Dietary Dogma: Tested and Failed

There were two recent studies that looked at diets. One compared the 2010 Dietary Guidelines against the typical American diet. The other compared multiple dietary interventions: Mediterranean diet, low-fat diet, and low-salt diet. This covers the main diets advocated most often by doctors, nutritionists, dieticians, and health officials. Yet neither study found a significant overall benefit to any of the recommended diets. That is shocking, when one considers how official experts and major institutions have pushed these diets for decades. The low-fat diet has been a favorite among dietary technocrats for about a half century (The Creed of Ancel Keys).

What these studies didn’t bother to consider is the benefits of traditional foods diet (Weston A. Price & Sally Fallon Morrell), paleo/hunter-gatherer diet, low-carb high-fat diet, ketogenic diet, carnivore diet, etc. Nor any of the related but less well known diets like ketotarian, pegan, etc. Nor related dietary strategies such as fasting, either intermittent or extended, along with calorie restriction. With a narrow focus, the comparisons were limited. Still, it is a powerful judgment that none of the diets that were tested stood out as being all that impressive. What is being brought under doubt represents the key message of authoritative opinion on diet and nutrition. These diets tested (official Dietary Recommendations, Mediterranean diet, low-fat diet, and low-salt diet) are among the best that the collective wisdom of mainstream thought has to offer.

Here is an intriguing point. The first study looked at the 2010 Dietary Guidelines as separate from weight loss, to determine what were the results of the diet itself (besides, even including weight loss, the low-fat diet is one of the worst, as studies show few people drop body fat when adhering to it — see meta-analysis by UK Public Health Collaboration, Eat Fat, Cut The Carbs and Avoid Snacking To Reverse Obesity and Type 2 Diabetes). This officially trumpeted dietary regime, a fad diet that hasn’t been around long by the way, had no noticeable affect on glucose homeostasis, fasting lipids, or type 2 diabetes. Let’s consider another study, as a comparison and to clarify a point (Parker N. Hyde et al, Dietary carbohydrate restriction improves metabolic syndrome independent of weight loss). As with the above mentioned study, body weight was carefully maintained so as to control for that potentially confounding factor. What were the results?

“Despite maintaining body mass, low-carbohydrate (LC) intake enhanced fat oxidation and was more effective in reversing MetS [metabolic syndrome, including type 2 diabetes], especially high triglycerides, low HDL-C, and the small LDL subclass phenotype. Carbohydrate restriction also improved abnormal fatty acid composition, an emerging MetS feature. Despite containing 2.5 times more saturated fat than the high-carbohydrate diet, an LC diet decreased plasma total saturated fat and palmitoleate and increased arachidonate.”

Interestingly, these particular two studies demonstrate that obesity by itself is not necessarily the problem. Rather, it is a symptom of the problem. Obesity can even be an attempt by the body to compensate in preventing something even worse (Coping Mechanisms of Health). The fundamental problem is the metabolic syndrome itself and the insulin resistance behind it, and any diet that doesn’t directly deal with that will be ineffective. Only some variation of a low-carb diet can accomplish that end.

It’s time to rethink dietary recommendations and guidelines. There are signs this is already happening. The public is already turning toward low-carb diets (Low-Carb Diets On The Rise). And slowly but surely the official position is shifting in this direction (Obese Military?, Weight Watchers’ Paleo Diet, American Diabetes Association Changes Its Tune, Official Guidelines For Low-Carb Diet, & Slow, Quiet, and Reluctant Changes to Official Dietary Guidelines). The evidence keeps accumulating. These recent two studies add to the growing pile. It’s getting harder and harder to ignore the obvious.

