I get invited to speak at a lot of conferences. This has been going on for several years now and I have developed a presentation that can be modified to fit different time slots and to appeal to different audiences, ranging from professional to lay people. It is not a static presentation; I am constantly updating my slides to accommodate new research findings. I have come to enjoy public speaking and I think my talks are generally pretty well-received. One of the rewards is that I occasionally hear that something I said actually changed someone’s life.
I was in northern Alberta recently to give a talk at a small conference. During the break a woman came up to me and said she had heard me speak four years earlier. I had completely forgotten about that particular talk but she hadn’t. She said that the take-away message for her was that she should get sugar and refined starch out of the diet of her kids. At the time she was living next to a 7-Eleven and her daughter was starting to gain significant weight. She told me that after hearing my talk she went home and followed my advice and now, four years later, has a daughter who is a slim, self-assured young woman. She was beaming with pride. She wanted to thank me.
This was not the first time. On another occasion, I was invited to speak at an Aboriginal conference on diabetes. I gave a one-hour plenary lecture and that was it, or so I thought. Several months later I got a call from a nurse working in a very remote northern First Nations community. She said that a local man with diabetes had heard me speak and had come home and lost 35 lbs and got off all his medication. Others in the community were adopting a lower carb diet following his example and were getting significant results. The nurse was being asked to help more and more people get on the diet and she was calling to seek my assistance. I was so intrigued by this that I took a week to go up there to visit and give them some guidance.
I could go on, but you get the picture. I sometimes feel like Johnny Appleseed, traveling about scattering this dietary advice and never really knowing how much of an impact I am having. Every once in awhile a story like these gets back to me and I feel like all the effort is worthwhile.
Unfortunately, not everyone agrees. I recently ran into someone who works in the north and she said, “I see you are presenting at the conference in XXXX next week”. I knew nothing about it so I asked her to send me the info to see if, indeed, I was expected somewhere and through a mis-communication did not have it in my calendar. She sent me a note later saying that she had checked and I no longer appeared on the most recent agenda. While I was relieved that there had not been a communications cock-up, I was also somewhat concerned as to why I had been deleted. It’s not that I feel I need to speak at every event. It’s because I know there are people who are opposed to my message and who would like to silence it.
Okay, now it sounds like I am wearing a tin-foil hat. Let me illustrate with a couple more stories. After speaking at a conference a couple of years ago, I got a call from the organizer who informed me that they had been told that, if I were to be invited to future conferences, their funding would be cut off. I have to admit that, even after all these years, I am still naive enough to be a little shocked by that kind of behaviour. To make it even more outrageous, this was the very conference where the man with diabetes was able to take my message home and improve his health and influence a lot of other people in his community.
Another conference story: I have been getting invited to speak at an annual diabetes update mainly targeted at physicians. Three years ago, I was asked to give a 15 minute presentation on a panel. As you can imagine, it is hard to do justice to a completely different and orthogonal to the mainstream approach to diabetes management in a time slot that small. But I tried.
When the conference evaluations were sent out, I was delighted to see that, of all the speakers, I had received the highest grades from the audience. I think this may have influenced the organizers to invite me again the following year, this time to give a 45 minute presentation. There appeared to be some residual nervousness on the part of the organizers, however, evidenced by the fact that I was placed at the very end of the program and by their request that I include a discussion of other topics like the merits of different glycemic foods, etc. Ignoring this, I gave my usual presentation, and, again got the highest marks on the speaker evaluation. In addition, there were a lot of written comments urging the organizers to give this topic more exposure. I have to tell you that I also get swarmed after these presentations with physicians who want to know where they can learn more and how they can apply this approach in their practices.
While I find all this quite heartening, the organizers continue to be somewhat ambivalent. This year I have been asked to return again, but, instead of giving my usual presentation, I am being asked to engage in a debate with a prominent obesity expert who will defend the status quo. I look forward to this challenge since I think that, if one is to maintain any kind of credibility, one needs to be able to defend one’s position. I am pleased to have an opportunity to present the evidence and argue its merits. Having said that, I do find it curious that there is this ongoing, deeply rooted fear of carbohydrate restriction. In some cases this is manifested by covering the ears and saying “la la la la la”. At least, in the instance of the diabetes update conference, I am still allowed to present and discuss the evidence. That is all one can ask for at this point and for that I am grateful.
Now, on the topic of guidelines, there have been some recent developments. From the experiences I have had with physician audiences, a couple of things are clear to me. First there appears to be a growing recognition by my colleagues “in the trenches”, that the current approach to obesity, metabolic syndrome and diabetes management is falling short of the mark. Secondly, there is an almost desperate need for more and different ammunition to fight these growing epidemics.
One of the ways physicians can be helped is through the publication of clinical guidelines and physicians’ handbooks. These are usually short, to the point, manuals that are designed to be clear and easily implemented in a general practice setting. Doctors have resource limitations, the most vital of which is their time. They don’t have the time to immerse themselves in the scientific literature on any given topic. They rely on others to do this and to translate research findings into practice guidelines that can be implemented quickly and effectively in a busy practice environment.
So, for diabetes, we have the Clinical Practice Guidelines published ever 5 years by the Canadian Diabetes Association (you can find it online and if you look very carefully you will find that I was involved in writing the Aboriginal diabetes section). The odd thing about this guideline is that there is no mention of carbohydrate restriction for obesity or diabetes management. Why this is odd may not be immediately obvious since it is par for the course for the large scientific authorities to ignore the scientific literature on low-carb diets. To understand why this is odd you need to look at the similar publication produced by the American Diabetes Association. Here is what they say: “For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be effective in the short-term (up to 1 year)”.
