A paper appeared recently in the prestigious Proceedings of the National Academy of Sciences (PNAS) that seems to have a whole lot of people on edge.  If you read the press accounts of this study, you might think anyone stupid enough to follow a low-carb diet would be doomed to certain death from heart attack.  But is that the case?  Or is it simply another instance of the media either failing to understand how science works or, worse, misreporting to get a better story?

I suspect the latter, but before we get into it, I need to go over a few blog housekeeping issues.

As I’m sure everyone has noticed, the look of this blog has changed – as has the look of the entire website.  Our designer and tech guys have been struggling to get everything working right, but, finally, my incessant whining got to them, and they went ahead and put the thing up in its not-completed state.  Please bear with us – it will ultimately work as it’s supposed to.  If you are having a problem, send me a description in the comments section.  Make sure you tell me what kind of computer you’re using (Mac (Intel or pre-Intel)  or PC) and which browser (Firefox, Internet Explorer, Safari, etc.) so that the gurus will know what to do to fix it.

I know the comments are screwed up right now, but don’t worry, they’ll be fixed.  Go ahead and comment away.  They’ll ultimately be up in a form you can recognize.

Once we get the blogs and website how they’re supposed to be, I’ll write a post describing all the features.

Also, our world-changing project has been slightly delayed through no fault of our own.  The new date for revelation has been pushed back from Sept 1 to Sept 15.  Sorry.  It’s been a real PITA for us, too.

Now, back to the PNAS paper.

As we all know, media reports can be totally misleading or even downright false.  Reporters have their own biases that creep into their work, and even when reporters think they are presenting the facts, they often report just one side of a story and ignore the other.  And, as we’ve seen from the previous post on the vitamin D-bate, reporters may just report a story in a way that makes for better reading without any regard for the substance of the issues.

The PNAS paper reported a study on genetically modified rodents, engineered to be more susceptible to heart disease.  As I’ve written many times in these pages, mice and rats aren’t just furry little humans – they are a different species altogether.  And although they are often used for medical experiments, the conclusions from the experiments cannot be applied to humans.  Like observational studies, rodent data can be used to establish hypotheses about human health and disease, hypotheses that can then be tested for validity.

In this case, the data on these genetically-engineered mice can’t even be extrapolated to normal mice much less humans.  Knowing just this much about the study tells us that whatever it shows has little relevance to us.  But that’s not what the media took away from the story.

The BBC came out with the following headlines that were picked up by a number of other media sources:

Low-carb diets ‘damage arteries’

And followed up with:

Low-carb slimming diets may clog arteries and increase the risk of heart attacks and strokes, a study suggests.

Diets based on eating lots of meat, fish and cheese, while restricting carbohydrates have grown in popularity in recent years.

But the Beth Israel Deaconess Medical Center in the US found such habits caused artery damage in tests on mice.

The researchers and independent experts both agreed a balanced diet was the best option.

Hmmm.  Sounds pretty brutal doesn’t it.  No hesitance there.  No equivocation.  Just a head on reporting of the facts.  I don’t think so.

Why not?  A number of reasons.  First, these researchers basically had a bias going in that low-carb diets cause heart disease even though they lower cholesterol and bring about other positive changes in lipid values, most notably reducing triglycerides, increasing HDL levels, and changing LDL particles from the small type B to the larger type A variety.  All of which changes, by the way, supposedly reduce the risk for heart disease.

The lead author of the study, Shi Yin Foo, MD, PhD, a clinical cardiologist,

first embarked on this investigation after seeing heart-attack patients who were on these diets – and after observing Rosenzweig [the researcher in whose lab she worked] himself following a low-carbohydrate regimen.

“Over lunch, I’d ask Tony [the aforementioned Rosenzweig] how he could eat that food and would tell him about the last low-carb patient I’d admitted to the hospital,” says Foo. “Tony would counter by noting that there were no controls for my observations.”

“Finally,” adds Rosenzweig, “I asked Shi Yin to do the mouse experiment – so that we could know what happens in the blood vessels and so that I could eat in peace.”

Do you think Dr. Foo has a little skin in this game?  Think she might have a motive for stacking the deck a little in setting this experiment up in a way that encourages a certain outcome?  This was not what you would call an unbiased quest for the truth.

I want to comment on something here as an aside.  I don’t know how old Dr. Foo is, but since she’s working in someone else’s lab, I would think she’s probably fairly new to the medical game.  She may have admitted a patient or two to the hospital with heart attacks, who, under questioning, may have admitted to following a low-carb diet at some point.  But I’m willing to put my experience with low-carb diets up against hers any day.  MD and I have followed over 10,000 patients on low-carb diets and have never had a single one have a heart attack.  So, I really doubt that Dr. Foo has admitted many – if any – patients who are actively following a low-carb diet.  But it does make for a good story.

Second, we’ve already mentioned that the mice were genetically engineered to be more susceptible to heart disease, so data generated from these rodents can’t be extrapolated even to other mice let alone to humans.

Third, the diet used wasn’t even a typical low-carb diet.  The researchers

had a diet specially made that would mimic a typical low-carb diet,” explains Foo. “In order to keep the calorie count the same in all three diets, we had to substitute a nutrient to replace the carbohydrates. We decided to substitute protein because that is what people typically do when they are on these diets.”

Oh, really?  This one statement shows Dr. Foo’s ignorance of low-carbohydrate dieting.  People don’t typically “substitute protein” when they go on a low-carb diet.  As anyone knows who has been on one, people substitute fat, the macronutrient that provides most of the calories on any low-carb diet.  The mice in this study were getting 45 percent of their calories from protein, which can be done, but isn’t what one finds in most typical low-carb diets.

MD and I have been traveling extensively lately, so I hadn’t really had the time yet to delve deeply into this study, but, fortunately, as it turns out, I didn’t have to.  Others have done it for me.

The Metabolism Society issued a press release on the paper to all its members.  You can read it in full below:

Researchers use mutant mice genetically engineered to be susceptible to heart disease to ‘prove’ carbohydrate restricted diets may harm arteries.

Defects in ApoE -/- result in defects in processing blood cholesterol.

As human studies continue to show the benefits of low carbohydrate diets and the general failure of low-fat diets, it is necessary for the nutritional establishment to find more and more obscure methods of attacking dietary carbohydrate restriction.

One method is to prepare mutant animal models, to use odd diets that humans would never consume, call them low carbohydrate diets and then show some deficit.  Because mice are not generally susceptible to atherosclerosis, it was necessary for Foo and coworkers to use an ApoE-/- mutant and a ridiculously high protein diet to vilify low carbohydrate diets which have been a useful alternative for many people suffering from obesity, diabetes and metabolic syndrome.

In keeping with the traditions in scientific research, the authors do not cite the numerous studies showing benefit of low carbohydrate diets compared to the low fat diet that has been in place during the obesity and diabetes epidemic.  That the NIH and other government agencies continue to fund this kind of biased research is probably a minor political problem in health care but should still be of concern to people who are confused about what their diet should be.

According to Dr. Richard D. Feinman, Biochemistry Professor at Downstate Medical Center in NY,  “It is a mistake to consider one experiment in a mouse mutant over riding the scientific literature where similar research trials on actual human beings clearly show benefit of carbohydrate restriction for all markers of metabolic syndrome. For some reason these studies are not the ones picked up by the media. I suppose actual advances in science aren’t hot topics for headline news stories when it concerns the proven benefits of carbohydrate restriction.

