I recently attended the annual scientific meeting on obesity in San Diego put on by The Obesity Society. This is a big gathering where researchers and clinicians gather to discuss all aspects of the science of obesity with one remarkable exception. Over the course of four and a half days, I did not hear the phrase “low-carb diet” cross the lips of a single presenter. I have been going to these meetings for several years now and it is quite clear that the organizers have no desire to look at low-carb research. Even when one of the recent past-presidents has a much anticipated two-year low-carb study published there is not a mention of it in the program. And when he does speak, he gives a totally unremarkable presentation on a different topic. It’s almost as though he is embarrassed for having done a study on low-carb and is happy to put that unfortunate experience behind him. The fact that even though he made several errors that mitigated against the low-carb diet arm, the fact that the low-carb diet results were still better than the low-fat, low-calorie arm probably just increased the embarrassment.

One of the things I find really odd at these meetings is that there are awards sessions every day where various researchers heap accolades on one another for advancing the science while the epidemic continues to rage on uncontrolled. It reminds me of that famous photo of the firemen posing while behind them a house is consumed by fire, or the infamous “Mission Accomplished” banner accompanying George Bush’s premature declaration of victory in Iraq. Making it even more surreal is the fact that a noticeable number of the acclaimed leaders in this global emergency are suffering its consequences themselves. We are not supposed to notice this, much less comment on it, of course. But, in what bizarre alternate universe do we find ourselves, when the experts who are expected to lead us out of this misery cannot make their prescriptions work on themselves? Suffice to say, I’ve yet to see a credible low-carb researcher with a personal weight problem.

I will continue to attend these meetings as there are basic science presentations worth attending and there are sometimes good discussions on specific issues like fructose which are germane to the low-carb field. I will also continue to give them feedback on the need to stop ignoring the low-carb science but I’m not holding my breath.

I spoke at another smaller conference this week in Toronto on vision care. Loss of vision due to poorly managed diabetes is the leading cause of blindness in this country. Considering that a very low-carb diet yields consistently excellent blood sugar control it makes sense that low-carb can have an impact in this area. I was thrilled that my presentation was the “warm-up act” for my good friend Gary Taubes. I gave my usual discourse on why I think we are using the wrong paradigm in our approach to conditions linked to insulin resistance – obesity, metabolic syndrome and type 2 diabetes – and why I think we need to add a low-carb diet to our therapeutic armamentarium.

It is always a pleasure to hear Gary speak. He gave a tour-de-force presentation on the history of the diabetic diet and how it has been influenced over the decades by a small group of prominent scientists whose evidentiary basis for steering diet recommendations was scant at best. Gary, in researching his excellent book, “Good Calories, Bad Calories”, has actually interviewed all the main characters who are still living and has an in-depth historical understanding of how we were so badly misled.

The highlight of that day, however, was lunch where I observed Gary struggling to have a hamburger (bunless of course) prepared to his liking and where we had some great conversation about family, friends, literature and, of course, diet. He has another book coming out soon. It is called, “Why We Get Fat And What To Do About It”, and will be released in December. You can pre-order it now on Amazon.com. This will be a good book for people who found “Good Calories, Bad Calories” challenging and who want practical advice on diet. In the meantime, for those who are seeking guidance on doing a low-carb diet, I highly recommend “The New Atkins for a New You” by my friends Westman, Phinney and Volek.

By law, the US Department of Agriculture must review and update its dietary recommendations for the American public every five years. The most recent report of the Dietary Guidelines Advisory Committee was recently released and can be found here – http://www.cnpp.usda.gov/DGAs2010-DGACReport.htm

As you might expect, there are no big changes. The usual advice to reduce fat, increase grain products, etc etc is proffered.

What is of greater interest, however, is a recently published article that examines the DGAC report and offers a reasoned critique of its recommendations. The paper focusses on the quality of evidence that is used as the basis for the recommendations and what appear to be a lot of conflict and contradictions in that evidence, even though strong recommendations are issued anyway. It makes for interesting reading if you are not already familiar with some of the issues currently being debated. The paper is skillful in highlighting the internal contradictions in the report itself and gives you insight into just how shaky and inconsistent are the foundations for current nutritional advice.

In the face of contradictory evidence: Report of the Dietary Guidelines for Americans Committee by Adele Hite et al.

