Saturday, October 22, 2011

Conventional Wisdom and the Lunatic Fringe

This weekend I had a terrific opportunity.  Nathan Rosenberg is an exceptional fellow who is co-president of the Harvard Food Law Society and a key organizer of next year's Ancestral Health Symposium.  He found me at AHS11 and asked me if I might be interested in speaking at Harvard Law School - I said sure, though I wondered what I would say, seeing as how doctors and lawyers are natural enemies. (Kidding.  Sort of.  Actually I have a GREAT lawyer.  He probably sleeps better not knowing about this blog.)

My talk is next week, on Halloween - the link is here.  I'm really looking forward to it.  My focus will be on how diet is likely a large actionable component of our mental health problems, and how mental health is both expensive and disabling.

However, on October 21st, the Harvard Food Law Society sponsored a great event - TEDx talks on obesity, with some of the foremost obesity researchers in the country (including Willet, Ludwig, Lustig, and Guyenet) along with many lawyers and policy makers talking about their efforts to encourage local agriculture and vegetable consumption over promotion of the commodities crops and CAFO operations.

The talks will be freely available some time - maybe follow the TEDx website?  They were fascinating - I was, frankly, shocked by Willet's dietary prescription based, for the most part, on epidemiologic evidence.   He advocates cereal fiber and polyunsaturated fats as a major portion of a "prudent" diet.  He was very pro-Mediterranean diet and whole foods, but was quick to say "it's all digested to the components" - so does he think a whole grain cracker fried in seed oil and sprayed with some vitamins is equivalent to nuts and legumes?  He was anti-saturated fat and red meat, but pro-poultry and fish.  He mostly stuck to obesity and heart disease, but used epidemiology and small, short randomized controlled trials as evidence.  Willet is, apparently, the 2nd (or 6th?  I forget) most cited person in the scientific literature.  He is HUGE.  He is conventional wisdom, in a nutshell, though Stephan Guyenet told me Willet is pro-egg, and Willet himself says that the food pyramid, demonizing fats and, in effect, promoting low-fat processed carbohydrates in favor of whole foods, was a public health disaster.

If we rely on epidemiology alone we would still have 90 y/o women taking hormone replacement therapy.  But Willet seemed convinced that confounders are easy to account for.  His confidence was… breathtaking.  Willet also dismissed anecdotes of traditional diets as the weakest form of evidence (which isn't entirely wrong, but ignores the compelling congruence of these healthy human diets across many cultures).  Willet also said that ancestral diets are not useful because "those people only lived to 50-55 and we don't want that."  Sigh.  Willet eats kashi grains for breakfast, apparently.

Ludwig's talk began, very promisingly, with an evolutionary history, but ended with the basic Harvard School of Public Health prescription for a healthy diet.  (Ludwig got a lot of media flack recently for suggesting that obese kids should be taken from their parents - the actual editorial he wrote suggests that foster care could be an option in intractable cases and I feel was taken out of context).  I was puzzled how we got to cereal fiber (how do we have cereal fiber, on a viable level, without processed foods?) and seed oils, but that's epidemiology for you.  He was quick to point out that if we substitute nuts and legumes for a big mac, once a week, we would have a measurable difference in obesity over time.  Okay - Stephan Guyenet was quick to point out the sleight of hand.  The substitution does not mean that red meat is bad for you.  Well - Ludwig looked great (very slender, not-inflamed looking at all) and apparently might be interested in speaking at AHS12.  It seems he is thinking in evolutionary health ways, but has not strayed from the conventional wisdom fold as of yet.  Very interesting.

Stephan's talk was excellent; it was mostly a historical review of the changes in the American diet over the past 150 years.  He pointedly showed the increases in fat (primarily polyunsaturated), poultry consumption, and linoleic acid over the last 50 years, coinciding with the obesity and diabetes epidemics.  His major point was that we have gone from all home-cooked foods to a high level of fast food, restaurant food, and pre-prepared convenience foods at home.  Does convenience kill?  Most likely...