Volek JS, Ballard KD, Silvestre R, Judelson DA, Quann EE, Forsythe CE, Fernandez ML, Kraemer WJ: Effects of dietary carbohydrate restriction vs low-fat diet on flow-mediated dilation. Metabolism 2009.

Volek JS, Phinney SD, Forsythe CE, Quann EE, Wood RJ, Puglisi MJ, Kraemer WJ, Bibus DM, Fernandez ML, Feinman RD: Carbohydrate restriction has a more favorable impact on the metabolic syndrome than a low fat diet. Lipids 2009, 44(4):297-309.

Of course, as you might expect, the press release wasn’t picked up by any of the major media outlets.

Jimmy Moore weighed in on the issue in an article in the Examiner.com in which he quotes numerous experts who have their say on this study.

And, Peter at Hyperlipid wrote two great posts taking the researchers to task and exploring  the kind of protein used and various other aspects of this study. (Here and here.)

So, I was left with nothing more to add other than to say what I’ve said countless times before:  Don’t rely on media reports to tell you anything.

(With apologies to Philip K. Dick for the title of this post.)

MD and I just got back from yet another cross-country trip, which gave me the opportunity to catch up on my reading.  While reading a golf magazine, of all things, I came across an article that demonstrates why all such articles should be taken with a grain of salt.  I can’t tell you how many letters MD and I get from people who become concerned because they read a piece in a magazine or newspaper that, for whatever reason, got under their skin.  So, I thought dissecting this article like I did a while back with a scientific study would be instructive.

Before taking these kinds of pieces seriously, you’ve got to realize how they are structured.  And believe me, they are as structured as a sonnet.

Freelance writers are always trying to get their pieces sold, and they write them to a formula that most magazines demand, which is why most of them are pretty much the same.  Just switch the experts and the subjects and you’ve got an article on most anything.  Magazine editors give writers assignments often telling them what they want the article to say and how many words they want it said in.  The writer’s job is to follow the format, cram the info into the required number of words and sound authoritative.

Your job as a reader is to realize this structure and plumb it for any valid info while not being distracted by the authorial sleight of hand.

This particular article, appearing in the July 2009 edition of Golf Digest, is cleverly titled “The vitamin D-bate,” and was written by an author with the initials RK.  I’m not trying to hide the name of the author to prevent embarrassing him or her – that’s how the author was listed at the end of the article

These pieces typically hew to the following format: they start with a lede that poses a dilemma followed by an introductory paragraph or two expanding upon the problem; they then have a statement from one ‘expert’ followed by a dissenting statement by another ‘expert;’ then they neatly tie the whole thing up with a pronouncement by the ultimate ‘expert’ who sagely answers the question posed in the lede.  All neat and tidy – and typically wrong.  In the case of the article under discussion, not only wrong, but breathtakingly stupid.

The lede for The vitamin D-bate is the subtitle of the piece.

Sun exposure is a source, but how much is necessary to stay healthy?

Since most golfers spend a fair amount of time in the sun, this should be of interest to them.  So, let’s read on to see how much vitamin D we really need.

After the lede we get the introductory paragraph.

In the vitamin world, D has become a rock star of late, with some experts claiming it might protect against cancer and reduce high blood pressure.  And we already know it’s essential for maintaining bone density and a functioning immune system.

Okay, articles are popping up all over about the benefits of vitamin D, and we’re convinced of its importance.  So how do we get it?

RK turns to the first ‘expert’ for advice.

It’s such an important vitamin that in May, the Skin Cancer Foundation doubled the recommended minimum daily intake from 10 micrograms to 25 (or 1,000 iu) for anyone younger than 50 who has limited sun exposure (including those who always wear sunscreen to protect their skin against the sun’s harmful rays). Ideally, the SCF says, people 18 or older should get up to 50 micrograms [2000 IU] per day.

Although the sun’s ultraviolet B rays help the body synthesize vitamin D, the SCF insists that the sun is not necessary to obtain sufficient amounts.  It suggests getting vitamin D from supplements and food such as milk, yogurt, egg yolks and oily fish (salmon, mackerel, cod).

At this point we need to ask ourselves ‘what is the expertise of the Skin Cancer Foundation?’  If we go to the SCF website, we discover that this foundation has been around for about 30 years and is underwritten by the cosmetics and skin care product companies.  Hmmm.  Maybe not the most reliable ‘experts’ on vitamin D.

But our freelancer has the needed quote to set up the debate.  Now RK decides to call the Vitamin D Council to come down on the opposite side of the debate. (The vitamin D Council really is the expert in this debate.) To get the debate going, however, RK needs to ask something provocative of whomever he speaks to at the Vitamin D Council. If this spokesperson tells RK essentially the same thing that the spokesperson from the SCF did, then there is no debate.  So, RK has to ask the right question to get the needed quote.

RK probably tees the question up much like this: I’ve been told by others that sun exposure isn’t necessary and that all one has to do to get enough vitamin D is to take a daily multivitamin and drink plenty of milk.  Is this true?

Of course the Vitamin D Council spokesperson is going to heartily disagree (and rightfully so) because it takes much more than that if there is no sun exposure.  (The Vitamin D Council recommends somewhere in the neighborhood of 5,000 IU per day, followed up with blood tests for levels.)  Now RK has the other side of the debate because the Vitamin D Council obliges.

However, the Vitamin D Council disagrees: “If one regularly avoids sunlight exposure…to obtain this amount from milk, one would have to drink 50 glasses.  With a multivitamin, more than 10 tablets would be necessary.  Neither is advisable.”

MD and I have played this little game countless times with freelancers.  So much so, in fact, that we’re really reluctant to speak with them because we never know where we’re going to end up in the article.  Usually the interviews are 20-30 minutes long, and end up with one sentence being quoted, and often quoted out of context.  I imagine RK spoke with someone from the Vitamin D Council for that much time, if not longer.  And used this one short quote.

RK really had to work to make this a debate to follow the format. The SCF spokesperson said that people who got little sun exposure needed to take supplements, and, in fact, recommended that ideally people should get up to 2,000 IU per day, which is way more than any daily multivitamin contains.  So, the SCF and the Vitamin D Council are more in agreement than they are apart, but RK has selectively quoted to make it seem like a disagreement.

Now, following the format, RK has to bring in a moderator and give us the final answer we’ve all been waiting for.

So, what should you believe?

Are you ready?

According to dermatologist Michael Kaminer, who treats hundreds of patients with skin cancer annually, the best thing to do is find a middle ground.

Well, the SCF recommends 2,000 IU per day and the Vitamin D Council recommends 5,000 IU per day, so is the middle ground 3,500 IU per day, an amount that splits the difference?

Not quite.

“During long, dark winters where we are covered in clothes, I take vitamin D supplements,” says Kaminer. “But in the summer, grease up with sunscreen, drink some milk, and hit the golf course! You’ll be swimming in vitamin D.”

Oh, really?

I told you it was breathtakingly stupid.

Does this guy understand that ultraviolet B (UVB) rays are what both make vitamin D and burn the skin?  If you put on sunscreen that blocks UVB, then you block the production of vitamin D.  Pretty much completely. Even weak sunscreens with an SPF of 8 block 95 percent of vitamin D synthesis.  So greasing up with sunscreen is definitely not going to have you “swimming in vitamin D.”

