The World Turned Upside Down: The Second Low-Carbohydrate Revolution (3 page)

"Sucrose-containing foods can be
substituted for other
carbohydrates in the meal plan or, if added to the meal plan, covered
with
insulin or other glucose-lowering medications."
[9]

The most difficult part of writing
this book is
understanding or, again, at least describing – I don't think it is
possible to
understand – how the whole field of medical nutrition could be wrong.
Way
wrong. Not in detail but totally off the mark. As misguided as the
alchemists'
pursuit of creation of gold. And, however bizarre the distance from
science in
this most scientific of ages, there is the real harm to patients. It is
hard to
explain because the esteem in which medicine is held is based on real
accomplishment and expertise and it is hard to see why they would go so
wrong
in nutrition. For me, having precedents makes it real if not completely
comprehensible. Here's one that I keep in mind. It's about the Israeli
Defense
Forces and Intelligence on the days before the Yom Kippur War:

The intelligence chiefs
believed they knew a deeper
truth...that rendered irrelevant all the cries of alarm going up around
them.
Zeira and his chief aides were to demonstrate the ability of even
brilliant men
to adhere to an
idée fixe
in the face of mountains
of contrary evidence
... They clung to their view even though the Egyptian deceptions were
contradicted by evidence of war preparations that AMAN's [military
intelligence] own departments were daily gathering.... But the
deception
succeeded beyond even Egypt's expectations because it triggered within
Israel's
intelligence arm and senior command a monumental capacity for
self-deception.

– Rabinovitch,
The
Yom Kippur War
.

They could have lost it all. They
could
have lost the whole
country. They were largely saved by a couple of field commanders
(notably Ariel
Sharon) who were wild and crazy guys. (Audacity and not following
orders may be
what saves nutrition as well).

Finally, this book is for the person
(and
those for whom she
spoke) who posted this on my blog.

How does one know if a study
is 'flawed'? I see a
lot of posts on here that say a lot of major studies are flawed. How?
Why? What's the difference if I am gullible and believe all
the flawed
studies, or if I (am hopefully not a sucker) believe what the Fat Heads
[a
low-carb site] are saying and not to believe the flawed studies – eat
bacon.

Where are the true studies
that are NOT flawed....
and how do I differentiate? : /

She was right to be suspicious. It is
not always easy. There
are so many nutrition papers that try to snow you with technical detail
and, in
fact, those are the ones  to be suspicious of. There are
technical parts of
scientific papers but you need to be sure that they aren't making it
harder
than it needs to be. And, some of the papers are simply not true. Most
researchers know that if you make up the data on a federally-funded
grant, you
can go to jail, but in interpreting things, you can say just about any
damned
thing. I will try to explain how to interpret these papers. In
particular, I
will try to explain what the statistics mean. What they mean for
somebody who
doesn't know much about statistics.

The second low-carb
revolution.

The killer-app is still the treatment
of diabetes with a
low-carbohydrate diet. Intuitively obvious, proved in many experimental
trials
and widely used anecdotally and clinically, there are virtually no
contra-indications. Resistance to its use appears to rest entirely with
pressure from political organizations, primarily the American Diabetes
Association (ADA) which, while looking for a way to save face, still
refuses to
endorse low-carbohydrate strategies. The latest guidelines emphasize
"individualization"
presumably as a way of softening their previous opposition to
low-carbohydrate.
The word is used 21 times in their position paper
[10]
.
However, what principles are to be used for each individual are not
stated. The
foolishness of recommending carbohydrates for people with a disease
whose most
salient manifestation is an inability to adequately metabolize
carbohydrates is
not disowned. "Individualization" is correctly called a cop-out.
According to
http://www.merriam-webster.com/) ("an excuse for not doing something;
something
that avoids dealing with a problem in an appropriate way."

We also have, at the same time, a
constant flow of blog posts
and books that show the low-fat-diet-heart hypothesis for the
intellectual and
clinical disaster that it really was (or is). The most recent, most
complete,
"A Big Fat Surprise"
[11]
is
surprising in its
description of the depths of self-delusion if not dishonesty in keeping
low-fat
alive. While the pace of criticism is increasing, these exposés
document that
the diet-heart hypothesis has been debunked since its inception. What
is new is
that the efficacy of statins, the last hope, the big bail-out for the
lipophobes, is now seriously in question.

