Lowering Blood Pressure & SPRINT

Imagine that a doctor said: “I’d like you to take this pill. It will reduce your risk of dying by 30%.” You’d pretty seriously consider it, if not jump at the chance…

The story

I happened to be in the car, with Radio 4 tuned in, last Wednesday (3rd Feb 2016) at 3.30pm. Dr. Mark Porter’s programme, Inside Health (the transcript is below the recording), had just started and I heard a researcher saying that his trial had been stopped just over three years into a five year study because the benefit was already so dramatic. This is the holy grail of randomised controlled trials – ‘we just had to stop the trial because it was unethical not to treat the control group because the intervention group was doing so well’. Having seen this happen more than once, it can also happen, funnily enough, when gaps that had emerged between the two groups start to narrow…

The researcher being interviewed was Dr. Paul Whelton. Whelton is the chair of the SPRINT (Systolic blood PRessure INtervention Trial) steering committee. The full paper for the trial can be seen here. (In Figure 3, the data available at four year shows the intervention and control group lines closer together than at the time the trial was stopped; funnily enough).

The trial enrolled over 9,000 people in the US between the dates of November 2010 and March 2013. There were many inclusion and exclusion criteria. These are very important, because they define the profile of people to which the results can apply. All participants had to be over the age of 50. And they had to have systolic blood pressure (the first number of the two e.g. the 140 in 140/90) between 130 and 180. And they had to have had a significant risk factor for cardiovascular disease (already had cardiovascular disease, already got chronic kidney disease and/or had a 10 year risk of 15% of higher on the Framingham scale). Two exclusion criteria were listed – the participant must NOT have diabetes and they must NOT have already had a stroke.

The aim of the trial was quite interesting – it was not to see if blood pressure medications were better than not taking medications. It was to see if what they called “intensive” blood pressure (BP) lowering treatment (to medicate people to get them below 120 systolic BP) was better than “standard” BP lowering treatment (to medicate people to get them below 140 systolic BP). The goal of this trial, therefore, was to see if giving more meds was better than giving fewer. The idea of not giving meds at all was not part of this trial.

The trial participants were also interesting – older people and sicker people – designed to ensure that there would be a decent number of deaths in a short period of time. This is not underhand – if the trial outcome is deaths, you need people to die!

4,678 were analysed for the intensive treatment group; 4,683 were analysed for the standard treatment group. At the time the trial was stopped, 155 people in the intensive treatment group had died and 210 people in the standard treatment group had died. Table 2 in the full paper has the statistics on this. This was presented as a Hazard (risk) Ratio of 0.73, which can be presented as a 27% difference between the two interventions. Indeed, Whelton presented this on Inside Health as “In fact their total mortality was reduced by close to 30% and I’ve never been in a trial where we’ve seen that before.”

Relative risk

That’s relative risk, which I have frequently explained as highly misleading. The absolute risk of dying in any 1 year of the study was approximately 1 in 100. In the intensive treatment group 1.03 people in 100 died; in the standard treatment group 1.37 people in 100 died. That’s 10 people in 1,000 vs. fewer than 14 people in 1,000. That’s hardly “Stop the trial! People are dropping like flies!”

Who didn’t benefit

Then is when it gets even more fun. Figure 4 in the paper is called a forest plot or a blobbogram. I kind of like the second name. All you need to look for in a blobbogram is whether each horizontal line touches or crosses the vertical line, which is drawn at 1.0. Any horizontal line that touches or crosses that vertical line is NOT significant. It could have happened by chance. You should ignore it.

The blobbogram in this paper tells us that, the intensive treatment made a significant difference for:

– all participants grouped together;
– people who didn’t have previous chronic kidney disease;
– people 75 years old or older;
– men;
– non black people;
– people who didn’t have previous cardiovascular disease; and
– people whose starting blood pressure was under, or equal to, 132.

The intensive treatment made NO significant difference for:

– people who did have previous chronic kidney disease;
– people under 75 years old (that’s 82% of participants for starters);
– women;
– black people;
– people who did have previous cardiovascular disease;
– people whose starting blood pressure was greater than 132 (that was 66% of people).

For the majority of people, therefore, there was no benefit from intensive treatment. (As an aside, is it surprising that lowering BP to below 140 makes no difference to people whose starting BP is already below 132?!)

Thanks to Dr. Margaret McCartney on Inside Health, the programme discussed the numbers needed to treat to impact one person. In McCartney’s words: “you had to treat 90 people in order to delay one death over the three year period of the trial.  Now that is important but it means that 89 out of those 90 people did not get benefit from having their death delayed and were at risk of just getting the side effects from the intervention. Is that worth it or is it not?  That’s for the patient to decide, not for me.”

Which brings us nicely on to…

The down sides

The side effects were serious. A Serious Adverse Event is defined as a “Fatal or life threatening event, resulting in significant or persistent disability, requiring or prolonging hospitalization, or judged important medical event.”

The paper reported: “Serious adverse events of hypotension, syncope [fainting], electrolyte abnormalities, and acute kidney injury or acute renal failure… occurred more frequently in the intensive-treatment group than in the standard-treatment group.” “A total of 220 participants in the intensive-treatment group (4.7%) and 118 participants in the standard-treatment group (2.5%) had serious adverse events that were classified as possibly or definitely related to the intervention (hazard ratio, 1.88; P<0.001).”

If you want to report deaths rates as 30% better than the standard treatment group, you should also report side effects as double that of the standard treatment group. Presenting benefit as 30% (relative) and the side effects as 4.7% (absolute) is naughty at best and deliberately misleading at worst. Some of those side effects are serious and nasty as well – acute kidney injury or acute renal failure? What would happen if the trial were kept to five years long, or extended for longer? Would significant numbers of people in the intensive treatment group die of kidney failure? How many will end up on lifelong dialysis as a result of this trial?

The honest patient conversation

This kind of trial informs medical policy – it is intended to. That’s why drug companies spend so much money funding research, researchers and research institutions. The messages that are best left in the minds of the medical world are 1) the trial stopped early i.e. you must get your patients on this treatment asap or you will be unethical and 2) there was a 30% difference in mortality i.e. you must get your patients on this treatment asap or you will be unethical.

Then the doctor conversation can be: “I’d like you to take this pill. It will reduce your risk of dying by 30%.”

As McCartney suggested, the good doctor sets out the facts in an understandable way and lets the patient decide if absolute benefit is worth the known (side effect) risk. The honest doctor conversation in this case – only even to be considered with patients over the age of 50 – would be:

“If you are male, or over the age of 75, or have no previous chronic kidney disease, or are not black, or have no previous cardiovascular disease, or have current systolic blood pressure under 132, AND over the age of 50 (because we didn’t test younger people), AND don’t have diabetes (because we didn’t test for people with that), AND haven’t had a stroke (because we didn’t test for people with that) … if you then take 3 pills a day (that was the actual number of pills administered) every day for 3.26 years, you have a 1 in somewhere up to 90 chance (Note 1) of delaying death i.e. you might not die within the 3.26 years – you might die the day after, or sometime after, we don’t know. Oh, and by the way, you double your (relative) risk of some serious side effects including acute kidney failure and you might faint here and there, so don’t idle at the top of staircases.”

Now who would jump at the meds?!

Generalisability

One of the key findings from this meta-analysis was that you can’t take six studies of 2,500 sick men and set dietary guidelines for entire populations. (Except that this is what happened – oh – and the studies themselves did not support the guidelines introduced). Research is said to lack “generalisability” if it is undertaken on, and/or shows results for a small or specific part of the population. Put simply, you can’t study people over 50, find significance for men or over 75s only and then apply guidelines to entire populations…

When McCartney joined the debate, so did Tony Heagerty, introduced as “Professor of Medicine at University of Manchester, who has a special interest in treating high blood pressure.”

Closing the debate, Porter asked Heagerty the key question: “Well this is the big question isn’t it Tony – does this one trial, which has come up with this finding and suggestion that we should be aiming at 120 – is that enough to change our current guidance and practice on it?”

Heagerty replied “I believe it does actually… the National Institute for Health and Clinical Excellence scoped out or looked for a reason to change guidelines in 2015 and the guideline writing committee felt there was no new evidence. I think that in 2016 the British guidelines will have to be readdressed with regard to targets for looking at effective blood pressure control.”

The paper’s own blobbogram confirmed that there was no significant difference for people under 75 years old (82% of the study participants). There was no significant difference for people with previous chronic kidney disease, or people with previous cardiovascular disease. There was no significant difference for women. There was no significant difference for black people and, perhaps most incredibly of all, there was no significant difference for people whose starting blood pressure was greater than 132 (66% of participants).

