..man, proud man,
Dress’d in a little brief authority,
Most ignorant of what he’s most assur’d…

From Measure for Measure by Wm Shakespeare

The web has been alive with commentary the past few weeks since Denise Minger lobbed her first cannonball of a critique across the bow of The China Study, the vessel T. Colin Campbell, Ph.D. rode to fame and bestsellerdom.  Seems like everyone is now jumping into the fray and gunning for poor Dr. Campbell, who early on in the fracas made a few halfhearted attempts to fight back but has now fled the scene.  I’ve been laying low watching it all play out, and so now figured it’s about time I add my two cents worth to the debate. But first a little history.

I met Dr. Campbell about ten years ago (five or so years before the publication of the popular book The China Study) when we both spoke at the same conference.  He was a nice enough man who spoke about the work he and his team had done in China gathering the data published in the massive 894 page monograph Diet, Life-style and Mortality in China (pictured above left).  As Dr. Campbell presented his data ‘demonstrating’ the superiority of a plant-based diet and demonizing protein of animal origin, I didn’t think much about it because the data was all in the form of observational studies, which, as all readers of this blog should know by now, despite often showing correlation don’t prove causation.  My lecture, which followed Dr. Campbell’s, was, as you might imagine, a lecture of a different sort.  Then we both sat on a panel after our talks and fielded questions.  And were both cordial to one another.

A few years ago, I became vaguely aware that Dr. Campbell had written a popular book on his work in China titled, appropriately enough, The China Study.  I assumed it pretty much mirrored his presentation I had watched, so didn’t rush out and grab a copy.  Over the past few years a number of people have asked about The China Study through the comments section of this blog, and I’ve typically answered that the data are all observational and so not really meaningful in terms of causation.

(Note: Throughout this post whenever I refer to the popular book Dr. Campbell wrote, I’ll call it by it’s title The China Study, and when I refer to the large study Dr. Campbell was involved with in China and was the basis for the monograph Diet, Life-style and Mortality in China, I’ll call it the China study.)

About a year ago, I wrote a guest post for Tim Ferriss’s The Four Hour Workweek blog.  It actually wasn’t a guest post as much as it was an excerpt of a chapter from our book The Six-Week Cure for the Middle-aged Middle extolling the virtues of saturated fat.  It was a popular post that has garnered to date 520 plus comments, many of them fairly spirited.  I agreed to answer a number of the comments and did so.  I noticed as I sifted through them that a handful were absolutely fawning of Dr. Campbell and The China Study.  Here is a sampling:

The number one study of diet and disease is the China Study. All other data points are slivers compared to the volume of data and statistical correlations that came from the China Study.

Have you read The China Study? Dr. Campbell points out repeatedly that none of the weight loss studies such as Atkins or South Beach diet follow any type of peer reviewed scientific method.

Tim…and to think I was such a big fan of yours. This is by far the weakest (and least cited) argument I have ever read on diet–especially increasing saturated fats. Half knowledge is a scary thing in the hands of influential people. Maybe it’s another genius marketing ploy (like the myth riddled protein Atkin’s diet)–people love to feel good about their personal yet poor decision making–and diet is very personal. Check out researchers that actually meant to study nutrition–like Dr. T. Colin Campbell’s The China Study comes to mind.

It was pretty apparent that the disease of non-critical thinking was at epidemic proportions.

After reading a number of these, I decided I had better take a look to see what Dr. Campbell had going on that had attracted such devotees.  I pulled up his book on Amazon and read through a few comments, most of which were even more nauseatingly gushing than the above.  I ordered a copy of The China Study.

I knew that both Anthony Colpo and Chris Masterjohn had done their own critiques of the original data, so I figured, what the hell, I’ll take a look at the ‘real’ China study (as opposed to the popular book of that name) and do one too.  And I’ll critique the popular book, which I figured was a rehash of the China project, while I’m at it.

I tracked down a copy of the 894 page book in a bookstore in the UK and forked over $240 to purchase it and have it shipped.  As I was awaiting its arrival I told Gary Taubes what I had done, and he replied that he had done the same thing himself a few years earlier.  And that I could have borrowed his.  And, even worse, that most of the data was available online for free.

When the book arrived, I was amazed at the size of it.  Not only was it the 894 pages as advertised, it was in a large format.  Much larger than a volume of the Enclyclopaedia Britannica.  It wasn’t at all what I thought it would be.

Here are a couple of photographs shamelessly using our own book to show the size of this behemoth

Of the 894 pages, the first 82 are a study overview, description of methodology and author commentary.  It is written in the form of a scientific paper with half the page in English and half in Chinese (which, presumably, is a translation of the English half).  The remainder of the 894 pages are raw data and correlations.  Page after page after page of correlations.  I didn’t bother counting them, but Dr. Campbell says there are 367 variables, each of which is compared with every other variable.  I don’t doubt him.  This study was a massive undertaking, requiring thousands upon thousands of man hours and God only knows how much money.  No one can possibly accuse the team members of not giving it their all.

Here is one page of correlations.  This one between stearic acid and all the other variables studied.

But in the end it is still only an observational study.  And even though – again, according to Dr. Campbell – there are over 8000 statistically significant correlations, correlations are not causation.  Any scientist worth his/her salt will tell you that all you can do with data from observational studies is use them to form hypotheses that can be rigorously tested in randomized, controlled trials.  Then and only then (assuming the study results show it) can you even begin to talk about causation. The whole enterprise, costly and time consuming though it was, was described perfectly by Shakespeare in the words of MacBeth:

…it is a tale
Told by an idiot, full of sound and fury,
Signifying nothing.

Once I saw that the original China study was nothing but a huge number of correlations, I quickly lost interest.  What is the point in going through the brain damage of ferreting around in these to see if Dr. Campbell interpreted them correctly when he tries to make his case that a plant-based diet is optimal.  It doesn’t really matter whether he interprets them correctly or not, they are only correlations.  Repeat after me one last time: Correlation is not causation, correlation is not causation, correlation is not causation…

I wondered why Dr. Campbell and his group didn’t spend a fraction of the time and money they spent on this behemoth of a spreadsheet full of correlations on a real study that could provide hard evidence.  Why not randomize subjects into two groups and provide one a plant-based diet and the other a meat-based diet or something similar.  Lock them down as Ancel Keys did if they had to.  Surely the money spent on the China study could’ve covered that.  Get some real data.  I discovered later that I wasn’t the only one who wondered that.  Even some of Dr. Campbell’s own colleagues abandoned him to this study and told him it would be worthless.  More about this later.

So enough for me.  I stuck my copy of the $240 book of correlations in my library and forgot about it.  Until Denise Minger’s critique hit the net.

Upon reading her blog post, my first reaction was This is great; someone took the time to do what I was going to do. I figured Dr. Campbell had cherry picked his correlations to  make the case he wanted to make, and I had seen Colpo and Masterjohn catch him on it.  Ms. Minger went even further and really caught Dr. Campbell with his pants down, correlation-misinterpretation speaking.  I continued to read with mounting glee Ms Minger’s successive critiques and a few other bloggers who had critiques of their own.  (Believe me, there is no dearth of material here for people to attack without any two attacking the same data twice.)

After this went on for a while, I had my second reaction to the whole affair.

Which was that I had fallen victim to the confirmation bias.  My bias was that Dr. Campbell was wrong, so I was more than happy to uncritically accept evidence confirming his error without lifting a finger to double check said evidence myself.  I knew that if a blogger somewhere had come out with a long post describing an analysis of the China study demonstrating the validity of all of Dr. Campbell’s notions of the superiority of the plant-based diet, I would’ve been all over it looking for analytical errors.  But since Ms. Minger’s work accorded with my own beliefs, my confirmation bias ensured that I accepted it at face value.

