Presentation at the Ancestral Health Symposium. Government can provide education and oversight of scientific publications and the press which accounts for the current nutrition mess.
1. Ancestral Health Symposium
The nutrition mess.
Can we fix it?
Richard David Feinman
Department of Cell Biology
SUNY Downstate Medical Center
Brooklyn, New York
feinman@mac.com
Monday, August 29, 2011
2. The first question we ask medical students:
“Do you think there has ever been a moment in the history of
medicine, when a majority of physicians and scientists held to
a theory that was wrong and dangerous and resisted change
despite contradictory evidence? Do you think that there has ever
been such a period?”
If you think it has happened before, you at least have to
consider the possibility that this is another such period.
My answer will be that current nutrition is a mess with
scandals equal to any in the history of medicine. I will
suggest a government solution.
Monday, August 29, 2011
3. The nutrition mess:
Mixed messages and ambiguous writing from health
organizations and their media.
...and the news services play along.
Sins of omission in the scientific literature: Failure to cite relevant
literature. Experiments with no null hypothesis.
Two worlds. Establishment nutrition does not cite or even
recognize carbohydrate restriction. Peer review is so biased as to
be meaningless.
Progression of scapegoats: cholesterol, saturated fat, trans-fat,
fructose.
Monday, August 29, 2011
5. Wait a minute...
Robert Lustig’s lecture on YouTube, with 1.5 million hits, asked,
as Gary Taubes put it: “Is fructose a toxin?.”
Case against fructose not established but, more important...
...suggestion for government intervention in terms of taxes on
sugar and pressure on private industry.
Government intervention has other mechanisms than punitive
measures. Government can evaluate the science -- even the science
of government agencies.
Beyond private industry, how about private health agencies? ADA,
AHA: are they accountable?.
Look at a couple of examples. But first, whaddaya’ know?
Monday, August 29, 2011
6. We ask incoming medical students...
1. The most energy-dense nutrient (most calories/gram) is
A. carbohydrate
B. fat
C. protein
D. ethanol
-
Monday, August 29, 2011
7. This is actually not good for such an educated group. But
they’re young, healthy and generally thin.
1. The most energy-dense nutrient (most calories/gram) is
A. carbohydrate
B. fat
C. protein
D. ethanol
carbohydrate = 4 kcal/g
fat = 9 kcal/g
protein= 4 kcal/g
ethanol= 7 kcal/g
• Everybody, including the National Boards, expects you to know
these numbers.
Monday, August 29, 2011
8. 2. For a slice of buttered bread,
which is more fattening?
A. the bread
B. the butter
C. both are equally fattening
D. cannot tell from information given
-
Monday, August 29, 2011
9. 2. For a slice of buttered bread,
which is more fattening?
A. the bread
B. the butter
C. both are equally fattening
D. cannot tell from information given
You cannot tell without knowing how much butter and how much bread.
• Energy-density, like any density, is an intensive property: two pieces of
bread have the same energy-density as one.
• Total calories is an extensive property = energy-density x grams.
Monday, August 29, 2011
10. 3. During the epidemic of obesity and diabetes, the macronutrient that
increased most was:
A. carbohydrate
B. fat
C. protein
D. all about the same, calories increased across the board.
Monday, August 29, 2011
11. 3. During the epidemic of obesity and diabetes, the macronutrient that
increased most was:
A. carbohydrate
B. fat
C. protein
D. all about the same, calories increased across the board.
Monday, August 29, 2011
12. The increase in calories during the obesity and diabetes epidemic was due largely
to carbohydrate intake. For men, the absolute amount of total fat and saturated
fat went down.
Monday, August 29, 2011
13. The problem:
“You are what you eat.”
Bad idea.
Dietary fat does not
necessarily turn to body fat.
Better: “You are what your
body does with what you eat.”
Metabolism describes how foods are
processed.
Hormones affect rates of metabolic
processes.
Did we get the message?
Monday, August 29, 2011
14. March. 1984 February. 2011
Cholesterol is proved deadly, and our diet may never be the same Other doctors are not so sure, and urge a stricter
This year began with the announcement by the Federal Government interpretation of the study. Says Dr. Edward Ahrens, a
of the results of the broadest and most expensive research project in veteran cholesterol researcher at Rockefeller University:
medical history. Its subject was cholesterol... Among the "Since this was basically a drug study, we can conclude
conclusions: nothing about diet; such extrapolation is unwarranted,
• Heart disease is directly linked to the level of cholesterol in the unscientific and wishful thinking."
blood.
