Why is there a tug of war between people who are pro-low carb and people who are anti-low carb?
I was recently invited on the radio to discuss the results of the PURE study, which was finally published. I was all excited, and had only the best intentions at heart. But unfortunately, it didn't go as expected...
The two interviewers moved the focus of the discussion away from the study, and led me into a dangerous mine field: the recommendations nutritionists and dietitians make. It is no secret that the vast majority of nutritionists base their recommendations on the official Food Guide, mainly, I think, because they are obligated to.
Our Canadian guide is pretty much a copy and paste from the American one, and is just as unsupported by science as theirs is. So it is no secret that patients generally following the Guide are usually not getting healthier or slimmer. As a clinician, it is exactly what I have been observing, in particular the patients with diabetes or other lifestyle-related chronic diseases.
In Canada, the Guide is currently under revision, which is one of the reasons I was excited about the publication of the PURE results.
Ok, first, let me state that I am aware that it's an epidemiological study; therefore direct causation cannot be established. But this study did show quite a few interesting things, notably:
- Saturated fats are not correlated to cardiovascular disease, heart attacks and increased cardiovascular mortality, hence non-causation can be inferred.
- There seems to be an association between high-carbohydrate intakes of any source and cardiovascular disease.
What the findings of PURE suggest
We all agree that causation is not established by associations. That doesn't mean we should just ignore the PURE study. Observed associations can help formulate good hypotheses for further research. I think the Canadian government, before it releases its new food guide, should order a few good randomized-controlled trials to test the associations PURE has found, and determine specifically if carbs can CAUSE cardiovascular disease. And it should pay attention to what is being said about fats in general, and saturated fats in particular (watch " Should dietary fat guidelines have been introduced? ")
To read about the PURE associations and non-correlations, check out this great post by 2 Keto Dudes. My favourite part:
"I'm looking at you Dietitians: this should be a teachable moment that we don't need to rely on weak associational results, when we can point to actual RCTs showing low-carbohydrate diets reversing type 2 diabetes possibly the primary risk factor for cardiovascular disease."
But I didn't get to say that on the air...
Why low carb is not a dangerous shortcut
I was annoyed, to say the least.
Many of my colleagues across the country were annoyed.
Many doctors, healthcare professionals and patients have faced "opinions" from others who are not well informed. Sometimes it's just plain ridiculous. Sometimes, it gets heavy. Especially if you're the only one doing what you're doing in your life.
So here's a much shortened version of our rebuttal, which has yet to be accepted by the newspaper, despite being signed by over 80 doctors all over Canada.
The nutritionists: The low-carb diet is the newest fad diet. Its goal is to bring about rapid weight loss.
Our reply: Human beings have been eating low carb for thousands of years. We've only been eating a high amount of carbs in the past 40 years or so. The real fad diet is the low-fat high-carb diet. The actual goal of low-carb diets is to reverse chronic diseases caused by lifestyle habits, such as type 2 diabetes, insulin resistance, hypertension, chronic fatigue, chronic pain, etc. The weight loss is more of a side effect, and it's definitely not always rapid.
The nutritionists: The low-carb diet is so restrictive that the probabilities of people sticking to it in the short or medium terms are very low.
Our reply: First, I don't find it very restrictive. But let's say it is. People who are vegetarians also face restrictions, and that doesn't seem to bother anyone. People with gluten intolerance also have to make choices when it comes to food. People who are eating a low-fat high-carb diet are also facing a lot of restrictions, if you think of it. Everyone makes choices when it comes to food.
Deciding not to offer a low-carb diet to your patients as an option because you have already decided they won't be able to stick to it is not good practice. Inform the patients, and then let them decide. And if it suits thousands of doctors and healthcare professionals out there, who have been eating this way for years, then it might work out for others too. People deserve to know it's an option.
Why all carbs are bad in some instances
The nutritionists: It's fashionable to make sugar the enemy number 1, but not all carbs are guilty. There is a difference between a fruit and a sweetened gasified drink.
Our reply: Indeed, there are differences between natural whole foods and transformed foods. Let's not forget, however, that most grain products recommended on the food guide are transformed foods. Also, it would be very simplistic to assume that just because something is natural, like a fruit, that anyone can eat 8 to 10 portions of it daily without consequences.
