169. CALORIES IN VERSUS CALORIES OUT

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

http://carbwars.blogspot.co.uk/2013/03/calories-in-versus-calories-out.html

 

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,

http://eating_academy.com/nutrition/do-calories-matter

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).

 

 

 

REFERENCES

  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

167. HUGE OPPORTUNITY FOR THE NEW GOVERNMENT TO DEVISE A RADICAL HEALTH POLICY (PART 2)

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.

REFERENCES

  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

 

 

 

 

 

166. HUGE OPPORTUNITY FOR THE NEW GOVERNMENT TO DEVISE A RADICAL HEALTH POLICY (PART 1)

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?

REFERENCES

  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

165. More Doubts about Crestor (Rosavustatin)!

A recent article in the BMJ highlighted concerns about the statin Crestor which in 2014 was the most prescribed brand name drug in the US, with 22.3 million prescriptions at a cost of $5.8bn. World-wide sales for 2013 were $8.2bn (1). The report is by Sidney Wolfe, who founded Public Citizen based in Washington DC and for many years was its director until he retired recently. The statin was approved for use as a cholesterol lowering drug in 2003, despite opposition from Public Citizen at the time.

In particular it was concerned because rhabdomolysis because Rosuvastatin is the only statin in which rhabdomyolysis was detected in randomized controlled clinical trials before the drug was approved. The objection pointed out that with cerivastatin which was eventually banned because of rhabdomyolysis, no cases had occurred in the clinical trials before its approval. Furthermore a recent study of 641?703 patients in the UK prescribed different statins, those taking rosuvastatin had a significantly higher risk of an abnormally raised creatine phosphokinase activity (which is a measure of muscle inflammation) than patients on large daily doses of other statins (simvastatin, pravastatin, or atorvastatin).

There was also serious concern seen during preapproval trials was renal problems. At the time, rosuvastatin was the only statin to have been associated with proteinuria and hematuria. According to FDA documents “in the subgroup of patients with dipstick [protein and blood] positive urine, the percentage of patients with an increase of serum creatinine of 30% over baseline was 14%, 16%, 24%, 33%, and 41% for 5 mg, 10 mg, 20 mg, 40 mg and 80 mg of rosuvastatin, respectively. . . These data suggest that some patients with greater levels of proteinuria and hematuria may progress to clinically relevant renal disease.”

An editorial in The Lancet in October 2003 also expressed reservations and commented that:

“Physicians must tell their patients the truth about rosuvastatin—that compared with its competitors, rosuvastatin has an inferior [clinical] evidence base supporting its safe use. AstraZeneca has pushed its marketing machine too hard and too fast. It is time for McKillop to desist from this unprincipled campaign.”

In 2010 it was approved to reduce the cardiovascular risk. This was based on the results of the JUPITER Trial. However in a review of several key aspects, Michel de Lorgeril and colleagues concluded that the results of the trial do not support the use of statin treatment for primary prevention of cardiovascular diseases and raise troubling questions concerning the role of commercial sponsors (2). Sidney Wolfe points out that the JUPITER study, was restricted to patients with both low density lipoprotein (LDL) cholesterol <130 mg/dL (3.4 mmol/L) and C reactive protein ? 2 mg/L (19 nmol/L) which is quite a limited population and therefore does not provide a justification for general usage.

It is also crucial to recognise that the JUPITER Trial was stopped early. Invariably those trials which are stopped early consistently overestimate treatment effects. In a major study the results of 91 trials which were stopped early were compared with 424 trials which were completed in accordance with the original plan. It was found that those which stopped early systematically overestimate treatment effects. Large differences in treatment effect size between truncated and non-truncated trials (ratio of relative risks <0.75) occurred with truncated trials having fewer than 500 events. In 39 of the 63 questions (62%), the pooled effects of the non-truncated RCTs failed to demonstrate significant benefit (3).

In some trials, it has been found that the benefits observed with an early stop have not been confirmed in a full-length trial. If clinicians act on the results of shortened trials it is likely that they will be misled when trying to balance benefits, harms, inconvenience, and costs of a specific health care intervention.

The JUPITER trial also found that those treated with rosavustatin had an increased incidence of T2D, which is consistent with an increase in the glycated haemoglobin (HbA1c) and reduced insulin sensitivity. Both of these factors are associated with increased incidence of heart disease, obesity and various cancers. Hence it may well be that any benefit attributed to a decrease in the risks of heart disease by the effect of the statin are counterbalanced by deleterious effects linked to increase in blood sugar and reduced insulin sensitivity. According to NICE, 77 people who have heart disease have to be taking statins for 3 years in order that one person will benefit. Hence it follows that those who experience the increased risk of developing T2D are probably not the same individuals who benefit from the reduced risk of heart disease.

In addition, rosavustatin is associated with relatively high incidence of rhabdomolysis (muscle pain and damage) renal failure.

On top of all this, the behaviour of the company AstraZeneca in promoting the statin does not exactly inspire confidence. In late 2004 there was an advertisement in the Washington Post which stated that:

The scientists at the FDA who are responsible for the approval and ongoing review of CRESTOR have, as recently as last Friday, publicly confirmed that CRESTOR is safe and effective; and that the concerns that have been raised have no medical or scientific basis,” claiming this was information provided by the FDA website, which was not correct. As a consequence the FDA wrote to the company demanding that it immediately stop the advertising because it contained false and misleading information about Crestor’s risks. The letter also stated that:

“The ‘patient safety’ print ad makes false or misleading safety claims that minimize the risks associated with Crestor, thereby suggesting that Crestor is safer than has been demonstrated by substantial evidence or substantial clinical experience.”

The agency wrote to the company again the following year about “misleading superiority claims” for Crestor in other promotional materials.

This is just one more example of a drug being granted approval despite doubts about the adverse side-effects which may be associated with it. Subsequently there have been very many reports of statin users with muscle pain. Even so NICE continues to play down this damage to health. Then in February Sir Rory Collins of Oxford University which analyses data on statins for the pharmaceutical companies admitted to a Sunday newspaper that:

“his team had assessed the effects of statins on heart disease and cancer but not other side effects such as muscle pain”.