In fact, if you’re not careful, you’ll end up more prone to the worst kind of skin cancer: melanoma.  Why?  Because a sunburn is nature’s way of telling you you’re getting too much sun.  Unless you’re a moron, you get out of the sun before you get badly burned.  With graduated sun exposure you develop a tan, which prevents burning because the tan blocks the UVB much like a sunscreen does.  But the tan blocks UVA also.  UVA is the wavelength that doesn’t really burn but does stimulate the melanocytes (the pigment producing cells), which can cause melanoma.  If you slather on the sunscreen and stay out in the sun all day, you don’t get burned, but you do get a ton of UVA, which, until fairly recently, wasn’t blocked by sunscreen.  Now sunscreens contain agents that block both UVB and UVA, but no one knows yet whether these will prevent melanoma in the long run.

The paradox of melanoma is that this cancer typically develops as a response to too much sun but people with chronic sun exposure incur it less frequently than those with sporadic sun exposure.  This paradox can be easily explained.  Those who are out in the sun a lot develop a tan.  The tan blocks UVA, so there is less of the simulation for melanoma.  Those who go into the sun occasionally – office workers who vacation at the beach for a week – use sunscreen and stay out too long, receiving way too much UVA. UVA that increases the risk for melanoma.

I didn’t intend this to be a discourse on melanoma, sunscreens and vitamin D, but the idiotic response given by the ‘ultimate’ authority in our Golf Digest article got me going.

The take-home message from this post is to look for the pattern in these kinds of articles because they’re pretty much all the same.  You end up with a freelance writer arranging the experts to prove whatever the freelance writer – who is certainly no expert – wants to prove.  Or it may not even be what the freelancer wants to prove, but it is a function of how the best quotes fit with the structure of the piece.  “Grease up,” “hit the golf course,:” “swimming in vitamin D” – all are more pithy and memorable than any of the quotes above them.  Chances are RK wanted to end the piece with a bang, so he/she used the better quote giver as the ultimate expert.

Just remember, these kinds of pieces are put together more for their style than their content, so don’t put much faith in their accuracy.

More on vitamin D:

For info on the sun, vitamin D and its relationship with folate, click here.

Also, here is a great calculator designed by Norwegian scientists to determine how long you need to spend in the sun at various times of the year and various latitudes to get 1000 IU of vitamin D.  I recommend at least 5 times this amount to get 5,000 IU.

Click here to get a chart of US latitudes and longitude.

H/T to Annlee Hines for providing the link.

Applebee's Quesadilla Burger

One of my readers sent me a link to a segment on ABC News with Charlie Gibson showing just how disgustingly slanted and inaccurate mainstream media reports can be.

Gibson leads into the segment about two reporters who underwent self experimentation on the adverse effects of unhealthy eating.  The reporters, ABC’s Yuji de Nies and Jon Garcia, set out to see what would happen if they consumed a giant meal containing over 6,000 calories.  Here is the result as they reported it.

Pretty brutal, eh?  But let’s shine the piercing light of good sense on what is going on here.  As you might expect, the reality is vastly different from that portrayed by ABC.

First off, let’s look at the actual nutritional content of the food eaten.  As reported in the piece, the total energy content of the meal was 6,190 calories, which included 187 grams of saturated fat.  These were the only parameters reported.  I took the time to go through the links in the article accompanying the video to find exactly where these foods came from.  Here’s what I found.

The burger is an Applebee’s Quesadilla Burger (served with fries, of course); the snack is The Cheesecake Factory Fried Macaroni And Cheese; and the dessert is Uno Chicago Grill Mega-sized Deep Dish Sundae (listed as cookie below).  How do I know these are the exact ones?  These were the ones referenced in the CSPI’s List of Most Unhealthy High-Calorie, Fat and Salty Restaurant Foods That May Clog Your Arteries.  After seeing the photos and comparing to what I saw on the video, these selections are the ones the reporters ate.

I then tracked down the Nutritional Facts for the foods involved (here, here, here and here) and put them into an Excel spreadsheet.  Take a look.

The first thing you might notice is that the total calorie count is 5,708, which is considerable, but is actually 482 calories fewer than the 6,190 reported.  Second, and this is a biggie, the saturated fat content of this meal is only 88 grams, not the 187 grams reported.

The reporters stretched the truth a little in that they reported as if the Mega-sized Deep Dish Sundae were a single treat to be consumed by one person at a sitting.  I’m sure it could be so eaten, but it’s actually designed for four people to share.  The Nutritional Facts list the calories per serving as 690 and the saturated fat as 17 grams.  I’ve used the amounts in all four servings, i.e., one entire four-person dessert, in my spreadsheet.

As you may have noticed, the total carb content of the meal is 745 grams, which converts during digestion to a little over three cups (3.1 cups to be exact) of sugar.  The ABC report, of course, failed to mention the carb content of the meal and ignored any immediate effect this huge intake of carb might cause.  One of the reporters, Jon, claimed that he was ’sluggish’ and ‘tired’; the implication being that this sluggishness resulted from his huge saturated fat intake.  No mention, naturally, of the enormous amount of carbohydrate and the large increase in insulin release it might cause.  From what I can see from the video, Jon looks to be sporting a little abdominal obesity, which would imply a degree of insulin resistance and hyperinsulinemia.  People with this disorder tend to over secrete insulin in response to carb intake causing an overshoot and reactive hypoglycemia (low blood sugar), which will indeed result in sluggishness.

It’s pretty impressive when the lab tech holds up the tube of blood taken after the meal and compares it to the one taken before the meal.  There is a lot of fat swimming in the serum, that’s for sure.  What the producers of this piece (and, sadly, the doctors commenting although they should know better) want you to take away from all this by the way they set it up is that all that saturated fat went directly into the blood.  And how can you argue with them?  It’s there for all to see.

Problem is, that’s what blood samples look like after almost any meal, especially one that contains carbohydrates.  The fat you see isn’t the fat the two reporters ate; it is the fat the liver has made from the carbohydrate.  It’s the same picture a tube of blood would show after either of the two doctors had eaten a high-carb, low-fat lunch.

The blood samples were taken two hours after the meal.  Dietary carbohydrate is absorbed directly into the blood and makes a pass through the liver where it stimulates the production of triglycerides, the fat you see in the blood.  Fat, especially long-chain saturated fat digests very slowly, and doesn’t reach the blood until much later than the two hour mark.  While carbs go directly into the blood, fats take a different route.  The process that breaks down dietary fat into its component fatty acids is a lengthy process as compared to the breakdown of carbs.  Once the fat has broken down, it has to combine with bile salts to make it into a form that is water soluble and can be taken up by the intestinal cells.  Once taken up, unlike carbs, which are sent directly to the bloodstream, fats go into the lymphatic system, a much smaller and more static transport system than the vasculature.  Once in the lymphatics, fats make their way to the thoracic duct, which empties into a large vein in the upper chest.  The lymphatics are small vessels and take a long time to move their contents along since there is no heartbeat pushing them as there is with blood.  As I say, the fat in the blood you see on the video didn’t come from the saturated fat in the diet, although that was definitely the implication.

But what about the ultrasound showing the blood vessels had changed?  Wasn’t that because of the fat?

I’m afraid not.  The fat from the diet wasn’t in the blood vessels yet, so it couldn’t be the dietary fat causing the change.  So what was it?

How about a little normal physiology.  Let me explain.  The body gets blood where it needs to get it by opening certain blood vessels while closing others.  Let me give you an example.  Have you ever jumped into cold water to go swimming and noticed that not long after jumping in you have to urinate?  What happened?

Your arms and legs have a radiator effect.  Since these appendages have little padding the blood circulating there is exposed to the cold water, and if nothing is done, the cold water cools the blood creating a big problem.  Your body compensates by shutting down the circulation to the skin and areas close to the surface in your arms and legs and shunts that blood to your core.  Your core already has plenty of blood when this happens, so it has to get rid of some.  It does so by sending it through the kidneys where the liquid portion is filtered out and becomes urine.  Suddenly your bladder is full and you have to go.