(An important note - heart disease has been in decline for the past 30-40 years, though it might be leveling off now.  It is unclear if that is due to aggressive control of high blood pressure, dietary changes, or even statins.  But don't make the false proclamation that heart disease is increasing lately, because it is not).

Lustig did his anti-sugar talk (which also pointed out the problems with epidemiology as a prescription, I am told) on Thursday night, when I could not attend.  He did attend the panel discussion, when he came out as neutral on sat fats, pro-omega3, anti-omega6, anti branched chain amino acids, and anti MCTs.  And, of course, anti frucrose, and while he would not come out against whole fruit whole hog, he did discuss the anecdote of the "fruit orgy" of orangoutangs where they seasonally develop insulin resistance and put on fat.  Lustig seems to feel that fructose, MCTs, and BCAAs are damaging to the mitochondria and lead to insulin resistance (thus he is anti-corn fed beef, as corn-fed beef is higher in BCAAs than grassfed, apparently.  I don't know enough to say whether that is wacky or not.)  Ludwig was quick to point out that there is no evidence linking fruit consumption to any chronic illness.  I'm quick to point out that I eat 1-2 bananas a day, and I rely on 1/2 banana before and after crossfit for happy lifting.

What we can all agree on - eat "real" food, and from a policy and preventative perspective, perhaps the most important, simple message is to eliminate sugar-sweetened drinks in the diet.  I think everyone would pretty much agree on that one too.

The policy/lawyer talks were terrific -- they were very interesting, and exciting, as these lawyers and seasoned politicians are going forth to help farmer's markets and soil preservation, water preservation, sustainable agriculture and align government policy incentives with the supply and availability of local, real foods.  Some of the real initiatives include penning legislation to abolish state sales tax at local farmer's markets (just as most states do not charge sales tax for staple food items at the grocery store), and streamlining state and local regulations to allow for farmer's market and production and sale of homemade low-risk specialty items (such as jams or apple pies). As the current farm bill heavily supports the commodity crops (corn, wheat, soybeans, etc.) and downgrades vegetables to "specialty crops," some changes would be nice!

I left the talks a little shaken.  I felt (as always) the standard anti-obesity message is not practical for a non-Mediterranean culture and likely to be a terrible failure here in the U.S., land of the processed health food,  and the pro-egg, fat-is-okay (albeit *cough* polyunsaturated) message has certainly not been carried to clinicians, nutritionists, and doctors in the field.   That Willet and Ludwig were not willing to support whole dairy or red meat/pigs was unfortunate.  The "whole foods" message gets really lost when we are parsing out red meat and even dairy.  Forget the "nuts and legumes" (seriously, legumes?  The only beans worth eating are refried in lard, amirite? - to clarify, this is my little joke, as beans upset my tummy) - how to we kick red meat and dairy to the curb without eating a crapload of disgusting kashi?  I can't fathom it - Stephan I think would advise in consideration of sustainability and a large scale policy level for us to add potatoes (not fried, but whole, baked or boiled potatoes) and use traditional methods to prepare grains.

However, today I was fortunate enough to be invited to a lunch with Stephan Guyenet, Mat Lalonde, and friends and significant others.  It was very refreshing to be with Mat and Stephan, who seem to be aligned with me about not supporting the some paleo fringe extremes (meaning acceptable carb levels vary, gluten and dairy levels vary in tolerance on an individual basis, etc.).  We were also concerned about ideologues who seem to support one aspect of a diet as the end all, be all to ill health (fructose, or wheat, or carbohydrate), when the scientific truth is far more complex.

One of the most interesting aspects of the discussion was reflection upon genetic adaptations to agriculture - hemochromatosis (a disorder where humans can't properly get rid of iron, which was likely protective in grain-eating, low iron situations but which would make a classic low-carb, ruminant heavy, offal heavy diet dangerous), lactose tolerance in adulthood, and variations in folate metabolism.  Evolution did not end with the paleolithic, of course, and while the generalities of "eat real food" are true for everyone, the specifics can vary a great deal depending on context - insulin resistance, obesity, large exercise volume, etc.