Once the fact that I had succumbed to my confirmation bias settled in around me, I became suffused with angst.  I had tweeted and retweeted Ms. Minger’s analysis a number of times, giving the impression that I had at least minimally checked it out and had approved it.  I had emailed it to a number of people, many of whom, I’m sure, had forwarded it on.  I’m sure I played a fairly large role in the rapid dissemination of the anti Campbell/China study info.

(It didn’t really make me feel better to know I wasn’t alone in falling into the confirmation bias quicksand.  Take a look at this post from Richard Nikoley’s Free the Animal blog.  I doubt that all these people checked Ms. Minger’s calculations before posting.)

My angst wasn’t because I had possibly fed the flames of a misinformation wildfire – I wasn’t particularly worried about that because mountains of other data (including first hand data from my own clinical practice) have persuaded me that Dr. Campbell is dead wrong in his ideas about the superiority of a plant-based diet.  No, my angst arose for two other reasons: first, because I was distressed that I so easily fell prey to the confirmation bias, and, second, because I felt I needed to go through all the calculations  myself to make sure Ms. Minger and others whose work I had circulated were truly correct in their analyses.

As I was wallowing in self pity over all this, I didn’t realize that salvation was at hand. And that my savior was none other than Dr. T. Colin Campbell himself.

Yep, his first response to Denise Minger’s critique of his work appeared on the Tynan.net website and rescued me from my pit of self-loathing.  In it, Dr. Campbell wrote:

But she suffers one major flaw that seeps into her entire analysis by focusing on the selection of univariate correlations to make her arguments (univariate correlations in a study like this means, for example, comparing 2 variables–like dietary fat and breast cancer–within a very large database where there will undoubtedly be many factors that could incorrectly negate or enhance a possible correlation). She acknowledges this problem in several places but still turns around and displays data sets of univariate correlations.

In other words, the China study is an observational study comparing one variable to another (univariate correlations) and, as such, meaningless.  And this from the man’s own pen.

Since these observational studies are meaningless in terms of causality, it doesn’t really matter how one slices and dices the data because meaningless correlations by any other names are still just as meaningless.  All this falderal over whether or not Dr. Campbell had his interpretations right was tantamount to the medieval theological argument over how many angels could stand on the head of a pin.  And my participation certainly wasn’t required.

I’d known this all before, of course, but somehow had lost my focus on it.

I was ready to wash my hands of the whole affair when I came across another statement Dr. Campbell made in his response to Ms. Minger’s critique.  Writing of her, he said:

One further flaw…is her assumption that it was the China project itself, almost standing alone, that determined my conclusions for the book (it was only one chapter!). She, and others like her, ignore much of the rest of the book.

Only one chapter? As I mentioned above, I always figured The China Study was simply Dr. Campbell’s tale of the China study and the conclusions he had drawn from it.  Now he says that only one chapter is about the China study, leaving me to conclude that the rest must be about something else.  I found the book, which I hadn’t yet taken from the pack it came in from Amazon, opened it and started reading.

Wow!

In 1976 author Mary McCarthy famously said live on the Dick Cavett show of her rival Lillian Hellman:

Every word she writes is a lie, including ‘and’ and ‘the’.**

I feel much the same way about The China Study.  Except it’s not really a lie, it’s an obfuscation.

In fact, in my studied opinion, The China Study is a masterpiece of obfuscation.

It is obfuscatory in so many ways it could truly qualify as a work of obfuscatory genius. It would be difficult for a mere mortal to pen so much confusion, ambiguity, distortion and misunderstanding in what is basically a book-length argument for a personal opinion masquerading as hard science.

Let me take just one tiny section of the book, one that is in no way atypical, and show you what I mean.

In Chapter 3 titled Turning Off Cancer, Dr. Campbell is starting to hit his stride in his anti animal protein jihad.  He has described the three stages of cancer – initiation, promotion and progression – and is setting the stage for his description of his laboratory work implicating animal protein in all three stages.

Here is his setup paragraph starting on page 50:

At the start of our research, the stages of cancer formation were known only in vague outline.  But we knew enough about these stages of cancer to be able to structure our research more intelligently.  We had no shortage of questions. Could we confirm the findings from India that a low-protein diet represses tumor formation?  More importantly, why does protein affect the cancer process?  What are the mechanisms; that is, how does protein work?  With plenty of questions to be answered, we went about our experimental studies meticulously and in depth in order to obtain results that would withstand the harshest of scrutiny.

The “findings from India that a low-protein diet represses tumor formation” were the results of a rodent study published in the Archives of Pathology in 1968 that Dr. Campbell wrote about 14 pages earlier in the book.  He mysteriously refers to the Archives of Pathology as an obscure journal when it is anything but.  It was published then by the American Medical Association and still is today under the new name Archives of Pathology & Laboratory Medicine.  But the notion of the paper initiating his quest being discovered by Dr. Campbell in an “obscure medical journal” fosters the impression of him as a leave-no-stone-unturned kind of guy.  Even the little throw away but incorrect phrase “obscure medical journal” is part of the greater picture of obfuscation that maintains throughout the book.

The study from India showed that rats given aflatoxin along with a high-protein diet got liver cancer while rats given the same amount of aflatoxin while consuming a low-protein diet didn’t.  Aflatoxin is a substance released from a fungus often found in peanuts, corn, other grains and even hay. It is converted in the liver to a much more toxic compound and is often used in laboratory experiments with animals to induce cancer and other problems.

Moving on, here is what Dr. Campbell has to say about protein and cancer initiation:

[I] How does protein intake affect cancer initiation?  Our first test was to see whether protein intake affected the enzyme principally responsible for aflatoxin metabolism, the mixed function oxidase (MFO).  This enzyme is very complex because it also metabolizes pharmaceuticals and other chemicals, friend or foe to the body.  Paradoxically this enzyme both detoxifies and activates aflatoxin.  It is an extraordinary transformation substance.

[II] At the time we started our research, we hypothesized that the protein we consume alters tumor growth by changing how aflatoxin is detoxified by enzymes present in the liver.

[III] We initially determined whether the amount of protein that we eat could change this enzyme activity.  After a series of experiments, the answer was clear (Chart 3.2).  Enzyme activity could be easily modified simply be changing the level of protein intake.

[IV] Decreasing protein intake like that done in the original research in India (20% to 5%) not only greatly decreased enzyme activity, but did so very quickly.  What does this mean?  Decreasing enzyme activity via low-protein diets implied that less aflatoxin was being transformed into the dangerous aflatoxin metabolite that had the potential to bind and to mutate DNA.

These four little paragraphs and accompanying chart take up less than a page in space, and are tiny glittering gems of obfuscation.  Let’s deconstruct.

First, take a look at how subtly these four paragraphs are written, especially II.  Note how he writes “the protein we consume”?  I’m sure many people took these paragraphs to mean that the studies were done on humans.  That’s almost the implication.  Reread them to see if they indicate anywhere that the author is talking about rat studies.

As Dr. Campbell progresses through this chapter, he does ultimately tell the reader he is talking about rat studies and not human studies, but he doesn’t mention the word rat for another two pages after the above paragraphs. By this time it’s probably implanted in the minds of many readers that he’s talking about human studies.

He describes experiments showing that rats getting diets high in casein (a milk/animal protein) develop more cancer at the same dose of aflatoxin than do rats getting a lower-casein diet.  The implication: animal protein causes cancer.

Dr. Campbell then gave his rats diets of varying amounts of plant protein (wheat gluten) and found that they did not get cancer after exposure to aflatoxin irrespective of protein dose.  Same thing happened with soy.  Implication: plant protein protects against cancer.

If you’re worried about cancer – and who isn’t – you’re now starting to look at animal protein a little differently.  Which is what Dr. Campbell wants.  But he hasn’t told you the complete story.