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A randomized controlled-feeding trial based on the Dietary Guidelines for Americans on cardiometabolic health indexes
by Sridevi Krishnan et al

To our knowledge, this is the first controlled-feeding trial to test the effect of a food-based dietary pattern following recommendations of the DGA [2010 Dietary Guidelines for Americans]. We measured cardiometabolic disease risk factors in an at-risk female cohort, while maintaining body weight, with the use of foods that are accessible and acceptable to the consumer. The higher quality of the DGA diet relative to the TAD [typical American diet] was confirmed by HEI scores of 98 and 62, respectively. We found that, in the absence of weight loss, consuming a diet based on recommendations of the DGA did not change glucose homeostasis or fasting lipids in our cohort. The 2015 DGA Advisory Committee report concluded that there was moderate evidence for reduction in type 2 diabetes risk associated with nutrient-dense diets (2); however, the results from our short-term intervention trial did not align with this evidence. By design, the intervention did not lead to significant weight loss, and because changes in body weight and body fat can play a role in the pathogenesis of type 2 diabetes (31), this may also explain why improvements in blood sugar control were not observed despite the improvement in diet quality.

Supplements and Diets for Heart Health Show Limited Proof of Benefit
by Anahad O’Connor

When Dr. Khan and his co-authors looked at various diets recommended for cardiovascular prevention, they found a similar lack of solid evidence.

That was certainly the case for low-fat diets, which health authorities have recommended for decades as a way to lower cholesterol and heart disease risk. Dr. Khan and his colleagues found that the most rigorous randomized trials provided no evidence that eating less fat, including saturated fat, had an impact on mortality or cardiovascular outcomes. Low-fat diets have largely fallen out of favor among health authorities in recent years, though the federal government’s dietary guidelines still encourage people to limit their intake of foods rich in saturated fat, such as butter, meat and cheese.

One diet that remains highly touted by health authorities is the Mediterranean diet, with its abundance of whole grains, beans, nuts, fruits and vegetables and olive oil. While clinical trials have found that it reduces cardiovascular risk, some of the major ones have been flawed, and experts who have scrutinized the evidence for the diet have urged caution.

One of the largest and most publicized Mediterranean diet trials, called Predimed and published in 2013, found that it reduced heart attacks and strokes. But last year it was retracted because of methodological problems. The Predimed authors published a new analysis of their data, claiming their conclusions had not changed. But other Mediterranean diet trials have been embroiled in similar controversies. After analyzing data from all the relevant trials, Dr. Khan and his colleagues found that “the totality of evidence did not favor the Mediterranean diet for cardiovascular outcomes.”

“It’s not favorable or harmful,” he added. “It’s just a neutral diet from a cardiovascular perspective.”

The one dietary intervention that seemed to have the most support from randomized trials was lowering salt intake, though the researchers graded the evidence only as having “moderate certainty.” And there was nuance. Low-salt diets reduced mortality from all causes only in people with normal blood pressure. Among people with hypertension, lowering salt intake reduced deaths from heart disease but not from other causes.

Dr. Topol said that in his own clinic he sees a wide range of responses to salt intake. Some people are very sensitive to salt: A small increase in salty foods can have a pronounced effect on their blood pressure. But others can eat salt-laden meals and their blood pressure will hardly budge.

Dr. Topol said he finds diet studies hard to interpret because they rarely take into account the unique way that different people can have markedly different responses to dietary changes, whether it is cutting back on salt or avoiding fat or carbohydrates.

“The problem we have here is that all these studies essentially treat all people as one,” he said. “I think that all these things are going to turn out to be quite heterogeneous. Maybe salt restriction really is beneficial for some, but we haven’t defined the people yet that would drive that.”

Official Guidelines For Low-Carb Diet

A while back, the Swedish government came around to advising a low-carb (and high-fat or at least not low-fat) diet for treating obesity, diabetes, and heart disease. They were the first Western country to do so. The government committee didn’t come to this official position casually, as they first reviewed 16,000 studies (Brian Shilhavy, Sweden Becomes First Western Nation to Reject Low-fat Diet Dogma in Favor of Low-carb High-fat Nutrition). The committee consisted of ten physicians, several of which were skeptics of the low-carb diet — far from being a foregone conclusion (Dr. Andreas Eenfeldt, “Fat Trims Your Waistline”).

The committee’s assessment of the low-carb diet was glowing: “…a greater increase in HDL cholesterol (“the good cholesterol”) without having any adverse affects on LDL cholesterol (“the bad cholesterol”). This applies to both the moderate low-carbohydrate intake of less than 40 percent of the total energy intake, as well as to the stricter low-carbohydrate diet, where carbohydrate intake is less than 20 percent of the total energy intake. In addition, the stricter low-carbohydrate diet will lead to improved glucose levels for individuals with obesity and diabetes, and to marginally decreased levels of triglycerides” (as quoted by Dr. Andreas Eenfeldt in Swedish expert committee: A low-carb diet most effective for weight loss).

