137. Corruption of the Scientific Literature: Ghost Writing

Anyone reading a scientific paper in a reputable journal which uses a peer-review system expects the information to be reliable and objective. Unfortunately this is not necessarily the case because there is now convincing evidence that the pharmaceutical industry devotes huge resources to influencing the way in which the material is presented with particular reference to the conclusions. Following court cases in the USA drug companies have been required to disclose documents which reveal that ghost writing and guest authorship is now common practice.

Ghost writing exists when someone has made substantial contributions to writing a manuscript and this role is not mentioned in the manuscript itself. It often occurs simultaneously with guest authorship (sometimes called honorary or gift authorship), where the contributions of the named authors are very limited, or non-existent (1). The prime purpose of these strategies is to ensure that the benefits of any drug involved in the research are presented in the best possible light and that any undesirable side-effects are minimized. Most of the hard work preparing the manuscripts is done by professional writers whose name may not even be included as an author. Those listed officially as authors are usually well-known in the field and are used primarily to lend credibility to the paper. According to Jerome Kassirer, a former chief editor of the New England Journal of Medicine:

“Ghost writing debases fundamental tenets of the medical profession. It violates authors’ personal integrity, responsibility, and accountability. More importantly, ghost writing threatens the very fabric of science and thus the validity of our medical knowledge, and in doing so it jeopardizes patient care.”(1)

He refers to one specific example in which the marketing department of a pharmaceutical company promoted one of its products by carefully selecting positive reports and playing down any risks. It then made an agreement with a reputable academic to be paid a fee to submit the paper to a journal under his own name (2).

Richard Smith, a former editor of the British Medical Journal, and a colleague concluded that:

The way medical journals publish the results of clinical trials has become a serious threat to public health” (3).

In their opinion, clinical investigators have become adept at selecting results favourable to their paymasters, very often pharmaceutical companies, which are used by them to promote their products. As a consequence the researchers profit financially and advance their careers. The editors are provided with material to publish and the companies/organisations which own the journals are profitable. The losers are the trial participants whose contribution to research is wasted, the patients who must swallow the drugs despite the distorted evidence, and the public who must pay for the drugs.

As an example of what is happening is that unfavourable results may be excluded or removed from the paper that is subsequently published. By contrast, favourable results may be published many times (cloning) and then subject to intensive marketing to ensure that they get noticed.

CASE STUDY

As a result of litigation about Hormone Replacement Therapy (HRT) the Wyeth pharmaceutical company had to release 1500 documents which have been analyzed to provide valuable insight into these issues (4).

HRT was approved in 1995 and promoted on the grounds that the treatment would prevent cardiovascular disease (CVD), osteoporosis, Alzheimer’s Disease, colon cancer, tooth loss, and macular degeneration. However in 2002 the Women’s Health Initiative (WHI) demonstrated conclusively that HRT failed to prevent CVD. It was also discovered that it increased the risk of breast cancer and stroke. Further analyses showed that HRT increased the risk of dementia and incontinence.

The documentation revealed that companies devote considerable resources to the preparation and publication of articles in the medical journals as well as posters for display at meetings in order to establish key marketing messages. It is common practice to employ specialist companies in education and communications to create the papers and get them placed in journals and magazines that will be read by those in the medical professions.

With respect to HRT, Wyeth engaged DesignWrite, whose role was to help the company decide what data to present, recruit “authors”, choose journals, create abstracts for meetings with the object of positioning the product appropriately to influence those responsible for prescribing. Between 1997 and 2003 DesignWrite produced over 50 peer-reviewed papers and more than 50 scientific abstracts and posters, journal supplements, internal white papers, slide kits and symposia.

The analysis of the disclosed papers came to the conclusion that DesignWrite helped Wyeth create ghostwritten reviews and commentaries which were to:

  • Mitigate perceived risks of hormone-associated breast cancer
  • Promote unproven, off-label uses, including prevention of dementia, Parkinson’s Disease and visual impairment
  • Raise questions about the safety and efficacy of competing therapies
  • Defend cardiovascular benefits, despite lack of reliable evidence to support this position
  • Position low-dose hormone therapy

Despite the fact that the WHI had established that HRT did not prevent CVD, stroke or Alzheimer’s Disease, other benefits were devised and promulgated. It was suggested that HRT treatment was repeatedly shown to increase collagen content, dermal thickness and elasticity. Many ghost written articles questioned the link between HRT and breast cancer or falsely implied that breast cancers associated with HRT are less aggressive.

The insight gained from these studies is truly alarming and demonstrates the extent to which information is being manipulated in order to promote the sales of drugs of doubtful efficacy. There is a total failure to apply any kind of ethical or socially responsible standards. Essentially it means that not only are members of the public being defrauded but that they may also experience serious damage to their health.

It is highly significant that when this case study was published in 2010 many doctors were still prescribing HRT to menopausal patients even though there was sound evidence of its danger. The author concluded that:

This non-evidence–based perception may be the result of decades of carefully orchestrated corporate influence on medical literature.”

 

REFERENCES

  1. P C Gøtzsche, J P Kassirer, K L Woolley, E Wager, A Jacobs, A Gertel, C Hamilton (2009)
    http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000023
  2. J S Ross et al (2008) Journal of the American Medical Association 229 (15) pp-1812-1800
  3. R Smith and I Roberts (2006)   http://www.plosclinicaltrials.org/article/info%3Adoi%2F10.1371%2Fjournal.pctr.0010006
  4. A J Fugh-Berman  (2010) http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000335

 

136. Stroke Association. Digging beneath the Surface

I have just received a mail shot from the Stroke Association which points out that research into stroke is currently woefully underfunded. In order to maintain its current commitment to stroke research and support further ground-breaking research projects in the future I am asked to donate £100. It continues:

“Tragically, approximately 50,000 people in the UK die from stroke each year. The known risk factors-such as high blood pressure, smoking, high salt intake and lack of regular exercise-increase the chances of having a stroke, but the truth remains that anyone, at any age, is potentially at risk of stroke.

Furthermore:

“..this is a particularly exciting time for stroke research as the ongoing development of technologies such as advanced Magnetic Resonance Imaging (MRI) scans and new drug treatments have the potential to vastly increase our understanding of how to effectively prevent and treat stroke. Money invested in stroke research is an investment in a healthier, more active and independent future for thousands of people across the UK”.

The letter includes a separate document describing research which is aimed at assessing the effectiveness of clot removing devices. This is being conducted by Professor K Muir who is SINAPSE Chair of Clinical Imaging at the University of Glasgow. It is hoped that this approach may prove to especially valuable for patients who do not respond well to the clot busting treatment with thrombolytic drugs.

The results of this project may ultimately benefit some patients. However the difficulty I have is that unless there is a genuine effort to identify the fundamental causes and take steps to eliminate them, it is highly likely that the person will suffer another stroke. The information provided in the letter states that there are more than one million people living with the after-effects of stroke and that half of all stroke survivors are left with disabilities. It is obvious that the main thrust of the Association’s work is to support research to find a “cure”. However the reality is that this approach can never overcome the disease effectively.

If we are to make genuine progress with strokes then it is essential to place the main emphasis on prevention. It is preferable to help people avoid having strokes in the first place rather than having to try to “cure” them after the event.

I have looked at the Association’s website (1) and it is clear that the prime objective is raise money to fund research to help people affected by stroke. The emphasis on providing advice on how to prevent strokes is somewhat limited. I was particularly interested to find out what information was given about a healthy diet. Here is what we are told about cholesterol:

Cholesterol is a type of fat produced by your liver. It is also found in foods like meat and dairy products.  Your body needs small amounts of it, but too much is unhealthy. Extra cholesterol can travel around the arteries in your body, narrowing them and increasing your risk of stroke.  You can lower your cholesterol by making sure your diet is healthy and low in saturated fats[i]. Your doctor may advise you to take medication, too.

If you are over 40, you should have your cholesterol checked regularlyIt should be under 5mmol/L. “

It is somewhat bizarre that one of the references cited in the above quotation is the NHS Choices website, which is not exactly a reliable fount of knowledge as I have shown recently (3). Apart from that, it is just re-gurgitating all the old rubbish about cholesterol and saturated fat (SFA), which has been totally discredited as explained in this blog (4). To say that cholesterol travels around the arteries causing them to narrow is a weird statement which has absolutely no basis. Cholesterol is a substance which is essential to life. In fact there is convincing evidence that too little cholesterol rather than excessive amounts may be dangerous to health (5). Similarly lowering cholesterol may cause undesirable side-effects. By contrast, the higher the level of cholesterol levels in the blood the greater the life expectancy especially in women (6).