I don't have a specific prescription on this blog for a very important reason, but let me be explicit  - for the most part, go archevore, exercise, tighten up the sleep, learn stress reduction, and that will help a great deal, and if all those things aren't in order, meds and strict ketogenic diets and supplements may well be shoveling sand against the tide.   This all doesn't mean I'm entirely anti-meds or anti-ketogenic diets - indeed, if the issues are substantial and significantly impair functioning, I want to help in whatever rational and evidenced-based way possible… but don't look for magic.  For the most part, it fails us.

How You Like Me Now?  The Heavy

26 comments:

  1. If Willet said that confounders are easily accounted for then why doesn't he account for them? Like here, he thinks that brown rice is awesome and that white rice isn't, but when you look at what they adjusted for it was: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3024208/table/T1/

    Where's sugar?! Why wouldn't you include sugar in your analysis for diabetes? If Lustig read this his head would explode. It's certainly a better job than many people do, but I would never risk my health on this stuff.

    Anyway, it sounds like you had a great time. Lunch with The Kraken and The Wizard? Awesome! And I agree with the general sentiment that we should just use our own brains and listen to all competent sources with a good idea of the nature of evidence. Unfortunately some people simply don't have the drive to learn or the mettle to deal with the world of health information, it takes a lot of changing one's mind.

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  2. I recently served as a healthy control for a near month long study by one of Willett's colleagues studying HDL and leucine. The study coordinator was amazed at my pre-study qualifying labs (HDL 98 and Trig 33). I explained the paleo diet I've been following and expressed my concern that following the assigned Healthy" diet which included refined carbs and sweetened fruit, among other things, would most likely adversely affect my HDL values. She brushed me off. I later discovered that she's an RD, and she was so intrigued by what I told her I ate that when the PI introduced himself, she requested that I tell him, too. He didn't seem at all surprised and stated that he had also needed to make significant dietary changes.

    But then I went on about Matty LaLonde is up on the main campus at FAS doing his biochem thing w/ a health dose of therapeutic nutrition speaking on the side. Ha! Maybe the word will finally get out and about at Hahvahd!

    I'm starting to wonder if Willett is losing some of his influence at HSPH at least....

    Happy for you that you got to chat with everyone. I let the Food Law Soc drop

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  3. A legume that most people find delicious (albeit in processed form) is fried chickpea batter. You could get most people to eat any vegetable when served in pakora form. I can think of several other forms of lentils and chickpeas that are quite tasty. While I've been convinced that whole grains aren't the wonders they're made out to be, I've seen legumes lumped in with them without convincing citation of any research. Can you point me to a quality discussion of the downsides of cooked legumes?

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  4. David - legumes (cooked) are the only foods that seem to upset my stomach, but I don't see a major downside to cooked legumes. Sure, there are some anti nutrients, but I don't see the major issues as one might find with seed oils, gluten, and vast quantities of sugar.

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  5. (soy and peanuts are probably special cases of nasty legumes)

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  6. I'm jealous that you got to hang out with Guyenet!

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  7. "..heart disease has been in decline for the past 30-40 years"

    I think the decline in smoking could have a lot to do with this.

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  8. I appreciate your summary of this conference.

    I have a lot of respect for Willett. I don't recall him ever giving an opinion on the omega-6/omega-3 ratio, which would entail a review of industrial seed oil consumption. Like me, perhaps he's never looked into it. I know he still favors substituting polyunsaturated fatty acids for saturated fats, to lower cardiovascular disease risk. But I seem to recall his co-authorship of some of the recent articles showing no relationship between saturated fat consumption and cardiovascular disease.

    I have some articles by Dr. Lands in my "read soon" pile. He's generally anti-omega-6.

