Just Read: EASL–EASD–EASO Clinical Practice Guidelines (and the health threat and confusion around) the management of non-alcoholic fatty liver disease

Association for the Study of the Liver E, Association for the Study of Diabetes E, Association for the Study of Obesity E. EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. 2016; http://linkinghub.elsevier.com/retrieve/pii/S0168827815007345

I know these are from 2016 which is a century ago in this field, I wanted to start somewhere.

A Growing Epidemic

I was introduced to the threat of Non-Alcoholic Fatty Liver Disease (NAFLD) not too long ago (at Low Carb San Diego actually), and the medical profession, not too long before that. As Nicolai Worm related, there were just 6 (six) pubmed references to NAFLD in the year 2000.

NAFLD is the most common liver disorder in Western countries, affecting 17–46% of adults, with differences according to the diagnostic method, age, sex and ethnicity [4]. NAFLD is also present in 7% of normal-weight (lean) persons [5], more frequently in females, at a younger age and with normal liver enzymes.

It travels with diabetes/insulin resistance

NAFLD is tightly associated with IR not only in the liver, but also in muscle and adipose tissues [44], and also with the MetS, defined as the cluster of any three of the following five features associated with IR: impaired fasting glucose (IFG) or T2DM, hypertriglyceridaemia, low high-density lipoprotein (HDL)- cholesterol (gender-adjusted), increased waist circumference (ethnicity adjusted) and high blood pressure [45].

There’s no identified drug treatment, only lifestyle changes have been shown to be effective

No drug has currently been tested in phaseI II trials and is approved for NASH by regulatory agencies. Therefore, no specific therapy can be firmly recommended and any drug treatment would be off-label.

Concerns

Confusion about what lifestyle/diet changes work best

Both of these approaches are included:

  • Low-to-moderate fat and moderate-to-high carbohydrate intake
  • Low-carbohydrate ketogenic diets or high-protein

I’m aware there are newer studies that try to tease this apart, I will post on those next.

Confusion around the importance

My (family medicine) specialty journal recently covered the topic of elevated liver tests, and in my opinion gave a confusing look at the importance of NAFLD

Nonalcoholic fatty liver is generally benign and treated successfully with lifestyle modificationOh RC, Hustead TR, Memorial Health H, Syed Ali KM, Pantsari MW. Mildly Elevated Liver Transaminase Levels: Causes and Evaluation. 2017 [cited 2018 Feb 19];96(11). Available from: www.aafp.org/afp

Later on in the article the association with diabetes is discussed.

Connection to the just published DIETFITS study, is the low fat diet a precursor to NAFLD?

In reviewing the well done DIETFITS study (see my post: Just Read: DIETFITS and Effect of Low-Fat vs Low-Carbohydrate Diet, real food is better, is the low fat diet worse for metabolic health? ), I found from doing calculations of lipid levels that the TG/HDL ratios improved in the low carbohydrate group, got worse in the low fat group. This is not discussed in the paper, just the fact that the lipid changes are significant. If this is the case and happens after just one year in a relatively healthy co-hort (about 1/3 with metabolic syndrome), does the low-fat diet then become diabetogenic?

I ended up going to the supplemental data to review lipid and metabolic health changes. I plotted those in the attached images, click on any to see full size.

I’m putting this here to note what a new phenomenon this is and the challenge of understanding how to manage it that exists. A few more posts coming before #LCB18.

1. Association for the Study of the Liver E, Association for the Study of Diabetes E, Association for the Study of Obesity E. EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. 2016; http://linkinghub.elsevier.com/retrieve/pii/S0168827815007345
2. Oh RC, Hustead TR, Memorial Health H, Syed Ali KM, Pantsari MW. Mildly Elevated Liver Transaminase Levels: Causes and Evaluation. 2017 [cited 2018 Feb 19];96(11). Available from: www.aafp.org/afp
3. Gardner CD, Trepanowski JF, Del Gobbo LC, Hauser ME, Rigdon J, Ioannidis JPA, et al. Effect of Low-Fat vs Low-Carbohydrate Diet on 12-Month Weight Loss in Overweight Adults and the Association With Genotype Pattern or Insulin Secretion. JAMA [Internet]. 2018 Feb 20;319(7):667. Available from: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2018.0245

Thanks for publishing my photos, in How to build bus lanes and bike lanes—faster – D.C. Policy Center

2016.10.16 DC People and Places 08314
2016.10.16 DC People and Places 08314 (View on Flickr.com)

Thanks again, @DCPolicyCenter, for using my photos to illustrate this excellent piece on accommodating active transportation in our nation’s capital.

