The Huffington Post is at it again- by promoting a nutrition quiz from the Physicians Committee for Responsible Medicine (PCRM).  One would think that a group like PCRM would be a responsible group, with a website that would have credible information. However, PCRM is a vegan organization that promotes an anti-dairy, anti-meat, anti-seafood, anti-egg diet, and the purpose of their quiz was to help evoke those ideas.  They have also sent out news releases that are bias to  a vegetarian diet and argues for it with half-truths that do little to advance their position, and a lot to reduce their credibility.

Recent breaking news quoted a paper in that indicated that fish oil did not prevent recurrence of heart problems and “evidence fails to support their use.”  PCRM did not include the conclusion:

“However, a diet high in fatty fish (≥2 servings of marine fish per week) should continue to be recommended for the general population and for patients with existing CVD because fish not only provides omega-3 fatty acids but also may replace less healthy protein sources, such as red meat.”

PCRM is anti-fish, as well as anti-dairy, and they fail to note that the American Heart Association recommendations for two meals a day being replaced by fish.

Recently PCRM released another study showing E. Coli was in 48% of chicken bought in 10 cities by their group. What they failed to state was that the E.Coli was not the type that causes humans illness.  Further, the major outbreaks of food-borne illness have recently come from produce and peanuts – as they are grown in soil that contains E. Coli. and can be contaminated with salmonella.  There are many types of bacteria in the soil, and E. coli is a common soil bacteria, but it is not the same type as that which comes from feces.

If you were a Vegan this might be your view of food

Here is their quiz with Science and Evidence based medicine rebuttal:

(1) Skim milk has the same amount of calories as cola

Yes, they are anti-dairy, and this is suppose to scare people into thinking that dairy is bad. For those who can tolerate milk, those who are not lactose intolerant, milk is a great source of nutrients.  Cola, not so much. They say all you need is water, nothing else – and we agree, however,  milk can have plenty of nutrients in them and should not be over looked.

(2) Cheese and steak have the same amount of cholesterol.

The first question you should ask is- so what? Dietary cholesterol has a minimal effect on the blood level of  the body’s cholesterol, we have known this since I was in medical school ( 1980’s). You can see my last post about fats to see more. That different amounts of cheese as well as a porterhouse steak have the same amount of cholesterol means nothing.  Very few physicians look simply at the cholesterol level, unless it is either very high >250 – and then we look at the underlying lipid profiles.

(3) Cheese is 70% fat.

Some cheese is, but again, cheese in moderation is not a bad thing. Some cheese is not  70% fat. By the way, most nuts, which this group advocates, are also 70% fat. They go on to say that Americans are eating three times the cheese we did in the 1970′s – probably not the case for some. Cheese is something that should be used in moderation – as it is dense with calories

(4) Frequent consumption of hot dogs and bacon makes it more likely you will get colon cancer.

In the one study, that has many flaws, if you eat a diet rich in processed meats your risk of cancer is higher- by a small amount. But that is a correlation, and not necessarily a causation, and when you work out the statistics, your chance of eating that much (a lot ) is not much, and your chance of getting cancer from it is – well, we don’t know. We don’t advocate eating a lot of processed any food. They state that the recommended amount of processed meats would be “none” – we would disagree, as do bacon lovers everywhere.  The correlation is so small with this as to be stretched.

(5) Women who regularly eat soy have a lower cancer risk.

This is not necessarily so.   Comparison studies have been mixed- so the answer is, we don’t know.  PCRM based their information about population studies from Asia- but other factors these women have include (a) less obesity (b) more physically active (c) drink less alcohol (d) eat more fruits and vegetables. Until the issue becomes clearer, many doctors recommend that women who take hormonal therapy or who have estrogen-receptor-positive breast cancer avoid soy supplements because they contain high concentrations of isoflavones. But in general, it’s fine to eat moderate amounts of soy foods as part of a balanced diet. One to 3 servings of soy a day (a serving is about a half cup) is similar to an average Japanese woman’s daily soy intake. If you are taking hormonal therapy to fight off a hormone-receptor-positive breast cancer, and you are concerned about any phytoestrogen effects, ask your doctor or registered dietitian about how much soy you can eat.

(6) Salmon has cholesterol and fat

Ah yes it does, and to repeat- consuming cholesterol is not the issue. Salmon fat is high in omega-3 fatty acids and quite healthy. Eskimos and maritime Native Americans had a diet rich in salmon and the lowest rate of heart disease on earth.  There is not convincing evidence to advocate taking fish-oil capsules, there is still evidence that replacing two meals a week with fish is protective for the heart.