Got that? What is arguably the world’s most pre-eminent authority on diabetes puts low-carb diets on the same footing as the usual low-fat low-calorie approach. You would think that would cause other diabetes organizations to take note and perhaps align their recommendations accordingly. You would be wrong!
The CDA guideline make no reference to low-carb diets at all. When the CDA guidelines were presented at their annual conference in 2008, I attended. At the panel discussion on diet, I got up and asked whether they had looked at the low-carb literature and, if not, why not, and if they had, why had they come to a different conclusion than that of the ADA? There was much confusion among the panelists until they decided that the issue of low-carb had been relegated to the section on obesity. As it happened, I bumped into the author of that section as I left the session so I asked him the same question. He responded that he hadn’t been asked to look at the low-carb literature hence the lack of any mention of it in that section. Okay, some passing of the buck was happening but, still, it struck me as odd that such a large and growing body of consistent evidence could be so completely and inadvertently overlooked.
Now, why did the ADA choose to include low-carb as a valid option while the CDA continued to ignore it? That’s an interesting question. I think I may know at least part of the answer. I attend the annual scientific meeting of the Nutrition and Metabolism Society which consists of researchers and clinicians who focus on carb restriction (I was awarded their annual prize for excellence at this year’s meeting, but that is another story). About three and a half years ago I was invited to speak on a panel at the annual meeting which happened to be in Nashville (yes, I did go to the Grand Ol Opry!). Also on the panel was a woman who was one of the lead authors of the ADA guidelines. There was a spirited discussion in which she was challenged as to why the ADA was not looking at the low-carb literature. At the end her response was that we should submit a paper to their journal, Diabetes Care, making our case for low-carb.
A number of us collaborated to produce a review paper which was submitted for publication. It bounced around in the review process for about 3 months and then was rejected. This happens all the time so I didn’t find that too remarkable. A version of the paper was eventually published elsewhere. The interesting development was, however, that the next revision of the ADA guidelines which was issued a few months later included low-carb diet as a valid option for weight loss. It appeared to me that once the ADA was forced to look at the literature, they had to conclude that the evidence supported a low-carb option.
So, what is it going to take to get the CDA to look at the literature and, hopefully, come to the same conclusion? I don’t know, but there is one opportunity on the horizon – the person who is scheduled to debate me on this topic is the very same author of the CDA guidelines section on obesity who has avoided recommending low-carb up to this point.
Wish me luck on that one!
There has been another guideline just released: the Canadian Obesity Network has produced the “Best Weight: A Practical Guideline to Office-Based Obesity Management”, authored by Drs Arya Sharma and Yoni Freedhoff.
Now, I have met both these gentlemen and they are recognized in Canada for their work on overweight and obesity. I have heard Dr Sharma speak at conferences and thought he had a reasonable approach. He essentially says that when someone presents with obesity, before prescribing a treatment he has to first understand why they have the problem. This is true when someone presents with any type of medical condition. So far, so good. Especially if you are familiar with the literature which shows clearly that people with insulin resistance do exceptionally well on low-carb and may even get worse on low-fat/calorie-restricted diets.
Dr Freedhoff, similarly, in the past has made statements generally supportive of low-carb and seemed to recognize the fallacy of the fat-is-bad meme. He is a proponent of the importance of calories but I could overlook that as long as he was able to recognize that carb restriction is a valid option. The last time I spoke to him, though, I have to admit I was a little concerned about his position on fat.
So, you can imagine my disappointment when I looked at the section of their guideline on dietary management. They steer people away from low-carb and also saturated fat while recommending unsaturated fat and lower calories. There is no recognition that low carb is a valid option. They recommend a minimum of 100 gm of carb per day to avoid “protein breakdown, muscle wasting and large shifts in fluid balance”. Huh?
They go on to suggest that most of the early weight loss on a low-carb diet is from the water released when glycogen is burned. And, in the section on fats, they state that “saturated fats have been strongly linked to cardiovascular disease” while unsaturated fats are fine.
First the carbs: yes, your liver will break down protein to produce the small amount of glucose your body still needs after you stop eating carbs. This is why, in studies that have looked at this, you generally see a small increase in protein consumption on a low carb diet. You certainly won’t see muscle wasting unless you are depriving yourself of an adequate amount of dietary protein which is not something you would do on any of the mainstream low-carb diet plans.
Yes, there are fluid shifts but this is a good thing. When you restrict carbs your kidney releases salt which takes water with it. This relieves fluid retention and lowers blood pressure, which are good things. Such is the natriuretic effect of low-carb dieting that most people will have to add salt to their diet to ensure they don’t get dehydrated because of the salt and fluid loss. Dr. Sharma in particular should know about this as he has done work on blood pressure and insulin resistance.
It is quite surprising to me to see, after the recent literature on saturated fat and cardiovascular disease, which shows there is no connection, that a new guideline would still demonize saturated fat. Similarly, we know that too much polyunsaturated fat in the form of high omega-6 vegetable oil is not healthy. Their guideline makes no reference to this fact.
I hope they have plans for an update sooner rather than later that offers a low-carb option. I also hope that, in the meantime, my colleagues “in the trenches” can find other sources that will give them useful information on how to manage a low-carb diet in a family practice setting. The Atkins corporation has developed a guide for physicians which they are starting to provide in the US. I have seen a draft and I think it, too, still needs work so I look forward to future editions which will undoubtedly be helpful.
Perhaps what all this means is that it’s time for me to get off my lazy duff and write that darned book!