As I’ve written often in these pages, rodents aren’t just furry little humans.  They are a distinct species separate and apart from humans.  The rodents usually used in lab experiments are Sprague-Dawley rats, and inbred strain that has a tendency to develop cancer easily. (See Abelson, PH. (1992) Diet and Cancer in Humans and Rodents, Science 255(5041); Jan 10: 141)  In fact, these rats can develop cancer just from a change in diet.  I ran quick checks on a bunch of the studies referenced in The China Study, and all checked used Sprague-Dawley rats.

And think about this.  If you were to visit a farm and search for rodents, where do you think you would be most likely to find them?  In the grain or in the milking area?  Like Dr. Campbell, I grew up in a rural area and spent a lot of time on a farm.  Rats and mice are in the hay and in the grain.  You have a helluva time keeping them out of the animal feed, which they eat, too.  Grain and hay are common places for growth of the fungus that produces aflatoxin.  Since rodents spend most of their days in this stuff (grains), and since they eat it as well, I would bet that most have adapted over the generations to  the combination of plant protein and aflatoxin.  If this did them in regularly, there wouldn’t be the rodent problem on farms that there is.  So, in my opinion, making a huge issue of the fact that rats didn’t get cancer after dosing with aflatoxin irrespective of how much plant protein they ate is pretty disingenuous.

Most disingenuous of all in the above four paragraphs and chart is the lack of full disclosure in these paragraphs of the very study Chart 3.2 is made from. Let me explain.

Certain enzymes in the liver convert aflatoxin into a more toxic substance that Dr. Campbell claims can initiate the formation of cancer.  He demonstrates in rat studies that giving the rats a lower protein diet decreases the activity of this enzyme, meaning that the lower the protein intake, the less conversion of the aflatoxin into the really nasty stuff.  Chart 3.2 above and on page 52 of his book shows this graphically.

When I pulled the study from which this chart was adapted (Mgbodile MUK and Campbell TC. (1972) Effect of protein deprivation of male weanling rats on the kinetics of hepatic microsomal enzyme activity, J Nutr, 102: 53-60.) and read it, I found a little disclaimer Dr. Campbell didn’t bother to mention in The China Study.  You can read the last paragraph of the study (highlighted in yellow) below:

Nice, eh?  He hits the nail on the head.  Protein utilization may be influenced by what is eaten along with the protein.  Sucrose (table sugar) was eaten along with the protein used in this experiment.  In other experiments corn starch was used instead of sugar and the effect of the protein on the enzyme was diminished, meaning that the protein along with starch did not have nearly the same effect as protein with the sugar.  Who knows whether or not it’s even the protein that has the effect and not the sugar?  It can’t be shown from this study. That caveat certainly didn’t make in into The China Study.

See what I mean about a masterpiece of obfuscation?

I could go on and on, but I’ll quit after I give you just a couple more examples.

On page 107 of The China Study Dr. Campbell writes:

At the end of the day, the strength and consistency of the majority of the evidence is enough to draw valid conclusions.  Namely, whole plant-based foods are beneficial, and animal-based foods are not.

Then one inch below (literally) he writes the following:

The China Study was an important milestone in my thinking.  Standing alone, it does not prove that diet causes disease. [Italics in the original]

So, the China study produces valid conclusions as to causality, i.e., “whole plant-based foods are beneficial, and animal-based foods are not.”  Yet the China study “does not prove that diet causes disease.”  Say what?

Don’t believe me, take a look at a scan of my copy:

On page 73 Dr. Campbell dons the mantle of prestige conferred by one of America’s most august newspapers.  Writes he referring to the China study:

We had a study that was unmatched in terms of it’s comprehensiveness, quality and uniqueness.  We had what the New York Times termed “the Grand Prix of epidemiology.”

A quick search of that phrase in the online version of the NY Times reveals that it came from an opinion piece by none other than Jane Brody, a kindred spirit to Dr. Campbell.  Brody, a lipophobe of the deepest hue, has written a number of low-fat cookbooks and is a believer in the plant-based diet. So she hardly qualifies as an unbiased commenter.

And speaking of the so-called plant-based diet, when Dr. Campbell responded to Ms. Minger’s critique, he took her to task for mentioning the words ‘vegan’ and ‘vegetarian’ as it applied to his work.

One final note: she repeatedly uses the ‘V’ words (vegan, vegetarian) in a way that disingenuously suggests that this was my main motive. I am not aware that I used either of these words in the book, not once. I wanted to focus on the science, not on these ideologies.

Just for grins, I turned to the index of The China Study to see if ‘vegan’ or ‘vegetarian’ were indexed.  Here’s what I found on page 417:

vegetarianism or veganism. See plant-based diet

When I flipped over  to ‘plant-based diet’ on page 414, I found a long grocery list of references.

Even in his online response to his opponents, Dr. Campbell apparently can’t resist obfuscating.

Okay, just one more, then I’ve got to draw this to a close.  Let’s go back to the bottom of page 52, the page the paragraphs above and Chart 3.2 appear on.  Dr. Campbell shows in Chart 3.2 how protein is involved in stimulating the liver to convert aflatoxin to the toxic product that he implies is involved in cancer initiation.  He then reports how he wanted to see if animal-based protein was involved in the other phases of the cancer progression cascade.  So he and his grad students started to look.  He writes:

As time passed, we were to learn something quite remarkable. Almost every time we searched for a way, or mechanism, by which protein works to produce its effects [on cancer formation and progression], we found one!

That, my friends, is almost the dictionary definition of the confirmation bias summed up in one sentence.

This tiny bit of the book that I’ve chosen to lay bare is truly the tip of the iceberg.  I could go on and on and on, but I’m sure you get the picture.

Before I finish, I want to get back to something I mentioned earlier about how one of Dr. Campbell’s own colleagues bailed out from the China study because he recognized it for what it was: a giant observational study that was meaningless.  Here is how Dr. Campbell describes it on page 105-106:

When we first started this project we encountered significant resistance from some people.  One of my colleagues at Cornell, who had been involved in the early planning of the China Study, got quite heated in one of our meetings.  I had put forth the idea of investigating how lots of dietary factors, some known but many unknown, work together to cause disease.  Thus we had to measure lots of factors, regardless of whether or not they were justified by prior research.  If that was what we intended to do, he said he wanted nothing to do with such a “shotgun” approach. [i.e., a big, meaningless observational study]

This colleague was expressing a view that was more in line with mainstream scientific thought than with my idea [i.e., a randomized, controlled trial that might demonstrate causality would be a better use of the funds.] He and like-minded colleagues think that science is best done when investigating single – mostly known – factors in isolation. [He and like-minded colleagues are correct.] An array of largely unspecified factors doesn’t show anything, they say. [They are right.] It’s okay to measure the specific effect of, say, selenium on breast cancer, but it’s not okay to measure multiple nutritional conditions in the same study, in the hope of identifying important dietary patterns.

I prefer the broader picture, for we are investigating the incredible complexities and subtleties of nature itself…

So I say we need more, not less, of the “shotgun approach.” We need more thought about overall dietary patterns and whole foods.  Does this mean that I think the shotgun approach is the only way to do research?  Of course not.  Do I think that the China Study findings constitute absolute scientific proof?  Of course not.  Does it provide enough information to inform some practical decision-making? [No.] Absolutely.

Dr. Campbell uses an impassioned written speech to persuade the scientifically untrained that the China study carries vastly more scientific value than it actually does. Once again, it’s a large observational study, but an observational study nonetheless.  And as such, it is useful only in developing hypotheses to be tested with randomized, controlled trials.  The entire 894 page study proves not a shred of causality.

What saddens me about all this is that hundreds of thousands (probably millions) of people who can’t (or won’t) read critically have fallen for the premise of The China Study without even thinking about it.  Believing that the entire book is based on the greatest and most important nutritional study ever completed.  What happened to the ability to read critically?  Has it vanished from the populace?  Based on the comments on The China Study on Amazon it would seem so.

