The World Turned Upside Down: The Second Low-Carbohydrate Revolution (9 page)

11.
 
 The dietary change that is
most likely to
increase
the risk of cardiovascular disease:

_____ unsaturated fat
→
saturated fat

(That is, unsaturated fat,
out; 
saturated fat. in)

__
X
__
unsaturated fat
→
carbohydrate

_____ carbohydrate
→
unsaturated fat

_____ carbohydrate
→
saturated fat

_____ saturated fat
→
carbohydrate

_____ saturated fat
→
unsaturated fat

Student
Performance on Question 11

This is one of the most important
observations because it has
been known for so long. I described in
the Introduction
my
early research into the
literature and my dismay at the results of the Nurses Health Study
[4]
. The demonstration that there
was an
increase
in CVD
incidence,
greater
risk, by taking fat out of your diet and putting in carbohydrate. Take
out fat,
any fat and replace with carbohydrate and risk goes up. This was
astounding
given the persistent low-fat message. It would have been reasonable for
the
study, done more than 15 years ago to have been the stimulus for a
change away
from that low-fat message. That didn't happen. Only a few years ago,
Walter
Willett himself was reported in the media as embracing a
low-carbohydrate diet
but little happened. It was clearly not a real passion with him and
they must
have gotten to him (whoever 'they' are).

Summary

Major points about lipids from the
second part of the quiz:

The terms "saturated" and
"unsaturated" can only be applied
to fatty acids, the constituents of fats and oils. The composition of
common
fats and oils is different from popular conceptions, e.g., beef tallow
is
almost half oleic acid, the main fatty acid of olive oil.

The dietary change that has the
greatest effect on
cardiovascular risk factors is replacement of fat with carbohydrate.
Low-fat
diets reduce LDL but low-carb diets reduce the important sub-fractions,
the
pattern B, that are more atherogenic. Reducing carbohydrate also
improves HDL.
The question that is posed is whether reducing carbohydrate diminishes
the
actual incidence of CVD. It would be difficult to answer that question
but it
must be considered. What you may not have known before the quiz: our
current
state of knowledge does not provide evidence that what you eat will
make any
difference in your risk of heart disease.

The ambiguity or, more precisely, the
near
absolute failure of
the diet-heart hypothesis contained the seeds of the first low-carb
revolution.
We'll look at that next and ask why another revolution is needed.

Chapter
4

The first low-carb revolution.

Revolutions - political
and scientific.

The first low-carbohydrate revolution
dates from about 2002
and as is frequently the case in politics, the revolutionaries saw
themselves
as a loyal opposition and probably thought that their ideas were not
particularly iconoclastic. Dr. Atkins was a physician and undoubtedly
had the
idea that he was only trying to help. He was obviously surprised at the
vehement backlash. Unfortunately, his response to criticism was less
like that
of John Adams than like John's cousin, Samuel Adams, described in
Don't Know Much
About History
as being better at brewing dissent than beer. However, it is doubtful
that much
could have been done and a real revolution can be dated to 2002 but,
like
political revolutions, has to be won again.

Scientific revolutions, like
political revolutions, usually
have to be won more than once. Gary Wills
[33]
described the Gettysburg Address as a statement that the Civil War was
a second
American Revolution. People of my generation may see the civil rights
movement
as a third. It's often the same for revolutions in science. We are
taught that
atomic theory comes from John Dalton, the Manchester school-teacher who
proposed it in 1799 but atoms were not truly accepted as real things
until
Einstein nailed it in 1905.

The idea that dietary carbohydrate,
sugars
and starches, have
some unique power to make people fat is pretty old. It would be hard to
identify the first farmer who fattened animals for market by feeding
them
grain. Brillat-Savarin, the father of modern gourmet cooking,
generalized the
principle to fattening people and claimed that there were folks who
were
"carbophores" and he admitted to being one himself
[34]
.
The mechanism: the anabolic effects of the hormone insulin, stimulated
primarily
by the sugar glucose, was a well established physiologic phenomenon
before the
first low-carbohydrate revolution. The scientific literature provides
many
examples of weight loss from carbohydrate restriction beyond the
reduction in
calories that usually went along with it. Although it has been around
in one
form or another for a long time, carbohydrate restriction only became
revolutionary with the ascendancy of a kind of low-fat
nutritional-medical
monarchy with powerful influence.