• Lowering cholesterol levels markedly reduces the incidence of
fatal heart attacks.
Monday, August 29, 2011
15. The nutrition mess.
A basic premise of the Dietary Guidelines is
that nutrient needs should be met primarily
through consuming foods. Foods provide an
array of nutrients and other components that
are thought to have beneficial effects on
health.
Nutrient-dense foods and beverages are lean or
low in solid fats
low in solid fats, and minimize or exclude added
solid fats, sugars, starches, and sodium. Ideally,
they also are in forms that retain naturally fats
exclude added solid
occurring components, such as dietary fiber. All
vegetables, fruits, whole grains, seafood, eggs,
fat-free unsalted nuts and seeds,milk
beans and peas,
fat-free
fat-
free and fat-free milk and milk products, and lean
lean meats
meats and poultry—when prepared without
adding solid fats or sugars—are nutrient-dense
without adding solid fats
foods.
Monday, August 29, 2011
16. PUFA for SFA PUFA:
reduces risk risk ↑
CHO for SFA CHO:
reduces risk risk ↑
NO EFFECT
Jakobsen MU, et al: Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies. Am
J Clin Nutr 2009, 89(5):1425-1432.
Statistical rule: If 95% CI crosses 1.0, no difference.
Almost none of the individual studies show an effect of saturated fat. And....
Monday, August 29, 2011
17. A basic premise of the Dietary Guidelines is
that nutrient needs should be met primarily
through consuming foods. Foods provide an
array of nutrients and other components that
are thought to have beneficial effects on
health.
Nutrient-dense foods and beverages are lean
or low in solid fats, and minimize or exclude
added solid fats, sugars, starches, and
sodium. Ideally, they also are in forms that
retain naturally occurring components, such
as dietary fiber. All vegetables, fruits, whole
grains, seafood, eggs, beans and peas,
unsalted nuts and seeds, fat-free and low-fat
milk and milk products, and lean meats and
poultry—when prepared without adding solid
fats or sugars—are nutrient-dense foods.
A deceptive message and
criticism ignored.
Monday, August 29, 2011
18. A basic premise of the Dietary Guidelines is
that nutrient needs should be met primarily
through consuming foods. Foods provide an
array of nutrients and other components that
are thought to have beneficial effects on
health.
Nutrient-dense foods and beverages are lean
or low in solid fats, and minimize or exclude
added solid fats, sugars, starches, and
sodium. Ideally, they also are in forms that
retain naturally occurring components, such
as dietary fiber. All vegetables, fruits, whole
grains, seafood, eggs, beans and peas,
unsalted nuts and seeds, fat-free and low-fat
milk and milk products, and lean meats and
poultry—when prepared without adding solid
fats or sugars—are nutrient-dense foods.
Monday, August 29, 2011
19. A basic premise of the Dietary Guidelines is
that nutrient needs should be met primarily
through consuming fog Foods provide an
Feds' food foods.
array of nutrients and wrong
Guidelines get it other components that
are thought to have August 5, 2010effects on
Last Updated: 3:26 AM, beneficial
Posted: 12:39 AM, August 5, 2010
health. 8
Comments:
Nutrient-dense foods and beverages are lean
orSteven Malanga minimize or exclude
low in solid fats, and
As government agencies in places like New York seek a
added solidin shaping diets, the next set of federal
greater hand fats, sugars, starches, and
sodium. guidelines, theypublished this year, could
nutrition Ideally, to be also are in forms that
retain controversialoccurring components, such
prove
naturally -- for growing scientific evidence
suggests that some federal recommendations have
as dietary fiber. All vegetables, fruits, whole
simply been wrong.
grains, seafood, eggs,isbeansitand peas,
The crux of the controversy the quantity of fat and
carbohydrates we consume and how influences
unsalted nuts and seeds, fat-free and low-fat
cardiac health. As Scientific American recentlypointed
milk and since the first set of guidelines in 1980, and
out, ever milk products, and lean meats
Americans heard that they had to reduce their intake of
poultry—when prepared without dairy products
saturated fat by cutting back on meat and adding solid
fats or sugars—are carbohydrates. They foods.
and replacing them with nutrient-dense dutifully
complied. Since then, obesity has increased sharply, and
the progress that the country has made against heart
disease has largely come from statin drugs.