The body has the ability to direct blood wherever it needs by its manipulation of blood vessel size.  Where do you think blood is needed after an almost 6,000 calorie meal?  That’s right.  The digestive tract.  It takes a lot of work to deal with 6,000 calories, and a lot of work requires a lot of oxygen, which comes from the blood.  So after a heavy meal, the body shunts extra blood to the guts where the works is being done.  It does this by opening or dilating the arteries carrying blood to the intestines and by narrowing the blood vessels in other parts of the body.

Now, think back to the video of the woman whose blood vessel (in her arm) is being examined by ultrasound.  When it’s compared to the previous ultrasound, the one before she ate, notice how much faster the heart is beating.  (The little swishing sounds you hear, each of which represents a heart beat, are spaced much closer together.)  The heart is beating faster because the body is working to digest an enormous amount of food, and this work stresses the heart in the same way that running down the street would stress the heart.  Work is work.

The digestive tract needs extra oxygen to do its work, this extra oxygen can get there only via the blood, so the intestines require more blood than normal.  This extra blood gets shunted there by opening the arteries that feed the gut and narrowing those that go other places where a lot of blood isn’t needed at the moment.  Such places as, say, a relaxed arm.

Anyone with a smattering of knowledge of normal physiology (and apparently an open mind) could predict that the artery in a relaxed arm would narrow after a heavy meal and that that artery would be back to normal six hours later (which it was so reported in this video).

What you’re seeing in this video is normal physiology at work interpreted as being abnormal by a couple of lipophobic doctors who should (and probably do) know better.  It makes for dramatic theater, but their interpretation is nothing but prevarication or ignorance or both.

But had they reported the truth, there would have been no story.  Kind of sad, isn’t it.

Since I’ve been asked about my take on the swine flu situation a few times in the comments section and numerous times by other people I know, I figured I would post on the subject.  Re the above cartoon: I agree with the President.

I don’t think the situation is nearly as bad as many people – including our esteemed Vice President – seem to think it is.  Whenever I hear reports of panic like those we’ve been bombarded with over the past week, I always think of what H.L. Mencken had to say in such circumstances:

The whole aim of practical politics is to keep the populace alarmed (and hence clamorous to be led to safety) by menacing it with an endless series of hobgoblins, all of them imaginary.

In this case, I don’t think it is the government that is spreading the panic – Biden’s gaffs notwithstanding – instead I believe it is the press.  The same Mencken quote could easily apply to the media.

You didn’t hear about Biden’s gaff?  Well, the spinmeisters got to it pretty quickly.

If, instead of running for their lives, people are running to the internet, glued to CNN, and the other 24/7 news channels and reading every newspaper and news magazine that comes along, the press is extremely happy.  It’s what they live for.  When they get a hot story like this one, they are loath to let it go until they’ve milked it for maximum exposure.  And they are milking this one for all it’s worth.  But remember, the media did this same thing a few years ago and inspired the same kind of panic over SARS, which ended up not amounting to much in terms of a real pandemic.

By now everyone knows that the swine flu in question is the H1N1 influenza A virus that was first thought to be similar genetically to influenza viruses that are found in pigs in North America.  More research has demonstrated that some of the genes involved are those that are found in pigs in Europe and Asia as well as birds and humans.

Based on the recent cases, this influenza doesn’t appear to be all that virulent.  In fact, it looks to be much less virulent than the standard old garden-variety flu that is common in the winter.

This influenza virus, like all influenza viruses, can mutate via a process called antigenic drift, which can make it either more or less virulent.  When we get the flu, we develop antibodies to the particular strain of influenza virus that infected us.  As this virus mutates a little, our antibodies can continue to beat it back because it is similar enough to the strain we got that our immune system recognizes it.  After a number of years of antigenic drift, the virus will have changed enough that our immune system no longer recognizes it, and we get infected again.  Measles, mumps and chicken pox are common viruses that don’t go through antigenic drift, so once we have them, we pretty much have immunity against then forever, but not with the flu.  Which is why once you get it, you don’t get it again for a number of years, then you come down with it once again.
Based on my own experience both being infected with the flu and taking care of patients infected with it has led me to believe that the influenza virus is becoming less virulent in general over time.  Why?  Natural selection.

Remember, natural selection works by spontaneous mutations that confer a survival advantage to the organism that carries them.  Such an organism has a better chance of surviving and passing the mutation along to its offspring.  With this in mind, consider the influenza virus.  It lives in humans, birds, pigs, etc.  It typically spreads via droplets disseminated by sneezing and coughing or close physical contact.  Think about what happens if a virus is extremely virulent.  The person (or animal) infected with it gets extremely ill, stays put, and maybe even dies.  This behavior reduces the chance of the virus’ spreading.  If however, the virus mutates to a much less virulent form, people who are stricken with it continue to work and socialize and don’t die.  The virus lives longer in the host and has a much greater chance of being spread, which is better for the virus.  So a lesser virulence confers a survival advantage to the virus, which is why I think the flu has become less and less problematic over time.

What can we do about this strain?

First, I don’t think it will amount to much because of the season.  I’m a firm believer in the notion that reduced vitamin D levels in the winter predispose us to the flu and other viral infections at that time.  Right now, it is late spring and nice and sunny with longer days.  People are getting out more and building their vitamin D.  For this reason alone, I don’t believe we’re going to see a pandemic.

It takes about 12 weeks to grow the virus in culture and use it to develop a vaccine, which is why the CDC can’t just crank out vaccine on the spur of the moment when a virus such as this one shows its face.  And even if a vaccine could be cranked out, it takes a while after the vaccination to develop the immunity, so it wouldn’t help immediately anyway. Since there will be no vaccine, we need to turn to other techniques to protect ourselves.  How can we do that?  By doing all the things we need to do to bolster our immune systems.

This swine flu is a type A influenza, which is a type that can usually be warded off prophylactically with amantidine (Symmetrel), an inexpensive drug that is readily available.  But from my reading, it looks like this particular strain of influenza A is resistant to that drug.  There are a couple of other drugs that are effective in the treatment of this flu – Tamiflu and Relenza – but I wouldn’t use them as a prophylactic.  Keep them in reserve in the unlikely event that you should actually contract this flu.  MD and I have gotten calls from friends and family all over the place wanting us to call them in prescriptions for these drugs, but we have refused because we don’t want to deplete supplies (which are limited) for those who actually get the flu.

As far as I’m concerned, the single best thing you can do is to make sure your vitamin D levels are where they are supposed to be.  On days that I’m not in the sun, I always take a 5,000 IU vitamin D3 capsule.  If I feel like I’m coming down with something or if I’m going on a long flight, I’ll take a 50,000 IU capsule.

In addition to the vitamin D, the other things you can do are as follows:

Eat plenty of good quality protein and fat.  Your immune system is made of protein and fat, so eat what it needs.

Avoid sugar and refined carbohydrates.  A number of scientific studies have shown that sugars and refined carbohydrates increase inflammation and, consequently, occupy much of the capacity of the immune system.

Get plenty of sleep.  Sleep is a great immune enhancer.  Remember all the times you’ve shorted yourself sleep and ended up catching a cold.  Get your rest.  If you have trouble falling asleep, try some sublingual melatonin.  It’s available at any health food store.  Put 1 or 2 mg under your tongue when it’s lights out.  Don’t use the melatonin unless and until you’ve turned the lights out and are ready to sleep.