The original Atkins book
[20]
appeared in
its first edition in the seventies, just about the time of the
codification of
low-fat as the desirable diet. The Atkins Diet was vehemently denounced
to the
point of having congressional hearings. An amusing moment was the
American
Medical Association (AMA) asserting that one of the dangers of a
low-carbohydrate diet for weight loss was that it might lead to
anorexia.

As in political revolutions, the
first low-carbohydrate
revolution was stimulated by a kind of manifesto, a document that
historians
describe afterwards as being a call to action. The equivalent of Thomas
Paine's
Common Sense, which fired everybody up for the American Revolution, was
Gary
Taubes's 2002 article in the New York Times Magazine Section:
What if it's
All Been a Big Fat Li
e
[35]
Figure 4-1
. Later
expanded into the book
Good
Calories, Bad Calories
[23]
,
Taubes
documented the political ascendancy of the low-fat paradigm and the
establishment of something like the Court of Low-Fat.

T
he
AMA, the American Heart
Association (AHA) and influential physicians were all received at
court. The
media and the government went along and that included the McGovern
Committee –
Tom Naughton's comedy documentary
Fat
Head
[36]
includes a clip of McGovern
explaining that congress did not have the luxury of waiting for all the
science
to be in.

Figure
4-1
. Thomas Paine's Common Sense and the
first page of Gary Taubes's
New York Times Magazine Section piece.

The McGovern hearings set a pattern
of ignoring dissenting
voices. Philip Handler, Head of the National Academy of Sciences who
testified
that there was little science behind this rush to judgment. I
recognized Handler
as part of White, Handler and Smith, authors of one of the few
comprehensive
biochemistry texts at the time, that is, he was a well-known
biochemist.

The first
low-carbohydrate revolution

There were many experimental and
clinical
trials that set out to
prove the diet-heart hypothesis. The first, the Framingham study, still
going
on, was a massive study of the behavior of residents of the small town
in
Massachusetts. The original results showed no effect of total or
saturated fat
or cholesterol on cardiovascular disease (CVD). Doubly disappointing in
that
the study
did
find an inverse correlation between cholesterol and CVD. The correlation is not
a
knock-out but there really was a correlation, now a classic in
epidemiology,
taught in statistics classes. The fact that diet did
not
correlate with CVD is less often
discussed. In fact, the results of the Framingham study were buried for
years
until a statistician had them published. It should have been the death
of
diet-heart right there. If fat were as bad as they said, there should
not be a
single failure like this. Not one. In actuality, almost every one of
the dozen
or so large trials that have followed Framingham has failed. Science,
however,
was not the major force. The lipophobes, as Michael Pollan calls them
[5]
, anointed themselves with the
power to dismiss each
experimental failure as loss of a minor battle in a war where victory
must
surely fall to them; just one more big clinical trial, just another
hundred
million bucks and you will see how bad fat is. Even when, in 2001, the
AHA
removed its proscriptions against total dietary fat, it was done
without
fanfare. What? You didn't know that? They're still down on saturated
fat and,
of course,
trans
-fat,
the easy target that appeared in the food supply because of the
pressure from
groups like the AHA to replace butter and other sources of saturated
fat. They
have, however, given up on total fat.

Although preceded by other exposés,
Taubes's book was the most
compelling presentation of how nutritional science had been taken over
by this
group of lipophobes. Numerous re-tellings have followed. The recent
"Big Fat
Surprise,"
[11]
is of
comparable literary quality to
"Good Calories, Bad Calories," and is more explicit in its
condemnations of the
players. Ultimately, with control over even the NIH, the low-fat mafia
(also a
common phrase) could now resist all scientific argument and dismiss all
of the
experimental failures of low-fat to give us anything at all. The
ascendancy of
low-fat was, and still is, coupled with a special hatred for
low-carbohydrate
diets and especially for its main exponent, Dr. Atkins, even after his
death.

