Archive for June, 2006
Earlier this week, the American Heart Association updated its dietary guidelines with a number of notable improvements, but one glaring flaw – a recommendation to reduce intake of saturated fat to less than 7% of calories. A number of researchers and scientistist are wondering “where is the evidence?” to support such a recommendation on a population-wide basis.
Today, Dr. Gil Wilshire, shares his thoughts with us in this space in a guest editorial.
ENOUGH IS ENOUGH
Gil Wilshire, MD, FACOG
As I get older and a bit wiser, I have learned to let emotions simmer down a bit before putting thoughts to paper. Restraint of tongue and pen is a true virtue. Suffice it to say that the recent AHA recommendation to further reduce dietary saturated fat consumption has left me angry, dumbfounded, and very frustrated. Now that I have had a chance to absorb this news, I believe I can now calmly formulate an intelligent response.
My thoughts gelled last night as I read the Skeptic column in this month’s Scientific American magazine. The author of this monthly piece, Michael Shermer, quotes Francis Bacon thusly:
The human understanding when it has once adopted an opinion (either as being the received opinion or as being agreeable to itself) draws all things else to support and agree with it. And though there be a greater number and weight of instances to be found on the other side, yet these it either neglects and despises, or else by some distinction sets aside and rejects, in order that by this great and pernicious predetermination the authority of its former conclusions may remain inviolate. (Novum Organum, 1620)
Clearly, what was true in 1620 remains true today. Once people’s minds are made up, they see what they want to see, and they gather information in a selective way.
Low-fat dietary recommendations were born in the late 1950’s out of the work of Ancel Keys. Although we can now see that these studies were fatally flawed by selection bias and confounding variables, the “conclusions,” which were actually inferences, were widely accepted. In the past, this phenomenon of acceptance of an authority opinion was common at this time. Healthcare workers and policy makers were generally unaware of the concept of evidence-based medicine, let alone the rigor of Level 1 evidence; that is prospective, randomized human studies.
Now it is 2006, and the low-fat and cholesterol dietary recommendations of Keys remain essentially unchanged, except for the fact that the extremists are now becoming ever more so. We are now experiencing the full onslaught of what Bacon so aptly described as “pernicious predetermination.”
What I find so alarming and disturbing is the fact that in the past half century NOT ONE SMIDGEN OF LEVEL 1 EVIDENCE HAS BEEN GENERATED TO SUPPORT THESE RECOMMENDATIONS. I don’t know how to say it any louder or clearer.
Virtually everything I do in my medical practice must have rigorous scientific validation before I use it on a patient. Why should public dietary advice be an exception?
My levels of alarm and frustration are very high. If people can convince themselves to drink cyanide-laced Kool-aid, I consider that to be their choice and their problem; but in this analogy, the powers that be want all the rest of us to drink it too! The low-fat proponents consider their position to be so obvious that it does not need any scientific validation. I’m sure they believe their position much the same way when people believed the sun revolves around the earth. It’s just obvious, no?
I now live and work in my newly adopted state of Missouri. They have a great motto around these parts: “Show Me.” Please somebody, anybody, show me a body of Level 1 (or well-done Level 2) evidence that supports low fat and low cholesterol dietary recommendations for the population at large! Show me some high-quality data. Show me that someone has bothered to properly test the 50 year-old hypothesis.
In the absence of this information, I would like to make the following recommendation:
AN IMMEDIATE MORATORIUM ON ALL POPULATION-WIDE DIETARY RECOMMENDATIONS THAT LACK SUPPORT FROM WELL-PERFORMED, PROSPECTIVE, EVIDENCE-BASED HUMAN STUDIES.
Sanity in this field will only come out of a complete overhaul. We need to tear down the current edifice of confusion to its most basic foundations, and rebuild it from the bedrock up.
As a side note, I am not blind to the ramifications of my statements. The thought of six billion or so apex predators (which we are) returning to a diet we evolved to eat is a very scary proposition. The current ravages of the bush meat trade in Africa would be trivial in comparison to the carnage wrought by billions of hunters on a global landscape. It is likely that Homo erectus has caused numerous mass extinctions of prey species in the past from uncontrolled hunting. Numerous animals and large fish are currently undergoing decimation.
