Just Read: “Why We Get Fat,” by Gary Taubes

I actually read this book some time ago and didn’t post on it until now.

This book would be a companion to 2017’s “The Case Against Sugar” also by Gary Taubes (see my review of that book here) (@GaryTaubes). Written in 2010, it explores the causes of obesity, and makes the case away from a “calories in-calories out” approach to an endocrine (hormonal) mediated one.

The reason I am interested in exploring this is because of the potential harm I see in blaming culture around obesity. What if the medical profession is telling people to do the wrong things, and then blaming them when their biology achieves the goals of their physician-directed behavior?

A recent (2012) study of medical students has shown that the explicit biases (ones they are willing to endorse) are:

  • Bias against lesbian, gay, bisexual, and transgender (LGBTQ) human beings
  • Bias against human beings who are obese

In fact, the bias against obese people is stronger than that against LGBTQ:

Explicit attitudes among medical students 54441
Explicit attitudes among medical students 54441 (View on Flickr.com)

Of all the dangerous ideas that health officials could have embraced while trying to understand why we get fat, they would have been hard-pressed to find one ultimately more damaging than calories-in/ calories-out. That it reinforces what appears to be so obvious— obesity as the penalty for gluttony and sloth— is what makes it so alluring. But it’s misleading and misconceived on so many levels that it’s hard to imagine how it survived unscathed and virtually unchallenged for the last fifty years. It has done incalculable harm.

Taubes, Gary (2010-12-28). Why We Get Fat: And What to Do About It (Kindle Locations 1187-1191). Knopf Doubleday Publishing Group. Kindle Edition.

This book is clearly not intended to guide a person on how to alter their diet in a step by step method – it is aimed more at a scientific explanation around the causes of obesity. There are other books to guide a person through a different dietary approach, most notably “Always Hungry,” by David Ludwig, MD (@DavidLudWigMD), which I’ll post on separately.

Just Read: Peter Drucker, The Effective Executive: The Definitive Guide to Getting the Right Things Done

This book was written 50 years ago, well read and reviewed, so I’m not going to add whole lot of insight to Peter’s work. It reads like it was written yesterday, and I’ll say there are few works that I have highlighted as much as this one. It’s the frankness and interest in the development of the reader that comes across.

The book is a lot about the 20th Century knowledge worker, with some hints about the 21st Century. One of my favorite 21st Century quotes relevant to this is at the bottom of the post.

First, a few quotes I relished, below.

On Being Future Focused (or as I say, the need to live in the future)

“There’ll always be a market for an efficient buggy-whip plant,” and, “This product built this company and it’s our duty to maintain for it the market it deserves.” It’s those other companies, however, which send their executives to seminars on creativity and which complain about the absence of new products. The need to slough off the outworn old to make possible the productive new is universal. It is reasonably certain that we would still have stagecoaches— nationalized, to be sure, heavily subsidized, and with a fantastic research program to “retrain the horse”— had there been ministries of transportation around 1825.
Drucker, Peter F. (2017-01-24). The Effective Executive: The Definitive Guide to Getting the Right Things Done (Harperbusiness Essentials) (p. 120). HarperCollins. Kindle Edition.

and

Outside of Victorian novels, happiness does not come to the marriage of two people who almost got married at age 21 and who then, at age 38, both widowed, find each other again. If married at age 21, these people might have had an opportunity to grow up together. But in seventeen years both have changed, grown apart, and developed their own ways.The man who wanted to become a doctor as a youth but was forced to go into business instead, and who now, at age fifty and successful, goes back to his first love and enrolls in medical school is not likely to finish, let alone to become a successful physician.

Drucker, Peter F. (2017-01-24). The Effective Executive: The Definitive Guide to Getting the Right Things Done (Harperbusiness Essentials) (p. 122). HarperCollins. Kindle Edition.

The lesson doctors also learn in the journey to leadership

When General Eisenhower was elected president, his predecessor, Harry S. Truman, said: “Poor Ike; when he was a general, he gave an order and it was carried out. Now he is going to sit in that big office and he’ll give an order and not a damn thing is going to happen.”
Drucker, Peter F. (2017-01-24). The Effective Executive: The Definitive Guide to Getting the Right Things Done (Harperbusiness Essentials) (p. 158). HarperCollins. Kindle Edition.

