Tag Archive for: EBM

It’s All About the Calories

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The paper advocating the carbohydrate-insulin model (CIM) for explaining the obesity pandemic, not only in the U.S. but throughout the world, was written by the leading experts in endocrinology and nutrition. There were experts who’ve conducted some of the major nutritional studies that you’ve heard about over the years, from the Women’s Health Initiative to studies on the ketogenic diet. This is an expert group.

I agree with their desire for more research in this area. They’re trying to find out what would constitute their definition of cause: what increases appetite? Does palatability drive food choices? What hormones impact how much a person eats? And more. Where I disagree is in their lack of acknowledgement of the energy balance model (EBM) as valid. I outlined a written response to send to the journal that would have been about five pages long. Here are my two primary arguments.

Prior Research on Weight Loss

The authors talk about prior research showing that a low-fat diet doesn’t work long term; one of the authors was heavily involved in the weight loss study on a low-fat diet in the Women’s Health initiative. Their analysis was incorrect. The objective of that study was to compare a group of normally fed women eating the typical American diet of close to 40% fat with a group who was going to lower their fat intake to 20%. In the analysis, there were no differences in weight loss over the course of the study. The results suggested that a low-fat diet doesn’t work.

Here’s the problem: looking at the data from that study, what you see is that the women who were supposed to achieve a 20% fat intake couldn’t get below 28%. That doesn’t meet the goals of the study and thus doesn’t support their conclusion.

The Minnesota Starvation Experiment

My primary argument goes back to the research done on conscientious objectors during World War II. I’ve talked about this fascinating study many times, but here’s the short version: for a period of six months, 36 men who were conscientious objectors had their caloric intake cut by 25%. Their physical activity was also increased; they had to walk up to 22 miles per week.

What was unique was that they were weighed every week and their caloric intake adjusted based on weight loss or weight gain. If they did not lose the required amount, they were given less food. If they lost too much, they were given more food.

What makes that study even more consequential is the types of food that they were given to eat. The menu was very low fat and had virtually no protein; it consisted of breads and starches from root vegetables. In the CIM, that would be just about the worst types of food to eat to lose weight. But remember, the purpose of that study was to feed people foods that would be available after the end of the war. Every subject lost weight and lost it on a linear basis; most emerged looking emaciated. That’s the only study I’ve ever seen where people lost weight in a linear fashion over that period of time, and they did it eating an almost 100% carbohydrate diet.

The Bottom Line

There are many other aspects of the paper that I could comment on, but those are my two strongest points. I do believe that insulin is the most powerful hormone in the body; it does help store food as fat if someone overeats for an extended period of time. That makes it more difficult to sustain weight loss until the body is retrained to lose weight and keep it off.

But let me be clear: it always was, it is, and it always will be about the calories regardless of the source. Eat too many and you gain weight. Eat fewer and you lose weight. For sure, make better choices on the selection of the food that you eat and move more. But it’s all about the calories. Period.

What are you prepared to do today?

        Dr. Chet

Reference: AJCN. 2021. doi: https://doi.org/10.1093/ajcn/nqab270.

The Weight Loss Battle: Carbs vs Calories

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As a member of the American Society of Nutrition, I get a news feed that lets me know what’s being published in their journals. A recent article talked about the carbohydrate-insulin model (CIM) as a cause of the obesity pandemic. The debate surrounded the question of whether the energy balance model (EBM) that says calories in should equal calories out is adequate to explain the 70% overweight population in the U.S. Instead, a large group of researchers suggested that it’s time to research insulin as it relates to the highly refined carbohydrate intake of the population as the actual cause of obesity.

But that’s not all. The article suggested that insulin causes the body to store excess carbs as fat. More than that, to maintain blood sugars, it forces people to eat more carbs because they’re actually being starved, which drives hunger and is actually responsible for obesity. They went on to explain the fallacy of the EBM model and to deal with the criticism of the CIM model. In actuality, the researchers want to study the CIM approach, and this was a call for research to find out what really causes obesity.

To say it didn’t sit well in the nutrition and medical community is an understatement. Over 100K responses were generated in a couple of weeks, and I guess the nutrition Twitter world went nuts. Why? This is actually a battle over the ketogenic diet and everything else that focuses on counting calories. I’ll give you my opinion and why I believe what I do on Saturday.

The Insider Conference call is tomorrow night at 9 p.m. Eastern. If you have questions about your health or products, become an Insider before 8 p.m. and you can participate. Even if you only want to listen, you’ll learn something new to improve your health and the health of others you know.

What are you prepared to do today?

        Dr. Chet

Reference: AJCN. 2021. doi: https://doi.org/10.1093/ajcn/nqab270.

“My Doctor Told Me”

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I get asked health questions all the time about weight loss, fitness, diet, and more. If a physician told the questioners something they should or should not do, they will let me know, and then I know my job just got harder. That’s why “my doctor told me” are four of the most powerful words I ever hear.

The problem when it comes to nutritional recommendations, which can include both diet and supplements, is that physicians are not trained in the basics of nutrition. They may have read a summary about a high-fat diet or a multivitamin and tell their patients not to try this or take that, but they have no basis of training to know whether the study was well done or not. Even when they get the training, the specter of evidenced-based medicine (EBM) raises its head.
 

The Problem with Evidence-Based Nutrition

I decided to check out the Gaples Institute website. There’s general information about a healthy diet for patients. There’s also a course that healthcare professionals can take online to learn about nutrition. I read the brochure that’s available for physicians to find out what they will learn in the four modules of the course.