In my opinion, there really isn’t much of substance in the entire 400 plus page book.  But I encourage you to buy it and read it to test your own critical reading skills.  If you don’t want to test your critical reading skills, you’ll at least enjoy coming across some real howlers such as this one believed only by the vegetarian/vegan zealots out there (oh, sorry, plant-based diet followers):

As you will see in this book, there is a mountain of scientific evidence to show that the healthiest diet you can possibly consume is a high-carbohydrate diet. [italics in the original]

I wonder if Gary Taubes, who wrote a vastly more scientific book, would agree?

Lest you think I’m being too hard on poor Dr. Campbell, let me tell you a few things.  First, as I mentioned earlier, the few sections of The China Study I dissected are just a tiny fraction of the whole.  I could go on and on. Second, Dr. Campbell mentions Protein Power by name on page 19 and labels it a modern protein fad diet that “continue[s] to inflict a great variety of dangerous health disorders.”  Third, he is absolutely and unnecessarily brutal in his treatment of Dr. Robert Atkins.  He has an entire section on Dr. Atkins starting on page 95 that runs for almost three pages.  After quoting from one of Dr. Atkins’ books, he writes the following about the deceased diet doctor:

There are snake oil salesman, who have no professional research, professional training or professional publications in the field of nutrition, and there are scientists, who have formal training, have conducted research and have reported on their findings in professional forums. Perhaps it is a testament to the poser of modern marketing savvy that an obese man with heart disease and high blood pressure [here he inserts a citation for an article discussing Dr. Atkins’ death] became one of the richest snake oil salesmen ever to live, selling a diet that promises to help you lose weight, to keep your heart healthy and to normalize your blood pressure.

A way below-the-belt commentary when you consider that Dr.Atkins was a trained cardiologist who took care of thousands of real, live patients throughout his career – he wasn’t, like Dr. Campbell, a bench scientist doing rat studies in a lab.  Bob Atkins and I have had our differences, but were he still alive, I would vastly prefer to put my own care in his hands than I would those of Dr. Campbell, who has never treated a patient in his life.

You may ask if I took anything of value from my reading of this book?  I did.  On page 107 Dr. Campbell writes the following:

The results of this study…convinced me to turn my dietary lifestyle around. I stopped eating meat fifteen years ago, and I stopped eating almost all animal-based foods, including dairy, within the past six to eight years, except on very rare occasions,  MY cholesterol has dropped, even as I’ve aged; I am more physically fit now than when I was twenty-five; and I am forty-five pounds lighter now than  was when I was thirty years old.  I am now at an ideal weight for my height.

I have no reason to doubt Dr. Campbell’s own medical and dietary history (except maybe for the part about being more physically fit than he was at age 25 – that’s a tough act for someone who is 73), so I’ll assume it’s all true.  As I recall, he had a trim physique when I met him 10 years ago, which, assuming nothing has changed, is probably the same.  And I’m going to take Dr. Campbell at his word about what he eats.

Granted, I’m younger than Dr. Campbell, but I follow almost the opposite diet as he does yet I, too, have low cholesterol, very low blood pressure and am ideal weight for my height.  What this all tells me is how wonderfully adaptive the human species is where diet is concerned.  It’s no wonder we took over the earth.

** Lillian Hellmann was predictably furious over McCarthy’s comment and adopted the typical American response: she sued.  In one of those turns in which the law of unintended consequences jumps up and bites one, many of her untruths came to light in the courtroom as McCarthy was forced to defend her statement.  Hellmann disengaged by dying during the proceedings.

You think carbohydrates aren’t addictive?  You think it’s easy to give them up?  You don’t think it possible that people might prefer carbs to life?

Think again.

A story appeared in the online version of Time Magazine last year that I read when it came out, put aside to blog about later, then got sidetracked.  A reader sent me a link to it a few days ago, which brought it back to the front of my mind.

The article discusses a study being done in Germany using a carb-restricted diet to fight cancer.  In pre-WWII days, a German scientist, Otto Warburg, received a Nobel Prize for his work in sussing out the fact that cancer cells don’t generate energy the same way that normal cells do.  Cancer cells get their energy, not like normal cells, from the mitochondrial oxidation of fat, but from glycolysis, the breakdown of glucose withing the cytoplasm (the liquid part of the cell).  This different metabolism of cancer cells that sets them apart from normal cells is called the Warburg effect.  Warburg thought until his dying day that this difference is what causes cancer, and although it is true that people with elevated levels of insulin and glucose do develop more cancers, most scientists in the field don’t believe that the Warburg effect is the driving force behind the development of cancer.

But it stands to reason that it can be used to treat cancer that is already growing.  Since cancers can’t really get nourishment from anything but glucose, it stands to reason that cutting off this supply would, at the very least, slow down tumor growth, especially in aggressive, fast-growing cancers requiring a lot of glucose to fuel their rapid growth.

Thomas Seyfried (the same Thomas Seyfried mentioned in the article) has shown that ketogenic diets in animals and humans can stop malignant brain tumors.  There is no reason to believe they wouldn’t work in humans as well.

A group in Germany is looking at such diets in a small pilot study.  Patients are only admitted to the study when all standard therapies – chemotherapy, radiation, surgery, etc. – have failed and they have basically been sent home to die.  In fact, a few were so far gone that they died within the first week of starting the study. You couldn’t ask for a study group more destined for failure, but, according to the Times article

The good news is that for five patients who were able to endure three months of carb-free eating, the results were positive: the patients stayed alive, their physical condition stabilized or improved and their tumors slowed or stopped growing, or shrunk.

If you understand the Warburg effect and the metabolism of cancer cells, it’s easy to see why this therapy works, even in patients who at at death’s door.  Since the cancers can use only glucose, and since glucose is made in the cancer cells slowly and inefficiently, the cancer cells have to rely on outside glucose to provide nourishment for their rapid growth and replication.  People on very-low-carb diets produce ketones, which take the place of glucose in other cells that can use these ketones for fuel.  But cancer cells can’t use the ketones since ketones have to be burned in the mitochondria, which are dysfunctional in cancer cells.  If you can keep blood sugar low, then growth of the cancer cells may be held in check long enough for the body’s own previously overwhelmed immune system to rally and beat the vulnerable cancer back.

Now, given all this, if you had a big cancer eating you alive and you were offered a chance for salvation by doing nothing more than following a low-carb diet, would you take it?  I certainly would.  But, not everyone does. I was stunned to read the comments of Dr. Melanie Schmidt, one of the researchers, about people dropping out of the study.

[Some] dropped out because they found it hard to stick to the no-sweets diet: “We didn’t expect this to be such a big problem, but a considerable number of patients left the study because they were unable or unwilling to renounce soft drinks, chocolate and so on.”

Let me see if I’ve got this right.  A lifesaving therapy is offered to patients who have undergone the misery of radiation therapy, chemotherapy, and surgery, and who are beyond hope, and this therapy requires nothing more than eating a lot of butter, meat, cream, cheese, etc. while avoiding most carbohydrates.  And a considerable number” drop out because they can’t give up carbs?

I say it again.  And you don’t think carbs are addictive?

As a coda to this post, I’ve got to tell you that MD at this very moment is rolling out a fondant that she made a couple of days ago.  She was dragooned into making the birthday cake for our granddaughter whose party is tomorrow.  The kid doesn’t want a store-bought birthday cake, she wants a custom-made cake by her Nanny, which has become a tradition.  She wants a Razor (a Swat Kat) cake, so MD is having to free-hand it.  Although she’s never made a fondant before, she figured that would be the easiest way to frost and decorate the cake she has in mind.  I wandered over to get a cup of coffee and pulled off a tiny piece of the stuff and popped in my mouth just to see what it tasted like.  Her fondant is made with powdered sugar, corn syrup, and lard (not the vegetable shortening called for in the recipe), and it is good beyond belief.  I’m sitting here writing this post, and after a tiny, tiny piece (maybe 3/4 inch by 1/2 inch by 1/8 inch) of fondant, I am obsessing over how easy it would be to walk the 10 feet to where it is and start throwing it down by the handfuls.  So, yes, carbs are addictive.  Especially the carb-fat combo.

