The study, linked to above, didn’t test the ingestion of avocados or olive oil, as depicted on the stock photos.
Although the Western diet is more nutrient diverse than the starch-oleate diet is, the 2 formulas have similar caloric densities and similar proportions of CHO and fat. The fact that starch oleate phenocopied the effect of the Western diet in mice provides a strong rationale to further pursue the disease- promoting potential of this nutrient pair.
I’m intepreting this that the issue is not the type of fat, but the proportion of fat and carbohydrate in the diet.
Notably, our earlier studies combined nutrients in a 60:20 CHO:fat ratio rather than the 42:42 ratio used in the current experiments. Dietary formulas with 60:20 CHO:fat provoke more hepatic DNL than those with 42:42 CHO:fat when compared with chow (A. A. Pierce, 2013 and C. C. Duwaerts, 2014 data not shown). Moreover, in the presence of abundant amounts of simple CHO, even a small amount of dietary saturated fat can accentuate DNL by inducing the enzymes in the lipogenic pathway.
I am unable to reconcile what’s being said to the public and what’s in the study, which worries me because this is what adds to confusion about what it is recommended that people eat.
This is the 4th in a series of papers looking at the justification for recommending low-fat diets for humans. Authored by Zoe Harcombe, PhD (@ZoeHarcombe), it's a summary of three previous metanalyses. I wrote about 2 of the 3 previous papers. One is behind a paywall and i only have so much control over time and space….
The headline is as it says in the title of this post: Dietary fat guidelines have no evidence base.
This paper goes into some of the consequences of this advice and points out some logic traps that we're still engaged in around diet.
A low-fat diet is not just a low-fat diet; it's a high-carbohydrate diet, because there are only three macronutrients and fat would need to be replaced with something in the diet.
Plant-based sterols (found in vegetable oils) have been shown to reduce cholesterol levels, however they do not result in reduction of CHD risk and "much evidence that they are detrimental"
If saturated fat is harmful, the highest intake of saturated fat in the diet today comes from processed foods
Saturated fat cannot be cut out of the diet without cutting out all fat – "It is worth noting that every food that contains fat contains all three fats: saturated; monounsaturated and polyunsaturated.65 The notion that saturated fat is harmful and unsaturated fat is healthful is illogical given their coexistence in foods required for human survival."
There is opportunity for strong agreement among health pro- fessionals. If the public health message were revised to advise citizens to eat natural food and not processed food, saturated fat intake would fall accordingly, although the health benefit would most likely be the concomitant reduction in sucrose, trans fats, refined carbohydrates and other processed ingredients deleteri- ous to human health.
There are no responses written to the article at British Journal of Sports Medicine.
Note the word change in the title of this paper – from “did” to “does,” because the next question to be asked if dietary fat guidelines were created without an evidence base in 1977 (US) and 1983 (UK), is: is there evidence now, 40 years later?
And the answer is still no
10 studies meeting review criteria (“RCTs that examined the relationship between modified or reduced dietary fat intake, serum cholesterol and mortality from CHD and all causes) were analyzed
This meta-analysis of 10 RCTs, in comparison with Harcombe et al’s review of 6 RCTs, increased the number of people studied from 2467 to 62447. It increased the number of women studied from 0 to 53 499, the majority. It increased the number of primary prevention subjects from 676 to 56291.
The big increase in subjects studied is due to the Women’s Health Initiative, which, despite demonstrating the successful reduction of calorie intake from fat and saturated fat, was a negative study.
The various methodological problems as well as the data failing to show reductions in CHD deaths from the other studies is laid out in detail.
There’s an additional summary paper that I’ll post on next. As Harcombe points out, the 2015 United States dietary guidelines no longer limit dietary cholesterol, and the UK guidelines never had a limit. The guidelines about fat intake are also changed, without a limit on total fat intake, but still with a recommended limit on saturated fat intake.
There are no responses to this paper listed on its web site. I’ll post on the fourth paper next.
This paper is the first in a series of four, looking at four questions, by lead author Zoë Harcombe, PhD (@ZoeHarcombe), whose work I have been following on social media and via postings on this blog – all of it interesting to me.
The first review examined RCT evidence available to the dietary guideline committees in 1977 and 1983.