As you can see, they went so far as to speak well of a stricter version of the low-carb diet. That is the way mainstream experts refer to what cannot be named. The ketogenic diet retains a stigma that isn’t easily shaken, despite a century of powerful medical research behind it. The ketogenic diet sneaks in, nonetheless — just low-carb with a bit more restriction, which sounds less threatening. But the saturated fat issue is still a sore spot, despite the lack of research ever causally linking it to any disease condition. It’s one step at a time. Openly and loudly declaring low-carb diets as an unequivocal good is a massive step forward. It swings the door wide open for the rest to follow.

The Swedish committee came out with their report in 2017. Now the Australian government has done a scientific review (Inquiry into the role of diet in type 2 diabetes prevention and management) and also taken the official position that low-carb diet should be the default diet for diabetes, although I’m not quite sure when this happened (here is a 2018 Position Statement: Low carbohydrate eating for people with diabetes). “A landmark Australian report has highlighted that remission, not just management, should be the target for type 2 diabetes interventions, and that low carb provides a valuable way to achieve this” (Jack Woodfield, Landmark Australian report promotes low carb approach for treating type 2 diabetes). The committee report even included mention of the benefits from “very low-carbohydrate” dieting, that is to say ketogenic (Ryan Mernin, Australian Lawmakers Propose Low-Carb as Official Diabetes Treatment). The Australian government has gone so far as recommending a campaign to promote diet as a primary approach, as opposed to mere treatment with drugs.

This is an amazing about-face from the position taken only a few years ago. “Fettke, an orthopedic surgeon,” Jennifer Calihan wrote, “was sanctioned in 2016 by regulators (the Australian Health Practitioners Regulation Agency or AHPRA) for recommending a low-carb lifestyle to patients he felt could improve their health by changing their diets. As we wrote in November 2016, Dr. Fettke was officially ‘silenced’ by the AHPRA; this means he was forbidden to give diet-related advice to his patients” (Dr. Gary Fettke exonerated! Receives apology from regulators).

How did that end? Two years later, those attacking him were forced to admit that they had wronged Dr. Fettke. “We are pleased to report that after careful review, the AHPRA has repealed its decision in its entirety, and cleared Dr. Fettke of all charges. He also received a written apology…” As when Tim Noakes won his case in South Africa, this was one more victory for the validity of low-carb diets. Other incidents where doctors have been attacked for advocating for their patients’ health have ended similarly. The tide has turned. It didn’t come out of nowhere, though. In 2017, an Australian government research agency put out a low-carb diet book (Dr. Andreas Eenfeldt, Australian Government Research Agency Releases Low-Carb Diet Book). It’s sad that they were doing this at the same time that regulators were attacking Dr. Fettke.

Some signs of change are seen in the UK as well. The UK National Health Service has officially stated that, “The Low Carb Program can help anyone with type 2 diabetes or pre-diabetes take better control of their condition” (Low Carb Program). That is a good start and might begin to catch the attention of policymakers in the US. The fact that the Pentagon and US military have been researching the ketogenic diet is a massive step forward (Obese Military?), but there seems to be resistance in implementing it, maybe because that would put the Pentagon in opposition to official USDA policy and there might be pressure in the government to not allow internal conflict.

Such shifts don’t happen easily or evenly. Governments lurch back and forth before finally taking a new direction. It’s been building up for a while. This has been true for many governments and health institutions, as they slowly and quietly shift away from the old high-carb dogma without ever admitting they were wrong, instead often hiding the changes of position on a back page of their official website without any public announcement reported by every major news outlet. This is how, without most people realizing it, new viewpoints take hold. Only future historians will look back and realize the dramatic paradigm shift that occurred.

