Archive for August, 2006
Talk about timing!
Soon after posting Evidence-Based Guidelines Needed for Diabetes Diet on Friday, I received an email alerting me to the release of the September 2006 issue of Diabetes Care online. Within the new issue is the latest update to the ADA’s Medical Nutrition Therapy [MNT] recommendations in Nutrition Recommendations and Interventions for Diabetes–2006: A position statement of the American Diabetes Association.
The full-text is available here (requires payment).
Surprisingly, there is little attention in the media – since Friday, there have only been a handful of articles relating to the updated recommendations. The few published are almost all identical in wording and based on the press release issued on Friday by the ADA.
The position statement is the second major update released by the ADA in less than a month. You may recall my previous article, ADA Consensus Statement Admits Recommended Lifestyle Intervention Fails; Solution: Medication, that highlighted the release of the new treatment algorithm, Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy: A consensus statement from the American Diabetes Association [ADA] and the European Association for the Study of Diabetes [EASD], in the August issue of Diabetes Care.
These two documents now stand as the “gold standard” for physicians and healthcare providers to determine the course of treatment for their patients at risk for or diagnosed with diabetes. While both documents claim an evidence-based approach in their creation, they rely heavily on previous reviews and time-honored dogma.
They also quietly tell us something that should make physicians and healthcare providers, and the general public question the trust bestowed upon the ADA as the leading, authoritative organization to find a cure, and more importantly be responsible to us for communicating the best science available. After decades of research time, millions of dollars, and billions of manhours – the ADA has not only failed find a solution to prevent diabetes, it is also currently unable to curtail the epidemic of diabetes.
While admitting the “current-day management has failed to achieve and maintain the glycemic levels most likely to provide optimal health care status for people with diabetes,” they continue down the very same path that leads to slow, insidious progression of the disease.
One example of this from the new MNT guidelines should suffice to highlight the insanity of it all:
“Sucrose can be substituted for other carbohydrate sources in the meal plan or, if added to the meal plan, adequately covered with insulin or another glucose-lowering medication.”
In other words, it’s fine to make your condition worse as long as you take and adjust your drugs.
I could spend hours picking apart the various recommendations that are destructive to the long-term health of those at risk for or diagnosed with diabetes, and then pull dozens of credible studies that found improvement with an alternative approach. I simply do not have that kind of time these days.
I have however, previously written a number of articles that sum up much of the research data available that has continued to be ignored:
What we have now, with these two new position statements, is clearly an effort to reduce the options made available to those at risk for or diagnosed with diabetes.
Rather than taking the time – and let me be clear, it is a time consuming process – to actually review the reams of data available that specifically found statistically significant improvements in those subjects with insulin resistance and impaired glucose tolerance or diabetes following a carbohydrate restricted diet, the ADA has firmly placed its stake in a failed dietary approach and simply added a pharmacuetical intervention at diagnosis in the hope that the drugs may at least slow progression if prescribed earlier.
That’s not all though.
The ADA isn’t simply standing its ground, as shaky as it is, here.
They’re not just ignoring evidence or dismissing data anymore – they’ve gone a step further to issue a blanket condemnation of a scientifically supported dietary intervention and crafted a message to healthcare providers and the public that tells them, in no uncertain terms, they can’t do it anyway, so don’t even bother to consider it.
In the real world, that’s called hubris – only pure arrogance leads an organization the size of the ADA to declare “we know what’s best for you,” while at the same time admitting it isn’t able to do more than stay the course and add drugs earlier.
I’ve reached the point where even my hope that the ADA will evaluate the evidence, take the valuable hard date available, and issue even a cautious guideline to carbohydrate restriction, has evaporated.
With these two new statements, the ADA has shown its worth in our future – a future which looks grim if nothing changes – the ADA is now irrelevant.
It is up to those who are truly committed to the use of evidence-based medicine to collaborate, unite and review the evidence to create a comprehensive guideline for use by healthcare providers. Those currently in practice and treating those at risk for or diagnosed with diabetes, and those investigating its potential, must take on the task since it’s clear the ADA is not going to do it.
It’s also time for those who are at risk for or diganoised with diabetes to step up and be heard – write letters to the editor of your local newspaper, the national newspapers and your congressmen. Tell them enough is enough – we want a all options, based on credible studies, provided to physicians, healthcare providers and the public!
Last week Dr. Mike Eades commented on the FDA approval of spraying viruses on our food in An opportunity for the law of unintended consequences to rear its head. I’m personally not fond of the idea food companies are going to be spraying viruses on our food in an effort to eliminate bacteria. One more reason, in my mind, to skip the processed foods and stick with real, whole food.