On the need to actually see what’s happening

With the coming of the computer this will become even more important, for the decision-maker will, in all likelihood, be even further removed from the scene of action. Unless he accepts, as a matter of course, that he had better go out and look at the scene of action, he will be increasingly divorced from reality. All a computer can handle are abstractions. And abstractions can be relied on only if they are constantly checked against the concrete. Otherwise, they are certain to mislead us. To go and look for oneself is also the best, if not the only, way to test whether the assumptions on which a decision had been made are still valid or whether they are becoming obsolete and need to be thought through again. And one always has to expect the assumptions to become obsolete sooner or later. Reality never stands still very long. Failure to go out and look is the typical reason for persisting in a course of action long after it has ceased to be appropriate or even rational.
Drucker, Peter F. (2017-01-24). The Effective Executive: The Definitive Guide to Getting the Right Things Done (Harperbusiness Essentials) (p. 159). HarperCollins. Kindle Edition.

The tragic, and shining example of this is the National Health Service’ Mid Staffordshire Hospital scandal – an estimated 400-1,200 deaths, in a place awash with data but not people seeing what was actually happening.

Being present saves lives.

Effectiveness in the 21st Century

…there is no inherent reason why decisions should be distasteful— but most effective ones are.
Drucker, Peter F. (2017-01-24). The Effective Executive: The Definitive Guide to Getting the Right Things Done (Harperbusiness Essentials) (p. 176). HarperCollins. Kindle Edition.

Peter Drucker operated in a (cis-gender, heterosexual, white) male-dominated business world, which we now understand brought with it tremendous limitations in terms of growth, profitability, and success of the organizations so led.

Equality equals health. It equals effectiveness also. Diversity also allows the human species to survive 🙂 .

The social movements of our time have demonstrated the additional creativity, courage, and effectiveness that comes from the non-traditional, out-of-the way places. Everyone is necessary, and the computer as described accurately 50 years ago, has limitations. (My favorite quote about that, from 1966, is at the bottom of this post)

Drucker presages that reality:

We will have to satisfy both the objective needs of society for performance by the organization, and the needs of the person for achievement and fulfillment.

Drucker, Peter F. (2017-01-24). The Effective Executive: The Definitive Guide to Getting the Right Things Done (Harperbusiness Essentials) (p. 192). HarperCollins. Kindle Edition.

And the leaders of our time exemplify it

You know one thing for sure: If you’re a woman and you’re effective, you will be a target,” Pelosi said. “It isn’t a problem for me, because I care more about being effective than I care about being a target.”Congresswoman Nancy Pelosi (2013)

Just Read: The Case Against Sugar

One of my earliest memories was the rush to the grocery store by my family to stock up on saccharin sweetened beverages when it was feared they would be pulled off the market, in 1977. The shelves were bare (it was as much an emergency as any I remember in the household)…

This was the headline (behind paywal, if you have library access):

By, Tom Shales. 1977. “Tears & Fears: Threat to Saccharin Spurs New Hoarding! Diet-Rite Dementia, Tab Teetotaling in the Offing?” The Washington Post (1974-Current File), Mar 15, 2..

I looked this piece of history up online after I read Gary Taubes’ The Case Against Sugar, and amazingly, in this piece from March, 1977, they seemed to express some of the wisdom that’s now being discussed 40 years later (almost to the day):

From Pending FDA Saccharin Ban A Bitter Dose for Many in U.S. – The Washington Post, April 4, 1977

There are various problems with the high current levels of consomption, according to food experts. Measured in calories, sugar and other sweeteners – the main other sweetener is corn syrup – now provide about a fifth of the average American’s daily diet. But sweeteners contain none of the protein, vitamins and minerals the average person needs. These things must come from the other four-fifths of the diet: in this sense, the sugar fifth is wasted.