So there are calls for UK wide guidelines to be changed for all people when absolute risk benefit vs. Serious Adverse Effect cost barely holds up for white men over 75 with no previous CVD and already low blood pressure.

This is when John McEnroe’s legendary comments springs to mind: “You cannot be serious”!

(Note 1) the number needed to treat included women/under 75 year olds etc, who we now know will not benefit, so the number needed to treat will change with the caveats spelled out. Even if you leave out the caveats and tell any non-diabetic/non-stroke patient over 50 they have a 1 in 90 chance of benefit and likelihood of side effects – some serious – I suspect they would decline the kind offer.

 

Posted in Conflict, Gov. Policy, Research
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Burning off calories (& food labels)

On 15 January 2016, the Royal Society for Public Health (RSPH) called for the introduction of ‘activity equivalent’ calorie labelling on food and drink. Such labelling would show how much activity would be required to burn off the calories contained in the food or drink. But would it?!

The press release can be viewed here. The call was made in an attempt to help with “the UK’s growing obesity crisis.” According to the press release, the RSPH’s said of activity equivalent labelling: our “own research found two-thirds (63%) of people would support its introduction, with over half (53%) saying it would cause them to make positive behaviour changes such as choosing healthier products, eating smaller portions or doing more physical exercise.” (The RSPH kindly shared by email that the research undertaken involved 2,010 UK adults, aged 18+, surveyed online between 11th and 13th December 2015).

The full position paper is here. The RSPH ‘hopes’ that prominent pictorial icons, alongside front of pack information, would increase consumer awareness of both calories contained within the food/drink and the activity required to burn off those calories. The icons are illustrated in the full position paper. An example bag of crisps is shown with a picture of someone: running; cycling and swimming and the numbers say that these activities would need to be done for 19, 23 and 13 minutes respectively to burn off the 171 calories in this particular bag of crisps.

The problems

1) The first problem is that all of this is based on the calorie theory: the idea that, one pound of fat equals 3,500 calories and humans gain one pound if they have a 3,500 calorie excess and lose one pound if they have a deficit of 3,500 calories. None of this has been sourced, proven, explained – anything. It remains the biggest dieting myth ever invented and perpetuated by human beings.

2) The second problem is that calories are not equal. If we proceed on the correct assumption that calories are units of fuel, nothing to do with weight, we will be on safe ground. This video shows how most of the fuel requirement of the body is determined by basal metabolic rate (the fuel needed by the body if we lie in bed all day) and that this, almost entirely, needs to be met by fat and protein. Carbohydrate is for energy only (and fat can meet energy needs just as well, arguably better).

3) It follows from (2) that all carbohydrate that humans consume must be burned off with activity or it will be stored as fat. It cannot be used for anything else. This means that any activity equivalent label only needs to list carbohydrate calories. This is the fuel that needs to be burned off, or it will be stored as fat (in what ratio, we do not know – certainly not in the 3,500 calorie ratio).

To take an example, 100 grams of Mars Bar contains 17g of fat, 4g of protein and 70g of carbohydrate (the rest will be water). If someone eats 100g of Mars Bar, they need to use up 70g – approximately 280 calories worth – of carbohydrate fuel. The fat and protein can be used by the body for maintenance and repair.

4) This brings us to another problem. We cannot choose what we want the body to burn for fuel – the body mechanisms and physiological state decide this for us. If we eat the Mars Bar and start running at 5 miles per hour, the body will first use any glucose already available in the blood stream. After this? Who knows. Maybe glycogen stored from carbohydrate eaten in the past 24 hours, maybe glucose from the Mars Bar, maybe fat from the Mars Bar (instead of using this for cell repair/maintenance). Who knows? This whole calories in/calories out mythical thinking has led to a lot of erroneous assumptions about food, activity and weight. This initiative perpetuates a lot of this bad science.

5) Notwithstanding that only the carbohydrate calories need considering, the pictorial icons are wildly inaccurate and yet would be taken as accurate by most people. In the full position paper, page 4 has a guide as to how much medium walking vs. slow running a person would need to do to burn off the example foods shown.

The source for the information is this very rough calculator, which doesn’t take gender into account and is not very sensitive to age. I’ve reverse engineered a couple of examples and the numbers seem to be based on a 50 year old (male or female) weighing 76kg (nearly 12 stone). This person would, allegedly, use up 436 calories running slowly for 42 minutes (close to the 445 for the sandwich). Weighing 50 kg, I would need to run for 65 minutes to achieve the same – a 55% margin of error. Other, more accurate, calculators available suggest I may need to run at 5 miles an hour for over 75 minutes to burn off the sandwich.

6) Problem six logically follows three, four and five above: the body needs to burn off all carbohydrate daily, not just snacks consumed. If this labelling route is a good idea, it should apply to every food containing carbohydrate, from fruit to lentils to yoghurt to brown rice.

Government guidelines advise consuming 55% of calorie intake in the form of carbohydrate. I would need to run for three solid hours to burn that off, even before starting the running needed to burn off any extra snacks!

7) Problem seven is huge and not widely known. I wrote about this in a blog in 2010. We don’t use up as much energy as we think. Exercise calculators take into account BMR (Basal Metabolic Rate). Hence, if watching TV requires 68 cals an hour (this is the calculation for a 140lb/10 stone person) and moderate walking burns 200 calories an hour (for the same person), then going for a walk should be viewed as the additional energy needed beyond doing nothing (i.e. 130 calories in this case). Some slimming plans encourage “treats for activity” e.g. jog for 20 minutes, have a (say) 200 calorie confectionery bar. It is quite UNlikely that someone would use 200 calories in 20 mins jogging above what they would need anyway pottering around the house or being at work.

8) Problem eight is that this is music to the ears of the fake food industry. Sure, they won’t like having to change labels if this becomes mandatory, but they would like to make portions smaller, to reduce ‘burn off’ times, while keeping the price the same, to boost profit. This is essentially what has been happening with the government (IR)responsibility deal.

9) The final problem is the same one encountered by all of these different initiatives by different organisations – the opportunity cost of what could be done instead. Instead of going to all this effort hoping that adding complex and inaccurate pictures to every fake food product will encourage people to avoid, or burn off, junk, why not advise people not to have the junk in the first place?

When people ask for my views of traffic light, or other labelling, schemes my response is always the same – our labelling policy should be simple: don’t eat anything that requires a label. Why is it so difficult for public health bodies to simply come out and say “Eat real food”!

No doubt the RSPH initiative is well intentioned, albeit without any evidence that it would have an impact. Sadly it suffers from so many flaws, I cannot see any good coming from good intentions. Well meaning “Eat real food” messages would be far simpler and more effective, yet somehow seem to escape the mind set of public health bodies.

Posted in Media comments, Obesity, Research
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Sugar the evidence

Just as this page documents recent academic articles questioning current dietary advice, so this page documents recent academic articles about sugar. All the papers are from 2015 onwards except the first two position papers, which are important to capture:

Position statement on Sugar & cardiovascular health: Johnson RK, Lustig RH, et al. “Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association”. Circulation. 2009

Position statement on Sweeteners & health: Gardner C, et al. “Nonnutritive sweeteners: current use and health perspectives: a scientific statement from the American Heart Association and the American Diabetes Association.” Circulation. 2012.

Articles from 2015:

Summary of evidence (Cochrane link). October 2015: Public Health England. “Sugar Reduction: The evidence for action.

Fructose & Cardiometabolic health. October 2015: Malik VS, Hu FB. “Fructose and Cardiometabolic Health: What the Evidence From Sugar-Sweetened Beverages Tells Us”. J Am Coll Cardiol.

Sugar sweetened drinks & Hypertension. October 2015: Jayalath VH, et al.”Sugar-sweetened beverage consumption and incident hypertension: a systematic review and meta-analysis of prospective cohorts”. Am J Clin Nutr.

Sugar & Tooth decay. October 2015: Meyer BD, Lee JY. “The Confluence of Sugar, Dental Caries, and Health Policy“. J Dent Res.

Sugar sweetened drinks & Global burden of disease. August 2015: Singh GM, et al; “Estimated Global, Regional, and National Disease Burdens Related to Sugar-Sweetened Beverage Consumption in 2010.” Circulation.

Refined carbohydrates & Depression. August 2015: Gangwisch JE, el al. “High glycemic index diet as a risk factor for depression: analyses from the Women’s Health Initiative”. Am J Clin Nutr.

Sugar, Tooth decay & Obesity. July-Aug 2015: Yeung CA, Goodfellow A, Flanagan L.”The Truth about Sugar”. Dent Update.