The piece mentions some of my favorite initiatives, including Vision Zero, and Complete Streets. These have made visible impacts on our lives here.

DC People and Places 18829
DC People and Places 18829 (View on Flickr.com)

The first photo, by the way, was taken at the intersection of U Street, NW and 16th Street, NW, described by many (some?) as one of the most agonizing intersections to plan around, because of it’s unique structure. It’s also historic in that it housed a young Marion Barry’s Pride, Inc., in the 1960’s.

The second photograph was taken the evening before President Barack Obama’s inauguration in 2013. The third photo is a general, “watching the future being born” in Washington, DC. People sometimes forget that the future doesn’t happen by accident.

New bike path on L Street - Washington DC 17772
New bike path on L Street – Washington DC 17772 (View on Flickr.com)

Enjoy.

How to build bus lanes and bike lanes—faster – D.C. Policy Center

Source: How to build bus lanes and bike lanes—faster – D.C. Policy Center

February 2018, What Am I Doing Now?

This is my February Now Update based on a movement created by Derek Sivers

(previous updates are here)

Greetings from Washington, DC (of course) and welcome to my ninth now update.

My Now (@NowNowNow) Profile is visible at Link: Ted Eytan, MD Profile on NowNowNow.com

2018.02.06 DC People and Places, PaintTheSky, Washington, DC USA 09835
2018.02.06 DC People and Places, PaintTheSky, Washington, DC USA 09835 (View on Flickr.com)

This update is nice and brief.

Just Read: DIETFITS and Effect of Low-Fat vs Low-Carbohydrate Diet, Real Food Wins; A Closer Look at the Lipids

And this tweet, from the future:

Until next month.

Just Read: DIETFITS and Effect of Low-Fat vs Low-Carbohydrate Diet, real food is better, is the low fat diet worse for metabolic health?

Gardner CD, Trepanowski JF, Del Gobbo LC, Hauser ME, Rigdon J, Ioannidis JPA, et al. Effect of Low-Fat vs Low-Carbohydrate Diet on 12-Month Weight Loss in Overweight Adults and the Association With Genotype Pattern or Insulin Secretion. JAMA [Internet]. 2018 Feb 20;319(7):667. Available from: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2018.0245

I updated the post with TG/HDL calculations and their significance, interested in others’ comments

Long anticipated study findings, previously reported in conference proceedings. I posted on the methods previously (see link below).

lipid changes, there are significant ones:

The 12-month changes in low-density lipoprotein cholesterol concentrations significantly favored a healthy low-fat diet. High-density lipoprotein cholesterol concentrations increased significantly more and concentrations of triglycerides decreased significantly more for the healthy low-carbohydrate diet group than for the healthy low-fat diet group.

Unfortunately, I couldn’t make sense of the values in Table 3 of the paper, so I ended up going to the supplemental data to review lipid and metabolic health changes. I plotted those in the attached images, click on any to see full size.

Study subjects show evidence of insulin resistance, is the low-fat diet diabetogenic?

As several recent studies have shown (including this one using Kaiser Permanente data), triglycerides and HDL may be more impactful to health in the long run than LDL-C changes.

From the paper referenced below:

The hazard ratio for having an insulin-resistant triglyceride/HDL-c ratio was 1.68 (95% CI, 1.57-1.80), compared with an insulin-sensitive ratioBertsch RA, Merchant MA. Study of the Use of Lipid Panels as a Marker of Insulin Resistance to Determine Cardiovascular Risk. Perm J [Internet]. 2015 Nov 2 [cited 2017 Oct 24];19(4):4–10. Available from: http://www.thepermanentejournal.org/issues/2015/fall/5945-insulin-resistance.html

Looking at the data, by this definition, the average TG/HDL ratio for all subjects is in the insulin resistance range, and only in the low-carbohydrate diet group does the average drop into the insulin sensitivity range.

Just Read: Challenging the role of LDL vs Insulin Resistance in predicting heart disease, via Kaiser Permanente data

This is especially interesting because

  • This is not a study of diabetes or lipid treatment
  • the study subjects are healthy, mostly white, and
  • specifically not on diabetes or lipid-lowering medications
  • Measures of liver dysfunction are not included (and they are not one of the outcomes)

Therefore, the concern is that the low-fat diet may be more diabetogenic than the low-carb one

Real Food wins, Industrialization & Genetic Testing doesn’t

This is great news. Preventing the further medicalization/industrialization of obesity, and potentially diabetes (although as stated above, this is not a study of diabetes)

We consider the differences betweenthe current findings an dthe studies cited to potentially involve diet quality beyond simply differentiating fat and carbohydrate intake. In this regard, refined grains are low in fat but considered of poor nutritional quality due to low-nutrient density relative to energy content. In contrast, vegetables are high in nutrient density,and relatively high in proportional carbohydrate content,but low in calories. Both diet groups in the current study were instructed to minimize or eliminate refined grains and added sugars and maximize intake of vegetables.