Wash your hands frequently and keep them away from your nose and eyes.  This is especially good advice when you are traveling or even just out and about.  Someone with the flu (or other virus) sneezes into his/her hand, touches a door handle, you grab the same door handle, then rub (or pick at) your nose, and Bingo! you’re inoculated.  So I repeat: wash your hands and keep them away from your nose.  Hand sanitizers help.  And, as if I need to tell anyone this, try to avoid having someone sneeze or cough in your face.

I would avoid kissing pigs and strangers.  Wait until this scare recedes into your rear-view mirror before you follow the lead of this youngster.

Follow the above recommendations, and I think you’ll do all you can to minimize your chances for infection.

If you do get the flu, have your doctor give you a prescription for one of the two drugs mentioned above.

But I doubt you will get infected.  And I suspect this whole thing will blow over in fairly short order.

Photo used under Creative Commons from Mr TGT

A few days ago the Washington Post published an article with what has to be one of the dumbest headlines I’ve ever read.

New Guidelines Make It Easy to Get Fit

The article goes on to discuss how new US government guidelines cutting the previously recommended amount of exercise required for some minimal level of fitness even more.  Which, of course, makes it easier to get fit.  Right?

Only the government could come up with such idiocy.  It fair takes one’s breath away.  Could anyone else in his/her right mind imagine such stupidity? Or is it just the people we give our tax money to that think this way?  Changing the guidelines helps us get fitter easier? Jesus wept.

This article (and the guideline changes behind it) reminds me of an old joke that I heard as a kid and thought pretty funny at the time.  And still do, I guess, since it points out the brainlessness of these kinds of statements.  Here goes.

Late in the afternoon, a man comes into his house panting, puffing and sweating profusely.  His wife looks at him and says ‘What happened to you?’

The man croaks out between gasps for air, ‘I ran home behind the bus and saved two dollars.’

His wife looks at him scornfully and says, ‘What an idiot.  Why didn’t you run home behind a taxi and save $20?’

That’s a joke, but it’s the same logic behind the “new guidelines mak[ing] it easy to get fit.”  One wonders why, if these new guidelines make it so easy, that the government doesn’t decrease the recommendations even more?  That would make it even easier.  In fact, why not recommend 3 minutes of exercise per day, then virtually everyone could become fit. Even the guy in the photo at the top of this post.

As the old miner said to Butch and Sundance:

Morons.  I’ve got morons on my team.

And indeed we do have morons on our team, and we pay them each April 15.

Last week a host of reports about a study showing that eating a big breakfast brings about a much greater weight loss than eating a smaller breakfast saturated the media. Predictably, the press was all over this report with varying flavors or reporting depending upon the reporters biases. Some, obviously carb biased, reported from a high-carb perspective; others – more well-balanced, no doubt – reported from that bias. Others simply focused on the ‘big.’ Let’s see what’s going on here.

The first thing one must realize is that this is not a paper published in a peer-reviewed journal, this is a poster presentation at a medical meeting, in this case the annual meeting of the Endocrine Society held in San Francisco last week. A while back I wrote at length on the difference between this type of presentation and a paper that has gone through the peer-review process. Poster presentations such as this one go through a sort of peer review process when they are presented in the sense that attendees ask questions and point out weaknesses. But the public never sees this. The public sees the press reports about these presentations without the peer review. Papers that are published run through the peer-review gauntlet before they see the light of day and are ever reported on.

The authors of this study or the university at which they are employed put out a press release on the results of the study. The press, eager to publish offbeat nutritional news, picks it up and runs with it. The gullible public takes it as gospel.

I tried to find the press release by going to the websites of the universities involved, but couldn’t come up with anything. Maybe some industrious readers will have better luck than I. A number of members of the media secured interviews with Daniela Jakubowicz, the lead author, so we can pretty much see where she’s coming from. Interestingly, she has a diet book out in Spanish titled ¡Ni una Dieta más!, which translates to Not Another Diet! The subtitle translates to: The circadian method that revs up weight loss, controls hunger and sweet addiction, and let’s you keep the weight off forever. It looks like this study is an effort to confirm the ideas in her book.

As I say, I couldn’t find the press release, but I did find the abstract of the poster on the Endocrine Society’s website.

[P3-220] Effect of Diet with High Carbohydrate and Protein Breakfast on Weight Loss and Appetite in Obese Women with Metabolic Syndrome.

D Jakubowicz, D Maman, P Essah, Hosp de Clins Caracas, Caracas, Venezuela; Med Coll of Virginia, Virginia Commonwealth Univ, Richmond, VA

Background: Insulin resistance, common in obesity, promotes weight gain. Weight loss diets for obesity are frequently unsuccessful due to a carbohydrate withdrawal effect that exacerbates carbohydrate craving and hunger. We hypothesized that a diet aimed at reducing hunger and carbohydrate craving would support weight loss in obese individuals.

Objective: The purpose of this study was to determine whether a diet consisting of a high carbohydrate and protein breakfast would promote weight loss, increase satiety, and reduce carbohydrate craving in obese women with metabolic syndrome.

Methods: In this 32-week prospective study, 94 obese sedentary women (age 31.67yrs, BMI 33.84kg/m²) with metabolic syndrome were randomized to one of two diets: 1) a strict low carbohydrate diet (LCH; n=46) consisting of 1085kc/day (carb:protein:fat 17:51:78g) with breakfast 290kc (7:12:24g), lunch 425kc (5:21:28g), and dinner 370 kc (5:18:26g) or 2) a LCH diet with the modification of a high carbohydrate and protein big breakfast (LCH+BB;n=48) consisting of 1240kc, (carb:protein:fat 97:93:46g) with breakfast 610kc (58:47:22g), lunch 395kc, (34:28:13g),and dinner 235kc (5:18:11g). The first 16wks aimed on weight loss and the last 16 weeks on weight maintenance (WM). A 3-h meal tolerance test (MTT) was performed with quantification of glucose, insulin and appetite scores (hunger, satiety, fullness, and desire to eat) using 100-mm visual analog scales (VAS) at 0, 30, 60, 120, and 180 min after LCH or LCH+BB breakfast.

Results: Both groups lost weight at 16 wks (LCH: -12.62kg, LCH+BB: -10.63kg, p=NS). During the WM phase, the LCH+BB group continued to lose weight (-7.52kg, p<0.001 vs. 16 wk) whereas the LCH group gained weight (+8.32kg, p<0.001 vs. 16 wk). At 32 wks, the LCH group lost 4.5% of their baseline weight. In contrast, the LCH+BB group decreased baseline weight by 21.3%. AUC for glucose and insulin responses to MTT improved in line with weight loss (p<0.001, NS between groups). Compared with LCH, LCH+BB reduced hunger (p=0.02), increased satiety (p=0.07), decreased desire to eat (p=0.02), and increased fullness immediately prior to lunch (p<0.001). In contrast to LCH, LCH+BB reduced carbohydrate craving scores (P<0.001).

Conclusion: A diet consisting of a high carbohydrate and protein breakfast facilitates weight loss by reducing hunger and diminishing carbohydrate craving. Effective weight loss strategies for obese individuals should focus on controlling appetite and carbohydrate craving.

By going over this abstract we can learn a lot. What we primarily can learn is what is missing in order for us to get the full and entire picture of what is going on.

We learn that 94 pretty obese sedentary women afflicted with metabolic syndrome were randomized to one of two diets, which is good. This is a prospective, randomized study. There is no mention of how these women were monitored or whether they had food provided for them or were simply instructed to follow specific diets.

