Wednesday, October 30, 2013

The Nutrition Debate #156: The New ADA Nutrition Guidelines: Some Misgivings

My last column, “Cowabunga, the ADA makes the turn,” is my overview of the groundbreaking move by the ADA to a patient-oriented approach to healthy eating for type 2 diabetics. Their new Position Paper, “Nutrition Therapy Recommendations for the Management of Adults with Diabetes” is a truly refreshing breath of fresh air; it is completely devoid of evidence of “industry support,” which plagues virtually every other dietary prescription coming out of government, public health/medical organizations (e.g., AHA or AMA) or public interest groups.

This new Position Paper is in strong contrast with the “Dietary Guidelines for Americans, 2010,” which has hardly varied from its inception in 1980. The 1980 cover states in boldface: EAT LESS FAT, SATURATED FAT, AND CHOLESTEROL. Its predecessor document, the 1977 “Dietary Goals for the United States,” was prepared, not by scientists, but by the staff of the Senate Select Committee headed by Senator George McGovern (Dem., S. Dakota) and aimed to promote the corn and soy bean-based Agribusiness industry. If you want to get your hackles up, read the “Illustrated History of Heart Disease 1825-2015,” a diet-heart “timeline” prepared by Diet Heart Publishing.

The new ADA Nutrition Guidelines are 22 pages long, including 14 pages of text and tables and almost 250 references. While I obviously am very pleased that the American Diabetes Association (ADA) has turned the corner on “nutritional therapy,” I would still pick a quarrel here and there. Their glycemic, blood pressure and lipid goals, for example, are unambitious in the extreme: They adhere to the “general recommended goals of the ADA for these markers.” Okay, they didn’t want to pick a quarrel there, obviously, plus they allow that “they may need to be adjusted for the individual…” based on various factors, from which I inferred (gasp!) less stringent goals as “can be found in the ADA Standards of Medical Care in Diabetes.”

And while this document was written by, for and from the perspective of the Medical Nutrition Therapist (MNT), it acknowledges that “a large percentage of people with diabetes do not receive any structured diabetes education and/or nutrition therapy” and that “in addition to MNT provided by an RD,
diabetes self-management education and support are critical elements of care for all people with diabetes and are necessary to improve outcomes in a disease that is largely self-managed.” This point is very important in two respects: Too few type 2 diabetics take responsibility for self-education or self-care (readers of this blog excepted, of course). Most type 2 diabetics just let their doctor (who is generally clueless in nutrition) take care of their diabetes; he takes their blood, writes a script, tells them to lose weight, and it’s “next patient”                   

The second reason is that most RDs and CDEs haven’t got the word yet; they still espouse the one-size-fits-all dietary advice in the Dietary Guidelines for Americans prescribed for the whole population, diabetics included – restricted-calorie, low-fat, and thus high-carb – which is very bad for the general population (raising their risk for CVD and diabetes) but disastrous advice for type 2 diabetics. So, hopefully, these new recommendations will have some impact on them, i.e., on the clinical practice of nutrition therapy. I can hope so, anyway. You could help (they’re “busy”) by printing this column – better yet, print the entire 22 page ADA document – and take it with you to your next appointment with your MD, RD or CDE. It’s “continuing education.”

Achieving and maintaining body weight goals and delaying or preventing complications of diabetes are other stated goals, and they say that “due to the progressive nature of type 2 diabetes, nutrition and physical activity interventions alone (i.e. without pharmacotherapy) are generally not adequately effective in maintaining persistent glycemic control over time for many individuals.” Now some of us (and I include myself among “us”), find that nutritional therapy alone, totally without physical therapy or pharmacotherapy, is sufficient in and of itself to keep type 2 diabetes in total remission! Progressive disease, harrumph!  I say this as a T2 of 26 years.

Anyway, achieving and maintaining body weight goals and delaying or preventing complications of diabetes are very important goals and highly desirous. The report states further, “More than three out of every four adults with diabetes are at least overweight, and nearly half of individuals with diabetes are obese.” And, “Among the studies reviewed, the most consistently reported significant changes of reducing excess body weight on cardio vascular risk factors were an increase in HDL cholesterol, a decrease in triglycerides, and a decrease in blood pressure.” See #67, #68 and #70, here, here, and here for my take on these topics.

“Weight loss appears to be most beneficial for individuals with diabetes early in the disease process.” (But your knees can benefit at any time.) If you are a newly diagnosed type 2, this might be helpful, and the ADA Position Paper wisely ducks the surgery issue. “Bariatric surgery is recognized as an option for individuals with diabetes who meet the criteria for surgery and is not covered in this review. For recommendations on bariatric surgery, see the ADA Standards of Medical Care,” they say. I say, read The Nutrition Debate #145, “Gastric Bypass vs. Medical Therapy for Metabolic Syndrome,” carefully before you contemplate bariatric surgery.
The ADA Position Paper does address the macronutrients individually, as well as various micronutrients, vitamins and minerals. It also expresses a “bias” (with reasons) for the Mediterranean Diet. I will delve into this and other aspects of this important new blueprint into the frontier of “nutrition therapy” in upcoming columns. Stay tuned. It should be interesting.

Saturday, October 26, 2013

The Nutrition Debate #155: Cowabunga, the ADA makes the turn

The American Diabetes Association (ADA) has just issued new nutritional guidelines for adults with type 2 diabetes, the first in 5 years, and I am ecstatic. I am so thunderstruck by this document, and what it represents, that I am at a loss to describe the breadth and scope in one column. The dimensions of this shift are great, and the more I think about it, the more excited I get. It may take a few weeks (and a few columns) for them all to sink in and for me to relate them to you. Here’s a first cut.