People can quibble about the definition of “low carbohydrate”

In the healthy low-fat diet vs the healthy low-carbohydrate diet, respectively, the mean 12-month macronutrient distributions were 48% vs 30% for carbohydrates, 29% vs 45% for fat, and 21% vs 23% for protein

Those proportions are not really a diabetes-remission diet

I’m cancelling my trip to Low Carb Breckenridge #LCB18. Just kidding 🙂 .

As I mentioned in this post yesterday, weight loss is one dimension of diet, metabolic health is a bigger universe than that. It is good to see that there’s a place for real food in everyone’s eating trajectory. This seems to be a common theme regardless of eating preference. Remember, this is how we got here:

More from my trip to the Library of Congress and incredible US News and World Report photo collection: 1968’s Harried Housewife Preparing Convenience Foods (and how her diet was re-engineered to be carbohydrate-rich)

Citation: Gardner CD, Trepanowski JF, Del Gobbo LC, Hauser ME, Rigdon J, Ioannidis JPA, et al. on 12-Month Weight Loss in Overweight Adults and the Association With Genotype Pattern or Insulin Secretion. JAMA [Internet]. 2018 Feb 20;319(7):667. Available from: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2018.0245

Post on the study design: Just Read: DIETFITS study design – Healthy Low Carbohydrate and Healthy Low Fat Diet Comparison for Weight Loss in non-diabetic humans

Thanks for publishing my photo, in Have you adopted your tag yet? – Greater Greater Washington

2018.02.06 DC People and Places, PaintTheSky, Washington, DC USA 09891
2018.02.06 DC People and Places, PaintTheSky, Washington, DC USA 09891 (View on Flickr.com)

Thanks for using my photograph @ggwash.

It’s of the iconic @HowardTheatre at sunrise, in the Shaw neighborhood of Washington, DC (of course).

I’m aware that this is a fundraising post for the non-profit publication Greater Greater Washington. I don’t endorse third party products or services on this blog, so the decision to contribute is not recommended by me. I am giving my support to the work that Greater Greater Washington does to reduce or eliminate inequity in our nation’s capital and overall help our citizens and by extension, the world, learn to love better.

This week, an anonymous donor is challenging five people to become adopt-a-tag sponsors. If 10 people make a donation of at least $175 (or $35/month), they’ll donate $2,000 to the reader drive!

Source: Have you adopted your tag yet? Do it this week and GGWash will get $2,000! – Greater Greater Washington

Thanks for including my photograph, in Public Grief Can Make Us Wise – SAPIENS

2017.10.18 War Memorials, Washington, DC USA 9654
2017.10.18 War Memorials, Washington, DC USA 9654 (View on Flickr.com)

Thank you for including my photograph in this excellent piece on acknowledging public grief, @Sapiens_Org, written by archeologist Richard Wilshusen.

In many ways, Washington, DC tends to be a nidus for public grief, and because of that there aren’t a shortage of photos showing its impact. One of the first photographs I ever took here was of a ghost bicycle with a message from a grieving mother to her daughter.

Ghost Bike

Photo Friday: Public Expression of Grief

I will never forget the public grieving after the murder of 49 people in Orlando, Florida in 2016, in Washington, DC, for its sadness, and also because of what I learned.

2016.06.15 Community Dialogue and Vigil Washington, DC USA 06196
2016.06.15 Community Dialogue and Vigil Washington, DC USA 06196 (View on Flickr.com)

As a man in his mid-60s who has lived through the Vietnam War and the AIDS crisis, and who has been devastated by my own personal losses of loved ones to suicide and depression, I know the necessity of grief. And as a professional archaeologist who has been involved with the repatriation and reburial of Native American remains, I have witnessed the power of collective grief in unifying tribal elders as they worked to have ancestral remains returned from museums for appropriate reburial. As a society, we must recognize the need to grieve in all cases of mass trauma and public tragedy.

Grief makes sense of loss and opens us to rebuilding all that is meaningful in life. Society would benefit if public grief were acknowledged more.