    -Steve

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  9. Hi Steve - Loving your new paleo diabetic blog! I have this wacky (unsupported, but not entirely my own) theory that obesity and insulin resistance are in part brought on by an excess of polyunsaturates, but that stuffing fat into the cells protects us against heart disease for some time, delaying it by 10-20 years…though the temporary "cure" ultimately worsens the disease. I don't know how much money I would put on that theory.

    Yes, Willet is an intriguing fellow, and has done tons of amazing work - but I still can't get over how certain he was of his epidemiology. I have mixed feelings, because on one hand he admits sat fat is neutral and we should eat whole foods, on the other hand he pens papers with a "polyunsaturated fat/saturated" ratio that makes sat fat look bad, and talks abut nutrients in isolation a great deal. Stephan pointed out that the data on the omega6/omega3 ratio in these epi studies are generally poor - you often can't even tell from a package what seed oil was used (was is canola, safflower, corn?)

    In all, I get a weird sense we are all on the same team (I have no beef with the Mediterranean diet to be sure, specially knowing from some mental health related epi studies that they studiously avoid seed oils and margarine, for the most part) - I do tend to think we don't need to be quite as restrictive and can add beef and (especially fermented) dairy to the fish, nuts, greens, and olive oil, and while in non-celiacs the sourdough traditional bread probably isn't a big deal… I'm obviously not a big pasta fan ;-)

    Lands is a good writer. Simopolous has some good papers too on O6/O3. It is affected by diet but also genetic differences and upregulation depending on diet, so, like everything, complicated.

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  10. Legumes - aside from the anti-nutrients, the fact you must soak, cook and whatnot to make them even vaguely edible they contain large quantities of carbohydrate - they also create large amounts of gas, and any 'food' that does that makes me wonder if it should really be going through my digestive tract ... but by apart from all that ...

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  11. Lustig should ditch "policy" and stick to science.

    Metabolic syndrome is healthier than fascism.

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  12. Good times being around such stimulating people - people that challenge your thinking, one way or another. Whilst it will be difficult to listen to one of the top researchers confidently challenge some of what we hold in our paleo paradigm, I think we need this. It can be too easy to shield ourselves from this sort of thing and become quite insular. If we (actually, you!), can sit there, listen to Willet, and be able to strengthen your thoughts and arguments, then that has to be a good thing.

    With regard to the likes of individual variation to gluten, dairy, and legume tolerance, etc., whilst I have no doubt that there are degrees of tolerance within people, we are faced with not knowing a) just how far this tolerance extends - just what dose we can handle, and b) we often do not know what dose we are getting from the foods than might contain some of these components. With many of these "intolerances" being clinically silent, and combined with the resilence of our physiology (as you point out above, perhaps we stuff fat into our fat cells in order to protect ourselves from cardiovascular disease, but really end up just delaying things by 10-20 years), what might appear to be tolerance in the short term might in fact still see an undermining of our health in the longer term. I do wonder how many people, who claim tolerance to foods that sit largely outside of our paleolithic history, still suffer health issues that could perhaps be traced back to these very foods? Perhaps they have delayed the onset, but still suffer it nonetheless? Perhaps a lunch date in 20 years time with all of these people would be very interesting indeed!

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  13. maybe, just maybe, a life span of 60 yrs is what the planet and human race needs. I'm Paleo, I don't want to live forever, I just want to feel and act young when I die, not hauling oxygen in a wheel chair on a dozen different meeds.

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  14. What scares me about legislating against sugar is that it sets a precedent for legislating against other things that "everybody knows is bad" like saturated fat. Denmark has already imposed a saturated fat tax which remains in place.

    This scares me, because in my opinion it's difficult or impossible to consume a healthy diet that doesn't contain a large portion of saturated fat, especially if you're pre-diabetic.

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  15. The lunatic fringe... some say there is a fine line between madness and genius.

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  16. Doc Em wrote: "I have this wacky (unsupported, but not entirely my own) theory that obesity and insulin resistance are in part brought on by an excess of polyunsaturates, but that stuffing fat into the cells protects us against heart disease for some time, delaying it by 10-20 years…though the temporary "cure" ultimately worsens the disease. I don't know how much money I would put on that theory."

