I read with some amusement the debates in the blogosphere about whether the insulin/obesity hypothesis (as espoused by my friend Gary Taubes) accurately explains the obesity epidemic or whether some other mechanism is at work, like the food reward hypothesis (as promoted by Stephen Guyenet). Although I clearly fall into the Taubes camp on this, I also think there is a lack of real world sensibility in having the debate at all (I think Gary might agree with me on this). So far, as I see it, the whole argument revolves around what causes obesity. While I agree that obesity is a big problem and that there must be some kind of valid explanation for why this epidemic has taken off over a few recent decades, what is missing is recognition that it’s not just about weight. The weight gain is associated with other chronic conditions which are actually the real issue. The current paradigm implies that weight gain is a causal link in the chain that connects to diabetes, cardiovascular disease and a host of other common conditions. I think that weight gain is not, in and of itself, causal. It is another of the conditions that are symptomatic of the underlying cause which is related to carbohydrates in the diet. The fact that you can have thin people develop hypertension, diabetes and heart disease suggests that weight gain is not causal. The fact that you can have obese people with normal cardiometabolic markers and outcomes reinforces this observation. So, when it comes to applying a therapy that is effective in offsetting the harms associated with weight gain (note I said “associated with”, not “caused by”) it is important to address the actual underlying cause. The evidence supporting the highly effective therapeutic use of LCHF diet for these conditions reinforces the idea that dietary carbohydrates are, in fact, the cause. Perhaps we need to add the qualifier, “in susceptible people”. In any case, clinicians who use this approach report remarkable results that go beyond the effectiveness of the usual drug based therapies. It all hinges, of course, on compliance.

The benefits of LCHF actually extend into other realms of pathology that have been hitherto unexplored in terms of a potential dietary cause. I have collected a few anecdotal reports of the kinds of things that continually amaze me when it comes to the benefits of LCHF.

Arthritis

A few years ago, after I had just figured out that a LCHF diet had fixed my own diabetes and metabolic syndrome, I began to speak out about its potential benefits for others. At the time, I was the Regional Director of the Pacific Region of First Nations and Inuit Health Branch of Health Canada. I was asked to speak at an annual meeting of the nurses who worked in rural and remote First Nations communities so I gave a talk about my experiences in reducing carbs and proposed that it might be useful for the management of their diabetic patients. After the meeting ended, I was approached by a nurse who told me a remarkable story. She was caring for a First Nations woman who had severe, debilitating osteoarthritis. The disease was so severe that the woman could not get off a chair without assistance. The woman was overweight so, for whatever reason, the nurses put her on the Atkins diet. After an initial weight loss of a few pounds, the woman relapsed and regained the weight and then tried the diet again. What was remarkable about this was that, as soon as the diet was started the arthritic pain virtually vanished. It returned when the diet was discontinued and vanished again as soon as it was re-started. Clearly this amazing recovery was not associated with weight loss, but rather was directly attributable to the diet. Later, when I met with Dr Eric Westman for the first time, one of the questions I asked was whether he had seen anything like this in his patients. He said he had. I have since heard similar case reports from others who use LCHF diets in their research or clinical practices. So far, I am not aware of a study that has looked at this specific finding but I continue to hear anecdotal stories of this kind of benefit from LCHF.

Milroy’s Syndrome

When we did the trial in Alert Bay, one of the subjects was a man who suffered from Milroy’s syndrome. This is a rare condition where the lymph system malfunctions and fluid accumulates, usually in the lower limbs. The only treatments are mechanical massaging to force the fluid out and the use of devices such as support hose to minimize the accumulation of fluid. In this man’s case, the condition had progressed to the point where he didn’t want to be seen in shorts because of the disfiguring swelling of this legs. After a few months on the LCHF study diet, his condition had almost completely resolved.

Hemochromatosis

Recently, I was contacted by a physician who has implemented a successful diet program in the small village in which he practices. We have been collaborating in an effort to ensure that the considerable weight loss achievements of his patients is sustainable over the long haul by re-introducing fats into their diets once they reach their weight loss targets. He has more recently been starting people on a LCHF diet at the outset. He contacted me to share the details of a woman who he was treating for hemochromatosis. This is a pathological condition where the body has excess iron stores. Left unchecked it can damage major organs and leads to other serious diseases including diabetes, cirrhosis, cardiomyopathy and arthritis. The most effective treatment is phlebotomy, ie blood letting. The woman he was treating was in constant pain and needed phlebotomy every 2 to 4 weeks. After she started the Atkins diet, she went into remission. The pain went away and she no longer needed phlebotomy. She relapsed on the diet and the pain and hemochromatosis returned. After some more phlebotomies, she re-started the diet and has been symptom free and has required no phlebotomies now for the past eight months.

Crohn’s Disease

I received a recent update from another successful diet project that I have been assisting in another small community. The results are pretty good for weight loss but, again, the most remarkable story is about a different condition. In this case it is Crohn’s disease. This is a very debilitating inflammatory condition of the bowel that makes life miserable for the sufferer and which is treated with a variety of drug and surgical interventions. There is no cure. A woman who had suffered from Crohn’s for twelve years went into complete remission after switching to a LCHF diet. Her symptoms completely resolved and her most recent endoscopy found no signs of the disease. She apparently cried upon hearing those results. I can understand why.