One of my all-time favorite nutritionists, Dr. Jonny Bowden, has a collection that anyone trying to lose weight should consider adding to their library – The Power to Change is a series of CD’s designed to motivate, motivate, motivate. There are three separate collections – Change your Body, Change your Life; 23 Ways to Improve your Life; and 9 Essential Steps to Weight Loss. Each may be purchased separately or you can save some money when you purchase all three. For the record, I receive absolutely NO compensation for linking to these great CD’s!
CalorieLab reported that Low-carb blogging is contagious….and then, Jimmy Moore highlighted the latest entry into the blogosphere by Dr. Mary Vernon with the newly created blog, Ask Dr. Vernon. I’m looking forward to future posts and hope you’ll add her blog to your “must read” list!
The great thing about a low-carb diet is that once you get into the groove, it gets easier with time. After three weeks, I’m in my groove and decision making, about what to eat, is best described as “auto-pilot” – I know what to eat and meals come together with little effort or planning. The only adjustment made in week two was the inclusion of more carbohydrate, specifically from nuts, seeds and some fruits. I continued this into week three and averaged 30-40g of carbohydrate each day. With a full range of options, this simply doesn’t feel like a diet.
So, how did I do in week three?
In week one and two I lost an impressive amount of weight – 15-pounds; more than I anticipated. Starting week three the scale actually bumped up a couple of pounds, then settled for a few days before starting a downward trend again. I awoke this morning with an additional 1-pound weight loss, to bring my three week total to 16-pounds. Yeah!
Now some may be thinking, that’s it? Yup – that’s it…and a pound in week three means, without giving it much thought, I maintained a calorie deficit without counting my calories. The scale going up-steady-down again in the week tells me that my glycogen stores stabilized this week also.
Where things stand today:
Target Weight Loss Week Three: 2-pounds
Actual Weight Loss Week Three: 1-pound
Total Weight Loss to date: 16-pounds
Remaining Weight to Lose: 4-pounds
As I start week four, I’ll gradually increase carbohydrate once again – this week targeting a minimum of 40g (net, deducting only fiber) carbohydrate each day and consuming up to 60g net. At the same time, I’ll make just one change – I’ll swap my morning heavy cream out and instead use half & half in my coffee.
This one minor change saves me 60-calories – enough to add more foods with slightly higher carbohydrate content. Basically this exchange buys me 15g of carbohydrate to use throughout the day, which I’ll enjoy with some more non-starchy vegetables, fruit and nuts!
With just four more pounds to lose, I’ll continue at this level of carbohydrate throughout the rest of my weight loss. These days I am in a bit of a time crunch, so I won’t post menus each day, but will post a few during the week to provide examples of what you can eat at this level of carbohydrate!
Monday I featured an online segment of dLife TV that highlighted the two sides of the debate about which type of dietary recommendation someone diagnosed with type II diabetes should receive. On one side we have those who feel recommending a low-carb diet, and thus advising a radical dietary modification, is an exercise in futility – either because the patient cannot or will not limit carbohydrate to control their disease; on the other side we have researchers publishing study after study with statistically significant improvements and physicians and healthcare professionals already making the recommendation to use a low-carb diet, who insist that when patients “see the pay off they stick with it.”
In the comments, Kevin Dill, who follows a low-carb diet himself, asked a good question:
I guess my only question is which definition of a low carb diet are we going to use?? While Dr Atkins has provided the most popluar version, is it any better than Protein Power, South Beach, the Zone, or any of the other of myriad interpretations of low carb when it comes to controlling blood sugar?. IS Ketosis necessary? or is simply reducing the carbs below a certain level, (what ever that may be), sufficient? IF low carb is the one true answer, then why has DEAN ORNISH also been successful?? The real culprit is not just the carbs, its the constant state of over consumption, compounded by a sedentary lifestyle. While I agree that a low/reduced/controlled carb diet should be offered as an option, its only opening up a whole new can of worms. If the low carb community can’t agree amongst itself which plan is “right”, how would you expect people who aren’t overly fond of the idea of reduced carbs to fair? But then again, they may do a better job with it as they do not have the emotional attachment that so many low carbers have to their chosen plan.
First some clarification – again – low-carb may not be the “one true answer” for every person diagnosed with type II diabetes. I’ve stated this previously and most recently on August 18th, “I don’t think that only a low-carb diet should be recommended, nor do I think that initiating a drug at diagnosis is necessarily a bad idea.”
My view is simply this – a low-carb diet has sufficient, credible and compelling data published at this point. Enough that it should be reviewed, an appropriate approach to low-carb eating defined, and then it offered as an option to anyone diagnosed with type II diabetes if they prefer to try to control their blood sugars with this alternative dietary approach. What we lack is a good, working definition of a low-carb (or controlled-carb, or carbohydrate restricted) diet and a clinical practice guideline. As pointed out above, which plan out there should be advocated as an appropriate diet for those diagnosed with type II diabetes?
