Feinman - The Nutrition Mess. Can We Fix It?

Richard David FeinmanDepartment of Cell BiologySUNY Downstate Medical CenterBrooklyn, New [email protected]

The nutrition mess. Can we fix it?

Ancestral Health Symposium

Monday, August 29, 2011

The first question we ask medical students:

“Do you think there has ever been a moment in the history of medicine, when a majority of physicians and scientists held to a theory that was wrong and dangerous and resisted change despite contradictory evidence? Do you think that there has ever been such a period?”

If you think it has happened before, you at least have to consider the possibility that this is another such period.

My answer will be that current nutrition is a mess with scandals equal to any in the history of medicine. I will suggest a government solution.


Two worlds. Establishment nutrition does not cite or even recognize carbohydrate restriction. Peer review is so biased as to be meaningless.

Mixed messages and ambiguous writing from health organizations and their media.

...and the news services play along.

Sins of omission in the scientific literature: Failure to cite relevant literature. Experiments with no null hypothesis.

The nutrition mess:

Progression of scapegoats: cholesterol, saturated fat, trans-fat, fructose.



Look at a couple of examples.

Robert Lustig’s lecture on YouTube, with 1.5 million hits, asked, as Gary Taubes put it: “Is fructose a toxin?.”

Case against fructose not established but, more important...

Wait a minute...

...suggestion for government intervention in terms of taxes on sugar and pressure on private industry.

Government intervention has other mechanisms than punitive measures. Government can evaluate the science -- even the science of government agencies.

Beyond private industry, how about private health agencies? ADA, AHA: are they accountable?.

But first, whaddaya’ know?


1. The most energy-dense nutrient (most calories/gram) isA. carbohydrateB. fatC. proteinD. ethanol -

We ask incoming medical students...


1. The most energy-dense nutrient (most calories/gram) isA. carbohydrateB. fatC. proteinD. ethanol

carbohydrate = 4 kcal/g fat = 9 kcal/gprotein= 4 kcal/gethanol= 7 kcal/g

• Everybody, including the National Boards, expects you to know these numbers.

This is actually not good for such an educated group. But they’re young, healthy and generally thin.


2. For a slice of buttered bread, which is more fattening?

A. the breadB. the butterC. both are equally fatteningD. cannot tell from information given-


2. For a slice of buttered bread, which is more fattening?

A. the breadB. the butterC. both are equally fatteningD. cannot tell from information given

You cannot tell without knowing how much butter and how much bread.

• Energy-density, like any density, is an intensive property: two pieces of bread have the same energy-density as one.• Total calories is an extensive property = energy-density x grams.


3. During the epidemic of obesity and diabetes, the macronutrient that increased most was:

A. carbohydrateB. fatC. proteinD. all about the same, calories increased across the board.


3. During the epidemic of obesity and diabetes, the macronutrient that increased most was:

A. carbohydrateB. fatC. proteinD. all about the same, calories increased across the board.


The increase in calories during the obesity and diabetes epidemic was due largely to carbohydrate intake. For men, the absolute amount of total fat and saturated fat went down.


The problem: “You are what you eat.”

Better: “You are what your body does with what you eat.” Metabolism describes how foods are processed.

Dietary fat does not necessarily turn to body fat.

Hormones affect rates of metabolic processes.

Bad idea.

Did we get the message?


Cholesterol is proved deadly, and our diet may never be the sameThis year began with the announcement by the Federal Government of the results of the broadest and most expensive research project in medical history. Its subject was cholesterol... Among the conclusions:• Heart disease is directly linked to the level of cholesterol in the blood.• Lowering cholesterol levels markedly reduces the incidence of fatal heart attacks.

Other doctors are not so sure, and urge a stricter interpretation of the study. Says Dr. Edward Ahrens, a veteran cholesterol researcher at Rockefeller University: "Since this was basically a drug study, we can conclude nothing about diet; such extrapolation is unwarranted, unscientific and wishful thinking."

March. 1984 February. 2011


Nutrient-dense foods and beverages are lean or low in solid fats, and minimize or exclude added solid fats, sugars, starches, and sodium. Ideally, they also are in forms that retain naturally occurring components, such as dietary fiber. All vegetables, fruits, whole grains, seafood, eggs, beans and peas, unsalted nuts and seeds, fat-free and fat-free milk and milk products, and lean meats and poultry—when prepared without adding solid fats or sugars—are nutrient-dense foods.

lean meats

A basic premise of the Dietary Guidelines is that nutrient needs should be met primarily through consuming foods. Foods provide an array of nutrients and other components that are thought to have beneficial effects on health.

The nutrition mess.

low in solid fats

exclude added solid fats

fat-free fat-free milk

without adding solid fats


PUFA for SFAreduces risk

CHO for SFAreduces risk

PUFA: risk ↑

CHO: risk ↑

Jakobsen MU, et al: Major types of dietary fat and risk of coronary heart disease: a pooled analysis of 11 cohort studies. Am J Clin Nutr 2009, 89(5):1425-1432.

Statistical rule: If 95% CI crosses 1.0, no difference.