Read more: http://www.nypost.com/p/news/opinion/
opedcolumnists/
feds_food_fog_1Sn8sLmkw7dv8wl47bqQKL#ixzz1GcdE
Monday, August 29, 2011
20. The nutrition mess.
Mixed message and ambiguous writing from health
organizations and their media.
Monday, August 29, 2011
21. The nutrition mess.
The news services play
along.
dumb, but...
Monday, August 29, 2011
23. CHAPEL HILL, N.C. – A diet high in saturated fat is a key
contributor to type 2 diabetes, a major health threat
worldwide. Several decades ago scientists noticed that
people with type 2 diabetes have overly active immune
responses, leaving their bodies rife with inflammatory
chemicals.
In addition, people who acquire the disease are typically
obese and are resistant to insulin, the hormone that
removes sugar from the blood and stores it as energy.
Monday, August 29, 2011
26. In fact...
Figure 1 Palmitate activates NLRP3-ASC inflammasome.
(a–d) ELISA for IL-1β (a–c), IL-18 (d) and IL-6 (e) in
supernatants of resting or LPS-primed bone marrow-
derived macrophages (BMMs) stimulated with palmitate
conjugated to BSA (PA-BSA) or BSA control.
cell study...no mice. CHAPEL HILL, N.C. – A diet high in saturated fat is a key
contributor to type 2 diabetes, a major health threat
worldwide. Several decades ago scientists noticed that
people with type 2 diabetes have overly active immune
Monday, August 29, 2011
27. The nutrition mess and the health agencies. First...
5. The dietary requirement for carbohydrate is:
A. approximately 130 g/day
B. approximately 50 % of calories
C. as much as possible
D. there is no dietary requirement for carbohydrate
6. The carbohydrate intake recommended by the USDA, the American Diabetes
Association and other agencies is:
A. approximately 130 g/day
B. approximately 50 % of calories
C. as much as possible
D. as little as possible
Monday, August 29, 2011
28. The nutrition mess and the health agencies. First...
5. The dietary requirement for carbohydrate is:
A. approximately 130 g/day
B. approximately 50 % of calories
C. as much as possible
D. there is no dietary requirement for carbohydrate
6. The carbohydrate intake recommended by the USDA, the American Diabetes
Association and other agencies is:
A. approximately 130 g/day
B. approximately 50 % of calories
C. as much as possible
D. as little as possible
Monday, August 29, 2011
29. could this be a place for government intervention?
● 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.
Monday, August 29, 2011
30. Goals of MNT that apply to individuals with diabetes
4) To maintain the pleasure of eating by only limiting food choices when indicated by scientific
evidence from the hedonists at ADA
Recommendations
● Nutrition counseling should be sensitive to the personal needs, willingness to change,
and ability to make changes of the individual with pre-diabetes or diabetes.
● For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be
effective in the short term (up to 1 year).
● For patients on low-carbohydrate diets, monitor lipid profiles, renal function, and
protein intake (in those with nephropathy), and adjust hypoglycemic therapy as needed.
sure, we don’t have a problem with low-carb
diets, if you don’t mind CVD
... dietary carbohydrate is the major determinant of postprandial glucose levels.
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.
I thought we wanted to reduce energy.
is there room for an alternative opinion?
Monday, August 29, 2011
32. “For weight loss, either low-carbohydrate or low-fat calorie-
restricted diets may be effective in the short term (up to 1 year).”
fat in the
“good
blood
the same ? cholesterol”
data from Foster GD, et al.: A randomized trial of a low-carbohydrate diet for obesity.
N Engl J Med 2003, 348(21):2082-2090.
Monday, August 29, 2011
34. Statistical Analysis
We used The previously mentioned longitudinal models preclude
a random-effects linear model that was fitted
to all observed data for each variable such as fixed imputation
the use of fixed imputation on each of the 307
...such as less robust approaches,methods (for example, last
participants (forthe primary analysis. Each carried
methods for example, last observationthe analysis of
random-effects
observation carried forward or slope to adjust
model consisted of a random participants with complete data
forward or the analysis of intercept and
for [that is, complete case variability due to [that is, complete case
participants with complete data within participant
individual participant analyses]). These alternative approaches
correlations among the observedunrelatedmodels implemented for
analyses]).... The data are longitudinalpreviously
assume that missing longitudinal to
data. These models also contained covariates, including
observed outcomes or baseline the following fixed effects:
this study relax follow-up visit, group assignment,
this missing-completely-at-random
main effects for each missing completely at random). The
treatment (that is,
interactions between each follow-up visitthis study relax this to
assumptionmodels implemented for and group related
longitudinal in different ways.... can be
indicator variables,because it valuecovariate inWe ways.