You just could not make it up!!

This information should be given to every individual before they agree to go on statins but I suspect it rarely happens.

REFERENCES

  1. http://www.bmj.com/content/350/bmj.h1388
  2. http://vernerwheelock.com/?p=670
  3. http://jama.jamanetwork.com/article.aspx?articleid=185591

164.NHS is not short of money!

When will the politicians face up to the fact that pouring more and more resources into the NHS will not solve our current health issues? The fundamental problem is that standards of public health are deteriorating while costs escalate. This is illustrated by the increased incidence of diabetes which has doubled in the past 15 years. All the indications are that this increase will continue. A report published in 2012 estimated the direct cost of patient care was £9.8 billion and the indirect cost related to increased death and illness, loss of work and the need for informal care was £13.9 billion (1). The vast majority of these cases are Type 2, which is the result of excess glucose in the blood. It is a particularly nasty disease. A 40-year old may expect to reduce life expectancy of at least 12 years AND will suffer many years of disability. Those with diabetes may be as much as 4 times more likely to develop heart disease, cancer and Alzheimer’s Disease as those without it.

The blunt truth is that current strategies are not working and there seems to be a general acceptance that things will continue to get worse. The NHS Choices website tells us that with respect to type 2 diabetes:

There is no cure for diabetes. However, treatment aims to keep your blood glucose levels as normal as possible, which will control your symptoms and minimise the risk of health problems developing later on.” (2).

Furthermore it continues:

“….. as type 2 diabetes is a progressive condition, you may eventually need to take medication to keep your blood glucose at normal levels. You may need to take tablets initially, but move on to injected therapies, such as insulin, at a later stage.”

This is a policy of absolute despair which is utterly and completely wrong! It is the excess insulin which has to be produced by the pancreas to cope with the high levels of glucose in the blood which damages the organs inside the body. This results in chronic conditions such as heart disease and Alzheimer’s Disease. So it is absolute madness to treat the patients with insulin, which only adds fuel to the fire.

There is no debate that the glucose in the blood comes from the diet. Therefore if we can reduce the amount of glucose originating from the food consumed, there will be less glucose available to be absorbed into the blood. So the solution is obvious. Change the diet by lowering the amount of sugar and other carbohydrate-containing foods such as bread, potatoes, rice and pasta which are the sources of the blood glucose. But unbelievably the NHS advice on healthy eating is to consume:

“A diet based on starchy foods such as potatoes, bread, rice and pasta”(3).

On top of this the growing demand for “low fat” foods over the past 40 years has made things even worse. Many of these have been formulated by removing fat from traditional products and replacing it with sugar.

The reality is that type 2 diabetes can be cured. This was conclusively demonstrated at the recent Low Carb Summit held in Cape Town. Numerous specialists from the USA, Canada, Australia, South Africa and the UK presented cast-iron evidence of successful treatment of type 2 diabetes with the simple strategy of helping their patients to reduce the amount of sugar/carbohydrates and to increase their intake of the healthy fats. Many of these were able to stop medication completely and as an additional benefit, actually lost excess weight without any difficulty.

One of the speakers was Dr Jay Wortman from Canada who suddenly woke up to the fact that he had all the symptoms of diabetes. He decided the only way forward was to eliminate as much sugar and starchy foods as possible from his diet in order to lower his blood glucose. He noticed an immediate improvement and within a few months his blood glucose was back to a normal level. What is more he lost weight at the rate of about one pound per day. He included plenty of vegetables as well as meat and dairy products in his diet. There are thousands of others with a similar story to tell. It is absolutely criminal that this information is not being presented to all those diagnosed with type 2 diabetes.

The message for UK politicians comes through loud and clear. We need a complete re-think about the current healthy eating policy. The advice to reduce fat and increase carbohydrates has been an absolute disaster and has been a major factor contributing to the incidence of type 2 diabetes. A radically different approach to dietary advice could improve the health of those who are affected and help to reduce the costs that are incurred in providing care and treatment.

But it is also essential to consider all the other costs associated with the NHS. Throwing money at the problem is not the answer. We have to be extremely hard-nosed about assessing the costs and benefits of any specific treatment or procedure.

In his recent Reith lectures on the BBC Dr Atul Gawande compared 2 similar communities of about 700,000 people in Texas in which the standards of public health were identical but the expenditure in one was double that of the other. The US as a whole spends more than twice the amount on health care per capita as other developed nations, but ranks 49th in life expectancy worldwide. UK politicians please note this is where we will finish up unless there is a fundamental re-think about how our health budget is spent.

The NHS spends far too much money on drugs and procedures that are ineffective. Many of them do more harm than good as shown by example here of treating diabetics with insulin. Does it really make sense to prescribe statins when 77 men have to be treated for 3 years for one to benefit? This only applies to those who have actually suffered from heart disease. For those who do not have heart disease and for all women the proven benefits are even less. This is before the adverse side-effects, which can be traumatic, are factored into the equation.

Unfortunately the politicians have fallen hook, line and sinker for the mantra pumped out by the drug companies which are extremely effective in promoting medicines which fail to live up to expectations. Before making any further commitments about putting more money into the NHS, I recommend that all politicians, civil servants and health administrators read the book entitled “Deadly Medicines and Organised Crime: How Big Pharma Has Corrupted Healthcare”(4). This is written by Peter Gøtzsche who is professor of Clinical Research Design and Analysis at the University of Copenhagen. This book exposes in detail how thousands of individuals are killed every year by prescription drugs, which are promoted and sold even though there is reliable evidence of the dangers they pose. Many of these companies flout the laws and have paid billions of dollars in fines and compensation. Because the profits are so enormous, these are simply regarded as the costs of doing business. He quotes a former vice-president of Pfizer who has concluded that:

“It is scary how many similarities there are between this industry and the mob. The mob makes obscene amounts of money, as does this industry. The side effects of organized crime are killings and deaths, and the side effects are the same in this industry. The mob bribes politicians and others, and so does the drug industry …”

The case he presents is extremely compelling. It follows from this that much of the money spent on drugs is not only ineffective but also a contributor to the ill-health. There is tremendous scope for saving large sums of the current health expenditure by reducing the amount spent on drugs of dubious value.