From my perspective, the question shouldn’t be “which popular diet to recommend,” but “what does the data tell us is a level of carbohydrate that results in statistically significant improvement?”
The only approach here, in my mind, is a strict evidence-based approach which demands we set aside opinions, beliefs, anecdotes and assumptions and carefully review the hard data as the basis of our first step to definition for clinical application.
As it is now, we have two camps in the diet debate: those who advocate the carb-rich diet, with 45-55% of calories from carbohydrate, espoused by the leading organizations and government, countered by an assortment of various approaches to carbohydrate restriction with limited definition for practical use with patients. The carbohydrate intake of the various published carbohydrate restricted diets out there is all over the place – some recommending as little as 20g net carbohydrate per day to start and maxing out at about 100g net a day, some more moderate levels ranging from 72g to 150g a day, and others allowing up to 40% of calories from carbohydrate.
The current recommendations are available almost everywhere you turn – in print, the internet & media and hand-outs in the doctors office; the carbohydrate restricted diets are often designed by trial-and-error by the patient advised to reduce carbohydrate with little practical advice about how to do that. While some physicians have created patient hand-outs, many will not due to a fear of what may happen for making a recommendation contrary to the established guidelines.
We know the diet promoted these days may slow progression in some, but has yet to halt progression or reverse the condition over the long-term; we know the low-carb diet – in dietary trials – reverses the condition in some, returning blood sugars, cholesterol, insulin, weight and blood pressure to normal levels and also reduces or eliminates the need for medication; but, in an on-your-own approach, undertaken without clinical guidelines based on evidence, carbohydrate restriction may or may not have the same beneficial effect.
Without a practical, clinical guideline, physicians and other healthcare professionals advising a low-carb diet are left to design what they think a carbohydrate restricted diet is, which may or may not translate to the actual type of diet designed in clinical trials that resulted in statistically significant improvements; and the oft-vague advice to reduce carbohydrate without specifics leaves too much room for error by the patient due to a lack of evidence-based information to use in their daily menu planning.If we maintain the status quo, that is each side in the debate remaining in their comfort zone surrounded by like-minded folks, unwilling to engage with the other, nothing will change. I’ve watched as opportunity after opportunity was lost the last four years to find common ground and agreement, all in the name of each side insisting they know better than the other, believing the other is too entrenched in their beliefs to even sit and review the evidence.
So while this status-quo approach has maintained each view within its own cocoon of knowledge, it’s established a precedent to dismiss, ignore and ridicule the other with little more than a belief that one side is right and one side is wrong.
If only it were that simple. If only things in this world were always black and white.
The only way to hammer out a definition and clinical guideline is to engage both sides and insist each side bring to the table their knowledge, understanding and evidence, review the evidence from the other side, and work together to improve the dietary recommendations for those diagnosed with type II diabetes.
This is no longer a matter of one side being right and the other wrong. We are in the middle of an alarming epidemic in the United States and can no longer afford to have either side sit on their laurels, basking in the belief they’re right, damn the torpedoes.
Evidence-based medicine demands we sit together, review the evidence and use that data to establish truly evidence based guidelines. It demands we take the findings and use them not only because we’ve taken the time and resources to search for greater understanding, but because the data is what it is and not simply an opinion or belief.
Evidence-based medicine demands we do this even when we do not like or agree with the weight of the evidence available.
At the present, all of the popular, published diets work, yet each has a particular spin to differentiate it from the others. Some are very low-carbohydrate initially and ramp carbohydrate back up to low- to-moderate levels, yet still strictly reduced levels over time; some reduce carbohydrate significantly and maintain that low level of carbohydrate for the long-term ; and some simply reduce carbohydrate to a moderate level and ask those following to maintain that reduced, moderate level over time.
Recently a “next generation” of carbohydrate restricted approaches has cropped up – glycemic index and glycemic load; banning the white stuff; consuming whole foods only; or limiting sugar in the diet. While these are not promoted as “low-carb,” they’re based on the functional understanding of carbohydrate and sugar in the metabolism.
Each of the above popular diet plans is designed mostly for those seeking to lose and maintain their weight. With few exceptions, they’re not specifically designed for those actively seeking to control their diabetes. While a number of these plans work well for those with type II diabetes, a person with type II diabetes is often left with too little information to make a decision from based on their current health status.
A clinical guideline, developed from the available data, in an evidence-based approach would enable a physician or healthcare professional to work with their patient to make a good decision about which dietary level of carbohydrate to use as a means of glycemic control.