Lest you get the wrong idea, our granddaughter’s parents keep her on a kid’s version of the low-carb diet most of the time.  The cake is a once a year deal.  Thank God.

Here we go again. No doubt you’ve seen on T V or read in the news that meat causes colon cancer. At least that’s the take home message you got if you saw any of these ‘news’ reports or read any of the articles about a new study published in the Journal of the American Medical Association (JAMA) this past week. Let’s take a look at what is really going on.

The study was pretty simple. Researchers looked at the diets of over 1000 subjects who had stage III colon cancer and who were enrolled in a chemotherapy trial. These subjects filled out food frequency questionnaires (FFQ) during their chemotherapy then again six months after. Researchers then stratified the data from the FFQs into what they called a Western dietary pattern and a prudent dietary pattern. After a little over 5 years of follow up about a quarter of these subjects had died from their colon cancer. Significantly more of the patients following the Western dietary pattern died than did those who followed the prudent dietary pattern. Therefore, say these researchers, those who have advanced colon cancer should avoid a Western dietary pattern in favor of a prudent dietary pattern in order to reduce their chances of dying from their disease. And the implication is that all of us should follow the prudent diet rather than a Western diet to maybe avoid getting colon cancer at all. And, as you shall see, what these researchers really want us to avoid is red meat.

Nice and tidy. Problem is that it’s all BS. And it’s the kind of BS that infuriates me because of the dishonesty involved. Let me show you what I mean.

The statistics involved in this paper are convoluted beyond belief. Very few people are going to go through the charts and tables and analyze these statistics as presented. I’m a pretty fair hand at statistics, and I didn’t want to spend the time to laboriously go through these to see if they were correct. I didn’t spend the time because it doesn’t matter if they are correct or not, so why bother. And that’s not to even mention that the nutritional data making up these statistics was derived from FFQs, which are the most notoriously inaccurate way to get nutritional data imaginable. The entire study is an observational study, and as such is absolutely worthless in determining whether the Western diet or the prudent diet or any other kind of diet causes colon cancer or anything else. But before we get into what an observational study really is and why it’s worthless, let’s look at a couple of other factors.

First, the researchers themselves cleverly defined the Western dietary pattern and the prudent dietary pattern so they could determine what made up each one. The prudent dietary pattern was filled with fruits, leafy vegetables, cruciferous vegetables, tomatoes, fish, poultry, wine, tea, and legumes. The Western dietary pattern was dairy, refined carbohydrates, red meat, sweets, desserts, margarine, processed meat, potatoes, French fries, snacks, beer, liquor, eggs, and sugar beverages among others.

Now this divvying up of all these foods into Western and prudent dietary patterns would be okay with me if that’s the way they reported it. I mean all the crap they put in the Western dietary pattern category is pretty much what makes up the typical American diet, and I, of all people, certainly wouldn’t be surprised to find that people following such a diet had their cancers worsen, but that’s not what the researchers reported. They focused on the red meat part of the Western diet in all their reports. It was made to sound like the red meat in the Western dietary pattern was the cause of all the woes, not the sugar, potatoes, sweets, high-fructose corn syrup sweetened beverages, margarine, and all the rest of the crap. Just the red meat. But before we get into examples of that, let’s look at what an observational study is and why these studies are worthless for determining the cause of anything.

Let’s say I come up with the idea that eating ice cream causes multiple sclerosis (MS). To study this I recruit 10,000 subjects and follow them for 5 years. Over this 5 year period I take nutritional surveys by having these subjects fill out detailed food diaries for 3 days every three months, and I have trained interviewers go over these food diaries with the subjects to make sure they included everything. I gather all this data for 5 years, then I look at the amounts of ice cream eaten by all the subjects, and I divide the subjects into quintiles (fifths) depending upon how much ice cream they ate. The top quintile would be the 2000 subjects who ate the most ice cream; the bottom quintile would be the 2ooo who ate the least; and the other three quintiles of 2000 subjects each would fall in the middle.

Now that I’ve got this data, I look to see how many of the subjects in each quintile developed MS during the course of the study. Let’s assume that 100 subjects in the top quintile of ice cream consumption developed MS and only 30 people in the bottom quintile developed MS. The number of cases of MS from the middle quintiles were between 90 and 4o with the higher quintiles developing MS at greater rates than the lower ones.

I could then put out a press release proclaiming that ice cream causes MS, which would be picked up by the press, and, before you know it, I’m on CNN and all the networks talking about my study. Life is great. I’m on TV. But hold on. Whoa, there, Bozo. Let’s take a few steps back and look a this study just a little closer.

The study I did was what is called an observational study. I didn’t give these subjects ice cream, placebo, medications, anything, I simply observed and tabulated their diets over a 5 year period. Those that ate the most ice cream had higher rates of development of MS, but the MS can’t be laid at the doorstep of ice cream consumption because there are too many other factors involved.

Maybe those who are prone to MS are, for whatever reason, driven to eat more ice cream. Maybe those who ate the most ice cream also ate the most cake, and we didn’t even look at cake. Maybe cake is the cause. Maybe those who ate the most ice cream also smoked the most. Maybe those who ate the most ice cream were the least active, and maybe lack of activity predisposes to MS. Maybe those who ate the most ice cream ate the fewest tomatoes, and maybe tomatoes are protective against MS. I could go on and on with the maybes coming up with countless scenarios showing that it isn’t really the ice cream that causes MS even though those who ate the most developed the most MS. The point is that in an observational study like this fictitious one I just came up with – which is no different than the JAMA study on the Western dietary pattern/prudent dietary pattern and death from colon cancer observational study – is meaningless in terms of what causes anything.

What observational studies are good for is creating hypotheses. For example, let’s say I did the above study and I was just looking to see which subjects developed what after 5 years. At the end of the study I discovered that a bunch of people had developed MS. I looked at all the different foods all the subjects ate and I noticed that the ones who ate the most ice cream seemed to develop MS at the greatest rate. So, I come up with a hypothesis that ice cream causes MS, then I get together the funds to test this hypothesis.

To determine if this hypothesis is valid I recruit 10,000 more subjects. This time I randomize them into two groups so that the ages, sexes, heights, weights, and any other thing I can think of are the same in both groups. Then I create a placebo that looks like ice cream, tastes like ice cream, but has no calories and isn’t really ice cream. (Actually, if I could come up with this placebo I would abandon the study, get filthy rich, and move to my own island.) I would then box the placebo and the real ice cream in identical cartons. I would have a staff of people who gave the ice cream or placebo to the subjects at regular intervals. The subjects would be instructed to never eat ice cream on their own, but to only eat the ice cream they were provided during the study.

I would then have a double-blind, placebo-controlled study. It’s double blind because the people administering the ‘ice cream’ don’t know whether its ice cream or placebo and the subjects receiving the ‘ice cream’ don’t know if it’s real ice cream or placebo.

After 5 years I could again determine how many subjects had developed MS and could compare it to the amount of real ice cream eaten by those subjects. If this time the results were the same, then I would have some reason to say that ice cream may indeed cause MS. But this would be a real, double-blind, placebo-controlled study, not an observational study.

Typically when hypotheses arise from data provided by observational studies, these hypotheses are destroyed when they are evaluated using a real study.

For the JAMA study to be able to say that the Western dietary pattern causes recurrence and death to a greater degree than does the prudent dietary pattern, the researchers would have had to randomize the patients into two groups, then give one group the Western diet and the other the prudent diet. And keep both groups on their respective diets for the 5 years, then see what happens.