A second problem is the more familiar and simpler one, that sweetened foods are fattening. A third, related problem is the pervasiveness of sweeteners. A high percentage of our food today is processed, as opposed to fresh, and a high percentage of processed food is sweetened.

More than two-thirds of our daily sugar and other sweeteners comes to us in processed foods, including soft drinks and other processed beverages.

The wisdom they may have not had, at least in popular thought, was that sugar is more than wasted calories. There’s evidence that it is a metabolically active distinct subtance that changes the chemistry of our bodies in ways other forms of calories do not.

And actually, many scientists already knew that, however that science wasn’t promoted or supported by various interests….

Exonerating Fat, Arguing Against Sugar

This book continues a series of works by Taubes and others calling into question a 40 year experiment (see: Just Read: Why Eating Fat May Not Make You Fat (The Big Fat Surprise) in changing American (and global) eating habits to banish fat, which by definition means promoting carbohydrates (you have to eat something).

And promote they did, according to the record –

et tu, Consumer reports? American Heart Association?

In our lifetimes…

The magazine Consumer Reports may have captured this logic perfectly (of creating sugar sweetened cereals) in 1986 when it claimed, “Eating any of the cereals would certainly provide better nutrition than eating no breakfast at all.”

(By the mid-1990s, even the American Heart Association was recommending we have sugar candies for snacks, rather than foods that contained saturated fat.)

Bringing Occam’s Razor

The book adopts a philosophy that is used in medicine widely – Among competing hypotheses, the one with the fewest assumptions should be selected. Otherwise quoted as “if it swims like a duck, sounds like a horse, etc etc.”

In doing so, the possible causes of what are known as “Western Diseases” (read location 3729 on kindle to see the list) are reviewed through a lens that involves insulin metabolism, and specifically insulin resistance, which is known to be central to diabetes and probably a requirement for obesity. The counter-discussion is that obesity is a cause of insulin resistance, this is what we were taught in medical school, and this is extensively reviewed in the book.

In any event, everything from gout to hypertension is recast in an Occam’s mindset, in that the things we’ve been taught about what causes these diseases (purines for gout, salt for hypertension) may actually link back to insulin resistance as causing the causes we were taught about.

Which happens to track the increase in consumption of sugar in society.

In fact, a review of my own postings from social media in 2012 reveals that I was unsure about the causes of hypertension, based on my own medical training and extensive review of the literature. That says something: (7) Ted Eytan’s answer to Does weight loss cause blood pressure to go down, or are both the result of something else (like more physical activity)? – Quora

The People and the Science

As with Nina Teicholz’ book, there’s a discussion of the people and personalities involved in the science and sociology of our diet, and like most humans, they are fallible, imperfect beings. It is true now that when I read a paper involving nutrition, I now have to study who the authors are and which institution they are from so that I can track back to the potential conflicts they may have. We always have done that with medical literature (review the science and relate it to the person doing the science), this book just gives a roadmap (along with Teicholz’) to the nutritional science community.

Where we came from

I have always believed that we have to know where we came from to know where we’re going, and there’s a ton of history in here. It’s a marvel to think about what was going on in Washington, DC, and even my home state of Arizona, when I was growing up, that would shape our country’s health destiny.

(side story: while I was an undergrad in Tucson, Arizona, I did some data entry on a nutritional study to get research experience, and I remember that the software that we were using didn’t have entries for the new “fat free” foods being marketed. My faculty sponsor told me, “Fat free salad dressing is really just sugar and water, so code it like that”)

The question of whether artificial sweeteners are healthy or not is not fully addressed in the book, because it’s not fully addressed in the science. What they (sweeteners) did, though, was raise the cry for a healthier life and a freedom from obesity and diabetes. Just read the quotes from the above Washington Post article:

“Please . . .” a woman from Dallas implores. “I don’t know what we would do for grandma if saccharin is banned.”

“I am . . . a former fat person!” another woman, from Huntington Beach, Calif., exclaim. “I use saccharin every day in cooking.”

“As the mother of a 12-year-old diabetic child, I appeal to you . . .” writes a third petitioner, from Dunwoody, Ga.

