175. A Case History of How Diet Can Overcome Inflammatory Arthritis

Jo Bellas is a mother of 3 children who works with her husband George in the family company based in Skipton which supplies all the essentials required in an office. In her early years she lived in Australia and was very active, playing lots of sports, enjoying life in the outdoors. A few years ago she noticed some pain in her knee. This got progressively worse with severe swelling and eventually reached the point where it was absolute agony to walk. After doing the usual rounds with the NHS she decide to consult a private specialist who told her that there was damage to one of the ligaments plus general “wear and tear”.

He suggested that an operation might be possible but this was not a particularly attractive option. The consultant could do the operation but it would not fix what he then believed to be a rheumatology issue, and Jo would need to get that under control before any operation. Consequently Jo consulted a rheumatologist who diagnosed inflammatory arthritis. The prognosis was that it was not curable, that it would get worse and the best hope was to “manage” the condition using drugs to address the symptoms to help Jo live a “normal” life.

This led to a succession of treatments with a variety of drugs which were designed to suppress the immune system. Some of these apparently worked for a while and then a different one would be tried. But there were side effects which included “brain fog”, fatigue, headaches and a general feeling of being “fed up”. In addition Jo was taking “loads of painkillers”. There was certainly no improvement in her state of health, rather the reverse as her elbows and shoulders became stiff and sore.

For a person on the right side of 40, the prospects looked pretty grim. In desperation, Jo got onto the internet and started doing research to see if there were any other possible options. She discovered the work of Dr Amy Myers, who is a trained MD, and has specialised in complementary medicine or what the Americans call “functional” medicine. As a student Dr Myers had suffered from Graves’ Disease, which is an overactive thyroid. She tried various alternative methods including Chinese Medicine and powdered herbs which tasted awful. When this did not work, she resorted to conventional medicine. This culminated in a procedure called “ablation” in which some or all of the thyroid function is destroyed using radioactive iodine. Eventually Dr Myers discovered complementary treatments which proved to be effective. This was so successful, she continued to develop her interests and expertise in functional medicine. She has established a very successful practice in Texas. Further information is available on her website (1).

Among other activities she had written a book entitled “The Autoimmune Solution: Prevent and Reverse the Full Spectrum of Inflammatory Symptoms and Diseases”. Jo purchased this book and followed the advice presented which has been used by many patients to cure or alleviate a whole range of auto-immune diseases which include allergies, Crohn’s Disease, Irritable Bowel Disease and asthma. To begin with Dr Myers recommends drastic changes to the typical American or British diet for a period of 30 days. The purpose of this protocol is to enable the body to recover and repair the damage which has occurred. Those who follow it must exclude the following from their diet:

  • Sugar
  • Gluten
  • Dairy
  • Grain
  • Caffeine
  • Alcohol

For Jo this meant making wholesale changes to her regular diet. In order to provide moral support her husband George volunteered to do exactly the same.

The beginning was not easy because she suffered severe caffeine and sugar withdrawal symptoms because her body was screaming out for carbohydrates. The good news is that after a few days the worst was over and then she started to improve. Within a very short time she felt very much better and was able to come off all the drugs with the exception of painkillers, which had been reduced substantially. This article is being written just before the end of the 30-day period. All the aches and pains have gone. All the issues with her stomach have disappeared. She used to have problems with acne but her skin has improved significantly. Various supplements are being taken which should help to repair any damage to the gut. Jo is sleeping much better.

It has not been straight forward to prepare the meals, because of the restrictions. There are also difficulties because the book has been written for an American audience. She spent a lot of time on “googling” the English names for many of the foods recommended. It turns out that many of the speciality vegetables and squashes which are common place in the US just do not exist here in the UK. A good example is Spaghetti Squash which can be used as a suitable substitute for traditional pasta.

The key ingredients which are allowed include:

  • All meat, ideally from grass-fed animals. Sausages are fine provided they are gluten-free. Fish is recommended.
  • Leafy green vegetables, especially those from the cabbage family, preferably organic. Legumes are not allowed.
  • Butter is banned because it is dairy but olive oil and coconut oil are absolutely fine. Avocadoes are another good source of fats.

For breakfast, Jo and George usually have burgers made from turkey or chicken mince or sausages fried in coconut oil. Although carbohydrate-containing foods such as rice and pasta are not allowed, a good substitute can be prepared from cauliflower. Sweet potatoes are one of the staples which are allowed so chips can be made using coconut oil. For a special dessert coconut milk can be whipped and flavoured with cinnamon and used to pour over berries. The spices which can be used include:

  • Cinnamon
  • Nutmeg
  • Cumin
  • Ginger
  • Turmeric

Sea salt and black pepper are also allowed.

They usually prepare double rations so save on preparation time.

Because Jo is so much better as she approaches the end of the initial 30-day period, she will be able to introduce some of the “banned” foods into her diet to see if she can cope with some of these such as eggs. However she considers herself to be relatively lucky to have made such excellent progress so quickly. Dr Myers emphasises that this must not be attempted until a complete recovery has been achieved, which may actually take many months. She also insists that gluten and dairy must be ruled out totally.

There is no question that in Jo’s case this has worked and she is very confident that it will continue to be effective in the long term. In fact her brother (in Australia) who has severe IBS felt better immediately after cutting out dairy and gluten. He no longer has stomach problems and his skin is healing very well. Jo’s mother who has several problems including diverticulitis also found a huge improvement in her health by making similar changes to her diet.

Jo’s comments below provide some valuable insight into her experience in recent years:

“Two years ago I tried both Gluten Free and Dairy Free as I had heard that this could help. However Dairy Free only lasted about a week because I liked the sweet things in life too much!  Gluten Free lasted about 4-6 weeks (my stomach did feel better whilst doing this although the rheumatoid arthritis symptoms were still there). My mistake was to substitute my unusual “unhealthy” diet for Gluten Free “unhealthy” options – thus completely ignoring anything to do with my gut which is where I KNOW now the healing process needs to start.  Because I was only tackling one of the many different problems, the improvement was minimal.

I am now only too well aware that I have a full blown auto-immune disease. This means that I had to do a complete overhaul of my diet…..no sugar, no gluten, no dairy, no grains, no legumes, no alcohol, no caffeine!! I needed to make fundamental changes in my approach to food. I had to be prepared for a rough few weeks and give my gut time to start healing itself. It was necessary to provide my body with all the essential nutrients which would help me recover and cut out everything that I now believe caused this disease in the first place.  I can say this now because OMG within 24 hours of starting I couldn’t quite believe how much better I was feeling!  Honestly, no word of a lie, it was almost instant! As soon as I stopped eating all those “nasties” and started giving my body what it needed (and giving it a helping hand with the recommended natural supplements that Dr Amy Myers recommends) my body started to respond…at last in a positive way!  Then within 3-4 days I found (unbeknown to me at the time) that I had stopped limping. I walked down the stairs like a normal human being. I was dumbfounded and my family could not believe the difference either. I felt better than I had done in years. At that point I stopped taking all my immune suppressant tablets and felt well enough to not have my biological injections.  Happy just does not quite explain it enough. My head is clear. I feel great. Yes I will sometimes sniff my colleagues caramel shortbread but that is as near as I’ll get from now on, although I am hoping to have a successful reintroduction of a few foods (fingers crossed!)…mmm…. Eggs…mmmm….Potatoes. But even if I cannot manage to re-introduce these foods successfully at the moment perhaps I can try again a bit later when I hope my gut has fully healed. The important point is that I am in control. It is my choice and my decision. So I am sure that between me and my body we will find our way to the other side!

I consider myself to be lucky to be where I am now, but I think I had to be at my lowest possible place both mentally and physically before I was ready to commit to this fully. I was depressed, grumpy, fed up, I could no longer play certain games with my children.  I could not even lift my youngest up anymore. I barely had the energy to get through my working day let alone go out and socialise. In short, I was at my lowest point imaginable and I could see no way out. I knew that unless I tried to do something myself things would only get worse. I was not willing to give up on enjoying my life without a fight!  Don’t get me wrong, it’s not easy but if a sugar and carbohydrate lover like myself can do it, believe me ANYBODY can.  I consider myself lucky, because I have found what seems to be the answer my body has been looking for, and also I am so lucky because I saw the results so quickly it gave me the encouragement and will-power to continue. The results speak for themselves   no-one can argue with that!”


This is a heart-warming story, which Jo is very keen to share with others in the hope that it will inspire some of them to follow suit and achieve similar success.

Many scientists will discount this case history on the grounds that it is “anecdotal”. In their view it does not comply with the standards of a formal Randomised Controlled Trial. If there were just a few individuals involved then I would have sympathy with the critics but when the approach works very effectively with a large number of people, then that cannot be brushed aside. The fact that the dietary changes are producing positive results when the conventional treatments using various drugs have failed so abysmally simply cannot be ignored. It is scandalous that this knowledge is not being shared with those who suffer from these conditions. At the very least, patients should be given the option so that they can try it for themselves. Even if it only works for some, they will benefit by significantly improving their own personal health and the demands on a hard pressed NHS will be reduced.