And the authors of this study indeed know and understand that these observational studies don’t mean squat in terms of causality and admit as much. They write these words buried in the back of this study:

Because this was a observational study, causality cannot and should not be drawn from these data. [my italics]

So, the authors know and admit that no conclusions in terms of causality can or should be drawn from this study. But they go ahead and do just that with this statement that is the very next sentence after the one above:

Nonetheless, the data suggest that a diet characterized by higher intakes of red and processed meats, sweets and desserts, french fries, and refined grains increases the risk of cancer recurrence.

So, you fess up that the study doesn’t legitimately say squat, then you say in the very next sentence that, well, we don’t care about the truth, we think it really does matter. Because, after all, no one cares about a meaningless study. You can’t issue a press release about a meaningless, observational study. Can you? The authors and the folks at JAMA apparently think so.

Here is the press release from JAMA.

DIET HIGH IN MEAT, FAT AND REFINED GRAINS ASSOCIATED WITH INCREASED RISK FOR COLON CANCER RECURRENCE AND DEATH

Patients treated for colon cancer who had a diet high in meat, refined grains, fat and desserts had an increased risk of cancer recurrence and death compared with patients who had a diet high in fruits and vegetables, poultry and fish, according to a study in the August 15 issue of JAMA.

Previous research has indicated that diet and other lifestyle factors have a significant influence on the risk of developing colon cancer. However, few studies have assessed the influence of diet on colon cancer recurrence and survival, according to background information in the article.

Jeffrey A. Meyerhardt, M.D., M.P.H., of the Dana-Farber Cancer Institute, Boston, and colleagues examined the influence of two distinct dietary patterns on cancer recurrence and survival in a group of 1,009 stage III colon cancer patients (cancer present in the colon and lymph nodes) enrolled in a clinical trial of postoperative chemotherapy in addition to other treatment. Patients reported dietary intake using a food frequency questionnaire during and six months after supplemental chemotherapy. Two major dietary patterns were identified, prudent and Western. The prudent pattern was characterized by high intakes of fruits and vegetables, poultry, and fish; the Western pattern was characterized by high intakes of meat, fat, refined grains, and dessert.

Patients were followed up for cancer recurrence or death. During a median (midpoint) follow-up of 5.3 years, 324 patients had cancer recurrence, 223 patients died with cancer recurrence, and 28 died without documented cancer recurrence.

The researchers found that a higher intake of a Western dietary pattern after cancer diagnosis was associated with a significant increase in the risk of cancer recurrence or death. Compared with patients in the lowest Western dietary pattern quintile (bottom 20 percent), those in the highest quintile (top 20 percent) experienced a 3.3 times higher risk for cancer recurrence or death. Patients in the highest quintile of Western dietary pattern were 2.9 times more likely to have cancer recur than those in the lowest quintile. Similarly, a significantly higher overall risk of death with increasing Western dietary pattern was observed. In contrast, the prudent dietary pattern was not significantly associated with cancer recurrence or death.

“Studies have shown an improved disease-free survival among patients who receive adjuvant chemotherapy following the surgical resection of stage III colon cancer. This is the first study, to our knowledge, in a potentially cured population of colon cancer survivors to address the effect of diet. Because this was an observational study, causality cannot and should not be drawn from these data. Nonetheless, the data suggest that a diet characterized by higher intakes of red and processed meats, sweets and desserts, french fries, and refined grains increases the risk of cancer recurrence and decreases survival. Further analyses are under way to better delineate specific nutrients or food groupings that may have the strongest association,” the authors write.

Do you see anything in this press release that says no conclusions can or should be drawn from this study since it is an observational study? I didn’t see anything like that. And did you notice how it is no longer a Western dietary pattern, but is now a meat, fat and refined grains diet. And note what is listed first: meat. Most analyses of the Western diet show that the single largest contributor of calories is sugar, which I’m sure is the case in this Western dietary pattern, but the authors and the press release writers for JAMA single out and lead the press release with meat. Not sugar. Not high-fructose corn syrup. Meat.

What’s even worse than the press release is the video that goes along with it. In this video a survivor (so far) of stage III colon cancer, John, is shown cycling and going about his life. A voice over announcer talks about the diagnosis and treatment of John’s colon cancer. Then the announcer says

As you’d imagine, after that, John would do a lot to stay healthy. Turns out what he eats, or doesn’t eat, could really help.

This while John is shown putting fish on the grill. Then cut to Dr. Jeffrey Meyerhardt, the lead author of the study, who says:

It’s not really increasing the amount of fruits and vegetables but really trying to reduce the amount of red meat intake and fatty foods and sugary, ‘desserty’ foods, that seems to be protective for colon cancer recurrences and survival.

Note the emphasis on red meat and fatty foods. As Dr. Meyerhardt finishes his line the video cuts to a steak on a grill, then to someone cutting a steak. The announcer then says:

That higher fat diet Dr. Jefery Meyerhardt describes is called a Western pattern diet. He and colleagues at Dana-Farber Cancer Institute studied that pattern in colon cancer patients. Their findings appear in JAMA, Journal of the American Medical Association.

While the announcer is talking there is more footage of red meat on a grill.

There is some more blather, then the announcer says:

Stage III colon cancer patients who ate high amounts of a Western pattern diet were about three times more likely to have recurrent cancer, or to die, compared to patients who ate less of those types of foods.

More footage of John and his wife eating fish and vegetables. Then the announcer again:

The study says improved outcomes are more likely if stage III cancer patients eat the way John does…lots of fish, chicken, brown rice, and less Western pattern foods, like red meat.

Actually the study says no such thing. The study says that “causality cannot and should not be drawn from these data.”

John finally speaks. He is eating his ‘healthful’ non-Western pattern diet along with his wife, and he says:

To cut down from one steak a week to one steak a month is not a big deal.

As you watch the video you notice that right at first the overall Western pattern diet is described as being filled with red meat, fatty foods, sweets, and desserts. Then as the video rolls on the Western pattern diet transmogrifies into the red meat diet. Anyone watching this video would come away thinking that eating red meat will cause colon cancer to worsen. And that if anyone who has colon cancer eats meat, they’re going to die.

And all this from a study whose authors tell us that the data cannot and should not be used to determine causality. This entire episode is an education in how this nonsense spreads. And another reason to never, ever believe anything you see on television or read in the papers about medical studies. Most of it is pure hogwash.

Why, you may ask yourself, do these highly trained scientists buy into all this when it’s so patently false? Because they want to. Remember the post about the book Stumbling on Happiness? It takes very little evidence to persuade someone of something he/she already believes is true. All of these people believe red meat is bad for us despite there being absolutely no evidence showing such. So it doesn’t take much to prove to them that it really is bad. In this case, it takes no data at all. Merely the suggestion of data. Pitiful.

Here is a link to the JAMA video from which I quoted above. Warning. It takes forever to download this thing, which is why I quoted from it instead of merely linking to it. It took me about 5-6 minutes, so don’t give up if you really want to see it. It is a masterpiece of anti red meat propaganda.

Ten or twelve years ago we wrote in Protein Power about the data contained in the vast amount of ancient Egyptian mummies. We pointed out that several thousand years ago when the future mummies roamed the earth their diet was a nutritionist’s nirvana. At least a nirvana for all the so-called nutritional experts of today who are recommending a diet filled with whole grains, fresh fruits and vegetables, and little meat, especially red meat. Follow such a diet, we’re told, and we will enjoy abundant health.

Unfortunately, it didn’t work that way for the Egyptians. They followed such a diet simply because that’s all there was. There was no sugar – it wouldn’t be produced for another thousand or more years. The only sweet was honey, which was consumed in limited amounts. The primary staple was a coarse bread made of stone-ground, whole wheat. Animals were used as beasts of burden and were valued much more for the work they could do than for the meat they could provide. The banks of the Nile provided fertile soil for growing all kinds of fruits and vegetables, all of which were a part the low-fat, high-carbohydrate Egyptian diet. And there were no artificial sweeteners, artificial coloring, artificial flavors, preservatives, or any of the other substances that are part of all the manufactured foods we eat today.