The paper can be found here: http://www.sciencedirect.com/science/journal/08999007

Here is my favourite part of the DGAC report: “Although adherence to the Dietary Guidelines is low among the US population, evidence is accumulating that selecting diets that comply with Guidelines reduces the risk of chronic disease and promotes health. Ultimately, individuals choose the types and amount of food they eat and the amount of physical activity they perform, but the current environment significantly enhances over-consumption of calories and discourages the expenditure of energy.”

Translation: “We think that people who stop eating the usual crappy American diet and follow our recommendations can improve their health, however, we are still working on the proof but nobody listens to us anyways. Therefore it is their fault they are fat and sick. Oh, and the environment we live in contributes to the problem, as well.”

After about 40 years of trying, if this was the correct prescription for our problems with obesity and chronic disease, you would think there would be, by now, irrefutable evidence that it works. After literally billions of dollars being thrown at this problem, we should be way beyond the “evidence is accumulating” stage of figuring out whether it works or not. That failure, along with a classic “blame the victim” and “blame the environment” approach, is what the DGAC report is founded on. I think Adele and her colleagues were far too polite in their critique. I shall tell her that over a glass of wine at the annual scientific meeting of  The Obesity Society this weekend in San Diego. I suspect that, privately, she may agree.

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!

You may have seen the article in Huffington Post by notorious Atkins-basher, Dr. Dean Ornish. He opens his irrational diatribe with this paragraph:

“A major study was just published in the Annals of Internal Medicine from Harvard. In approximately 85,000 women who were followed for 26 years and 45,000 men who were followed for 20 years, researchers found that all-cause mortality rates were increased in both men and women who were eating a low-carbohydrate Atkins diet based on animal protein.”

At the same site, another low-fat acolyte, Dr David Katz, is eager to pile on with the headline, “The Beef with Atkins”. He gives us a clue as to whether he has any preconceptions with this statement: “Do I think eating a high-meat, low-plant diet increases risk of death and disease? Hell ya!” and goes on to try to explain away the unexplainable.

From all this you might conclude that someone has done a study with a lot of people doing Atkins for a lot of years and that there is now proof that, compared to a control diet, Atkins led to higher death rates. If that’s what you thought, and that’s clearly what Ornish and others of his ilk, would like you to think, you would be completely wrong.

Where to begin. I suppose the first point to make here is that nobody in this study was doing Atkins. The lowest level of carbohydrate consumption reported was in the range of 180 g per day. That doesn’t resemble any version of Atkins that I am aware of.

Maybe, even more importantly, is the nature of the study itself. It is an observational study which means that no intervention was tested. What the researchers did was enlist a large number of people, in this case, nurses and other health professionals, and surveyed them with questionnaires over a period of years. Food recall questionnaires are highly unreliable (to get a sense of just how unreliable they are, have a look at this commentary by Chris Masterjohn – http://blog.cholesterol-and-health.com/2010/09/new-study-shows-that-lying-about-your.html). The reported results appear to be based on data gathered in 1986 and then extrapolated. A single questionnaire is used to try to determine what people ate over the previous year. How accurately can you tell me what you ate over the last month? Last week? You can see why this might be a tad unreliable. Still, I think you will be surprised just how wildly unreliable this kind of data is if you visit Chris Masterjohn’s site. Yet, it is the standard for these kinds of studies.

In this study, the food recall questionnaires considered “plausible” reported caloric intakes ranging from 500 to 3500 kcal per day. How many people get by on 500 kcal per day, do you think? Not too many. So, in the analysis, median or average numbers were chosen which still look, in all groups, to be significantly lower than what any American presently eats. The men reportedly ate about 2000 kcal per day while the women ate between 1600 and 1800. That should make for a pretty slim bunch of typical Americans! Interestingly, these absurd numbers for caloric intake are averaged while the analysis is done to determine the amounts of carbs, proteins, fats, etc in the various deciles. One wonders what would the data have looked like if they averaged the macronutrients and broke the caloric intake into deciles. The first decile would be 500 kcal per day, the next 800 kcal per day, the next 1100 kcal per day, etc etc. Do you see the problem? Of course it would be absurd to think that the first groups in the series could eat so few calories and actually live. That study would never get published. However, when these data are flipped around and the analysis is done the other way to determine macronutrient proportions by decile the study gets published. In what universe does that make any sense?