Obviously these are just case reports and more research would be needed to verify that these and possibly other conditions can be treated or cured by switching to a LCHF diet and to rule out other possible confounding factors. For the time being, however, those who suffer from these conditions should be encouraged to try the diet. As we now know, there is no downside and the potential upside could be seriously life-altering.

LCHF is about so much more than just weight loss. Eventually the research will be done to explore these other benefits. In the meantime, these squabbles about the various arcane explanations for weight gain that overlook both the well-documented and the anecdotal accounts of the other benefits of LCHF are seriously missing the mark. The proof is in the LCHF pudding, IMHO. And, as you can see from the photos of what I eat in earlier posts, you would have to agree that there is no shortage of “food reward” in the LCHF diet that I follow.

When I attended the big scientific conference on Pre-Diabetes and Metabolic Syndrome in Barcelona in 2007 (I have blogged about my clash with Dr Frank Sacks there previously), the program included a lecture by Dr Jesse Roth, a gentlemanly old professor, who had an impressive resume including significant work at the senior level of the National Institutes of Diabetes and Digestive and Kidney Diseases. He spoke about which came first, insulin resistance or hyperinsulinemia. In the course of his lecture, I thought I detected somebody who might be sympathetic to my interest in LCHF diets so at the end I approached him and asked whether the development of insulin resistance might be the cell’s defence against too much intracellular glucose. He responded, quite unequivocally, that the cell didn’t want to burn glucose but did so only because the body had to get rid of it. As often happens in these settings, somebody else intercepted him with another question before I had a chance to follow-up. Nevertheless, his comment got me thinking about one of the principle arguments that we hear in defence of dietary carbohydrates, that glucose is the preferred fuel of the cells in our body. This idea is often used to justify a diet high in carbs, even among people who have carbohydrate resistance.

It is true, when you present a range of fuels to the cells, glucose, fatty acids, protein, mainly, the cells will burn glucose first. From this we deduce that they do that because they prefer glucose. What if the opposite were true; that they burn it because they don’t like it and must dispose of it as quickly as possible?

Consider that, if you have a normal blood sugar, you have about a teaspoon of glucose in your blood. It’s not that much when you think about it. Your body likes to keep it in that range and will go to extremes to make that happen. If your blood sugar drops too low, you are at risk of impaired brain function, loss of consciousness and possibly death. This is what sometimes happens to type 1 diabetics who take too much insulin for the amount of carbs they have eaten. If you have a normal metabolism, your body has methods available to ensure this does not happen. If your blood sugar drops too low, you will release glucose from your glycogen stores and, if you deprive yourself of dietary sources of glucose, over time your liver will kick in with gluconeogenesis to convert protein to glucose.

On the other hand, if your blood sugar gets too high, your body goes to work to correct this problem, too. Consider that if you have an excess of as little as a half a teaspoon of glucose in your blood, over time that will cause serious harm. This is what happens in uncontrolled diabetes. Think of that for a moment – as little as a half a teaspoon of excess glucose will harm you over time. Does that not suggest that glucose is a toxic substance? Well your body thinks so because it goes to extraordinary lengths to keep your blood sugar in the normal range.

The primary agent that the body uses for this purpose is insulin. I am sure most are familiar with the idea that insulin is needed to let glucose into the cells so it can be burned. This is one way of disposing of excess glucose. It turns out that insulin has other ways to attack this problem, too. In the presence of high blood sugar and high insulin levels, the liver will turn glucose into fat. And, at the surface of the fat cells, when insulin levels are high, the fat that travels in the bloodstream in the form of triglycerides, is pushed into the fat cells and kept there. All this makes sense when you consider that it is done to keep glucose levels down in the normal range. It is pushed into the cells to be burned, it is turned into fat which is pushed into the fat cells where it can be kept out of the way so as not to interfere with the primary goal of burning off the glucose as quickly as possible.

Think again of that normal amount of blood glucose – one teaspoon. And consider what happens when you eat a typical high-carb meal. Let’s say you have a nice pasta dinner like the ones I used to enjoy in an earlier life. A big plate of pasta represents a lot of starch, all of which gets digested and absorbed as glucose. Add a nice foccacia bread which is also a starch. And for dessert, let’s have a big piece of apple pie a la mode (I used to make excellent pies). The crust of the pie and the sugar in the fruit and ice-cream all contribute to the flow of glucose from the gut into your blood stream. Ah, what the heck, let’s finish with a nice cup of coffee sweetened with a couple ounces of Bailey’s. Sounds pretty yummy, right? I used to eat like this all the time, right up to the point where I got type 2 diabetes.

Consider what is going on at the metabolic level when you eat a high-carb meal like that. Think of the amount of starch and sugar you have eaten which is quickly digested and flows into your blood in the form of glucose. There are many teaspoons of glucose in that meal. What you have done is you have created a metabolic emergency. Your body is desperate to keep your blood glucose in the normal range while your bloodstream is being flooded with glucose from that meal. You can imagine the work that insulin must do, and in fairly short order, to control this flood of glucose and to protect you from its toxic effects. It is no wonder that our metabolic systems break down as we continue to eat this way over the course of years, with the development of insulin resistance, hyperinsulinemia and, eventually, for a lot of us, type 2 diabetes.