Source: Public Grief Can Make Us Wise – SAPIENS

Thanks for publishing my photo, in Events: 14th Street update, CSG x JUMP happy hour, and creative placemaking in DC, Greater Greater Washington

2017.05.01 Capital TransPride Producers, Washington, DC USA 4384
2017.05.01 Capital TransPride Producers, Washington, DC USA 4384 (View on Flickr.com)

Thanks for publishing my photograph, @ggwash.

I actually didn’t recognize it as mine initially, because the perspective of the now-bustling 14th Street NW is not one I am used to. And then I realized I took it during my service as a member of the producer team of @TransPrideDC. It’s a perfect metaphor to all of the wonderful things that working with innovators in out of the way places brings.

Here’s a better shot of the facade of one of the buildings in the photo. Isn’t Washington, DC beautiful?

2017.03.25 DC People and Places 01762
2017.03.25 DC People and Places 01762 (View on Flickr.com)

There’s a meeting about making 14th Street more friendly for people walking and biking, a CSG and JUMP bike happy hour, and a talk about creative placemaking in DC this week.

Source: Events: 14th Street update, CSG x JUMP happy hour, and creative placemaking in DC

Just Read: Evidence that supports the prescription of low-carbohydrate high-fat (or healthy-fat) diets: a narrative review

Noakes TD, Windt J. Evidence that supports the prescription of low-carbohydrate high-fat diets: a narrative review. Br J Sports Med [Internet]. BMJ Publishing Group Ltd and British Association of Sport and Exercise Medicine; 2017 Jan 4 [cited 2018 Feb 19];51(2):133–9. Available from: http://dx.doi.org/10.1136/bjsports-2016-096491

Somehow I missed this article, or actually, I’m still catching up 🙂 .

As the title says, this is a good review of the state of low-carbohydrate diets, how they are thought to work, and what their impacts are.

Thinking “healthy fat” rather than “high fat” diet

I appreciate the comment

Therefore, even though the relative contribution of fat to dietary energy intake may increase, the absolute fat intake may not. As a result, the term ‘high fat’ diet may be misleading. Hence, the term low-carbohydrate healthy fat is probably more appropriate.

And I may begin to use this as the full representation of “LCHF” because “high fat” seems shocking to fellow physicians, who, for 70 years, have received nutritional education, just not in a rigorous, academic manner:

Physicians’ 20th Century Nutrition Education: via Medical Journal Advertisements (Food Has Always Been Medicine)

I also appreciate the fairness of this statement:

LCHF diets clearly perform at least as well as do any other dietary approach, even in trials in which energy intake on the LCHF diet is unrestricted (ad libitum).

There’s a lot more in the piece about why this way of eating is metabolically useful, beyond weight loss, which I think confuses a lot of people, who believe the sole advantage is weight loss (it’s more than that)

My Prep for Low Carb Breckenridge

I’m going to Low Carb Breckenridge in a few weeks, and my education has in a sense come semi-full circle this time compared to my visit to Low Carb San Diego. I find it interesting that I’m willing to say I’m going to Low Carb Breckenridge before I actually go. I only posted about Low Carb San Diego after it was over (see: Adventures at Low Carb San Diego.

This time around, I’m interested in following up on some items I discovered for the first time in San Diego, or want to gain more perspective on based on various conversations. This is in addition to the basics the paper lays out well about metabolic changes, and studies on efficacy for reversing diabetes and weight loss (which are two separate things).

  • Non-Alcoholic Fatty Liver Disease – NAFLD – this is especially new to me (and the medical profession). Noakes’ treatment of the management of NAFLD is a little light in this piece. I’m going to post more about what I’m reading in the next few days, which to me looks like a lack of consensus on what works. However, from a plausibility perspective, LCHF should be superior to LFHC (low fat, high carbohydrate).
  • Animal vs. Plant sources of food – This continues to come up in my world. I’ve done some posting on this already (see this series of posts) which demonstrates to me that this topic is more nuanced than polarized. I believe the common ground are around real vs processed foods (of any source)

The paper reinforces understanding about the negative health consequence of industrial vegetable oils and what we now know about lipid profiles. Interestingly, a response to the article hearkens back to the 20th century understanding, which is about LDL-C only….

The paper is an overall good read, and I find as an adult learner that getting the information presented via multiple perspectives helps a little at a time.

The Unfortunate Continuation of Health Professions Council of South Africa (HPCSA) Campaign against Professor Noakes

Concomittant to reading and benefitting from the information in this article, I along with many, learned that the HPCSA has decided to appeal its own decision acquitting Tim (@ProfTimNoakes) after he was brought up on charges for sending a single informational tweet to a breastfeeding mother.