Current policies are going nowhere. The case for a totally different approach is absolutely convincing. Do we have any politician with the ability and drive to take things forward? This issue will have to be tackled eventually so why not sooner rather than later?

REFERENCES

  1. http://www.diabetes.org.uk/about_us/news_landing_page/nhs-spending-on-diabetes-to-reach-169-billion-by-2035/
  2. http://www.nhs.uk/conditions/Diabetes-type2/Pages/Introduction.aspx
  3. http://www.nhs.uk/Livewell/Goodfood/Pages/Healthyeating.aspx
  4. Peter Gøtzsche (2013). “Deadly Medicines and Organised Crime: How Big Pharma Has Corrupted Healthcare” Radcliffe Publishing London

163.Low Carb Helps Aussie Cricketers to Improve Performance

Peter Brukner is the medical adviser to the Australian cricket team. A few years ago he became concerned about his general health. He had learned that Tim Noakes had switched to a diet which was low in carbohydrates and high in fat (LCHF) so he decided to investigate. He read “The Diet Delusion” by Gary Taubes (1), which he describes as the “the most amazing book I have ever read”. As a result he decided to try the LCHF diet himself. He has described his progress on hid blog (2).

At the time Peter was 60 years old and weighed 90.4kg with a BMI of 28 and a family history of Type 2 Diabetes (T2D). His blood tests indicated that he has degree of insulin resistance (IR). After 2 months his weight had dropped to 82.5kg and his well-being had improved enormously. He had more energy, felt less sleepy in the afternoons and was sleeping better at night.

He had no problems with the diet which consisted of eggs and bacon for breakfast; cold meats, salads and cheese for lunch; fish or meat for dinner with lots of vegetables, followed by berries and cream for dessert. For drinks he had water, coffee, beef broth and most nights a couple of glasses of red wine. Snacks have mainly been almonds. There was no problem with hunger pangs and occasionally missed lunch without any difficulty (3).

After 3 months his weight was below 80kg and because he looked too skinny he eased off a bit and his weight settled down at 81-82kg. After 8 months, his blood tests showed that his triglycerides had fallen from 2.1 to 1.3 which is all good news. There was an increase in the total blood cholesterol (TC) which did not bother him. Much more important was the test which confirmed that that he did not have a “fatty liver” (4).

This improvement in his health made quite an impact on some of the players who wanted to discover more about what he had done to achieve this. In a talk, Peter describes some case studies of elite athletes which he has kept anonymous (5).

  • The first one had a long history of weight problems who had a history 27 muscle injuries which meant that he had missed about half of all the test matches, in which he could have played. As a result of his change in diet he “felt fantastic” and had enjoyed the best 8 months of his career
  • The second one was overweight. Because of injury he had not played for some time and so his fitness levels had deteriorated. When he changed to a LCHF diet he lost 7 kg. As a result he was able to train harder and longer so that his improved very significantly. There was also a substantial reduction in the skinfold thickness demonstrating that he has lost body fat. He is now back playing and performing very well
  • The third one was on the verge of the Australian cricket team but had to stop playing cricket 3 years ago because of chronic knee pain. He tried all sorts of specialists without any great success and then he developed pain in his other knee. He was diagnosed with sero negative arthritis and prescribed some very powerful drugs, which he had to treat himself by injection. As a result he was able to resume training. At this point he decided to try the LCHF Within weeks on an LCHF diet which he followed religiously. But after 3 weeks the pain had disappeared completely and he forgot to do the injection. Almost one year later he was still off his medication. His ability to train has improved significantly and he is feeling very happy with life.

Although Peter did not identify individuals, it is probably no secret that one of them is Shane Watson, who has been happy to go public (6). In a You Tube video, he describes how he had serious problems in maintaining his weight on a diet which complied with the conventional guidelines in which the emphasis is on lowering the fat and consuming plenty of carbohydrate-containing foods such as rice and pasta. He explains how he had a “fat phobia” and was very worried about his cholesterol and concerned that if he ate excessive fat his arteries would get clogged up. Having observed the success of Peter Brukner with LCHF, he also studied the Gary Taubes book and decided to follow suit. He is absolutely convinced that when he switched to LCHF his general health improved. In particular he discovered that he did not eat as much and that hunger was no longer a problem. His life has changed for the better, his endurance has improved and he has limitless energy. As an all-rounder this must make a great difference to his ability to perform on the field. His father suffered from T2D and has also benefitted because by adopting an LCHF diet he has been able to control his blood sugar. His mother has lost weight by using the same approach.

Word has spread amongst the cricketing community. David Warner, Mitchell Johnson and Usman Khawaja have all switched to LCHF with very positive results (7). The Indian cricketer Rahul Dravid is another convert who lost 7kg and feels very much better as a result of his dietary change.

Professional sport is a tough business which can place tremendous strains on the body and although this is anecdotal evidence it fits in very well with all the other information which has accumulated. However these people are driven by results and there their experience cannot be readily dismissed. The facts that injuries have been reduced and that training is improved obviously makes a huge contribution to the performance on the field where it matters.

There are also examples from other sports and I hope to cover these in separate post.