If you step back and look at the
data, the "concerns," the
voices on the Huffington post or the numerous blogs belonging to
dietitians who
have set up a business, it shines through that the easiest way to lose
weight
is to go on a low-carbohydrate diet. The "concerns," voiced for forty
years,
have never materialized and the tests of carbohydrate restriction come
out in
its favor, however poorly they are cited. There are now dozens of
implementations, although the Atkins name has attained a somewhat
generic
status like Kleenex®.  Silence is, in fact, the most widely
used tactic of the
nay-sayers although they are surprisingly aggressive when they do say
something.

At the same time, there is a frantic
effort to seek out an
alternative, Mediterranean diets, low-glycemic (GI) index diets,
low-sugar
diets or whatever Dr. Oz is pushing when you read this. This book has
been
sometime in the writing and when I wrote the previous sentence, I meant
"Dr.
Oz" in the generic sense of the latest cure-all, not knowing what he
actually
thought but, by May of 2014, Dr. Oz was, in fact, pushing a
low-carbohydrate
diet, or at least running along side it. The interview with a proponent
of
dietary carbohydrate restriction can be seen at http://bit.ly/1uOoL1D
under the
headline "...Dr. Peter Attia and Dr. Oz on Saturated Fat. Oz Admits He's
Been
Wrong." This has to be taken as an important sign of the progress in
the second
low-carb revolution although I am not sure what Dr. Oz will be pushing
when
this book is in front of your eyes.

metabolic syndrome,
metabolic control.

There is almost nothing in biology
that is not connected
with feedback. This fundamental idea is widely ignored but it is
pervasive. If
you reduce your intake of cholesterol, your body will respond by
synthesizing
cholesterol. If you stop eating carbohydrate, your body will respond by
synthesizing glucose and making other fuels available. This grand idea
puts
severe limitations on what you can do (as in the case of cholesterol)
but can
point to some opportunities (as in the case of carbohydrate reduction)
but
generally, it suggests caution in jumping to conclusions.

The paradox is that, given the first
principle, there is a
global effect of the hormone insulin. We can get very far simply by
regulating
this hormone. While not free from feedback, the effects of manipulating
insulin
can be highly predictable, the main theme of this book. Always in the
background is the metabolic syndrome (MetS). The observation, generally
credited to Gerald Reaven, endocrinologist and currently Professor
Emeritus at
Stanford, was that a collection of seemingly different physiologic
effects –
overweight, high blood pressure, high blood glucose, high insulin and
the
collection of blood lipid markers referred to as atherogenic
dyslipidemia (high
triglycerides, low HDL) – were all tied together by a common causal
thread, the
disruption in the metabolic response to insulin
[12]
.
The physiologic markers of MetS predict progression to the associated
disease
states (obesity, diabetes, hypertension and cardiovascular disease) but
all
respond to dietary carbohydrate restriction. That is the big pitch.
This
observation provides evidence that it really is a syndrome (has a
common
underlying cause) and simultaneously points us to the most effective
treatment.
No dietary approach is better and no drug will target all of the
markers.

There are, in fact, critics of MetS
who doubt that it is a
syndrome at all but what they really mean is that the effects have to
be
treated with a collection of drugs, drugs for diabetes, drugs for heart
disease, drugs for high blood pressure. A low-carb diet which is widely
accepted as effective for weight loss is likely a strategy for general
health
for most people. Acceptance of such a notion is the goal of the
revolution.

Oddly enough, the bright light on the
horizon is the
ketogenic diet for cancer. Oddly, because carbohydrate-restriction for
diabetes
is a slam-dunk and that should have been the crystallizing point for
change. As
a therapy, it virtually guarantees results insofar as there is anything
like a
guarantee in this business. Carbohydrate restriction follows from basic
biochemistry and there are a large number of very strong tests. Yet
there is
extensive resistance to its use for people with diabetes.

Against this background, treatment of
cancer is not
encountering the same obstinacy despite the fact that we have very
little solid
evidence at all. We do see a close connection of cancer with obesity
and
diabetes and the role of insulin which seems to carry the day as it
couldn't
for obesity and diabetes. I describe work by my colleague, Eugene Fine,
targeting insulin in the treatment of cancer. I describe this work and
its
acceptance, despite its small size as a research project, as the sign
of future
progress
[13]
. If it turns
out that we learn to treat
diabetes by learning to treat cancer, it would not be the strangest
thing that
ever happened in science.

