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.