This Medscape Alert, authored by Miriam E. Tucker, sums is up nicely right off the bat (the World Series in Baseball started this week). Her lede is, “New nutritional guidelines from the American Diabetes Association focus on overall eating patterns and patient preference, rather than any particular dietary prescription.” Please pause and reread that. Let it sink in for a minute. “The authors intentionally avoid using the word diet,” Alison Evert, lead author, told Medscape Medical News.

“Throughout the document, we refer to 'eating plans' or 'eating patterns' rather than 'diet,'” Evert, MS, RD, CDE, told Medscape. “We want to work with patients and help them achieve individual health goals. A variety of eating patterns can help, and people are more likely to follow an eating plan that speaks to them," she said. Boy is that true! “Doctors and dietitians have long recognized that ‘diets,’ (or Way of Eating in VLC parlance), work best if you, the patient, like them.” To which I add, “And you are more likely to stick to it if you can lose weight without hunger and cravings…and feel great!”

“Indeed, the new evidence-based position statement…reviews the evidence for several popular eating plans, including Mediterranean style, vegetarian, low fat, low carbohydrate, and Dietary Approaches to Stop Hypertension (DASH), but does not recommend any specific one.”"Personal preferences (e.g., tradition, culture, religion, health beliefs and goals, economics) and metabolic goals should be considered when recommending one eating pattern over another," the statement says (emphases mine). From where I sit, with all “eating plans” “allowed” by the ADA, the ‘pros’ of VLC will stand out.

Remember, it was only a few decades ago that Robert Atkins, MD, was scoffed at and ridiculed. And it’s been only 11 years since Gary Taubes’s seminal piece, “What If It's All Been a Big Fat Lie,” was published in The New York Times. Then, after years of ‘anecdotal reports’ of the success of Low Carb eating on both weight loss and “metabolic goals,” in 2010 the ADA allowed that low carb dieting could be tried for a year but the long term safety of low carb eating was unknown, and then last year they allowed, maybe for two years… Well, they’ve decided. Low Carb is safe, folks. YOU can now pick the eating plan that works best for you, and the ADA says, “…we want to work with patients and help them achieve (their) individual health goals” because “nutrition therapy is a core tenet of diabetes management.” You can now choose the eating plan that works best for you, finally.

Of course, to get to this point the ADA had to construct a giant ‘workaround.’ Here’s how they did it. Starting with the 2008 guidelines, and in recognition of the growing controversy around macronutrient proportions (e.g., low-fat, high-carb vs. low-carb, high-fat), they ducked. It was a beautiful finesse. With respect to the current guidelines for each macronutrient – dietary fat, protein and carbohydrate – they declare that “the evidence is inconclusive…therefore, goals should be individualized.” That’s very convenient, courageous and a brilliant entrée to the new rationalization for the switch.

 It’s now carte blanche, folks. The only caveat - your eating pattern should consist of “nutrient dense foods in appropriate portion sizes to improve overall health.” Otherwise, choose your eating plan “based on personal preferences, (e.g., tradition, culture, religion, health beliefs and goals, economics) and metabolic goals…” In case this groundbreaking development is not clear to you yet, in the first paragraph this new nutrition guidelines statement declares definitively, “It is the position of the American Diabetes Association (ADA) that there is not a “one-size-fits-all” eating pattern for individuals with diabetes.  

It further urges “that each person with diabetes be actively engaged in self-management, education and treatment planning with his or her health care provider” since “for many individuals with diabetes, the most challenging part of the treatment plan is determining what to eat.” They got that right! And this: “Carbohydrate intake has a direct effect on postprandial glucose levels in people with diabetes and is the primary macronutrient of concern in glycemic management.” And this: “Monitoring carbohydrate amounts is a useful strategy for improving postprandial glucose control. Evidence exists that both the quantity and type of carbohydrates in a food influence blood glucose level, and total amount of carbohydrate eaten is the primary predictor of glycemic response.” We type 2s all know this, but I never expected to hear it from the ADA.
Their concluding statement: This “Position Statement” was produced for the ADA by the “Nutrition Recommendations Writing Group Committee,” which “disclosed all potential financial conflicts of interest with industry,” according to the report. “Members of this committee, their employers, and their disclosed conflicts of interest are listed in the ACKNOWLEDGEMENTS. The ADA uses general revenues to fund development of its position statements and does not rely on industry support for these purposes,” they say (emphasis mine). “This position statement was written at the request of the ADA Executive Committee, which has approved the final document,” they acknowledge. I say, “Congratulations to all.” This is a patient-centered manifesto.

Wednesday, October 23, 2013

The Nutrition Debate #154: Salt, Sugar and Fat

Since last March, when it was published, I have resisted commenting on Michael Moss’s popular eBook, Salt Sugar Fat: How the Food Giants Hooked Us. I do not want to be perceived as negative. In other areas of my writing, my commentary has led readers to say I am just an old-style, country curmudgeon. And Mr. Moss, a New York Times investigative reporter since 2000, has made a career out of sensationalizing popular causes, even when the popular idea is a myth. Lumping together salt, sugar and fat as an unhealthy agglomeration is just one of those myths. I get curmudgeonly just thinking about it.

So, when The Lancet, a peer-reviewed medical journal, published this week a “Perspective” titled “Salt, Sugar and Fat or branding, marketing, and promotion,” by Dariush Mozaffarian, it caught my attention. As both a cardiologist and epidemiologist at the Harvard School of Public Health, his take would be “informed” and “professional,” vs. a rant such as I might have written. Turns out, it is. Dr. Mozaffa’s “perspective” is well-reasoned, balanced and, to my surprise and delight, in the end, negative, at least in the areas of interest to me and to anyone committed to public health and “re-education.”