  1. http://www.amymyersmd.com/

174. Academy of Nutrition and Dietetics Comments on Latest version of Dietary Guidelines for Americans

.Every 5 years the Dietary Guidelines in the USA are reviewed. The latest exercise is in progress and the first draft was released in February 2015 (1). The crucial and potentially contentious aspects relate to fat, sugars and salt. The position of the Dietary Guidelines Advisory Committee (DGAC) was that it:

“…encourages the consumption of healthy dietary patterns that are low in saturated fat, added sugars, and sodium. The goals for the general population are: less than 2,300 mg dietary sodium per day (or age-appropriate Dietary Reference Intake amount), less than 10 percent of total calories from saturated fat per day, and a maximum of 10 percent of total calories from added sugars per day.”

It continues:

“Sources of saturated fat should be replaced with unsaturated fat, particularly polyunsaturated fatty acids.”

Essentially this is in line with the conventional approach which has been in place in a great many countries since the 1980s. However there are growing doubts about the validity of this strategy particularly because of the growing incidence of obesity and Type 2 Diabetes (T2D) despite the fact that the advice to reduce fat, especially the saturated fat (SFA), is actually being implemented. Furthermore a number of systematic evaluations have been conducted, which have shown that there were fundamental flaws in the original evidence used to justify these recommendations. In addition, there have been investigations which demonstrate that the level of cholesterol in the blood (TC) is not a reliable indicator of the risks of heart disease. In a recent comprehensive study in Norway the TC levels in 52,087 men and women aged 20-74 years were measured over a 10-year period and any deaths were recorded. The results showed that in both men and women there was no statistically significant increase in the risk of death at higher TC levels. In men it was found that with those low TC levels, which comply with current official advice that the total death rate was actually increased. For women the results were even more striking: the higher the TC levels, the lower the risk of dying from all causes.

The authors commented as follows:

’If our findings are generalizable, clinical and public health recommendations regarding the ‘dangers’ of cholesterol should be revised. This is especially true for women, for whom moderately elevated cholesterol (by current standards) may prove to be not only harmless but beneficial.’’

They went on to conclude:

‘’Our results contradict the guidelines’ well-established demarcation line (5 mmol /L) between‘good’ and ‘too high’ levels of cholesterol. They also contradict the popularized idea of a positive, linear relationship between cholesterol and fatal disease. Guideline-based advice regarding CVD prevention may thus be outdated and misleading, particularly regarding many women who have cholesterol levels in the range of 5–7 mmol/Litre and are currently encouraged to take better care of their health’’(2).

The latest development is the growing acceptance and awareness that excessive consumption of sugar and carbohydrates is a critical factor contributing to T2D, heart disease and various cancers. The research which demonstrates this is convincing (3). In addition there are large numbers of individuals who have effectively cured their own T2D by switching to a diet which is low in carbohydrates and high in fat (LCHF) which is in direct contradiction of the conventional recommendations (4).

However things may be starting to change. The USA Academy of Nutrition and Dietetics has over 75,000 members made up of registered dietitian nutritionists, dietetic technicians, registered, and other dietetics professionals holding undergraduate and advanced degrees in nutrition and dietetics, and students. The Academy is committed to improving the nation’s health and advancing the profession of dietetics through research, education and advocacy. In a response to the latest draft version it has made a number of key points including the following:

  • Genuine doubts about the advisability of making a recommendation on sodium intake which would apply to everyone. More specifically it draws attention to studies and reviews which demonstrate an increase in mortality at the recommended intakes. In fact, the optimal ranges for sodium intake are significantly greater than the DGAC’s recommended maximum intake. In other words there is a distinct danger that those who conscientiously follow the guidelines and lower their intake of sodium may actually be damaging their health. The Academy urges the DGAC to exercise caution in drafting the recommendation on sodium intake. In particular it expresses concern that the Scientific Report’s section on sodium intake appears to use the conclusions of several studies which were limited to those “who would benefit from blood pressure lowering” as a basis for making a general recommendation that all American adults consume less than 2,300 mg/day of sodium. Clearly it would not be valid to extrapolate such results to the population as a whole.
  • The recommendation to reduce the intake of saturated fat (SFA) is based on the assumptions that TC and LDL Cholesterol are significant risk factors for heart disease and that these are raised by the SFA. The Academy comments that even if the SFAs increase the TC and LDL Cholesterol levels, this is essentially irrelevant to the question of the relationship between diet and risk for cardiovascular disease. In 2010 the USA Institute of Medicine concluded unequivocally that these markers were not suitable for use as surrogates for the impact of diet on heart disease. In the light of these conclusions the Academy was concerned that the evidence does not lead to the conclusion that saturated fats should be replaced with polyunsaturated fats (PUFAs) for the greatest health benefit. It is highly significant that the Academy should take this position because it paves the way for abandoning the advice to lower the SFA and provides an opportunity to advise an increase, which can be justified on the basis of extensive evidence (5).
  • The Academy goes on to recognize that the SFAs should not be replaced by carbohydrates but despite the above comment after a rather convoluted argument finally reaches the conclusion that:This is surprising because there has been no attempt to distinguish between the omega-3s and the omega-6s even though the difference is absolutely crucial. In fact there is extensive reliable evidence which indicates that omega-6:omega-3 ratio is far too high in many countries and can reach values as high as 50. Ideally the ratio should close to unity and certainly no higher than 4 (6). A very high omega-6:omega-3 ratio promotes the pathogenesis of many diseases, including cardiovascular disease, cancer, and inflammatory and autoimmune diseases. As most of the normally available PUFAs are omega-6s the advice to increase them will only exacerbate the current position (7, 8). The only sound advice which can be given on the basis of current knowledge is that sugar and other sources of carbohydrates should be replaced by SFAs.
  • “Therefore, it appears that the evidence summarized by the DGAC suggests that the most effective recommendation for the reduction in cardiovascular disease would be a reduction in carbohydrate intake with replacement by polyunsaturated fat.”


The Academy report certainly represents progress. The stances on salt and SFAs are an important step forward but it is particularly unfortunate that the input on PUFAs is so pedestrian and simply ignores much relevant evidence which demonstrates why recommending an increase is likely to be harmful. Nevertheless it is important to see this in a positive light. At the very least it will help to persuade more people that cholesterol can no longer be regarded as a major risk factor for heart disease.



  1. http://www.health.gov/dietaryguidelines/2015-scientific-report/PDFs/Scientific-Report-of-the-2015-Dietary-Guidelines-Advisory-Committee.pdf
  2. H Petursson et al (2012). Journal of Evaluation in Clinical Practice 18 (1) pp 159-168
  3. http://www.sciencedirect.com/science/article/pii/S0899900714003323
  4. http://vernerwheelock.com/?p=422
  5. http://vernerwheelock.com/?p=155
  6. A P Simonopoulos (2002) http://www.ncbi.nlm.nih.gov/pubmed/12442909
  7. http://vernerwheelock.com/?p=153
  8. http://vernerwheelock.com/?p=370

173. Australian Dietitian Expelled from Her Professional Body for Advocating a Low Carb Diet?

Jen Elliott, a dietitian with 35 years’ experience, has been expelled from the Dietitians Association of Australia (DAA) because of her recommendation to lower carbohydrate diets to people with insulin resistance and type 2 diabetes (T2D) (1). The complaint originated from another dietitian who did not agree with the approach taken by Jen who claimed that the recommendation of:

“a very low carbohydrate diet for type 2 diabetes management is inconsistent with Evidence Based Practice”.

A further complaint was that one of her clients was not happy with an interview.

In response Jen pointed out that:

  • The DAA does not give specific advice but refers to the American Diabetes Association (ADA) for this.
  • The ADA notes that there is no “one-size-fits-all” eating approach in diabetes management and that the chosen eating pattern should be designed to improve glucose, blood pressure, and lipids.
  • ADA documentation suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals.
  • Evidence is inconclusive for an ideal amount of carbohydrate intake for people with diabetes. Therefore, collaborative goals should be developed with the individual with diabetes.
  • Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation, remains a key strategy in achieving glycaemic control.
  • Evidence is insufficient to support one specific amount of carbohydrate intake for all people with diabetes.

In the light of these points it would seem that recommending a diet low in carbohydrates is consistent with the DAA policy such as it is. Jen also pointed out that there is extensive evidence to show that the quantity and type of carbohydrate in a food influence blood glucose level, and total amount of carbohydrate eaten is the primary predictor of glycaemic response. There are of course hundreds, if not thousands, of individuals who can confirm this from their own personal experience. As a consequence they have effectively cured their T2D, been able to come off drugs, and improve the quality of their lives.

Although Jen explained to the client the pathways of carbohydrate metabolism and how to determine the appropriate intake for a specific individual, the person alleged she dismissed previous evidence based advice and as a result was left confused and disgruntled. So clearly there are two very different versions of what happened at the interview.