Sugar sweetened drinks & Type 2 diabetes, independent of obesity. July 2015: Imamura F, et al. “Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction”. BMJ.

Sugar consumption & Addiction. June 2015: Tryon MS, et al. “Excessive Sugar Consumption May Be a Difficult Habit to Break: A View From the Brain and Body”. J Clin Endocrinol Metab.

Sugar sweetened drinks, Diabetes & Kidney disease. June 2015: Yracheta JM, et al. “Diabetes and Kidney Disease in American Indians: Potential Role of Sugar-Sweetened Beverages“. Mayo Clin Proc.

Sugar & Aging. March-April 2015: Ross SM. “Sugar-induced aging: the deleterious effects of excess dietary sugar intake”. Holist Nurs Pract.

Fructose & Type 2 diabetes. March 2015: DiNicolantonio JJ, O’Keefe JH, Lucan SC. “Added fructose: a principal driver of type 2 diabetes mellitus and its consequences”. Mayo Clin Proc.

Sugar sweetened drinks & early onset of menstruation. March 2015: Carwile JL, et al.Sugar-sweetened beverage consumption and age at menarche in a prospective study of US girls”. Hum Reprod.

Sugar sweetened drinks & Snacking. March 2015: Bleich SN, Wolfson JA. “U.S. adults and child snacking patterns among sugar-sweetened beverage drinkers and non-drinkers”. Prev Med.

Sugar sweetened drinks, Hypertension & CVD. March 2015: Xi B, et al. “Sugar-sweetened beverages and risk of hypertension and CVD: a dose-response meta-analysis”. Br J Nutr.

Conflicts of interest in the sugar industry & UK institutions & individuals. February 2015. Gornall J. “Sugar: spinning a web of influence”. BMJ.

Sugar & CVD. Jan-Feb 2015. Ross SM. “Cardiovascular disease mortality: the deleterious effects of excess dietary sugar intake”. Holist Nurs Pract.

Sugars, Metabolic Syndrome & Cancer. January 2015. Das UN. “Sucrose, fructose, glucose, and their link to metabolic syndrome and cancer”. Nutrition.

Sugar & FDA approval: Is it even safe? 2015: Card MM, Abela JF. “Just a Spoonful of Sugar Will Land You Six Feet Underground: Should the Food and Drug Administration Revoke Added Sugar’s GRAS Status?” Food Drug Law J.

(Please note, this is just a selection of articles on sucrose/sugar from 2015. On the date of this post, a pubmed search of (“sucrose”[tiab]) OR “sugar”[tiab])(tiab picks up the words sugar or sucrose in the title or abstract) in humans from 1 January 2015 to 19 January 2016 produced 677 articles. I picked review articles, which looked easier to digest than this one!)

For older articles, see the c.140 references at the end of this post.

Posted in Dieting, Ingredients, Media comments, Obesity
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Dietary Guidelines for Americans 2015

Did you know that, until the final quarter of the twentieth century, public health dietary advice in the US and the UK focused on minimum intakes, to ensure that populations consumed adequate nutrients? The US 1950s-1970s “Basic Four Foundation Diet” recommended four or more bread and cereal portions daily, two cups or more of milk and two or more servings of meat (Ref 1). The UK favoured micro nutrient recommendations; until the first macro nutrient guideline was introduced in 1950 with British Medical Association advice that dietary fat intake should provide a minimum of 25% of daily calories (Ref 2).

The first public health dietary guidelines to set maximum intakes were those announced by the US Select Committee on Nutrition and Human needs in 1977 (Ref 3). These were followed by(Carter, 1977) UK public health dietary advice issued by the National Advisory Committee on Nutritional Education in 1983 (Ref 4). Dietary recommendations in both cases focused on one macro nutrient, fat, and a component part of that macro nutrient, saturated fat. The specific targets were to i) reduce overall fat consumption to 30% of total energy intake and ii) reduce saturated fat consumption to 10% of total energy intake.

As there are only three macro nutrients (carbohydrate, protein and fat), and since protein tends to stay fairly constant in either a plant or animal based diet at approximately 15%, if fat is restricted, carbohydrate increases (and also – if carbohydrate is restricted, fat increases). Fat and carbohydrate are the two most dependent variables in the diet. As human diets restricted fat to c. 30%, therefore, carbohydrate increased to 55-60% of our dietary intake. Since these guidelines were introduced, epidemics of obesity and type 2 diabetes have developed: coincidence or cause?

The 1980 Dietary Guidelines for Americans

The first issue of the famous American publication, issued every five years, came out in 1980. It presented the views of the 1977 Select Committee in a form intended to be digestible (excuse the pun), by all Americans. The 1980 publication, jointly written by the United States Department of Agriculture and the United States Department of Health, Education and Welfare, had seven dietary guidelines as follows:

1) Eat a variety of food;

2) Maintain ideal weight;

3) Avoid too much fat, saturated fat and cholesterol;

4) Eat foods with adequate starch and fiber;

5) Avoid too much sugar;

6) Avoid too much sodium;

7) If you drink, do so in moderation.

All pretty vague and unhelpful, to be honest – “maintain ideal weight” – by doing what exactly?! How much is “too much”?! What is meant by “adequate”?!

The 2015 Dietary Guidelines for Americans

Wind forward 35 years and the Dietary Guidelines are scrutinised like no other American health document. They were published on January 7th 2016, which amused me in itself. The committee know five years in advance that the guidelines are due in 2015 and they have 365 days to publish them and still they were late!

There are five guidelines in the latest edition:

“1)    Follow a healthy eating pattern across the lifespan. All food and beverage choices matter. Choose a healthy eating pattern at an appropriate calorie level to help achieve and maintain a healthy body weight, support nutrient adequacy, and reduce the risk of chronic disease.

“2)    Focus on variety, nutrient density, and amount. To meet nutrient needs within calorie limits, choose a variety of nutrient-dense foods across and within all food groups in recommended amounts.

“3)    Limit calories from added sugars and saturated fats and reduce sodium intake. Consume an eating pattern low in added sugars, saturated fats, and sodium. Cut back on foods and beverages higher in these components to amounts that fit within healthy eating patterns.

“4)    Shift to healthier food and beverage choices. Choose nutrient-dense foods and beverages across and within all food groups in place of less healthy choices. Consider cultural and personal preferences to make these shifts easier to accomplish and maintain.

“5)    Support healthy eating patterns for all. Everyone has a role in helping to create and support healthy eating patterns in multiple settings nationwide, from home to school to work to communities.”

Blah, blah, blah… If anything, these are more vague and useless than the original 1980 guidelines. They are certainly more verbose. They are, however, supplemented with specific recommendations, supposedly setting out how to achieve these general guidelines:

“Consume a healthy eating pattern that accounts for all foods and beverages within an appropriate calorie level.

“A healthy eating pattern includes:

–      A variety of vegetables from all of the subgroups – dark green, red and orange, legumes (beans and peas), starchy, and other;

–      Fruits, especially whole fruits;

–      Grains, at least half of which are whole grains;

–      Fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy beverages;

–      A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), and nuts, seeds, and soy products;

–      Oils.

“A healthy eating pattern limits:

–      Saturated fats and trans fats, added sugars, and sodium

“Quantitative recommendations:

–      Consume less than 10 percent of calories per day from added sugars;

–      Consume less than 10 percent of calories per day from saturated fats;

–      Consume less than 2,300 milligrams (mg) per day of sodium;

–      If alcohol is consumed, it should be consumed in moderation – up to one drink per day for women and up to two drinks per day for men – and only by adults of legal drinking age.”

The four interesting things about the latest guidelines:

1)     Dietary cholesterol:

The recommendation to limit dietary cholesterol intake to 300 milligrams a day has prevailed in the US since 1977 (Ref 3). This has been dropped from the 2015 guidelines. The Dietary Guidelines Advisory Committee (DGAC) report from February 2015 declared that this recommendation would not be brought forward because available evidence shows no appreciable relationship between consumption of dietary cholesterol and blood cholesterol (Ref 5). All of those years of demonising super-nutritious foods, like eggs and seafood, were all for nothing. There was no evidence.

2)     Total fat:

The DGAC demonstrated further movement away from the original dietary guidelines by containing no total fat recommendation and a change in position on dietary fat and cardiovascular disease (CVD). The advisory report documented the findings of the meta-analyses by Skeaff, Siri-Tarino, Hooper and Chowdhury (Refs 6-9) and concluded that reducing total fat does not lower CVD risk.

The paper from my PhD from the same month stated the same: there was no evidence whatsoever against total fat for heart deaths or deaths from any cause.