And this commercial from 1979, when a calorie was a calorie, and people were so…thin*.

*As a former fat person, the intent of sharing this bit of history is not to fat shame, it’s to explore the history of obesity and causes that might be reversible or preventable in the interest of health, with the recognition that health is multi-dimensional and factorial 🙂

Just Read: Environmental Impacts of the U.S. Health Care System – (Carbon as a currency for health)?

This review could be considered an update to the brief analysis that appeared in 2009 describing US Health Care’s contribution to green house gas (GHG) emissions to be 8% of the country’s total.

And now it’s up to 9.8% (or maybe 9.3% since the models used to calculate the number are based on 2002 standards around energy generation).

I took the time in 2009 to review the models used carefully, because in life, I always read the whole paper, not just the abstract, and you should too. It’s fair to say that they are (a) complex, and (b) subject to a lot of uncertainty. I have actually been told that some of the assumptions made may not be correct, however, until I get that info, I’m just going to go with the numbers presented here.

2017.03.23 Impacts of Healthcare on the Environment 0157014
Fig 1. Time series of life cycle GHG emissions from US health care activities. Shown for 2003–2013, in absolute terms (orange bars) and as a share of U.S. national emissions (blue line). Mt = million metric tons.

Eckelman MJ, Sherman J (2016) Environmental Impacts of the U.S. Health Care System and Effects on Public Health. PLoS ONE 11(6): e0157014. doi:10.1371/journal.pone.0157014

2017.03.23 Impacts of Healthcare on the Environment (View on Flickr.com)

This paper goes beyond GHG emissions, though:

These impact categories include global warming; stratospheric ozone depletion (allowing higher levels of short-wave ultraviolet light through the atmosphere, increasing the health risks of skin cancer); respiratory disease from inhalation of primary and secondary particulate matter (PM) and from ground-level ozone (smog) stemming from emis- sions of criteria air pollutants; cancer and non-cancer disease through inhalation and ingestion routes of chemical exposure; environmental effects of acidification (from formation and deposition of acid rain) and eutrophication (algae blooms from excess nutrients) in soils and surface waters; and ecotoxicity that reflects the toxic burden of all emitted chemicals to aquatic organisms.

The tweet being made about the piece is that the US Healthcare System emits more carbon than all of the United Kingdom, but really that’s not a useful comparison because of the population differences.

Carbon as a Currency for Health/Life

It’s probably better to note that the National Health Service in the UK contributes 3-4% of the national GHG emissions, which mirrors to some extent the difference in GDP spend on health care, which was previously highlighted so eloquently to me by Brian Masterson, MD, who was then at the Military Health System in 2014, which I’ll repeat here:

20-20-20, 3-3-3

  • 20: % of GDP spent on health care in the United States
  • 20: % of youth out of high school who are fit for the military today
  • 20: % of the outcomes of health that come from health care

The delta on average between our expenditure on health care and other countries is about 12 %, with which

  • 3: % of the GDP is spent on defense today
  • 3: % of the GDP would fund every eligible student to attend a state university
  • 3: % of the GDP to make Social Security solvent for every American alive today
  • 3: % left over

If carbon emissions parallel use of services/supplies/people, then there’s an interest in using the right amount of these to obtain maximum achievement of life goals for a population (see numbers above). And therefore right amount will result in right amount of GHC emissions.

The physician role

The thing to notice carefully about the GHG emission sources, which are based on the expenditure categories of our health system (Table 1) is that they are 80% directed the things physicians do – not just providing medical services, but ordering tests, pharmaceuticals, hospitalizations.

The group physicians for climate (@DocsforClimate) recently convened in Washington, DC with this understanding:

And I have yet to meet a physician who wakes up hoping to provide too much or the wrong type of health care.

Beyond the right amount of things, there’s the way things are produced

Again the assumption (reality) that physicians work every day to perform well for their patients, it’s easy to walk into any health care environment and see opportunities. From the paint on the wall to the light bulbs in the fixtures, the soap in dispensers, the eventual location of discarded e-waste…

Physicians have a role in this too, as they did in the creation of the new Kaiser Permanente San Diego (@KPSanDiego) Medical Center (click here to see video, – LEED Platinum promotes health and it looks good too) .