The low-fat idea wasn't good to begin
with, but, of the
tests of the idea that failed, one after another, nothing was more
embarrassing
than the
Women's
Health Initiative (WHI)
which reported in 2006: "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 coronary heart disease (CHD),
stroke,
or CVD in postmenopausal women...." A multi-center, $400 million study,
the WHI
had assigned 19, 541 postmenopausal women to the dietary intervention
and a
control group of 29,294 women, in a free-living setting. As such, its
failure
should have been a bombshell. It was not long before Dr. Elizabeth
Nabel,
director of the National Heart Lung and Blood Institute of the NIH
appeared on
television to assure the nation that, instead, recommendations had not
changed,
that you really needed to reduce saturated fat. Nothing's changed,
despite the
scientific study that they had funded showing that a change
was
needed. It is
serious. The refusal to accept the failure of a scientific test and the
stubborn insistence on doctrine was palpably harmful. The WHI women
weren't
getting any better and the population at large, doing its best to
adhere to
low-fat, was getting fatter and more diabetic in this period. Refusal
to see
the WHI for what it was, represented a clear statement that the
lipophobes,
starting at the top, at the NIH, were going to stonewall any effort to
change.

"The shot
heard 'round the world"

If
What if
it's All Been a Big Fat Lie
was the
Common Sense
of the first low-carbohydrate
revolution, the "shot heard 'round the world" was the report by Gary
Foster and
coworkers
[37]
showing that
the Atkins diet actually
improved markers for cardiovascular disease, the lipophobes' main
"concern"
about low-carbohydrate diets.

Figure 4-2
.
First
page of Foster, et al.
[37]

It was the specter of fat that
hovered
over everything. Foster's
demonstration had a big impact because he spoke for the whole
nutritional
establishment; he later described, in public lectures, how he and his
collaborators had been having lunch at a scientific meeting, bemoaning
their
inability to sweep the Atkins diet from their sight. They decided to
get a
grant to trash the diet and so they did – one suspects that their
intent was
clear in the grant application; not to test
whether
the Atkins diet was good or bad – try to get a grant to do that – but
to show
just how bad it was. They carried out a one-year study comparing a
low-carbohydrate diet modeled on the Atkins diet with a low-fat diet.
What they
found, instead of what they wanted, was that:

Subjects on the low-carbohydrate
diet had lost more weight
than subjects on the conventional diet at 3 months...

This part was not a surprise.
Everybody knows somebody who
has lost a lot of weight on the Atkins diet and nutritionists had more
or less
granted the idea that low-carbohydrate diets were good for weight loss.
Although they usually insisted that it was "just a reduction in
calories." (If
you've tried to lose weight, though, you know that there is no "just"
about
it). The kicker, though, was that Foster report that:

...After three months, no
significant differences were
found between the groups in
total
or low-density lipoprotein cholesterol
concentrations. The increase
in
high-density
lipoprotein
cholesterol
concentrations and the
decrease
in triglyceride concentrations
were greater
among subjects on the
low-carbohydrate diet than among those on the conventional diet
throughout most
of the study. Both diets significantly decreased diastolic blood
pressure and
the insulin response to an oral glucose load.
[37]
.
(
my
emphasi
s).

In other words, the low-carb diet was
better on HDL a ("good
cholesterol") and especially triglycerides. Most of all, there was no
increase
in LDL – low-density lipoprotein cholesterol
(
LDL) which is what your doctor takes as the
traffic light for
determining whether you need to be prescribed statins.

More work needs to be
done

What was the conclusion? "Longer and
larger studies are
required to determine the long-term safety and efficacy of
low-carbohydrate,
high-protein, high-fat diets." This strange conclusion indicates the
persistent
difficulty in making progress. Low-Fat diets do worse on most markers
and can't
do better than a draw on anything else but we are expected to be
worried about
the low-carb diet? If the low-fat diet is worse, shouldn't we be
worried about
long term safety and efficacy of
that
diet? In fact, Foster's experiment was consistently described as the
"diets
were the same at one year" and that was supposed to be a draw. There
probably
are sporting events where the champion keeps the title in the case of a
draw
but the idea that the low-fat diet was some kind of champion with a
long term
record of success is absurd. The background assumption that we have
some
"prudent diet," some diet of "moderation," this is what is called in
computers,
vaporware. The "conventional diet" is exactly the one that gave us the
epidemic
of obesity and diabetes.