The case for lowering SFA is based on the belief that it raises blood cholesterol and therefore increases the risks of developing heart disease. As the “cholesterol theory” no longer has any justification the advice to reduce SFA cannot be sustained. Furthermore it is ludicrous to attribute similar characteristics to a family of fatty acids which vary in size from 4 carbon atoms to over 20. It is now widely recognised that many of the individual fatty acids are important nutrients in their own right and if the body lacks an adequate supply it may not be able to function effectively.

In recent years, it has become very clear that it is sugar and refined carbohydrates rather than the SFA which is the primary cause of many of the common chronic diseases, including heart disease, Type 2 diabetes (T2D), cancer and possibly even Alzheimer’s Disease. For example, many individuals with T2D have been able to overcome the condition effectively by reducing the amount of sugar and refined carbohydrates in their habitual diet (7). Therefore it is significant that the chances of developing a stroke are increased the higher the level of triglycerides (fat) in the blood, which in turn is largely determined by the amount of carbohydrates consumed (8).

Confirmation is demonstrated in an article by Laura Schoenfeld which recommends the following advice on healthy eating, which will help to avoid raised blood pressure that is a critical risk factor for stroke (9). These are as follows:

  • Reduce excessive carbohydrate intake, especially refined carbs and sugars
  • Increase intake of beneficial minerals like potassium, magnesium, and calcium
  • Eat grass-fed dairy products like ghee, butter, and cheese
  • Eat at least one pound of fatty fish per week
  • Drink tea
  • Eat more beets.

These are eminently sensible and if followed will help to reduce the risks of wide range of common diseases. The Stroke Association would do well to take note of this information and completely revamp the advice it provides on diet.

CONCLUSION

Despite the impression which people may have about the Stroke Association, the work that it does will certainly not help to reduce the incidence of strokes in the short term. According to its own publicity one its objectives is:

Life-saving research: working towards a world with fewer strokes”.

While I accept that the results of the research may help those who suffer a stroke to improve their chances of survival, it is difficult to understand how it will lead to fewer strokes. As the Association appreciates, many of those who survive will be seriously incapacitated. The only way to reduce the number is by prevention. There is a considerable body of knowledge on how to achieve this. In particular, by evaluating diet and if necessary making changes.  The Association could make a very significant contribution by disseminating what is currently known. As I have already explained the information about healthy eating shown on the Association’s website cannot be supported by reliable research and it is highly likely that those who follow the advice will experience a deterioration in their health. Recommendations to consume sources of carbohydrates such as bread, potatoes, rice and pasta will result in high levels of blood glucose, which will stimulate excessive insulin production and cause damage to many organs by insulin resistance.

In my opinion the work of the Stroke Association while appearing very laudable, will have little impact on the incidence of strokes. The approach adopted in most of the research projects is to try to find a cure. As I have explained this is largely a forlorn hope. The key question is “Who actually benefits?” The answer of course is the research community plus the manufacturers of the drugs and the devices which may possibly alleviate (not cure) the condition. The website lists many pharmaceutical companies among the sponsors! What do the stroke sufferers and the fundraisers gain? The harsh reality is “not a lot”!

So I will not be donating to this particular charity and I would respectfully suggest that anyone else who is considering making a donation asks some penetrating questions before parting with hard-earned cash.

REFERENCES

  1. http://www.stroke.org.uk/
  2. http://www.stroke.org.uk/referenced/how-prevent-stroke
  3. http://vernerwheelock.com/?p=614
  4. http://vernerwheelock.com/?p=554
  5. http://vernerwheelock.com/?p=505
  6. http://vernerwheelock.com/?p=105
  7. http://vernerwheelock.com/?p=558
  8. http://onlinelibrary.wiley.com/doi/10.1002/ana.22384/abstract
  9. http://chriskresser.com/6-ways-to-lower-blood-pressure-by-changing-your-diet


 

135. Spin and Bias in Reporting Trials on Pharmaceuticals

There is now convincing evidence that the manufacturers of drugs are absolutely unscrupulous in the way in which their products are marketed. Invariably the benefits are emphasised and overplayed while any side-effects are minimized. However all drugs have to be thoroughly tested and evaluated before they can be granted approval by the authorities. But questions have been raised about the objectivity and reliability of the information submitted by the companies as part of the approval process and how this is communicated to the medical/scientific community.

Turner and colleagues examined the data submitted by drug companies to the US Food and Drugs Administration (FDA) in support of applications for approval for 12 different anti-depressants. This information was then compared with what was published in the scientific literature, which is how the medical community learns about the drugs (1). The authors had access to the official reviews conducted by the FDA and used this to classify the anti-depressants as positive, negative or questionable (neither positive nor negative). In total there were 74 studies submitted to the FDA, of which 38 were judged to be positive and 37 of these were subsequently published as scientific papers. This left 36, of which 24 were considered negative and 12 questionable. Three of these were published as not positive and 22 were not published. However the remaining 11 were published but in the opinion of Turner et al were presented as positive, despite the fact that this was in direct conflict to the FDA decision!

It was noted that in all these journal articles the methods reported appeared to depart from the pre-specified method submitted to the FDA.  Although for each of these studies the finding with respect to the protocol-specified primary outcome was non-significant, invariably the authors were able to identify a different outcome that was positive which was then highlighted as if it were the primary outcome. The non-significant results for the pre-specified primary outcomes were either subordinated to non-primary positive results or omitted.

Essentially what is happening is that the positive results were made available which is perfectly reasonable. Some of the negative results probably never see the light of day but would certainly be of value to the medical profession. The twisting of results to give a favourable impression, which is in direct conflict with the results of the trial, is totally unacceptable.

A similar but more comprehensive approach has been adopted in 2 reports published by the Public Library of Science (PLoS). This is a non-profit scientific publishing project aimed at creating a library of open access journals and other scientific literature under an open content licence (2,3).

In the first one, all New Drug Applications (NDAs) submitted to the FDA between January 1998 and December 2000 were analysed (2). This consisted of 909 trials with 90 different drugs. Of the trials, 394 of them were matched to publications in the medical literature. A total of 340 trials were judged to be pivotal and 76% of these were published. There was strong evidence of publication bias in the sense that trials with statistically significant results were more likely to be published than those which were non-significant.

In the second study, Kristin Rising and colleagues analysed NDAs which were submitted in the years 2001 and 2002 (2). These were then compared with the relevant scientific publications. This study reached conclusions that were effectively the same as those studies described above. There was evidence of failure to publish and selective reporting of data. Once again the results of trials which were favourable to a specific drug were highly likely to be published. However where this was not the case it was found that there could be quite critical differences between the trials as they were described in the FDA reviews and their corresponding publications. There were 43 outcomes that did not favour the drug. Of these just under half of them (20) were not mentioned in the papers. In the remaining 23, the statistical significance changed between the NDA and the paper in 5 of them and in another 4 a positive outcome was given in the paper even though this was in conflict with the FDA review. In other words the favourable impression presented for these drugs could not possibly be justified.

It is clear that in the immediate period after approval by the FDA, which is the most relevant to public health, there is incomplete and selective publication of the results of the investigations which underpin the approval. As a consequence clinicians are likely to make inappropriate treatment decisions. The failure to provide complete and accurate information must be a severe impediment to any scientist wishing to improve the efficacy and safety of these drugs. In fact it has been advocated that publication bias should be regarded as a form of scientific misconduct (4).

A review by the Cochrane Collaboration identified 5 separate papers on publication bias which were published between 1992 and 1998 (5). These studies showed that trials with positive findings (defined either as those that were statistically significant, or those findings perceived to be important or striking, or those indicating a positive direction of treatment effect), had nearly four times the odds of being published compared to findings that were not statistically significant, or perceived as unimportant, or showing a negative or null direction of treatment effect. It was recommended that clinical trials are registered before recruiting participants so that review authors know about all potentially eligible studies, regardless of their findings.

In 2007 new legislation was introduced in Europe and in the US which has attempted to overcome these abuses. Nevertheless any meta-analysis which includes results obtained before that date must be regarded as suspect unless the authors were successful in obtaining all the relevant information on trials which produced negative outcomes that were not published.