The next thing you need to know is that observational studies do not tell you anything about what causes what. They are useful for generating hypotheses which can then be tested using intervention trials to see if a hypothesis based on the original observations is valid. The reason that relying on the original observations is fraught with hazard is because, as I said, you cannot draw conclusions about causality, but also because of the high likelihood there will be unaccounted for factors that  explain the observation rather than the variables you hypothesized were responsible.

In this study, they divided the entire study population into deciles based on their reported consumption of carbohydrates. The percentage of calories from carbs ranged from about 37% to about 60% (for comparison, I eat about 5%). They then arranged two other decile groupings based on another comparison which looked at their consumption of animal sourced fats and proteins vs. vegetable sources. They found that the lowest carb group that ate the highest amount from animal sources had 23% higher all-cause mortality compared to those who ate the fewest calories from animal sources. Now you can see why the vegan zealots are very pumped about this and why their leaders are using every opportunity to hitch their anti-Atkins message to these findings, in spite of the fact that the study had nothing whatsoever to do with the Atkins diet or a vegan diet, for that matter.

So, 23% greater chance of dying – that sounds serious. Is it really? Let’s look a bit further. Apart from the problems inherent in determining causality, another issue that arises from the use of observational data of this sort is the size of the observed hazard ratio. Given all the potential problems with this kind of data, one wants to see a hazard ratio which is either below 0.5 or above 2.0. The hazard ratio here was 1.23, which falls significantly short of the mark.

The researchers also did a sensitivity analysis to determine how large a confounding variable they would have to have overlooked in order to void these findings and came up with 20%. In other words, a factor that could affect mortality by 20% would have to have been missed in arriving at these results. That sounds pretty big, right? How could they miss something so big?

Well, consider this. In an earlier study using questionnaires from this same group, it was determined that the use of hormone replacement therapy (HRT) conferred significant protection from cardiovascular disease. The hazard ratio was 0.39, well under the 0.5 point at which you should normally take notice. That sounds pretty good. Where can I sign up for some HRT?

Not so fast! A subsequent study which tested this observation using a large randomized control trial actually found that HRT increased the risk of CVD, by a factor of 1.29 (in a randomized controlled trial, a hazard ratio of 1.29 is considered to be significant). The unaccounted for factors in this case were five times as great as the 20% needed to void the carbohydrate mortality link in the current study. Five times as big and it was still overlooked! This is precisely why one should not draw conclusions from observational data until it is tested through properly designed intervention trials.

Okay, I will grant you that it’s not always possible to do the kinds trials needed to test every observation and that, by default, we may need to rely on the evidence we have in hand from observational studies. If that is the case, then we need to work within some parameters which will improve our chances of being right. In the case of smoking, for instance, the hazard ratios for harm when smokers are compared to non-smokers are north of 10. Remember that you want to see ratios above 2.0 before you get too concerned about observational data. Remember, also that the ratio reported here was 1.23.

Secondly, you want to see other things in the data. For instance, a dose-response effect would be supportive and a lack of it would suggest problems in the data. Dose-response means that as you increase the factor that you think is causing mortality, you want to see the mortality rates rise alongside those increases. In this study, there was no dose-response effect. Although the published study does not provide information for each decile, we can see what happened at the 1st, 5th and 10th decile. The high-vegetable group was actually eating more animal protein and fat and more saturated fat than the high-animal group at the 1st and 5th deciles. Only at the 10th decile are they eating less and, even then, not hugely less (30% vs. 45%).

Okay, while you are trying to get your head around that, consider that the reported hazard ratios for all-cause mortality at the 5th decile still favoured the high-vegetable group, the ones who are eating the most animal protein and fat at this point! Such an inconsistency in the data surely suggests there are other significant factors at work here. How this got by the reviewers and into print is a mystery to me.

What about the high-vegetable low-carbers? First of all, they are hardly low-fat vegans. They were eating about 30% of their calories from animal fat and protein. And, when you look at this group’s all-cause mortality rates, they have a hazard ratio of 0.80, which means 20% less mortality than people eating less animal fat and protein! How does that support the vegan or low-meat or low-fat agendas? It doesn’t. For the men, those who ate 38% of their calories as fat vs those who ate 24% had a 19% reduction in mortality. Let me emphasize that – the people in the high-vegetable group who ate more fat, more animal fat and more animal protein had a lower mortality rate. Why didn’t Ornish’s headline say: “Eating More Meat and Fat Reduces Your Risk of Dying”? This would be just as valid, in fact, more valid than the ridiculous headline suggesting that the diet had anything to do with Atkins and mortality.  This part of the study findings is not mentioned in either of the Huffington Post pieces or in any other mainstream media coverage that I have seen. You have to ask yourself “Why?”.