It’s nowhere near enough. Four 45-minute modules? I’ve been studying nutrition for 30 years, and there’s still so much I don’t know; it’s impossible for them to learn enough in three hours to reliably counsel their patients. In addition to that, the Gaples Institute uses the same low-fat approach to reducing the risk of heart disease that has been used for the past 50 years. And how has that worked for us? We have the highest obesity rate we’ve ever had.

Yes, physicians should understand there are better fats than others. Yes, physicians should understand that refined carbohydrates and deep-fried foods should be limited. But because the materials use data from large epidemiological studies that fit the EBM criteria, this is not real nutrition training. It provides them a single way to teach their patients, and that’s not providing any real nutrition training.

To say I was disappointed would be an understatement. Physicians need in-depth nutrition training, not a course that teaches a specific dietary approach to disease prevention. That doesn’t mean the Gaples approach won’t help some patients, but it ignores alternative approaches that might also help patients. While I said that “my doctor told me” were the most powerful words I hear from people, I also know that if they hear something they don’t like, they won’t do it, evidence based or not. Knowing what to do next requires real training in nutrition. That won’t happen in a three-hour course.
 

The Bottom Line

We’ll just have to wait and see what happens with nutrition training for physicians. It’s not really their fault; there’s so much to learn about treating disease, it leaves little to no time to teach prevention. For now, that’s left up to us as patients. While nutrition is complicated, you can always count on these six words to help you prevent degenerative disease:

Eat less. Eat better. Move more.

What are you prepared to do today?

Dr. Chet

 

References:
1. JAMA Online. 4/11/2018.
2. Arch Intern Med. 2011;171(14):1244-50.

 

Guidelines for Type 2 Diabetes: EBM in Practice

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The American College of Physicians (ACP) has established guideline statements for the management of HbA1c in non-pregnant adults using medication. They considered the research behind guidelines set by four other major physician organizations for treating type 2 diabetes. After reviewing that data, they have proposed four guidelines for use when treating patients. These are non binding guidelines; the choice is always left to the physician and the patient. But I think they get back to what evidence-based medicine should have always been about: use the best science and research and work with the patient to see what they want to do. Let’s take a look.

ACP Guideline Statements

These are the statements:

Guidance Statement 1
Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients’ preferences, patients’ general health and life expectancy, treatment burden, and costs of care.

Guidance Statement 2
Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes.

Guidance Statement 3
Clinicians should consider de-intensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%.

Guidance Statement 4
Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions (such as dementia, cancer, end-stage kidney disease, or severe chronic obstructive pulmonary disease or congestive heart failure) because the harms outweigh the benefits in this population.

EBM and Guideline Statements

I think the Guideline Statements reflect what EBM was always supposed to be about: consider the patient and what they want. I have spoken to many adults with type 2 diabetes who become frustrated with their inability to reach the HbA1c goals their physician has set. If they can’t reach it, more medication seems to be the only solution, and that’s not what they want.

I think these guidelines bring the patient or their caregiver into the equation. What price does the patient have to pay with their body? How much will it affect their life positively or negatively? Are there real improvements in quality of life if the HbA1c is 6.5% versus 7.0%? What is the cost of emotional stress?

The new guideline statements are a great addition to a physician’s repertoire: treat the patient as an individual. The patient comes before statistics and hazard ratios.

The Bottom Line

While not all organizations are going to adopt these guidelines, they’re important. There has been significant pushback from other organizations, all suggesting that there are new medications that may prevent some of the negative effects of prior treatment. “New medications”—they’ve learned nothing.

The one opportunity I see is that there’s hope for all of us who want to work at getting control of our lifestyle and reduce the dependence on medications as recommended by statement three. You say you don’t want to take medication? Excellent! Here is your chance to prove it.

Eat less. Eat better. Move more.

What are you prepared to do today?

Dr. Chet

 

Reference: Ann Intern Med. doi:10.7326/M17-0939.

 

What Is Evidence-Based Medicine?

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The term evidence-based medicine (EBM) dominates the scientific literature related to the treatment of disease. In short, the use of EBM is intended to treat patients based on the best available science and research; only the largest, best designed, and strongest studies are used when setting up the standards for treatment. That seems to make sense. That applies to the use of medications for the treatment of type 2 diabetes in adults as well as other diseases.

In the past, physicians primarily depended on their training. It doesn’t mean they didn’t use science to guide their decisions, but where and how physicians were trained influenced their treatment decisions more than research and science. That’s why EBM was developed; the use of solid evidence when considering treatment of patients keeps treatment up to date.

The problem is that the way EBM evolved appears to have excluded one of the primary purposes of how it began: consideration of the values and preferences of the patient. Treating patients should never be a one-way street. Your doctor should be a trusted advisor, not a dictator, and should give you the most up-to-date options for treatment of your condition; then you decide together which treatment option fits your life. The clinical and research evidence guides the physician in what to do along with knowledge of your personal health history, but only in the context of what you want.

For example, if after discussing all the options, a patient decides an earlier death is preferable to extending life by taking medication and suffering horrible side effects, that’s a valid preference that the doctor must respect. Another example: if the patient’s life expectancy is less than 10 years or so, pain management may be a better option than joint replacement when all the ramifications of major surgery are considered. That kind of joint decision-making is what EBM is supposed to be all about.

Saturday I’ll look at the guidelines for HbA1c proposed by the American College of Physicians in light of EBM. It’s a Memo you don’t want to miss.

What are you prepared to do today?

Dr. Chet

 

Reference: Ann Intern Med. doi:10.7326/M17-0939.