I also wish nothing ill upon our grain farmers. I now live in the Heartland, and one would be hard-pressed to find a more honorable and hard-working bunch of people anywhere in the world. I understand the economic implications of a shift back to meat-based protein food sources would be profound.
Nevertheless, if a grain-heavy food pyramid is being promoted because it is in our country’s best economic interests, then just tell me and also communicate this to the American public. I’m actually OK with that. I am willing to put environmental stewardship ahead of my personal interests, just don’t call it good nutrition, evidence-based, a balanced diet or healthful eating and expect me to buy it or promote it to patients with chronic disease.
We are in a health crisis in the United States. Surely, with all of our accumulated knowledge and wisdom, we can find a workable solution that is supported by evidence, is economically feasible and returns our population to good health.
Over the last few days, since posting my challenge, to anyone out in cyber-space, to create a menu within the new 2006 American Heart Association (AHA) Diet & Lifestyle Guidelines and meet all essential nutrients as established by the Institute of Medicine, I’ve received more than a dozen menus. All within the calorie level (1956-calories for a female, age 30, BMI 24.99, light active) and also within the limit of less than 7% saturated fat. Those submitting a menu are finding however, their attempt to meet all essential nutrients is impossible within the restriction of saturated fat.
The AHA remains silent on an individuals ability to follow their guideline. They have not provided the public with a sample menu as a guide, have not detailed what types of foods are required to meet their guideline and have not even offered a single-day menu as proof it can even be done.
For the American public – the target of this new guideline – this should be a wake-up call to demand accountability from the AHA. When an organization, held in high esteem as the AHA is, recommends a particular dietary approach, the public deserves to know what it takes to follow the guideline, what is the scientific basis of the guideline, and what is the real risk, the real potential consequence to health, if one doesn’t follow the guideline.
Without this vital information, the public is left with no real help to modify their diet for the better and is set up for failure.
Without this important information, the public is left helpless to help themselves.
Which begs the question, is that the point?
The AHA has a responsibility to each and every person in the United States when it issues a population-wide dietary recommendation; it has an obligation to detail how to follow the guideline and meet nutritional requirements; it has a duty to provide the public with access to the scientific evidence it analyzed to reach its guideline; and it holds the burden of proof to show the public that their recommendation not only reduces health risks when followed, but leads to improved long-term health outcomes.
At present, the AHA is not providing the public with any useful information to follow their guideline and has not established there is a scientific basis for limit on saturated fat that supports its recommendation on a population-wide basis.
You know what I call that? A population-wide experiement without consent.
The public must start to demand evidence, demand accountability and demand workable solutions to our national health crisis. Don’t leave the AHA the option, in years to come, to opine “if only the public would follow the guidelines…”
It’s time to demand they show us how to follow the guideline, provide a real example of how to eat according to the guideline and meet all nutrient requirements, and provide quality evidence that following it for the rest of our life will reduce risk and improve long-term health outcomes!
An article in EurActiv.com – Obesity debate: personal responsibility needed – caught my attention last week with the opening sentence, “Scientists wish to bring some ‘common sense’ to the debate on obesity: no need to demonise sugar or any other food as a culprit for obesity – the problem remains imbalance of energy intake and consumption.”
Last week EU and US scientists gathered at an event titled “Managing Sweetness” and developed a consensus statement defending the role of sugar in a balanced diet. They argued for bringing personal responsibility back to the core of public health policy and called on the EU and the member states to take the lead in shaping strategies to help individuals learn to manage their diets.
Some background, the Managing Sweetness event is the second one hosted by Oldways Preservation Trust – the first was held in Mexico City, October 21-23, 2004. That conference also led to the creation of and publication of a consensus statement regarding sugars in the diet. Interestingly, the Oldways website has no information about the current conference on their website – nothing, not even the date or location. But with the article above, we know the event took place and that it was hosted again by the Oldways Preservation Trust.
So what are we to make of this new – still unreleased – consensus statement?
We have a good idea of what’s to come – managing weight is all about personal responsibility for consumption of sugars and total calories in the diet. Everything, including sugars, in moderation is just fine and dandy. Don’t ask for a definition of “moderation” – that’s part of the personal responsibility required of anyone taking responsibility for what goes in their mouth.