REFERENCES

  1. Gary Taubes (2007) “The Diet Delusion” Vermillion: London
  2. http://www.peterbrukner.com/
  3. http://www.peterbrukner.com/two-months-of-low-carb/
  4. http://www.peterbrukner.com/my-lchf-diet-after-8-months/
  5. https://www.youtube.com/watch?v=JMuD4Z-Oxys
  6. https://www.youtube.com/watch?v=LeyufWjByG8
  7. http://www.reddit.com/r/keto/comments/1rb34q/we_just_went_mainstream_in_australia/

162. Another Desperate Attempt to Defend the Conventional Dietary Guidelines.

In the light of the excellent paper by Zoe Harcombe and her team which demonstrated conclusively that there was no reliable evidence on which to base the official dietary guidelines when first devised in the USA and in the UK, the BBC has featured this issue in a radio programme (1). This includes interviews with Zoe herself and Aseem Malhotra who explained why the advice to reduce total fat and especially saturated fat (SFA) is fundamentally flawed and has been a crucial factor responsible for the current high levels of obesity and Type 2 Diabetes (T2D). These were followed by what I can only describe as an extraordinary interview with Simon Capewell, who is Professor of Clinical Epidemiology at the University of Liverpool. He also has roles in which he advises the British Heart Foundation, the European Society of Cardiology, Heart of Mersey, National Institute of Clinical Excellence, Public Health England and the World Health Organisation. In his opinion the research by Zoe Harcombe is flawed because it failed to consider the totality of evidence. He goes on to say that there have been “over 1000 papers” since then which support the current guidelines. He cites the work of his own research team which claims it has established that there is a fall in the intake of SFA which is correct. Then he goes on to say there has also been a fall of 20% in the levels of blood cholesterol (TC) from which he concludes that this proves the advice has been responsible for the fall in the death rates from heart disease. To his credit the interviewer points out that this is all based on epidemiology, which cannot demonstrate “cause and effect”. The interviewer quite rightly suggests that there may have been other factors which have contributed to the decline in deaths from heart disease, such as the reduction in smoking and the improvements in treatment. It is true that the mortality due to heart disease has fallen and improvements in treatment and care have had a major impact. According to British Heart Foundation statistics, the percentage of women aged 55-59 years old dying after a heart attack almost halved between 1968 and 1998 while that for men aged 60-64 fell by a third (2). This report comments that measuring morbidity is much more problematic than monitoring mortality so we cannot be sure that there has actually been a genuine decrease in the chances of suffering from heart disease and if so the magnitude of the change.

Anyone who considers that lowering TC is beneficial must be deluded. Just watch this You Tube video (3).

Simon Capewell goes on to imply that Ancel Keys was correct when he concluded that there was a direct correlation between the amount of fat/SFA in the diet of different populations, the level of cholesterol in the blood (TC) and the death rate due to heart disease. In fact he even states that Keys has been vindicated by subsequent studies. This position is absolutely remarkable. The fact is that the work of Keys was full of inconsistencies, was based on data from 6 different countries and made the fatal mistake of assuming that an association is evidence of cause and effect. The work of Keys has been totally discredited by Zoe Harcombe (4), Malcolm Kendrick (5) and most recently by Nina Teicholz (6). The reality is that when information is obtained from many different countries there is no relationship. It just so happened that Keys conveniently omitted:

  • Countries where people eat a lot of fat but have little heart disease, such as Holland and Norway
  • Countries where fat consumption is low but the rate of heart disease is high, such as Chile.

I would strongly recommend that if you really wish to understand what went on then have a look at these references. It is absolutely disgraceful and it simply beggars belief that anyone should even attempt to justify this rubbish!

Simon Capewell states that the dietary guidelines were “prophetic and solid” and “that history has demonstrated how very sound they were”. This is unbelievable! How on earth can anyone reach this conclusion, when we look at the current state of public health in the UK, the USA and most of the rest of the world????

Obesity is an obvious issue of concern but a more accurate indication of public health is shown by the incidence of T2D, which in the UK had doubled in the last 15 years. Those with T2D have a reduced life expectancy and an increased risk of retinopathy, stroke, kidney failure, heart disease, cancer, Alzheimer’s 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 (7).

T2D is caused by excess glucose in the blood. This stimulates the pancreas to produce insulin. The continuous production of high amounts of insulin cause damage to the various body organs which can result in many different chronic diseases. The solution is obvious…..lower the blood glucose by reducing the consumption of sugar and the other foods that contain carbohydrates, which are broken down to produce glucose. These foods, primarily potatoes, bread, rice and pasta must be replaced by other foods, especially those animal products such as meat, dairy and eggs, all of which contain fat. This is direct contrast to the current guidelines which Simon Capewell praises so highly.

The evidence has been very neatly summarised in a recent paper (8). There is absolutely no doubt that this approach works very effectively. At least one of the authors, Dr Jay Wortman, has been able to cure his T2D by altering his own personal diet along these lines. There are literally hundreds of individuals who have achieved exactly the same result (9). The presentations at the recent Low Carb Summit in Cape Town showed just how persuasive our knowledge is at present. Several practising clinicians showed how successful the Low Carb High Fat (LCHF) diet with their own patient records (10).

So we have now reached a point where we have the knowledge not only to halt the current inexorable rise in the incidence of chronic disease but to reverse it. Regrettably the official approach by government and the NHS in the UK is making things worse with the result that millions are suffering unnecessarily and many of these are dying prematurely. It is imperative that there is a complete re-evaluation of public health policy. We have to accept that what is being done at present is one of the main reasons why things are deteriorating.

To identify why there is so little progress, we only have to consider the views expressed by people like Simon Capewell who seem to defend the status quo come what may. Because of his role with so many key organisations, he has enormous influence. But in order to maintain his stance he has to manipulate and misinterpret the evidence.

If we are ever to make the break-through, it is essential the Simon Capewells of this world are tackled at every possible opportunity. His errors are so fundamental that you do not need to have specialised knowledge to do so and I would encourage all those who are aware of the benefits of LCHF, especially those with personal experience, to make your views known to anyone in a position to make the changes. For a start the forthcoming General Election in the UK is a timely opportunity to force the issue on the political agenda. If enough of us rally round then maybe the message will begin to get through.