I could go on but there are other sites you can visit to get more informed criticism. I recommend Chris Masterjohn’s site mentioned above. Also, Denise Menger, a new voice of reason in the diet debates, can be found at http://rawfoodsos.com/ where her deft evisceration of “The China Study” is also worth a read. Another fairly recent and very funny commentator is Tom Naughton at his blog http://www.fathead-movie.com/. I recommend his movie, “Fat Head”, as well. Also, have a look at the usual reliable sources  such as Jimmy Moore’s www.livinlavidalowcarb.com and the Eades at www.proteinpower.com (although I haven’t seen a comment from Mike yet).

So, what can we learn from this? The study is so deeply flawed, it is hard to figure out whether there is anything here of importance. As I said at the beginning, all this type of study can do is generate hypotheses that need further testing. One intriguing hypothesis, of course, is that a higher fat, higher animal protein, lower carb diet high in vegetables seems to confer a better all-cause mortality rate. That would be the one I would like to see pursued. Funny how that sounds eerily similar to the diet recommended in the most recent Atkins book, too. Ornish and Co. are, of course, free to pursue their agenda, too, and I wish them luck. However, it cannot be a happy time for this crowd. As more evidence piles up demonstrating the benefits of low-carb over low-fat, they do seem to be getting more desperate.

I think what we are actually witnessing here is a paradigm in its death throes. This would explain the stunning perfidity of its proponents who appear willing to pull out all the stops in fighting their rear-guard action to save a belief system that is rapidly devolving into shambles. No Geneva convention here, folks. Flat out lies and misrepresentions are justified when defending the faith. And a lazy and, and possibly corrupt, media is all that is needed to keep the lies coming. Stay tuned. I am sure we will see more of the same.

ps – edited to correct error picked up by commenter

Isabelle is one year old now and thriving. She has pretty much stopped breast feeding but still gets a little formula. She gets a varied diet of foods high in protein and fat along with lots of non-starchy vegetables, all of which she eats with gusto. Her breakfasts now are gently scrambled egg with spinach puree, kind of a baby version of eggs florentine. She drinks water, mainly, but still likes to sample our beverages at the dinner table. Apart from some formula, she never gets any liquid sugars as juice or otherwise, something I would recommend to anyone whether they are doing low-carb or not. When she was born she was a tiny bit below the 50th percentile for height and weight. Within a few months she began to climb up the growth chart to the point where she is now at the 95th percentile for both height and weight. She is very active, crawls like a bullet and pulls herself up on the furniture and walks while holding onto things. She took her first unassisted steps these last couple of days. Lots of talking, too, but in a language in which we are not fluent. It is fun to witness the emerging personality. She is definitely a go-getter. When Alex was very young his first vocalizations were little sing-song syllables like “daa-daa-ah”. Isabelle’s are more like the sound of a revving motorcycle, “rrrrrRRRR, rrrrrRRRR, rrrrrRRRR”. She has us in stitches when she does that. At the same time she has a sweetness that melts your heart. One smile and her daddy is reduced to a puddle. She adores her brother and lights up whenever he enters the room. Even the cat gets little hugs and gentle touches now that Isabelle is mobile enough to catch her.

She is certainly not demonstrating any adverse effects from a diet devoid of sugar and starch. Perhaps the most interesting development is her position on the growth curve since Alex, Anne and I are all of average height. I have warned Alex to be very nice to her as she is going to be in a position to kick his butt before long. He is actually a very good big brother, gentle and caring.

The other thing we notice is that Isabelle has never had any rashes or illness except for one bout of a very mild malaise with a slight fever a few months back. No rashes at all. I remember Alex used to get yeast rashes and all the usual respiratory infections. In fact, we all seem to be avoiding these things since we started eating low-carb. In the high-carb past, I always succumbed to one or two major colds every year. Now, when these things are in the community, I might experience a day or two of mild sniffles but nothing more. Same for Anne. The other thing I have noticed is that I never get cold sores anymore, either. I used to get them pretty reliably when I went skiing. The UV light at high altitude seemed to trigger it and I would get a few bouts every winter. Now it happens very rarely and, when it does, the sores are mild and resolve quickly. There is definitely an immune system benefit from low-carb that needs to be further explored in the research.