The second review examined epidemiological evidence available to the dietary guideline committees.
The third review examined RCT evidence available today, to see if extant dietary guidelines have been proven in retrospect.
The fourth review examined epidemiological evidence available today, to see if extant dietary guidelines have been proven in retrospect.
The recommendations we’re talking about are these, adopted by the United States in 1977 and the UK in 1983:
The dietary recommendations in both cases focused on reducing dietary fat intake; specifically to (1) reduce overall fat consumption to 30% of total energy intake and (2) reduce saturated fat consumption to 10% of total energy intake.
What’s the evidence?
There wasn’t convincing evidence available regarding fat intake reduction when the guidelines were introduced.
From the literature available, it is clear that at the time dietary advice was introduced, 2467 men had been observed in RCTs. No women had been studied; no primary prevention study had been undertaken; no RCT had tested the dietary fat recommendations; no RCT concluded that dietary guidelines should be introduced.
An exchange between Dr Robert Olson of St Louis University and Senator George McGovern, chair of the Dietary Committee, was recorded in July 1977. Olson said “I pleaded in my report and will plead again orally here for more research on the problem before we make announce- ments to the American public.” McGovern replied “Senators don’t have the luxury that the research scientist does of waiting until every last shred of evidence is in”.
And the only way to interpret this literature is to use the responses and social media
Unlike almost any other topic in medicine/health I have encountered, it is clear that it’s not enough to read the journal article – you have to read the responses to the journal article, the declared interest statements, and then go to social media to critically analyze the analysis.
The responses to the paper inquire about evidence that was available after the guidelines were introduced, which is covered in papers 2,3,4 that I’m reviewing.
Regardless, it’s worth noting that the responses do not dispute that there wasn’t convincing evidence available when nutritional guidelines for 220 million Americans and 56 million UK citizens were created.
Stumbling on Happiness is very science-laden look at how our brains work, what happiness is (or how it’s perceived), and some useful lessons. It’s a little hard to describe what the advice is; I’d operationalize it as “risks taken aren’t as risky as we think they are, we are more resilient than we think we are, trying to be planful about a future we can’t predict is prone to errors.”
Gilbert speaks about people’s recollection of missing trains on their commute. When asked to recall the “worst” such experience, they recall bad experiences. They are less able to remember the less memorable, less-than-worst experiences.
I can relate. I had this experience relatively recently, walking in Washington, DC, and stumbling upon the most prophetic art installation in an alley. Note in the VR view that it’s across from a large cemetery.
I think it’s very relevant here, and I’ll end this post with the photographs – click to see what the signs say. I feel comfortable that I won’t have these regrets. Will you?
“Signs of Regret” – see http://microshowcase.com/signs-of-regret-installation/ “If we were walking down a street that ends with our lives, what are the road signs we might wish to heed as we travel? –Brian Levy” Washington, DC USA #theta360 – Spherical Image – RICOH THETA
The tendency that causes us to overestimate the happiness of Californians also causes us to underestimate the happiness of people with chronic illnesses or disabilities.
(Ed. Comment – I think DC people are pretty happy 🙂 )
As one group of researchers noted, “Resilience is often the most commonly observed outcome trajectory following exposure to a potentially traumatic event.” Indeed, studies of those who survive major traumas suggest that the vast majority do quite well, and that a significant portion claim that their lives were enhanced by the experience.
Regret is an emotion we feel when we blame ourselves for unfortunate outcomes that might have been prevented had we only behaved differently in the past, and because that emotion is decidedly unpleasant, our behavior in the present is often designed to preclude it.
We overestimate how happy we will be on our birthdays, we underestimate how happy we will be on Monday mornings, and we make these mundane but erroneous predictions again and again, despite their regular disconfirmation. Our inability to recall how we really felt is one of the reasons why our wealth of experience so often turns out to be a poverty of riches.
Just catching on overdue summer reading, this is a piece written by Hedy Wald, PhD (@Hedy_Wald) clinical associate professor of family medicine, Warren Alpert Medical School of Brown University (#FMRevolution 🙂 ).