Yet sometimes the shift is quite dramatic. Belgium’s Royal Academy of Medicine recently stated in no uncertain terms that children, teens, pregnant women, and nursing mothers should not follow a vegan diet. A precedent was set with a 2017 case of a child’s death from a vegan diet where the parents were given suspended jail time (Mitchell Sunderland, Judge Convicts Parents After Baby Dies from Vegan Diet). The Belgian government has decided that from now on they will legally prosecute other parents in cases such as these (Susan Scutti, Is vegan diet healthy for kids? Belgian doctors say no). In other countries, there have been similar prosecutions against vegan parents when children have died. And before this decision in Belgium, there was a 2016 proposal for prosecution in Italy (BBC, Italy proposal to jail vegans who impose diet on children).

This fits into the larger shift I’m talking about. Veganism is typically high-carb and low-fat, not to mention low-protein (e.g., fruit smoothies loaded with sugar) — the complete opposite of the typical LCHF diet that emphasizes moderate-to-high protein intake, such as fatty animal foods. It’s true a vegan could go on a LCHF diet and some do and yet few choose to do so since, without animal fat, it seems glucose becomes the preferred fuel for the body.

The prosecution of vegan-related childhood death is a real shocker, considering veganism has been held up as the ultimately healthy plant-based diet for decades. Veganism had become quite trendy among celebrities, but that is likely reversing as well. This past year or so, a large number of well known vegans, many of them vegan advocates with sizable followings, have given up the vegan diet and gone back to eating animal foods. Other than some Hollywood stars, the most famous example is that of Tim Shieff, a professional athlete who had become a leader in the vegan movement but began eating meat again because of serious health concerns. So, along with an emerging shift in public policy, there has also been a shift in public perception about diets.

This new dietary attitude is not limited to more progressive countries elsewhere. We are seeing these same trends even in the corporatist United States, the epicenter of high-carb advocacy by government authorities and institutional experts and big food lobbyists. There has been a slow revolution. Some years back, the American Heart Association snuck in some changes to sugar intake and it barely received any media attention — no public announcement, no apologies, as if that was always their position. That was amazing. All the way back to the 1950s, the AHA had led the charge in blaming fats and exonerating sugar. Almost three quarters of a century of being wrong and now they’re backtracking. The U.S. government followed suit in 2015 (Jen Christensen, 2015 Dietary Guidelines). Neither of these was a defense of low-carb diets, but it was a reversal of course without explanation. Even Walter Willett who followed in Ancel Keys footsteps admitted that they had been wrong in having put all blame on saturated fat and that was a mind-blowing admission, considering how hard those like him had defended the status quo and attacked all alternative views with many careers destroyed in the process.

Just this year, the American Diabetes Association also changed its tune. Once again, there was little fanfare. It’s as if a volcano erupted in the middle of New York City and no media outlet thought to send a reporter to the scene to see what happened. Suddenly, a volcano in New York City is the new norm. The ADA went even further than did the AHA, in that they specifically and clearly declared that LCHF diets are not a fad and are not dangerous. This thawing of dietary ideology has been slowly cracking the edifice of the glacier that had enclosed public debate since the mid-20th century. The growing evidence simply can’t be denied, as the research on low-carb including keto has shown positive results, the shift having taken hold in the 1990s with the Charlie Foundation. The new direction was initially imperceptible to anyone not paying attention. I barely noticed this myself until quite recently, even though I’ve long thought of sugar as an addictive drug and even though I did experiment with the low-carb diet earlier last decade, but I didn’t realize how much the science itself was going down a different path.

Dr. Robert Lustig points out how he was taught this information in his nutritionist education, but then had it drilled out of him in medical school. He forgot about what he had learned and followed establishment thought for the next twenty years. It’s maybe not surprising that he re-awoke to his horrible mistake around the time the Charlie Foundation was established. He was angry, presumably for having failed his patients in providing them the best care but no doubt also for allowing himself to be duped. Many other doctors and other health experts have grown angry as well and that anger has driven a sense of passionate advocacy and moral responsibility. It wasn’t merely a personal failure but that of an entire field and public health was the victim, that is to say hundreds of millions of Americans suffered the consequences.