After 16 weeks, the weight loss phase of the study, the women on the low-carb arm lost 27.7 pounds (12.6 kg) whereas the women on the higher-carb arm (the big breakfast group) lost 23.3 pounds (10.6 kg). I find it interesting that the lower-carb group lost almost 20 percent more weight than did the higher carb group, yet the researchers reported this difference to be non-significant. I don’t believe this. Not with 46 subjects in one arm and 48 in the other. The numbers simply don’t bear that out.

If you look at the caloric difference between the two diets, it turns out that the low-carb subjects were getting 155 kcal less than the higher-carb subjects, calculating out to about 4.96 pounds difference, which is close to the 4.4 pound difference that actually occurred. We can say that the difference in weight loss didn’t really have anything to do with diet composition, but a lot to do with caloric intake. At these low-caloric intakes, calories are what counts. Not diet composition.

Now comes the interesting part of this study, which is the part that isn’t mentioned. The abstract says that after the first 16 weeks of the weight loss phase of the study, the two groups were put on maintenance diets. There is no mention of calories, macronutrient composition, or meal timing. Presumably the big breakfast group continued to skew most of their calories toward the breakfast meal at the beginning of the day, but the abstract doesn’t tell us. This is one of the things that would never, ever fly through the peer-review process.

All we learn is that after the next 16 weeks on the mystery diet, the higher-carb, big breakfast group continued to lose big time, dropping another 16.5 pounds (7.5 kg) while the poor subjects in the low-carb group actually packed on an extra 18.3 pounds (8.3 kg). There is something fishy going on in Venezuela, and it ain’t just Hugo Chavez. There is no way that these two groups could have had anywhere near the same number of calories and had these results be this divergent. It’s impossible, and (to put it in Samuel Johnson’s favorite words) there’s an end on’t.

I suspect the diets were fiddled with to bring about the results the researchers wanted. That’s the only option.

Having said that, let’s look at another aspect of this study that bears scrutiny. The hunger scores were evaluated using a meal tolerance test at 0, 30, 60, 120, and 180 min after breakfast. Now if I were to do this test anywhere from right after breakfast to 3 hours after breakfast and the only data you had to go on was the fact that one group got a breakfast that contained over twice as many calories as the other, which group do you think would be the least hungry over the next few hours: the group with the little breakfast or the group with the big breakfast? This is the test that was done. And reported. And picked up on by the press. This is one for the having-a-keen-grasp-of-the-obvious award.

I’ve seen a number of studies showing that caloric intake skewed to the first part of the day, i.e., a big breakfast, small dinner, seems to result in more weight loss than the same number of calories skewed later in the day, i.e., small breakfast, big dinner, so I don’t have an argument with this idea. The argument I have is that this is a poorly reported study that doesn’t contain enough information to allow an appropriate understanding of what really went on, yet it’s being used by both the press and it’s author to imply something that isn’t necessarily true: that a big, high-carb breakfast is better for you in terms of weight loss than a low-carb breakfast.

Daniela Jabukowiz herself is not a proponent of the low-carb diet. As she said to one of the reporters covering this travesty:

Most weight loss studies have determined that a very low carbohydrate diet is not a good method to reduce weight.

Oh, really. I would think it is just the opposite. Whenever low-carb diets are compared to low-fat diets, the low-carb diets kicks tail. At the very worst, both diets are about even. But the vast majority of studies show the low-carb diet to be superior.

I can pretty much guarantee you that this study will never see the light of day in a peer-reviewed journal. This is confirmed by one of the press members reporting about this presentation who wrote:

Plans to publish the paper in a journal were not announced.

I’ll bet they weren’t.

It should come as no surprise to anyone that the media in general dislike low-carb diets. They use a number of tricks to denigrate carbohydrate-restricted diets at every opportunity. I’m going to start a series of posts showing the different methods used by our friends in the press to downplay the efficacy of the diets that millions of people have found so effective.

One of the most common methods the media uses to disparage low-carb diets is to give any study that makes these diets look bad, no matter how suspect such a study might be, full coverage. We saw this in the mega coverage a few weeks ago of a poster presentation (not even an article in a peer-reviewed journal) allegedly showing that the Atkins diet causes vascular damage. I dissected this ’study’ and the media coverage of it in a previous post. This method isn’t particularly subtle, so we’ll leave it because I want to deal with the sort of crafty, underhanded ways that the media work to bring about their ends.

Another way the media disses low-carb diets is to simply downplay them. Or even fail to mention them at all. In June 2001 Woman’s World did a cover story about Kathleen Hays the (at that time) CNBC financial commentator who is also a friend of mine. She worked out at Fred Hahn’s facility in New York and did Slow Burn strength training. She also followed the Protein Power diet. When approached by Woman’s World to do the story she told them that she had been following a low-carb diet along with her strength training. They told her they weren’t interested in her diet – they wanted to do an article on her method of exercise. And so they did. You can read the story by clicking the Woman’s World picture on Fred’s website. Not a mention of a low-carb diet. Anywhere. The implication is that she lost her 28 pounds by simply doing strength training.

Sometimes the media slips in the fact that a low-carb diet was part of an overall weight-loss plan, but then totally focuses on some other aspect of the regimen.

A reader this blog sent me a classic example of this method. He sent a link to a CNN story about a man who had ‘walked off’ a huge amount of weight, or at least that’s what the article wanted readers to believe. The headline in big bold print stated

WEIGHING NEARLY 400 POUNDS, MAN WALKS OFF HALF HIS WEIGHT

The article then goes on to describe the epiphany that Mr. Novak (the subject of this article) experienced. He was at a football game and went for refreshments. Upon returning to his seat, Mr. Novak

started getting winded. “I didn’t feel right, I started sweating. I didn’t think I would make it back up. My heart [was] beating a million times a minute; I thought I was having a heart attack.”

Novak stood against a cold wall for 20 minutes to catch his breath. Fortunately, he wasn’t having a heart attack but he was so frightened that thoughts of his family began to race through his mind.

“A lot of things went through my head, about saying goodbye to my kids,” says Novak choking back his tears. “I told my friend, ‘This is it, I’m not going to live like this no more.’ “

Like many people who undergo similar experiences, Mr. Novak decided to do something about his condition. He came up with his own game plan and got started.

He began simply by walking — one mile a day and eating a low-carbohydrate diet of 15-30 grams a day.

There it is. The only mention of a low-carb diet in the entire article. The rest of the piece discusses Mr. Novak’s walking regimen.

“I walked off my first 100 pounds,” he says. “Walked it off, an hour a day. I lost 100 pounds in seven months.”

Now, it is admirable that Mr. Novak was able to continue his regimen, but it’s a little disingenuous to imply that he ‘walked’ off a 100 pounds in seven months. In fact, it’s not only disingenuous, it’s impossible. If we simply do the math, we find that the number of calories expended in walking an hour times 30 days per month times seven months gives us (and this is generous) about 42,000 kcal. If we divide the 42,000 kcal by the 3,500 kcal it takes to lose a pound of fat, we get 12 pounds. So, at best, Mr. Kovak’s walking an hour a day got rid of 12 pounds. What happened to the other 88 pounds? Could it be that the low-carb diet was responsible for that? I would think so. But did the low-carb diet get any credit? Nope. None.

Before you blame Mr. Novak for telling porkies, remember the story above about Kathleen Hays. She tried to tell them that she attributed most of her weight loss to the Protein Power diet, but they didn’t want to hear that. We don’t know what Mr. Novak said versus what the press reported.