Now, consider the possibility that we weren’t meant to burn glucose at all as a primary fuel. Consider the possibility that fat was meant to be our primary fuel. In my current state of dietary practice, I am burning fat as my main source of energy. My liver is converting some of it to ketones which are needed to fuel the majority of my brain cells. A small fraction of the brain cells, around 15%, need glucose along with a few other tissues like the renal cortex, the lens of the eye, red blood cells and sperm.Their needs are met by glucose that my liver produces from proteins. The rest of my energy needs are met with fatty acids and these come from the fats I eat.

If you have seen my earlier posts on physical stamina, you will know that I believe my exercise capacity is certainly much better now than it ever was when I was eating a high-carb diet and depending on glucose for my fuel. There is evidence that the brain, when burning ketones, is more efficient than when it is burning glucose. Less oxygen is needed to produce ATP, the energy molecule, when burning ketones. It also appears that when burning fats and ketones, the problem of excess oxidative stress is resolved. Oxidative stress is being implicated in a host of pathological conditions and may very well be the common factor that explains why serious diseases like cancer, heart disease and diabetes are linked. I also know that my inflammatory markers are very low on a low-carb high-fat diet. We know that there is an inflammatory underpinning to chronic diseases of all types. The inflammation and oxidative stress problems are linked and there is a bit of a chicken and egg issue there in terms of which causes which. It is somewhat moot, however, when it comes to a LCHF diet since both are profoundly reduced.

Another way to look at the question of whether fat is the preferred fuel is to ask yourself, in what form does the body store fuel? We store some glucose in the muscle and liver in the form of glycogen. This is available in times of acute stress as a fast source of emergency fuel but it doesn’t last very long. Our glycogen stores are quickly depleted. The long term storage form of fuel is fat. We store both the fats we eat and the carbs that our liver converts to fat in our adipose tissue. When we need to access that fuel, we release it as fatty acids and burn it as such. We don’t convert it into glucose. This implies to me that the body prefers fat over glucose.

If you accept that we were meant to eat primarily fat rather than carbs, then the question arises as to whether different types of fat are better than others. We have long been admonished about the dangers of saturated fat because of the purported causal link to heart disease. Saturated fats are those that tend to remain solid at room temperature. Butter, coconut oil, bacon fat, lard and the fats on meat are examples of fats that have high proportions of saturated fatty acids. Recently, however, the evidence that supported this idea has been under attack and there is newer  and more convincing research showing that, not only does dietary saturated fat not cause heart disease in general, certainly in the context of a low-carb diet it may actually improve your cardio-metabolic risk profile. At the same time, meta-analyses of research on fat consumption and obesity rates are confirming that fat in the diet is not the cause of excess body fat.

On the other hand, the vegetable oils that we have been encouraged to eat in place of saturated fats, are being implicated in the rise in chronic disease. Remember that inflammation is an important underpinning of chronic diseases of all types. It turns out that the vegetable oils that have become ubiquitous are very rich in omega-6 fatty acids and these are implicated in the promotion of inflammation (this is why you are advised to avoid most vegetable oils with the exception of olive oil and canola which are relatively low in omega-6). So, it is important to consider which fats and oils you are eating after all but not in the way most people think.

One last piece of this puzzle fell into place for me when I collaborated with my friend and colleague, Dr Steve Phinney , to study a popular west coast traditional food, oolichan grease. The west coast First Nations people ate a traditional diet that was high in fat and low in carbs. An important part of this diet was a unique marine oil. They have been harvesting the oolichan fish and rendering and eating its fat for centuries, if not millennia. It is a big deal. In modern times there is a lot of work involved so in the old days, before there were powered boats, modern nets and other technologies, the oolichan harvest represented a huge undertaking. Whole villages moved to the oolichan camps along the rivers in which the fish would spawn and they would stay there for months catching and processing the fish. When the oil was extracted it was stored in water-tight bent-wood cedar boxes and was remarkably durable. It was highly valued as a staple food and was traded inland to populations who didn’t have access to the fishery. “Grease trails” were established through the coastal mountains for this purpose and there are accounts from early explorers who reported seeing whole villages trekking inland with everyone carrying boxes of grease to trade.

The question that intrigued us was why did they go to all that effort to render the fat from that particular fish when there were other abundant sources of fat available in this environment? There were sea mammals like whales, seals and sea lions. There were land mammals like moose, deer, elk and mountain goat. There were other fatty fish like salmon, herring and halibut. Yet, for some reason, going back into ancient times these people went to great lengths to extract the oil from that one particular little fish.