Here is how Jen describes what took place:

“The client told me that she understood what I had explained but that it was different to what she had read and had been previously told. I should stress that what I had explained was the physiological response to carbohydrate intake and the rationale for engaging in regular exercise and monitoring carbohydrate intake. I then suggested that an eating plan that was consistent with her usual eating pattern, but which also suggested some limitation of carbohydrate foods ie the CSIRO Wellbeing diet, may be suitable. I asked if she would like to trial the eating plan, went through the guidelines with her and provided her with a copy of page 3 from the Wellbeing diet booklet. As is my practice, I said that I recommended trialling the eating plan for 2 weeks to see how it suited her and we could discuss this at a review apt in 2 weeks. The appt was made at the end of the interview and later cancelled by the client. I would also like to address specific allegations made in the letter of complaint from the patient to DX. 1. That I do not support what the Diabetic Dietitians say. My response to clients who question why my approach may be different to what they have heard or been taught, is that there is not a ‘One size fits all ’approach when it comes to managing diabetes. This is in line with ADA guidelines that state, “A variety of eating patterns (combinations of different foods or food groups) are acceptable for the management of diabetes. Personal preferences (e.g., tradition, culture, religion, health beliefs and goals, economics) and metabolic goals should be considered when recommending one eating pattern over another.” I provide people with information about the possible underlying causes of the disorder, so that they have the knowledge and tools to evaluate different diet approaches and find what works for them. If a client said to me that they had seen another dietitian and the advice given suited them, I would encourage them to follow that advice. If a client said to me that they had received advice from another dietitian but that they wanted to seek my advice as well, then I would do as I explained above. I agree with and follow the principle of not a one-size-fits-all approach; therefore I do not denigrate the practices of others. I provide information and insufficient to support one specific amount of carbohydrate intake for all people with diabetes.”

Note: CSIRO is the Commonwealth Scientific and Industrial Research Organisation of Australia.

In response to this Jen was sent a letter specifically asking her to reply to the charges that:

  • Your recommendation of a very low carbohydrate diet for T2D management being inconsistent with Evidence Based Practice
  • The patient letter indicates that I dismissed previous evidence based advice given to this patient and provided contradictory advice, resulting in a confused and disgruntled consumer.

This seems rather peculiar as Jen had already answered these allegations comprehensively in her previous letter.

Nevertheless, Jen responded this time with support from Dr Richard Feinman and Dr William Yancy.

Dr. Feinman is the lead author on the recent review:

“Dietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence base” (2).

The review provides an evidence-based medicine perspective supporting low-carbohydrate diets. The paper has 26 authors with excellent credentials including at least one well-known former critic of low carbohydrate diets.

Dr Yancy is co-author of the ADA guidelines who included the following comment in a letter to Jen:

“The evidence supporting a low-carbohydrate diet is ample at this point. The only data we are missing is a trial with one of the ultimate disease endpoints like mortality or heart attacks. Of course, the low-fat/high-carbohydrate diet does not have evidence showing it improves those outcomes either—the trials that have been done were negative. And, in head-to-head trials with intermediate outcomes, low-carb diets quite clearly do better for improving HDL and triglycerides, and much of the time do better for improving glycemia and weight. Since we did the evidence review for the ADA guidelines, 3 more RCTs in patients with DM have shown greater benefit with the low-carb diet.”


Jen also provided a comprehensive response to the second charge, which included detailed comments on the complaint from the other dietitian (DX). Here is an extract:

“DX says ”The dietary advice is not that of the wider scientific community” and “A low carbohydrate diet is not best practice for diabetes care”. DX obviously is unaware of ADA guidelines, which DAA recommends dietitians follow.

 “The diet described by the client with carbohydrate once per day…….” DX should have checked her facts, as she is mistaken in what she believes I recommended to the client. If I had recommended carbs in one meal per day, which I clearly did not, it would nonetheless be supported by ADA’s guidelines.”

All the publicly available information can be accessed at (1).

A subsequent development has appeared on Facebook. In response to the following comment from George Henderson:

I am disappointed by your recent decision to expel Jennifer Elliott for recommending the lower carbohydrate CSIRO Wellbeing diet to a patient with Type 2 Diabetes” (3).

The DAA replied:

“Hi George. Please note that the former DAA member you mention was not expelled for recommending the lower carbohydrate CSIRO Wellbeing diet to a patient with Type 2 Diabetes, as you suggest. In line with DAA’s complaints procedures, we are not able to go into detail about this case – this information is confidential. What we can say is that a complaint was made against the former DAA member regarding professional competence, through DAA’s formal complaints process and this was assessed by DAA’s Complaints Committee. As a result, this person’s DAA membership has been cancelled. It is incorrect to suggest the former member is in trouble because she had certain views on nutrition and dietary approaches. DAA wishes to be clear that the outcome of the complaint against this former member relates to professional competence – and this is the reason DAA’s Complaints Committee revoked this person’s DAA membership.”

This is in direct contradiction to what Jen herself understands which relates to her dietary advice. This must mean that her expulsion was based entirely on the complaint from the client about the way the interview was conducted and the implications of that for professional competence. This seems extraordinary as it depends entirely on who you believe. Jen has presented her account which totally disputes that of the client. So without any corroboration, the DAA decision is inexplicable.

It is obvious that there is a lot more to this than meets the eye. The DAA cannot hide behind confidentiality. On the face of it the behaviour of the DAA is irrational, unjustified and disgraceful.


  1. http://linkis.com/com/2pNvU
  2. http://www.sciencedirect.com/science/article/pii/S0899900714003323
  3. https://www.facebook.com/dietitiansassociation/posts/10206562152909378?ref=notif&notif_t=like


172.Response to Article by Director General of the British Nutrition Foundation (BNF)

In a recent issue of “Food Science and Technology”, Professor Judith Buttriss, who is Director General of the BNF, discusses the role of sugars in diet and health (1). Based on draft reports from the World Health Organisation (WHO) and the UK Scientific Advisory Committee on Nutrition (SACN) she concludes that the calories in sugar are no more responsible for obesity than other calories consumed in excess of expenditure. She goes on to suggest that the mechanism for weight gain is likely to be the excess energy intake rather than any physiological or metabolic effect of sugars per se. This is a remarkable position, which demonstrates an apparent ignorance of current scientific knowledge.

In reality we now have very convincing evidence that obesity is not caused by consuming more calories than are being used. There is overwhelming evidence that simply reducing the intake of calories just does not work.  This is all explained by in the excellent book “The Obesity Epidemic” by Zoe Harcombe (2).What is absolutely crucial is the content of the diet NOT the amount of food consumed. It is time the nutrition world woke up to the fact that the body does not utilise food in the same way as a bomb calorimeter. All calories are not equal because the metabolic processes which deal with fat, protein and carbohydrates are all quite different.

Sugar is broken down to glucose and fructose, which is now recognised as a disastrous combination with respect to health.

Raised levels of glucose in the blood will eventually cause Type 2 Diabetes (T2D). Obviously this is the result of excessive consumption of sugar and other foods containing starch which is broken down to produce glucose. In response the pancreas is stimulated to secrete insulin. One of the functions of the insulin is to reduce the level of blood glucose which it does by directing it to the liver where it is converted into fat, which is then stored. Hence body weight is gained and if the same type of diet is maintained over a period, the inevitable result is obesity. It also means that the body is effectively overloaded with fat. One consequence of this is that the level of triglycerides in the blood, a reliable risk factor for heart disease is raised. Another is that some of the fat accumulates in the liver, which results in the “fatty liver” condition.

Because the fat is stored, satiation is not achieved, which explains why a person consuming a diet high in carbohydrates is continually hungry and therefore consumes excessive quantities of food. Conversely a person consuming a diet low in carbohydrates and high in fat will find that hunger is satisfied quite easily.

It is also important to appreciate that the continual exposure of the body to high levels of insulin causes the condition of insulin resistance (IR). There is now convincing evidence that hyperinsulinaemia and insulin resistance are all related to heart disease, stroke, hypertension and obesity or what has become known as “metabolic syndrome”.

However the picture gets even worse when we factor in the role of fructose. This is because the metabolism of glucose and fructose are different.  First of all the presence of fructose in the blood does not stimulate the secretion of insulin by the pancreas. Consequently it has been promoted as a “healthy sweetener”. On the other hand it can only be metabolised in the liver whereas glucose can be utilised throughout the body. This places a huge demand on the capacity of the liver, which means that it limits the ability to cope with other carbohydrates. One of the by-products of the fructose metabolism is uric acid which causes gout and increases blood pressure.

The fructose also causes insulin resistance in the liver so that extra insulin has to be produced, which increases the demand on the pancreas that eventually leads to the failure of the organ resulting in T2D. The extra insulin forces fat into the cells giving rise to weight gain and obesity. Over the years the increased consumption of sugar and High Fructose Corn Syrup (HFCS) which is a mixture of glucose and fructose has been closely followed by increased incidence of obesity. Confirmation of the damaging effects of fructose are shown by the following investigations:

  • 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(3)
  • 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 (4).


Excess sugars in the body react with proteins to form Advanced Glycation Endproducts (AGEs), which means that the normal functioning of the proteins is impaired. In particular they contribute to premature aging, the development of atherosclerosis and complications in long-term T2D. The affinity of fructose for proteins is about 8 times greater than that of glucose (5).

Even further confirmation is provided by the research which demonstrates that those who reduce their sugar and other carbohydrates can successfully cure T2D (6,7). On top of this they invariably lose weight and improve the risk factors for heart disease by reducing the level of triglycerides in the blood and raising the HDL Cholesterol. In spite of the fact that mainstream medicine regards T2D as incurable, hundreds if not thousands of individuals have successfully overcome the disease by reducing the amount of sugar and other carbohydrates in their diet.