I signed the petition representing myself, with this comment:

In the history of medicine it has always been the case that interprofessional collaboration is better for the people we serve, who need us at a time of unprecedented threat to their health.
We learned this again and again in the ethical crises that shaped our generation of physicians. If the HPCSA changes course now it will see itself on a different side of history. We’re here to help, because we care. ✌️#LessCarbsAndLessCarbon #dontfearfat

As I wrote in my review of Noakes’ and Sboros (@MarikaSboros) book on the ordeal, I still wish that the HPCSA will learn from what is looking more and more like a mistake (noting, their twitter feed @HPCSA_ hasn’t been updated since 2015, that says something). I know because I have seen the medical profession fail spectacularly in my career ((9) The Embrace of Failure TED EYTAN and REGINA HOLLIDAY TEDxAlvaPark 2012 – YouTube). On the one hand, I wish the experience of being a part of this on every nurse and doctor in their lifetime. On the other, I wish that the suffering of all parties will end, so that we can focus on what’s best for the health of the people we serve.

Just Read: Tim Noakes and Marika Sboros – Lore of Nutrition: Challenging Conventional Dietary Beliefs

I’m looking forward to convening with experts and learners in a few weeks to see how I can serve better.

Photo Friday: The Lot at the Liz Under Construction & 40 Years of Compassion, Washington, DC USA

2018.02.04 LizLot Under Construction, Washington, DC USA 2317
2018.02.04 LizLot Under Construction, Washington, DC USA 2317 (View on Flickr.com)

This week’s photograph was taken on historic 14th Street Northwest, in Washington, DC, USA (of course). It’s this historic because this is what the building looked like in 1942:

8c26601u-266
Washington, D.C. Automobile store on 14th Street which has stock of frozen cars, May 1942 8c26601u-266 (View on Flickr.com)

There’s a lot of history between 1942 and 2018, including the destruction of this street following the assassination of Martin Luther King, Jr., another destruction following a drug epidemic, and then another, of the LGBTQ community terrorized by HIV and a medical and public safety community who ignored their suffering.

An important exception was Whitman-Walker Health, celebrating its 40th year this year, and received support from actress Elizabeth Taylor, whose namesake medical center operated in this building, and will, again.

Liz is memorialized just a few blocks away in recognition of the fact that she didn’t walk away:

Photo Friday: Thank you Liz Taylor in Watercolor, Shaw Neighborhood, Washington, DC USA

Although Taylor is no doubt a alluring figure to look at, there is a deeper meaning behind the mural. The mural is meant to pay respects to the late actress for her foundation’s generous support of the Whitman-Walker Health Center, which helped to prevent the spread of AIDS and provided treatment to those affected by HIV/AIDS.

I still hear stories of the way human beings were treated and I am incredulous – both by the hostility they faced in a world that didn’t want them to exist, and the compassion they faced when they sought treatment here. Both have shaped a generation of physicians and nurses, especially mine 🙂 .

Additional photos of the building are below, and more information about the art and cultural events surrounding the rejuvination of this community treasure: The Lot at The Liz – Whitman-Walker Health

Thanks for publishing my photograph, in Metrorail is no longer the second-busiest rapid transit system in the country – D.C. Policy Center

2016.09.20 Didactics at Unity Health Parkside Family Medicine Residency 08035
2016.09.20 Didactics at Unity Health Parkside Family Medicine Residency 08035 (View on Flickr.com)

Thanks for using my photograph, @DCPolicyCenter (and syndicated to @ggwash) as part of another great analysis of community conditions in our nation’s capital.

Transportation is changing, it’s a part of health, and building and operating transit systems are among the most far reaching human endeavors. I was fascinated (and still am) behind the story of Washington, DC’s metro, which you can read here – as much about technology as society. And, by the way, a nice debunking of the myth that the then-affluent Georgetown rejected a metro station in their neighborhood.

The Great Society Subway: A History of the Washington Metro (Creating the North American Landscape)

The photo was taken at the Minnesota Avenue Metro Station, in Ward 7, a place that demonstrates that even with metro access, #CarFreeDC is still challenging when everyone doesn’t have what they need:

Thanks for using my photo, in No Easy Access: Can D.C. Break Down Barriers To Food, Health Care And Transportation? – The Kojo Nnamdi Show

By the way, to get to this metro station on the day I took this photograph, I strategically did not take metro, opting for the DC streetcar, a bus, and a walk, to stimulate learning, which readily happened. Washington, DC continues to provide more learning per square millimeter than any other place I have been.

Metrorail is no longer the second-busiest rapid transit system in the country – D.C. Policy Center

Source: Metrorail is no longer the second-busiest rapid transit system in the country – D.C. Policy Center