Were the nutritionists of today right about their ideas of the ideal diet, the ancient Egyptians should have had abundant health. But they didn’t. In fact, they suffered pretty miserable health. Many had heart disease, high blood pressure, diabetes and obesity – all the same disorders that we experience today in the ‘civilized’ Western world. Diseases that Paleolithic man, our really ancient ancestors, appeared to escape.

The press has been filled with reports of the recent discovery – thanks to DNA analysis – of the mummy of Queen Hatshepsut, who ruled Egypt for around 15 years 3500 years ago.

According to the New York Times, Hatshepsut’s mummy is that of an obese, diabetic 50 year old woman with bad teeth. All the conditions that nutritionists today would have us believe would be prevented by Hatshepsut’s diet. It certainly didn’t work for her. And she is not a special case – most Egyptian mummies show the same disorders, especially the bad teeth. The skeletal remains of Paleolithic man, who consumed a meat-based diet, showed strong, perfect teeth. Bad teeth are the hallmark of carbohydrate consumption.

Here is an X-ray of Hatshepsut’s mouth. You can see cavities, lost teeth, and evidence of severe tooth abscesses, which had to have been miserably painful.

Hatshepsut’s statue pictured to the right shows her in her idealized form. I’m sure most of the Egyptian graphics and statuary of the time represented people in a thin, healthy state instead of the shape they were really in. Based on the mummy data many ancient Egyptians were obese, which is clearly not represented in their contemporary artistic renditions. If one were to look through on issue of Cosmopolitan or GQ or virtually any magazine to day and look at the people in all the ads, one would think no one is obese now. Which clearly isn’t the case. I suspect that the ancient Egyptians intuitively figured that thin and trim people were more attractive than obese ones and created their pictures accordingly.

One other interesting aspect of Hatshepsut’s mummy is that it appears that she died from metastatic cancer. Cancer has been tough to find in mummified and skeletal remains, leading most researchers to assume that the rates of cancer today are driven by environmental contaminants that weren’t present in ancient times.

The moral of this tale of ancient poor health is that a whopping load of carbs – even non-refined carbs – didn’t do Hatshepsut a whole lot of good, and they don’t do us much good either irrespective of the bleatings to the contrary by today’s nutritionists, who are woefully unaware of the history of the high-carb diet.

Newspapers are always on the lookout for man-bites-dog kind of stories to sell papers. The more off beat the story, the more it flies in the face of what seems normal, the more newsworthy it is, at least in the eyes of the inky wretches who publish the dailies. It shows just how deeply ingrained in the minds of so many is the notion that dietary fat is bad for us when a series of studies showing that cutting fat from the diet doesn’t do squat makes the front page headline of the New York Times, the country’s most influential paper. And I don’t mean just the front page, but the actual top-of-the-page, main headline. The idea that fat might not be harmful is apparently a man-bites-dog story of the highest order.

Here’s the headline, right up top.

Low Fat Diet Does Not Cut Health Risks, Report Says

The first paragraph of the accompanying article sums it up pretty nicely:

The largest study ever to ask whether a low-fat diet reduces the risk of getting cancer or heart disease has found that the diet has no effect.

USA Today weighed in with an article entitled

Cutting Fat Alone Isn’t Enough, Women Advised

The Knight-Ridder news service, the providers of copy to many local papers including ours headlined their article

Low-Fat Diet Fails to Cut Risk

The reports referenced in these articles were three studies appearing in this week’s The Journal of the American Medical Association detailing the results of a massive, government-funded ($415 million) study, The Woman’s Health Initiative, showing that postmenopausal women who followed a low-fat diet for 8 years suffered the same rates of heart disease, colon cancer and breast cancer as those who ate what they wanted.

Almost 50,000 overweight women aged 50 to 79 were divided into a study group (the low-fat group) and a control group. The study group was given intensive dietary counseling and much hand holding. Subjects in this group were instructed to reduce their fat intake to 20 percent of their total caloric consumption and to increase the amount of fruits and vegetables to at least five servings daily and grains to six servings daily. This group

received an intensive behavioral modification program that consisted of 18 group sessions in the first year and quarterly maintenance sessions thereafter. Each group had 8 to 15 women and was led by a specially trained and certified nutritionist. Each participant was given her own total fat gram goal based on her height. The intervention emphasized self-monitoring techniques and introduced other individually tailored and targeted strategies, such as motivational interviewing.

The members of the control group were given a copy of Nutrition and Your Health: Dietary Guidelines for Americans and sent on their way.

All the heavy duty counseling paid off in that the women in the study group did manage to reduce their fat intake from about 38 percent to 24 percent of calories by the end of the first year and to 29 percent by the end of the study. The women in the control group, who also started at 38 percent, reduced their fat intake to 35 percent by the end of the first year and had drifted back up to 37 percent.

When the study ended and the incidence of cardiovascular disease, breast cancer and colon cancer in the two groups was tallied, there was virtually no difference between the two groups.

I felt that the New York Times had the most even-handed coverage of these reports, although, as we will see, they didn’t do their homework very well. The paper quoted extensively from Dr. David A. Freedman, a statistician at the University of California, Berkeley, who isn’t connected with the study but has published extensively on the design and analysis of clinical trials. Dr. Freeman, who basically opined that the results should be taken seriously, opined:

The studies were well designed and the investigators tried to confirm popular hypotheses about the protective effect of diet against three major diseases in women.

But, the diet studied here turned out not to be protective after all.

We, in the scientific community, often give strong advice based on flimsy evidence. That’s why we have to do experiments.

Needless to say, these findings were a huge shocker to the reduce-your-fat-intake-and-you’ll-decrease-your-risk-for-everything crowd. And, as you might imagine, excuses were thick on the ground.

Dean Ornish, who is fast aboard the low-fat freight train hurtling pell-mell toward irrelevance and oblivion, complains that the women didn’t lower their fat intake enough, and that they didn’t eat enough fruits and vegetables, and that the study wasn’t long enough. If it had gone on for a few years more, says the author of a number of low-fat books, a difference between the two groups might have immerged.

Yeah, well, ‘might’ won’t feed the whippet.

I was struck by the realization of exactly how difficult it must be to reduce fat in the diet to the 20 percent range. These women who all had loads of hands-on counseling and care during the first year could reduce their fat intake to 24 percent and no lower.

After a careful review of these papers a couple of other things caught my attention.

The first thing was that although the women in the study group reduced their fat intake, not only were they not protected against disease, they didn’t really lose any weight to speak of. Most of the cut-your-fatters such as the above mentioned Ornish believe and propound that reducing fat will bring about weight loss. Ornish’s best-selling book Eat More, Weigh Less actually instructed readers not to worry about anything but cutting fat. As long as fat intake goes down, so will weight.

Sorry, Deano, but these studies prove you wrong even there. But, who knows, maybe if the studies had lasted a little longer, the weight loss would have become apparent.

The other thing I noticed was that not only did the women in the study group cut the fat, they cut the calories. At the start of the study the women were consuming 1790 kcal per day. After one year their intake was down to about 1500 kcal daily and continued to drift down a tiny bit more to 1431 kcal by the end of the study. So, these women consumed roughly 300 fewer kcal per day over the course of the study, which calculates out (300kcal/day times 365 days/year times 8 years) to a reduction of about 876,000 kcal in all. If we divide that 876,000 kcal reduction by 3500 (the number of kcal in a pound of fat), we find that these women should have each lost about 250 pounds, which would have been difficult since they started with an average weight of about 170 pounds. Well, not only did they not lose 250 pounds, they didn’t lose any weight at all. So what happened?