According to Dr. Mozaffarian, Moss “shines” and “the text sparkles” as he “argues that the food industry manipulates and is deeply dependent on these three ingredients to create maximally alluring, addictive products that drive overconsumption, obesity and other chronic diseases. Moss “smoothly and deftly walks us through these fascinating stories, yet he seems to miss his own point.” According to Dr. Mozaffarian, “Salt Sugar Fat is, however, unconvincing when Moss attempts to link these fascinating stories and products, including their successes, failures and health effects, back to salt, sugar and fat.”

He allows that the case made by Moss for salt is “reasonable,” but that “a central tenet – that fat content in foods induces overconsumption and poor health – has been disproven by prospective studies and randomized trials.” Hallelujah, I say! “Yet this folklore is repeatedly asserted,” Mozaffarian continues, “overlooking the evidence that both the total fat content of foods and the overall fat content of the diet has little, if any, influence on major diseases, including type 2 diabetes, heart disease, or cancers” [emphasis added]. AMEN! Would that this message could be broadcast on a continuous loop over the air until is sinks in. Drumbeaters and axe grinders like me would have to find other ‘work,’ or go fishing, or take up golf.

Dr. Mozaffarian’s indictment of the 3rd member of this cabal, sugar, starts off a bit timidly, to my taste: “All refined carbohydrates – whether white bread, white rice, most potatoes and breakfast cereals, or packaged foods containing these refined grains, cereals, and starches – have largely indistinguishable metabolic harms as sugars.” He’s not a type 2 diabetic, obviously.  “Whereas sugars in liquid form are most obesogenic, there is only limited reliable evidence to suggest that sugars in foods are any worse for health than other refined carbohydrates and starches – all are detrimental (emphasis mine again). “This key issue is only mentioned by Moss in the first chapter, then seems to be promptly forgotten,” he quips.

Early in his perspective, Dr. Mozaffarian’s review makes a glancing but unmistakable blow at Ancel Keys’s “Six Country Study” with this comment: “During the 1950s and 1960s, crude comparisons across nations, basic feeding studies and animal experiments began to document how our diets might influence chronic conditions, such as heart disease and cancers.” He makes a similar jibe when referring to Moss’s piece with “the described ‘science’ seems to be highly selective, relying on hand-picked subsets of rat experiments, short-term trials in volunteers, and ecological comparisons.” Ouch!

Nevertheless, “the focus on how diet affects obesity and its complications, including diabetes,” was the impetus for this eBook. “People have recognized for millennia that overeating leads to weight gain,” Mozaffa says, but then he brightens my day with this follow-up: “Yet, this was historically attributed to weakness of individual will.” Do I detect the skepticism of a scientific mind at work here? Then, Dr. Mozaffarian-the-epidemiologist emerges: “Obesity’s remarkable and rapid contemporary rise across diverse races, social classes, cultures and nations – including perhaps most influential of all, in children – has created a new awareness that external influences on dietary choices are likely powerful and widespread…”

Here is the common thread that links Moss and Mozaffarian: “external influences on dietary choices,” but here is also where they depart. Mozaffarian says, “Throughout Salt Sugar Fat Moss attempts to indict these three ingredients as principal forces behind product development and sales, Yet, time and again, the stories reveal the true drivers of the success of individual products and our modern overconsumption: the immense and pervasive power of modern advertising and promotion.” One simple example Dr. M. cites is how Coca Cola came to dominate globally with its systematic, data-driven strategy to infiltrate life’s ‘special moments’ and create early brand adopters. Global sales of Coke skyrocketed from about US$4 billion to $18 billion between 1980 and 1997 – without changes in sugar, salt or fat,” he notes.
 Dr. Mozaffarian concludes that, “Ultimately, the irony is that in trying to bring everything back to these three ingredients- whether related to food formulations, product success, or health – Salt Sugar Fat sensationalizes their true role. The real story, otherwise compellingly told, is not the allure of salt, sugar, and fat, but the remarkable power of modern branding, marketing and promotion. The real story for me is how the Harvard School of Public Health has got it right. Go Harvard!

Saturday, October 19, 2013

The Nutrition Debate #153: “Salt: friend of foe?”

A recent Lancet article (Volume 381, Issue 9880. 5/25/13), “Salt: friend or foe?” revisits this perennial conundrum. It begins,

“Dietary guidelines advise against the consumption of too much salt. A high intake of sodium causes raised blood pressure – an established risk factor for heart disease, stroke and kidney disease. But how much salt is too much? And could a very low salt intake also be detrimental?”

What was the impetus for this latest foray into the controversial “effects of salt consumption on health outcomes”? The answer: a May 14, 2013 Consensus Report, “Sodium Intake in Populations: Assessment of Evidence” prepared by the Institute of Medicine’s (IOM) “Committee on the Consequences of Sodium Reduction in Populations.” The Centers for Disease Control and Prevention (CDC) asked IOM to do the study since IOM “serves as adviser to the nation to improve health.” Who better, then, to examine the question, right?

The casual observer might not see what’s at play here, but for me the key words are the first two in the lead quote above: “Dietary guidelines”; they are obviously an indirect reference (since “guidelines” is not capitalized) to the most recent “2010 Dietary Guidelines for Americans.” In the Guidelines, the authors at the USDA/HHS call for the general population to have “a goal of reducing sodium intake to less than 2,300mg/day, and further reducing intake to 1,500mg/day” among very large population subgroups including everyone 51 years older and older, all people who have hypertension, diabetes, or chronic kidney disease, and all African Americans.  The American Heart Association (AHA) “even advises that everyone adheres to the 1,500mg/day limit, irrespective of age or race,” according to the Lancet article.