Finally it is essential to explain what has happened over the past 30 years during which time obesity, T2D and kidney disease have all increased to unprecedented levels, despite the fact that the official recommendation to reduce the intake of saturated fat (SFA) by 25 % was achieved by about 2000. Although there are no detailed statistics on how the intake of sugar has altered, there can be no doubt that it has increased very substantially over this period. Between 1975 and 2000 the consumption of soft drinks increased 4-fold. There has also been a huge increase in the sales of “low fat” products. Many of these, such as yoghurts, are often devised by replacing the fat with sugar. The latest UK survey shows that for children aged 4 to 10, the average intake of sugar is 14.7% of energy for those aged 11 to 18 years it is 15.6% (8). It is clear that sugar has to implicated in the deterioration of public health.


We now have overwhelming evidence from a range of different sources and disciplines which have established beyond reasonable doubt that excessive consumption of sugar is damaging to health. It has been a major contributor to the increased incidence of obesity and T2D that has occurred in so many countries over the past 40 years. From a public health perspective there are very sound reasons that every effort should be made to reduce the consumption very substantially.

The conclusion of Professor Buttriss that:

“…evidence to support sugar as a primary cause (of obesity) is incomplete at best…”

Is somewhat disingenuous and is obviously based on the discredited concept that obesity is simply caused by consuming more energy than is expended. We now know that obesity is a disorder of the metabolism, which is primarily caused by excessive insulin production. The solution is obvious: reduce the amount of carbohydrates, especially the sugar!


  1. J Buttriss (2015) Food Science and Technology 29 (1) pp14-15
  2. Zoe Harcombe (2010) “The Obesity Epidemic” Columbus
  3. P A Akinynju et al (1968) Nature 218 (5145) pp 975-977
  4. K Stanhope et al (2009) Journal of Clinical Investigation 119 (5) pp 1322-1334
  5. C G. Schalkwijk et al (2004) Diabetes/Metabolism Research and Reviews 20 (5) pp 369-382
  6. J V Nielsen et al (2005) Upsala Journal of Medical Science 1 (10) pp 69-74
  7. RD Feinman et al (2015) Nutrition 31 (1) pp 1-13
  8. https://www.gov.uk/government/news/new-national-diet-and-nutrition-survey-shows-uk-population-is-eating-too-much-sugar-saturated-fat-and-salt

171. Bad Science

In an ideal world, the various checks and balances that are applied would ensure that information presented in the scientific journals, especially those regarded as prestigious, is sound and reliable. Unfortunately there is convincing evidence that this is not the case. In an article published in the BMJ, Tricia Greenhalgh and colleagues have concluded that evidence based medicine is in crisis (1). The following reasons are cited:

  • The drug and medical devices industries increasingly set the research agenda by defining what counts as a disease. Then they specify which tests and treatments will be evaluated and choose the measures which will be used to determine the effectiveness.
  • There is just too much information so that the clinical guidelines are not manageable.
  • Most of the current work will only result in very small gains. The large scale trials which must be done to detect these marginal benefits tend to over-estimate them while at the same time the adverse side effects are played down.
  • As people age, they are more likely to suffer from several different conditions at the same time. These are very difficult to treat with the result that the management of one disease or risk state may cause or exacerbate another—most commonly through the perils of polypharmacy in the older patient.
  • As the examples above show, evidence based medicine has drifted in recent years from investigating and managing established disease to detecting and intervening in non-diseases. Risk assessment using “evidence based” scores and algorithms (for heart disease, diabetes, cancer, and osteoporosis, for example) now occurs on an industrial scale, with scant attention to the opportunity costs or unintended human and financial consequences (1).

John Ioannidis concluded that many published research findings are false or exaggerated, and an estimated 85% of research resources are wasted (2).

Richard Smith, a former editor of the BMJ has argued that the fundamental issue is the publication of papers in medical journals which report the results of trials on various drugs (3). These are likely to be much more effective in influencing doctors to select these drugs for treatment of patients than advertisements. Independent research has shown that studies funded by a company were four times more likely to have results favourable to the company than studies funded from other sources. This is achieved by asking the right questions. Smith describes how that approach is implemented:

  • Conduct a trial of your drug against a treatment known to be inferior
  • Trial your drugs against too low a dose of a competitor drug
  • Conduct a trial of your drug against too high a dose of a competitor drug (making your drug seem less toxic)
  • Conduct trials that are too small to show differences from competitor drugs
  • Use multiple endpoints in the trial and select for publication those that give favourable results
  • Do multicentre trials and select for publication results from centres that are favourable
  • Conduct subgroup analyses and select for publication those that are favourable
  • Present results that are most likely to impress—for example, reduction in relative rather than absolute risk.

If all this fails to produce positive results then it is rare for any negative results ever to see the light of day. In addition the impact of the favourable results are enhanced by publishing the same information in several different journals. Because the drug companies usually conduct trials in several different centres, there is huge scope for publishing different results from different centres at different times in different journals. It’s also possible to combine the results from different centres in multiple combinations. A few years ago the biotechnology firm Amgen selected 53 reports of research, many of them related to cancer, which might offer potential for subsequent development by the company. It found that the results of only 6 (11%) could actually be replicated successfully (4). In order to investigate further where possible the original authors were contacted to discuss the discrepant findings, exchange reagents and repeat experiments under the authors’ direction, occasionally even in the laboratory where the work had been done.

It was discovered that studies which could be reproduced, the authors had paid close attention to controls, reagents, investigator bias and describing the complete data set.

By contrast it was found that when this was not the case, data were not routinely analysed by investigators blinded to the experimental versus control groups. Results were often published which in agreement with working hypothesis, but which were not representative of the complete set of data. It emerged that there are no guidelines which require all data sets to be reported in the paper. In fact, original data sets are often removed during the editorial process. Essentially similar conclusions were reached by a team from Bayer Healthcare in Germany (5).

John Ioannidis and colleagues have identified a number of reasons why so much research is poor quality (6). These include:

  • Poor protocols and design. Some research is done using a rudimentary protocol or possibly no protocol at all. Even when there is a formal protocol, it may not be publicly available. Although changes may have to be made during the course of an investigation, these are often poorly documented.
  • Poor utility of information. Many studies are conducted without any attempt to assess the value or usefulness of the information that will be generated.
  • Statistical power and outcome misconceptions. In order to achieve statistical power, researchers may choose outcome measures which are clinically trivial or scientifically irrelevant. This can happen in studies on heart disease where there is no difference between treatments in death rates but there can be significant differences if other symptoms of the disease, which are assessed subjectively are included in the analysis.
  • Insufficient consideration of other evidence. Most studies are designed and conducted in isolation. In a broader context, the failure of researchers on heart disease to recognise the damage that can be caused by raised blood glucose insulin resulted in the continued emphasis on fat/cholesterol. Ultimately this led to recommendations to alter the habitual by reducing fat, especially the saturated fat, and increasing carbohydrates. It is now becoming clear that this has been an absolute disaster and is one of the main reasons why obesity and T2D has reached epidemic levels.
  • Subjective, non-standardised definitions and vibration of effects. This refers to subjective judgments which leave room for so-called vibration effects during the statistical analysis which means that the results can differ depending on how the analysis is done. This can lead to bias especially if the investigators have a preference for a particular result. This provides an opportunity for the researchers to design the study protocol in such a way that would favour the outcomes that will satisfy the sponsors. This could help to explain why the source of funding has such a strong influence on the results obtained.

He goes on to explain that many biomedical researchers have poor training in research design and analysis. Physicians who conduct research usually have a short introduction to biostatistics early in medical school, and subsequently do not receive any further formal training in clinical research. The little training that they receive often focuses on data analysis, and rarely includes study design, which is arguably the most crucial element in research methods.

Much flawed and irreproducible work has been published, even when only simple statistical tests are involved.

Research is often done by stakeholders with conflicts of interest that favour specific results. These stakeholders could be academic clinicians, laboratory scientists, or corporate scientists, with declared or undeclared financial or other conflicts of interest. Much clinical research is designed and done under the supervision of the industry, with little or no input from independent researchers. Clinicians might participate in this process simply through the recruitment of study participants, without making any meaningful contribution to the design, analysis, or even writing of the research reports, which might be done by company ghost writers.


This is a very sorry state of affairs. Enormous amounts of money and human resources are being devoted to research in the biological sciences, yet all the indications are that in many cases the results are not worth the paper they are written on. On top of all this there is the failure of the refereeing system used by the scientific journals to identify the flaws contained in the papers submitted for consideration publication. Furthermore the findings often are absolutely crucial in the determination of commercial strategies and national policies. It is somewhat salutary that these are being constructed on a foundation of sand. For example it means that it is relatively easy or the data to be manipulated to suit other agendas, such as the case submitted for official approval of a drug. The same considerations apply to the development of dietary guidelines and the poor standard of the background science is one of the reasons why it is so difficult to determine the relationship between diet and health.

There are many reasons why public health policies in many countries are failing but the lack of a sound reliable evidence base is fundamental and until this is fixed, progress will be extremely difficult to achieve.


  1. http://www.bmj.com/content/348/bmj.g3725
  2. http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001747
  3. http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0020138
  4. http://www.nature.com/nature/journal/v483/n7391/full/483531a.html
  5. http://www.nature.com/nrd/journal/v10/n9/full/nrd3439-c1.html
  6. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62227-8/fulltext



On return from holiday, you open the front door and discover that there is water all over the place. Obviously there has been a leak somewhere and the house is flooded. As soon as you get over the shock, you call a plumber. Just imagine your reaction if you are told that it is impossible to stop the flow of water. You must to accept that you have to cope as best you can with this excess water. There may be scope for diverting some of the water but you will have to do what you can with buckets and mops as long as the house is still standing.