In the video that accompanies the print article, the low-carb diet is mentioned exactly once, and is mentioned quickly. All the video is about his exercise regimen. Every shot almost shows some sort of exercise device or a clip of Mr. Novak exercising. Again, the media is in charge of editing the video footage. We haven’t a clue what Mr. Novak really told them.

When the great unwashed masses read this article or watch the accompanying video, they will finish with the idea firmly implanted that if they go out and walk an hour a day, they will lose 100 pounds in seven months. Nothing could be further from the truth. Maybe if they incorporate a 15-30 gram per day low-carb diet along with their walking, but not just by walking alone.

This is but one way the media have of downplaying low-carb diets. In posts to come, I’ll show some even more subtle ways that the folks in the press flim flam their audience. Just beware of what’s going on and don’t be taken in.

If you find ways in which the press is playing fast and loose with the facts on low-carb dieting, send them my way. I can always use bad examples.

(Hat tip to John for this one.)

There’s a hold up in the Bronx,
Brooklyn’s broken out in fights.
There’s a traffic jam in Harlem
that’s backed up to Jackson Heights.
There’s a scout troop short a child,
Kruschev’s due at Idlewild!
Car 54 where are you?

Anyone who watched TV in the early sixties no doubt remembers the hilarious show Car 54 Where Are You? starring Fred Gwynne and Joe E. Ross as New York uniformed police officers Francis Muldoon and Gunther Toody. Muldoon and Toody were well meaning but hopelessly inept, always screwing things up in outrageous fashion, causing no end of grief and embarrassment to their precinct commander Captain Block, who had to sort out the idiocy and try to make things right.

Now comes the medical equivalent of Muldoon and Toody in the persons of in-training physicians Tsuh-Yin Chen, M.D. and William T. Smith, M.D. The role of precinct commander in this production is played by one Klaus-Dieter Lessnau, M.D., who, unlike Captain Block, only adds to the problem with another layer of ignorance and stupidity. And whereas Car 54 Where Are You? left its viewers with their sides hurting from laughter, the repercussions of our medical drama will be felt painfully in the world of nutrition for years to come. A well-respected medical journal will have a blot on its record in much the same way CBS did after rushing to air the discredited George Bush Air National Guard story before it was authenticated, and, lastly, the whole episode will serve as a cautionary tale to anyone considering going to the emergency room of a teaching hospital.

Our drama unfolds not on the TV screen but in the emergency room of Lenox Hill Hospital in New York. The script for this show is contained in an article in the current issue of The Lancet entitled “A life threatening complication of Atkins diet.” Let’s tune in.

First, a brief synopsis of what happened–a treatment as they say in Hollywood–then we’ll review the case in more detail to see what really happened.

An obese woman who had been on the Atkins diet for the previous month came to the emergency room complaining of shortness of breath. The resident physicians who saw her found evidence of elevated ketone bodies in her blood, diagnosed her with ketoacidosis, admitted her to the intensive care unit, gave her IV fluids, tested and x-rayed everything, and discharged her four days later after a complete recovery. The resident physicians along with their attending physicians wrote this case up as an example of what could happen to someone following a low-carb diet and got it published in a prestigious British medical journal, accompanied with an editorial issuing a further warning as to the risks of low-carb dieting. The press was all over the story and one of the attending physicians issued statements to anyone who called.

Let’s look a little deeper. This is the patient’s history:

In February, 2004, we saw a 40-year-old obese white woman who complained of dyspnoea (shortness of breath). 5 days earlier, her appetite had decreased, and she had felt nauseous and had since vomited four to six times daily. She became increasingly short of breath, and presented to us as an emergency.

She had strictly followed the low-carbohydrate high-protein Atkins diet, eating meat, cheese, and salads for the previous month.

This lady was truly on the Atkins Diet:

She took vitamins recommended by the diet: chromium picolinate, Atkins Basic3 (multivitamins; Atkins Nutritionals, Inc, USA), Atkins Essential Oils (omega fatty acids), Atkins Dieters’ Advantage (electrolytes and extracts), and Atkins Accel (a “thermogenic” formula). As instructed by the original Atkins diet book, she monitored her urine twice daily, with dipsticks strongly positive for ketones. She reported a weight loss of about 9 kg over this 1-month period.

Here is her presentation and the doctors’ physical findings along with my commentary:

On presentation to the emergency department, our patient was in moderate distress, with a respiratory rate of 20-30 breaths per min.

‘Moderate distress’ breathing at a rate of 20-30 breaths per minute? I don’t think so. A normal respiratory rate is between 12-20 breaths per minute, but obese people tend to breath a bit faster since they have a lot going on metabolically and need a little more oxygen. I wouldn’t say that an obese person breathing 20-30 times per minute was in distress, especially in view of the rest of the physical exam, which we’ll see in a moment. The resident physicians are trying to make a case for severe metabolic acidosis with this patient. If the patient truly was in severe metabolic acidosis (as type I diabetics can be if they go into ketoacidosis) she would have been demonstrating a type of breathing called Kussmaul breathing, which is characterized by rapid, deep, labored, sighing breaths familiar to anyone who has ever seen a bad case of ketoacidosis. We’re this patient exhibiting Kussmaul breathing, I’m sure it would have been identified as such in the published case report.

On examination, her bowel sounds were hyperactive and she had mild epigastric tenderness. Otherwise, clinical examination was unremarkable with normal vital signs.

Okay, when the resident physicians listened to this patient’s abdomen they heard more active, louder bowel sounds than normal and when they pushed on her abdomen she told them it was mildly tender. And her clinical examination was ‘unremarkable’ and her vital signs (blood pressure, heart rate, etc.) were normal. It doesn’t sound like someone in distress to me. When patients are in distress, their heart rates and/or blood pressure readings are usually elevated.

Her body-mass index was 41.6 kg/m2.

Interestingly, the case report doesn’t tell us this patient’s height or weight, only her body mass index (BMI). I assumed a height of 5′ 5″, which, when run through the BMI calculator, gives a weight of 250 pounds.

So, let’s see what we’ve got so far. An obese, 40 year old lady who has been nauseated and vomiting (4-6 times per day) for the past five days shows up in the emergency room. She is breathing a little faster than normal, but, given her weight, probably not by much. She doesn’t appear to be in any distress and all her vital signs are normal. Her abdomen is a little tender (whose wouldn’t be after vomiting for five days?) and her bowel sounds are hyperactive (think of the last time you got some kind of abdominal flu; I would be willing to bet that you could hear your own bowels gurgling without the aid of a stethoscope). Every doctor who has taken care of patients for any length of time has seen this same picture countless times. It’s a diagnosis that can be practically made from across the room.

The patient has gastroenteritis, an infection (probably viral) of the gastrointestinal tract. She may be a little dehydrated if she hasn’t been able to keep any fluids down, but she has probably been able to hold some fluids on her stomach or her blood pressure would be low and her heart rate rapid from the dehydration. If you’re the physician taking care of this patient you might want to run a couple of other tests just to make sure, which you do and find out that her blood sugar is normal (so you know she isn’t a diabetic in ketoacidosis) and her amylase is okay (so she doesn’t have acute pancreatitis) and her liver enzymes are normal (so she probably isn’t afflicted with hepatitis) and her white blood cell count is elevated, which goes along with an infection. You then might drip a liter of fluid into her intravenously to rehydrate her and make her feel better, give her a shot to reduce the nausea and vomiting or maybe a prescription for a suppository for the same thing, tell her to drink only clear fluids, and come back if she doesn’t get any better. In virtually all cases the patient will get well.