I won’t keep you in suspense any longer. What are the “implications for population-based efforts” at dietary guidelines for sodium consumption? According to the IOM, the “assessment of evidence” of “sodium intake in populations,” is as follows:

·         The available evidence on associations between sodium intake and direct health outcomes is consistent with population-based efforts to lower excessive dietary sodium intakes.

·         The evidence on health outcomes is not consistent with efforts that encourage lowering of dietary sodium in the general population to 1,500mg/day.

·         There is no evidence on health outcomes to support treating population subgroups differently from the general U.S. population.

Alright, I won’t quarrel with the first conclusion. “Excessive dietary sodium intakes” are obviously…well, “excessive.” We are all told how processed and prepared foods are loaded with hidden salt, especially soup, right? The solution: Don’t buy or eat processed or prepared foods. Eat only “real” food – whole foods – and add salt to your taste.

The second conclusion is startling and really troubling. Lowering dietary sodium in the general population to 1,500mg/day, as the American Heart Association purportedly recommends, is not consistent with the evidence? And this a principal conclusion from a distinguished committee at the Institute of Medicine? What do they say to support this conclusion?

“…(T)he committee concludes that the evidence supports a positive relationship between higher levels of sodium intake and risk of CVD. This is consistent with existing evidence on blood pressure as a surrogate indicator of CVD and stroke risk for the general population. The committee also concludes that studies on health outcomes are inconsistent in quality and insufficient in quantity to determine that sodium intakes below 2,300mg/day either increase or decrease the risk of heart disease, stroke, or all-cause mortality in the general U.S. population.”

Wow. But how about those “special population” subgroups that taken in their entirely make up a majority of the adult population of the United States. Is there really “no evidence to support treating population subgroups differently…”? Here’s what the IOM committee, examining this specific question, said about that:

“The committee found no evidence for benefit and some evidence suggesting risk of adverse health outcomes associated with sodium intake levels in ranges approximately 1,500 to 2,300mg/day among those with diabetes, kidney disease, or CVD. Further, the evidence on both the benefit and harm is not strong enough to indicate that these subgroups should be treated differently than the general U.S. population. Thus, the evidence on direct health outcomes does not support recommendations to lower sodium intake within these subgroups to or even below 1,500mg/day.” (emphasis mine)

Okay, you say this is just an internecine quarrel between government agencies, pitting the medical (AHA), public health (HHS) and agribusiness (USDA) establishments against the less influential CDC and IOM. In fact, if you hadn’t read this Lancet article about an obscure IOM report here, it is not likely you would have read about it anywhere else. IOM and CDC don’t get much notice in the popular press regarding American dietary choices. But, there has been and will be plenty of talk in the blogosphere. My post #74, “No Added Salt? Why?,” had 5 links to good sources on salt in the diet: here, for Gary Taubes’s “The (Political) Science of Salt” from 1998 and here for his 2012 NYT op-ed “Salt, We Misjudged You”; this from a stunning 2011 article in Diabetes Care about a University of Melbourne study; this Chris Kresser article, “The Dangers of Salt Restriction” about a 2011 study reported in JAMA; and this from the Drs. Michael and Mary Dan Eades of “Protein Power.”

Wednesday, October 16, 2013

The Nutrition Debate #152: Set Point Theory – More Ramblings

“Set Point Theory” gets almost 100 million hits in Google. I’m not going there. This piece is simply ramblings on the recent convergence of a few thoughts about Set Point Theory and where I think the research is going.

My current interest was spurred by my own (n=1) experience. I’ve been working on losing weight (as always) and recently  reached another weight loss “plateau.” I eat a Very Low Carb Ketogenic Diet, and for the last two weeks my weight hasn’t changed. It goes up or down a pound or two (of water weight) daily, but has not gone lower from week to week. We’ve all been frustrated by this experience and wonder why and what can we do about it.

A number of years ago the public came to be acquainted with the scientific concept that our metabolisms “adjust” (slow down) as we attempt to eat a restricted-calorie, balanced diet, as recommended by mainstream medicine. It senses that we are in “semi-starvation mode,” and hormonal changes beyond our conscious control initiate this change. The “body” decides, independently of our intention, to conserve energy as a survival mechanism. That is why, we are told today, it is so hard to lose weight. Our body fights us “tooth and nail” to preserve our weight. And “it” wins every time.

My own recent experience has been that this “slowed metabolism” did not apply to me.  I find that my energy level is elevated when I diet. The reason is that all of my weight loss (170 pounds during my initial loss) was attributable to Very Low Carb (VLC) eating in which low serum insulin, a consequence of the VLC Way of Eating (WOE), allowed my body to access body fat for energy. The body got the signal (from the absence of carbohydrate intake) that fat storage had to be mobilized to maintain homeostasis. And since I had plenty of fat in “storage,” my body did not sense it was threatened.

Thus, the high-fat dietary intake of the VLC diet was thus supplemented by lipolysis, the breakdown of body fat for energy, enabling the body not to sense “semi-starvation” because it was not being starved. It got all the nutrients it needed from a combination of fatty food ingested and fat broken down – so long as I ate the right foods to satisfy every aspect of my macro and micro nutritional needs. Kudos to the Jaminets in “Perfect Health Diet” for that “needs” insight.