This is absolutely ridiculous. There is no question that the leak can be fixed and that as a consequence the flooding can be stopped. The house can be cleaned up and the occupants can repair any damage and get on with their lives. If one plumber says the problem cannot be solved then no doubt another one will be found who can provide a satisfactory solution.

Although you may think the scenario painted here is ludicrous, the point I am trying to make is that Type 2 Diabetes (T2D) is an exact parallel. Instead of your house being flooded with water your body is being flooded with sugar. The excess water causes damage to furniture, carpets, services such as electricity and gas, and possibly even the structure. Similarly excess sugar in the blood sticks to proteins so that their function is impaired. It combines with haemoglobin so that the efficiency of oxygen transport is reduced. As a consequence the extremities may be starved of oxygen, which explains why it is sometimes necessary to amputate the limbs of those who suffer from T2D. Internal organs, especially the brain can also be damaged. The risk of developing Alzheimer’s Disease is increased very substantially in diabetics. Excess glucose in the blood stimulates the production of insulin, which is required by the body to deal with the glucose. However the high levels of insulin also cause internal damage as shown by insulin resistance in many organs.

The top priority must be to prevent the build-up of sugar inside the body. The solution is obvious. Identify the source and stop the flow in just the same way as you stop the flood in your house.

However unless you are fortunate enough to have one of the very few enlightened doctors that are about in the UK, you will be given the official line as illustrated by the NHS Choices website which tells us quite bluntly there is no cure for T2D (1). This means that if you have been diagnosed with T2D, you will need to look after your health very carefully for the rest of your life. Furthermore your GP will be able to explain your condition in detail and help you to understand your treatment. If there are any problems, you may be referred to a hospital-based diabetes care team, which will closely monitor your condition to identify any health problems that may occur.

It goes on to say that T2D usually gets worse over time and although lifestyle changes may help to control blood glucose levels, eventually medication will probably be needed. There are various combinations of drugs that can be used, culminating with insulin that has to be applied by injection.

To return to the house flooding analogy, what this means is that you will just have to put up with the effects of the excess water as long as you remain in that house. However there is now overwhelming evidence from a variety of sources that T2D can be cured or at worst alleviated in exactly the same way as in a flooded house: you simply stop most of the sugar from entering the body. The specific form of sugar in the blood which is causing the trouble is glucose. This originates from the diet. First of all, there is the ordinary table sugar which is broken down to glucose and fructose.  Although fructose does not accumulate in the blood, there is growing evidence that it also causes harm inside the body. Secondly, there are the foods such as potatoes, flour, bread, rice and pasta that contain starch, which is broken down into glucose. The answer is blindingly obvious, reduce the consumption of those foods which contribute to the glucose in the body. If we go back to official source of information we find that the dietary advice is that:

“The important thing in managing diabetes through your diet is to eat regularly and include starchy carbohydrates, such as pasta….”

This is absolutely unbelievable because it means that more glucose will enter the body when action should be taken to reduce it. This is like telling the flooded householder that it is a good idea to let the bath overflow fairly regularly!

The Diabetes UK website states that:

“Carbohydrate is a nutrient that is an important source of energy in the diet. All carbohydrates are broken down into glucose which is essential fuel for the body, especially the brain.”

It goes on to advise that we should limit our intake of saturated fat and choose the ‘low fat’ versions where possible (2).

This really is rubbish! The body is perfectly capable of using fat as a source of energy, although it may take a few days to adapt. Carbohydrates are not required. There is overwhelming evidence that people can lead a perfectly healthy life with a minimal amount of carbohydrates in their diet. The brain can utilise ketones (which are derived from fat) as a source of energy.

Low fat foods are disastrous for diabetics because the fat is often replaced by sugar which makes the disease even worse.

To cap it all, recent research has indicated that the standard treatments are ineffective. In a study using information from databases in Saskatchewan on 12,272 patients with T2D, it was found that the all-cause mortality rate increased with exposure to insulin (3). Table 1 shows that those with the highest exposure had almost 3 times the death rate of those who were not treated with insulin. A similar trend was found for death due to cardiovascular diseases.

Table 1. Relationship between insulin exposure and mortality

Insulin exposure Hazard ratio
None (reference) 1.00
Low 1.75
Moderate 2.18
High 2.79


Information obtained from almost 50,000 patients with T2D on the UK General Practice Research Database between November 1986 and November 2008 was used to relate all-cause mortality to the type of treatment (4). It was found that those who successfully reduced their blood sugars using insulin-based therapy had an all-cause mortality which was 49% higher than those who were not treated in this way and had higher blood sugars. These treatments equate to the mop and buckets attempts to deal with the flooded house.


There is ample research to demonstrate that T2D can be cured by simply reducing the consumption of those foods which release the glucose into the blood (5). This is confirmed by hundreds of personal case histories from individuals who have transformed their lives by this approach. What is particularly impressive is that many of these have been able to cease all medication, which is proof of the success that has been achieved. One good example is that of a medical doctor in Canada. Dr Jay Wortman. He is how he describes his experience:

“The first thing that happened was that my blood sugar normalized. This was almost instant and was followed by a dramatic and steady loss of weight. I started dropping about a pound a day. My other symptoms swiftly vanished, too. I started seeing clearly, the excessive urination and thirst disappeared, my energy level went up and I began to feel immensely better.” (6).

Still not convinced, then have a look at what Dr. Jason Fung in Toronto has achieved. He actually persuades his patients to subject themselves to a period of fasting. It is somewhat surprising that this is not as traumatic as one would expect. While the first day or 2 may be difficult, Dr. Fung has found that within a short time the ability to utilize fat is activated quite quickly, so that the body can draw on the stores of fat to meet the requirements for energy. Although it may take some time for substantial weight loss to manifest itself, there is a rapid reduction in the fat content of the liver, which demonstrates that the procedure starts to have a beneficial effect very quickly.

Here are 2 testimonials as described by individual patients:

    • “My name is Marg. Just 8 months ago I walked into the building for my appointment with Dr. Fung thinking this is a waste of my time. I had tried everything. My eye sight was getting really bad, I had to have surgery. I have been over weight my whole life it seems. I could not even bend over to tie my shoes. I could hardly breathe as I walked through the door, but I continued on hoping to find something to at least help with my diabetes that I have had for 25 years. I recall Dr. Fung introducing himself and telling me I was there because I needed help. I thought to myself here we go again, however, the doctor carefully explained I had options. I could have an operation or I could Fast which could help me get off Insulin. I was then introduced to Megan who helped and guided me on how to get started Fasting. I was told to try and Fast as long as I can. Megan took my measurements and could not even reach around me. I was told to come back in a week. I went home feeling excited and anxious, could I actually do this? I told my family and they were so encouraging. I thought could this be what I have been looking for my whole life? Prior to seeing Dr. Fung I was taking 60-20-60 units of Insulin and 2000 mg of Metformin a day. Within 11 days of my first appointment I was decreasing my Insulin as my readings were already dropping. By the 12th day I completely stopped taking the Insulin. It was not easy I did a complete fast for approximately 4 weeks. However just not having to take Insulin was so encouraging!! I then started the next phase of eating 2 times one day and Fasting until lunchtime the next day. Pills were next I starting cutting down by September 6th, I took my last Metformin. I have already lost 66lbs and several inches from my waist. I have dropped from a 5X to a 3X. I can honestly say I have not felt this good in years. I can pick up the newspaper and actually read it. I can also bend down and tie my own shoes” (7).
  • “Kirk: I have been overweight since 3rd grade. Having tried numerous diets and methods of losing weight, I became desperate for a solution and received approval for gastric bypass surgery. During a regular visit to Dr. Fung I mentioned this and he asked if I would be interested in taking part in a new dietary management program he was starting. I feel very blessed that this happened because I was totally put off the gastric bypass surgery after attending an information session at Toronto Western. I began the Intensive Dietary Management program in June of 2013 and with the help & encouragement of Dr.Fung, Megan and my family (especially my daughter Catherine whom we call the food police) I have achieved fantastic results.Before the program I was taking 9 pills a day, 3 types of which were to help control my diabetes and one for high blood pressure. Today I take only 2 pills a day, one of which is for diabetes control. My A1C level is now better controlled, although my insulin resistance is still an issue. I have more energy, increased mobility and look forward to continuing in the program. The monthly group sessions are enjoyable and a good source of information……Thank you, Kirk” (8).


  • In the past eighteen months I have seen my weight reduced from 360 lb. to 244 lbs. Yes that’s a 116 lbs. or the equivalent of a small adult. My waist size decreased substantially from a starting point of 63 inches and now is 48 inches, a reduction of 15 inches! Most amazing of all is the reduction in prescription drugs.



This is not rocket science but quite simply the application of common sense which obviously works very well for many people. T2D is a very serious disease in its own right but also increases the risks of developing various other diseases including heart disease and Alzheimer’s Disease. Individuals who suffer from it have a reduced life expectancy and deterioration in the quality of their lives. The costs of treatment are at least £10Bn per year in the UK and the incidence is expected to continue increasing.