We think we got the answer when we had the grease analyzed in the Minnesota lab of our friend and colleague Dr Doug Bibus.  It turns out that the fatty acid profile of the oolichan grease is remarkably similar to that of human fat. That is at once a startling and revelatory discovery. If the body’s preferred fuel is fat, then it stands to reason that when the body stores fat it would do so with the fatty acid profile it prefers to burn. It follows then, that if you are burning fat from your diet, the preferred dietary fat would be the one that has a similar fatty acid profile to the one you store. These ancient people figured out that the fat from the oolichan fish was the most preferred fat from all the choices they had in their environment. And, they did this without the use of a gas chromatograph! This is a wonderful story of ancient dietary wisdom that helps advance our understanding of current dietary science. The coastal people figured out that their low-carb traditional diet was highly sustainable when they ate the fat that most resembled their body fat. This strikes me as an important clue to the puzzle of how to sustain a modern LCHF diet.

After we completed our study of oolichan grease which resulted in the publication of a scientific paper, Dr Phinney concocted a faux oolichan grease for his own use. He mixes one part butter, two parts olive oil and one part canola oil to approximate the fatty acid profile of the real oolichan grease. He stores this in his fridge and uses it for all his cooking needs.

The key to sustaining a LCHF diet is in the fats. You need to get comfortable with fat consumption in general and saturated fats in particular and you need to avoid the high omega-6 oils.

We were meant to burn diesel, not gas.

Phinney SD, Wortman JA, Bibus D. Oolichan grease: a unique marine lipid and dietary staple of the north Pacific coast. Lipids. 2009 Jan;44(1):47-51

Recently, the Globe and Mail online edition published an article with this headline:

“Just cut calories – protein/carb/fat ratio doesn’t matter: study”.

The article led with this:

“There’s no shortage of diet plans promising to melt away the pounds by calling for strict proportions of protein, carbohydrate and fat.

But, according to a new study, it doesn’t matter where the calories come from. What matters most for shedding body fat is simply eating fewer calories – and sticking to your plan, be it high protein, low carb or low fat.”

Okay, that gets my attention and you can understand why. It flies in the face of everything I have learned about low-carb dieting since my epiphany over nine years ago. So, what was this new study and how did it arrive at this remarkable conclusion? The article goes on to say:

“Some, but not all, studies have demonstrated that high protein, low carbohydrate diets work better than others at losing fat and preserving muscle mass over the short term.”

Oops! The studies I am familiar with looked at high fat, low carbohydrate diets and yes, they are better at causing fat loss and preserving muscle mass. But, let’s let the author, Leslie Beck, the G&M nutritional writer, make her point:

“Participants were assigned to one of four diets: 1) low fat (20 per cent daily calories), average protein (15 per cent); 2) low fat (20 per cent), high protein (25 per cent); 3) high fat (40 per cent), average protein (15 per cent); or 4) high fat (40 per cent), high protein (25 per cent).”

Okay, right away we have a bit of a problem. The range of carbs goes from 65% to 35%, from fairly high to not terribly low in terms of the kind of diet others have studied and to which people like me adhere. On the other hand, if there were to be a benefit from carb restriction, one would expect to see at least some signs of it within this range. Let’s not be too deterred just yet. Leslie goes on:

“Each diet was low in saturated fat and cholesterol and high in fibre, included low glycemic carbohydrates and was designed to cut 750 calories a day. All participants were offered group and individual counselling sessions over two years.

Body fat and muscle mass was measured using CT (computed tomography) scanning after six months and two years of follow up.

At the six-month mark, participants had lost, on average, more than nine pounds of total body fat along with five pounds of lean muscle, but had regained some of this after two years. Fat loss or muscle loss did not differ between the four diet groups.”

Whoa! Look at that muscle loss. That’s not good. How in the heck did that happen?

“As well, the proportion of protein, carbohydrate or fat in the diet did not affect the amount of abdominal fat, visceral fat or liver fat that was lost during the study. After six months, participants shed about 40 per cent of visceral fat and 60 per cent of liver fat.

At the two-year follow-up, people were able to maintain a weight loss of more [than] nine pounds, including three pounds of abdominal fat.

The bottom line: The major factor for weight loss was adherence to a calorie-reduced diet, not the proportion of carbohydrate, protein or fat it contained. People who followed their diets better lost more weight and body fat than those who didn’t.”

Well. That’s pretty clear, isn’t it? How can you argue for any exceptional benefits for a carb-restricted diet in the face of such conclusive evidence to the contrary? All you need to do is reduce calories and, macronutrient proportions be damned, just stick to it and you will do as well as the next guy (or gal). Isn’t that what everyone has been saying all along? Now that it has been well and truly confirmed we can fold our low-carb tent and go home. This is clearly the position that Leslie takes in her article which, I am sure, has the defenders of the status quo dancing with glee everywhere.

So, why haven’t we seen the magic reduction in obesity rates one would expect with this prescription being so simple and clear and all?

Maybe we should have a closer look. The first thing we discover is that this “new” study is anything but. This is a recently published paper generated from data collected between October 2004 and December 2007. Those data are over four years old and the principle article from this study was published in the New England Journal of Medicine in February 2009, exactly three years ago. In that report we learned that the weight loss was the same regardless of the dietary macronutrient pattern. This more recent paper goes into the findings with respect to which fat depots were affected, ie liver, visceral or subcutaneous. Okay, fair enough, there is more to discuss than the simple weight loss and metabolic marker values of the first paper. This is done all the time. One dataset can lead to a number of publications over a period of years. The main point, though, is not new. It was published three years ago at which time Leslie did a similar article extolling the virtues of simple calorie restriction. Why the need to make the same point again now from the same dataset? Hmmm? Good question. Feeling a little defensive, are we? A little bit under siege, perhaps? Interestingly, although the recent Nature article condemning sugar, by Robert Lustig, got oodles of media coverage, not a mention was made of it in the G&M. I digress.