What your body’s total needs are, and the mechanisms that detect and respond to them, is still a mystery. It is also why many of us eat a diet of mixed “real foods.” It is also the reason we eschew completely all grains and as much fructose and seed oils as we possibly can, to avoid harm. If we do, our body will be “happy” and we will “feel great” (in the words of J. Stanton) – and lose weight. So, why have I plateaued this time? Some thoughts.

My wife related how she remembered this subject when she was low-carbing “before Atkins.” (I wonder if she realizes how much she is dating herself.) Her response over breakfast today was, “Be patient, it (weight loss) will start up again,” and “You may just need to ‘jump start’ it by fasting. That reminded me of a suggestion from Holly on the Bernstein Forum that she remembers back in the late 80’s and early 90s a concept called “calorie confusion” in which you vary the total calorie content from meal to meal to trick your body into thinking you have a deficit. Who knows? Just sayin’.

And that reminded me of a diet I read and wrote about here called “The 8-hour Diet,” in which you eat all your food in any day within an 8-hour “fed” period. The theory is that gives your body a chance to get into “fasting” mode for 16 hours a day, when it will burn body fat for energy. I like this idea but how it relates here is that the author suggests doing it only 3 times a week. Sounds to me like “calorie confusion,” Intermittent Fasting, and lack of commitment combined!

That idea led me to a New Year’s Resolution idea last January from David Mendoza from his blog here. His suggested “weight loss tip” was that whenever your weight drifts above “target,” you skip dinner that day. That would be a 19 hour fast for me. I could probably do that several days every week. I’m not hungry on my VLCKD. And I did do that recently two days in a row. I actually ate only breakfast for two days and my weight dropped like a stone.

So, the common thread of all these rambling thoughts is that fasting, so long as you are in fat burning mode to begin with, and thus not experiencing hunger or any mysterious drives or cravings, is an effective way to jump start weight loss again. The inescapable conclusion, however, is that set-points can even set in when you are ketogenic. Your body gets “happy” to be in a “constant” state of ketosis instead of a “dynamic” state. Homeostasis has many under-understood aspects. Perhaps J. Stanton on a post at said it best: "It's tempting to talk about “set points” and leave the discussion there — but as I've said before, “A 'set point' is just a homeostasis we don't understand.” The trillions of cells in our bodies each have metabolic requirements for macro- and micro-nutrients, as well as a functional hormonal environment (the “milieu intérieur”).*
* “Milieu intérieur” is a reference to a seminal concept of the mid-19th French physiologist Claude Bernard, “one of the greatest of all men of science.” This concept has come to be known in English today as homeostasis. Look him up here!

Saturday, October 12, 2013

The Nutrition Debate #151: Homage to Vilhjalmur Stefansson by his wife Evelyn

This entire column, with thanks to my editor, is an excerpt from the Canadian blog Empirica, by L. Amber Wilcox O’Hearn.

“I recently came across an edition of Richard Mackarness's book Eat Fat and Grow Slim. It includes a preface written by Stefansson's wife, Evelyn…. I reproduce it here because it is an interesting perspective from a wife and home-maker.


One morning at breakfast, the autumn of 1955, my explorer-anthropologist husband, Vilhjalmur Stefansson, asked me if he might return to the Stone Age Eskimo sort of all-meat diet he had thrived on during the most active part of his arctic work. Two years before, he had suffered a mild cerebral thrombosis, from which he had practically recovered. But he had not yet succeeded in losing the ten pounds of overweight his doctor wanted him to be rid of. By will power and near starvation, he had now and then lost a few of them; but the pounds always came back when his will power broke down. Doubtless partly through these failures, Stef had grown a bit unhappy, at times grouchy.

My first reaction to his Stone Age diet proposal was dismay. I have three jobs. I lecture, in and out of town, and enjoy the innumerable extracurricular activities of our New England college town of Hanover, New Hampshire. Forenoons I write books about the arctic, "for teen-agers and uninformed adults," to be able to afford the luxury of being librarian afternoons of the large polar library my husband and I acquired when we were free-lance writers and government contractors, which library now belongs to Dartmouth College. I take part in a course called the Arctic Seminar, and last winter was director. I sing in madrigal groups and act in experimental theater plays. Only by a miserly budgeting of time do I manage these things. "In addition," I thought to myself, "I am now supposed to prepare two menus!"

But aloud I said: "Of course, dear." And we began to plan.

To my astonished delight, contrary to all my previous thinking, the Stone Age diet not only proved effective in getting rid of Stef's overweight, but was also cheaper, simpler, and easier to prepare than our regular mixed diet had been. Far from requiring more time, it took less. Instead of adding housekeeping burdens, it relieved them. Almost imperceptibly Stef's diet became my diet. Time was saved in not shopping for, not preparing, not cooking, and not washing up after unrequired dishes, among them vegetables, salads, and desserts.

Some of our friends say: "We would go on a meat diet too, but we couldn't possibly afford it." That started me investigating the actual cost of the diet. Unlike salads and desserts, which often do not keep, meat is as good several days later as the day it was cooked. There is no waste. I found our food bills were lower than they had been. But I attribute this to our fondness for mutton. Fortunately for us it is an unfashionable meat, which means it is cheap. We both like it, and thanks to our deep freeze, we buy fat old sheep at anything from twenty-two to thirty-three cents a pound and proceed to live on the fat of the land. We also buy beef, usually beef marrow. European cooks appreciate marrow, but most people in our country have never even tasted it, poor things.