3)     Saturated fat:

Alas, the fact that there is also no evidence against saturated fat was a step too far for the 2015 dietary guidelines committee to acknowledge. Hence the saturated fat guideline has been reiterated, with the same recommendation to consume less than 10% of total calories from saturated fat per day.

The consequence of the total fat guideline being conspicuous in its absence, while maintaining the saturated fat guideline is that the consumption of unsaturated fat is free to increase. This is precisely what Unilever and fake food companies want to happen, as they have replaced butter, for example, with cheaper and poor quality vegetable oils. They have reformulated so many junk food products to be rich in cheap vegetable oils and poor in natural ingredients. They have invented the low fat dairy products, endorsed by the guidelines, and replaced the lost taste of fat with cheaper and nutritionally useless sugar. Which brings us to…

4)     Added sugar:

It is not widely known that one of the seven original 1980 dietary guidelines was “Avoid too much sugar”. This has largely been missed/ignored – whatever has happened – sugar concern and awareness has really only come to the fore in the past couple of years (albeit as a resurrection of the 1970s work of Professor John Yudkin).

The 2015 guidelines specify that people should have less than 10% of their calorie intake in the form of added sugar. For a typical female, consuming approximately 2,000 calories a day, that would be 200 calories from added sugar – 50 grams of sugar at c. 4 calories per gram. That’s a lot.

Far more importantly however, is the continuation of the nutritional ignorance that has got us in this dietary mess. While recommending less sugar, the Dietary Guidelines are concomitantly advising more fruit, more grains, more beans/pulses, more starch – all things that are, or break down into, sugar. The different forms of sugar are listed here, where fruit is used as an example to show that it is essentially sugar, with far fewer nutrients than people think.

Eat real food!

The only guideline that the US government needed to issue was “Eat real food”! The only debate is then – what should that real food be? If we choose food for the micro nutrients it provides (vitamins and minerals), the answer is obvious. We need to prioritise meat, fish, eggs, dairy, non-starchy vegetables and sunflower seeds. Fruit, grains and starchy vegetables really don’t get a look in.

I suggest that for three key reasons – lobbying by the fake food industry; ignorance on the part of the dietary guidelines panel; and a reluctance to change views, as this would be seen as an admission of previous wrong doing – the 2015 guidelines are what they are. Americans are stuck with bad advice for another 5 years, just as they have been for the 35 years previously. The smart people will ignore these guidelines and work out for themselves that real food is the only choice and some real food is substantially better than others.

As Sally Fallon Morell says “Evolution is no longer the survival of the fittest, but the survival of the wisest.”

Be wise!

References:

Ref 1: Davis C, Saltos. E. Dietary Recommendations and How They Have Changed Over Time,. In: United States Department of Agriculture ERS, editor. Agriculture Information Bulletin No (AIB-750) 494 pp; 1999.

Ref 2: Foster R, Lunn J. 40th Anniversary Briefing Paper: Food availability and our changing diet. Nutrition Bulletin 2007; 32(3): 187-249.
British Medical Association. Summary of dietary allowances based on the recommendations of the British Medical Association. London: HMSO; 1950.

Ref 3: Select Committee on Nutrition and Human Needs. Dietary goals for the United States. First ed. Washington: U.S. Govt. Print. Off.; February 1977.

Ref 4: National Advisory Committee on Nutritional Education (NACNE). A discussion paper on proposals for nutritional guidelines for health education in Britain. 1983.

Ref 5: Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. In: Department of Health and Human Services (HHS), editor.; 2015. p. 571.

Ref 6: Skeaff CM, Miller J. Dietary fat and coronary heart disease: summary of evidence from prospective cohort and randomised controlled trials. Ann Nutr Metab 2009; 55(1-3): 173-201.

Ref 7: Siri-Tarino PW, Sun Q, Hu FB, Krauss RM. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. The American journal of clinical nutrition 2010; 91(3): 535-46.

Ref 8: Hooper L, Summerbell CD, Thompson R, et al. Reduced or modified dietary fat for preventing cardiovascular disease. Cochrane database of systematic reviews (Online) 2011; (7): CD002137.

Ref 9: Chowdhury R, Warnakula S, Kunutsor S, et al. Association of Dietary, Circulating, and Supplement Fatty Acids With Coronary Risk: A Systematic Review and Meta-analysis. Ann Intern Med 2014; 160(6): 398-406.

Posted in Dieting, Gov. Policy, Obesity, Research
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Sugar in fruit

Five a day is not an evidence based nutrition message. In this post I ask the question – is it still a good message – even though it’s not evidence based? I give five reasons as to why it is not a good message: the lost opportunity of making “eat real food” as well known as “five a day”;  people having five a day ‘as well as’ not ‘instead of’; making bad choices to get five a day; the problem of fruit and starchy vegetables for carbohydrate sensitive/insulin resistant people; and the weight issue with fructose. As Gary Taubes says “If you’re overweight, fruit is not your friend.”

2015 has seen far greater awareness about sugar and there have been many newspaper articles showing how many teaspoons of sugar are in everything from pizza to prosecco. This post is about sugar in fruit.

Different forms of sugar

When we say sugar, we tend to mean sucrose – added white sugar – the stuff with no fat, no protein, no vitamins, no minerals – just empty carbohydrate calories. However, there are many other sugars in food:

  • The simple sugars (monosaccharides) are: glucose; fructose; and galactose.
  • The disaccharides (two sugars) are: sucrose (one molecule of glucose and one of fructose) – what we know as table sugar; lactose (one molecule of glucose and one of galactose) – what we tend to call milk sugar; and maltose (two molecules of glucose) – less familiarly known as malt sugar.
  • Polysaccharides (many sugars)  include digestible forms of carbohydrate…
    –    Glycogen – is the form in which animals (including humans) store energy – in the liver and muscles in the body;
    –    Starch – is the form in which plants store energy – as in grains, pulses, potatoes and root vegetables.
  • … and indigestible forms of carbohydrate – collectively called fibre:
    –    Insoluble fibre – which does not dissolve in water e.g. cellulose, hemicellulose and lignin;
    –    Soluble fibre – which dissolves, or swells, in water e.g. pectins, mucilages, and gums.

Sugar in fruit

Sucrose, table sugar, is one part fructose and one part glucose. Fruit sugar is commonly assumed to be fructose, but this is incorrect. Fruit sugar is also part fructose/part glucose. Bananas and dates, as examples on this infographic, are almost equal balances of fructose and glucose – sucrose in effect. Apples have more than twice as much fructose as glucose, but don’t think of this as healthy. Read the work of Dr Robert Lustig and Dr Richard Johnson to see how fructose is not the halo sugar that fruit pushers would like to claim. It is particularly implicated in the obesity epidemic and Non Alcoholic Fatty Liver Disease (NAFLD).

In the following infographic, don’t be fooled by bananas seeming to be lower in sugar than apples and grapes. The medium banana with 14 grams (3.5 teaspoons) of sugar has 27 grams of carbohydrate in total. Even if we generously ignore the 3 grams of fibre, that leaves 10 grams of carbohydrate, which also breaks down into sugar.

The sugar in fruit is thus barely different to the sucrose in pizza or prosecco. The body does not know if glucose and fructose came from a banana or a chocolate bar. The body just registers the sugar – sucrose in effect – and has to deal with it.

The infographic

The sources of information (US Department of Agriculture database) and the micro nutrients for the fruits and chocolate are in the table below. 100 grams of each product have been analysed to compare like with like. The highest provider of each vitamin and mineral has been highlighted in red and bold. Nutritionally, ‘junk’ milk chocolate provides more micro nutrients than any fruit comparator. (The chocolate should ‘win’ for vitamin A too, as it will contain some retinol – the form in which the body needs vitamin A). If you want to compare fruit with genuinely nutritious foods, check this.