That’s how this works – as Hedy herself states in the paper:
Relationships influence adoption of professional values within PIF (Professional Identity Formation). Students actively construct PIs through interactions with patients, mentors, and colleagues within complex learning environments…
Professional Identity Formation
[PIF] is the transformative journey through which one integrates the knowledge, skills, values, and behaviors of a competent, humanistic physician with one’s own unique identity and core values …. The education of all medical students is founded on PIF.
identities stabilize in early adulthood, yet transformation continues throughout life
This paper is an introduction to an entire issue in Academic Medicine and interestingly to me, the concepts here are extremely relevant to much of the work I write about (and do) in Washington, DC that I call “helping the world learning to love better” (aka, the reason why we are all here).
Reading the title is reminder of my work with the LGBTQ community and the unstoppable human drive to live in one’s identity – there is transformation to a well adult in this population that occurs (verified by extensive science) which is very similar to transformation to a physician. The journeys are parallel in my mind.
There are many jokes that come to mind when we talk about becoming physicians, which I won’t repeat here. The expression that I like that’s not a joke is “once you get the two letters after your name, they can never be taken away.” I say it not with entitlement, but with responsibility.
The reality is that every physician, regardless of where they work or were trained, always have a commonality of experiences that are unmatched by most humans in any discipline (and the same is true for every profession). To an extent I feel a cohesion/congruity in every conversation, from the simplest to the most intense, with other physicians. After that, it’s what you do with it that matters, and I believe by definition every physician (and really everyone in health care) is exceptional; you have to be to do a job this challenging.
As I review the components discussed with Wald and relate them to my experience, I can recall great moments of supportive identity formation, alongside poor moments – usually as a result of neglect.
I recounted some of these in my post about Jess Jacobs’ death, nearing the one year mark. (see: Remembering Jess Jacobs – by the way the most read post on this blog, ever). However/and I do relate to these components in my own identity formation – here I am writing a blog, after all 🙂 .
I would like to touch on resilience a bit because it is without a doubt the (a) word of the decade. Wald quotes it as “responding to stress in a healthy way with “bouncing back” after challenges and growing stronger.”
I think for me, it’s also the unstoppable drive as a physician to build resilience in others. Again, I feel this is a common experience that physicians have. Regardless of how we get here, we can’t or won’t walk away, even when we walk away, if that makes sense. See the few examples below from just the past month (and note, more reflection).
Yes, we go to dance parties in front of legislators’ homes, candle light vigils, marches, and parades, to help others live their healthy identities, too.
I sometimes experience people who are not physicians ascribe some of what we do to preservation of self, rather than preservation and support of the people we serve, which is a mistake.
I also strongly identify with what Wald says about studying history
…there is a growing recognition that essential lessons for students and doctors derive from studying history even as medicine remains committed to pushing the frontier of knowledge.
In some of the work that I do, there’s tension between “heritage” and “the future”. Partially because I am a history geek, I study the people and places who were from the future in their time, and so there’s no tension for me. To know where you came from helps the knowing of where you’re going to, especially if you live in the future. And if you live in the future, that means not living someone else’s life, with the other misfits….
Speaking of living in the future, I finally got to meet Hedy earlier this month. I can’t believe of all the times I didn’t have my camera handy this was the time. In any event, it happened, and I’m delighted to learn that there is a community of experts interested in helping generations of physicians from today and tomorrow establish healthy professional identities. My generation of physicians trained during one of the most profound ethical crises in modern medicine (HIV/AIDS), and as a result we emerged with the goal to change everything. We need all the support we can get, allies need allies.
I am gifted (or cursed?) with a photographic memory, and I remember the time in medical school where we were taught, in an innovative new curriculum for its time, that sex and intimacy were not another part of a person’s humanity, they are inextricably linked.
Unfortunately, we weren’t taught about the human drive to live in one’s identity, how it can be more powerful than the will to live, and how health care can undermine both.
I also remember the times that transgender women have told me after vaginoplasty procedures that their surgeon’s guidance on supporting and maintaining the neo-vagina was “ask your friends what to do.” This advice doesn’t work when a person’s friends are all cisgender men (or cisgender women). Not a very humane or respectful way to protect the investment made in a complex procedure by patient and surgeon.
This is why, when friend and community colleague Connie Rice posted her guide, “Care and Feeding of Your New Vagina,” I was immediately interested and decided to post it here.