We still have the problem of the results themselves. How is it that fairly large variations in macronutrient content seem to have no effect on weight loss and other important factors? Let’s dig a little deeper, shall we?

Whenever a diet study is reported in the lay media, I always dig up the original article to see what actually happened. In this case, I did that back in 2009 and I did it again here. What I found is quite disturbing and can perhaps give some insight into why there is so much confusion about what might be the ideal dietary choice for weight loss.

The crux of the problem, as I see it, is the use of an “intention to treat” analysis. What this means is that the researchers design a trial where different subjects are assigned different treatments, in this case, different dietary patterns. During the course of the trial some subjects drop out for various reasons and others fail to comply with the study protocol to which they are assigned. That is not surprising, it happens all the time. The problem is that the prevailing wisdom, in terms of the best way to analyze a dataset that is messy because of these issues, is that everyone’s results at the end of the trial are analyzed as though they hadn’t dropped out and as though they had stuck to their assigned protocol. This kind of study with this kind of analysis is called an “effectiveness” trial.

There is a valid reason for doing this. If you want to find out how effective an intervention might be in the real world you have to factor in whether people will comply with it. You may discover the cure for cancer but it would turn out to be useless if nobody could comply with it. This is important information to know.

Problems with this approach arise, however, when efficaciousness conclusions are drawn from these types of effectiveness findings.  In the vernacular there is no difference between “efficaciousness” and “effectiveness”. However, in the scientific world there is a very important distinction. If I want to know if a drug or diet is efficacious, I need to apply it to somebody and observe what happens when they comply with taking the drug or following the diet. That is a very different approach than trying to figure out how well therapies might work at the population level. In a study of efficaciousness, one is measuring one thing: the biological effect of the intervention. In an effectiveness study, on the other hand, one is measuring the biological effect plus the mitigating factors of attrition and compliance. In an effectiveness study where the intervention is very potent but where compliance is poor, after an intention to treat analysis has been applied the results will indicate that the intervention was not particularly useful. This is exactly what happened with this diet trial.

In the most recent paper (but not so much in the earlier one, which is interesting in itself), the authors admit that by the 6 month point their subjects were not fully compliant with their prescribed diets. Here’s how they characterized that:

“Differences between macronutrient amounts at 6 mo were all in the directions predicted on the basis of macronutrient assignments, although target intakes were not fully achieved.”

In other words, people had only partly complied with the diets they had been prescribed. It gets worse at 24 months, however. By the end of the study the only difference between any of the groups was in the fat consumption between the highest and lowest assigned groups. And how big was that difference? About a teaspoon of fat per day!

Let me emphasize that. By the end of the study, everybody still in the study was eating exactly the same thing except for two groups whose only difference amounted to about as much fat as you would get from eating a single bite of cheddar cheese.

Hmmm. That’s disappointing, right? The researchers invested a lot of time, money and effort in conducting this study to find out whether different proportions of macronutrients would generate different results and their subjects didn’t comply with the diets they were prescribed. That’s a pretty big fail (as my eleven year old son would say). When things go so completely off the rails, how can one draw any meaningful conclusions? Common sense would suggest that you can’t. Ah, but we don’t rely on common sense when doing nutritional studies, you see. We rely on an intention to treat analysis. This allows the researchers to publish their results as though everyone did comply with their diets and draw conclusions about the merits of the prescribed diets even though nobody complied with those diets. Wow, that’s amazing, isn’t it? Talk about your Hail Mary Pass!

Of course, knowing this, why would you be surprised to learn that the results were the same for each of the diet groups? You wouldn’t. But, when the paper is published the authors still make claims about the efficaciousness of the different diets.

In the 2009 paper, the authors conclude:

“Reduced calorie diets result in clinically meaningful weight loss regardless of which macronutrients they emphasize.”

And in the more recent paper, the authors conclude:

“Participants lost more fat than lean mass after consumption of all diets, with no differences in changes in body composition, abdominal fat, or hepatic fat between assigned macronutrient amounts.”

Duh! They all ate the same thing. Why would you expect any differences? Oops, I let common sense intrude again, forgive me.

The authors of the 2009 study comment on compliance thusly:

“Despite the intensive behavioral counseling in our study, participants had difficulty achieving the goals for macronutrient intake of their assigned group.”

And:

“In addition, trials of low-carbohydrate diets have reported a very low incidence of urinary ketosis after 6 months suggesting it is futile to sustain a low intake of carbohydrates.”

As I have blogged earlier on the altercation I had with Dr Frank Sacks, lead author on this study, at the Metabolic Syndrome meeting in Barcelona in the spring of 2007, I won’t go into great detail here. Suffice to say that after he presented some data on the merits of high protein, I suggested it may actually have been reduced carb that generated the benefits. This provoked him to respond was an angry rant about how low-carb had no scientific merit whatsoever. Of course, he was still in the midst of running this study in which he purports to investigate the merits of carb-restricted diets. Am I the only one who senses a bias here that might have crept into the way the study was conducted? Naw, that couldn’t happen in the pristine world of nutritional research.