Obviously something is amiss.

In going through the paper on cardiovascular disease I came upon the following paragraph about how the caloric intake as well as the macronutrient intake was determined in the Methods section:

All participants completed an FFQ (food frequency questionnaire) designed specifically for the study at baseline and 1 year. Thereafter, one third of the participants completed the FFQ each year in a rotating sample: completion rates were 100% at baseline and 81% thereafter. Data on follow-op dietary intake were computed from FFQs administered from years 5 through 7 (designated as year 6 follow-up), thus including all the participants.

Here is an interesting note:

Four-day food records were provide by all women prior to randomization.

As we saw in a post not too long ago, FFQ are next to worthless. Four-day food diaries are much more accurate, but much more costly. The directors of these studies spent $415 million to do this part of it. I’m sure they spent a bunch getting and evaluating the baseline intake, which at about 1800kcal/day sounds right for 50-79 year old women. Then they went the cheap route to get the follow up data. The fact that according to their data these women were consuming roughly 17% fewer calories per day over the course of the study and not losing weight didn’t tip the researchers off that something was amiss.

Not only didn’t it tip them off, they thought it was a helluva study. Dr. Michael Thun, a director of research for the American Cancer Society, was quoted in the New York Times as describing these studies as being so large and so expensive that they were

the Rolls-Royce of studies.

Someone needs to tell Dr. Thun that it’s not the amount of money spent, but the quality of the data that makes a good study.

The only thing that keeps me from writing these studies off as a waste of time and money is the fact that the control group also consumed way, way fewer calories as determined by their FFQs and didn’t lose any weight over the 8 years. I guess we can make the assumption that the subjects in both groups fudged their FFQs proportionately and so at least the differences in macronutrient composition are relatively valid.

So with all due respect to Dr. Freedman, the statistician at the University of California, Berkeley, I don’t believe the studies were particularly well designed. I would feel a whole lot better about them if they had used a different methodology to obtain their dietary data.

It’s a real shame to spend $415 million of our dollars—yours and mine—and not get anything better than this.

Today’s JAMA contains three papers showing that the low-fat diet does not reduce the risk for colon cancer, heart disease or breast cancer.

Data from the giant Women’s Health Initiative Dietary Modification Trial show that after 8 ½ years post menopausal women consuming a diet meant to contain about 20 percent of calories as fat, but in fact containing about 28 percent of calories as fat, showed no decrease risk for breast cancer, heart disease or colon cancer compared to a control group of women consuming their regular diet.

To read the full text of the paper on breast cancer click here.

To see the abstracts of the other two papers click here and here.

This same issue contains two editorials that show the bias of the editorialists in the direction of the low-fat diet. In one in the very last paragraph the authors just can’t help themselves. Despite these studies showing no benefit to the low-at diet, these guys just can’t leave it at that.

Despite null findings from the WHI Dietary Modification Trial, dietary changes can have powerful, beneficial effects on CVD risk factors and outcomes. To reduce the risk of CVD, individuals should maintain a desirable body weight, be physically active, avoid tobacco exposure, and eat a diet consistent with national guidelines [the low-fat diet]. Additional results from the WHI Dietary Modification Trial, likely forthcoming, should provide valuable evidence that will refine these recommendations and further enhance CVD prevention efforts in women.

So, what they’re saying is that despite these studies showing no benefit to low-fat diets it is advisable to follow a low-fat diet. Hmmm.

Many thanks to Regina Wilshire (her excellent blog is Weight of the Evidence) for giving me the heads up that these studies were coming out.

I’ll have much more to say later after an exhaustive evaluation of all these papers.

MD and I are flying back home tonight, so I’ll be back at it at full speed in short order.

A couple of weeks ago I posted on the large JAMA study showing that, contrary to what we’ve heard ad nauseum over the past decade, fiber consumption produced no protective effect against colon cancer. Now comes one of the more bizarre studies that I’ve ever read.

The British journal Colorectal Disease published a paper a few months ago with the promising title “Diet and colorectal cancer: implications for the obese and devotees of the Atkins diet.” Hey, now were getting somewhere thinks I when this little baby fell into my hands through the agency of the university inter-library loan department. Then I began to read it.

I don’t know if medical journals have the equivalent of slow news days or if this particular journal, which I hadn’t previously seen, is a lower tier journal, but I can’t figure how this paper got published. I’m glad it did because most people will only get to read the abstract (my university didn’t have a subscription to the journal, thus my reliance on inter-library loan), and the abstract implies much that isn’t developed in the paper. I’m sure many people writing articles on low-carb diets will in the future reference this paper as one that shows low-carb diets to reduce the risk of colorectal cancer. The paper, however, doesn’t really do that. In fact, it doesn’t do much of anything.

When we take a look at the abstract, we – as low-carb devotees – see some exciting stuff:

Colorectal cancer (CRC) is the second most common cause of cancer-related death in the Western world and its prevalence is increasing. Potential causes of this increase are changes in diet and the increases in obesity seen. This paper looks at the literature surrounding diet and obesity and the links to this increase in CRC. Heralded as a weight loss miracle we investigate whether the literature suggests the Atkins diet may actually do more harm than good by acting to increase an individual’s risk of CRC. Obesity has been demonstrated to be a major factor in the increase in CRC although links to changes in diet are more tenuous. Published studies on diet suggest the Atkins diet may help reduce rather than increase the risk of CRC.

As we go through the paper, however, excitement wanes.

Basically, the paper can be summarized pretty quickly. Here is the Cliff Notes version.

Obesity is a huge problem worldwide. Many people looking for a solution have tried the Atkins and other low-carbohydrate diets. These low-carbohydrate diets recommend meat accompanied by non-starchy vegetables. Studies have shown a correlation between meat consumption and colorectal cancer (CRC). Other studies have shown no correlation between meat consumption and CRC. Studies have shown that consumption of non-starchy vegetables and fruits are protective against CRC. Some studies have shown a correlation between fat consumption and CRC; others have shown no such correlation. some studies show that carbohydrate intake, especially of sugars and refined starches, increase the risk for CRC; these findings have not been confirmed in other studies. The paper then makes a strange comment:

The reduction in carbohydrate on this diet (Atkins) may result in less fruit and vegetables ingested and for this reason the Atkins diet may actually increase the risk of CRC. This should not be the case for the phases where more carbohydrate is permitted; the problem is that as with many diets, there tends to be high rates of noncompliance and the initial induction phase may deter people from eating fresh fruit and vegetable, despite some public health measures of encouragement to do otherwise. Of additional concern is that dieters may solely utilize the ‘induction’ phase of the Atkins diet plan as an effective weight loss strategy before reverting back to an unhealthy regime of sugary foods.

More Cliff Notes:

Once again studies have shown dietary fat to cause increased risk for CRC; others don’t. Most studies have shown that obesity is a risk factor for CRC. In fact, obesity is probably the most significant risk factor. Low-carbohydrate diets are lower in calories than non-diets. Consuming fewer calories brings about weight-loss. Weight-loss reduces risk for CRC. And, therefore, the Atkins and other low-carb diets are a go. As the authors conclude:

Until there is more conclusive evidence, it does not appear that the Atkins diet plan should be rejected. Indeed, from the current evidence it may actually be beneficial by reducing the risk of developing CRC; total energy intake may be a more significant risk factor and any diet conferring a decreased calorie intake would presumably decrease this risk.

There is so much data out there showing that low-carb diets reduce the risk of CRC in so many ways that it’s really a shame that this kind of wishy washy crapola uses up valuable ink.

Reading this paper makes me recall the one and only time I ever listened to Howard Stern when I heard him say the following to a Star Trek fanatic who had spent God only knows how much time trying to derive the language of Klingons:

It’s lame, Dude. It’s really lame.