The World Turned Upside Down: The Second Low-Carbohydrate Revolution (45 page)
Read The World Turned Upside Down: The Second Low-Carbohydrate Revolution Online
Authors: Richard David Feinman
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APPENDIX
blog post "From a
future history of diabetes"
I don't believe in time travel, of
course, so when somebody
sent me the following article that was supposed to be a chapter from a
Study of
the History of Diabetes from 2016, I didn't think about it much.
Then I
read an
article
about a woman who had been charged
with neglect in the death of her son from complications due to
diabetes.
It seems she "was trying to live by faith and felt
like God would
heal him." For some reason, that made me think of the Future History,
so here
it is.
Chapter
IV. ACCORD to The Court
We have seen how, early in the
history of medicine, diabetes
was recognized as a disease of carbohydrate intolerance and how, until
the
discovery of insulin, removing carbohydrate from the diet became the
major
treatment (Chapters I and II). We chronicled the shift away
from this
medical practice under the influence of low-fat recommendations and the
ascendancy of pharmacology that followed the discovery of
insulin.
Nonetheless, it persisted in the popular mind that you don't give candy
to
people with diabetes, even as health agencies seemed to encourage
sucrose
(sugar) consumption.
The rather sudden reappearance of
carbohydrate restriction,
the so-called modern era in diabetes treatment, is usually dated to
2008, the
precipitating event, publication of the ACCORD study in which a group
undergoing "intensive treatment" to lower blood glucose
showed unexpected
deaths
[1]
. ACCORD
concluded that "These findings
identify a previously unrecognized harm of intensive glucose lowering
in
high-risk patients with type 2 diabetes." The intensive treatment
turned out to
be intensive pharmacologic therapy and this flawed logic lead to a
popular
uprising of sorts, a growing number of patients claiming that they had
been
hurt by intensive drug treatment and typically that they had only been
able to
get control of their diabetes by adherence to low-carbohydrate diets.
Blogs
compared the ACCORD conclusion to an idea that alleviating headaches
with
intensive aspirin led to bleeding and we should therefore not treat
headaches.
The conflict culminated in the large
judgment for the
plaintiff in
Banting v.
American Diabetes Association
(ADA) in 2014,
affirmed by the Supreme
Court in 2015. Dalton Banting, coincidentally a distant
relative of the
discoverer of insulin, was an adolescent with diabetes who took
prescribed
medications and followed a diet consistent with ADA
recommendations. He
experienced worsening of his symptoms and ultimately had a foot
amputated. At
this point his parents found a physician who recommended a
low-carbohydrate
diet which led to rapid and sustained improvement. The
parents claimed
their son should have been offered carbohydrate-restriction as an
option.
The case was unusual in that Banting had a mild obsessive-compulsive
condition,
expressed as a tendency to follow exactly any instructions from his
parents or
other authority figures. Banting's lawyers insisted that, as
a
consequence, one could rely on his having complied with the ADA's
recommendations. Disputed by the defense, this was one of
several issues
that made
Banting
famous for vituperative courtroom interactions between academics.
Banting was a person with type 2
diabetes. Unlike
people with type 1 diabetes, he was able to produce insulin in response
to
dietary (or systemic) glucose but his pancreas was progressively
dysfunctional
and his body did not respond normally, that is, he was
insulin-resistant.
Although most people with type 2 diabetes are at least slightly
overweight,
Banting was not, although he began gaining weight when treated with
insulin.
The phrase "covered with insulin..."
rocked the court: the
president of the ADA, H. Himsworth, Jr., was asked to read
from the 2008
guidelines
[2]
:
"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."
Jaggers (attorney for Banting):
"Are there other diseases
where patients are counseled to make things worse so that they can take
more
drugs."
Himsworth: "We only say 'can
be.' We don't
necessarily recommend it. We do say that 'Care should be
taken to avoid
excess energy intake.'"
It soon became apparent that
Himsworth was in trouble.
He was asked to read from the passage explaining the ADA's
opposition to
low-carbohydrate diets:
"Low-carbohydrate diets might seem to
be a logical approach
to lowering postprandial glucose. However, foods that contain
carbohydrate are
important sources of energy, fiber, vitamins, and minerals and are
important in
dietary palatability."
Jaggers: "Important sources of
energy? I thought we
wanted to avoid excess energy," and "would you say that taking a
vitamin pill
is in the same category as injecting insulin?"
Finally,
Jaggers: "Dr. Himsworth, as an
expert on palatability,
could you explain the difference between Bordelaise sauce and Béarnaise
sauce?"
[laughter]
Damaging as this testimony was, the
tipping point in the
trial is generally considered to have been the glucometer
demonstration.
Banting consumed a meal typical of that recommended by the
ADA and
glucometer readings were projected on a screen for the jury, showing,
on this
day, so-called "spikes" in blood glucose. The following day,
Banting
consumed a low-carbohydrate meal and the improved glucometer readings
were
again projected for the jury. Defense argued that one meal
did not prove
anything and that one had to look at the whole history of the lifestyle
intervention but was unable to show any evidence of harm from continued
maintenance of low blood sugar despite testimony of several expert
witnesses. In the end, the jury agreed that common sense
overrides expert
testimony and that Banting should have been offered the choice of a
carbohydrate-restricted diet.
Banting
was held in New York State which adheres to the
Frye
standard: in essence, the idea that
scientific evidence is determined by "general acceptance." The explicit
inclusion of common sense was, in fact, a legal precedent
[3]
.
The Supreme Court ultimately concurred and held that the more
comprehensive
standards derived from
Daubert
v. Merrill-Dow
, could sensibly be seen to
encompass common sense.
The final decision in Banting lead to
numerous law
suits. The ADA and other agencies changed their tactics
claiming that
they never were opposed to low-carbohydrate diets and, in fact, had
been
recommending them all along
[4]
.
This is discussed
in the next chapter.
References
1. Gerstein, H. C.
et
al
., Effects of intensive glucose lowering in
type 2 diabetes.
N Engl J Med
358 (24),
2545 (2008).
2. American Diabetes Association,
Nutrition Recommendations
and Interventions for Diabetes–2008.
Diabetes
Care
31 (Suppl 1), S61 (2008).
3. Berger, M, Expert Testimony: The
Supreme Court's Rules
Issues in
Science and Technology
(2000).
4. American Diabetes Association,
Nutrition Recommendations
and Interventions for Diabetes–2016.
Diabetes
Care
36 (Suppl 1), S12 (2013).