Carbs contain glucose, or glucose and fructose. While glucose can be used by any cell in the body, such is not the case with fructose. Fructose can only be used by the liver for energy, but the liver tends to transform it and stock it in its cells. An excess of fructose, and of carbs in general, can contribute to the development of fatty liver. (Watch Dr. Nicolai Worm on fatty liver)
For type 2 diabetic patients, for instance, eating a banana or 2 slices of whole-wheat bread, or drinking a small 8 oz. can of Coke (which all have about the same amount of carbs) will produce the same effect: blood-sugar levels will rise. Insulin will be needed, either from the pancreas, or from the pancreas and an injection. An injection prescribed by a doctor.
Medication will be needed, usually in increasing doses as time goes. It's not uncommon to see diabetic patients on 3 or 4 sugar-lowering drugs... to control the high sugar levels that are caused by carbs.
Wouldn't it make more sense to just eat less sugar, so that sugar levels rise less? So that less medication is needed?
Drugs have side effects, and cost money. And the worse part is, they may not even prevent some of the complications associated with diabetes. Because the root cause of the problem has not been addressed, only the symptoms.
Any doctor and any dietitian out there working with type 2 diabetic people will confirm this: our patients usually don't get better with time. Quite the opposite. Having perfect sugar levels on a multitude of drugs, including insulin, is falsely reassuring.
Dying of a heart attack with perfect sugar levels is not the goal.
Telling patients to eat loads of carbs, even if natural and wholesome, and then having to make them take medication to control what this does inside their bodies is what is absurd.
Why a balanced diet is not a good idea
The nutritionists: Chronic diseases are not caused by sugar or fat, but by an excess of transformed and ultra-transformed foods that are rich in fat, sugar and sodium. We have to stop trying to isolate one nutrient and aim at eating a balanced diet.
Our reply: Again, most grain products on the food guide are precisely that: transformed and ultra-transformed. What should we think of this product, which used to get the seal of approval of the American Heart Association? Made with whole grains.
By "eating balanced" I gather that we mean eating according to the Canadian Food Guide. How is eating over 65% of intakes in the form of carbs, as recommended, something "balanced"?
And where is the science behind the recommendations made by the Guide? Where are those famous long-term studies and RCTs to show that eating low fat high carb is the healthiest and safest way for everyone on this planet? Search all you want, you will not find any.
Giving people the wrong instructions
The nutritionists: Health is not only about quantities of nutrients, but about adopting healthy habits globally.
My reply: I dislike this argument profoundly. And you should too. Let me translate it:
If you are not currently healthy, i.e. if you are overweight, or have type 2 diabetes, or hypertension, or gout, or a cardiovascular disease, or chronic fatigue, or chronic pain including migraines, or Alzheimer's, or a fatty liver, etc., it is because YOU have not adopted healthy habits. It is your fault. You got your just deserts.
It couldn't be because you are eating according to the Guide. It couldn't be because you are following advice given to you by healthcare professionals. It couldn't be because we made you believe that it's all about calories in/calories out, and therefore you need to exercise+++ and to cut down on calories to have a healthy weight. We gave you a simple enough solution. If you're still sick after that, it's clearly YOUR failure.
Just for kicks, next time my husband wants to cook something, I'll give him the wrong ingredients, and the wrong instructions. When his recipe fails, I'll just blame him, and make him feel like he's a bad cook, and that he is responsible for us going hungry that night.
There were more of those statements in the letter. I could write a whole book of rebuttal just with that letter. But beyond being annoyed at the simplicity of their arguments and the fact that their statements are not supported by scientific evidence, I am saddened about the general lack of open-mindedness and scientific curiosity. I would love to work with nutritionists to teach low carb to patients who are interested in trying it. I am convinced nutritionists would love to get the results we are getting in our practice.
In the end, though, the biggest absurdity is probably to be engaged in a tug of war between healthcare professionals who are pro-low carb and healthcare professionals who are anti-low carb, when the real issue should be to get all of our food guides and nutritional recommendations based on scientific evidence, without any influence from anyone who has financial interests in them.
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Dr. Èvelyne Bourdua-Roy