It’s been building up for a while. And the public hasn’t been entirely kept in the dark. The internet opened up public debate like never before. At the same time research was proving that low-carb works, people were experimenting on themselves and discovering the truth of this. This initially led to a backlash by the powers that be, but the public awareness keeps gaining momentum. The ketogenic diet has become the most Googled diet. One hears about low-carb diets all the time thee days, even when it is simply another denial of the facts. Suppression of truth through silence is no longer an option. Authorities are forced to respond one way or another, and increasingly that has meant a gradual movement toward low-carb. Maybe unsurprisingly, as more Americans embrace low-carb diets following the peak of sugar intake in 1999, for the first time in decades the diabetes epidemic seems to be subsiding.

There have been widely read journalistic accounts of what has gone so wrong in the field of diet and nutrition, specifically the work of Gary Taubes and Nina Teicholz. Several popular documentaries have also had quite an impact, from Pete Evans’ The Magic Pill to Tom Naughton’s Fat Head. On social media, there has been growing influence of low-carb advocates, including many doctors and scientists. Some low-carb Facebook groups have millions of members. And a video of a biochemistry talk criticizing sugar by Dr. Robert Lustig has received millions of views.

I’ve argued that changes will come from below before we see changes in public policy, but in some countries the government is taking the lead. In the United States, it’s going to take a while for low-carb diets to make their way into the official dietary recommendations. The main problem is the U.S. was the original force behind the high-carb, low-fat fad diet and the reason other governments adopted it. There are too many American experts who built their careers on it and several highly respected institutions that fully embraced it. They can never admit they were wrong. I’m sure many of the people involved see the writing on the wall, but they are trying to figure out how to switch their position while saving face and without too many people noticing. Only after many other Western governments take up the low-carb approach will the U.S. government follow their example. Then and only then, if we are lucky, the entire food system of transnational corporations might begin to fall in line.

Consensus will eventually shift. Most of the experts that once were against low-carb will suddenly be for it or else they’ll simply become irrelevant and forgotten. A generation will grow up not knowing anything else and the former dietary ideology will quickly fade from public memory, but the consequences on public health will epigenetically linger for many generations more. Fortunately, individuals don’t have to wait for the rest of society to catch up. What you do as an individual can improve your health, along with the health of your children and grandchildren. One thing that is guaranteed is that low-carb is a vast improvement over what most Americans are eating and what the United States government is recommending. That much is clear from the science.

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For more info, see:

Slow, Quiet, and Reluctant Changes to Official Dietary Guidelines

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5/14/20 – The official changes in support of low-carb diets continues to spread among major health institutions around the world. A new consensus is slowly being established about the health benefits of varying degrees of carbohydrate restriction. Canada is the most recent country following this trend. Below is a recent article describing this shift in mainstream opinion among experts and officials, specifically about our northern neighbor:

Diabetes Canada Deems Low Carb and Very Low Carb Diet Safe and Effective
by Joy Kiddie

Diabetes Canada has just released a new Position Statement acknowledging that a low carb and very low carb (keto) diet is both safe and effective for adults with diabetes.

Reflecting back on their 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada release in April 2018 and covered in this article,  Diabetes Canada clarified in today’s  Position Statement that it was not their intention to restrict the choice of individuals with diabetes to follow dietary patterns with carbohydrate intake that were below the consensus recommendation of 45-60% energy as carbohydrate, nor to discourage health-care practitioners from providing low-carb dietary support to individuals who wanted to follow a low-carb meal pattern.

In the new Position Statement, Diabetes Canada acknowledged what I’ve written about previously, that Diabetes Australia, Diabetes UK, and the American Diabetes Association (ADA) in conjunction with the European Association for the Study of Diabetes (EASD) have developed position statements and recommendations regarding the use of low carbohydrate and very low carbohydrate (ketogenic) diets for people with diabetes. They state that from these previous international position statements and recommendations, several consistent themes have emerged — specifically that low carbohydrate diets (defined as less than <130 g of carbohydrate per day or <45% energy as carbohydrate) and very low carbohydrate diets (defined as <50 g of carbohydrate per day) can be safe and effective both in managing weight, as well as lowering glycated hemoglobin (HbA1C) in people with type 2 diabetes over the short term (<3 months).