When you eat as a primitive Eskimo does, you live on lean and fat meats. A typical Stefansson dinner is a rare or medium sirloin steak and coffee. The coffee is freshly ground. If there is enough fat on the steak we take our coffee black, otherwise heavy cream is added. Sometimes we have a bottle of wine. We have no bread, no starchy vegetables, no desserts. Rather often we eat half a grapefruit. We eat eggs for breakfast, two for Stef, one for me, with lots of butter.

Startling improvements in health came to Stef after several weeks on the new diet. He began to lose his overweight almost at once, and lost steadily, eating as much as he pleased and feeling satisfied the while. He lost seventeen pounds, then his weight remained stationary, although the amount he ate was the same. From being slightly irritable and depressed, he became once more his old ebullient, optimistic self. By eating mutton he became a lamb.

An unlooked-for and remarkable change was the disappearance of his arthritis, which had troubled him for years and which he thought of as a natural result of aging. One of his knees was so stiff he walked up and down stairs a step at a time, and he always sat on the aisle in a theater so he could extend his stiff leg comfortably.

Several times a night he would be awakened by pain in his hips and shoulder when he lay too long on one side; then he had to turn over and lie on the other side. Without noticing the change at first, Stef was one day startled to find himself walking up and down stairs, using both legs equally. He stopped in the middle of our stairs; then walked down again and up again. He could not remember which knee had been stiff!

Conclusion: The Stone Age all-meat diet is wholesome. It is an eat-all-you-want reducing diet that permits you to forget you are dieting--no hunger pangs remind you. It saves time and money. Best of all, it improves the temperament. It somehow makes one feel optimistic, mildly euphoric.

Epilogue: Stef used to love his role of being a thorn in the flesh of nutritionists. But in 1957 an article appeared in the august journal of the American Medical Association confirming what Stef had known for years from his anthropology and his own experience. The author of this book has also popularized Stef's diet in England, with the blessing of staid British medical folk.

Was it with the faintest trace of disappointment in his voice that Stef turned to me, after a strenuous nutrition discussion, and said: "I have always been right. But now I am becoming orthodox! I shall have to find myself a new heresy."

Evelyn Stefansson

April 22, 1959

Wednesday, October 9, 2013

The Nutrition Debate #150 – Another Milestone, Amid Ramblings and Ruminations

A year and a half ago, as this blog reached the 3,000 page-view mark, my hometown weekly newspaper advised me that they “had done enuf on carbs and fat.” So, we both moved on. Since then I have published over 100 more columns online, and just passed the 30,000 page-view threshold, with a pace of 4,500 per month and accelerating. I also increased my publication rate to two columns per week. The newspaper is still published, but is delivered only sporadically and never forwarded to our winter home in Florida.

In a parallel universe, I think the world of the Alternative Hypothesis of Nutrition, of eating Low-Carb High-Fat (LCHF), is also growing steadily. It’s not exploding exactly, but it is “mushrooming,” that is, popping up here and there and everywhere in unexpected places and in similar, easily recognizable forms. This is very gratifying. I am, of course, encouraged and buoyed by these mostly piecemeal advances. I see them everywhere, on the radio, on TV, in print, and in the proliferation of web-based resources. I also see them in my own rapidly growing readership. I am especially gladdened to see so many “foreign” readers, thanks in part to Google Translate: China, the Ukraine, Canada, Germany, the UK, Russia, France, Singapore, Australia, Sweden and the Philippines

One of the basic premises of The Nutrition Debate is that we as individuals are in charge of our own health because diet is a large part of health. The conditions that we have always associated with aging are increasingly being seen as instead being associated with diet. This old idea is back - “Let food be thy medicine” Hippocrates.  No surprise then, that we are interested in getting the best dietary advice. Unfortunately, the medical professions – and I think they would be quick to agree – are not trained in nutrition. They are trained in diagnosing and treating disease rather than prevention.

Equally unfortunate, the dietetics profession and the diabetes educators, while trained in nutrition, are misinformed, to be kind. They (in general) are the last persons whose advice we should seek and follow, and I do not see this changing soon. They follow the conventional wisdom of the AHA and the ADA. And large organizations can be very slow to change. It is such a shame… and so illogical that these two professions, medicine and dietetics, who should be interested in science and who should be open minded about unproven, even disproven hypotheses like the diet/heart hypothesis, are ignoring the increasing body of undeniable, irrefutable evidence that eating a low-fat, high-carbohydrate diet is what is making us sick. So you must seek your own dietary advice.

If you think this is a daunting prospect, just remind yourself that your doctor monitors your health and is very results oriented. He is interested in health outcomes: a good weigh-in and good lab tests – in other words, things that you are in charge of. You make these things happen. Will he care about how you do it?  If he is surprised at your improved or even stellar results, he may ask you how you did it. And don’t you be surprised if he is openly skeptical, or offers another explanation when you tell him. And be pleased if he just quietly accepts your explanation, even with a wry grin, and maybe an upturned corner of the mouth and a glint in his eye. Mine was. He was always glad to see me because he knew it was going to be a “happy” consultation, because with my treatment plan, my diabetes is not a progressive disease.

If your doctor is pleased with your health outcome, but not well disposed towards your methods, consider that you don’t have to tell him how you did it. The fact that he is stuck in his ways is not your problem. Your health is your problem; and hopefully a long term one. He’s gotta do what he’s gotta do. He needs to follow the standards of practice of his specialty to protect his practice from a liability lawsuit and to get paid for his service from whatever insurance you have. There are other factors at play besides the “best interests” of the patient. Such is the current state of the health care business.