REFERENCES

  1. E H Turner et el (2008) New England Journal of Medicine 358 (3) pp252-260
  2. K Lee et al (2008) PLoS Med 5 (9) e191
  3. K Rising et al (2008) PLoS Med 5 (11) e217
  4. I Chalmers (1990) Journal of the American Medical Association 263 (10) pp1405-1408
  5. S Hopewell et al (2009) The Cochrane Library, Issue 1: John Wiley & Sons

134. It is all happening in South Africa

We have now reached a position where it is absolutely obvious that the conventional recommendations on Healthy Eating which advise reducing saturated fat (SFA) and increasing complex carbohydrates are fundamentally wrong! In fact they are a key factor responsible for the deteriorating standards of public health in many countries as illustrated, for example, by the increasing incidence of Type 2 Diabetes (T2D). Despite the overwhelming evidence the official government policies, reinforced by the attitudes of the public health professions and institutions, continue to promote policies which are untenable. There can be little doubt that this is responsible for immense suffering and premature deaths. Ultimately these policies will have to be completely revamped although it would be a mistake to underestimate the reluctance of the establishment to admit its errors.

The shining light on the world stage is current developments in South Africa. Four years ago Tim Noakes, who is Professor of Sports Science at Cape Town University and a keen marathon runner, realised that his poor health was related to his habitual diet, even though he was complying with the official recommendations. He decided to evaluate the scientific literature which underpins the conventional advice and to his surprise discovered that the rationale just did not stand up to rigorous scrutiny. As so many others have recognised, the formulation of the recommendations which was undertaken by a US Senate Committee, was characterised by incompetence and influenced by leading academics more interested in pushing a dogma than trying to get at the truth.

As a consequence, he made changes to his own personal diet and within a very short period he lost weight and his risk factors for various diseases soon showed significant improvement. This was convincing proof to him that the key to a healthy diet is low not high carbohydrates and high fat not low fat.

Eventually he decided that he had to go public with this information and together with some colleagues produce a book entitled “The Real Meal Revolution”. The initial print run was for 3,000 copies. However it proved to be so popular that it was the Number One on sale of books in South Africa, where it has remained for over 20 weeks. Total sales are over 120,000. It really has struck a chord for the simple reason that it works. What is more the benefits, especially weight loss, are evident within a matter of weeks. Contrast this with the conventional approach to losing weight by calorie reduction, which rarely is effective. Furthermore the few who are successful invariably regain the weight lost within a relatively short period. There are uncanny parallels between the reception of “The Real Meal Revolution” and that of the pamphlet distributed by William Banting, a London undertaker 150 years ago (1). This explains why the term “Banting Diet” has been coined to describe a diet which is in line with the advice currently promulgated by Tim Noakes. There are Banting restaurants being established and members of the South African Parliament are taking a positive interest. It is possible that this may lead to a radical change in public health policy. If so, this could be a major breakthrough.

With this background, the fact that Tim and his colleagues have decided to organise an international Summit in Cape Town next February could turn out to be of enormous significance. Already many of those who are actively promoting and campaigning for a re-think on nutrition policies have signified their intention to be present. It is to be hoped that there will be a critical mass which will have an enormous impact right across the globe.

The first event which will be for two days is aimed primarily at medical practitioners. The content will focus on scientific data, studies and facts relating to a lifestyle based on a  Banting type diet.  This will be followed by a one-day event which will be geared to the needs of the general public.

Further details are available on the official website at http://www.lowcarbhighfatexperts.com/

This Summit will be a unique occasion, which I expect will have ramifications way beyond Cape Town and South Africa. I am confident that bringing together most of those who have been researching and disseminating the relevant information about the benefits to health of a diet low in carbohydrates and high in fat will convey a very powerful message, which will be felt around the world.

When dietary guidelines, which deal with the major constituents in the diet of fat, protein and carbohydrates, were first introduced the changes in eating habits were stimulated by the signals sent out by governments, professional institutions and bodies such as the World Health Organisation. These were then amplified by health promotion agencies, consumer organisations and the food industries. The food manufacturers and retailers had a particularly strong influence because of the resources available for marketing purposes. The big problem we have now is that these policies and strategies have become so firmly embedded that there is very powerful resistance to make any fundamental change to the messages that are being pushed out. As things stand at present certain foods which are perceived as “healthy” under current official guidelines will suddenly be regarded as “unhealthy” if the validity of the low carb approach becomes accepted as the norm. So companies providing such foods are unlikely adopt the new concepts without a fight. But perhaps what is of greater significance is those academics, civil servants and public health professionals who will have to admit that they have been wrong. Tim Noakes has already experienced the wrath of his academic colleagues (2).

As a consequence of the firmly entrenched establishment positions, it is highly unlikely that change will be achieved by a top down approach. I believe that the pressure for change will probably be generated from the bottom up that. In other words it will be dependent on people power. This is why I am convinced this Summit in South Africa could be the turning point. However it will only happen if the key messages are presented clearly and concisely so that there is no doubt about the way food consumption patterns have to be changed and how this can be achieved. “The Real Meal Revolution” certainly meets these objectives and so the big challenge is to replicate this in other countries. It is striking how many people have found that it is easy to adopt the principles and to get quick results with respect to weight loss. Even more significant is the number who have been able to improve their personal health. An excellent example is shown by the numerous case studies of individuals who have overcome T2D to such an extent that it has been possible to cease all treatment with drugs (3).

If all goes well I can envisage the Summit having an impact in a number of different ways, including the following:

  • Those who attend will gain new insight and understanding of how to achieve change and go home full of ideas and inspiration to make waves
  • It will provide knowledge and information and so provide a boost to those who promulgating these concepts via the social media
  • Already, there is coverage in some of the mainstream media and with luck this may well become much more extensive.

It really is very exciting. I plan to be there and I anticipate that it will a fascinating and stimulating experience.

REFERENCES

  1. http://vernerwheelock.com/?p=630
  2. http://vernerwheelock.com/?p=565
  3. http://vernerwheelock.com/?p=422

133. Obesity. A Public Policy Disaster!

In a previous blog (1) I was highly critical of the article on obesity which was written by The Guardian health editor, Sarah Boseley (2). It now emerges that the article was based on a book by Boseley which has just been published (3). Furthermore the launch of the book has been supported by an interview with the government’s chief adviser on obesity, Susan Jebb, who is professor of diet and population health at Oxford University (4). In this she is quoted as saying that people who are overweight may have to resign themselves to a lifetime of strategic dieting. The object should be to lose at least 5% of body weight at least every 5 years.

Jebb’s position is based on a number of assumptions all of which are extremely dubious. These are;

  • That being overweight or obese is damaging to health
  • That weight can be lost by reducing calorie intake
  • Weight loss will be beneficial to health.

I will consider each of these in detail.

Body Mass Index (BMI) which is calculated using information on height and weight is used to determine the different categories of overweight/obesity. Hence we have:

  • BMI 20-25 Normal
  • BMI 25-30 Overweight
  • BMI 30-35 Mildly obese
  • BMI    >35 Seriously obese

There is now extensive and convincing evidence that the greatest life expectancy is experienced by those who are classified as “Overweight”. In addition, there is no reliable evidence that there is any reduced expectancy even in those who are mildly obese (5). It is true that those who are seriously obese do have an increased mortality but the picture changes when the effect of physical fitness is incorporated.

The information in Table 1 shows that for those who are physically fit the death rates are pretty much the same irrespective of BMI. However for those who are not physically fit, the picture is totally different. For all categories the death rates are very much greater when compared with those who are fit but the greatest differences are shown for those with a BMI >35, which is not surprising. But what is especially interesting is huge difference in those with the normal BMI <25. This is highly significant is that those who on the basis of BMI alone would be regarded as healthy actually includes the unfit with a relatively high death rate.

This information demonstrates that if the government genuinely wishes to improve public health then it should forget about advising people generally to lose weight but place much greater emphasis on achieving a reasonable degree of physical fitness. Encouraging people to walk about one mile a day or take up activities such as dancing or gardening are likely to have enormous benefits even if body weight does not alter.

TABLE 1

EFFECT OF PHYSICAL FITNESS ON DEATH RATES (PER/1000 PERSON-YEARS) FOR DIFFERENT BMI CATEGORIES

BMI FIT UNFIT
18.5-24.9 1.2 4.9
25.0-29.9 1.2 2.7
30.0-34.9 1.6 2.5
>35.0 1.2 4.8

 

Nevertheless it is true that there are some people who are extremely overweight with BMIs which are >35 that are also inactive. Part of their problem may well be that they are so heavy that even a reasonable degree of activity is not feasible. There can be little doubt that some loss of weight would be beneficial and perhaps enable them to take to take some exercise. However the conventional approach which focuses on calorie reduction just does not work! This has been established by numerous studies (5).