 Per 100 grams Large apple Medium banana Grapes Medjool dates Orange juice Milk chocolate
Vitamins
A (IU) 54.0 64.0 66.0 149.0 200.0 195.0
B1 (Thiamin) (mg) 0.0 0.0 0.1 0.1 0.1 0.0
B2 (Riboflavin) (mg) 0.0 0.1 0.1 0.1 0.0 0.2
B3 (Niacin) (mg) 0.1 0.7 0.2 1.6 0.4 0.5
B5 (Pantothenic Acid) (mg) 0.1 0.3 0.1 0.8 0.2 0.5
B6 (mg) 0.0 0.3 0.1 0.2 0.0 0.0
Folate (mcg) 3.0 20.0 2.0 15.0 30.0 12.0
B12 (μg/mcg) 0.0 0.0 0.0 0.0 0.0 0.7
C (mg) 4.6 8.7 10.8 0.0 50.0 0.0
D (IU) 0.0 0.0 0.0 0.0 0.0 0.0
E (mg) 0.2 0.1 0.2 0.0 0.0 0.5
K (μg/mcg) 2.2 0.5 14.6 2.7 0.1 5.7
Minerals (Macro)
Calcium (mg) 6 5 10 64 11 189
Magnesium (mg) 5 27 7 54 11 63
Phosphorus (mg) 11 22 20 62 17 208
Potassium (mg) 107 358 191 696 200 373
Sodium (mg) 0 1 2 1 1 79
Minerals (Trace)
Copper (mg) 0.0 0.1 0.1 0.4 0.0 0.5
Iron (mg) 0.1 0.3 0.3 0.9 0.2 2.3
Manganese (mg) 0.0 0.3 0.1 0.3 0.0 0.5
Selenium (mcg) 0.0 1.0 0.1 0.0 0.1 4.5
Zinc (mg) 0.0 0.2 0.1 0.4 0.0 2.3

Some people don’t like it when I say that “fruit is sugar, with a few nutrients, and not as many as you’d think.” The truth hurts, no matter how softly spoken.

Posted in Ingredients, Media comments, Obesity, Research
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Vitamin D Deficiency

US Guidelines

In 2010, at the time of writing my obesity book, the US did not have a “Dietary Reference Intake” for vitamin D. Instead, the US had an “Adequate Intake” suggestion – they thought that 400IU (10mcg) would be adequate.

This was revised in 2011 when the US decided that the Recommended Dietary Allowance (RDA) for everyone from the age of 1 to 69 should be 600IU (15mcg) and 800IU (20mcg) for those aged 70 and over. (This post doesn’t discuss the different forms and sources of vitamin D, but this is an added complication.)

UK Guidelines

The Dietary Reference Values 1991 book is still the UK ‘bible’ for recommended nutrient intakes. This has no vitamin D targets for anyone aged 4 to 64, unless pregnant or breastfeeding – then it’s 10mcg per day. Over 65’s are also advised to have 10mcg daily.

The official European position still seems to be that of the early 1990s. This leads to this 1993 document (page 143), which confirms the lack of targets for those aged 4 to 64, as set out in the UK Dietary reference values book (1991).

On the same “European Food Information Council” site, a “mini guide” from June 2006 suggests that “European Union Recommended Daily Amounts for Nutritional Labelling of Food Products” for vitamin D should be 5 µg (that’s 5mcg).

I have no idea why the US originally only saw fit to suggest an adequate intake until 2011, or why the RDA is now 15mcg. I have no idea why the UK still doesn’t consider vitamin D to be a vital nutrient with a daily requirement. I have no idea why the recommendations for vitamin D differ from 0mcg to 15mcg for UK to US populations. This is clearly not robust, or scientific.

What I do know is:

1) Vitamin D is utterly vital for human health

Vitamin D is critical for the absorption of calcium and phosphorus. Deficiency in vitamin D can lead to tooth decay, muscular weakness and a softening of the bones (rickets), which can cause bone fractures or poor healing of fractures. Enter “vitamin D” into pubmed and over 65,000 academic articles will be listed. Vitamin D is increasingly being studied as a critical factor in the most serious human health conditions, not least heart disease, cancer and diabetes.

Vitamin D is found naturally in oily fish (for example herring, halibut, catfish, salmon, mackerel and sardines), eggs and dairy products and unnaturally in fortified breakfast cereals. (You never need junk cereals to get vitamin D – take a supplement if you don’t want to consume vitamin D naturally for some reason).

2) The average person is not getting enough vitamin D

a) US data is quite old. This November 2014 factsheet references a journal article from April 2010, which reviews data from 2005-2006.

Average male intake from diet alone for adult males in the US ranged from 5.1mcg for 19-30 year old males to 5.6mcg for males ≥ 70 years old. Average female intake from diet alone for adult females in the US ranged from 3.6mcg for 19-30 year old females to 4.5mcg for females ≥ 70 years old.

The article reported that 37% of the US population take vitamin D supplements, and this increased the intake to 6.9mcg for 19-30 year old males and 8.8mcg for males ≥ 70 years old and to 5.0mcg for 19-30 year old females and 10mcg for females ≥ 70 years old.

The lowest intake, diet alone for 19-30 year old females was less than a quarter of the US RDA; even the highest intake – women over 70 years old taking supplements – was two thirds of the intake recommended.

b) The UK data is provided annually by the UK Family Food Survey. The most recent report at the time of writing this blog is the 2013 Family Food Survey. This reported that the UK average intake of vitamin D from all food and drink was approximately 3mcg for each of the five years from 2009-2013 (Table 3.7 UK average energy and nutrient intakes from all food and drink 2009-2013). This is one fifth of the US recommended daily intake.

What the data tells us

Public health officials in the US and UK should be issuing emergency notices that vitamin D deficiency is a serious health risk to citizens. Populations should be advised to consume more foods naturally rich in vitamin D – oily fish, eggs and dairy products. Oh, but those just happen to be the fat rich foods that fat phobic public health advisors tell people to avoid! Even when oily fish is recommended, it is rarely more than twice a week. Yet we need approximately 220g of sardines (with bones) every day to meet the RDA of 15mcg of vitamin D. Vegetarians would need to eat 39 medium eggs each day (2,455 calories) to get 15mcg of vitamin D.

The other urgent piece of health advice needed is – sunbathe! We need to be exposed to the sun – without sunBLOCK – for a safe number of minutes (depends on skin type, location, time of the year etc) as regularly as possible to build up our vitamin D reserves. Being a fat soluble vitamin (along with A, E and K), vitamin D can be stored by the body. A good build up during summer months will help for annual health, but we should be rolling up our sleeves and trousers to expose limbs even on sunny winter days and/or consuming sufficient dietary vitamin D during the winter period.

What do our dear governments do instead? Scare us away from sun exposure, tell us to cover up and/or use sunBLOCK every time the sun shines and advise us to keep avoiding fat in food.

Just to complete the trilogy of bad advice – vitamin D is made when sunlight synthesises cholesterol in skin membranes. Avoiding vitamin D rich foods AND blocking sunlight from the skin AND cholesterol lowering medications and dietary supplements (e.g. plant sterols) ALL conspire together to lower vitamin D.

Dr. Robert Scragg, Associate Professor in Epidemiology at the University of Auckland, New Zealand, proposed back in December 1981 that vitamin D deficiency plays a key role in cardiovascular disease. If he was right, our diet/sun/cholesterol advice is not only wrong – it’s doing the exact opposite of what it hoped to do – raising, not lowering, heart disease.

Posted in Gov. Policy, Research
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Diet advice for diabetics

Nina Teicholz shared an interesting anecdote with me recently. She had watched a public meeting where a senior figure involved in the US dietary guidelines said she wished people “would stop believing the ‘old wives tale’ of the low-fat diet”. The powers that be clearly want us to believe that they never issued that low-fat advice. Silly us – we must have dreamed it!

This is not just an anecdote; it’s a strategy. To come out and announce that they got things wrong could be very costly for governments and organisations, which have issued low fat/high carb dietary advice for decades. There could (and should) be law suits. People will have suffered obesity and type 2 diabetes, to say nothing of cancer, heart disease and mental illness, as a result of advice that has been so alien to what human beings have evolved to eat.

The strategy of such advising organisations seems to be to change advice, ideally with repeated subtle changes that are barely noticed over time, until the advice becomes half reasonable and advisors can deny ever having issued the bad advice in the first place. This avoids ever having to come out with the statement “we were wrong”, which could invite the legal action.

One of these subtle, yet seismic, shifts occurred in the draft dietary guidelines for Americans 2015. Check out p90 “Cholesterol is not a nutrient of concern for over consumption.” Crikey O’Riley! All those years of demonising eggs and seafood and telling us to avoid animal foods because of their dietary cholesterol content. All wrong. But we won’t say we were wrong – we’ll just say that this is no longer “a nutrient of concern.” Check out the full 571 pages for total fat if you like. You’ll find the 30% limit on total fat, issued in 1977, conspicuous in its absence. More accurately – it’s gone. Disparu. As if it never existed. You can just hear the US advisor saying how silly we were to believe that low-fat diet “old wives tale.”

The same is happening in the world of diabetes, so sod this subtle/unnoticed change malarkey – here is the shift in diabetes UK diet advice:

Thanks to the wonder that is the web archive site, here is the Diabetes UK advice on March 18th 2015.

Here is the same page on April 8th 2015.

Diabetes UK advice is based on the UK eatbadly plate, so you’ll see the five, so-called, food groups. (They are not food groups – try these).