Organization.

If we had ham, we could have ham
and eggs, if we had eggs.
–
Old
American idiom
.

It's all tied together. The science
is not divorced from the
politics. The Framingham study
[14]
,
the first very
large population trial would test not only a scientific principle –
whether
dietary fat and cholesterol are related to risk of cardiovascular
disease (they
were not) – but also whether the recommendations of health agencies
were a rush
to judgment (they were). The study had such a large political component
that,
striking as the scientific outcome was – there was no effect of dietary
fat,
saturated fat or cholesterol on cardiovascular disease – it just
couldn't be
seen to fail. The results were not published and were buried for years
until
rediscovered by a statistician who had it published. This intertwining
of the
political and the science is a pattern that persists and I try to tell
both
stories and the effect of their mixture.

I have opted for loose organization
and some degree of
repetition. Put another way, because everything is tied together,
regardless of
what kind of organization I chose, the output will be loose. My main
principle,
however, is that basic science comes first. I give preference to the
demonstrations in nutritional and medical practice that come out of the
fundamental results of biochemistry, of hard science. Big clinical
trials have
to be judged on their inherent strength but, if they contradict basic
science,
they have an obligation to explain why. And science is continuous with
common
sense. It doesn't matter how many statistical tests you have, if the
results
violate common sense, it is unlikely to be science.

The poor research published by
prestigious
people and prestigious
institutions means the nature of science itself has to be investigated.
So, we
will have to define scientific principles and explain how to read a
scientific
paper and decide if peer review has done its job. Finally, I will
provide
information on cooking and eating.

But first, the answer. In
Chapter
1
, I give you the bottom line,
the practical consequences of the science. The rest of the book will
try to
justify the statements and recommendations.

PART
I - NUTRITION AND
METABOLISM. THE STUFF YOU EAT AND WHAT HAPPENS TO IT.

Chapter
1

The
Summary in
Advance

"What should I eat?" That's the
question that I
invariably get at my lectures to medical students or presentations at a
scientific meeting or even in a private conversation about scientific
experiments. The level of technical detail that I discuss varies with
the
audience but people always want to know the bottom line. It is not
unreasonable
to ask for practical advice.

Sometimes the question is framed as
"What's the best diet?"
which I can answer with the old joke about the guy who goes to the
butcher and
sees that pork chops are $8 a pound.

Customer
:
"Why so much?
Across the street, he is selling them for $5 a pound."

Butcher
:
"Why don't you buy
them there?"

Customer
:
"Today, he's all
out."

Butcher
:
"When I'm all out,
they're only $2 a pound."

The best diet is the one that works.
It doesn't matter how
"scientific" it is or how "healthy" your physician thinks it is. If you
gain
weight, or if your fasting blood sugar goes up, it's useless or worse.
It would
be hard to say that the diet recommended by government and private
health
agencies has provided much help for the current widespread obesity and
diabetes. Defenders usually tell you that it is because people are not
really
following the guidelines. They don't say how they know that the
recommendations
are good if nobody follows them. So here are three rules that I propose
as a good
guide. Also, a few principles that will help you follow them. These are
different from what your doctor may say and the rest of the book will
justify
these principles.

The three rules for
getting control of your
diet.

Rule
1
. If you're OK, you're
OK.

Rule
2
. If you want to lose
weight: Don't eat. If you have to eat, don't eat carbs. If you have to
eat
carbs, eat low-glycemic index carbs.

Rule
3
. If you have diabetes
or metabolic syndrome, carbohydrate restriction is the "default"
approach, that
is, the one to try first.

Rule
1
is actually surprising
to many people: If you don't have a weight problem, if you feel OK, if
you are
healthy and if you do not have a family history of disease, there is no
compelling reason to change your diet. You may want to find out more
about
nutrition and biochemistry but the idea that there was once a Garden of
Eden
diet that we all ate until somebody brought high fructose corn syrup
into the
world and all our woe seems unlikely.

Not everybody has this view. There is
the idea, not always
said explicitly, that, analogous to Freud's "Psychopathology of
Everyday Life,"
we are all doing something wrong and life is a continuous battle
between what
are bodies really need and the pressures of civilization. It's not like
that.
We evolved to be adaptable. Lots of dietary approaches work and none of
us are
going to get out of this alive.