In the 1990s an NIH Technology Assessment Conference Panel in the USA concluded that as many as 40% of women and 24% of men were trying to lose weight at any given time (6). Many have tried a variety of methods, such as diets, exercise, behaviour modification, and drugs. In controlled settings, participants who remain in weight loss programs usually lose approximately 10% of their weight. However, one third to two thirds of the weight is regained within 1 year, and almost all is regained within 5 years. For many overweight persons, achieving and maintaining a healthy weight is a lifelong challenge.

Despite persistent failure, the official advice in many countries continues to focus on calorie reduction. Invariably this is achieved by reducing the intake of fat on the grounds that fat is a concentrated source of calories. The inevitable result is an increase the proportion of carbohydrate-containing food and very often an increase in the absolute amounts. There is no question that a diet which is high in sugars and refined carbohydrates results in a rapid release of glucose, which is soon reflected in a raised glucose level in the blood. There is now convincing evidence that a diet of this type leads to the deposition of body fat and if it is maintained over a long period, it is virtually certain that the person will become obese. This explains why it is almost impossible to lose weight using a diet which is high in carbohydrates and low in fat. The reality is the only people who succeed in the short term are those who effectively starve themselves. Therefore it is not in the least surprising that invariably any weight lost is eventually re-gained.

What is even worse is that those few who succeed in losing weight by this approach are probably damaging their health (7). For example, a study conducted in Southern California monitored 140 men and 90 women with and without diabetes aged between 40 and 79 when the work commenced in 1972-1974. The follow-up was done after 12 years. It was found that those who lost 4kg or more had an increased death rate compared those who did not lose weight (Table 2). Similar results were obtained after excluding cigarette smokers, those who were depressed, had a low BMI and those who died within 5 years of losing weight(8). 

TABLE 2 CHANGE IN DEATH RATE AS A RESULT OF LOSING WEIGHT

Non-diabetic men +38%
Non-diabetic women +76%
Diabetic men +266%
Non-diabetic women +65%

 

Those who adopt the calorie reduction approach very often end up “weight cycling” with repeated weight loss followed by re-gain. It has been established that these people have a very much higher death rate than those who steadily gain weight throughout life (9).

On the other hand, diets which are low in carbohydrates and high in fat are extremely successful in achieving weight loss. What is even more significant is that these diets are also very effective in reducing risk factors for heart disease and various cancers. For anyone who would like further information these books will be most illuminating (10,11,12).

Although the authorities have been very resistant to changing the official advice, there has been a significant breakthrough in Sweden where a report from the Swedish Council on Health Technology Assessment which concluded that a low-carbohydrate diet is clearly more effective than today’s conventional advice (13).

As long ago as the 1860s, William Banting, a London undertaker, after trying all sorts of remedies eventually found that a diet low in carbohydrates and high in fat enabled him to overcome his “corpulence”. Prior to this he could not even bend down to tie his shoe laces (14). He published a pamphlet, which proved to be very popular because people recognized how successful his approach was. One hundred and fifty years later we still have not learned the lessons!

REFERENCES

  1. http://vernerwheelock.com/?p=468
  2. http://www.theguardian.com/society/obesity
  3. Sarah Boseley (2014) “The Shape we’re in: How Junk Foods and Diets are Shortening Our Lives” Faber &Faber
  4. http://www.theguardian.com/society/2014/jun/25/overweight-diet-obesity-adviser-susan-jupp
  5. http://vernerwheelock.com/?p=218
  6. Ann Intern Med. (1992)116(11) pp 942-949. doi:10.7326/0003-4819-116-11-942
  7. http://vernerwheelock.com/?p=221
  8. N M Wedick (2002) Journal of the American Geriatric Society 50 (11) pp 1810-1815
  9. Vanessa A Diaz (2005) Journal of Community Health 30 (3) pp 153-165
  10. Gary Taubes (2007) “The Diet Delusion” Vermillion: London
  11. Zoe Harcombe (2010) “The Obesity Epidemic” Columbus
  12. Nina Teicholz. (2014)“The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet” Simon & Shuster: New York
  13. http://vernerwheelock.com/?p=542
  14. http://vernerwheelock.com/?p=630

     

 

132. The Real Meal Revolution in South Africa

It really all is happening in South Africa. A few years ago Tim Noakes who is Professor of Sports Science at Cape Town University discovered that he has developed Type 2 Diabetes (T2D). This was despite the fact that as a marathon runner he was physically fit. Furthermore he had followed the conventional dietary guidelines which advised limiting the consumption of fat, especially saturated fats (SFAs) and eating plenty of complex carbohydrates.

As a consequence, he examined the scientific research in order to try to understand why he was suffering from T2D and what steps he might take to overcome the condition. Much to his surprise he concluded that the rationale which was used to formulate the Healthy Eating guidelines was fundamentally flawed. The origin of the guidelines was in the USA during the late 1970s. While there were many critics at the time, the momentum generated by those who supported the case for reducing fat/SFA was so powerful, that all opposition was simply swept aside. Because the guidelines were incorporated into the official policy, it was almost impossible for any researchers to obtain funding for studies which might raise questions about the validity of the policy. Nevertheless there have been individuals who have persistently voiced their opposition, notably Uffe Ravnskov (1) and colleagues in The International Network of Cholesterol Sceptics (THINCS). More recently the weaknesses in the “cholesterol theory” have been highlighted in books by Malcolm Kendrick (2), Gary Taubes (3) and Zoe Harcombe (4). A further contribution was made this year by Nina Teicholz (5) with the publication of “The Big Fat Surprise” which has had an enormous impact.

As a result of what he had found out, Tim Noakes decided that he had to admit (as I have had to do myself!) that his acceptance of the established guidelines was a mistake. In mitigation I should say that the mistake we had both made was to have faith in the official bodies, including the World Health Organisation (WHO) and to trust that the policies were firmly based on sound science. Sadly it is now evident that this faith was misplaced. Certainly I have now learned to appreciate that these issues are not determined by people who are independent, objective and competent. In reality powerful persuasive individuals can have undue influence not to mention the financial vested interests of those involved in the key decisions.

As a result of his discoveries, Tim made changes to his own personal diet and very quickly realised that by reducing his intake of carbohydrates he was able to control his T2D. In fact he found that he could only tolerate a very small amount of carbohydrates.

Tim was so convinced of the significance of his new understanding that he decided to go public and to share his knowledge and insight with the general public in South Africa. He has also been very active on the social media which means that his ideas and information are now accessible globally.

In combination with a few colleagues, he has produced a book entitled “The Real Meal Revolution” (6), which explains his current thinking on Healthy Eating and how it can be put into practice. The book classifies foods as Green, Orange or Red indicating the frequency with which they can be consumed and also includes a selection of recipes. The term “Banting” has been used to describe a diet which conforms to the principles laid down in the book. This is derived from the experience of William Banting, a London undertaker, who was so seriously overweight that he could not bend down to tie his shoelaces (7). Having tried various ways to lose weight, he eventually succeeded with a diet based on meat, fruit and vegetables but avoiding sugar and starchy foods. He wrote a pamphlet, which proved to be very popular. By all accounts those who followed the advice managed to lose weight.

Originally 3,000 copies of the book were printed but the demand has exceeded all expectations. To date over 160,000 copies have been sold and it has been the top seller in South Africa for over 20 weeks. Clearly it has struck a chord. The obvious explanation is that the readers are finding out for themselves the diet works and that there is an obvious effect very soon after changes are made.

The book explains how the push to reduce fat/SFA following the formulation of the US dietary Guidelines in 1977 was the direct cause of the epidemics of obesity and T2D which has occurred in many countries commencing about1980. On the other hand, there is sound scientific evidence that a diet which is high in fat and low in carbohydrate can reverse T2D and reverse many of the risk factors for heart disease. In addition, most of those who switched to a Banting diet also lost weight.

The basic guidelines are as follows:

  • Avoid all processed foods
  • No sugar
  • No grain products
  • The oils to use should be extra virgin olive oil or virgin coconut oil but do not use seed oils such as rape seed oil, sunflower oil. The dangers of oils which are high in omega-6s are explained here (8)
  • Carbohydrates should be from vegetable sources. Some oats and rye may be used sparingly but avoid other grains
  • Meat
  • Dairy products are fine but the full fat versions should be used.
  • All soya products should be avoided.