When I hear this nonsense about the inability of anyone to sustain a low-carb diet over the long haul, I think about how we approached smoking cessation. We knew that compliance rates with the various approaches to smoking cessation were poor. However, we also knew that it was the best approach for the prevention of tobacco-related illness and consequently, a great deal of effort was directed at addressing the compliance issues. Had we assumed the posture of current researchers who dismiss a low-carb diet as too difficult to sustain, we would never have achieved any success in diminishing the harm of tobacco. Fortunately, we have the data from case reports and from high-compliance studies by researchers like Jeff Volek and Eric Westman, which tell us that carbohydrate restriction is the best therapy for obesity, metabolic syndrome and type 2 diabetes.

We should really be focusing on the compliance issues at this point instead of constantly trying to defend against the smoke screen thrown up by biased researchers and their poorly done studies and a lazy media that is only too happy to report their misconstrued results as fact. A pox on all their houses!

Dr Richard Feinman has posted a commentary on the important work done by Jeff Volek’s group at UConn in which the respective roles of dietary saturated fats and carbohydrates has been elucidated. If you are harbouring any doubts about the safety of eating saturated fats while restricting carbs I encourage you to read his discussion of this important research:

http://rdfeinman.wordpress.com/2012/02/22/saturated-fat-on-your-plate-or-in-your-blood/

For Valentine’s Day, my wife gets treated to her favourite meal – Salad Nicoise. It is made with green beans and red onion tossed in olive oil and salt and roasted in the oven, kalamata olives, capers, hard boiled eggs, roma tomatoes, and fresh Ahi tuna seared on the grill. The dressing is olive oil, crushed garlic, Dijon mustard, lemon juice, coarse pepper and salt.  Accompanied with a dry sparkling rosé. Yum!

If you have been following the saga of my attempts to have comments posted at the Huffington Post, I have an update.

Dr Robert Lustig recently published an article in Nature in which he argued that we need to take drastic measures to reduce the consumption of sugar. His is a well-reasoned argument based on evidence that sugar, and the fructose component in particular, is uniquely harmful. Remember that all sugar is 50% fructose and 50% glucose. High Fructose Corn Syrup (HFCS) tends to have a bit more fructose because this is the molecule that delivers the most sweetness. HFCS is typically 55% fructose and 45% glucose. In terms of effect, both sugar and HFCS are the major sources of fructose in our diet and have been increasing in consumption over the decades during which we have been experiencing the twin epidemics of obesity and type 2 diabetes. There is physiological evidence that fructose consumption can be implicated in a number of conditions including insulin resistance, fatty liver, gout and hypertension. Lustig’s article has generated the predictable backlash from the vested interests in the agri-food sector whose bottom lines would be severely affected if people stopped eating all the useless crap they produce and which fills the centre aisles of the supermarket.

Meanwhile, over at HuffPo, Dr David Katz has weighed in with an article entitled, “Sugar, On a Slippery Slope” (http://www.huffingtonpost.com/david-katz-md/sugar-regulation_b_1255695.html), where his basic argument is that the poison is in the dose. He says that it isn’t sugar per se that is a problem but rather that people eat too many calories of which some are sugar. He goes on to vilify diets that exclude the “nutrients du jour”, an obvious dig at low-carb diets.

Here are his own words:

There is no question that excess sugar is one of the great liabilities of the modern diet, and consequently, one of the great liabilities of public health. Excess sugar intake is implicated in everything from obesity to diabetes to coronary artery disease. Because excess consumption of sugar induces hormonal imbalances — notably high levels of insulin — which in turn foster inflammation, excess sugar intake is linked to cancer risk as well. Finding effective ways to reduce ambient sugar intake is not only warranted, but rather urgent — as we confront epidemics of obesity, diabetes and associated chronic diseases.

Wow! That’s pretty damning. I guess he is on our side after all. How can you not be in favour of harsh measures to constrain the consumption of something so obviously toxic to the human body?

Here’s how:

Regulating nutrients, per se, is a slippery slope. If we regulate sugar, we should certainly regulate trans fat — which is far less important to palatability, and more toxic in smaller quantities.

And:

And if so, what about the real culprit in much of what most ails modern public health: calories? The root cause of most diabetes and much other chronic disease is obesity, and the most indelible link between weight and food is not composition, but quantity. If sugar is poison because of the harms of excess, so too — and then some! — for calories. Shall we regulate the quantity of food people eat?

This is a classic reductio ad absurdum argument. In addition, it is based on the faulty studies that tested low-carb diets against other macronutrient variations which concluded that they all delivered the same benefit, or rather, lack of benefit (I will post another discussion on some recent examples of this soon).

And this:

We have decades of dietary debacles to show we are unlikely to get to health one nutrient at a time. It is past time to start thinking about the overall nutritional quality of foods, and diet — which are what truly matter to health outcomes. Sugar is an important component of this, to be sure — but only a component.