Here are the key differences (vetbatim extracts are in italics). I’ve noted the issue with glucose under the category:

Daily recommended amounts Daily recommended amounts
Starchy foods

(glucose)

5-14 portions

One-third of your diet should be made up of these foods, so try to include them in every meal.”

[A slice of bread is given as an example portion – a diabetic was thus advised to eat the starch equivalent of up to 14 slices of bread every single day.]

 

Try to have some starchy food, especially the wholegrain options, everyday. Carbohydrates breakdown to glucose in the blood so keep an eye on how much you eat. Depending on your diabetes treatment, and nutritional goals, you may be advised to:

• estimate the amounts of carbs you are eating

• reduce the amount of carbs you eat

• choose healthier sources

• spread your intake through the day.

Fruit & veg

(glucose & fructose)

Aim for at least five portions” (5-a-day of course!) No change
Dairy products

(glucose & galactose)

Aim for three portions …

…choose lower fat alternatives (but look out for added sugar in its place)”

No change
Pulses beans & nuts (also provide glucose) Aim for 2-3 portions”

 

Include some food from this group everyday and aim for two portions of oily fish a week
Foods high in fat & sugar “Technically, your body doesn’t need any foods in this group, but eating them in moderation can be part a healthy, balanced diet” No change

You can see the unannounced, seismic, change in the Diabetes UK advice. “5-14 portions of starchy foods a day/one third of your diet” has become ‘have some every day, but you may well need to reduce your carb intake.’

This is good. Don’t get me wrong. But it’s still not enough. The whole eatbadly plate should be dropped. The key piece of advice should be “eat real food” and choose food for the nutrients that it provides and then you will naturally choose meat, fish, eggs, dairy, non-starchy vegetables and a few seeds. Five-a-day should be ditched 1) for being non-evidence based and 2) because fruit is essentially sugar (with far fewer nutrients than people think) and sugar is not going to help diabetics. The junk segment is not even worthy of comment. However – it’s a start – a move in the right direction.

What annoys me though is that Diabetes UK have not had the decency to come out and say “we were wrong; the low carb people were right and we’re sorry.”

Luckily for me, all I have is annoyance. Those who have followed the 5-14 portions of starch advice will likely have far more serious issues to face.

Posted in Dieting, Other Diets, Research
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World Health Organisation, meat & cancer

Today, 26th October 2015, the World Health Organisation declared the consumption of red meat as “probably carcinogenic to humans, based on limited evidence that the consumption of red meat causes cancer in humans” and declared processed meat as “carcinogenic to humans, based on sufficient evidence in humans that the consumption of processed meat causes colorectal cancer.” The red meat association was observed mainly for colorectal cancer.

The experts concluded that each 50 gram portion of processed meat eaten daily increases the risk of colorectal cancer by 18%.”

From the headline “carcinogenicity of consumption of red and processed meat”, we’re already down to colorectal (bowel) cancer and “probably”.

The press release is here. The Lancet article is here or here (it may not be on open view for long).

So do we need to stop eating red meat and/or processed meat? Let’s dissect the headline more accurately:

1) Where this data comes from

The gold standard of evidence is a meta-analysis of randomised controlled trials – pooling together studies where an intervention was matched against a control group to see what impact A had on B. As far as I am aware, no intervention studies have ever been done testing the impact of 50 grams of processed meat per day as an isolated intervention, or any amount of processed or red meat as a sole intervention for that matter.

We are thus looking at observational studies. This is where a large group of people (e.g. the Nurses’ Health Study or the Health Professionals Follow-up Study) are asked loads of questions and given health tests (blood pressure, weight, height, cholesterol ho ho etc) at the start of the study. This is called the baseline. These people are then followed for years to see what conditions they go on to develop.

Researchers then look at the data to try to see patterns. No pattern = no journal article, so look hard! They may observe a pattern between people who consume processed meat and people who go on to develop bowel cancer. This is then reported in a journal article and it is all such articles that have been reviewed by the World Health Organisation.

The first point to make, therefore, is that all of this is based on notoriously unreliable dietary questionnaires. Many ask what you ate yesterday or over the past 7 days. Here’s the European Prospective Investigation into Cancer questionnaire, one of the best possible questionnaires, as it asks for food intake over the past year. How accurate do you think yours would be?

2) One’s diet vs. one food

By singling out red meat/processed meat in this way, the whole diet and lifestyle of a person is not taken into account. There is a world of difference between the health of a burger/hot-dog/ketchup/white bun/fizzy drink guzzling couch potato and a grass-fed-steak eating/CrossFit/six-pack Paleo specimen.

As I showed in this blog, the baseline for the processed meat eaters showed that they were far less active, had a higher BMI, were THREE TIMES more likely to smoke and almost TWICE as likely to have diabetes. This makes processed meat a MARKER of an unhealthy person, not a MAKER of an unhealthy person.

Even if all the smoking/exercise/other conditions baseline factors are adjusted for, there is no possibility of adjusting for all the dietary factors that make up the couch potato vs. the Paleo buff. The whole diet is not adjusted for when the one line (meat) is targeted.

3) Real food vs. processed food

I’m a real foodie. I pretty much spend my life writing and talking about real food and the nutrition it contains. I am the first to say “Do eat real food; don’t eat processed food” and I include processed meat as processed food – something to avoid. However, this WHO report describes processed meat as “meat that has been transformed through salting, curing, fermentation, smoking or other processes to enhance flavour or improve preservation.”

As Peter Cleave, Surgeon Captain, (1906-1983) said: “For a modern disease to be related to an old fashioned food is one of the most ludicrous things I have ever heard in my life.” To think that real meat, or meat preserved in natural ways, is bad for us is ludicrous. 1) You’d have to explain how we survived the past 3.5 million years, since Australopithecus Lucy first walked upright; especially how we survived the ice age(s). 2) You’d have to explain why all the nutrients we need to live (essential fats, complete protein, vitamins and minerals) are found in meat if it were trying to kill us at the same time.

Meat needed to be naturally preserved with salting, curing, drying, smoking etc or we would have needed to binge on the kill and risk dying of starvation before the next kill. The WHO report should have separated traditional ways of preserving meat from modern manufactured processing (where sugars and chemicals are added – just read the label). Similarly – if there is any harm in red meat, it will be because manufacturers have got involved and fed the poor animals grains, which they cannot digest and then pumped them with drugs to medicate the resulting illness. (Chris Kresser presents the view on nitrates here, if you’re interested).

This should be a call to action to get back to your butcher, know him/her by name, know where your meat comes from, know how s/he prepares bacon & hand-made sausages and enjoy the health benefits of real food while supporting the grafters who provide it.

4) Association vs. causation

Even allowing for the weakness of observational studies, and the unreliability of dietary questionnaires, and the notion that food consumption can be a marker not a maker of health, and the whole dietary intake that has not been taken into account and the ignorance of the chasm between real and processed food, this is still association, not causation.

I always wish that these huge and expensive studies would ask what colour socks the participant is wearing. I bet I could find an association between red sock wearing and one type of cancer if I looked hard enough. Would the headline be red socks cause cancer?!

5) Relative vs. absolute risk

The press release headlines with “each 50 gram portion of processed meat eaten daily increases the risk of colorectal cancer by 18%.” Crikey. 18%! Put that bacon sarnie down now (see – don’t blame the bacon for what the white bread & ketchup did!) This, however, is the game that all of these observational study research press releases play and it’s disgraceful scare-mongering.

Shall we look at the absolute risk?

Cancer Research UK has terrific statistics on all types of cancer. I’ve just looked at the UK. They do have data for other countries if you want to do your own rummage. The incident rate for all people in the UK, age-standardised (you pretty much won’t see bowel cancer before the age of 50 – look at the age data), in 2011 was 47 per 100,000 people.

47 per 100,000 people.

You would need to know 2,128 people, including enough older people, to know 1 person who developed bowel cancer in the UK in 2011.

Now – let’s do that relative vs. absolute risk thing.

Assuming that everything the WHO did had been perfect and that there really was an 18% relative difference between those having 50g of processed meat a day and those not (and assuming that nothing else was impacting this), the absolute risk would be 51 people per 100,000 vs. 43 people per 100,000.

Now where’s the bacon and egg before my CrossFit session?!

The likely harm of this report:

The Lancet article does at least have the decency to mention the nutritional value of red meat: “Red meat contains high biological value proteins and important micronutrients such as B vitamins, iron (both free iron and haem iron), and zinc.” That’s still a bit of an understatement. Try both essential fats; complete protein; and the vitamins and minerals needed for life and health.