Big Pharma, Agribusiness and the Public Health Establishment are all engaged in this giant corrupt bargain. The media just trumpets their latest marketing message.  The “Alternative Hypothesis” movement, to borrow a phrase from the iconic Gary Taubes, is made up of serious health care researchers and practitioners who think “otherwise” so we should all be grateful for the small but important changes we see. The trend and the rate are accelerating, just as the readership of this blog is. The only dragon we have yet to slay is the saturated fat/dietary cholesterol demon, and that one cannot be long for this earth. We just need to keep hammering out the mantra: “Dietary Cholesterol has nothing to do with Serum Cholesterol.” And we need to get more doctors to test for “big fluffy” (Pattern ‘A’) vs. “small dense” (Pattern ’B’) LDL, and to care more about how to get lower triglycerides and higher HDL by diet alone – low carb dieting – than about lowering high Total Cholesterol and LDL with statins and other drugs.

Remember: The TG/HDL ratio is an important metric. TG:HDL <1.0 for optimum health and minimum cardiovascular risk. So is A1c. Heart attack risk falls as the A1c drops to 5.5 and below. You can set these targets as your goals and reach them with a low carb approach. “Eating Clean,” is the way to achieve a healthy heart disease risk (lipid) profile. And lose weight. And improve blood pressure. And reduce inflammation…

Saturday, October 5, 2013

The Nutrition Debate #149: Feral Cat Feeding Frenzy

We have had a small colony of feral cats for 5 years. When four adolescent siblings appeared on our rear terrace one day, we fed them. What happened next was predictable. They returned every morning and evening for “two squares.” We tried to do what we considered was the responsible thing, but we were only able to trap, neuter and release three of them to the “wild.” They were truly feral and were too old to be domesticated. But in the spring the 4th, -just our luck - was obviously pregnant, and one fine day in April she delivered her litter. We found her nest and at 4 weeks separated six adorable kittens, domesticated them, and found them homes. But “Mommy” continued to elude us and reproduce. She also soon introduced another feral, who we think was her mother, to our banquet, and she too was fertile.

To make a long story short (and get to the point), we finally, after four years, have caught and neutered (spayed or altered) all the fertile ferals in our colony and the population has stabilized at seven adults. We feed them at least twice a day and have become quite attached to all of them, even though we still can’t touch or even get close to any of them.

And every year, when the weather turns cold as winter approaches in our temperate climate (upstate New York), I’ve observed that our small feral cat colony knows it’s time to fatten up for the long winter siege. Their appetites seem insatiable, by any measure greater than usual. Ordinarily cats know not to overeat. If they are “full,” they leave food on the “plate.” But their appetites definitely change when they sense they will need fat reserves to survive a long winter. Gary Taubes describes this mammalian behavior in “Good Calories – Bad Calories” (pg. 294). It’s an example, he says, of hormonal control of feeding behavior, just as growth hormones account for the appetites of children. Children don’t get fatter (on a “proper” diet); they get plump briefly and then get taller very quickly. And when cold weather is coming, cats eat voraciously to fatten up for winter.

The temporary fat provides insulation from the cold as well as body fat reserves. Of course, these cats don’t “know” why they have rapacious appetites as the days get shorter and colder. Their unconscious brains function autonomically regulating homeostasis on a daily and seasonal basis. Their hormones “tell” them to eat. It prepares them to live off body fat during the time when they will be unable to hunt or are less likely to be successful at hunting. It’s a survival behavior. When spring comes, and the fat reserves that enabled them to survive are depleted, their eating behavior will return to “normal.” They will need to be lean again to have the agility to hunt. “Fat cats” don’t get the “early bird.”

What can we learn from these observations? Well, we’re mammals too, and it’s only been 500 generations or so (10,000 years) since we learned to grow food as crops and then harvest and store them for winter. This was at the beginning of the Neolithic Age. The time before that is referred to as the Paleolithic Era, hence what is known today as Paleo dieting. But in today’s world, we (most of us, especially those who will be reading this) live in an environment of abundance in the food supply. Our modern lifestyle allows us to shop at the local super market rather than “hunt and gather” or grow our own food supply. The market is filled with a cornucopia of foods all year long, many of them “processed,” which means they have already been “partially digested”! White flour milled from whole grain is a perfect example, as are fruit juices and smoothies. Even fruits, which are primarily sucrose, fructose and glucose – all simple sugars, with a little fiber and pectin, have all been hybridized to make them even sweeter (and larger) than they ever were in ancestral times.

The result: When processed carbs dominate our diet, we eat every day like winter is about to descend on us at any minute. The same autonomic control system that tells the feral cat to prepare for winter, tells us to “overeat.” Not the same mechanism, but the same effect because there is no seasonal change. Spring never comes on this way of eating. We never get any leaner. We’re always hungry for “sugar” (glucose from carbohydrates). It’s never ending – a perpetual continuum.

The alternative is the way we were designed to eat. It takes both an understanding of what drives our eating behaviors and the wish to emulate that Way of Eating. Our bodies were designed to eat after a period of mild ketosis following a meal. It is a natural state. Food wasn’t always abundant. The cycle then was: feed, then fast, repeated maybe once or twice a day. If you do this in combination with eating very few carbohydrates, you will find you can do it without hunger. And if you need to lose weight, you can further restrict your protein calories (to a point), and do that as well, also without hunger.

Our feral cat colony ate twenty times more (by weight) for breakfast today than we did. It was a veritable feeding frenzy. But their feeding frenzy is being driven by the onset of winter. Our society is being driven by an over dependence on boxed, bagged, and “predigested” processed foods that we have come to overly rely on “for our convenience.” It is also with the blessing and encouragement of our government whose misguided advice is still being driven by 50 years of bad science, among other things.  The “corrupt bargain” of government funding, well-meaning but overreaching “big government” “fat cats” who want to tell us what we should eat, and the forces of “big agribusiness” (and “big pharma”) that profit from it. As individuals in society we need to learn to think for ourselves, to recognize what is really in our best interest. We need to learn what actions can lead to health, and then act.