NO EFFECT

Almost none of the individual studies show an effect of saturated fat. And....


Nutrient-dense foods and beverages are lean or low in solid fats, and minimize or exclude added solid fats, sugars, starches, and sodium. Ideally, they also are in forms that retain naturally occurring components, such as dietary fiber. All vegetables, fruits, whole grains, seafood, eggs, beans and peas, unsalted nuts and seeds, fat-free and low-fat milk and milk products, and lean meats and poultry—when prepared without adding solid fats or sugars—are nutrient-dense foods.


A deceptive message and criticism ignored.







Feds' food fogGuidelines get it wrongLast Updated: 3:26 AM, August 5, 2010Posted: 12:39 AM, August 5, 2010Comments: 8

Steven MalangaAs government agencies in places like New York seek a greater hand in shaping diets, the next set of federal nutrition guidelines, to be published this year, could prove controversial -- for growing scientific evidence suggests that some federal recommendations have simply been wrong.The crux of the controversy is the quantity of fat and carbohydrates we consume and how it influences cardiac health. As Scientific American recentlypointed out, ever since the first set of guidelines in 1980, Americans heard that they had to reduce their intake of saturated fat by cutting back on meat and dairy products and replacing them with carbohydrates. They dutifully complied. Since then, obesity has increased sharply, and the progress that the country has made against heart disease has largely come from statin drugs.

Read more: http://www.nypost.com/p/news/opinion/opedcolumnists/feds_food_fog_1Sn8sLmkw7dv8wl47bqQKL#ixzz1GcdE


http://www.nypost.com/p/news/opinion/opedcolumnists/feds_food_fog_1Sn8sLmkw7dv8wl47bqQKL




http://www.nypost.com/p/news/opinion/opedcolumnists/feds_food_fog_1Sn8sLmkw7dv8wl47bqQKL#comments_block

http://www.nypost.com/p/news/opinion/opedcolumnists/feds_food_fog_1Sn8sLmkw7dv8wl47bqQKL#comments_block

http://www.nypost.com/p/news/opinion/opedcolumnists/feds_food_fog_1Sn8sLmkw7dv8wl47bqQKL#ixzz1GcdEIK42






The nutrition mess.

Mixed message and ambiguous writing from health organizations and their media.


The nutrition mess. The news services play along.

dumb, but...


does anybody get hurt?


CHAPEL HILL, N.C. – A diet high in saturated fat is a key contributor to type 2 diabetes, a major health threat worldwide. Several decades ago scientists noticed that people with type 2 diabetes have overly active immune responses, leaving their bodies rife with inflammatory chemicals.

In addition, people who acquire the disease are typically obese and are resistant to insulin, the hormone that removes sugar from the blood and stores it as energy.




Figure 1 Palmitate activates NLRP3-ASC inflammasome. (a–d) ELISA for IL-1β (a–c), IL-18 (d) and IL-6 (e) in supernatants of resting or LPS-primed bone marrow-derived macrophages (BMMs) stimulated with palmitate conjugated to BSA (PA-BSA) or BSA control.

In fact...

cell study...no mice. CHAPEL HILL, N.C. – A diet high in saturated fat is a key contributor to type 2 diabetes, a major health threat worldwide. Several decades ago scientists noticed that people with type 2 diabetes have overly active immune


A. approximately 130 g/dayB. approximately 50 % of caloriesC. as much as possibleD. there is no dietary requirement for carbohydrate

5. The dietary requirement for carbohydrate is:

A. approximately 130 g/dayB. approximately 50 % of caloriesC. as much as possibleD. as little as possible

6. The carbohydrate intake recommended by the USDA, the American Diabetes Association and other agencies is:

The nutrition mess and the health agencies. First...


A. approximately 130 g/dayB. approximately 50 % of caloriesC. as much as possibleD. there is no dietary requirement for carbohydrate

5. The dietary requirement for carbohydrate is:

A. approximately 130 g/dayB. approximately 50 % of caloriesC. as much as possibleD. as little as possible

6. The carbohydrate intake recommended by the USDA, the American Diabetes Association and other agencies is:

The nutrition mess and the health agencies. First...


● Sucrose-containing foods can be substituted for other carbohydrates in the meal plan or, if added to the meal plan, covered with insulin or other glucose lowering medications.

could this be a place for government intervention?


is there room for an alternative opinion?

Goals of MNT that apply to individuals with diabetes4) To maintain the pleasure of eating by only limiting food choices when indicated by scientific evidenceRecommendations● Nutrition counseling should be sensitive to the personal needs, willingness to change, and ability to make changes of the individual with pre-diabetes or diabetes.● For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be effective in the short term (up to 1 year).● For patients on low-carbohydrate diets, monitor lipid profiles, renal function, and protein intake (in those with nephropathy), and adjust hypoglycemic therapy as needed.