The official approach to this particular disease is incompetent and irresponsible. The current strategy is expensive, ineffective and causes unnecessary suffering to many people and their families. It is unbelievable that there has been a total failure to tackle the problem, when there is so much evidence to demonstrate that answers are readily available.

From a much broader perspective, this particular example highlights the fundamental fault in the current policy on healthcare not only here in the UK but in many other countries. Essentially the emphasis is on fire-fighting, which means that invariably considerable damage has been done before any action is taken. It follows that if real progress is to be achieved than there has to be a very significant shift in attitude and resources towards prevention. Looking back, it is evident that the most significant advances have been made in this way. Examples include:

  • Smoking and lung cancer
  • Clean water and a range of infectious diseases
  • Ensuring adequate intakes of vitamins and minerals

The only logical way forward to achieve this objective is to cut back drastically on the resources directed to curative medicine. There will undoubtedly be massive opposition to any attempt to do so. The extremely powerful vested interests will fight tooth and nail to maintain the status quo. Nevertheless the fact remains that existing policies are not working. If the example of T2D described here is symptomatic of other diseases/treatments then it follows that in spite of all the efforts and expenditure, standards of public health are not being improved. Ultimately the issue will have to be addressed. Why not tackle it sooner rather than later?


  1. http://www.nhs.uk/Conditions/Diabetes-type2/Pages/Treatment.aspx
  2. https://www.diabetes.org.uk/About_us/What-we-say/Food-nutrition-lifestyle/Consumption-of-carbohydrate-in-people-with-diabetes/
  3. J M Gamble et al (2010) Diabetes, Obesity and Metabolism 12 (1) pp 47-53
  4. C J Currie et al (2010) Lancet 375 (9713) pp481-489
  5. http://www.sciencedirect.com/science/article/pii/S0899900714003323
  6. http://www.drjaywortman.com/blog/wordpress/about/
  7. http://intensivedietarymanagement.com/idm-patient-profile-december-2014-margaret/
  8. http://intensivedietarymanagement.com/idm-patient-profile-november-2014-kirk/


This contribution is by Judy Barnes Baker and I am most grateful to her for permission to re-post here. The original can be seen at



Ask anyone and they’ll tell you the solution for obesity. Eat less; move more. Our collective weight problem would go away if all the overweight people just quit eating more calories than they burn. Couldn’t be simpler.
There are 4,086 calories in a pound of fat. Divide that by the 7 days in a week and you get 584 calories. So if you eat 584 calories less per day you will lose a pound a week. If you continue to eat 584 fewer calories every day for a year you will lose 52 pounds. In 10 years, you will lose 520 pounds. In 20 years you will lose 1,040 pounds. Doesn’t sound so logical anymore, does it?
Consider this: A person who is 50 pounds overweight is wearing 204,300 calories of fat. That is enough calories to live on for 6 months. So why does a fat person get hungry?
Our bodies have a set point based on hormones that determines how much we weigh. The hormones tell you when to eat and when to stop with hunger signals. To change the set point you must change the hormones. Insulin is the master hormone. It is released in response to eating carbohydrates and it signals the body to store fat.
When you eat fewer calories and/or burn more with exercise, your metabolism, sensing that you are going through a famine, slows down to conserve energy. You will become more sedentary, your body temperature will drop, your energy level will go down, and your weight loss will slow down or stop.
By limiting carbohydrates, you can reduce your ability to store calories as fat. In spite of what you may hear from the critics of low-carb, I can assure you that the second law of thermodynamics is fully accounted for in the equation. All the energy goes somewhere, just not to your belly or your backside. We might be able to predict how much gasoline a finely-tuned car would use to travel a certain distance, but the human body is not a closed system like an engine. And the car won’t help you reach your destination by adjusting its rate of fuel consumption to make sure you get there.
How much fat you accumulate is not determined by how many calories you eat versus how many you burn, but by how the nutrients in those calories affect the hormonal regulation of metabolism. If a food stimulates the release of insulin, it is more likely to be stored as fat. If it doesn’t, it is more likely to be used as energy. The metabolism of an obese person is obviously biased toward saving calories as fat rather than spending them as energy, but that can be modified by dietary choices.
Most people believe in the calories-in-versus-calories-out hypothesis because they think they have witnessed it with their own eyes. Shows likeThe Biggest Loser perpetuate the myth. You may have read about a study of the contestants on the show conducted by Darcy Johannsen et al, who reported that by the end of the 30th week, the participant’s had slowed their metabolisms by 504 calories more per day than would be expected by their weight loss. That means that by losing weight the eat-less-move-more way, these big losers now have to eliminate the equivalent of one meal a day compared to what they ate before the intervention just to stay at their original weight. www.weightymatters.ca/2011/02/biggest-loser-destroys-participants.html.
A more recent (2012) study from Johannsen’s team titled, Metabolic Slowing with Massive Weight Loss despite Preservation of Fat-Free Mass, investigated whether exercise during weight loss would prevent a drop in metabolism as long as the subjects lost fat but retained non-fat mass.http://jcem.endojournals.org/content/early/2012/04/24/jc.2012-1444.short This is the conclusion from the study: “Despite relative preservation of FFM (fat-free mass), exercise did not prevent dramatic slowing of resting metabolism out of proportion to weight loss….”
The next time you hear someone bemoaning the fact that “diets don’t work,” you’ll know why.

“Obesity is a growth disorder just like any other growth disorder. Specifically, obesity is a disorder of excess fat accumulation. Fat accumulation is determined not by the balance of calories consumed and expended but by the effect of specific nutrients on the hormonal regulation of fat metabolism. Obesity is a condition where the body prioritizes the storage of fat rather than the utilization of fat….

The energy content of food (calories) matters, but it is less important than the metabolic effect of food on our body.”

~~Dr. Peter Attia,


Here is a previous post on the subject:http://carbwars.blogspot.com/2008/01/biggest-loser.html
Post Scripts:

  1. A Reuter’s story (March 7, 2013) reported that a survey from the Centers for Disease Control and Prevention (CDC) showed that US calorie consumption has gone down for the last 10 years but obesity has risen. The co-author of the study said, “It’s hard to reconcile what these data show, and what is happening with the prevalence of obesity,” but that didn’t keep him from trying. He never considers that his basic beliefs about what causes obesity might be flawed. The findings appeared in the American Journal of Clinical Nutrition. Here is the article:http://reut.rs/WvGhcO
    2.The Journal of the American Medical Association (June 2012) reported about a clinical trial from the Boston Children’s Hospital conducted by Dr. David Ludwig. Ludwig et al put obese subjects on a starvation diet until they had lost 10 to 15% of their weight in order to replicate those who are pre-obese for testing. They fed the subjects one of three different diets; one diet was low-fat/high carb; one was low-glycemic; and one was low-carb/high fat and protein. All three diets contained the same number of calories.
    The results: the low-carb group burned 300 calories more per day than the low-fat group and 150 more than the low-glycemic group. Gary Taubes had this to say about the study: “If we think of Dr. Ludwig’s subjects as pre-obese, then the study tells us that the nutrient composition of the diet can trigger the predisposition to get fat, independent of the calories consumed. The fewer carbohydrates we eat, the more easily we remain lean. The more carbohydrates, the more difficult. In other words, carbohydrates are fattening, and obesity is a fat-storage defect. What matters, then, is the quantity and quality of carbohydrates we consume and their effect on insulin….More research is necessary to shore up this finding, but, at the moment it would appear that not all calories are created equal….” www.livestrong.com/article/559435-know-thy-enemy-carbs/#ixzz2NieQ9q2y

Image above from Wikopedia.  (C) 2012, Judy Barnes Baker, www.carbwars.blogspot.com

168. Beware Jamie Oliver’s Food Revolution!

Jamie has been very busy with his Food Revolution Day which is part of his campaign to persuade governments to take action to combat obesity. While this is obviously a laudable objective, the harsh reality is that the strategies he is advocating are doomed to failure. So before you agree to lend your support to this initiative, it is important to examine what exactly Jamie is promoting. I have no quarrel with his encouragement of cooking skills and the use of whole foods. However digging a bit deeper it is evident that when it comes to the dietary guidelines, he is endorsing precisely those that are still being advocated by governments and the mainstream health professionals, which have not worked. There is no question that these have prompted the vilification of fat and contributed to increased consumption of carbohydrates which is probably the prime cause of the increase in the incidence in obesity.

On one of Jamie’s websites there is an article entitled “Understanding good and bad fats” (1). Here is an extract:

“In the Western world, fat consumption is far too high. The World Health Organisation (WHO) has estimated that by 2015, 1.6 billion adults will be overweight – that’s almost a quarter of the world’s population! Although we all need a small amount of fat in our diet, we need to be careful about the amount of fat we’re consuming, as there are many associated health problems such as weight gain, and higher risk of diabetes, cancer and heart disease.”

It continues:

“A diet rich in saturated fat can cause the cholesterol level in the blood to rise, which in turn can lead to thinning of the arteries, potentially causing a blockage and increasing the risk of a heart attack. We should all aim to keep the levels of saturated fat in our diet low.”

“The best source of omega 6 is seeds and their oils (hemp, pumpkin, sunflower, sesame and corn). These fatty acids are also found in a wide variety of nuts, grains and vegetables – so an easy way of getting some into your diet is using vegetable oils for cooking. Omega 6 fatty acids are also helpful in the clotting of blood, skin health, and to help lower cholesterol.