Similarly, I can’t remember the last time Alex had a cold. I think he missed one day of school last year and none the year before. He is a very sturdy little boy with lots of energy. He is good-natured with never any acting-out or discipline issues, at home or at school. He does well academically and has developed close friendships with other boys his age, all of whom we approve of. There are never any outbursts of temper or whining. Anne and I often talk about how blessed we are in this respect. Physically, he is slender like little boys are supposed to be with good muscle development and definition. His skin glows and his eyes are bright. Anne thinks he will be Hugo Boss model material when he gets older but I suspect all moms think that way. I really think the absence of sugar and highly refined carbs from his diet is a major factor in his robust health and well-being. He eats more carbs than the rest of us but there is no sugar in our household and the carbs he does eat are the less-refined types. For instance, for breakfast he will have a one-egg omelette (because one egg is un oeuf) with a piece of whole wheat toast covered in almond butter. Water is his preferred drink. Our biggest challenge with him is when he is outside our home, of course. Everywhere you go people are pushing sugary things. When he is surrounded by his little buddies who are all indulging, it is hard for him not to indulge, too. At his soccer game yesterday, they handed out cartons of some kind of juice-like abomination during half-time and I noticed he drank some. He felt crappy when he got home and spent the rest of the afternoon lying on the sofa. I don’t think he will do that again.

Okay, I am sure these musings about kids and low-carb are of limited general interest. I will, nevertheless, keep you updated on progress in this modest clinical trial of mine. In the meantime, everyone, and I mean everyone, needs to work together to get the sugar and particularly the liquid sugar out of our kids’ food supply. I challenge anyone to show me a shred of evidence to suggest this is not a good idea.

As you can see I have been AWOL for awhile. It’s obviously time for an update.

The big news is that we have a daughter! Isabelle is almost a year old now and is thriving. She is a low-carb baby. Her mom ate a very low carb diet throughout the pregnancy and since. The only noticeable difference was a complete absence of morning sickness. During the last pregnancy when we were still eating a high carb diet, morning sickness was a big problem. Anne kept food at the bedside and would snack in the wee hours as this seemed to reduce the severity of the morning sickness somewhat. Our cat learned to hang around to snack on the crumbs. Of course, the snacks back then were high carb foods such as muffins and cakes. This time, none of that, just the usual very low carb diet of meats, fish, poultry, dairy and lots of non-starchy vegetables. The other thing we noticed was that there was no excess weight gain.

Isabelle was born at term via a scheduled section (we agonized over this but since a section was needed the first time, and it was truly needed, we opted for it again this time. As one of my OB friends says, “I never regretted doing a section, but there have been times when I have regretted not doing one).

Isabelle weighed 6 lb 15 oz and her Apgars were excellent. She thrived on breast milk alone until that wasn’t enough and then we supplemented with formula and then pureed food which we make ourselves.

It is remarkable to think that she has never been exposed to sugar, in utero or since. The kinds of foods we make for her now consist of pureed meats, non-starchy vegetables and dairy products. For instance, we steam and puree cauliflower with a cheese sauce, or a meat and tomato sauce, or spinach with cream cheese. Unlike her brother, she has an enormous appetite and loves every kind of food we give her. Even things you wouldn’t expect like olives and smoked salmon. She loves it all and eats with gusto. She eats with us in her high chair at the dinner table and will try some of our adult food, too. Yesterday, she ate some small pieces of steak. She loves to chew on pork ribs.

She also likes wine. We generally have a glass of wine with dinner and she will look at the wine glass and then at you and then at the glass, and then back at you until you finally offer her a drink. If you do she will forcefully grab the glass and have a sip. I often drink very dry reds and I wouldn’t expect a child to like the taste but you can tell she does. She never gets more than just a tiny taste but I can tell she would drink more if I were to let her. We also usually have sparkling water at the dinner table and Isabelle loves that, too.

The funny thing is that there was only one instance where she rejected food that was offered to her. I was speaking at a conference in Seattle and Anne and the kids came along as it was on a weekend. I was busy with the meeting so Anne took the kids to a diner for breakfast. The only food they had that she thought was suitable for Isabelle was oatmeal. Isabelle refused to eat it – that’s my girl!