Which begs the question, how many times are we going down this path before we take a long hard look at the metabolic consequence of excessive carbohydrate in the diet and its direct influence on hunger and appetite?
How much longer are we going to capitulate to the politics that are beneath the surface in this type of consensus statement?
How much longer are we going to appease the food industry and put the financial health of food manufacturers ahead of the health of our adults and our children?
The idea that many “experts” still continue to hold the opinion that it’s just a matter of willpower to simply eat less calories, that if one just takes “personal responsibility” and eats “everything in moderation” they’ll lose weight…well, it just mystifys me how, after decades of this idea making the rounds while at the same time not working for millions of people, we’re still stuck on it.
Of course personal responsibility does come into play – we each choose what we will eat each time we’re hungry. However, the influence a food has on our metabolic response is tied to a number of things – calories, weight of food and beverages consumed, macronutrients in food consumed, micronutrients delivered in food consumed, etc. Basically, once we’ve made a conscious decision about what to eat, our metabolism then takes over and we are no longer consciously “in control” of what happens next. When hunger is triggered a few hours after eating, there is only so long a person can and will ignore the very real, very physical signals the body is sending to urge consumption of more food.
Now the experts, backed by the food industry, are counting on you to eat everything in moderation, even if the very things triggering your hunger are making it difficult to eat less. When you can’t, when your hunger is too intense, it’s your own fault. It’s not the excessive sugars, it’s not the food you’re eating – it’s your fault, your lack of personal responsibility and will power.
Personally, I don’t buy it.
As I said, there is a level of personal responsibility involved, but where is the integrity of these experts to tell you how different foods are affecting your metabolism, affecting your hunger triggers, affecting your level of satiety? Where is their personal responsibility to communicate the science honestly to you, the consumer?
Why do these esteemed professionals not communicate about the satiety value of quality protein? Oh, if they did, you’d consume less calories, less food and may even feel better. But, you’d also be eating less processed food, less added sugars and spending less money on the very foods your body no longer hungers for.
Why do these experts not communicate the various data from studies that finds if you consume less carbohydrate, you’re more likely to spontaneously – without specifically being told to do so – lower calorie intake? Could it be that you’d again be eating less food, less processed foods and less of the very things that trigger your hunger to eat more?
So while the experts are continuing to push this idea of personal responsibility, isn’t it time they took some themselves and told the truth? The truth that what you eat now has a powerful effect on when you’ll be hungry again and what you’ll be likely to choose to eat later?
The first menu received, just hours after posting my $1,000 Challenge, was created by a VP of Nutrition with one of the major online diet sites:
Breakfast: Oatmeal (regular), Walnuts, Skim Milk and Blueberries
Lunch: Turkey breast, Salad Greens, Tomatoes, Broccoli Florets, Olive Oil & Vinegar
Dinner: Red Wine, Baked Salmon, Sweet Potatoes, Carrots, Spinach, Hummus, Cantaloupe
Snacks: Yogurt, Orange, Almonds & Raisins
With 1950-calories and less than 7% saturated fat the above menu met the AHA Diet and Lifestyle Guidelines. However, it failed to meet the DRI for Vitamin D, so I didn’t analyze further for other essential vitamins, minerals, trace elements, EAA or EFA levels.
Please note, I am not including the quantity of food to eat in the menus I’m posting. The reason – the challenge must be fair. Those seeking to prove a menu can be created with less than 7% saturated fat and provide all essential nutrients must do it themself without starting with someone else’s failing menu!
So, the challenge remains open – no menu has been received that meets the new AHA guideline and provides all essential nutrients!
This week, the American Heart Association (AHA) revised it’s 2000 Dietary Guidelines with a new title and updated recommendations. The 2006 American Heart Association Diet and Lifestyle Recommendations include the following major changes:
- including “lifestyle” in the title to emphasis the importance of diet and lifestyle
- minimizing the intake of food and beverages with added sugars;
- emphasizing physical activity and weight control;
- eating a diet rich in vegetables, fruits and whole-grain foods;
- avoiding use of and exposure to tobacco products;
- achieving and maintaining healthy cholesterol, blood pressure and blood glucose levels; and
- further reducing saturated and trans fatty acids in the diet
The media has focused its attention on the stricter limit for trans-fats to less than 1% of total calories in the diet. None in the mainstream media seem to be asking about the new stricter guideline for saturated fat – the new recommendation is to limit saturated fat intake to less than 7% of total calories. And let’s be clear, it’s not 7% or less saturated fat – it’s a very clear recommendation to consume less than 7% of energy from saturated fat. The omission of the little “equal sign” under the “less than” sign makes this a “less than” recommendation, not an “equal to or less than” proposition.