REFERENCES

  1. http://www.bbc.co.uk/programmes/b054t9hn
  2. https://www.bhf.org.uk/~/media/files/research/heart-statistics/bhf-trends-in-coronary-heart-disease01.pdf
  3. https://www.youtube.com/watch?v=i8SSCNaaDcE
  4. Zoe Harcombe (2010) “The Obesity Epidemic” Columbus p 87
  5. http://drmalcolmkendrick.org/2013/03/13/the-untainted-mind/
  6. Nina Teicholz. (2014) “The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet” Simon & Shuster New York
  7. http://jama.jamanetwork.com/article.aspx?articleid=197439
  8. http://www.nutritionjrnl.com/article/S0899-9007(14)00332-3/pdf
  9. http://vernerwheelock.com/?p=422
  10. http://vernerwheelock.com/?p=729

 

161. More Reflections on the Cape Town Low Carb Summit: Old Mutual Shows the Way Forward

If anyone had doubts about why the current official dietary recommendations which emphasise the benefits of a diet low fat and high carbohydrates are fundamentally flawed, they should have been at the recent Low Carb Summit in Cape Town. When all the available scientific evidence is collected together it is abundantly obvious that the existing approach has been absolutely disastrous. In addition, there are an enormous number of individuals, who have improved their own personal health by switching to a diet which is high in the right type of fats and low in carbohydrates (LCHF, widely referred to as the Banting diet). All of these simply cannot be written off as anecdotal. To do so is to imply these people are all charlatans!
At the end of the conference the following statement, endorsed by all the speakers was issued:
“The mainstream dietary advice that we are currently giving to the world has simply not worked. Instead it is the opinion of the speakers at this convention that this incorrect nutritional advice is the immediate cause of the global obesity and diabetes epidemics.
This advice has failed because it completely ignores the history of why and how human nutrition has developed over the past three million years. More importantly, it refuses to acknowledge the presence of insulin resistance (carbohydrate intolerance) as the single most prevalent biological state in modern humans.
Persons with insulin resistance are at an increased risk of developing a wide range of chronic medical conditions if they ingest a high carbohydrate diet for any length of time (decades).”
Or to put it another way:
“Excessive insulin in the body causes damage to the internal organs, which in turn leads to chronic diseases/conditions including Type 2 Diabetes (T2D), obesity, high blood pressure, fatty liver, heart disease, Alzheimer’s Disease and cancer. The insulin production is stimulated by the high level of glucose in the blood, which is caused by the consumption of sugar and refined carbohydrates. Hence a diet which is low in carbohydrates and has fat as the main sources of energy will result in better health and a reduced risk of developing many diseases.”
The key message from the conference is that the time for debate is over. The emphasis now must be to focus on how the message can be disseminated to all those people who could benefit by altering the composition of their diet. Ideally national policies should be re-vamped but there is so much entrenched opposition and built-in inertia in most governmental systems that this approach is unlikely to be successful in the short term. In the real world, the starting point has to be with the grassroots. As awareness of the effectiveness of the LCHF gathers momentum, there will be opportunities for businesses to capitalise and generate further impetus.
This is already happening in South Africa and some other parts of the world. One of the most significant aspects of the Cape Town conference was the sponsorship by Old Mutual, which is an international investment and insurance company. One of the keynote speakers was Dr Peter Bond who is the company’s Chief Medical Officer. In particular, he described how the standards of public health across the globe are deteriorating because of the increasing incidence of T2D, obesity and the various related diseases. According to company estimates, 3.5 million South Africans have T2D and 50% are unaware of the condition, which is often only diagnosed when an insurance examination is done. As a consequence the application may be declined or subjected to an additional mortality or morbidity loading. Seven out of 10 women and 4 out of 10 men are overweight or obese, which is double the global rate of almost 30%. It is evident that current strategies are not working. Data collected by Old Mutual confirms that total cholesterol (TC) is NOT an effective measure of mortality risk. If currents trends are maintained, then the costs of health care will continue to rise. From the company perspective, this means that the premiums will have to be increased and therefore customers may allow their policies to lapse and it becomes much more difficult to get new business. Old Mutual sells critical illness products: so if those who purchase these policies can be persuaded to adopt lifestyle changes such as a LCHF diet, everyone benefits. The costs of pay-outs will be reduced, which results in lower premiums and increased profitability. From the individual perspective, a reduction in the chances of a serious illness equals better health and quality of life.
Although Dr Bond stated that he was not endorsing any particular diet or way of eating the company has clearly recognised the significance of the event and the impact that the Banting approach is already having in South Africa. All the indications are that the response to the Old Mutual involvement has been very positive.
The crucial factor is that the business understands there is a powerful incentive to encourage people to follow a healthy lifestyle. This may prove to be of huge significance in promoting the benefits of a Banting diet to a much wider audience. The fact that Old Mutual operates in many different parts of the world could be vital. If the initiative in South Africa is a success, then we may expect to see it repeated in many other countries. Assuming this happens, competitors are likely to follow suit. Ultimately governments will wake up to the fact that there are actually ways of halting the apparently inevitable increases in the costs of health care.
This approach is in stark contrast to many other businesses currently involved in health care where consistent poor health equates to the continued demand for drugs and use of the various tests and procedures. As one cynic has pointed out, drug companies derive little benefit if their products successfully cure patients. The ideal for them is to have patients who remain ill and therefore continue to purchase their products. However the reality is that many drugs show absolutely no benefit and are a waste of money (1).
The LCHF approach has tremendous potential to reverse the current disastrous trends in chronic disease patterns and it is imperative that all possible opportunities are exploited so the basic messages are disseminated as widely as possible and as quickly as possible.
REFERENCE
1. http://vernerwheelock.com/?p=587

160. Tim Noakes Answers His Critics

This is a repost from Karen Thomson’s Blog. The original can be sourced at
http://buff.ly/1EuS5zJ

I am very grateful to Karen and Tim for permission to re-post.