She is at the stage now where she crawls like a little bullet and pulls herself up onto chairs, furniture, your leg, etc. etc. She also has a lot to say. She gives big speeches with lots of pointing and gesturing. We are convinced she is very bright and will be talking early (all parents think this, don’t they?). We, of course, attribute all her exceptional behaviour and development to the fact that she has never been exposed to sugar.

On other fronts, I am just now getting back to work after taking a parental leave (since I am about to turn 60, I figured it was my last opportunity to take advantage of that benefit). I thought I would have time to write and perhaps do a book while on leave but it is amazing how your day fills up with busy work when you have a little child in the house. Juggling the needs of our 10 year old son along with those of an infant daughter kept Anne and me running all day and sometimes through the night.  It was a good for me to be able to spend more time with our son and to help him adjust to having a sibling. Alex and I were able to get about 45 days skiing this winter and, by the end of the season (his seventh!), we were skiing the most challenging double black diamond runs together. Alex has become such a capable skier that he doesn’t hesitate to tackle the steepest runs. He can beat me flat out in the moguls now but I still have the advantage on the groomers; for the time being anyway. We’re pretty evenly matched when it comes to off-piste and this is where we have the most fun, too.

Alex started skiing when he was three but I think Isabelle will start earlier. I look forward to the days when we can all go off-piste together.

Back on the research front, there have been developments. Studies continue to accumulate and not a single one has demonstrated any significant problem with eating a very low carb diet. On the contrary, the studies tend to be consistent in their results in terms of weight loss and improved markers of cardiometabolic risk.  The amount of benefit seems to hinge on two factors: the metabolic status of the subjects and the degree to which they comply with the diet. It is becoming increasingly clear that people who are developing insulin resistance, even in its early stages, derive enormous benefits from carb restriction. Of course, compliance with any diet will deliver results and low-carb is no exception. The interesting thing, I find, though is how these things are analyzed and reported.

The conventional approach in terms of analyzing data from a randomized controlled trial is to use an “intention to treat” analysis. This means that every person who initially signs up for the study will be included in the final analysis whether or not they actually followed the diet to which they were assigned. While this approach is helpful in determining whether a particular intervention will be effective at a population level, it can be confusing if you are trying to determine if the intervention can do what it is supposed to do. This approach is the norm in large drug trials where the efficacy of the drug has already been established through other kinds of trials. However, in dietary trials, this approach can obscure the potential benefits of a diet if there was poor compliance during the study.

Let me illustrate with an example. Assume you are doing a study to determine if seatbelts will protect you in a car crash and the majority of the subjects did not actually wear their belts during the study. Using an intention to treat analysis, you might conclude that there was little value in seat belts when in fact they are very valuable. Unfortunately, this is exactly what is happening in the low-carb literature that gets published in scientific journals and that you often see reported in the mainstream media.

Let me use another analogy – smoking cessation. We know from our understanding of the pathophysiology associated with tobacco use that smoking cessation will deliver an enormous benefit in terms of reduction in cancer and cardiovascular disease. We also know that compliance rates are very low with virtually every type of smoking cessation intervention. Do we, therefore, suggest that there is no value in smoking cessation interventions? Of course not! We direct our attention to the problem of compliance. This is what should be happening with low-carb diet. Instead we continue to see studies like the recent one by Frank Sacks et al (Comparison of Weight-Loss Diets With Different Composition of Fat, Protein, and Carbohydrates, New England Journal of Medicine 2009), which found no difference between low-carb diets and low-fat or mediterranean diets. They had poor compliance and they used an intention to treat analysis and they concluded that all that mattered was calories. One of my colleagues communicated with them asking why they didn’t address the issue of poor compliance and their reply was essentially that they didn’t think people could comply with low-carb.

A more recent study, just published this week, was a much anticipated two year trial of low-carb  vs low-fat in which the weight loss was no different but the low-carb folks had greater improvements in cardiometabolic risk factors (Foster et al, Weight and Metabolic Outcomes After 2 Years on a Low-Carbohydrate Versus Low-Fat Diet, Annals of Internal Medicine 2010). Okay, that’s good, to a certain extent. The interesting, and somewhat troubling thing about this study is that they excluded at the outset anyone with hypertension, dyslipidemia or type 2 diabetes. Well, we know that people with those conditions represent a huge proportion of the people with insulin resistance who happen to be the very people for whom this diet has been shown to deliver the greatest benefit. Looking on the bright side, I guess we can conclude that even after you screen out the people who can benefit most, and even after you do an intention to treat analysis, low carb can still whup low fat.