It shows through humor and frank and direct language, that body positivity, including sex, and intimacy are inextricably linked, for all humans, regardless of identity.
It also shows the impact of more human beings living in their true identity thanks to broader access to medically supervised transition care. I see this wherever I go now – more humans living, not dying, and now, living healthy. Washington, DC, by the way, has the highest proportion of transgender people in the United States, 500% higher than New York or California.
I don’t know if there are any surgeons still recommending that transgender women learn how to maintain their neo-vaginas by asking their friends or not. If they are, a guide like this is going to be a lot more useful and health promoting.
Connie began her career as an avionics technician in the US Marine Corps and has been in technology ever since. She’s the proud parent of three Eagle Scout sons. She bikes extensively and rides 5000 miles a year or more. Connie transitioned to female beginning in 2010 and over the next several years.
Connie feels lucky that her education, career, and family allowed her to make this change and felt a strong need to give back to the community. She is a transgender activist and member of Equality Virginia’s Transgender Activist Speakers Bureau where she works to further community understanding of transgender issues.Care and Feeding of Your New Vagina, Connie Rice
David covers just enough of the science to be useful for someone to understand the why of this approach:
So, in the 1970s, prominent nutrition experts began recommending that everyone follow a low-fat diet, in the belief that eating less fat would automatically help lower calorie intake and prevent obesity. Thus began the biggest public health experiment in history. Over the next few decades, the U.S. government spent many millions of dollars in a campaign to convince Americans to cut back on fat, culminating in the creation of the original Food Guide Pyramid…
Ludwig, David. Always Hungry?: Conquer Cravings, Retrain Your Fat Cells, and Lose Weight Permanently (p. 18). Grand Central Publishing. Kindle Edition.
And one example of the answer to whether this approach worked (the Look Ahead Study):
The study, conducted in sixteen clinical centers in the United States, assigned about five thousand adults with type 2 diabetes to either a low-fat diet with intensive lifestyle modification or to usual care. The study, published in the New England Journal of Medicine in 2013,33 was terminated prematurely for “futility.” Analysis by independent statisticians found no reduction of heart disease among participants assigned to the intensive low-fat diet, and no prospect of ever seeing such a benefit emerge.
Ludwig, David. Always Hungry?: Conquer Cravings, Retrain Your Fat Cells, and Lose Weight Permanently (p. 59). Grand Central Publishing. Kindle Edition.
There’s tons of published information about these findings, though, this book is more directed at successful behaviors.
The book is really designed as a plan to change dietary habits to ones that are more consistent with maintaining a healthy weight. Ludwig appropriately diminishes the argument that being overweight is about lack of self-control or too-large portion sizes or calories-in vs calories-out.
Although the focus on calorie balance rarely produces weight loss, it regularly causes suffering. If all calories are alike, then there are no “bad foods,” and the onus is on us to exert self-control. This view blames people with excess weight (who are presumed to lack knowledge, discipline, or willpower)—absolving the food industry of responsibility for aggressively marketing junk food and the government for ineffective dietary guidance.
Ludwig, David. Always Hungry?: Conquer Cravings, Retrain Your Fat Cells, and Lose Weight Permanently. Grand Central Publishing. Kindle Edition.
One of the challenges of moving away from a low-fat diet, though, is that there are extreme versions of the opposite, such as ketogenic diets. These may be successful for some, however, they require a level of commitment and medical supervision that’s not feasible for everyone.
From my read, Ludwig takes a very reasonable patient-centered approach (since he’s a physician, after all :)), and steers away from extremes into a slow modification approach that a person could follow if they were thusly motivated (and that’s the caveat, see below). He does not permanently forbid foods and the book is obviously written with enough guardrails (he is a physician after all…) that it appears safe relative to other guides I have seen.
I have recommended this book to some people, and my assessment of the uptake is “marginal,” not because of the book, because of where people are in their journey. Which is fine, that’s where information fits in, for the times that support is there and people are ready.
As Ludwig states, we’re in the middle (maybe the end?) of a 40-year failed experiment in changing the nutrition habits of the world. The data shows that people did in fact listen to the advice given and changed their habits (yet another perpetuated myth – “if people would just do as they were told”). It’s going to be an exciting next 40 years….
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:
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.
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.
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.
…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)