What starts as a seemingly innocuous article on tribalism has sparked a firestorm of reaction from the low-carb community.
Dr. Ethan Weiss (a cardiologist and follower and financial investor in low-carb lifestyles) and Nicola Guess, RD, PhD (who uses LCHF nutrition with her patients) published the article in STAT on May 9, 2019. The overall premise is easy to agree with. We are all subject to a degree of tribalism that, if we aren't careful, could undermine our objectivity.
STAT: Is tribalism undermining objectivity about low-carb, high-fat diets?They correctly point out how this is the case for "guns, climate change, abortion, politics, and the like." Suffice it to say, no topic is beyond reproach when it comes to believing so strongly in something that you can lose sight of objectivity. Nutrition is a prime example as many defend their "beliefs" so strongly that they refuse to even consider alternatives. While this clearly does not apply to everyone, it is rampant in the vegan community and has infiltrated the LCHF community. We should be thankful for Dr. Weiss and Guess for bringing the topic to the forefront and helping us look in the mirror to make sure we maintain an element of objectivity.
The authors rightly acknowledge the numerous health benefits of a low-carb diet, and write that it is an immensely valuable tool for helping patients transform their lives. However, they go on to question the safety of LCHF based on elevated blood cholesterol levels and heart disease risk, and note that they are "disturbed by the discourse surrounding these diets, which often feels less like science and more like cheerleading."
I applaud them for bringing us back to the science, but I would contend the science of cholesterol as it applies to LCHF lifestyles is less settled then they imply.
For starters, rising cholesterol, specifically LDL cholesterol, is only an issue for the minority of individuals following a LCHF diet. Published studies for weight loss and diabetes management show that few subjects experience a significant rise in LDL. Other studies, such as those in highly trained athletes, and numerous anecdotal reports (and personal clinical experience) show that increased LDL is a real occurrence, although the exact percentage is unknown and is estimated at 15-25%. This is a paradigm I constantly fight in my practice. Eating LCHF does not, by definition, mean an increase in LDL cholesterol. Instead, it usually means an increase in HDL and decrease in triglycerides, and may or may not raise LDL significantly.
Questioning the magnitude of the role of cholesterol in the presence of metabolic health is a nuance without a definitive conclusion. However, it is a question built on a strong scientific base.
So, where do we draw the line? While we need to acknowledge we can overstate the position that "elevated cholesterol is harmless," we also need to acknowledge the value in an open scientific debate. The authors fear we have gone too far and are at the point of
reductionism and the creation of false dichotomies. We believe that scientists, health care professionals, and journalists must avoid intentionally confusing or alarming the public in an attempt to discredit legitimate science, ultimately in the name of advocating for an agenda.
That is different than saying the question is answered and all debate needs to stop. Rather, as long as the debate is based on scientific principles, then healthcare professionals, journalists and scientists should continue to search for answers as they apply to the unique physiology of LCHF lifestyles.
In fact, Dr. Weiss mentioned that options exist, such as "seeking testing to better define cardiovascular risk." This is a key statement for me as we have to acknowledge the weak association between LDL and all-cause mortality, especially in the subset of people who are metabolically healthy and have naturally low triglycerides and high HDL levels (as Dave Feldman of choletserolcode.com has been promoting for years). It is exactly this population who would benefit from additional testing rather than assuming all LDL is dangerous. I have a feeling Dr. Weiss would see the value in this although he didn't specifically say it in his article.
The conclusion of the article unfortunately takes a different tone and pulls out the "anti-vaccine" card.
In addition to being dangerous, such ostensible advocacy appears to be an intentional attempt to degrade the public's trust in science. One need look no further than the tragedy of the false story linking vaccines to autism as an example of what can and will result.
If we question the risk of LDL when combined with optimal metabolic health, are we intentionally attempting to "degrade the public's trust in science?" Far from it. Rather, for the most part, we are trying to better understand the existing science and how it applies to us as individuals, rather than being grouped in with entire populations metabolically deranged individuals who eat a low-fat or standard American diet. We should encourage this type of nuanced investigation rather than shut it down as part of blinded tribalism. Comparing this to the anti-vaccine movement is way off base and I wonder if, given the opportunity, the authors would take back that comparison.
I think we can all agree that being blinded by one's own beliefs is part of human nature, and something we need to actively try to avoid. That's a far cry, however, from intentionally misleading or falsifying science. That is why we should applaud the authors for stimulating the discussion about tribalism and objectivity.
At Diet Doctor, we are committed to being transparent about the quality of evidence that supports our claims as well as the evidence that goes against our claims. We hope to continually maintain objectivity and avoid the sort of blinded tribalism that can part of human nature.
Thank you for reading, and please let us know how we are doing in our quest for objectivity.
Thanks for reading,
Bret Scher, MD FACC