(7) An egg has more cholesterol than a Big Mac

Cholesterol is not an issue in diet but the 540 calories in a Big Mac compared to the 90 calories in a large egg is. The calories in a Big Mac come from 29 grams of fat, while only 5 grams of fat from an egg. While PCRM has an issue with dairy, as do some from the Paleo diet, eggs are a healthy source of protein.  If you get rid of the yolk you can get rid of a lot of the calories also. The amount of cholesterol is less important than the lower calories- and you could always use egg whites which have less fat, much less cholesterol, but a great source of protein.

(8) Milk, Beans, and broccoli are all high in calcium

This is true, and for those who need a good source of calcium but do not drink milk, there are some good alternatives. They point out that the calcium in the beans and broccoli is absorbed at a rate of  50-60%, while milk is just  32%. What they fail to point out is that 1/2 cup of broccoli contains 21 mg of calcium while 8 oz of nonfat milk contains 300 mg. That means from broccoli you get 11 mg of Calcium which is about 1 percent of the daily requirement. If you get non-calcium enriched milk you are still getting 100 mg of calcium or ten times the amount you would with broccoli.

Vegetarians may absorb less calcium than omnivores because they consume more plant products containing oxalic and phytic acids . Lacto-ovo vegetarians (who consume eggs and dairy) and non-vegetarians have similar calcium intakes. However, vegans, who eat no animal products and ovo-vegetarians (who eat eggs but no dairy products), might not obtain sufficient calcium because of their avoidance of dairy foods.

In the Oxford cohort of the European Prospective Investigation into Cancer and Nutrition, bone fracture risk was similar in meat eaters, fish eaters and vegetarians, but higher in vegans, likely due to their lower mean calcium intake.  It is difficult to assess the impact of vegetarian diets on calcium status because of the wide variety of eating practices and thus should be considered on a case by case basis.

(9) Fish and Beef have no fiber

Quite true- there is no fiber in meats. This is why a balanced diet contains fruits and vegetables. However, fish and beef contain better sources of fat absorbable vitamins, calcium, B12, protein, and other nutrients than vegetables do.

(10)  A skinless roasted chicken breast has more calories per ounce than soda or white rice

This is quite true- and mainly because of the fat content of the chicken. But chicken has more nutrients than white rice and more than soda.

PCRM also was responsible for the comments that E. Coli was found in many of the chicken products.  What they didn’t say was that the E. Coli they found were not the same as responsible for food borne illness.  In fact, the E. Coli they found was the kind commonly found in the soil, where the very plants grow that they advocate consuming. The pro-Vegan group also neglected to mention that the majority of Salmonella infections that have caused major outbreaks have come from agricultural products, including peanuts, that they advocate for a healthy diet.

It appears that PCRM is more propaganda than science. If you are going to advocate for a position, your position is diminished when you don’t tell the full story. If cornered in press conferences they avoid the answers to the questions. This is not a place to get information at all.

In the case of diet and lifestyle, there is a lot we do not know- but PCRM as a source of nutritional information is less than adequate, in that often it does not tell the whole story.  As a website for health and information it is more like a political party than a resource for those looking for evidence based medicine or science based medicine.

One of the misleading advertisements from PCRM

Campbell didn’t start out as a vegetarian, he grew up on a farm, and spent the first few years of his career thinking that the farm diet was the healthy way for a person to live.  On the basis of his early work with some proteins and cancer, and some statistical work he did from rural China villages he wrote The China Study. In it he formed the conclusion that an animal based diet is the promoter for cancer, and that if people converted to a whole plant diet (not processed flours, pastas, or processed, white, rice ) they would lose weight, have less cancer, less heart disease, and less obesity.

To be fair, let me quote him:
“In fact, dietary protein proved to be so powerful in its effect that we could turn on and turn off cancer growth simply by changing the level consumed.” (page 6-7)

The premise for much of this comes from a Campbell’s work with aflatoxin – a potent carcinogen that is found in peanuts. Campbell’s work noted that with adding a milk protein casein – there was a direct relationship to the extent that rats appeared to get foci of cancer.  Campbell then extrapolates that data from a milk bio-active protein to all animal proteins.

“..People who ate the most animal-based foods got the most chronic disease.  Even relatively small intakes of animal-based food were associated with adverse effects. People who ate the most plant-based foods were the healthiest and tended to avoid chronic disease.”