To achive this, one must strictly limit consumption of animal foods and regular dairy. There is no way around it when we consider that every liquid oil provides some saturated fatty acids along with the monounsaturated and polyunsatured fats. Basically, this particular guideline is establishing a population-wide recommendation to move to a vegetarian diet without stating it as such.
What’s very troubling with the recommendation is that there is no clear, convincing evidence that reducing saturated fat intake to less than 7% of daily energy will prevent chronic disease, improve quality of life in the long-term or increase life expectancy.
After pondering how to communicate how the new stricter limit on saturated fat is dangerous, I concluded I could write, write, write and bore you to death with statistics, data and decades of research findings – or – I could get to the point very quickly with some basic, public information and add a simple challenge to readers.
First some basic information:
On average, as the statistics from 1970-2000 highlight, we’ve increased our consumption of carbohydrates – significantly – along with our intake of overall calories; our intake of fat, saturated fat and protein has remained more or less stable. In fact, men actually reduced both fat and saturated fat as percentage of their daily calories and in absolute grams eaten each day.
As a nation, our dietary modifications have made us fatter, more have developed Type II Diabetes, and significantly more are taking one or more prescription drugs each day (in 2000, 44% of the population), and an alarming number require three or more prescription medications each day (in 2000, 17% of the population).
We have to ask, what will happen if we do manage to convince the population to reduce saturated fat even more?
Based on studies that have investigated the role of saturated fats in our metabolism, we must ready ourselves for larger numbers of people with nutrient deficiencies, especially the fat soluable vitamins; growing numbers suffering with obesity and insulin resistance, leading to more people with Type II Diabetes; a greater reliance on prescription medication to alleviate the chronic conditions caused by our diet; and more foods touting the benefits of their “low-fatness” to convince you to eat more of it instead of eating animal foods that have saturated fat.
The fact is, limiting saturated fat to less than 7% of calories will directly reduce intake of critical essential micronutrients, fatty acids and amino acids; reduce the absorption of essential fat soluble vitamins; and inhibit the absorption of important minerals. We know this – it’s found in numerous studies and surveys. Data from nutritional surveys of people in the US continue to show nutrient deficiencies.
That will only be exacerbated even more if they strictly limit saturated fat to less than 7% of calories.
Now the challenge:
I contend, one simply CANNOT plan a day’s menu for a eating and keep saturated fat at less than 7% of energy while at the same time meet essential nutrient-requirements for fatty acids, amino acids, vitamins, minerals and trace elements.
It can’t be done.
Take a look at the AHA document, full-text this time – there is not one example of how to eat within the document. No example menu to show following their dietary recommendation will provide for all essential nutrients. No example menu to even show how to eat according to their new guidelines.
It can’t be done and meet nutrient requirements.
So, my challenge is – if someone can prove me wrong – create a menu with about 2,000-calories (the IOM establishes a 30-year old female with a BMI of 24.99 who is “low-active” requires 1,956-calories per day), using common whole foods and that menu conforms to the new AHA recommendations, I’ll eat my words, issue a public written apology and reward the person with $1000.00.
Yup, if someone can create a menu, I’m willing to pay to see it.
The AHA didn’t think it important to take the time to show anyone reading their recommendations HOW TO DO IT, so I’m willing to here if someone creates a one-day menu and sends it to me and it’s within the AHA guidelines. Sad when you think about it – the AHA has the in-house experts on hand to do so!
Heck, they even have menus in their No-Fad Diet book…oh, wait, those menus don’t conform to their new guidelines and have way too much trans-fats! But, I digress…
Anyone up for the challenge?