Carbon not the goal, a better world is

A simple reminder…

091207usatoday global warming.91

Citation: Eckelman MJ, Sherman J (2016) Environmental Impacts of the U.S. Health Care System and Effects on Public Health. PLoS ONE 11(6): e0157014.

Just Read: Triglycerides and Cardiovascular Disease – American Heart Association Scientific Statement

Yes, all 40+ pages of the American Heart Association’s scientific statement, published in 2011 (the most recent one – citation below), for leisure.

Why?

Triglycerides are that lipid component in our blood that we (or let’s say I) are trained not to pay that much attention to, especially relative to cholesterol (LDL, HDL, etc), and yet its story unlocks a lot of mysteries around nutrition and health (again, for me).

Jumping right in.

  • “It is especially disconcerting that in the United States, mean triglyceride levels have risen since 1976, in concert with the growing epidemic of obesity, insulin resistance (IR), and type 2 diabetes mellitus (T2DM).”
    • As much as we’re fighting LDL, we don’t seem to be winning on this one. Why? And does it matter? (several reasons, and yes)

The dyslipidemic triad and diabetes

High triglyceride levels that accompany either normal or impaired fasting glucose predict the development of Type 2 Diabetes,1and therefore, hypertriglyceridemic states should prompt surveillance to rule out T2DM. In addition, 35% of T2DM adults have fasting triglyceride levels > 200 mg/dL associated with decreased HDL-C and small, dense LDL particles.

Size matters – of LDL particles, that is

LDL particles in patients with DM may be atherogenic even at normal LDL-C concentrations..In addition, hypertriglyceridemia is associated with small, dense, and CE-depleted LDL particles. Thus, individuals with T2DM and mild to moderate hypertriglyceridemia exhibit the pattern B profile of LDL (smaller, denser particles) described by Austin and Krauss; these particles be more susceptible to oxidative modification and catabolism via macrophage scavenger receptors

That’s the not good thing that happens inside blood vessels that causes disease and it’s connected to triglycerides.

In other words (my interpretation), it’s not what triglycerides mean by themselves, it’s the pattern that they are connected to. And therefore, looking at just one number (LDL) has limitations to predict disease. On the other hand, focusing on LDL is easy to do and simple to understand…hence the need for this scientific statement to understand the biology better than most people probably do.

Continuing on.

How we got here. The low-fat diet aka SnackWells USA

The relationship between percent of total fat intake and change in triglyceride and HDL-C concentrations was reported in a meta-analysis of 19 studies published by the Institute of Medicine. In this analysis comparing low-fat, high-CHO diets versus higher-fat diets, for every 5% decrease in total fat, triglyceride level was predicted to increase by 6% and HDL-C to decrease by 2.2%

Overall, optimization of nutrition-related practices can result in a marked triglyceride-lowering effect that ranges between 20% and 50%. These practices include weight loss, reducing simple CHO at the expense of increasing dietary fiber, eliminating industrial-produced trans fatty acids, restricting fructose and SFA, implementing a Mediterranean-style diet, and consuming marine-derived omega-3 PUFA (Table 11). Dietary practices or factors that are associated with elevated triglyceride levels include excess body weight, especially visceral adiposity; simple CHOs, including added sugars and fructose; a high glycemic load; and alcohol.

And the American Heart Association recommended high carbohydrate diets and even candy in the prevention of cardiovascular disease. Oops.

For the biologists/scientists – how carbohydrates may result in higher triglycleride levels and unhealthy lipid profiles

Mechanistically, high CHO intake triggers pancreatic insulin release in response to increased blood glucose. Insulin, in turn, activates sterol regulatory element–binding protein, (SREBP-1c), a transcription factor that regulates fatty acid and triglyceride synthesis. Recently, 2 additional transcription factors, X-box binding protein 1 (XBP1) and CHO response element–binding protein (ChREBP), have been identified as inducers of hepatic lipogenesis in response to ingested CHOs (eg, fructose and glucose) that is independent of insulin.431,432 In contrast, unsaturated fatty acids reduce or inhibit SREBP-1c transcription, thereby reducing hepatic fatty acid synthesis430 and plasma triglycerides.

