohydrate-loaded foods is what makes us fat, even if we exercise our butts off for hours at a time. But you’ve all heard this from me ad infinitum and ad nauseam. Peretti takes the story in a slightly different direction, which I think is quite novel and worthy of consideration.

His “scenario two,” the food industry’s reaction to obesity being the first, was this: “But, seen purely in terms of profit, the biggest market wasn't just the clinically obese (those people with a BMI of 30-plus), whose condition creates genuine health concerns, but the billions of ordinary people worldwide who are just a little overweight, and do not consider their weight to be a significant health problem.” “That was all about to change,” he said. “A key turning point was 3 June 1997. On this date the World Health Organisation (WHO) convened an expert consultation in Geneva that formed the basis for a report that defined obesity not merely as a coming social catastrophe, but as an ‘epidemic’.”

The author was one of the world's leading obesity experts, Professor Philip James, who in 1995 had set up a body called the International Obesity Task Force (IOTF). The WHO report re-defined obesity: the cut-off point for being overweight went from a BMI of 27 to a BMI of 25. Quoting Joel Guerlin, a US author who has examined the work produced by Met Life’s chief statistician Louis Dublin, this change “wasn’t based on any scientific evidence at all.” "Dublin essentially looked at his data and just arbitrarily decided that he would take the desirable weight for people who were aged 25 and apply it to everyone." Nevertheless, overnight, millions of people around the globe would shift from the "normal" to the "overweight" category.

Oh, and, by the way, where did the funding for the WHO report come from, Peretti wondered? He asked Professor James, who replied, "Oh, that's very important. The people who funded the IOTF were drugs companies…They used to give me cheques for about 200,000 (pounds) a time. And I think I had a million or more." And did they ever ask him to push any specific agenda, Peretti asked? "Not at all," James replied. That wasn’t necessary. The WHO report was all they needed.

Peretti concludes with this sad scenario: “There now exist two clear and separate markets. One is the overweight, many of whom go on endless diets, losing and then regaining the weight, and providing a constant revenue stream for the both the food industry and the diet industry throughout their adult lives. The other market is the genuinely obese, who are being cut adrift from society, having been failed by health initiative after health initiative from government.”

Readers of this column know that there is a happy alternative for both the see-saw dieters and the truly obese: Low Carb.

The Nutrition Debate #140: Peanuts, My Nemesis, and Why I Don’t Eat Them

My name is Dan, and I am a peanut addict. I love peanuts. I crave peanuts. I am addicted to peanuts, or at least I used to be. I gave them up almost a year ago, and do not eat them anymore. That’s why I have waited until now to write about them. I can now do it safely since I am no longer tempted by them. Why is another story, and the subject of another column – or even a book, for someone who has a better understanding of the very complex questions of why we eat and what we eat. But for this humble blogger, I will just tell you why I have concluded that I should not eat peanuts.

For the irregular reader of this column (published every Wednesday and Saturday), I am a 72 year old, 27-year type 2 diabetic who eats a Very Low Carb Ketogenic Diet (VLCKD) for weight loss and blood glucose control. I am Carbohydrate Intolerant. I treat my broken glucose metabolism just with minimal oral diabetes medications. I do not want to use injectables like insulin or incretin memetics. I also eat this way because I can do it without hunger, obtain very good improvement in blood pressure (with weight loss), and greatly improved blood lipids, especially HDL and triglycerides.

In the world of nutrition gurus that I follow, peanuts and other legumes are on many people’s lists of foods not to eat. I have been trying for years to stop eating them. So, now that my body is “happy” with the way I eat and what I eat, I finally decided to just do it – stop eating peanuts altogether, “cold turkey.” For convenience (mine) the page references that I provide here are all from a very good book that I recommend as a shelf reference in good Paleo nutrition principles and practices: “Perfect Health Diet” (Scribner 2012), by Paul and Shou-Ching Jaminet. To be clear, I do not recommend this book for its approach to eating for full-blown Type 2 diabetics. They have, sadly, missed the mark there.

First of all, peanuts are not nuts. They are legumes. Peanuts grow in the ground, not in trees as with true nuts. The peanut plant grows above ground with a pea-like flower. The long flower stalk then bends to the ground and continues to grow. The mature fruit develops there into a legume pod, the peanut, containing 1 to 4 dry seeds. Other common above-ground legumes include soy beans (edamame), fava, kidney, pinto, garbanzo, and lima beans, black-eyed peas, and lentils, and unfortunately for those with a legume allergy, sweet peas and green beans. As a type 2 diabetic, with the exception of cooked young green beans, I avoid legumes, peas and sugary vegetables (corn, beets, and carrots).

Legumes are “almost grains” (pg 209),” just as dangerous as grains when eaten raw and still risky after cooking.” They are on the short list of “DO NOT EAT” foods (pg xix): grains and cereals, sugars, beans and peanuts, and Omega-6-rich vegetable seed oils (soybean oil, corn oil, safflower oil, peanut oil, and canola oil). That’s pretty “exclusive” company. It gets a grade of “F” (pg 172) in the list of “The Best Plant Food Energy Sources,” listed after wheat, corn and other grains.

But what’s the problem with legumes, you ask? The Jaminets say, “Many legumes are highly toxic in their raw state: raw kidney beans at 1% of diet can kill rats in two weeks.” (All the Jaminets’ references are on their Perfect Health Diet website.) “Legumes are toxicologically similar to grains. Like grains, they are eaten by herbivores and have developed toxins against mammals, including humans.” Plants can’t run away from grazing animals, so toxins are their defense system. Of course, ruminants then developed a way to circumvent the plant’s defense: the four-compartment stomach.

The Jaminets offer a “sample of known toxicity effects from legumes”: “1) leaky gut, bad digestion, diarrhea, bloating; 2) retarded body growth and shrinkage of organs; and 3) heart disease and tendon damage.” Leaky gut (demonstrated in rats) allowed bacteria and toxins to enter the body, block production of stomach acid and thus prevent proper digestion of proteins. In the gut, the kidney bean lectin PHA induced immature gut cells that were “easily exploited by diarrhea-inducing bacteria such as E. coli” (pg 210). “Feeding rats the alpha-amylase inhibitor found in kidney beans leads to extreme gut bloating,” which lead occasionally to a ruptured intestine.” It gets worse from there. Read Chapter 20.

“Many legume toxins can be destroyed with overnight soaking and thorough cooking, but not all.” “Traditional cuisines that make heavy use of legumes, such as Indian cuisine, used very long cooking times as well as lengthy detoxification methods – overnight soaking, sprouting, and fermentation. Even with such methods, not all toxins are removed. But at the hasty pace of modern lives, few people soak their beans overnight or cook them for hours. It may be no coincidence that with India’s modernization, its rates of diabetes and obesity have soared.” (pg 212).

“Peanut and soybean allergies are among the most common allergies” (pg 212). And “People with celiac disease who aren’t healed by removal of wheat often turn out to have antibodies to soybeans or other legumes and need to remove legumes from their diet as well.” “Significantly raised antibody titres were found frequently in the coeliac group, particularly those patients showing a suboptimal response to a gluten-free diet,” according to the Jaminet source cited.

The Jaminets’ conclusion: “(W)e believe there is little reward and much risk to eating toxin-rich legumes such as beans and peanuts. The only legumes we eat are peas and green beans.” I concur, and I no longer eat peanuts.