2012 Nutrition and Metabolism Symposium

Saturday, May 5, 2012
nms The Nutrition and Metabolism Sympposium has become something I look forward to a great deal. This year was my sixth one, and now I am seeing the same people again and again, and enjoying it so much. Each year there is a different focus (last year was about ketogenic diets). This year there were two different focii: one was helping physicians to translate the theory into practice, and the other was looking at policy issues generated by the knowledge that the standard Dietary Guidelines do not work for a significant portion of the population.

I thought the first part was extremely valuable. Again and again I see the problem that even physicians who are OK with their patients following a low-carb diet for health (or even encourage it) have no idea how to support their patients in following a way of eating that is so counter the usual recommendations.

The afternoon started out with Dr. Eric Westman (co-author of New Atkins for a New You and others) conducting an information session as if we were his patients. He provided us with a handout he uses at the Lifestyle Medicine Clinic at Duke University Medical Center called the "No Sugar No Starch diet" (if you are interested, it's also available near the back of the book by Gary Taubes, Why We Get Fat, but it's also basically the Atkins diet).

First of all, I like the title. You don't have to explain what a "carb" is, or how "low" is "low". It's just very simple: don't eat sugar, don't eat starch. Why? Because "Carbs make you hungry."

People started to ask the typical questions (Can I eat this? Can I eat that?") and the answer was "if it isn't on page 4, don't eat it". Again, very simple. Simple, but very different, so you have to learn this new way. He compared it to learning to drive on the other side of the road.

Dr. Westman then led us through the low-carb basics, how to read a nutritional label, etc. I'm sure the doctors there learned a lot about how to approach patients with this diet change in a positive way.

Dr. Mary Vernon then talked about how she works with her patients. (Dr. Vernon is also an animal trainer and at one point she said, "I don't educate my patients; I train them.") She teaches them about the diet, and then asks, "Can you do this for a week?" "How about two weeks?" "Great, come back in two weeks, and if you have trouble, call me."

She emphasizes to both physicians and patients to take their attention off of weight. She said "overweight is not a disease any more than a fever is a disease". Focus on the fuel source, and on the health results (blood work, blood pressure, etc.). She's says it's not uncommon for people to have delayed weight loss, and that's all right if other things are improving.

I was moved when Dr. Vernon talked about the benefits to physicians of using a low-carb approach to treat their patients. The main one is that it's so rewarding: you enjoy seeing patients who are improving, and "you get to work miracles". She listed off the many changes patients often experience (e.g. no heartburn, improved migraines and sleep apnea) and some surprising ones like improvements in narcolepsy and schizophrenia. (Dr. Westman told the story of a patient who came to him for weight loss; he didn't know she was schizophrenic. When she came back she announced that she'd stopped hearing voices. He was surprised.) Of course, we don't know what it is about a low-carb diet that may have had these positive effects -- it could be gluten or other components of grains, it could be the ketosis, or lots of other possibilities.

Loren Cordain gave a great talk about paleo eating. Whereas Friday he focused more on the evolutionary science, this time he talked about nutrition. He said they did an analysis of 5 days of menus from the USDA Dietary Guidelines Web site and compared it to 5 days of Paleo eating, and how the USDA diet was lower in almost every nutrient (often by a lot) than the paleo diet, and that the USDA diet didn't measure up to the basic recommendations on many nutrients.

Dr. Cordain also asked the question "why aren't hunter-gatherers calcium deficient?", since that is the one area that the Paleo Diet doesn't live up to the recommendations. He thinks this is due to adequate vitamin D due to lots of natural exposure to sunlight and/or consumption of fish and marine mammal organ meats.

How to implement the Paleo Diet in modern times? He said a good start is to take the "My Plate" logo and simply cross out the grains and dairy portions.

I really enjoyed the talk by Christopher Gardener, the scientist who headed a famous big diet study a few years ago. Although the Atkins group had the biggest weight loss, it wasn't by much. Also, people did not follow the diets, so what was being tested was more about compliance. Gardener went on to speak about what we have come to realize about the benefits of low-carb diets: better blood lipids, etc., that we all are familiar with by now.

But here's something that wasn't published in the original study, and this is the problem with averages: Although the Atkins group loast an average of 10.5 lbs, and the others lost about half that, there was a 66 pound RANGE of weight change within each group, with some people in each group actually gaining weight. Given that information, it is almost useless to say, "this group lost an average of 10 pounds and this group lost an average of 5 pounds". The important question is: why do some people do better or worse on any given diet? Gardener and his fellow researchers looked into their data and essentially found that people who have problems processing carbohydrate (insulin resistant, metabolic syndrome, or on the diabetes spectrum) did not do well when they were assigned to a low-fat diet, while those who were insulin-sensitive (no problems with carbohydrate) could do well on either type of diet.

Dr. Gardener then talked more about the factors of 1) insulin resistance (he talked about this study by Cornier and a couple of others) and 2) genetics, including this research. Of course, those two factors may not be at all independent, but the science has not been done to figure this out.