Wednesday, October 2, 2013

The Nutrition Debate #148: Obesity, a Condition of Genetic Susceptibility?

There’s no question about it in my mind. Obesity is, in large measure, for most of us, a condition of genetic susceptibility. I have to qualify this because I want to address in particular NOT the very small number of people who have a rare genetic disorder (e.g.: Prader-Willi syndrome). I want to address the one-third of us, and I certainly include myself, which I suppose gives me a bias, who will gain weight eating the same foods in the same amounts that the other two-thirds do who do not gain weight. We did, at one time, eat the same foods and amounts without gaining weight, but then something changed, and that something is not simply behavioral (although it lead to ‘behavioral’ change), nor is it less physical activity.

My bias, while it has to be accounted for, is also an advantage. I am simply amazed by several respected authors in the health and nutrition field, whom I will not bash here, who just don’t get it. It’s too bad, but I think you just have to be in our shoes to understand – to know, actually, how the body responds to carbohydrates once your metabolism becomes disregulated – deranged, really, by insulin resistance and the resulting intolerance for carbohydrates of any stripe.

Anyway, I do not seek sympathy. I would hope for understanding of the science, based on emerging (and long forgotten or ignored) knowledge. That would enable empathy, I suppose, but more importantly, an interest in furthering 1) the science, for those who endeavor in that field, and 2) acceptance by the medical and public health establishments of the evidence presented by those serious researchers. Unfortunately, both the medical and public health establishments today are thoroughly corrupted by Agribusiness and Big Pharma. So, only independent researchers and writers, most of them younger and unencumbered by conflicts of interest or conscience, can make a difference. I am but a speck in this firmament, but I power on, seeking the truth, and “broadcasting it” to a small (but rapidly growing) following. Thank you for reading.

My bias is generally informed by the 3-time award winning science writer, Gary Taubes. His seminal tome, “Good Calories – Bad Calories,” is a foundation document. My column #5, “Gary Taubes and the Alternative Hypothesis,” has his “10 certain conclusions” which lay down the basis for my, and many others’, understanding of the science of obesity.

And in #120, “Nutrigenomics -- an Emerging New Science,” quoting from Wikipedia, I wrote: “It is hoped that by building up knowledge in this area, nutrigenomics will promote an increased understanding of how nutrition influences metabolic pathways and homeostatic control, which will then be used to prevent the development of chronic diet related diseases such as obesity and type two diabetes.” Obesity, then, by this definition, clearly is a condition of genetic susceptibility.

Recently, in this piece by Patti Neighmond, broadcast on NPR, Dr. Lee Kaplan, an obesity specialist and director of the Mass. General Hospital Weight Center, said, “We’re all wired in slightly different ways,” adding that “those subtle differences are reflected in how the body deals with energy stores and fat.” The piece continues, “There are thousands of genes in the body, and Kaplan says about 100 of them are involved in making some people more susceptible to weight gain.”

Dr. Osama Hamdy, who directs the Obesity Clinical Program at the Joslin Diabetes Center in Boston, then said:  “The reality is, if you have that genetic susceptibility to gain weight, you will gain weight easily, no matter what. Genetic susceptibility has to do with hormones and chemical systems in the body that direct appetite, metabolism and the absorption of nutrients and fat. One of those hormones is leptin. It's produced by fat cells and tells the body when it's eaten enough.”

Hamdy says the majority of people who are obese are resistant to leptin. "The brain is shielded from the information on how much fat you have in your body. The brain is under the assumption all the time that you need more fat." Other hormones make some people get hungry more often than others. Then there's another system of brain chemicals, the endocannabinoid system. When it malfunctions, it fails to tell the body to stop eating appealing foods. For example, if you've always loved the sugary taste of ice cream, you may end up eating way too much of it simply because an enzyme in your brain fails to halt the chemical signal to eat as much of the beloved food as you can.

A 2009 study on the genetic susceptibility of weight gain found that when 12 pairs of identical twins were overfed 1,000 calories a day for about three months, each set of twins gained a different amount of weight. Some only gained about 8 pounds, while others gained nearly thirty pounds. But within the pairs of twins themselves, the weight gain was the same.

Another piece, by Bruno Waterfield, in a British newspaper, The Telegraph, recently reported that Paul van der Velpen, the head of Amsterdam’s health service, said, “Just like alcohol and tobacco, sugar is actually a drug.” Van der Velpen claims that sugar, unlike fat or other foods, interferes with the body’s appetite creating an insatiable desire to carry on eating, an effect he accuses the food industry of using to increase consumption of their products, Waterfield said. “Sugar upsets that mechanism. Whoever uses sugar wants more and more, even when they are no longer hungry. Give someone eggs and he’ll stop eating at any given time. Give him cookies and he eats on even though his stomach is painful,” van der Velpen argued. I can relate to that. I wonder if I am being objective. I wonder if van der Velpen is fat too, or does he just “get it.” I wonder…
Postscript: Here’s a video (Part 1 of 3) about Dr. Jay Wortman’s diet experiment with First Nation people in British Columbia, produced by the CBC:  I made a related post in The Nutrition Debate #61, “Steffansson and ‘the Eskimo Diet,’ over a year ago and will return to the subject in #150, “Homage to Vilhjalmur Steffansson by his wife Evelyn,” next week.