    You know that's pretty interesting because a friend of mine who's less scientific and rigorous than me about this stuff (and that's saying something) but pretty brilliant and intuitive, was pontificating his own hypothesis that obesity and insulin resistance could be a protection against cancer. This wasn't based on anything specific like stuffing PUFAs away to avoid CHD but something more general like the fact that skinny people seem to be more prone to early cancers, if less prone to CHD. At least I think that's how the hypothesis went, we were drinking wine in a cafe at the time and things got a bit fuzzy.

    It's interesting that obesity and the hormonal responses known as metabolic syndrome might actually be the body's optimal long-term response to NAD howitzers.

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  17. I just want to add that Willett's moustache is spectacular. That is all.

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  18. I read an article in the New York Times this morning by Daniel Kahneman called "Don't Blink! The Hazards of Confidence" that I thought had some relevance to this discussion vis-a-vis "conventional wisdom":

    http://www.nytimes.com/2011/10/23/magazine/dont-blink-the-hazards-of-confidence.html?pagewanted=4&_r=1&ref=health

    Pertinent quote: "Facts that challenge...basic assumptions--and thereby threaten people's livelihood and self-esteem--are simply not absorbed."

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  19. Thanks for a great post. We ALL sleep better knowing you are blogging.

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  20. Dr. Deans,

    When you note that heart disease has been in decline, can you provide the working definition of heart disease?

    Does it mean that there have been less people showing up at ERs suffering from heart attacks? Or does it refer to a measure of LDL-C?

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  21. I think I found the definition of heart disease. Wow, that covers a lot of ground.

    http://circ.ahajournals.org/content/123/4/459.full.pdf+html

    I don't know about Willet, but Krauss put the final nail in the saturated fat coffin a while ago. I don't know how or why these alleged experts cling so tightely to a fiction that has been disproven time and again. When it comes to the lipid hypothea-sis, it reminds me that we are no better off in many respects than was Galileo.

    http://www.ajcn.org/content/early/2010/01/13/ajcn.2009.27725.abstract

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  22. I want to thank you for helping people understand that for good mental health you have to feed the body (which includes the brain) well! It's amazing how most people don't know this simple fact of healthy brain function.

    And secondly, I'm commenting on your general premise of promoting animal products because you don't know how vegetarians get certain nutrients. I'd suggest you actually study healthy vegetarians (by which I mean herbivores, not "not-eat-meaters" :), especailly studying raw foodists who are always much, much healthier than everyone else, in all ways. Studying those of us who are eating the most nutritious foods available (mostly dark leafy organic greens, plus some fruits, other veggies, and nuts) will help you understand where we get the nutrients we need to be exceptionally healthy.

    Good luck!

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  23. @turil- Greens aren't nutritious, humans aren't herbivores...

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  24. Dr. Deans,

    I wanted to chime in and say I find your blog incredibly informative, and it's my top choice for nutrition info. I think of all the "paleo" bloggers, your style is best -- strong research, explained well, and your general nutrition advice is dispensed in a somewhat Clint Eastwood-esque manner: He doesn't make a big production of filming scenes, he doesn't do a big countdown, he just quietly says go and lets the actors do their thing. It's low-fuss and natural, not something done with tons of fanfare (or so I've read). So thanks for being so simple and direct, and non-sensationalizing with your writing. Nutrition info can be overwhelming if you let it.

    On another note, I'm a student as HSPH, and boy... do I get frustrated in class. In the past week I've been lectured on "what is a healthy diet?," the benefits of polyunsaturated fats, etc, etc. You know the drill. I think Walter Willett is speaking to us later in the semester; too bad you can't be invited in, that would really shake them up. (I'd love it.)

    Anyway, huge thanks for all you do. Your blogging style is certainly my favorite.

    Cheers,
    E

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