The longer the established dogma remains and the longer those advancing carbohydrate restriction continue to differentiate and try to gain a some kind of recognition from the establishment by crafting “politically correct” diets, the more consumers will be confused and the less likely they’ll be to get it right on their own or with their physician.
The time is now to take the leap from talking the talk of evidence-based medicine, to walking the walk and practicing what we preach – an actual review the data and then following the principle of evidence-based medicine to establish an evidence-based clinical guideline for dietary recommendations for those diagnosed with type II diabetes.
It will be a start, it will enable those diagnosed to decide if such a dietary approach is something they’re willing to try, it will open the door to new avenues of research and it will potentially allow us to reverse the trend of increasing incidence of diabetes that, if we do nothing, promises to destroy our future.
The question really is, are the powers that be up to the task of a truly evidence-based approach? If they are, we can look forward to an evidence-based clinical guideline; if not, don’t expect much to change anytime soon.
Reprint from the Vancouver Sun
Diet change resisted, despite the evidence
Thursday, August 24, 2006
In a backgrounder released in March, the provincial health ministry announced the following ActNow BC targets for 2010: “Increase the percentage of the B.C. population that is physically active by 20 per cent; increase the percentage of B.C. adults who eat at least five servings of fruits and vegetables daily by 20 per cent; and reduce the percentage of B.C. adults who are overweight or obese by 20 per cent.”
Laudable as these goals are, they were remarkable in their ambition, as no other jurisdiction in the world has been able to accomplish such improvements in a general population.
As someone familiar with the research on obesity and the associated chronic diseases, I assumed that there must be a new and innovative secret weapon up the government’s sleeve to make it possible to reach such ambitious targets in so short a time.
Unfortunately, it now appears otherwise. All need not be lost, however.
Even with a mere three years left, it would still be possible to make real gains if people were prepared to abandon the current failed dietary dogma and objectively consider an emerging body of evidence that points us in a completely different direction.
There is credible scientific evidence that a diet high in carbohydrates, like the one we are encouraged to eat by all manner of authoritative sources, is actually contributing to overweight, obesity and the resulting epidemics of chronic diseases. On the flip side, there are numerous studies that demonstrate that low-carbohydrate diets are effective at reversing these conditions.
First: For the vast majority of the past two million years, our forebears ate a low-carb diet. The agricultural, grain-based diet we eat today emerged a short 10,000 years ago, a blink of the eye in terms of evolutionary time.
Second: Mainstream belief systems resist change, even in the face of compelling evidence. Consider that less than 200 years ago, the medical establishment firmly believed that blood-letting was the best treatment for fever.
When an early study showed that blood-letting was not effective, the establishment responded that blood-letting should start earlier and be done more vigorously.
This is not unlike the current response to the colossal failure to reverse the epidemics of obesity and chronic disease. We are told that the cure is known, our only failure is that we haven’t tried hard enough to deliver it.
Unless we are prepared to shake off this dogmatic approach and consider new, credible evidence that points us in a more promising direction, I fear we are doomed to fail in the 2010 quest and, more importantly, in the larger effort to mitigate the human and societal costs of these preventable epidemics.
Dr. Jay Wortman is with the department of health care and epidemiology at the University of British Columbia.
With the summer bounty of squash, it’s often difficult to eat it all before it spoils. In addition to sauteeing it with butter and herbs, I also make it into soup that can be frozen for consumption later in the year.
Creamy Summer Squash Soup
1 medium-large green squash, cut up
1 medium zucchini, cut up
3 small orange squash, cut up
1 yellow summer squash, cut up
1 flat top squash, cut up
1 medium yellow onion, peeled, whole
1 small red onion, diced
1 tablespoon chopped garlic
1/2 teaspoon ground corriader
1/4 teaspoon ground nutmeg
2 cups organic (or fresh) chicken broth
1/2 cup organic heavy cream
1/2 stick of organic butter
Water or chicken broth as needed for consistency
Salt & Pepper to taste
Sour cream (organic)
In a large pot simmer cut squash in chicken broth, butter, chopped onion, whole onion, garlic and spices until squash is cooked soft and tender. Remove whole onion and discard. Puree squash and broth mix together and add heavy cream, add more chicken broth or water to desired consistency for a creamy soup. Season with salt & pepper to taste. Serve hot, topped with a dallop of sour cream.
If freezing, do not include sour cream! Add it once it’s thawed and re-heated.
I’ve posted menus over the last two weeks to provide some insight into how I eat when following a low-carb diet. If you’ve been reading them each day, you might have noticed they’re consistently similar each day. This week, with no increase in carbohydrate, my menu is going to look very similar to last week’s, and with time limited this next week, I won’t be posting menus each day since 14-days worth of menus are available as example!