And then there's the Nutritional
Guidelines for Americans
from the USDA (Department of Agriculture) – the Department is
specifically
charged by congress with providing advice to people who are healthy,
that is,
people who don't need advice, or, as we say in Brooklyn, fixing
something that
ain't broke. Like psychoanalysts, they feel endowed by their creator
with the
intuitive power to penetrate unspoken, unmeasured, deep truths and are
able to
tell us that we are not eating the right thing and that we are at risk
for some
future disease. They are, however, quick to take offense if you suggest
that
their inability to control the epidemic of obesity and diabetes makes
it very
unlikely that they know what the right thing is.

Rule
2. If you want to lose weight:
Don't eat. If you have to eat, don't eat carbs. If you have to eat
carbs, eat
low-GI carbs.

I said this as a joke at a conference
but there is much truth
in it. Not that starvation is a good long-term strategy – the danger is
that
you will lose muscle mass along with your fat – but frequently we think
that it
is important to eat all the time. That is not true and intermittent
fasting,
which is garnering a certain amount of interest, may be a very useful
strategy
for weight loss. There are exceptions: some medical conditions,
diabetes in
particular, may require individual variation. Calorie reduction is
beneficial
for diabetes but the need to avoid ups and downs means that there are
other
considerations. We tend to think that hunger is some kind of
physiologic signal
telling us that our body needs food. We think that this is a signal
that must
be answered immediately. It's not like that. Chapter 13 will make the
argument
that hunger only means that you are in a situation where you are used
to
eating. It may be a situation, like the business lunch or the tail-gate
party,
that has little to do with your state of nourishment. The hunger pangs
that you
feel may be real enough but you are not compelled to answer them.

Calories are a measure of the total
energy available from
burning food. The less food you eat, the less energy you will have. Not
all
calories are the same though. Many experiments that show success with
calorie
reduction, on analysis, reveal that the effect was due to the
de facto
reduction in
carbohydrate. Some dietary strategies will waste more energy than
others (as
heat and other unproductive effects). That's what the second part of
Rule 2
says, but it is still
true that if you don't eat,
you will get thin.

Carbohydrate
restriction.

Calories count but the advice from
experts that
only
calories
count is
wrong. There are great advantages to diet strategies that go beyond
calories.

For most people the best long-term
(or short-term) strategy
for weight loss will be to reduce carbohydrate intake. There are
extensive data
in the medical literature to support this idea but the best evidence
may be
anecdotal. In the field of weight-loss, anecdotal evidence is pretty
good.
Everybody knows somebody who lost a lot of weight on the Atkins diet.
Some
report that the pounds seem to "melt away." There is no guarantee that
you will
have the same experience and everybody hits a plateau but it is still
your best
bet. People who are on low-carbohydrate diets – and they usually are
the people
who have had trouble with other kinds of diets – will tell you that
they are
easy to stay on. Those who quit, may or may not gain weight but rarely
gain
back all of the lost weight. People who give dire warnings about
low-carb diets
almost always are people who have not tried them and when they tell you
that
patients can't stay on low-carb diets, it turns out they have never
actually
recommended them to their patients. Even these people sometimes change
their
mind. My experience, also, is that it is a ratchet. People rarely go
back to
low-fat. And contrary to the
kvetching
on TV, there are many things to eat. Chapter 25 will give you some
recipes to
get you started.

Low-carb diets follow from basic
biochemistry. The key
factor is improved control of insulin, the anabolic (building up)
hormone that
is most reliably controlled by carbohydrate. They are consistently
successful
and that is what keeps it going. As in any diet, people may quit at a
certain
point – we have 600 million years of evolution and a lifetime of
behavioral
conditioning telling us to eat anything that tastes good – but once
successful,
even if we fall off the wagon, it is usually to a low-carb diet that we
go back
to. Nutritionists will tell you that "yo-yo dieting" has some risk but
there is
no evidence for that and, of course, we are happy for the period where
we are
thin, however long that is.

Whatever is good or bad about
low-carbohydrate strategies,
for most people, low-fat diets are worse than doing nothing. Some
people can do
well on them – there is an advantage in feeling hungry – but most of us
can't.
If you can get yourself into the frame of mind where you like the "lean
and
hungry" feel, then anything that reduces calories will be okay. All
diets have
recidivism but most people on low-fat, calorie-restricted diets don't
even get
the opportunity to fall off the wagon – if you don't lose weight, there
is no
wagon. That the experts tell you that it is better to lose weight
slowly should
be a tip-off. Everything else we do in life we try to do as quickly and
efficiently as possible. We recognize that it may take longer than we
want.
Only psychoanalysis and conventional low-calorie weight loss set out to
go slowly
by design.