There are numerous case studies which confirm that the effectiveness of diets based on these principles, have enabled people to recover from serious disabilities. It is also relevant to point out that this approach also works very well with athletes and that the advice to load up with carbohydrates does not stand up to scrutiny. Ron Clarke who set 18 world track records in the 1960s effectively used a Banting type diet.

There are details of how the diet is effective in overcoming many diseases/conditions. Examples include:

  • T2D is caused by excess glucose in the blood, which stimulates the pancreas to produce insulin. Persistent high levels of insulin damages various body organs which can result in a range of chronic diseases. It follows logically that this can be prevented/alleviated by reducing the amount of sugar and refined carbohydrates in the diet. The book refers to 14 patients who had succeeded with this approach. This fits very well with other case studies where similar success has been achieved (9)
  • The Banting approach definitely works for those who wish to lose weight but it is essential to ensure that the carbohydrate intake is kept to a minimum
  • Cancer cells can only function effectively if they have a constant supply of sugar. On a Banting diet there will be virtually no sugar. The healthy cells will adapt so that they can utilise fat. The cancer cells are not capable of doing this so will not survive.

It is evident that the impact in South Africa has been enormous. Restaurants which serve Banting menus have sprung up all over the place. Tim is in demand to speak to large audiences. He has even been invited to meet some of the politicians in the South African Parliament so it will be interesting to see if there are any policy initiatives there. If so that could be a breakthrough because the vast majority of countries which devised a nutrition policy have essentially followed the lead of the USA. What is undeniable is that the conventional approach simply has not worked. In fact it has failed spectacularly and has undoubtedly contributed to the current public health problems as demonstrated by the increased incidence of T2D and obesity.

By contrast, there is now overwhelmingly evidence that the Banting approach does work and that for most people who have tried it, results as shown by weight loss are evident within a matter of weeks. Nevertheless I must stress that weight loss per se is probably welcomed by most people, the benefits to health in terms of reduced risks to many diseases is of much greater significance.

It is therefore inevitable that awareness will continue to grow. It will be fascinating to see how quickly other countries learn from the experience of South Africa.

“The Real Meal Revolution” is to be launched in the UK sometime in February 2015. For those who are interested, there is lots of information on the website at http://realmealrevolution.com/

The Banting approach can be summarised with the following ten commandments:

  • Eat enough animal fat
  • Eat enough vegetables
  • Don’t snack
  • Don’t lie to yourself
  • Don’t over- or under-eat
  • Don’t eat too much protein
  • Be alert
  • Avoid too many fruits and nuts
  • Control your dairy
  • ·         Be strong!

There is also a selection of recipes which demonstrate how to prepare dishes which are tasty, attractive and comply with the advice. Examples include:

  • Coconut bread made from almond flour, coconut flour, golden flax seeds, salt, baking soda, baking powder, eggs, xylitol, coconut oil and apple cider vinegar
  • Beef goulash soup made from butter, onions, carrots, celery ,garlic, pepper, beef mince, mushrooms, paprika, cumin, cinnamon, thyme, tomato paste, bay leaf, tinned tomatoes, chicken stock, Greek yoghurt or sour cream and parsley
  • Scotch eggs made with pork sausage, onions, parsley, sage, salt, pepper and butter.

 

Finally here are some examples of the foods in the different categories.

GREEN which are very low in carbohydrate content and so there is no limit on the amount that may be consumed. Eggs, fresh meat, high quality sausages, cottage cheese, cream, butter, olive oil, coconut oil, duck fat, pumpkin seeds, pecan seeds, all green leafy vegetables, cauliflower, mushrooms, onions and tomatoes.

ORANGE which contain a medium amount of carbohydrates (between 6 and 25%) and should not be consumed in excessive amounts. Apples, bananas, blackberries, gooseberries, grapes, oranges, peaches, raspberries, strawberries, cashew nuts and butternut squash.

RED which contain lots of carbohydrates and should only be eaten occasionally. Flour, bread, cakes, biscuits, couscous, rice, pasta, thickening agents, all processed foods, fruit juice, potatoes, legumes, beetroot, peas, parsnips and of course sugar in any shape or form as well as any foods which has sugar as an ingredient.

It should be stressed that this advice must be followed for those who suffer from T2D or the condition known as Insulin Resistance, which means that the sensitivity of various organs in the body has been impaired. However there is no doubt that everyone who reduces their intake of carbohydrates is likely to benefit from improved health and also prevent the deterioration which invariably happens eventually in those in those whose habitual diet has a high carbohydrate content.

It is important to introduce the changes gradually so that the body can adapt to utilise fat as a source of energy instead of the carbohydrates. The initial period may be difficult but provided the discipline is maintained this can be achieved quite quickly. Experience shows that a noticeable reduction in body weight can occur within a week or two of commencing the new regime. For those who are on medication to control blood glucose there is a danger of hypoglycaemia (ie the blood glucose becomes too low) unless the dosage is reduced. Hence assistance may be needed on glucose monitoring.

I am absolutely convinced that this approach is correct. There is a sound scientific basis which simply does not exist for the conventional recommendations. This is confirmed by my own experience, that of friends and numerous case histories which are readily accessible on the internet. Although Tim Noakes argues that it is all or nothing, my approach would be to start out by making changes to your regular diet and keep making adjustments based on what is acceptable to you personally and what is being achieved. Ideally you should be able to have blood samples analysed occasionally to assess progress. Total cholesterol is not critical so look at triglycerides, HDL cholesterol and glycosylated[VW1] [VW2]  haemoglobin.

REFERENCES

  1. U Ravnskov (2009) “Fat and Cholesterol are Good for You” GB Publishing: Sweden
  2. M Kendrick (2007) “The Great Cholesterol Con” John Blake: London
  3. Gary Taubes (2007) “The Diet Delusion” Vermillion: London
  4. Zoe Harcombe (2010) “The Obesity Epidemic” Columbus
  5. Nina Teicholz. (2014)“The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet” Simon & Shuster: New York
  6. http://realmealrevolution.com/
  7. http://vernerwheelock.com/?p=630
  8. http://vernerwheelock.com/?p=153
  9. http://vernerwheelock.com/?p=422

 


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131. The Banting Diet

William Banting was a London undertaker during the 19th century who in his later years suffered from obesity. Having tried various strategies he was advised to consume a diet which was low in sugar and other saccharine foods, which proved so successful that he decided to write a pamphlet describing his experience. This blog is based entirely on the fourth edition, published in 1869,  for which he charged one shilling (5p in today’s money) in order to cover his costs of production (1).

Here are a few extracts from the preface which have the advantage of recording some of the responses to the earlier editions:

  • “It is with no slight degree of pride and satisfaction that I presume to publish a fourth edition of my Letter on Cor­pulence, in the hope and belief that it may still further interest and benefit the Public
  • It has happily attained a world-wide circulation, and afforded me a vast amount of pleasure and gratification, derived from the conviction that I have been the means of bringing under public consideration and discussion one of the little known and much neglected laws of nature. The popularity of my unpretending brochure is manifest, not only in the surprising sale of no less than 63,000 copies, in this country alone, but by its translation into foreign languages and its large and rapid circulation in France, Germany, and the United States. In addition to this I have received nearly 2,000 very complimentary and grateful letters from all quarters of the world
  • The great principle which Mr. William Harvey (my medical adviser), of Soho Square, inculcated, having been confirmed by my own personal experience, I was enabled to speak with perfect confidence, and I became invulnerable to the ridicule, contempt, or abuse which were not spared in the earlier stages of the discussion. I believe I have subdued my discourteous assailants by silence and patience; and I can now look with pity, not unmixed with sorrow, upon men of eminence who had the rashness and folly to designate the dietary system as “humbug,” and to hold up to scorn the man who put it forth, although he never derived nor sought pecuniary or personal recompense, but simply desired, out of gratitude, to make known to other sufferers the remedy which he had found so efficacious to himself. I heartily thank the public press for the general fairness of its criticisms, and feel deeply indebted to the Morning Advertiser for its able article on 3rd October, 1865, when I was so sadly and unjustly attacked by certain pro­minent members of the British Association, whose feelings, now that the subject has been more widely and intelligently examined and discussed, I do not envy
  • It has been reported to me that many medical men have argued that I could not have consulted any eminent mem­bers of their fraternity on the subject of obesity. I beg leave emphatically to assure the public that, for the 20 years, previous to consulting Mr. Harvey, I had no occasion to consult a medical man, for any other ailments except those which are the inevitable consequences of corpulence; and that, although my medical advisers were neither few, nor of second-rate reputation, not one of them pointed out the real cause of my sufferings, nor proposed any effectual remedy, until I appealed to my friend, Mr. Harvey, the celebrated aurist, on account only of deafness
  • It is possible, and I think probable, that even Mr. Harvey was somewhat surprised at the extraordinary and speedy result of my rigid adherence to his advice, because he had long before prescribed the proper dietary system to reduce or cure corpulence, but his patients having hitherto impru­dently slighted his prescriptions, it was only my very strict compliance that completely proved the accuracy of his judgment. My only merit consists in entire obedience to Mr. Harvey’s advice. To him alone belongs all the credit of the remedy. He was the first to lead me on to the true road of health, and I was probably the first of his many patients who kept to it
  • Another eminent medical man, whose letter will appear among the rest, was actually giving my pamphlets in the course of his practice. I was greatly surprised to hear of it, and wrote to ascertain the fact. He invited me to call on him, and showed me that my information was correct by pointing to a pile of them lying upon his table. He complimented me upon the publication, as it contained sound advice in cases like my own; and added, that the discovery was not Mr. Harvey’s, but was derived from “Mons. Bernard, of Paris.” I replied that Mr. Harvey had told me he had first derived his information from lectures which he had heard in Paris, by Mons. Bernard, in regard to diabetes, and some other complaints, but that he had himself applied it to cases of corpulency. He admitted that the simple record of my own experience of the value of the system had brought it to the clear light of day, and that if it had been written by a medical man, it would scarcely have been noticed by the general public at all
  • Probably no one was ever subjected to more ridicule and abuse than I have been, in English as well as in foreign journals. My only object, however, has been the good of my fellow creatures. To have accomplished this object, in any degree, is a sufficient reward for my expenditure of time and means, and an ample compensation for the insolent contempt of some, and the feeble ribaldry of others
  • I have ascertained, by repeated experiments, that five ounces of sugar distributed equally over seven days, which is not an ounce per (lay, will augment my weight nearly one pound by the end of that short period. The other forbidden elements have not produced so extraordinary a result. In these, therefore, I am not so rigid. Some people (as will be seen by their letters) find other things detrimental. I never eat bread unless it is stale, cut thin, and well. toasted. I very seldom take any butter, certainly not a pound in a year. I seldom take milk (though that called so, in London, is probably misnamed), and I am quite sure that I do not drink a gallon of it in the whole year. I occasionally eat a potato with my dinner, possibly to the extent of 1 lb. per week. I spoke of sherry as very admissible, and I am glad of this opportunity to say, that I have since discovered it promoted acidity. Perhaps the best sherry I could procure was not the very best, but I found weak light claret, or brandy, gin, and whisky, with water, suited me better; and I have been led to believe that fruit, however ripe, does not suit me so well taken raw as when cooked, without sugar. I find that vegetables of all kinds, grown above ground, ripened to maturity and well boiled, are admirable; but I avoid all roots, as carrot, turnip, parsnip, and beet. I have not taken any kind of medicine for eighteen months, and find that my dietary contains all the needful regimen which my system requires. In the firm belief and conviction that the quality in food is the chief desideratum, and that the question of quantity is mere moonshine, I take the most agreeable and savoury viands, meat and game pies, that my cook can concoct, with the best possible gravies, jellies, &c., the fat being skimmed off; but I never, or very rarely, take a morsel of pie or pudding crusts
  • The subjoined correspondence is only a portion of upwards of 1,800 letters which I have received. There is scarcely one out of the whole which does not breathe a spirit of pure thankfulness and gratitude for the benefits derived from the dietary system, and contain the most flattering encomiums on my character and motives.”

COMMENT

The publication of the pamphlet obviously had an enormous impact. It is quite revealing that Banting tried so many different approaches which turned out to be complete failures. The success achieved by so many others who followed his example was absolutely phenomenal and provided convincing evidence of its validity. Despite this Banting, was subject to criticisms from many quarters. In particular, the ignorance and arrogance of the mainstream medical profession is clearly demonstrated.

Here are some extracts from the main body of the pamphlet:

  • Few men have led a more active life—bodily or mentally—from a constitutional anxiety for regularity, precision, and order, during fifty years’ business career, from which I had retired, so that my corpulence and subsequent obesity were not through neglect of neces­sary bodily activity, nor from excessive eating, drink­ing, or self indulgence of any kind, except that I par­took of the simple aliments of bread, milk, butter, beer, sugar, and potatoes more freely than my age required, and hence, as I believe, the generation of the parasite, detrimental to comfort if not really to health and comfort
  • Although no very great. size or weight, still I could not stoop to tic my shoe, so to speak, nor attend to the little offices humanity requires without considerable pain and difficulty, which only the corpulent can understand; I have been compelled to go down stairs slowly backwards, to save the jar of increased weight upon the ancle and knee joints, and been obliged to puff and blow with every slight exertion, particularly that of going up stairs. I have spared no pains to remedy this by low living (moderation and light food was generally prescribed, but I had no direct bill of fare to know what was really intended), and that, con­sequently, brought the system into a low impoverished state, without decreasing corpulence, caused many obnoxious boils to appear, and two rather formidable carbuncles, for which I was ably operated upon and fed into increased obesity
  • Bread, butter, milk, sugar, beer, and potatoes, which had been the main (and, I thought, innocent) elements of my subsistence, or at all events they had for many years been adopted freely
  • These, said my excellent adviser, contain starch and saccharine matter, tending to create fat, and should be avoided altogether
  • For breakfast, at 9.0 A.M., I take five to six ounces of either beef mutton, kidneys, broiled fish, bacon, or cold meat of any kind except pork or veal; a large cup of tea or coffee (without milk or sugar), a little biscuit, or one ounce of dry toast; making together six ounces solid, nine liquid.
  • For dinner, at 2.0 P.M., Five or six ounces of any fish except salmon, herrings, or eels, any meat except pork or veal, any vegetable except potato, parsnip, beetroot, turnip, or carrot, one ounce of dry toast, fruit out of a pudding not sweetened, any kind of poultry or game, and two or three glasses of good claret, sherry, or Madeira— Champagne, port, and beer forbidden; making together ten to twelve ounces solid, and ten liquid.
  • For tea, at 6.0 P.M., Two or three ounces of cooked fruit, a rusk or two, and a cup of tea without milk or sugar; making two to four ounces solid, nine liquid.
  • For supper, at 9.0 P.M. Three or four ounces of meat or fish, similar to dinner, with a glass or two of claret or sherry and water; making four ounces solid and seven liquid.
  • For nightcap, if required, A tumbler of grog—(gin, whisky, or brandy, without sugar)—or a glass or two of claret or sherry
  • This plan leads to an excellent night’s rest, with from six to eight hours’ sound sleep
  • My former dietary table was bread and milk for breakfast, or a pint of tea with plenty of milk, sugar, and buttered toast; meat, beer, much bread (of which I was always very fond) and pastry for dinner, the meal of tea similar to that of breakfast, and generally a fruit tart or bread and milk for supper. I had little comfort and far less sound sleep
    • I have not felt better in health than now for the last twenty-six years.
    • Have suffered no inconvenience whatever in the probational remedy or since.
    • Am reduced nearly 13 inches in bulk, and 50 lbs. in weight.
    • Can perform every necessary office for myself.
    • The umbilical rupture is cured.
    • My sight and hearing are suprising at my age.
    • My other bodily ailments have become mere matters of history.
    • Total loss of weight in 12 months 46 lbs
    • All symptoms of acidity, indigestion, and heartburn (with which I was frequently tormented) have vanished. I have left off using boot-hooks, and other such aids, which were indis­pensable, but being now able to stoop with ease and freedom, are unnecessary. I have lost the feeling of occasional faintness, and what I think a remarkable blessing and comfort is, that I have been able safely to leave off knee-bandages, which I had worn necessarily for many years, and given up the umbilical truss
    • The great charm and comfort of the system is, that its affects are palpable within a week of trial, which creates a natural stimulus to persevere for few weeks more, when the fact becomes established beyond question
    • I only entreat all persons suffering from corpulence to make a fair trial for just one clear month, as I am well convinced, they will afterwards pursue a course which yields such extraordinary benefit, till entirely and effectually relieved, and be it remembered, by the sacrifice merely of simple, for the advantage of more generous and comforting food. The simple dietary evidently adds fuel to corpulent fire, whereas the superior and liberal seems to extinguish it.”