... dietary carbohydrate is the major determinant of postprandial glucose levels. Low-carbohydrate diets might seem to be a logical approach to lowering postprandialglucose. However, foods that contain carbohydrate are important sources of energy,fiber, vitamins, and minerals and are important in dietary palatability.

sure, we don’t have a problem with low-carb diets, if you don’t mind CVD

from the hedonists at ADA

I thought we wanted to reduce energy.



data from Foster GD, et al.: A randomized trial of a low-carbohydrate diet for obesity. N Engl J Med 2003, 348(21):2082-2090.

the same ?

fat in theblood

“goodcholesterol”

“For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be effective in the short term (up to 1 year).”



Statistical AnalysisWe used a random-effects linear model that was fittedto all observed data for each variable on each of the 307participants for the primary analysis. Each random-effectsmodel consisted of a random intercept and slope to adjustfor individual participant variability due to within participantcorrelations among the observed longitudinaldata. These models also contained the following fixed effects:main effects for each follow-up visit, group assignment,interactions between each follow-up visit and groupindicator variables, and baseline value as a covariate. Weestimated with maximum likelihood by using the PROCMIXED procedure in SAS, version 9 (SAS Institute, Cary,North Carolina). A parallel longitudinal model structurebased on main effects for visit, treatment group, and baselinevalue and visit-treatment interactions was implementedwith logistic regression for binary outcomes. Wedid estimates by using generalized estimating equations underthe logistic regression model for correlated longitudinalbinary outcomes implemented in the GENMOD procedurein SAS, version 9. Predicted values for each treatmentand visit combination at the mean level of the baselineoutcome, with corresponding lower and upper confidencebounds, were produced under each model for the figures.

The previously mentioned longitudinal models precludethe use of less robust approaches, such as fixed imputationmethods (for example, last observation carriedforward or the analysis of participants with complete data[that is, complete case analyses]). These alternative approachesassume that missing data are unrelated to previouslyobserved outcomes or baseline covariates, includingtreatment (that is, missing completely at random). Thelongitudinal models implemented for this study relax thismissing-completely-at-random assumption in different ways. The generalized estimating equation– based longitudinallogistic models assume that missing data are unrelatedto previously observed outcomes but can be related tothe treatment because it is a covariate in the model. (thatis, covariate-dependent missing completely at random)(18). The likelihood-based mixed-effects models further relaxthe covariate-dependent missing-completely-at-randomassumption by allowing missing data to be dependent onpreviously observed outcomes and treatment (that is, missingat random). To assess departures from the missing-atrandomassumption under informative withdrawal—thatis, the missing weights are informative for which patientschose to withdraw or continue to participate in thestudy—we present sensitivity analyses. As such, we assumethat all participants who withdraw would follow first themaximum and then minimum patient trajectory of weightunder the random intercept model.

...such as fixed imputation methods (for example, last observation carried forward or the analysis of participants with complete data [that is, complete case analyses]).... The longitudinal models implemented for this study relax this missing-completely-at-random assumption in different ways.... can be related tothe treatment because it is a covariate in the model.

Oh, hell...intention to treat


Suppose we plot drop-outs vs. difference between groups.


DISCUSSIONOur study has 2 main findings. First, neither dietary fat nor carbohydrate intake influenced weight loss when combined with a comprehensive lifestyle intervention.

Samuel Klein, MD

Klein S, Wolfe RR: Carbohydrate restriction regulates the adaptive response to fasting. Am J Physiol 1992, 262:E631-636. “carbohydrate restriction, not the presence of a negative energy balance, is responsible for initiating the metabolic response to fasting.”

The data? No dietary records were reported.



Bethesda, we have a problem.


8. Several large clinical or population studies have been carried out to determine if there is an association between dietary saturated fat (SF) and cardiovascular disease (CVD). The trial(s) that have successful shown such an association:

A. The Framingham Study.B. The Multiple Risk Factor Investigation Trial (MR FIT).C. The Women’s Health Initiative.D. All have demonstrated a relation between SF and CVDE. A and BF. Only AG. None have demonstrated a relation.


8. Several large clinical or population studies have been carried out to determine if there is an association between dietary saturated fat (SF) and cardiovascular disease (CVD). The trial(s) that have successful shown such an association:

A. The Framingham Study.B. The Multiple Risk Factor Investigation Trial (MR FIT).C. The Women’s Health Initiative.D. All have demonstrated a relation between SF and CVDE. A and BF. Only AG. None have demonstrated a relation.


At the end of our clinic day, we go home thinking, "The clinical improvements are so large and obvious, why don't other doctors understand?" Carbohydrate-restriction is easily grasped by patients: because carbohydrates in the diet raise the blood glucose, and as diabetes is defined by high blood glucose, it makes sense to lower the carbohydrate in the diet.


Returning to the first question a moment in the history of medicine. Ignaz Semmelweis was a physician in Vienna in

early nineteenth century. One ward in the General Hospital had much greater incidence of puerperal fever (infection following childbirth) than the other. In the latter, babies were delivered by midwives; in the first, by doctors, some of who had just performed autopsies. Semmelweis suggested that physicians should wash their hands between procedures but many refused, some because it was in conflict with established medical practice. Some, because it was too much trouble.

In my opinion much harm is being done because physicians refuse to wash their hands of low-fat and other bad ideas.


Health & Medicine

Feinman - The Nutrition Mess. Can We Fix It?