The scientific literature backs up
the anecdotal evidence.
Jeff Volek, one of the major researchers in carbohydrate restriction
put this
spin on it: "Nutrition research is hard. Too many things change and
it's easy
to come up with nothing. When you study low-carb diets, people lose
weight. Put
people on a low-carb diet and you get real data." As I finish this
book, the
long-standing refusal of the nutritional establishment to face the data
is
finally falling away. It will be increasingly easy to follow a
low-carbohydrate
approach. It will be more common to have the support of physicians.

Experimentally, carbohydrate
restriction has better
compliance than anything else possibly due to the greater satiety of
protein
and fat or, more likely, the poor satiety in most carbohydrates.
Current
fashion is to say that sugar is addictive which trivializes the
serious,
sometimes life-threatening consequence of real addictions, like alcohol
and
narcotics but, for whatever reason, people on low-carbohydrate diets
reduce
food intake spontaneously and, in addition, benefit from an inherent
efficiency
in weight lost calorie-for-calorie. The doctrine that only calories
count is
not true however vehement its defense. You can test for yourself, at
least at
the level of perception. You can find out if, on a low-carbohydrate
diet you
seem
to be eating more
even while losing weight .

Later chapters will describe
experimental studies that
support these conclusions about low-carbohydrate strategies but there
is one
truly remarkable phenomenon that tells you about the edge that
low-carbohydrate
diets have in satiety. When diet comparisons are carried out
experimentally,
most often the protocol is to allow the low-carbohydrate group freedom
to eat
ad
lib
as long as they
follow the restrictions on carbohydrate. Low-fat controls, on the other
hand,
are restricted to a fixed number of calories. The rationale is that
many
popular low-carbohydrate diets, like the Atkins Diet, put no limit on
consumption – the idea is that fat and protein intake is self-limiting
when
carbohydrate is low. Setting up the experiment this way is poor
experimental
design in that you are now testing two things: the ability of a
low-carbohydrate diet to limit caloric intake as well as the proposed
difference
in physiologic effects of the type of diet. (It also raises the stakes
on the
carbohydrate-restricted diet). Nonetheless, the fact that the
low-carbohydrate
diet almost always wins in such comparisons tells you that, as
advertised, you
don't have to count calories in a diet based on carbohydrate
restriction.
(Again, not that calories don't count, but rather that they take care
of
themselves).

The greatest virtue of carb
restriction is its fail-safe
feature. If you are not rapidly losing weight or seem to hit the wall,
it is a
way of eating (WOE) that gives you freedom from the sense of fighting a
war
against fat. You will almost never gain weight and you will escape that
overbearing feeling that every meal is a battle. The real threat of
overweight
is not health. Mortality correlates with weight only at the very
extremes. The
real threat is the sense of loss of control. I am not a health care
provider
but I get emails from executives, officers in the military, people who
hold
dominion over their professional world but who have trouble controlling
their
own body mass. For the average person, it can take over their life. It
can be a
tremendous psychological burden. Cut out most of the carbs in your life
and
life is better.

The glycemic index (GI) follows from
the same principle as
carbohydrate restriction, control of insulin effects, but the approach
focuses
on the predicted effect of dietary carbohydrate on your blood glucose.
Numbers
are assigned to different foods based on the increase in blood glucose
for the
two hours following ingestion of fixed amounts of carbohydrate. This
number,
the GI, is relative to the effect of the same amount of pure glucose
or,
following nutritionists' seeming penchant for imprecision, to the same
amount
of white bread. In the end, a low-GI diet is a weak form of
low-carbohydrate
diet. It never does as well as real low-carbohydrate diets in
experimental
trials and it is easier to simply reduce carbohydrate because you know
what
you're doing whereas low-GI has all kinds of practical limitations.
Because it
is fundamentally an experimental, as opposed to theoretical parameter,
the
average of the GI of the different individual foods in a meal is not
guaranteed
to be the GI of the actual meal. (And, of course, it involves counting
and
calculation which is just how diets maintain control over your life).
For many
nutritionists, it is a politically correct
alternative
to low-carbohydrate diets but the point of
Rule
2
is that it is strictly secondary to real reduction in
total
carbohydrate.