We know from a small number of good studies now that low-carb diet is an excellent first line therapy for the range of conditions associated with insulin resistance just like smoking cessation is the ideal intervention for the prevention of the harms associated with tobacco. And just as we do with smoking cessation, when it comes to low-carb diet, we need to turn our attention the problem of compliance.

Speaking of compliance, the other recent bright spot is that there is a new Atkins book out. This one is authored by three of the scientists who have been doing some of the best research on low-carb over the years. Drs Steve Phinney, Eric Westman and Jeff Volek are people I consider to be good friends and excellent colleagues. The new book is different from earlier editions in that it contains the scientific references of studies supporting low carb diets. In addition, there is a discussion of important issues related to compliance like the role of fats and the need for salt replacement. I highly recommend this book as I think it offers new and valuable information that should make it easier to follow a low carb diet and to sustain it over the long haul. It is called, “The New Atkins for a New You” and is available at Amazon.com.

Now that I am back into working mode, I shall attempt to be more attentive to this blog. A recent commenter suggested that it be used as a forum for people to share their stories. I am okay with that. The way it is set up now I have to approve each new poster but once you have been approved your subsequent posts automatically go onto the site. I would still have some editorial control in terms of being able to delete inappropriate posts. I would expect people to be respectful and observe the ground rules and I have no doubt this would be the case as I haven’t had a problem of that nature since the inception of the site. It would be my preference not to get into an individual counseling relationship with posters as I am not entirely comfortable with what may be construed as practicing medicine over the internet. I am, after all, a doctor and am bound by the rules and regulations of my licensing body. If this were to become a forum where others shared experiences and advice on how to stick to this diet, I would be happy to continue it in that vein.

I look forward to your comments and feedback.

The documentary is going to be re-broadcast on CBC Newsworld, The Lens, on August 18, 2009. Check your local listings for the times.

I have other news – my wife is pregnant with our second child. She is due at the end of August. It has been a low-carb pregnancy and everything has been fine. Two things seem different from the first pregnancy (nine years ago!) – she didn’t have any morning sickness and she hasn’t gained excess body fat. I will post a note after the delivery.

I plan to take some parental leave and will have more time to devote to this blog. I also am planning to do some writing and, if I can find a publisher, perhaps get a book out on this diet.

I am also in the process of developing a couple more research projects. One in children and the other in adults, both looking at the benefits of low-carb for metabolic syndrome. I am intrigued by recent literature that suggests that it is the fructose component of carbs that may have the most damaging effect when it comes to metabolic syndrome. I am hoping to compare a low-carb approach, which we know works, with a fructose-free diet, to see what are the relative benefits. In the meantime, I have no hesitation telling people, especially with regard to children, to minimize their fructose intake. High fructose corn syrup is an obvious villain, but remember that plain old sugar, in any of its forms, is 50% fructose, too. I think we are heading to a time when there will be recognition that all caloric sweeteners are dangerous to your health. Stay tuned on that one.

Dear readers,

I didn’t provided a direct e-mail address here because I was worried that I would be inundated with e-mail questions rather than posts that could be viewed by others for educational purposes.  

For those who want to contact me directly for other purposes such as invitations to speak, research collaborations, etc., all you have to do is post a comment and indicate in it why you are seeking my e-mail address and I will reply directly to you. If you don’t want your comment posted here, please state that clearly in your note, otherwise I will post it with my reply.

I also want to extend an apology to the other Jay Wortman, the Oracle consultant in Belgium, who has been kind enough to forward me the inquiries that found their way into his inbox.

Dr. Jay

Dear readers,

My Big Fat Diet is going to be shown again on CBC Newsworld’s “The Lens” on January 6, 2009. For broadcast times, check your local listings. 

By way of update, the show won a Silver Chris award at the Columbus Film Festival and was shown at the Native American Film Festival in San Francisco. So far there has not been an American broadcast although a number of dvd copies have been purchased from Mary’s website by Americans (www.mybigfatdiet.net). I expect it is just a matter of time before an American broadcaster picks it up.

Happy New Year to everyone!

Dr. Jay

You can now purchase a dvd copy of MBFD on Mary Bissell’s website – see links section.