Using drugs to treat

However, in LIPID, although baseline triglyceride level was not signifi- cantly associated with CVD risk in patients given placebo, each 89-mg/dL decrease in on-treatment triglyceride level in patients given pravastatin significantly decreased CVD risk by 11%, as well as by 14% after adjustment for nonlipid risk factors. However, the lipid-related parameters most strongly associated with CVD risk in LIPID were apo B, LDL-C, and the ratio of TC to HDL-C

Again, the dyslipidemic triad.

Taken together, reductions of 50% or more in triglyceride levels may be attained through intensive therapeutic lifestyle change.

A low fat, high carbohydrate diet increases triglycerides and decreases HDL, the opposite, a higher fat, lower carbohydrate diet reduces triglycerides and increases HDL. For me this explains the non-sequitir of my pathology textbook in medical school stating that high carbohydrate diets are a risk factor for heart disease at the same time high carbohydrate diets were being recommended to prevent heart disease.

A discussion of statins is out of scope here – many many many, many many, articles already cover this.

Andrew Weil, MD’s advice to us in medical school – understand what you’re prescribing to your patients

…I think he may have said that we should try every drug we prescribe to understand its effects (with rationality of course) but human memory can be semi-faulty after so many years…either way it was something of a gift for him to be on faculty at my medical school (University of Arizona) because it promoted an embrace of curiosity that persists to this day, every day.

In any event, I’ve switched to a low carbohydrate diet over the past year. I’m not ready to share my personal health information here, but I will eventually. And my biology is tracking science, as expected, because, well, that’s how science works :).

More to come. In the meantime, here’s a helpful piece on the low-fat diet and what it has done for our health.

Citation: Miller M, Stone NJ, Ballantyne C, Bittner V, Criqui MH, Ginsberg HN, et al. Triglycerides and Cardiovascular Disease. Circulation [Internet]. 2011 [cited 2016 Dec 25];123(20).

Just Read: A Transgender Military Internist’s Perspective – #WhatADoctorLooksLike

This article, published in JAMA Internal Medicine describes the personal journey of a physician who is now serving as their authentic self:

…today I serve as a female physician in every respect within the Department of Defense. Last month, I graduated the Army Medical Department’s Advanced Course with honors, and now I look forward to the sec- ond half of my military career being treated like any other capable military physician.

The commentary, by Jamie Henry, MD (@MAJ_JLee_MD), concerns another paper in the journal

Schvey NA, Blubaugh I, Morettini A, Klein DA, KL M, G B. Military Family Physicians’ Readiness for Treating Patients With Gender Dysphoria. JAMA Intern Med [Internet]. 2017 Mar 13 [cited 2017 Mar 16];104(7):e5–6.

which, sadly, shows an important part of our profession unprepared, and in some cases, unwilling to provide care to their patients in need.

Depending on how full your glass is, the figure that 76% say they can provide “non-judgemental care” is either good or bad.

  • Good, because 24% admit that they have bias. To not admit bias leads to more harm and errors, multiple studies show this.
  • Bad, because 24% of physicians will provide care in a biased fashion, which is harmful
  • Good or bad: The 76% who say they can provide “non-judgemental care” may have hidden biases. The literature here is also helpful – there is the “illusion of objectivity” which describes the idea that people who believe they are not biased can be the most biased in their behavior (see these posts on my blog about this).

As Dr. Henry states, there is still a long way to go.

At the same time, how incredible is it that a person can have this aspiration, and fulfill it, because the only prerequisite is that they are human.

I went to medical school for a number of reasons, but primarily I wanted to heal—myself and others.

  • heal society too, which is what will happen, as we change forever #WhatADoctorLooksLike

Also noting the work of Jesse Ehrenfeld, MD – @DoctorJesseMD – working to be an ally for the LGBTQ community.

Love this century 🙂 .