What will be the consequences of this report scaring people away from real meat? It takes approximately 250g of sirloin steak to get the daily 10mg of zinc; over a kilo of the same steak to get the recommended daily iron requirement – and in the right form for the body. How about over 20 eggs to get the same iron intake? Still in a useful form to the body. Or 4.5 kilos of brown rice to get iron in the wrong form for the body?

What do I take from this report? There is a heck of a lot of bad science coming out the World Health Organisation, an organisation that should know better, but then there have previous cases of not knowing better.

Nothing has changed from my fundamental belief that human beings should eat real food (especially grass-fed, naturally reared meat and naturally preserved meat). Avoid processed food, including meat processed by fake food companies. And take every observational study that doesn’t know these five points above with a hefty pinch of salt.

Posted in Gov. Policy, Media comments, Research
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Jennifer Elliott vs Dietitians Association of Australia

This is my first guest blog post. It is written by Jennifer Elliott, an Australian dietitian who has become well known this year, in the diet and health on line community, for having been de-registered by her professional body: the Dietitians Association of Australia (DAA). Her case has led to her employer taking the extraordinary position that “Nutritional advice to clients must not include a low carbohydrate diet…” Even more extraordinary when you discover that Jennifer’s advice was being given in the context of insulin resistance and type 2 diabetes and she was merely suggesting that people with an inability to handle glucose/carbohydrate (i.e. diabetics) may benefit from consuming less of it. Here Jennifer shares her story, with links to her blogs, for those who would like to know more.

In Jennifer’s own words…

“I have been a dietitian for 35 years and for over 10 years have recommended carbohydrate restriction to clients with type 2 diabetes (T2D) and insulin resistance (IR).

This was not my practice in the early days. When I graduated in 1979, the Australian Dietary Guidelines had just been released. We were taught that these guidelines were the basis of a healthy diet for everyone and for many years I believed this.

I converted my parents to a low-fat, almost vegetarian diet, with plenty of wholegrain carbs, fruits and vegetables. I was part of the new generation of dietitians who were spreading the word about healthy “complex carbohydrates”, as they were then known.

When I started a family, I took it a step further by moving to the country for the best lifestyle possible for my children; home grown/ home cooked vegetarian meals, little processed foods, plenty of outside play and TV time limited to what my now adult children refer to as deprivation levels.

Two of my children thrived in this environment – healthy, energetic and lean – but my middle daughter, Jeanne, was different. She gained weight around the tummy at an early age, seemed to have less energy than her siblings, was a mouth-breather, suffered with reflux and could be moody at times. All signs I now recognise as relating to insulin resistance (IR).

At around 12 years of age she gained a lot of weight quite quickly and by age 14 was borderline obese. And I was at loss to explain why.

I am forever grateful for what happened next. I was in the right place at the right time to meet a GP whose family situation was remarkably similar to mine: three slim, high energy, eat-what-they-like children and one with a weight problem. After hearing about the presence of IR in young, seemingly healthy children (and not just in people with diabetes as she had been taught), this GP had her daughter tested and suggested the same for Jeanne. A two-hour Glucose Tolerance Test (GTT), with the addition of five insulin measures, showed normal blood glucose levels (BGLs) but a high insulin response, fitting the diagnostic criteria for IR.

Fifteen years ago, my knowledge about IR was limited to its connection with type 2 diabetes. The significance for a 14 year old with normal BGLs was a mystery to me.

The research begins

I started with a Google search of IR, which brought up 1.3 million entries and the accompanying question of why hadn’t I been taught any of this?

I narrowed my search down a little and started reading. It wasn’t like researching for a school assignment that I had no interest in. This was finding out what was happening biochemically to my daughter, as well as five million other people in Australia with this condition. It was fascinating. Answers to all the pieces of the puzzle were in the literature and I found explanations for Jeanne’s mouth breathing and snoring; why the weight went on predominantly around her tummy; why she seemed not to have an off-switch when it came to eating at times; her mood swings, reflux and lack of energy.

Carbs and insulin

It was clear that higher than normal insulin levels were to blame and that a diet designed to reduce these levels is what was needed. It was also clear that a reduced carbohydrate diet was the way to go. We started experimenting with different diet approaches, and, with instant feedback available from what I jokingly called my live-in guinea pig, I learnt more than would ever be possible from just the literature or in a clinical setting. This experience was invaluable.

The diet we settled on was very low carb during the day, but allowing some carbs in the evening meal. For Jeanne, the eating plan was generally eggs, bacon, tomato, avocado for breakfast; protein and salad at lunch; protein and veggies for the evening meal with some carbohydrate in the form of fruit, yoghurt or dark chocolate, etc.

This worked well: no excessive hunger, good energy levels, even moods, no reflux and easily maintained healthy weight. Jeanne has now been eating this way for many years and has maintained all those positive changes. She doesn’t think of herself as being “on a diet”, because as she says, “This is just the way I eat”.

Advising clients on low carb (LC) diets

Before I started advising clients on a lower carb approach for IR and T2D, I anticipated the FAT problem. One of the main arguments against LC is that such diets are higher in fat, particularly saturated fat, and the belief that this will increase the risk for heart disease. Although this is not bourne out in clinical trials, where an improvement in lipid profiles is generally observed, I realised that I didn’t know enough to argue a case for a higher fat diet if I was taken to court (my benchmark).

To be fully confident in recommending my new LC diet approach to clients, I started researching what I, and I believe all dietitians who have qualified since, have never been taught: the basis for the diet/heart hypothesis.

The end result was the publication of my paper: Flaws, Fallacies and Facts: Reviewing the Early History of the Lipid and Diet/Heart Hypotheses and confidence that the diet/heart hypothesis is so flawed that it should not be used as the basis of diet recommendations.

I cautiously introduced the idea of my new approach to GPs in my area. I explained that I would be trialling restricted carbs to people who fit the diagnostic criteria of Metabolic Syndrome and were therefore likely to be IR (high triglycerides, elevated BGLs, central weight, low High Density Lipoprotein and high Blood Pressure). I asked that recent biochemistry be provided and rechecked after three months to assess effects of the diet and that medications, especially BP and blood glucose lowering meds, be monitored and reduced if required.

The results were as expected; weight loss, improved BGLs and reduction in medications.

One example of the benefits of carb reduction was seen in a man with T2D, who after 7 weeks on a LC diet stopped taking insulin, lost 13 kg and reduced his HbA1c from 10.7 to 7.7 mmol/l.

Charged with using a “non-evidence-based” dietary approach

For the last 10 years, GPs have been referring patients to me because of the diet approach I use and the results they have seen in their clients. That all changed recently when a dietitian initiated an inquiry into my use of LC diets, alleging that they are not evidence based.

My work places and the Dietitians Association of Australia (DAA) conducted investigations into the allegation. I was confident that the verdict would be in my favour, not only because of the positive results clients were achieving, but also because I was following the latest guidelines from the American Diabetes Association, as is recommended practice for dietitians in Australia.

How naïve!

I was deregistered by the DAA in May 2015, for reasons that are not entirely clear. It appears that they didn’t like the way I kept notes on one client.

It is also apparent that the DAA endorses a regular intake of carbohydrate foods for management of various conditions including diabetes and obesity.

Based entirely on my deregistration from the DAA, the Southern New South Wales Local Health District (LHD) dismissed me and have instructed that dietitians in the LHD must follow DAA’s recommendations for diabetic diets, and are prohibited from advising clients on low carb approaches. And if any of the GPs, who used to refer to me, ask for LC advice for their patients, they will be advised “a low carbohydrate intake diet is not currently supported by the DAA”.

International Support

Richard Feinman, Professor of Metabolism and Cell Biology at the State University of New York, made an innocent offer of help last year, which morphed into another full-time job for him. He has read all the correspondence and decisions, offered to discuss the science behind LC with the DAA (was refused) and has been as incredulous as myself with the final decisions.

I have written about this fiasco on my blog and have received incredible support from people all over the world. Letters in support of LC diets as well as calls for my reinstatement have been sent to the DAA and Health Ministers. Whereas I was once quite hopeful that these voices would be listened to, it looks like I was a little optimistic.

What now?

Loss of employment and being forced out of my comfort zone has led to some unexpected developments. I’m looking at extending the content of my book into a 12-week online program for people with T2D, and there’s a chance a local GP surgery will join with a NSW university in a clinical trial comparing the LC approach I recommend with standard higher carb advice.

When we could see the way it was headed, Professor Feinman asked how I would feel if I didn’t get my job back but my case became a catalyst for change. Increased awareness of the benefits of LC would be a start and perhaps many more people would hear that T2D and IR can be managed and often reversed with carb restriction. I’d definitely be happy with that.”