“A healthy diet is all about balance. Bear in mind the proportion of fatty foods you should be having at each meal according to the eatwell plate (see Understanding the eatwell plate), and try to make sure your meal includes foods from all of the different food groups. Fat is a small, but essential, part of the diet. Try to make good choices about the types of fat you eat and this should help to keep your cholesterol low, and your arteries healthy.”

Unfortunately this is the same old rubbish that has got us into trouble in the first place! It really is about time that Jamie and his advisers got themselves up to date. They have slavishly followed the government guidelines to such an extent that they support the notoriously discredited Eatwell plate.

Are they not aware of the fact that the “cholesterol theory” just does not stand up to rigorous examination? There is actually an increase in total mortality with low cholesterol values: the highest life expectancy is found in those with raised cholesterol levels, especially women. It is now becoming very clear that the support for cholesterol as a risk factor for heart disease is primarily limited to the pharmaceutical industry so that it can justify the case for the use of statins.



To be fair, Jamie is taking a strong line on sugar which is absolutely correct. However if progress is to be made then people have to be advised on a suitable replacement for the sugar which is removed from the existing diet. With the conventional approach the answer is the complex carbohydrates but these also cause the blood glucose to increase, which is the real problem. This is because insulin has to be produced by the pancreas to cope with the sugar. If the body is continually subjected to high sugar/carbohydrate then there will be insulin resistance, which is damage to the organs leading to a range of chronic diseases. Eventually the pancreas cannot cope and the result is Type 2 Diabetes.

The ideal replacement is fat but here again Jamie gets it wrong. Olive oil a monounsaturated fat is absolutely fine but Omega-6s/vegetable oils are a big NO NO. Current diets in the UK and in many other countries are far too high in Omega-6 content and there is not enough Omega-3. At these levels the excess Omega-6s contribute to the development of inflammation which can trigger the processes leading to heart disease and cancer. It is rather ironic that we should be consuming MORE saturated fat. The arguments to lower it have all been discredited. In fact the consumption has fallen in the last 40 years and where did it get us? So butter, cheese, full fat milk and the fat in meat, especially from grass-fed animals is all good news.


If Jamie is genuinely interested in tackling obesity (and I have no reason to believe otherwise) then he really must take a good hard look at the nutritional advice he is promoting. The relevant information is not hard to find. There are plenty of books and blogs available.

I would suggest that his starting point might be to go to the Diet Doctor website (2). Here he will see that Sweden is the one country where the increasing trend in obesity has been halted and that it is now starting to come down. Guess what? Butter consumption is now higher than it ever as before and there has actually been a shortage.

He should also make himself familiar with what is happening in South Africa. Go to the Biz News website and look at some of the articles by Marika Sboros (3).

Here is very good scientific paper which sets out the case in support of diets which are LOW in carbohydrates and HIGH in fat (4).

Finally he should read the books by Gary Taubes (5), Nina Teicholz (6), Zoe Harcombe (7) and Tim Noakes et al (8).





  1. http://www.jamieshomecookingskills.com/pdfs/fact-sheets/Understanding%20good%20and%20bad%20fats.pdf
  2. http://www.dietdoctor.com/obesity-is-exploding-in-europe-except-in-this-country
  3. http://www.biznews.com/category/lchf-health-summit/
  4. http://www.nutritionjrnl.com/article/S0899-9007(14)00332-3/pdf
  5. Gary Taubes (2007) “The Diet Delusion” Vermillion: London
  6. Nina Teicholz. (2014)“The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet” Simon & Shuster: New York
  7. Zoe Harcombe (2010) “The Obesity Epidemic” Columbus
  8. T Noakes, S-A Creed, J Proudfoot & D Grier (2014) “The Real Meal Revolution: Changing the World, One Meal at a Time” Quivertree Publications


In part 1, I described how there is a real scope for reducing the expenditure on drugs and many medical procedures which make little contribution to improving health and very often do more harm than good. In this blog the emphasis will be to focus on the potential for curing and preventing diseases by making simple changes to the habitual diet.

This is best illustrated by considering diabetes. During 2013-2014 there were 45.1 million items prescribed for diabetes, with a net ingredient cost of £803.1million (1). This represents an increase of 66.5% in the number of items and 56.3% in the net ingredient cost since 2005-2006. In England it is estimated that 6% of the population has diabetes and the total cost is currently about £10billion, which is 10% of the NHS budget (2). It is expected that by 2025 there will be 5 million people with diabetes in England (3). Those with diabetes have a reduced life expectancy and an increased risk of retinopathy, stroke, kidney failure, heart disease and amputation of limbs.

A man diagnosed with diabetes at age 40 will lose almost 12 years of life and 19 Quality Adjusted Life Years (QALYs) compared with a person without diabetes. A woman of the same age will lose about 14 years of life and 22 QALYs (4).

Type 2 diabetes (T2D) is responsible for the increased incidence referred to above. There is ample evidence that it can be controlled, possibly even cured completely by making changes to the diet. The condition is directly due to the increased level of glucose in the blood. As a result the pancreas has to produce insulin to keep prevent excess glucose in the body. Excess insulin damages many of the organs, which can eventually lead to a range of diseases. If there is excessive glucose over a prolonged period the pancreas is unable to cope and the glucose becomes rampant, causing all sorts of damage. The solution is obvious. Reduce the amount of glucose which enters the body by altering the diet. Sugar is one of the main culprits, so it should be avoided like the plague. In addition starch is broken down to produce glucose. This means that foods such as refined flour, rice or pasta should be limited because the starch is released quickly giving rise to big increases in the blood glucose.

We now have convincing evidence that a diet which is LOW in CARBOHYDRATES and also HIGH in FAT can effectively cure T2D in many cases (5) and that it should always be used as the first approach to treatment. This has been confirmed by numerous individual case studies from individuals. Dr Jason Fung in Toronto has been treating patients successfully by advising them how to change their diet (6). Dr Sarah Hallberg is another physician who has achieved similar results (7).

Because  those with T2D have an increased risk of many other diseases/conditions, a reduction in the incidence of T2D would result in a big improvement in the standard of public health. Furthermore there is now good evidence that a diet which is high in sugar/carbohydrates is a critical factor in the development of diseases which include cardiovascular disease, Alzheimer’s Disease and various cancers.

Sweden is probably the first country to make adjustments to the national diet in line these concepts. Butter consumption has increased to such an extent that shortages have been reported (8) and the incidence of obesity is starting to decline (9). There is also evidence that the incidence of T2D is falling and I hope to access the data in the near future.

The fundamental problem is that here in the UK and in most other countries the official dietary recommendations are almost entirely in direct conflict with the concepts outlined here.

According to the current official advice on Healthy Eating in the UK:

  • ‘’We all need some fat in our diet, but eating too much makes us more likely to become overweight. What’s more too much of a particular kind of fat – saturated fat – can raise our cholesterol, which increases the risk of heart disease’’
  • ‘’Eating too much fat can make us more likely to put on weight, because foods which are high in energy (calories). Being overweight raises our risk of serious health problems such as heart disease, type 2 diabetes and high blood pressure’’
  • ‘’Starchy foods such as potatoes, bread, cereals, rice, pasta should make up about one third of the food you eat’’.

As a consequence, the messages that you should reduce the consumption of fat, especially the saturated fat (SFA) and increase that of carbohydrates/starchy foods were heavily promoted. This was reinforced by the food industry which developed a range of products which could be marketed as “low fat”. All of this helped to alter the national diet so that the consumption of the carbohydrates increased at the expense of fat. Two of the main reasons were the low fat foods, in which the fat was frequently replaced by sugar and the explosive growth in the market for soft drinks, which can have a high content of sugar. These changes in consumption patterns have been accompanied by increases in the incidence of obesity, T2D, Alzheimer’s Disease and kidney disease. There are very sound scientific reasons for concluding that the dietary changes are largely responsible for this deterioration in public health standards.

It follows from this that there will have to be major changes in the official advice on Healthy Eating. This will not be easy because there are very powerful interests which will defend the existing established recommendations. The new ministerial team responsible for health must recognise that that that they should not rely entirely on the existing agencies such as NICE and the Scientific Advisory Committee on Nutrition (SACN). In recent years there have been a number of excellent evaluations of nutritional science that challenge the current conventional wisdom. These include “The Diet Delusion” by Gary Taubes (10) “The Big Fat Surprise” by Nina Teicholz (11) and “The Obesity Crisis” by Zoe Harcombe (12). In the past year “The Real Meal Revolution” by Professor Tim Noakes and colleagues in South Africa has had a massive impact and been on the best seller list for about 6 months (13). There is absolutely no questions that these publications are striking a chord with many individuals. Essentially they all agree that a healthy diet is low in sugar and starchy foods but also relatively high in the SFAs. There are literally thousands of individual case histories which demonstrate that changing to such diets are associated with improved health and weight loss. Even our Prime Minister has decided that he will be “cutting the carbs” (14).

We can be reasonably confident that the “establishment” does not take kindly to these concepts. In South Africa Tim Noakes has been subjected to rather hysterical criticism from those who still support the status quo. The reality is that this is not based on an objective view of the science. Many of the criticisms are absolutely extreme and cannot be supported by reliable scientific evidence. In truth, these critics are somewhat pathetic and lack the integrity to admit that in the past they got things badly wrong.