Here are the specifics the menu must include, to conform to the AHA guidelines:
- 1,956-calories from food and beverages detailed with quantity to consume
- No vitamin supplements may be included to meet essential nutrient DRI’s, the AHA specifically recommends foods for meeting nutritional needs
- Essential nutrients must provide atleat 98% of DRI: Recommended Intake for Individuals based on a female, 30 years old
- Essential nutrients not to exceed established Upper Tolerable Limits for a female, 30 years old
- Less than 7% of calories from Saturated Fat
- Less than 1% of calories from Trans-fats (industrial and naturally occuring)
- Total Fat – no specific limit
- Whole Grain foods must be included as part of grains included
- Vegetables must be included and may be fresh, frozen or canned
- Fruits must be included and may be fresh, frozen or canned
- Dairy must be included
- Nuts, Seeds, Legumes, lean meats, poultry and fish allowed in menu
- Added Fats and Oils – depends on what you can fit in with 1,956-calories
- Added Sugars – allowed, but keep to a minimum, especially beverages
- Cholesterol – no more than 300mg
- Sodium – no more than 2300mg
- Alcohol – no more than one serving (4-oz wine, 12-oz beer, 1.5-oz hard liquor)
- July 18, 2006: Must comply with the AHA guideline to include a wide variety of foods
You can email your submissions for review and analysis. I’ll maintain this challenge online through August 31, 2006. Foods included in the menu must have a nutrient profile available in the USDA Nutrient Database for analysis. Only one submission per person (or organization) allowed.
Over the next few weeks and months I’ll present menus submitted along with analysis to determine if it meets nutrient requirements and conforms to the AHA recommendations. If anyone creates a menu that conforms to the above, you’ll know when I make a public written apology here on my blog and cut a check to the person who created the menu.
The American Heart Association has placed a page on their website with a general guideline of how many servings of each food group to eat daily (or weekly) as part of a diet that complies with their new 2006 Diet and Lifestyle Recommendations issued last month. Because my challenge requires those submitting menus to comply with the AHA guidelines, the foods included in the menu must comply with this additional information. This guideline is similar to the two dietary patterns the AHA pointed to in their full-text paper previously.
In the July issue of Current Opinons in Clinical Nutrition and Metabolic Care an interesting review was published – Effects of dietary protein on glucose homeostasis [Carbohydrates]. Within the abstract the authors write, “Recent intervention trials revealed that, in the short-term, the intake of proteins at the expense of carbohydrates increases satiety and thereby lowers intake of calories. High protein intake augments prandial insulin secretion and might thereby improve glycaemic control in type 2 diabetic patients.”
Then they turn to the predictable – issue a caution and the reasons why such a diet should be avoided. “On the other hand, epidemiological studies suggest that chronic high dietary protein intake is associated with increased incidence of type 2 diabetes. Furthermore, a short-term increase in plasma amino acid concentrations has been shown to directly induce insulin resistance in skeletal muscle and stimulate endogenous glucose production.”
So what is one to make of this? Does a low-carb diet offer a benefit or not?
To answer that we have to determine if the authors provide justification for their position. It’s important to keep in mind when reviewing a study or review of studies that it is the obligation of the author to build an explicit arguement for their claim using appropriate data. It is our obligation as readers to determine if the claims are warranted.
The big question here is, are the studies cited to highlight potential adverse effects similar in context? Basically, is existing data about potential adverse effects from other studies transferable and thus appropriate for extrapolation?
In this case, the answer is a firm “no.”
The reason is that the studies used to support the beneficial effects of low-carb diets are well-controlled clinical trials that specifically investigate a low-carb diet; those used to claim potential adverse effects are epidemiological studies and data from studies where amino acids are directly inflused into the blood stream. Neither specifically include low-carb dieters or sub-groups consuming a carbohydrate restricted diet.
This is an important point. Especially when we’re mindful of the fact that it is incumbent upon the authors to articulate their position and also reference data in the right context. In this case, the context is a low-carbohydrate diet. Where data is cited for potential detriment, the findings must be in the context of a low-carbohydrate study population, or the authors must acknowledge their extrapolation is beyond the specifics studied in those references they do use and justify why using studies out-of-context is warranted in their review.
They do neither. And we find the epidemiological studies are problematic mainly due to the fact they are not in the proper context. That is, they’re investigating the effect of dietary habits of a large population consuming a carbohydrate-rich diet. So, while the finding that one is at an increased risk for diabetes when they consume high amounts of red meat and processed meat applies to a population consuming a carbohydrate-rich diet, it cannot be extrapolated to apply to a population consuming a low-carbohydratre diet. It’s out of context and beyond the scope of the data available.