the treatment and baseline is a as a covariate. the model.
missing-completely-at-random assumption in different
estimated with maximum likelihood by using the PROC
The generalized estimating equation– based longitudinal
MIXED procedureassume that missing dataInstitute, Cary,
logistic models in SAS, version 9 (SAS are unrelated
Northpreviously observed outcomes but model structure
to Carolina). A parallel longitudinal can be related to
based on main effects forit is a covariate in the model. (that
the treatment because visit, treatment group, and baseline
value covariate-dependent missing completely at random)
is, and visit-treatment interactions was implemented
with logistic likelihood-based mixed-effects models further relax
(18). The regression for binary outcomes. We
didthe covariate-dependent missing-completely-at-random
estimates by using generalized estimating equations under
theassumption by allowing missing data to be dependent on
logistic regression model for correlated longitudinal
binary outcomes implemented in the GENMOD (that is, missing
previously observed outcomes and treatment procedure
in SAS, version 9.assess departures for each treatment
at random). To Predicted values from the missing-atrandom
and visit combinationinformative withdrawal—that
assumption under at the mean level of the baseline
outcome, missing weights are lower and upperwhich patients
is, the with corresponding informative for confidence
bounds, were produced under each model for the fi
chose to withdraw or continue to participate in the .
Oh, hell...intention to treat
study—we present sensitivity analyses. As such, we assume
that all participants who withdraw would follow first the
maximum and then minimum patient trajectory of weight
under the random intercept model.
Monday, August 29, 2011
35. Suppose we plot drop-outs vs.
difference between groups.
Monday, August 29, 2011
36. Samuel Klein, MD
DISCUSSION
Our study has 2 main findings. First, neither dietary fat nor carbohydrate intake influenced
weight loss when combined with a comprehensive lifestyle intervention.
The data? No dietary records were reported.
Klein S, Wolfe RR: Carbohydrate restriction regulates the adaptive response to fasting.
Am J Physiol 1992, 262:E631-636. “carbohydrate restriction, not the presence of a
negative energy balance, is responsible for initiating the metabolic response to fasting.”
Monday, August 29, 2011
39. 8. Several large clinical or population studies have been carried out to
determine if there is an association between dietary saturated fat (SF) and
cardiovascular disease (CVD). The trial(s) that have successful shown such
an association:
A. The Framingham Study.
B. The Multiple Risk Factor Investigation Trial (MR FIT).
C. The Women’s Health Initiative.
D. All have demonstrated a relation between SF and CVD
E. A and B
F. Only A
G. None have demonstrated a relation.
Monday, August 29, 2011
40. 8. Several large clinical or population studies have been carried out to
determine if there is an association between dietary saturated fat (SF) and
cardiovascular disease (CVD). The trial(s) that have successful shown such
an association:
A. The Framingham Study.
B. The Multiple Risk Factor Investigation Trial (MR FIT).
C. The Women’s Health Initiative.
D. All have demonstrated a relation between SF and CVD
E. A and B
F. Only A
G. None have demonstrated a relation.
Monday, August 29, 2011
41. At the end of our clinic day, we go home thinking, "The clinical improvements are so large
and obvious, why don't other doctors understand?" Carbohydrate-restriction is easily
grasped by patients: because carbohydrates in the diet raise the blood glucose, and as diabetes
is defined by high blood glucose, it makes sense to lower the carbohydrate in the diet.
Monday, August 29, 2011
42. Returning to the first question a moment in the history of
medicine. Ignaz Semmelweis was a physician in Vienna in
early nineteenth century. One ward in the General
Hospital had much greater incidence of puerperal
fever (infection following childbirth) than the
other. In the latter, babies were delivered by
midwives; in the first, by doctors, some of who had
just performed autopsies. Semmelweis suggested
that physicians should wash their hands between
procedures but many refused, some because it was
in conflict with established medical practice. Some,
because it was too much trouble.
In my opinion much harm is being done because physicians
refuse to wash their hands of low-fat and other bad ideas.
Monday, August 29, 2011