His first declaration came from his lab studies where he examined the biologic influence of a milk protein (casein, which is a bio-active protein) on rats who were fed a potent carcinogen. The rats that were given more of this milk protein developed more foci of liver cancers.

Casein makes up 20-45% of the protein in human milk.  Does this mean that mother’s should not breast feed their children? That we should not be drinking milk at all? Does this mean that all animal based proteins are cancer causing, and the reason we develop cancers?

The answer to all the above questions are NO.  Simple experiments done with rats do not form universal answers to major health questions, nor do they provide us with scientific insight into the health of human beings.

First, let’s look at proteins. Proteins are called the building blocks of tissues.  They are complex molecules that contain a number of amino-acids.  Amino acids are divided into two types: essential and non-essential amino acids.  Essential amino acids are those amino acids that humans cannot make, and thus we must get them from our diet.  When you eat protein, the digestive process breaks down the proteins into the various amino acids which are then carted away by the blood stream and used to build or rebuild cells in your body.  That is the simple stuff. Proteins are found in animals and plants.  Once the protein is digested, and the amino acids are freed, your body has no idea if that amino acid came from a bean or a T-bone steak. The lysine (an essential amino acid) your body gets from a T-bone steak looks no different than the lysine your body gets from a soy bean or a walnut.

Proteins can have more of an effect than just being used as a source for amino acids. The way proteins are put together they look less like pearls on a string (amino acids being the pearls) and more like rather complex geometric shapes.  Some of those shapes can unlock powerful changes in a person. Allergies, for example, come from proteins that turn on an overwhelming inflammatory response in people who are sensitive to them.  Take that same protein and alter its structure so that the 3D structure of the protein is altered (this can be done by changing a single amino acid, or heating a protein, or putting the protein in a acid environment) – and that protein won’t cause the same reaction.

Proteins are quite complex – just to give you an example, here is a representation of what some people think the protein ovalbumin looks like (this is the protein found in egg whites):

A 3-D look at ovalbumin, the protein found in egg whites

One of my favorite proteins because almost 30 years ago we used some genetic modification of this protein expression in a virus, but that is another story.

Proteins are complicated 3-D structures, and like keys into locks, if you change a bit of their structure they no longer unlock the reaction.  Some proteins cause other reactions in people besides the allergic reaction — but anyone can be allergic to almost any protein, except most people are not allergic to proteins their own body makes – except in some severe auto-immune disorders (arthritis, Lupus).

Other keys that proteins unlock can be hormonal.  Insulin is a protein – it is made up of a chain of amino acids and looks like this:

The primary structure of insulin - each amino acid in sequence

Insulin’s is a protein, that if given in the blood stream will unlock cells and force glucose into cells. Without insulin blood sugar rises, people can go into coma, and long standing low insulin levels can cause all the complications of diabetes. But insulin is a bio-active protein.

But if you eat insulin, when the insulin is in the stomach, the acid of the stomach will quickly change the structure of the insulin, it will break down, and ultimately not be a bio-active protein, but instead become just a source of amino acids for the body to use.

Back to Casein- which isn’t a single protein, but a group of proteins found  in milk.  In Campbell’s work he gave rats that had been subjected to a cancer causing agent high doses of casein. He then examined their liver for foci of pre-cancer lesions, and noted they were higher with the higher levels of the milk protein.  From that he determined that depending on the level of protein, its possible to turn cancer genes on or off. This becomes a later theme of the book. Increased levels of animal proteins cause human disease from heart to cancer, and here is some experimental evidence to prove it.

Casein is a bio-active protein- which is not surprising. If you want mammals to grow you want to give them proteins that will not only break down to supply nutrition, but will also serve to promote growth of those cells. One could conclude that if you have a cell that has been treated with a carcinogen that adding something that makes it grow will increase its growth.

A non-casein example is hormones and prostate cancer, for which Charles B Huggins received the Nobel prize in 1966. Huggins found a number of cancer cells were turned on and off by hormones.  Estrogens are not proteins, they are another class of chemical compounds – but the idea that a chemical compound could signal and cause growth in cancer cells was well established with Campbell did his work with rats.

Back to the questions: Casein does not appear to have a role in any human carcinogensis. In fact, those milk proteins do appear to have a protective effect against cancer in humans. Campbell’s work with rats has not been reproduced to find the reason he saw what he saw at that time.  Whether the test he used to predict cancer, and the proteins he fed those rats exposed to that carcinogen apply to humans in any way is more than any speculation.

Milk is more than casein proteins, there are also whey proteins- which have also been found to have an effect with cancer, a protective effect.