I've got to say that I was pleased that Dr. Gardener talked about this, and about many of the other points I and others have tried to hammer home:

  • When people talk about whole grains being less glycemic, this is only true for whole, intact grains. "Whole grain flour" is not "whole" any more, and just as glycemic as white flour.
  • Quality matters. Processed foods that are marketed as "low-carb" or "low-fat" are often deceptive.
  • It's good for everyone to cut out added sugars, flour, and fruit juice.
  • Different people do best with different amounts of carbohydrate.
Dr. Steve Phinny talked about "Dietary Fat - the Key to Sustainable Nutritional Ketosis". Dr. Phinney has done seminal work in the area of keto-adaptation and athletic performance. (I've just started reading his most recent book with Dr. Jeff Volek, The Art and Science of Low Carbohydrate Performance, a companion to last year's The Art and Science of Low Carbohydrate Living.)

He emphasized the importance of eating enough fat. This is especially vital after weight loss slows and stops (during weight loss, we are "eating" our body fat).

The right kind of fat is vital. Sometimes people who are having trouble eating "enough fat" are eating the wrong kinds. "Many people we counsel, including health care professionals, have to be begged, cajoled, or browbeaten into eating enough of the right kinds of fat. But when they do, the response is "Wow!"

He made the point that people who complain about the high cost of low-carb eating are probably trying to eat a lot of protein. "Good fat" is not more expensive than "good carbs".

The reason many people are not as successful as they could be eating low-carb is that those particular people would do better on a consistently ketogenic diet (under 50 grams net carb).

Our body fat is a little over half monounsaturated fat, and most of the rest is saturated. It's possible that this is a good amount to shoot for in the diet.

Avoid soy oil, including maynnaise and salad dressings made with it. He has observed in his research that people don't do well with large amounts of omega-6 laden oil.

"When in doubt, eat less carb; when in doubt, eat more fat."

This is getting ridiculously long, but I want to say a few things about the last portion of the symposium, which was about nutrition and diet policy, because there were some very interesting people and information. (Note: The U.S.D.A declined to participate.) Rather than summarize or critique these, I'm just going to pull out one or two important pieces of information from each talk.

Stephanie Chiuve, from the Harvard School of Public Health led us through how the purpose and history of the USDA Dietary Guidelines have evolved through the years, she asked the question, "Are the Dietary Guidelines fulfilling their purpose?" The answer, clearly, is "no". It turns out that greater adherence to the Dietary Guidelines do not predict better health! (Actually, with men, the most adherent were VERY SLIGHTLY healthier than the least; with women there is absolutely no correlation at all between adherence and health.)

The Harvard group has their own guidelines, which does better at predicting health, but it has some issues. I spoke to the presenter about a couple of things, and we just had to agree that it's difficult to tease things out. One example: they are negative on red meat, but red meat consumption is highly correlated with refined carb consumption (so is the problem really the meat?) Then, because they don't want people to eat red meat, they don't tell people to eat monounsaturated fat (like olive oil), because in the U.S. diet, most of the monounsaturated fat comes from red meat and other animal fat. So they tell people to eat polyunsaturated fat instead. But why not just tell people to eat vegetable oils, so olive oil, avocado, etc, could be included? I should have asked this, but I think the answer might be that some vegetable oils are high in saturated fat, like coconut oil. So you can see how this kind of goes around and around.

Dr. Elizabeth Mayer-Davis presented a "Review of the American Diabetes Association (ADA) Nutritional Guidelines". I was very much looking forward to this talk, since there is so much confusion among health care professionals, health writers, and my readers about this. I will be writing more about this in the near future, as I had an opportunity to talk to Dr. Mayer-Davis about this in a follow-up phone call, and will also be talking to other people from the ADA. But here is the bottom line:

There is no "Diabetes Diet". The guidelines are for an individualized plan that enables the patient to achieve optimal blood glucose control and weight loss. A low-carb diet is perfectly fine if it helps achieve these ends for the individual patient, and the patient is willing to do it.

During my phone call with Dr. Mayer-Davis, we discussed the problem of diabetes educators and other health care professions not getting this message. I will report on this separately.

Co-author of Atkins Diabetes Revolution, Jackie Eberstein's talk was called "Carbohydrate Restriction: From Practice to Policy". She spoke about the people who aren't well-served by the traditional low-fat/high-carb diet recommendations. She charted how rates of obesity and diabetes took off like a rocket when these guidelines were put into effect, and how food trends have changed over time. That the people who are most at risk from these changes are those who have family histories of diabetes, metabolic syndrome, and conditions associated with insulin resistance (e.g. PCOS). Also gestational diabetes and carbohydrate addiction (she's going to be talking about carb addiction next week on the Low Carb Cruise.) These people need different dietary guidelines.

She also talked about how we need a standard definition of a "low-carb diet". She proposed that under 225 grams of carb per day be labeled a "moderate-carbohydrate diet", 50-130 be "low-carbohydrate", and under 50 be "low-carbohydrate ketogenic".

Biochemistry professor Dr. Richard Feinman criticizes the current dietary guidelines on many fronts, including lack of scientific accuracy, ignoring or misinterpreting relevant literature, highly biased writing, and an unwillingness to accept responsibility for failure of previous versions. In addition, he feels they contain imprecise and confusing definition of terms, and show a disdain for the intelligence of the reader. He gave many examples of this, including the term "solid fats". He gives examples of diabetics who have been hurt by the current guidelines.

So, whew! Got some of the basics written up before heading out again on thelow-carb cruise!

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