PROF TIM NOAKES – THE OLD MUTUAL HEALTH CONVENTION PRESENTATION SUMMARY
By Karen Thomson, February 25, 2015

Written by Prof Tim Noakes
My critics have called me deluded and dangerous. In the South African Medical Journal in 2013, they said I have cherry picked, misinterpreted data, I don’t understand the science, I’ve lost my way, flouted the Hippocratic Oath, and I’m damaging patients and the population.
Last year, for the first time in the history of the University of Cape Town, no senior academic has ever been criticized as publicly as I was. Senior colleagues, including the Dean of the Medical Faculty at UCT (who has since moved upwards and onwards – a reward for his bravery perhaps) sent a letter to the Dean of all South African medical schools and to the press, saying:
“There is good reason for concern that this diet may rather result in nutritional deficiencies, increased risk for heart disease, diabetes mellitus, kidney problems, constipation, certain cancers and excessive iron stores in some individuals in the long-term.”
They said I was “making outrageous unproven claims about disease prevention, and maligning the integrity and credibility of peers who criticize his diet for being evidence-deficient and not conforming to the tenets of good and responsible science. This goes against the University of Cape Town’s commitment to academic freedom as the prerequisite to fostering responsible and respectful intellectual debate and free enquiry.”
The letter ended: “UCT’s Faculty of Health Sciences, a leading research institution in Africa, has a reputation for research excellence to uphold. Above all, our research must be socially responsible. We have therefore taken the unusual step of distancing ourselves from the proponents of this diet.”
The authors didn’t stop there. They ran a website in which they collected extraneous material, selected what they said was my argument, and threw in blogs by people unrelated to the topic, all without giving me the right of reply.
Clearly their goal was to prove that I’m deluded and dangerous. Rather than attacking the science, they attacked me personally and said I was practising junk science.
These are not ugly, horrible people. They were saying what they believed out of a deep sense of conviction.
Are they right, or am I right? We can’t both we right.
I will present the evidence to show that my opinion is scientifically based, does not break any of the rules of good science, that I have a right to that opinion, and that my critics are the ones who are practising junk science, and are endangering people’s health.
They don’t understand causation science, hazard ratios, insulin resistance as well as the special role of gluten, the leaky gut and non-coeliac gluten intolerance in human ill-health.
The key problem is that both sides believe the facts sit with them. At the first international low-carb, high-fat summit in Cape Town, we spent three days discussing evidence for and against low-carb, high-fat diets to treat insulin resistance.
We need to begin by looking at the quality of the evidence.
My critics say low-carb diets are proven not to work and saturated fat is proven to increase the risk of cardiovascular disease (CVD). They say we only have anecdotal evidence for low-carb, high-fat diets for the treatment of insulin resistance (IR) and diabetes.
That’s not correct. We have the evidence: all randomized, controlled trials (RCTs) either show that high-fat outperforms low-fat diets, or long-term RCTs show no evidence that a low-fat diet does any good.
My critics have ignored all the RCTs and other evidence that dispute their theories. In so doing, they have not practised good science according to the rules laid down by Sir Austin Bradford Hill, who is revered as the “father of medical statistics”.
Bradford wrote a series of article in 1937 in the Lancet describing the use of statistics in medical science. It was a completely new science. He was one man who really understood it, and he laid down levels of information for causation, starting from anecdote (case history), and including cross-sectional study, randomized, controlled, prospective, clinical trials, and finally systematic review and meta-analysis.
He explained that it was possible to prove causation from associational studies, but only if certain criteria were met. He listed nine such considerations, but I have focused in this paper on only two: coherence and strength of association.
He wrote in 1965: “Here then are nine different viewpoints from all of which we should study association before we cry causation. What I do not believe…is that we can usefully lay down some hard-and-fast rules of evidence that must be obeyed before we accept cause and effect.
“None of my nine viewpoints can bring indisputable evidence for or against the cause-and-effect hypothesis and none can be required as a sine qua non. What they can do, with greater or lesser strength, is to help us make up our minds on the fundamental question – is there any other way of explaining the set of facts before us, is there any other answer equally, or more likely than cause and effect?”
Bradford Hill designed and completed the first RCT in 1950 (Streptomycin in TB meningitis) and with Sir Richard Doll “proved” that smoking causes lung cancer initially from an associational study (which cannot prove causation). He found that the Hazard Ratio for lung cancer in smokers was 10-30 times higher than in non-smokers. Such a high value could only indicate causation in his opinion.
He wrote: “On the other hand the death rates from coronary thrombosis in smokers is no more than twice, possibly less, the death rate in non-smokers (ie Hazard Ratio of 2 or less). Though there is good evidence to support causation it is surely much easier in this case to think of some features of life that may go hand in hand with smoking – features that might conceivably be the real underlying cause or, at the least, an important contributor, whether it be lack of exercise, nature of diet or other factors.
“But to explain the pronounced excess in cancer of the lung in any other environmental terms requires some feature of life so intimately linked with cigarette smoking and with the amount of smoking that such a feature should be easily detectable. If we cannot detect it or reasonably infer a specific one, then in such circumstances I think we are reasonably entitled to reject the vague contention of the armchair critic ‘you can’t prove it, there may be such a feature’”.
Bradford Hill has since died, and many researchers have ignored his criteria and flipped into a model of junk science – the scientists who are more interested in getting funding and more work, not discovering how to make people healthier.
In science, the bar has dropped to the lowest level of scientific “proof” conceivable – so low that researchers now ignore what Bradford Hill taught and accept any Hazard Ratio above 1.0 as definitive evidence of causation. Poor Bradford Hill turns in his grave with every new publication.
That means just about anything can be proved to cause anything. The result is that have grown an entire discipline of nutritional science based on this improper understanding of Bradford Hill’s doctrines. And we wonder why we have got it all so very, very wrong.
So all the associational nutritional studies used to justify the 1977 USDA (low fat) Dietary Guidelines are based on studies with Hazard Ratios usually between 0.7-1.3. Bradford Hill would not have accepted any of these studies as evidence for causation, or allowed them to be used as the sole justification for novel global dietary guidelines. In fact studies using such feeble criteria for causation are simply scare-mongering, the ultimate junk science.