We find similar problems with the data presented from studies where subjects were infused with amino acids directly into their blood stream. They too were consuming a typical diet before the testing. But more importantly, humans don’t typically have amino acids infused into them. So the delivery of the amino acids makes the extrapolation of this data subject to suspicion as a justification to say the data should apply to those following a low-carb diet. In this case, it’s not even comparing apples to oranges, it trying to compare apples to rocks.
In this study, the authors do not meet their obligation to build an explicit arguement for their claim. And, it seems, they missed the opportunity to highlight an area of research where data is slim – the metabolic effect of protein intake in the long-term while consuming a carbohydrate restricted diet.
In an interesting twist this week, in an updated WedMD article, American Diabetes Association spokesman Nathaniel G. Clark, MD acknowledged in an interview that carbohydrate restricted diets help people with type II diabetes control blood sugar.
In previous articles, I’ve stated evidence-based medicine must be the gold standard used for making for recommendations; I’ve pointed to the consensus driven, dogmatic position of the ADA; and I’ve stated in no uncertain terms that the ADA must be held accountable for the health harming position, based on opinion not data, it takes.
Now the excuse from the ADA is that they do not recommend controlling carbohydrate because patients find them too restrictive. “We want to promote a diet that people can live with long-term,” says Clark, who is vice president of clinical affairs and youth strategies for the ADA. “People who go on very low carbohydrate diets generally aren’t able to stick with them for long periods of time.”
The WebMD update was prompted by the publication of Low-carbohydrate diet in type 2 diabetes. Stable improvement of bodyweight and glycemic control during 22 months follow-up, in the peer-reviewed journal, Nutrition & Metabolism.
The study started as a six month study to compare the effect of a low-carb or low-fat diet in those with type II diabetes. The original study data was published in 2005. In the present study, the researchers wanted to determine to what degree the changes among the 16 patients in the low-carbohydrate diet group at 6-months were preserved or changed 22 months after start, even without close follow-up. They also noted that 2/3 of the original low-fat group modified their diet after the study term and also showed improvement after making the dietary change. At the 22-month mark it was concluded that the improvements found at six months had a lasting effect on both body weight and glycemic control.
Noteworthy is that this is the first “long-term” study – one that didn’t even include intensive follow-up and tracking for compliance – at almost two years. Without dietary counseling those who experienced the dramatic improvements stuck with the diet – even the majority of those subjected to the low-fat diet saw the results in the group following the low-carb diet and jumped at the chance to follow a low-carb diet and experienced the improvements too in the period between six months and twenty-two months.
So, it’s now difficult for the ADA to say there’s no data. What they’re doing now is changing their tune – patients don’t want to follow the diet, it’s too hard.
Again we see the ADA purposely avoiding evidence-based medicine standards.
Quite frankly, it doesn’t matter if a patient can or will follow the dietary protocol the evidence shows is superior to the current recommendations. Evidence-based medicine demands these findings be not just acknowledged in an interview, but presented to the patient as a line of defense in their management of the disease.
It’s nothing but pure arrogance for the ADA to arbitrarily decide that it will not fully disclose the benefits of a carbohydrate restricted diet, as shown by the evidence, to patients because it feels patients won’t want to follow the diet.
Since when does the ADA or any other medical organization decide what a patient wants?
Those with type II diabetes, those with pre-diabetes, and those at risk for developing insulin resistance which will lead to diabetes must be given all the facts so they can make a decision based on the full data available – anything less fails the standard of informed consent.
This study shows that individuals, when given an opportunity to experience the health changing effects of carbohydrate restriction, stick with it for the long-term. And who wouldn’t? Just imagine what their health would be today if they never enrolled in the study and never were given the information about how to properly follow a carbohydrate restricted diet – they’d be progressively deteriorating!
Instead, their improvements are persisting – because they chose to continue eating a carbohydrate restricted diet.
It’s time the ADA takes the evidence-based approach seriously and abandons this notion they know what a patient wants.
At the end of the day, you’ll be hard pressed to find a majority of those with diabetes willingly opting for more medication and progressive deterioration rather than just give up the bread, pasta, rice and potatoes!