CONCLUSION

Banting certainly enjoyed a wide range of tasty foods. He limited the intake of carbohydrates but had plenty of others which contained fat. Essentially he followed the same basic principles which so many in recent years have found works very well as means of controlling Type 2 Diabetes (T2D) but is also effective as a means of losing weight. However there may well be serious doubts about recommending his intake of alcoholic beverages to all and sundry. Despite the success of the Banting approach and the widespread dissemination of how it was achieved, the valuable lessons have been forgotten as shown by the obesity crisis. It is rather ironic that so many people find themselves in the same position of Banting in the days before he encountered the progressive Mr Harvey. Banting died in March 1876 aged 81 years.

Although all this happened 150 years ago, the insight gained is just as applicable today as it was then. What is more there is now sound science, which provides detailed confirmation of the experience of Banting. Despite all the opposition which still exists, most people who reduce their intake of sugar and other carbohydrate-containing foods, will not only lose weight but also lower the risks of developing heart disease, T2D, cancer and Alzheimer’s Disease.

 

REFERENCE

  1. http://www.lowcarb.ca/corpulence/corpulence_full.html

 

130. A Little Bit of History about LDL Cholesterol

The cholesterol lowering campaign really took off in 1985 with the recommendations of a Consensus Conference sponsored by the National Institutes of Health in the USA (1). I have just come across a commentary written at the time by Gerald Reaven which is absolutely fascinating (2). It is certainly highly relevant to recall the key points which were made almost 30 years ago!

The main conclusion was that raised levels of LDL Cholesterol in the blood plasma are causally related to the development of Cardiovascular Disease (CVD). Therefore steps should be taken to lower the LDL Cholesterol by the use of diet and/or drugs, in order to reduce the incidence CVD.  In particular, everyone except children under the age of 2 years should be advised to adopt a diet that reduces the intake of fat from 40% calories as it was then to 30%. Saturated fat (SFA) should be reduced to less than 10% calories while polyunsaturated fat (PUFA) should be increased. In addition, massive education programmes should be launched to ensure that health professionals were aware of the importance of treating hypercholesterolaemia and the food industry was to be encouraged to develop and market products in line with the dietary advice.

First of all, Gerald Reaven pointed out that Implementation of the recommendations would mean there would inevitably be an increase in the carbohydrate content of the national diet in the USA but that there had been no attempt by the Conference to assess the impact of this. In his view, there was enough credible evidence to postulate that a “low fat high carbohydrate (LFHC) diet” would result in metabolic changes in many people, which would be deleterious to health. In particular changes in blood glucose, insulin and HDL Cholesterol would actually increase the risks of developing CVD. This is rather ironic since the justification for the changes was to reduce risks of CVD.

He suggests that the older the individual and /or the more glucose intolerant the greater the chance that LFHC diets would result in significant increases in postprandial blood glucose, which is a risk factor for CVD. Furthermore for those consumers who have impaired glucose tolerance or full blown Type 2 Diabetes (T2D) the recommendation is even more questionable.

He then goes on to consider the role of insulin and states quite bluntly that raising the level of insulin in the blood increases the risk of CVD even in those who do not have T2D. Furthermore there is abundant evidence that increasing the carbohydrate content of the diet will augment the plasma insulin response of normal individuals. Therefore it is predictable that the insulin levels will be raised. While this might not be a major problem in those who are young, slim and physically active, it is almost certainly damaging for those who are getting on in years, well-nourished and sedentary.

A LFHC diet is known to raise the level of triglycerides in the blood, which is associated with an increased risk of CVD. While the importance of this has been questioned, Reaven argues that there is enough evidence to take this seriously. In particular he notes that this may be related to a fall in the level of the HDL Cholesterol, which could be another reason why an LFHC diet would increase the risks of CVD.

Even accepting the “Consensus” position that the LDL Cholesterol should be reduced and that the HDL Cholesterol is beneficial then it follows that the objective should be to increase the HDL:LDL in order to reduce the risks of CVD. Obviously this is what would happen if the LDL Cholesterol is lowered and the HDL Cholesterol is unchanged. Unfortunately because an LFHC diet also reduces the HDL even more than occurs with the LDL Cholesterol, the net effect is to lower the ratio! This is not exactly what the Consensus Conference was trying to achieve.

Finally here is a comment on the organisation of the conference which speaks for itself:

The most efficient way to reach a consensus concerning a complex issue within a short period is to make sure that controversial views are not represented on the panel. It is clear that the panel assembled by the NIH met this criterion; ie, no one who had published scientific evidence that might have led to the presentation of formidable arguments contrary to conventional wisdom was a member of the panel. I believe it is the responsibility of the organizers of such conferences to make sure that dissenting voices are present, and their absence raises substantial questions concerning the utility of the recommendations that are issued.”

 

CONCLUSION

Although the information presented here is entirely from the USA, the circumstances in many other countries are virtually the same. Here in the UK, over the past 30 years or so there has been an enormous increase in the use of the lipid lowering drugs (by a factor of about 20) (3). At the same time some of the fat in the diet has been replaced by carbohydrates (4). Although there has been quite an improvement in longevity the impact of this on the quality of life has been tempered by the increase in dementia. The incidence of obesity is evident, while the fact that T2D has doubled in the past 15 years and is expected to continue increasing is clearly a major public health issue. There is absolutely no question that Gerald Reaven has been totally vindicated by events. The fears which he outlined in 1985 have materialised.

It was evident that the doubts which he and others expressed were simply swept aside by those who were determined to implement their own agenda. The current position is now even worse because it is clear that the policy has been a disaster. Yet there is still a complete failure on the part of governments and health professionals to face up to reality. In the meantime huge numbers of people who faithfully comply with the official advice are suffering unnecessarily and many die prematurely. It is difficult to imagine a greater public health policy disaster. It is right up there with those wars which have been started on a false prospectus.

REFERENCES

  1. http://jama.jamanetwork.com/article.aspx?articleid=397825
  2. http://jn.nutrition.org/content/116/7/1143.full.pdf
  3. http://www.bhf.org.uk/plugins/PublicationsSearchResults/DownloadFile.aspx?docid=508b8b91-1301-4ad7-bc7e-7f413877548b&version=-1&title=Coronary+Heart+Disease+Statistics+2012+&resource=G608%2f1012%2fCHA
  4. http://vernerwheelock.com/?p=606

 

 

129. “A CALORIE IS A CALORIE”

The conventional view of energy in food is that it is measured by the bomb calorimeter, which many of us used in our physics classes in school. A known amount of material is placed in the calorimeter and incinerated. The rise in temperature is then used to calculate the energy/calorie content. Using the same principle humans can be placed inside a much more sophisticated and bigger calorimeter so that the calories expended can be measured. If these are greater than those consumed this means some of the body’s reserves have been used and therefore the individual exhibits weight loss. Similarly if more calories are consumed than are the total lost then there will be weight gain. As a consequence it has led to the assumption that weight loss can be achieved by reducing the total number of calories consumed. This has been the accepted mantra by health professionals, those who wish to lose weight and especially the weight loss industry.

The reality is that it does not work! (1). In a recent article in the Journal of the American Medical Association (2, 3) David Ludwig and Mark Friedman pose the questions:

“But what if we’ve confused cause and effect? What if it’s not overeating that causes us to get fat, but the process of getting fatter that causes us to overeat?”

They put forward the view that that there are certain factors, which stimulate the fat cells in the body to take up and store excessive amounts of constituents which are rich in calories and consequently are not available to meet the normal requirements for maintenance. In order to survive, the brain makes the person feel hungry and so more food is consumed. So while the immediate problem is solved in the short term, the long term result is weight gain and ultimately obesity. Essentially the reason the usual approach to slimming fails is that it is accompanied by persistent hunger and the only ones who succeed are those who effectively starve themselves.

The article emphasises that there is no doubt that the hormone insulin is the dominant factor which influences the storage of calories in fat cells. When excess insulin is used to treat T2D it causes weight gain whereas insulin deficiency causes weight loss. From a dietary perspective it is the consumption of sugar and refined carbohydrates which cause the production of insulin by the pancreas in order to control the build-up of glucose in the blood. So the more of these foods that are consumed the more insulin will be available. Therefore it is quite consistent that the increase in the consumption of sugar and refined carbohydrates in the USA, the UK and many other countries has been accompanied by an increase in the incidence of obesity.