Since most such studies originate from departments of epidemiology that consider themselves at the forefront of hard science, author James Le Fanu proposes a simple solution: “Meanwhile the simple expedient of closing down most university departments of epidemiology could both extinguish this endlessly fertile source of anxiety-mongering while simultaneously releasing funds”.
Interestingly, a recent report – A Systematic Review of the Evidence Supporting a Causal Link Between Dietary Factors and Coronary Heart disease – used four Bradford Hill criteria (strength, consistency, temporality and coherence) to evaluate all the evidence from dietary studies. The study showed strong evidence for vegetables, nuts, “Mediterranean” and high quality dietary patterns for “protective effects against CHD”. These are exactly the components that the Banting high fat diet promotes. They also showed strong evidence that trans-fatty acids and foods with high glycaemic index or load (ie high carbohydrate diets) as “harmful effects promoting CHD”. These are exactly the foods that the Banting high fat diet does not allow. The study found insufficient evidence for: Saturated and polyunsaturated fatty acids; total fat; alpha linolenic acid; meat; eggs; milk.
So if my critics were steeped in the science as they claim, they could only have concluded in their letter to the Deans of all the Medical Schools and to the media, that my advice was completely compatible with the most rigorous science currently available. That I am also correct to argue that there is no evidence that a high fat diet causes anything. Instead they concocted an argument based on evidence that Bradford Hill would have rejected. And this from leading scholars at a leading medical institution in this country.
In his book, The Rise and Fall of Modern Medicine, James Le Fanu says: “Bear in mind Sir Austin Bradford Hill’s insistence that statistical inferences by themselves have no meaning unless they are internally coherent, that is to say, when several different types of evidence for an association between an environmental factor and disease … are examined, they (must) all point to the same conclusion.”
“Put another way, no matter how plausible the link between dietary fat and heart disease might seem, just one substantial inconsistency in the statistical evidence effectively undermines it.” There is now more than one substantial inconsistency that should long ago have relegated the low fat diet to the dust bin of bad science.
My critics also like to say that we only have anecdotal evidence for the benefits of low-carb, high-fat diet. That’s simply not true. There is significant anecdotal evidence, and all of science begins with anecdote. But we also have a wealth of RCT evidence for the superiority of low-carb, high-fat diets of low fat, high carbohydrate diets.
A speaker at the summit, Canadian Dr Jay Wortman, told how he became diabetic 12 years ago, cut carbs from his diet (as a doctor he knows that carbs raise blood sugar), within days his symptoms had improved, and he has been without evidence of diabetes ever since.
Two of my clients attended the summit: Billy Tosh weighed 163kg in July 2012, was close to a heart attack, and had type 2 diabetes and hypertension. By March 2013, Billy had lost 84kg, his hypertension has gone, and he is free of symptoms of diabetes and hypertension. Brian Berkman weighed 153 kgs in July 2011, was diabetic, hypertensive and considering bariatric surgery. By January 2013, he had lost 82kg and is free of symptoms of diabetes, is no longer hypertensive, and avoided bariatric surgery.
Is that all just anecdote? Probably not. I don’t claim they are cured, but they don’t require medication and are without evidence for diabetes.
There are many other case histories of spontaneous recovery from type 2 diabetes, a condition that my profession teaches is irreversible, will require increasing medication for life and has, in essence, a hopeless outlook with the only certainty – more drugs, more illness, more disability.
How many subjects do you require in a trial to prove an effect?
In his book, The World Turned Upside Down, author Richard Feinman said: “It depends on how many people recover spontaneously.”
If there has never been a reported reversal of Type 2 diabetes mellitus (T2DM) in patients following conventional medical advice (which there has not), then a single case is not an anecdote. It is a black swan – in other words something that contradicts our previous beliefs, for example that all swans must be white to be classified as swans. The presence of a black swan requires the immediate funding of a proper scientific study – a randomised controlled clinical trial – to test whether it is possible to reverse T2DM with a low carbohydrate diet.
A key question has been: you can’t prove causation without randomized controlled trials (RCTs). But as I’ve already shown you can in fact surmise causation in cross-sectional study if you fulfill certain strict Bradford Hill criteria. And when applied to cross-sectional dietary studies, the Hill criteria support the health benefits of the low carbohydrate diet. But let’s first consider the evidence from RCTs.
One of my fiercest critics was involved in the most significant RCT: The Women’s Health Initiative Randomized Controlled Dietary Modification Trial, published in the JAMA in February 2006. It was a large trial of 48,836 post-menopausal women, followed over 8.1 years looking at the effects of low-fat eating and costing about $700 million. The study concluded: “Over a mean of 8.1 years, a dietary intervention that reduced total fat intake and increased intakes of vegetables, fruits, and grains did not significantly reduce the risk of CHD, stroke, or CVD in postmenopausal women and achieved only modest effects on CVD risk factors, suggesting that more focused diet and lifestyle interventions may be needed to improve risk factors and reduce CVD risk.” Another two very expensive low-fat RCTs have come to the same conclusions.
The WHI study authors should have designed their study as the test of a null hypothesis: Specifically, if you reduce your fat intake, you will reduce heart attacks and cancer rates. If the results don’t support the hypothesis, then the hypothesis is clearly wrong and must be abandoned (if one is practicing good rather than junk science).
Instead, when the authors discovered that the data did not support their original hypothesis, they simply added an ad hoc modification. So in a news release, Dr Elizabeth Nabel then head of the National Institute of Health – the statutory body that had funded the study with tax payers’ money – suggested that the findings “could have been due to chance”, and that the participants could still have been eating too much fat.
Actually no, Dr Nabel. That’s not science. The study disproves your hypothesis. When the hypothesis is disproven, you have to come up with a new one and then attempt to disprove it.
Albert Einstein said: “No amount of experimentation can ever prove me right;
a single experiment may at any time prove me wrong.”
The WHI study should have been considered the definitive disproof of the authors’ hypothesis that eating less fat will prevent heart disease. But instead the authors and the NIH marketed it as if it supported their hypothesis. That is not science. That’s science driven by industry or governments that are determined to find an outcome that supports their position, regardless of the facts. Why bother to do research if you “know” the outcome before the start? Of if you will interpret any outcome to support your ingrained prejudices?