Then as you’re discussing all this with the patient, you find out that OH MY GOD, SHE’S BEEN ON THE ATKINS DIET! Now, if you’re an experienced physician, you tell her to not worry about her diet for a while until she gets over her nausea and vomiting, but that once she’s recovered she can return to her low-carbohydrate weight-loss efforts..

If you’re Muldoon and Toody, however, you panic. Low-carb diets cause ketosis, you think. Maybe she’s in ketoacidosis, which can be fatal. Since you’re an idiot, you ignore her normal blood sugar level, which should tell you that she’s making plenty of her own insulin. As the level of ketone bodies rises in the blood, it stimulates the release of insulin from the pancreas. The spurt of insulin then shuts down the process that makes ketones. Ketones only rise to dangerous levels in people who have type I diabetes and can’t make their own insulin. If the system didn’t work this way, people who starved would die from ketoacidosis relatively quickly, but they don’t; they live for weeks without food before they succumb to protein malnutrition, not ketoacidosis. The idea that this patient, who had a normal (or probably an elevated) insulin level was in dangerous ketoacidosis is absurd, but Muldoon and Toody don’t realize this because the patient HAS BEEN ON THE ATKINS DIET, FOR GOD’S SAKE.

In their frenzy of misdiagnosis, the panic-stricken Muldoon and Toody check the patient’s blood levels of beta-hydroxybutyrate, a specific ketone body, and find it to be high. They, of course, don’t bother to realize that, the Atkins diet notwithstanding, elevated levels of ketones would be expected since the patient hadn’t been able to hold anything on her stomach for five days, and when people don’t consume food they break down body fat for energy and produce ketones in the process. Nope, that would be way too rational. These doctors-in-training have the diagnosis of ketoadidocis burned into their brains thanks to the red herring of the Atkins diet, and they’re looking for anything to confirm it. They check a bunch of other labs that don’t really show anything all that earth shattering (and, in fact, don’t even really compute–but that’s a technical issue beyond the scope of this post) and admit the patient to the intensive care unit. Car 54 Where Are You?

In a typical teaching setting, the next morning the resident physicians would present their patient who is now resting comfortably in the intensive care unit at about $5,000 per day, and whom, in their own minds at least, they had just snatched from the jaws of impending death from ketoacidosis, to their attending physician. In a typical teaching hospital, the attending physician, who would have had a number of years of patient experience, would gently (or maybe not so gently) tell the residents that they had overreacted a little and would walk them back through the situation with a Socratic-type dialogue that would probably go something like this:

‘You checked this patient’s blood sugar and it was normal, right? Okay, now, what does that blood sugar tell you about the condition of the patient’s pancreas? Uh huh, that’s right, it’s making plenty of insulin. Okay, now, if the patient is making plenty of insulin, is it really possible that she could be in life-threatening ketoacidosis? Okay, guys, let’s review how ketones are made…’ You get the picture. I know how these little dialogues go because I was a resident at one time and I was on the other end of a number of them. In fact, I had an attending physician in surgery, famous for his sarcasm, who, had I done something like these two had done here, would have led me through the whole Socratic-dialogue process so that I could see every misstep I made along the way, then would have shaken his head and said, “Well, Doc, which is it? Are you stupid or do you just not care?”

But that wasn’t how this one must have gone there at the Lenox Hill Hospital. Instead of Captain Block gently reading Muldoon and Toody the riot act, our leader, Dr. Klaus-Dieter Lessnau, must have fallen into the OH MY GOD SHE’S BEEN ON THE ATKINS DIET trap. Instead of showing his underlings the folly of their ways, he jumped right in there with them, wallowed in their stupidity, kept this poor patient in the intensive care unit for four days, and may have even said, ‘let’s write a paper on it.’ After the paper was published and made the news, our attending was ever so eager to bask in his 15 minutes of fame and talk to any reporter that called and further memorialized his own boneheadedness. See here, here, and here. Had members of the press possessed even a smidgen of medical knowledge or had they checked with anyone other than Dr. Lessnau himself, the many pieces appearing about this fiasco might have been entitled something along the lines of:

Buffoons misdiagnose mild gastroenteritis, cost patient thousands.

Unfortunately, however, the press, afflicted with its own pro-low-fat bias, has been more than happy to take this opportunity to lambaste low-carb diets. Car 54 Where Are You?

In a perfect world, after this idiocy had consumed both the residents and their attending physician, and was then written up and sent out to journals for publication, someone, somewhere, with good sense, doing peer review would see it, realize it for what it was, and reject it. I have no way of knowing, but I suspect from the dates involved that that is exactly what happened. These events took place over two years ago in February of 2004, and were, I’m sure, written up shortly thereafter, and shipped off to some medical journal. I seriously doubt that The Lancet was the first choice. I would imagine that these authors received a number of rejections, but kept sending the paper out. It finally fell on fertile soil with The Lancet where not only did the editors fall for this ignorance hook, line, and sinker, they saw fit to publish a supporting editorial written by a dietitian turned PhD at the University of Minnesota. Car 54 Where Are You?

The editorial goes through the following argument. Although a number of studies have shown the low-carbohydrate to be superior to the low-fat diet in oh so many ways, we’ve got to be concerned about dieter safety. The report by Muldoon and Toody shows what can happen to a dieter on a low-carbohydrate diet. This patient could have died. The Atkins diet (and by extension all low-carbohydrate diets) are unbalanced. If you don’t believe it, compare the Atkins diet to the 2005 US Dietary Guidelines (and we all know how perfect those are). We’ll even provide the table. There, you see:

Clearly, the Atkins diet is not nutritionally balanced.

And they finish off with:

Special care needs to be taken when formulating the best prescription for weight loss, because people choosing to lose weight range from being marginally to significantly overweight, and might have a wide range of disease risk factors with varying levels of severity. As researchers and clinicians, our most important criterion should be indisputable safety, and low-carbohydrate diets currently fall short of this benchmark.

So, with this paper and accompanying editorial all the low-fat zealots have gotten what they’ve been waiting for. For years when MD and I and Robert Atkins and Ron Rosedale and Robert Crayhon and Jonny Bowden and a host of others have extolled the virtues of the low-carbohydrate diet, all the naysayers said: Where are the studies? All your clinical experience is simply anecdotal; we want to see the science. Show us the studies.

Well, over the last three or four years these pinheads have been deluged with studies showing the superiority of the low-carb diet over the low-fat diet for not just weight-loss, but for lipid lowering, blood sugar control, and blood pressure reduction as well. In any head to head challenge, the low-fat diet hasn’t been able to lay a glove on the low-carb diet.

Now that the low-fatters have been bloodied with all these studies they have been demanding for years, they haven’t given up, they’ve only changed their strategy. Since they can’t successfully argue on the merits, they’re resorting to scare tactics. Sure, they’ll say, you’ll lose weight alright, solve your lipid problems, and all the rest, but look at that poor lady who almost died. It was written up. That could happen to you, you know.

And to think that The Lancet has been a party to this travesty is almost beyond belief until it is recalled that it was The Lancet that published the Dean Ornish I’ve-proved-that-my-diet-has-reversed-heart-disease paper back in 1990. Like the current paper, the 1990 Ornish paper, in my opinion, was not worthy of publication without some serious rewriting. But, it is obvious that the powers that be at The Lancet have a bias in favor of low-fat dieting. And, based on the publication of these two papers, not just a mild bias, but a totally slanted perspective. In fact, I think that the name of the journal should be changed the The Slantcet.

Car 54 Where Are You?