We really need ministers with the ability, confidence and determination to consider all the evidence objectively and decide the way forward. It is imperative to appreciate that existing policies are failing badly. We cannot continue indefinitely with the same strategy. Einstein’s definition of insanity was to continue doing the same thing and expecting a different result!

Do we have the politician with the necessary attributes to face up to these challenges? There really is the potential to start out on a path which will lead to significant improvements in health without the need for continuous growth in expenditure.


  1. http://www.hscic.gov.uk/catalogue/PUB14681/pres-diab-eng-200506-201314-rep.pdf
  2. http://www.diabetes.org.uk/Documents/About%20Us/Statistics/Diabetes-key-stats-guidelines-April2014.pdf
  3. http://www.diabetes.org.uk/Documents/Reports/State-of-the-Nation-2012.pdf
  4. http://jama.jamanetwork.com/article.aspx?articleid=197439
  5. http://www.sciencedirect.com/science/article/pii/S0899900714003323
  6. https://www.youtube.com/watch?v=mAwgdX5VxGc
  7. https://www.youtube.com/watch?v=da1vvigy5tQ
  8. http://www.dietdoctor.com/butter-shortage-in-sweden
  9. http://www.dietdoctor.com/obesity-is-exploding-in-europe-except-in-this-country
  10. Gary Taubes (2007) “The Diet Delusion” Vermillion: London
  11. Nina Teicholz. (2014)“The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet” Simon & Shuster: New York
  12. Zoe Harcombe (2010) “The Obesity Epidemic” Columbus
  13. T Noakes, S-A Creed, J Proudfoot & D Grier (2014) “The Real Meal Revolution: Changing the World, One Meal at a Time” Quivertree Publications
  14. http://www.independent.co.uk/news/people/david-cameron-on-his-patriotic-struggle-to-quit-bread-9976617.html







Now that the Conservatives have enough MPs to form a government, they should seize the initiative to tackle some fundamental issues about public health. At the outset it is crucial to question much of the current thinking.

It is essential to appreciate that the present strategies are just not working. The incidence of Type 2 diabetes (T2D) has doubled in the past 15 years and is expected to continue increasing. The picture for obesity is somewhat similar. Although life expectancy has increased, more and more people suffer from conditions such as Alzheimer’s Disease which means that the costs of care are escalating.

Lack of resources is not the fundamental problem with the NHS. If we keep throwing money at the system, we will finish up like the USA, which spends more than twice the amount on health care per capita as other developed nations, but ranks 49th in life expectancy worldwide.

The prime objective of any national health policy ought to be to ensure that that the standards of public health are as high as possible. Unfortunately the politicians have allowed themselves to be influenced by vested interests which have succeeded in manipulating policy formulation so that they (the vested interests) actually benefit in a big way.

There is absolutely no doubt that enormous sums of money are being spent on drugs which are totally ineffective and many do more harm than good. An excellent example of this is “polypharmacy”, which is the prescription of multiple drugs, especially for elderly people. The new Minister for Health would do well to ask for hard evidence that the policy is effective. No doubt he/she would be surprised to learn that a study conducted in Israel evaluated the impact of reducing the medication in elderly patients in nursing homes (1). At the outset the average number of medications was just over 7. It was found that out of 190 it was possible to stop some drug usage in 119 of them so that the average usage was reduced by 2.8. The results showed that the mortality rate in the control group whose medication remained the same was 45% but in the study group whose medication was reduced the mortality rate was only 21%. Furthermore 30% of those in the control group had to be referred to hospital whereas only 11.8% of those in the study had to be referred. These figures are absolutely staggering and have been confirmed repeatedly by other workers. Above all, the results demonstrate conclusively the damage to the individual patients that is caused by the excessive use of drugs. There really can be no other explanation.

In his excellent book “Doctoring Data”, Dr Malcolm Kendrick is critical of the Quality Outcome Framework (QoF) because it provides guidelines on “risk factors” which have to be measured and used as a basis for prescribing drugs as a preventative treatment (2). In his experience this has resulted in patients with an average number of medications of 10. This is much higher than in those patients involved in the research described above. The only way to prove that a specific combination will be effective is to conduct thorough trials which are designed to find out the benefits and assess the adverse side-effects. This has certainly never been done and is pretty well impossible to do because of the number of possible combinations is infinite. Even for a limited number of trials, the expense would be enormous and realistically will never be made available. However before we get to that point there is simply no reasonable justification for such a programme. The reality is that many of the drugs which are widely used can hardly be justified in their own right let alone in combination with others. Despite all the hype the benefits of statin use are minimal. When the latest NICE recommendations were being announced, the spokesman Mark Baker accepted that 77 people with previous heart problems would have to be treated for 3 years in order that one would benefit. And what exactly is the benefit…an extra 6 months of life (thanks again to Malcom Kendrick, 3). Then there are the adverse side-effects such as the aches and pains which seem to affect most of those I know who have been on statins. Some unfortunates suffer cognitive impairment. It is now becoming apparent that statins can substantially increase the risks of developing Type 2 Diabetes. For men without any heart issues and for all women there is no convincing evidence that there will be any reduction in mortality but of course these people will still experience the same incidence of adverse effects.

The more I discover about drugs and the way they are being used the less convinced I am of their value. No doubt there are some drugs which are effective but there is absolutely no doubt many drugs have no benefit whatsoever. The NNT (Number Needed to Treat) website (4) is an excellent source of reliable information on the effectiveness of various drugs. Consideration of those dealing with heart conditions shows that for about half of them the evaluation was that “none would helped”. When there is a benefit it is limited to relatively few people….a particularly good one would be for 10% of those treated to be helped. In my experience, most people would expect that there would be some benefit as a result of a drug treatment. If the chances of success were as little as 10% which has to be set off against any harmful effects, how many would agree to the treatment if this information was spelled out before any decision on medication was taken?

But there is not only excessive use of drugs.

In 2010, Dr Atul Gawande was named by Time magazine as one of the world’s influential thinkers.

In one of his Reith lectures last year he described a comparison he made between the medical facilities in 2 Texas communities (5). One was McAllen and the other was El Paso County. Both of these counties have a population of roughly seven hundred thousand, similar public-health statistics, and similar percentages of non-English speakers, illegal immigrants, and the unemployed. Yet in 2006, Medicare expenditures which is the best approximation of the costs of health care in El Paso was $7,504 per enrollee—half as much as in McAllen (6). There was no evidence to indicate that the treatments and technologies available at McAllen were any better than those found elsewhere in the country. The annual reports that hospitals file with Medicare show that those in McAllen and El Paso offer comparable technologies—neonatal intensive-care units, advanced cardiac services, PET scans, and so on. Public statistics show no difference in the supply of doctors. In fact Mc Allen actually has fewer specialists than the national average.

Dr Gawande eventually gained access to commercial insurance data which revealed that compared with patients in El Paso and the country as a whole, patients in McAllen were given more diagnostic testing, more hospital treatment, more surgery and more home care. More detailed information was obtained from Medicare payment data. This showed that between 2001 and 2005, critically ill patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received 20% more abdominal ultrasounds, 30% more bone-density studies, 60% more stress tests with echocardiography, 200% cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and 530% more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. So Dr Gawande had absolutely no doubt that the primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.


All of this shows unequivocally that enormous sums of money are being wasted in health treatments that are useless and in many cases do more harm than good.

If the new Minister is to do the job properly then he/she must make it a priority to ensure that all expenditure on treatment and diagnostic procedures is justified on the grounds that it makes a significant contribution to improvements in health and that any adverse effects are definitely outweighed by the benefits.

I find it particularly galling that soon after the results of the UK General Election were announced  the former Minister of Health, Jeremy Hunt, was still talking about putting more money into the NHS.

It is blindingly obvious that a new approach is essential. The new Minister will have to exert control right from the beginning otherwise the existing apparatus of advisers and agencies will ensure that things carry on as before. There are many individuals the Minister could invite who are independent of vested interests and have the authority and expertise to provide the necessary input.

I have already mentioned Dr Atul Gawande and Dr Malcolm Kendrick who would be ideal. Other suggestions could be:

  • Dr Peter Gøtzsche, Professor of Clinical Research and Design Analysis at the University of Copenhagen
  • Dr Tim Noakes, emeritus professor of Sports Science at the University of Cape Town
  • Dr Richard Smith, Former editor-in-chief of the BMJ (British Medical Journal).

While there are very powerful interests that will fight tooth and nail to maintain the status quo, the political rewards for the person who can devise and implement a cost-effective strategy that results in significant improvements in health are immense. Can David Cameron find anyone with the capability of achieving these objectives to take on the Health portfolio?


  1. D Garfinkel et al (2007) Israel Medical Association Journal 9 (6) pp430-434
  2. M Kendrick (2014) “Doctoring Data: how to sort out medical advice from medical nonsense”. Columbus
  3. http://drmalcolmkendrick.org/2014/12/01/what-is-t/
  4. http://www.thennt.com/home-nnt/
  5. http://downloads.bbc.co.uk/radio4/open-book/2014_reith_lecture3_edinburgh.pdf
  6. http://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum?currentPage=all