But the finding that low-fat diets did not reduce the risk of cardiovascular disease is entirely predictable as a high carbohydrate diet produces a specific atheroma-generating metabolic profile in those who are metabolically vulnerable because they have insulin resistance.
For example, there is one study that looked at the progression of
coronary atherosclerosis (narrowing of the coronary arteries) in postmenopausal women by Harvard researcher David Mozaffarian and others, and published in the American Journal of Clinical Nutrition in 2004. The study concluded: “In postmenopausal women with relatively low total fat intake, a greater saturated fat intake is associated with less progression of coronary atherosclerosis, whereas carbohydrate intake is associated with a greater progression.” In other words the study found that higher intakes of “healthy” carbohydrates and “healthy” polyunsaturated fats was associated with more rapid disease progression, whereas women who ate the most saturated fat showed NO disease progression. Naturally this study has been buried, never to be heard of again. More recently, a study in the Journal of Nutrition in February 2015, confirmed that “ Dietary intake of saturated fat is not associated with risk of coronary events or mortality in patients with established coronary artery disease.”
But the strongest evidence against this fake hypothesis has been provided by Nina Teicholz in her riveting book, Big Fat Surprise: Why Butter, Meat and Cheese belong in a Healthy Diet. Teicholz reviews the absence of science behind the hypothesis that saturated fat causes disease. Dr Richard Smith, a former editor of the BMJ, had this to say about this book which should be required reading for all:
“The title, the subtitle, and the cover of the book are all demeaning, but the forensic demolition of the hypothesis that saturated fat is the cause of cardiovascular disease is impressive.
“Indeed, the book is deeply disturbing in showing how overenthusiastic scientists, poor science, massive conflicts of interest, and politically driven policy makers can make deeply damaging mistakes.
“Over 40 years I’ve come to recognise what I might have known from the beginning that science is a human activity with the error, self deception, grandiosity, bias, self interest, cruelty, fraud, and theft that is inherent in all human activities (together with some saintliness), but this book shook me.”
At the Old Mutual Health Summit, Zoe Harcombe presented more novel evidence against the fake hypothesis. She asked the question: What evidence was available from RCTs in 1977 and 1983 to support the adoption of those novel low fat guidelines. Her study reported in the BMJ Open Heart journal one week before the Summit concluded that “Recommendations were made for 276 million people following secondary studies of 2467 (ill) males with reported identical all-cause mortality. RCT evidence did not support the introduction of dietary fat guidelines.”
So now we know that there was no evidence available in 1977 to support the change in dietary advice that became the global standard. And we also know that no evidence has accumulated in the past 40 years to show retrospectively that those guidelines are correct and supported by the most rigorous science.
And more global experts are beginning to weigh in their support almost on a daily basis. Thus in an editorial in Diabetes Management in 2014, Dr Osama Hamdy, Medical Director of Joslin Obesity Centre’s Obesity Clinical Programme, wrote:
“It is clear that we made a major mistake in recommending the increase of carbohydrates load to >40% of the total caloric intake (especially for person with type 2 diabetes mellitus). This era should come to an end if we seriously want to reduce the obesity and diabetes epidemics. Such a move may also improve diabetes control and reduce the risk for cardiovascular disease. Unfortunately, many physicians and dieticians across the nation are still recommending high carbohydrates intake for patients with diabetes, a recommendation that may harm their patients more than benefit them.”
Yet my critics continue to ignore all the evidence that favors the health benefits of high-fat diets and the absence of evidence supporting low fat diets.
Could be due to the Upton Sinclair Theorem, which states: “It is difficult to get a man to understand something, when his salary depends upon his not understanding it”.
Perhaps the most important reason why the value of low carbohydrate diets are not yet properly appreciated especially by my profession is because we do not appreciate the importance of the condition of insulin resistance (IR) which is perhaps the single most important biological condition across the globe. So it is my argument that the global epidemics of obesity, diabetes, hypertension, gout, and atherogenic dyslipidaemia (high triglycerides, low HDL-C, increased number of small LDL-C particles, and increased triglyceride-rich remnant lipoproteins) and perhaps also cancer and dementia, are really the tip of the iceberg – the markers of an underlying biological predisposition that becomes apparent in those exposed to high carbohydrate diets and then presents as one of more of those conditions.
So it is my thesis that IR is the most prevalent biological condition in the world. It remains hidden as long as diets are not high in sugar and refined carbohydrates. But in the face of a high carbohydrate diet eaten for decades, the IR leads to all the common chronic diseases that we face today. But the problem is that IR is not taught in many medical schools or schools of dietetics and nutrition and this perhaps is the key problem. For if we don’t recognize the single most important factor predisposing to chronic ill health across the globe, then we are not likely ever to be able to cure or reverse those diseases. Especially if the cure is to remove the cause which is a high carbohydrate diet.
Ignoring IR undermines the modern practice of chronic medicine. If all the conditions linked to IR are caused ultimately by high carbohydrate diets – that is by a nutritional factor, as I believe they are, we don’t need medication, and the pharmaceutical industry that is designed to market its drugs to treat those conditions. For these are not conditions caused by the lack of a specific pharmaceutical chemical. They are caused by too many carbohydrates in the diet.
We fuel the fire with carbohydrates, and try to put it out with pharmacologic drugs that do not address the real cause.
Our critics’ views are based on the belief that all humans can metabolise carbohydrates equally. The condition of IR disproves that idea. Instead IR shows that for some even the smallest amounts of carbohydrate eaten for decades are enough to seriously damage our health in the long term.
In Black Holes and Baby Universes and Other Essays, Stephen Hawking says: “People are very reluctant to give up a theory in which they have invested a lot of time. They usually start by questioning the accuracy of the observations. If that fails, they try to modify the theory in an ad hoc manner. Eventually the theory becomes a creaking and ugly edifice.
“Then someone suggests a new theory in which all the awkward observations are explained in an elegant and natural manner.”
At the low-carb, high-fat summit in Cape Town, I believe that’s what we have done. We have exposed the creaking, ugly edifice of conventional wisdom on nutrition, and explained an alternative in an “elegant and natural manner”.