In an earlier study David Ludwig and colleagues compared diets which contained the same amount of calories but very different proportions of carbohydrates and fats (4). The subjects were middle-aged men and women who were overweight or obese. They found that those on the diet containing 60% fat and 10% carbohydrates had a total energy expenditure of 3137 Kcalories /day whereas those on the low fat diet with 20% fat and 20% carbohydrates had only 2812 Kcalories/day….a reduction of over 300/day. This is a huge difference but the most important conclusion to emerge is that this confirms the fact that not all calories are equal! This should come as no surprise to anyone who recognises that the ways in which fat, protein and carbohydrate are metabolised and utilised in the body are totally different. Nevertheless the significance of the impact on the energy expenditure is absolutely crucial because it demonstrates the futility of formulating diets on the basis of calorie content irrespective of the constituents. This insight also helps to understand why the odds are stacked against the conventional calorie control approach to lose weight since a low fat diet seems to be utilised very efficiently with energy loss kept to a minimum. The study also monitored some of the other indicators of health and in general the more favourable results were obtained with the high fat diet. In particular, the levels of triglycerides, a heart disease risk factor was 107 mg/dl in those on the low fat diet but only 66 mg/dl in those on the high fat one. In fact work with rats has suggested that even on a low calorie diet which is high in refined carbohydrates, there is a tendency towards obesity as shown by fat deposition (5).

There really is nothing new about the findings. Over 50 years ago, Kekwick and Pawan conducted a series of experiments with iso-caloric diets (all with the same calorie content) and concluded that the:

“..rate of weight loss varied so markedly with the composition of the diet on a constant calorie intake, it is suggested that obese patients must alter their metabolism in response to the contents of the diet. The rate of insensible loss of water has been shown to rise with a high-fat and high-protein diets and to fall with high-carbohydrate diets” (6).

There have been a number of other investigations which all reach similar conclusions but have not been accepted by mainstream nutritionists on the grounds that the results do not comply with the First Law of Thermodynamics. This states that the  total energy of an isolated system is constant; energy can be transformed from one form to another, but cannot be created or destroyed. However this logic is totally fallacious because the First Law relates to an isolated system and therefore we need to have information on all the energy inputs and outputs. As the study by Ludwig and Friedman showed there is marked variation in the energy loss with the diets of different composition, the fact that weight loss varies is entirely consistent with the First Law. Those who claim that the variation in weight loss is in conflict with the First Law are obviously making the false assumption that the energy retained in the body will be precisely the same for every diet irrespective of the composition. Clearly this is impossible and therefore wrong because the biochemical steps involved in the breakdown and utilisation of fat, protein and carbohydrate are all different. There is ample evidence available to confirm this. For anyone interested in a more detailed consideration of this issue plus a discussion of the role of the Second Law of Thermodynamics, consult this reference (7).

CONCLUSION

The focus on calorie control as a means of weight loss is based on a fundamentally flawed concept. It does not work and there are millions of people who can confirm this from their own personal experience. The message is quite clear. It is not the amount of food which determines your weight or your ability to lose it but the quality in terms of the relative proportions of fat and carbohydrate. If you wish to lose weight and improve your health then it is abundantly obvious that the answer is to reduce the carbohydrates and increase the fat.

REFERENCES

  1. http://vernerwheelock.com/?p=218
  2. http://jama.jamanetwork.com/article.aspx?articleid=1871695
  3. http://www.nytimes.com/2014/05/18/opinion/sunday/always-hungry-heres-why.html?_r=0
  4. http://jama.jamanetwork.com/article.aspx?articleid=1199154
  5. http://www.ncbi.nlm.nih.gov/pubmed/15337404
  6. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(56)91691-9/fulltext
  7. http://www.nutritionj.com/content/3/1/9

 

127. Beware of Fructose!

The original work of Ancel Keys which eventually led to the dietary guidelines recommending a reduction in total fat and particularly saturated fat (SFA) was based on epidemiological studies which related the national fat data to the incidence of heart disease (1). However almost invariably countries which have a high intake of fat also have a high intake of sugar and it is very likely that if this had been the focus of attention, similar associations would have emerged for sugar and heart disease. The work of Keys has been subjected to devastating criticism and in the view of many who have analysed his results it has been totally discredited.

By contrast there is growing evidence that an excessive intake of carbohydrates is a critical factor which contributes to a variety of diseases/conditions which include obesity, hypertension, diabetes and heart disease. This is confirmed by the improvements in health which have been observed by those who make substantial reductions in the amount of carbohydrates in the regular pattern of food consumption.

Recently the spotlight has focussed specifically on sucrose (table sugar) and High Fructose Corn Syrup (HFCS). Sucrose breaks down to a 50:50 mixture of glucose and fructose. HFCS is essentially similar and is widely used in foodstuffs, especially in the USA where there has been a progressive increase in the amount consumed since it was first introduced in the 1970s. Over the next 30 years the fructose consumed in the USA had increased by 30% (2). HFCS-55, which consists of 55% fructose and 42% glucose, is used primarily in sweetened beverages and is also used to sweeten other products (e.g., baked foods and confectionaries).

There are a variety of reasons which taken together make a very compelling case that sugar and HFCS are largely responsible for the deterioration in standards of public health which have been observed in many different countries. The epidemiological evidence shows that there is a close association between the increase in the consumption of these sugars and the increase in the incidence of obesity. Further understanding emerges from a consideration of the different roles of glucose and fructose in the body. At the outset it is crucial to emphasise that although they are very similar in chemical structure they have distinctly different functions and are metabolised by totally different pathways. There is now growing evidence that it is the fructose which is responsible for many of the public health concerns that have arisen in recent years.

In 2002 it was suggested that fructose plays a critical role in the development of Metabolic Syndrome, which is a cluster of diseases/conditions namely obesity, diabetes, hypertension, raised blood triglycerides and low HDL Cholesterol. This was based on evidence from both animal and human studies. In particular when comparisons are made between fructose and sugar (which produces fructose and glucose) it was found that there was greater weight gain, raised blood pressure and raised blood triglycerides with the fructose treatment on its own (3).

Here are some specific examples:

  • The level of triglycerides in the blood was raised when young men were given a diet which was supplemented with 200 g sucrose/day but when the sucrose was replaced with starch, which breaks down to glucose only there was no change(4)
  • In a study conducted in Denmark with healthy men and women aged between 20 and 50 years a comparison was made between supplementation of the regular diet soft drinks containing sucrose and artificial sweeteners. It was found that after 10 weeks the blood pressure had increased in the sugar group but in the other group it had decreased. The body weight increased in the sucrose group but decreased in those using the sweeteners (5)
  • A comparison was done over 8 weeks in which healthy men and women consumed 25% of their energy either as fructose or glucose. Although both groups gained the same amount of weight, those consuming fructose synthesised more fat in the liver and had a greater amount of subcutaneous fat. This is consistent with the fact that virtually all the fructose has to be utilised by the liver which primarily converts it into fat that is stored. The fructose group also had more oxidised LDL Cholesterol and a higher concentration of small dense particles of LDL Cholesterol, both of which are risk factors for heart disease. Insulin sensitivity was reduced in the fructose group but not in those consuming glucose (6).

All of these results provide convincing evidence that fructose is much more damaging to health than glucose. The experimental data fits in very well with the epidemiological information which relates the changes in the incidence of various diseases with the patterns of consumption. There seems very little doubt that increasing consumption of sugar and of HFCS has been the critical factor responsible for the obesity epidemic. Therefore it would be sensible to emphasise the importance of reducing sugar consumption in the advice given to the public. Regrettably because of the obsession with fat and SFA in particular the message is not getting through. Sales of Sugar Sweetened Soft drinks remain at a very high level. Furthermore “low fat” foods continue to be promoted heavily and consumers purchase them in the belief that they are healthy even though the fat taken out has largely been replaced by sugar!!!

REFERENCES

  1. A Keys (1970) Circulation 41 (1) pp 188-195
  2. G  A Bray et al (2004) American Journal of Clinical Nutrition 79 (4) pp 537-543
  3. S S Elliott et al (2002) American Journal of Clinical Nutrition 76 (5) pp 911-922
  4. P A Akinynju et al (1968) Nature 218 (5145) pp 975-977
  5. A Raben et al (2002) American Journal of Clinical Nutrition 76 (4) pp 721-729
  6. K Stanhope et al (2009) Journal of Clinical Investigation 119 (5) pp 1322-1334