And he concludes with this:

We eat too much sugar; doing so conspires against our health, and needs to change. The ends are clear, the best means are less so. I worry that some good intentions could bog us down in conflict that forestalls all progress, distort the relative importance of just one nutrient relative to overall nutrition, and land us on a slippery slope headed toward unintended consequences. The sweet spot will be defined by what works in the real world to improve the quality of prevailing diets, and health.

Now, when I first read this, it immediately occurred to me that the whole piece could have been written by the PR people at Coca-Cola. It so nicely dovetails with the kind of smokescreen they and other sugar-dependent companies send up whenever some science has shed light on the harms of their principle ingredient and profit centre. It’s all very reminiscent of the tactics used by the tobacco industry when their products first came under attack.

In the past, I have had my differences with Dr Katz and have been frustrated at times when my reasoned but pointed comments on his articles are censored (see Ornish Filter posts below). It has always struck me as odd, however, that a fellow MD, knowledgeable about nutrition and chronic disease, Director, no less, of the Yale Prevention Research Center, could be so stubbornly averse to acknowledging the now obvious benefits of dietary carbohydrate restriction. Well today, I think I got my answer. Here is a comment from TinaFxyz that did make it past the censors:

One has to question Dr. Katz’s motives. His “Turn The Tide” foundation­’s lead sponsor is Hershey Foods. Is it a surprise that he doesn’t want any restrictio­ns on sweets?

He supports the convention­al wisdom regarding obesity. From his “Turn The Tide” website: “Obesity is fundamenta­lly simple. We gain weight when too many calories in exceed too few calories out”. Without going into all of the reasons why this is wrong (read Taubes and Lustig, each of whom obliterate this false hypothesis­), this message absolves Katz’s corporate benefactor­s, which is why they give him money to spout this nonsense.

What he is saying is that candy, soft drinks, fruit juice, refined grains, and other processed and carbo-load­ed foods aren’t the problem – obese people are the problem because they eat too much of it and don’t exercise enough. Katz surely knows that if people ate fish, meat, eggs, olive oil and butter, cheese, leafy and non-starch­y vegetables­, they could eat as much as they want and maintain a healthy weight. But I guess its more lucrative to take money from candy companies (Hershey), cereal manufactur­ers (Nature’s Path, Quaker Oats), diet pill and supplement manufactur­ers (Natural Factors, Juice Plus+, Nutrition 21), soybean processors (Central Soya Company) and processed food distributo­rs (Topco Inc.).

All of those companies listed above are sponsors for his research groups and various business activities – I found all of this informatio­n from the links that Dr. Katz himself provided in his article.

Kaboom! Well, there it is for all to see. Is this guy going to take a public position that is fundamentally against the interests of the corporations that fund his work?

There is a well known concept in the business and academic world known as “conflict of interest”. There is also a lesser known concept in the philosophy of art world known as “corruption of consciousness”. I think they both have relevance here.

I wonder how long TinaFxyz will continue to have her comments published on HuffPo.

Issy continues to thrive on her LCHF baby diet, although what she eats doesn’t really resemble baby food anymore. She pretty much eats what we eat. For instance, she loves a good steak. I have to prepare an extra serving for her now. And, she loves to have a drink of red wine with her steak, or she would if we let her. She’s definitely Daddy’s little girl.

Here she is skiing the men’s downhill race course at Whistler:

This is my favourite run at Whistler. It goes from the very top of the mountain to the very bottom. It is a vertical drop of a mile and the run itself is 7 km long. I love to ski it non-stop. It is my favourite way to end a day of skiing. I finally got around to timing myself.

Have a look and do the math!

To put this in context, there was a race of the same distance but on a different route running that same day. I noticed that Rob Boyd, a famous Canadian world class downhill racer in his younger years, did it in 5:22 minutes. Of course he had to ski through gates but he also didn’t have to dodge other skiers, he had proper racing gear and he is 16 years younger than me (http://www.skimuseum.ca/biodata.php?lang=en&id=58).

My motive for sharing this with you is not purely for reasons of braggadocio. I know I couldn’t have performed like this 10 years ago when I was eating a typical high carb diet. The fact that I can do it now is amazing to me because I am definitely not a jock. I do a little cardio and core workout most days but I certainly am not a gym rat of any sort. I think this speaks to one of the significant benefits of a LCHF diet. It gives you energy, strength and stamina.

I’m thinking I’ll enter that race next year. I’ll let you know how that turns out.

My Swedish colleague, Dr Andreas Eenfeldt, has been doing a lot to promote LCHF both in Sweden and abroad. I have spent time with him at the scientific meetings we both attend. He wrote about my research and My Big Fat Diet in his recent book which has become a best-seller in Sweden and which is being translated into other languages. Unfortunately, I don’t think it is available in English, yet. He also did a video interview with me which is posted on his blog and is also available on YouTube (http://www.youtube.com/watch?v=U4y8-1J_Jqw).