It is not the first time that someone doing bench research takes their ideas from the laboratory bench and applies them globally.  It is what we are supposed to do.  We are supposed to see the large picture. In this case, Campbell’s conclusion was that animal protein induced cancer, which did not happen with plant protein.

For part one of The China Study- while he reports years of his research as a basis for his beliefs, it does not hold up for all animal proteins. Animal proteins for the most part are broken down and serve as sources of amino acids and nutrition. Milk is an essential part of all mammal diets for their young . The world of research has gone beyond Dr. Campbell’s bench days, and is now looking at pathways of cell cycles within pathways, and nowhere to be found is the broad picture that plants are better than animals.

Many of the hypothesis that were generated in the laboratory I worked in no longer apply either. Some have, but research has become more and more focused on other pathways, with new pictures.

Bernard Roizman, my science mentor- where I spent many wonderful years in his lab

Still, for those who read The China Study, and wonder if milk is bad for you, or your baby, or if this is the simple model for cancer and turning off cancer genes — it is not.

In a future article on the China Study, we will focus on how they conducted the epidemiological research in China.  We will take a unique perspective on it, we’ll take it from China itself, to see the pros and cons of how the rural village research and death statistics worked.

For real science- we are juggling what we eat to find the best fit

Re-reading the study about red meat and its increase in mortality, I continue to go back to the gold standard of lifestyle epidemiology- smoking.  People who smoke one pack of cigarettes a day have a 20-fold increase in lung cancer. 86% of all lung cancers in the United States occur with smokers, or ex-smokers.  One can reverse prove this- people who quit smoking decreased their risk of heart disease as well as lung cancer for every year they had stopped. This was the gold standard that all other lifestyle researchers are trying to find. After smoking the next great one was second-hand smoke, and sadly the correlations between mortality and second-hand smoke fell apart – although that did not stop public statements.

Still others try to find that meat, or fat, or carbs, or something causes an increase in the rate of death. So what did is the real red meat of this study (sorry).

What this paper discovered was that the increased risk is that less than one person in one hundred died (less than 0.2% with heart disease and 0.32% with cancer – as opposed to the gold standard of a 20 fold difference).  Let us put this into the context that the article did not, and that most media did not – that one person in one hundred over a 28 year period who died also smoke more, drank more, had less physical activity, and was obese.

The article states they did a multivariate analysis to adjust for age, race, smoking, drinking, activity, caloric intake, and obesity – and removing those factors they still have, in the highest quartile, the increased rate of death with less than a 1.2 fold difference (compared to 20 fold for smoking and lung cancer).  For those of you not statistically or mathematically prone, this simply means they found a way to negate the influence of each of those factors so that the simple and singular analysis of each quartile (quartile one being the lowest meat eaters and quartile 5 being the largest consumers of meat) stands alone. They do not show us this data – we just take them at their word that this person who died, the one person in 100 in 28 years, who drank more, smoked more, was obese, did minimal physical activity, and ate more meat- died because they ate more meat.

Some nutritionists think we should graze on plants

Does this study really tell us that substituting one meat free meal a week will decrease mortality? Not really.  This was a statistical trick to take the people from one quartile to another- and in that they reduced risk.

If you examine the raw data, without statistical manipulations- you find that death rates go down with increased meat consumption until the fourth and fifth quartile.

Does this article shed light on how we should eat or what we should eat? No, it does not. In fact, this article is a statistical nightmare of a piece that gained attention because of its conclusions.

Take heart, there have been prospective studies of diets to see how they work, and these have been short-term studies, but they were corrected for variables. The diets examined include low-carbohydrate diets, Mediterranean diets, the Ornish diet, and others (Gardner CD, Kiazand A, Alhassan S, et al.: Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women. JAMA 297:969–977, 2007) and Comparison of the Atkins, Ornish, Weight Watchers, and Zone Diets for Weight Loss and Heart Disease Risk Reduction: A Randomized Trial Michael L. Dansinger, Joi Augustin Gleason, John L. Griffith, Harry P. Selker, Ernst J. SchaeferJAMA. 2005;293(1):43-53.)

We have moved beyond poorly done population studies – and are into trying to determine what is the best diet for people to consume.  We have more questions than answers – but the science tells us a few things:

Weight loss is good for all of us

(a) No matter which died patients are placed on, if it yields weight loss (probably meaning people are compliant on the diet)  reduced the cardiac risk factors including C-reactive protein, insulin levels, and reducing the low-density lipoprotein/high-density lipoprotein ratios.