Jennifer Elliott

My close

I first came across Jennifer when I read her paper, referenced above. I highly recommend reading it. Jennifer was working from the other side of the world in a similar area to me – examining the evidence base for our global dietary guidelines. Jennifer found that there was no evidence. I have found the same. We have both challenged our respective governments to show us the evidence. Both have failed.

This was bad enough. What happened next beggared belief. The Dietitians Association of Australia (DAA), declared war on one of their own members; deregistered a highly experienced, research-driven practitioner and took away the job, income and livelihood of a committed professional, whose only crime was to try to improve the health of her clients. And Jennifer didn’t just try; she succeeded. Against all measures that matter: weight; reliance upon medications; blood glucose levels; blood lipid levels; health; energy and so many more.

If the DAA position were evidence based, other approaches that work should still be embraced. Nothing that can help patients should be dismissed. The fact that the DAA position is not evidence based, just makes their stance worse. I think that Jennifer sealed her fate when she wrote that brilliant paper, challenging everything that she had been taught. Credit to her, you would think, but no. The paper was published in October 2014 and the DAA executed their revenge soon afterwards.

I sincerely hope that Richard Feinman is right and that this case will be a catalyst for change. It needs to be. Something good needs to come from this because, as it stands, this has been a lose, lose, lose for everyone: a personal loss for Jennifer; a huge loss of credibility and reputation for the DAA; and an immense loss for patients who are being denied the opportunity to benefit from anything other than conventional advice.

Just as a final thought, here are the sponsors of the Dietitians Association of Australia. Jennifer didn’t stand a chance.

Posted in Conflict, Gov. Policy, Other Diets
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National cholesterol month

I was at a dinner party recently when the subject of cholesterol came up. Every (lay) person around the table turned out to be an expert: “Cholesterol is bad”, said one. “Well actually there’s good and bad cholesterol”, clarified another. “Our cholesterol shouldn’t be higher than five”, volunteered one sage. Five what? They had no idea. Why is cholesterol bad? Not a clue. If ever there were a substance vilified with the utmost ignorance – cholesterol is it.

This month, October, is national cholesterol month in the UK. September was national cholesterol month in the US. Call me cynical, but staggering the months gives one sixth of the year when the increasingly global on-line world is being manipulated to have cholesterol front of mind. Leading the charge in the UK appears to be Heart UK – an organisation masquerading as a charity, which more accurately should be seen as a voice piece of the cholesterol lowering industry. Here are Heart UK’s backers.

This is what we should be told in national cholesterol month and these are the things that my fellow diners should have been saying about cholesterol:

1) Cholesterol is utterly life vital

Every human being would die instantly without cholesterol. Every single cell in the human body depends upon it. We would have no digestion or hormone function without cholesterol. Cholesterol is critical for brain and memory functions – even though the brain is only 2% of the body’s weight, it contains approximately 25% of the body’s cholesterol (Ref 1). Cholesterol is essential for bones and all the roles performed by vitamin D. We could not reproduce without this life vital substance. Hence, not only would humans die without cholesterol, the human race would die out.

2) Cholesterol is so vital that our body makes it

It cannot be left to chance that we would need to get cholesterol from an external source, such as food. One of the key reasons that we need to spend approximately one third of our lives sleeping is to give the body time to produce cholesterol, repair cells and perform other essential maintenance.

3) There is no such thing as good and bad cholesterol

The formula for cholesterol is C27H46O. There is no good or bad version. Ignorant people call HDL ‘good’ cholesterol and LDL ‘bad’ cholesterol. Neither HDL nor LDL are even cholesterol – they are lipoproteins. HDL is High Density Lipoprotein and LDL is Low Density Lipoprotein. HDL is smaller than LDL and is therefore higher in density. Lipoproteins carry cholesterol, protein, phospholipids and triglyceride around the blood stream to undertake vital roles.

4) The cholesterol blood test is a guess

The standard blood test can only measure total cholesterol & HDL. So we have one equation, four unknowns, only two of which can be measured:

Total cholesterol = LDL + HDL + Triglycerides (VLDL)/5

Any GCSE maths student will tell you that this is insolvable.

Your best option is not to get your cholesterol ever tested and then you can never be a victim of the cholesterol lowering machinery that will kick in if your guestimate fails the following test…

5) There is no science behind the number “5”

Even after years of artificial intervention, the average cholesterol level in the UK is somewhere between 5.6 – 6.3 mmol/l (Ref 2) (216-244 mg/dl). The powers-that-be have decided that this should be 5mmol/l (193 mg/dl). This is like saying that the average height for a woman is 5’4” and we have decreed that it should be 5’1”. We could then stop the body from performing a natural function (growth) by administering drugs to stop growth hormones from doing their job. I trust that this analogy disturbs you. It is, however, frighteningly similar to what we are doing with attempts to lower average cholesterol levels.

6) “There’s no connection whatsoever between cholesterol in food and cholesterol in blood. And we’ve known that all along.” Ancel Keys

Dietary cholesterol is only found in animal foods – meat, fish, eggs and dairy. Ancel Keys spent the 1950s feeding humans high levels of animal foods to see if dietary cholesterol had any impact on blood cholesterol levels. He concluded unequivocally that it did not. He never deviated from this view. While exonerating cholesterol, Keys also exonerated animal foods at the same time – and any substance contained therein. If large intakes of animal foods have no impact on cholesterol levels, then neither animal foods per se or any component of these foods (water, protein, cholesterol, saturated or unsaturated fat) have any impact on cholesterol levels!

Unaware of this irrefutable logic, diet ‘experts’ will tell you that saturated fat raises LDL and unsaturated fat raises HDL. They won’t tell you how. I have yet to find a biochemist who can explain how this can happen – let alone that it does. As every food that contains fat contains all three fats (saturated, monounsaturated and polyunsaturated) you cannot consume any food that has saturated and not unsaturated fat, or vice versa.

Even if the very small 3 grams per 100 grams of unsaturated fat in sirloin steak (Ref 3) could raise HDL and even if the even smaller 2 grams per 100 grams of saturated fat in sirloin steak could raise LDL – where would this leave our insolvable equation?!

The US dietary guidelines are due to be re-issued this year. The draft report announced in February 2015 that “cholesterol is no longer a nutrient of concern” (Ref 4). It never was you Muppets!

7) Low cholesterol is associated with higher mortality. High cholesterol is associated with lower mortality

I have analysed cholesterol levels and death rates for all 192 countries for which the World Health Organisation has data. You may need to read this carefully. The lower the cholesterol levels, the higher the death rate; the higher the cholesterol levels, the lower the death rate. This holds for men and women and for heart disease deaths and total deaths from any cause – for all the countries in the world. Knowing how utterly vital cholesterol is to human life, this makes complete sense (Ref 5).

8) Follow the money

Why would humans put so much effort into stopping the body from doing something that it is designed to do – make cholesterol?

Statins are drugs that impair the body’s production of cholesterol. One statin alone, Lipitor, has been worth $125 billion to Pfizer since 1997 (Ref 6). This statin is the most lucrative drug in the world. It is not the only statin.

Thankfully statins don’t work perfectly. If they stopped the body producing cholesterol altogether they would have a 100% death rate.

An entire low-fat spread industry, worth billions, has emerged simply by adding plant sterols to margarines because the brainwashed public will buy anything with “cholesterol lowering” properties. These plant sterols compete in the human body with human cholesterol and the overall impact on heart health is serious (Ref 7). I trust my body to make the cholesterol it needs. I’m not going to replace this with a foreign compound.

Back to the dinner party: While my healthy heart sank at the nonsense being asserted by intelligent acquaintances, there was an upside to their naive acceptance of propaganda: When the cheese course arrived, there was plenty to be enjoyed by the enlightened!

References:

Ref 1: http://www.neurology.org/content/71/17/1368.extract

Ref 2: http://www.zoeharcombe.com/2014/06/diabetes-cholesterol-bp-normal-is-no-longer-normal/

Ref 3: http://nutritiondata.self.com/facts/beef-products/7493/0

Ref 4: http://health.gov/dietaryguidelines/2015-scientific-report/

Ref 5: http://www.zoeharcombe.com/2010/11/cholesterol-heart-disease-%E2%80%93-there-is-a-relationship-but-it%E2%80%99s-not-what-you-think/

Ref 6: http://www.crainsnewyork.com/article/20111228/HEALTH_CARE/111229902/lipitor-becomes-worlds-top-selling-drug

Ref 7: http://thescipub.com/abstract/10.3844/ojbsci.2014.167.169

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