A few years back, I was at a scientific conference on pre-diabetes and metabolic syndrome in Barcelona. As usual in these meetings, everything was oriented towards pharmaceutical interventions with little mention of diet. In fact, the only time diet was referenced in virtually all sessions was when people would say, almost robotically: “caused by a high fat diet”. The prevailing meme was that obesity, pre-diabetes, metabolic syndrome and type 2 diabetes were all “caused by a high fat diet”. Finally, at the end of the meeting there was a panel session on diet which I attended, of course. I blogged about this earlier, but to recap, a couple of very prominent nutritional researchers gave talks about the benefits of higher protein diets while disparaging low-carb diets even though the higher protein was achieved by reducing carbs. When it came time for questions I was first to the microphone and suggested to them that the metabolic benefits they has attributed to high protein were more likely due to the fact that they had also reduced carbohydrates and that they should consider going lower on the carbs to achieve even greater benefits. Well, didn’t I throw the cat amongst the pigeons. First of all, there was a ripple of applause in the audience after my comment. Then one of the prominent researchers (from Harvard!) responded with the most venal diatribe against low-carb diets that you can imagine (I found out later that he was actually conducting a trial comparing low-carb vs conventional diet at the time). It was rather remarkable because the level of debate in these meetings is usually pretty good. Perhaps the applause had motivated him to want to nip this insurrection in the bud. Whatever his reasons, I was stunned at this departure from decorum and decided not to respond in kind. When the session ended, and as I exited the room, I found myself surrounded by other participants who were incensed at his behaviour.  The odd thing was that a majority of them seemed to be young, attractive Norwegian women. This did not displease me, of course, as I basked in their sympathy but I recall thinking there must be something positive going on in the nordic world.

Fast forward to today and there is, indeed, something happening over there. In Sweden, Norway and Finland,  low-carb dieting has seen a remarkable revival. A recent poll in Sweden found that 23% of the population was restricting carbs. One of the consequences of this sudden shift in diet is that the nordic countries are experiencing severe butter shortages (you can learn more about this by visiting Dr Eenfeldt’s blog at www.dietdoctor.com). This is a wonderful development in terms of it being an indication of how completely has been the shift in perceptions of fat and saturated fat. I also hope they resolve it so that people can access the butter they need. In the meantime, however, Norwegians can get a pound of butter by paying $2 million krone ($360,000) for a car:

Source: www.dietdoctor.com

It is interesting to note that the “Ornish Filter” that I blogged about earlier is still alive and well over at the Huffington Post. I have had difficulty getting my comments published on their diet and nutrition articles and this seems to have begun after notorious lipophobe, Dr Dean Ornish, became their health editor. Today there was an article by a regular contributor, Dr David Katz, Director of the Yale Prevention Research Centre, in which he discussed his role as a judge in determining which diets were best for an article in U.S. News and World Report. In case  you haven’t seen this earth-shattering publication, the consensus was that Weight Watchers was the best diet. Other runners-up included the Mediterranean Diet and the DASH diet. Katz goes into a bit of a diatribe about how this is a “ringing endorsement of balanced, sensible approaches to weight control”. He also lauds the Ornish diet which was actually fairly far down the rankings of this little exercise and which, with its extreme fat restriction, could hardly be called balanced and sensible.

Anyway, here is the Katz article if you want to waste 15 minutes of your life that you will never get back:

http://www.huffingtonpost.com/david-katz-md/best-diet_b_1193807.html?ref=healthy-living#comments

The reason I write about it today is that I am still amazed at the blatant censorship they practice to silence those who are articulate in defending an opposing point of view. In the past, my pointed but non-abusive comments have been rejected on more than one occasion. Today was no different. I posted following comment:

“I am not surprised that you and 21 other like-minded people voted for WW and rejected diets that are considered to be “wild distortions of a healthful dietary pattern” (except for your friend Ornish’s wildly distorted diet, of course).

About 150 years ago, when the great minds of the day all believed in the miasma theory of disease, the idea that if doctors washed their hands after dissecting a corpse, fewer of their patients would die of peurperal fever was considered to be “wildly distorted” and was rejected even in the face of mounting evidence in its favour.

Eventually, the current consensus that a carbohydrate restricted diet, high in fat and saturated fat, is a “wild distortion of a healthy dietary pattern” will be recognized as a folly similar to that which drove Semmelweis insane for suggesting that doctors should wash their hands.”

Apparently this comment was deemed to be unpublishable in the Huffington Post. I guess they don’t want to be reminded that being part of the consensus is not a guarantee that you are going to be right. Perhaps they are becoming aware of and are threatened by the growing literature that supports a LCHF diet. Perhaps they think my comments are too dangerous for public consumption. Who knows what they think. What we can learn from this is that even people in high places who have access to a bully pulpit are afraid of the truth when it comes to LCHF, so afraid that they feel they have to silence their critics rather than engage in a debate. I guess I should view this as a good sign. Their edifice is becoming so fragile that it cannot withstand too many more pointed barbs. It will eventually collapse into dust but, for the time being, they will do whatever they can in their efforts to preserve their increasingly discredited paradigm. For my part, I will keep poking. Perhaps a comment or two will make it through the Ornish Filter. If not, I always have my blog.

Update:

I tried to post a comment on the Huffington Post directing people to this blog to see the earlier comment that was censored. Guess what! That comment was censored, too! These guys are really threatened by LCHF. We may be reaching the tipping point. Stock up on butter!