(b) We really don’t know about fats, as much as we think we do

(c)  No one seems to like bread these days

(d) We all like grass fed beef, flaxseed fed chicken eggs, and anything that is free on a range (home on a range).

(e) We all like whole plants- but some of us like them more than others

(f)  Exercise is universally associated with better results, and you cannot exercise your way out of obesity.

To paraphrase Gary Taubes of “Good Calories, Bad Calories”- nutritional epidemiology is closer to pseudoscience than it is to science.

When the Archives of Internal Medicine published the article “Red Meat Consumption and Mortality” all I could think of is “here we go again.”

First to go through this paper- which is a statistical population study from the Health Professionals Follow-up Study (HPFS) and the Nurses’ Health Study (NHS). Of the 140,000 combined participants they tossed out 20,000 because of a history of the diseases reported or those who did not fill out the forms perfectly.

To start with – this is not a study where people were followed from baseline to death to see if what they ate contributed, and determining amounts along with following other variables as they progress (lifestyle issues with exercise, smoking, etc). This instead is a study based on food questionnaires, and statistical analysis. Correlation does not imply causation.

One has to be careful with epidemiological studies, as they are not  proof of a cause, rather they point to a number of variables that might be involved to form a hypothesis. It is these same types of statistical studies that told us that women should use hormone replacement therapy because it prevents heart attacks in 1991, only to be told 11 years later that it might cause heart attacks. It is a sampling bias of those individuals who choose to participate in the studies that led to the erroneous conclusions.

The second issue with these studies is the ability of the food questionnaire and its accuracy. This has been studied – that is, the ability of people to recall and fill out what they ate. We do this in our office all the time- ask people what they eat—and since we are involved in weight loss and healthy lifestyle here is what we can say: people have no ability to remember what they ate, how much they ate much beyond the last day. When studied by others, looking at the questionnaire (FFQ or Food Frequency Questionnaire) in the Nurses’ Health Study was found to be useless. As reported by others, the accuracy of the questionnaire compared to reality was unacceptable.

For example, 20 per cent of the nurses reported living on 1200 calories per day or less, and low intake of red meat, and 20 percent report over 2000 calories a day.

In the study the first table showed that the highest reported red meat consumption was associated with smoking, drinking more, obesity, and higher calories. Oh wait- have you ever heard that smoking, obesity, eating more calories, or drinking more might lead to an early death? Perhaps you have, in fact, there are some correlations (which don’t imply causation) for these, and there are some great prospective studies showing that obesity leads to early death.  Of course, in any statistical paper you can remove the confounding factors – and THEY DID NOT in this paper.

One other cute correlation- in the data, those who report eating the most red meat had the lowest cholesterol levels. Yes, that is odd isn’t it. Readers of this blog know that cholesterol and meat have less to do with one another – and that isn’t a statistical issue, that is just basic biology.  Eating more meat does not mean you will have a higher cholesterol – having bad genetics does.

Here is what three systematic reviews of prospective studies show in the relationship between saturated fat and heart disease- zip. There has been a consistent lack of an associated between saturated fat intake and heart disease. While this new study statistically makes the argument that changing diet would decrease events from heart disease and cancer, when looked at (references below) none of the pooled studies show a change in that risk relationship. And, when some studies have shown a change in risk, when the data was examined there was no difference in mortality. While some say red meat clearly is bad, the evidence is anything but clear. Proving again that population studies, without isolating the variables, without having a scientific basis, are worthless.

Finally, the science of red meat—what do we know? Red meat is a large category of meats includes everything from bacon (considered “processed” by some and delicious by others) to cows raised on grain, and cows raised on grass. Grass fed beef have higher levels of omega-3 fatty acids. Consuming different red meats mean you are consuming different levels of ingredients. Lumping them together is just sloppy science.

Nothing like great grill marks on a steak

Skeaff CM, Miller J. Dietary fat and coronary heart disease: summary of evidence from prospective cohort and randomised controlled trials. Ann Nutr Metab 2009;55:173–201.

Mente A. A systematic review of the evidence supporting a causal link between dietary factors and coronary heart disease. Arch Intern Med 2009;169:659–69.

Siri-Tarino PW, Sun Q, Hu FB, Krauss RM. Meta-analysis of prospective cohort studies evaluating the association of saturated fat with cardiovascular disease. Am J Clin Nutr 2010;91:535–46.

The Paleolithic diet presumes that foods eaten during the stone-age (Paleolithic era from 2.5 million years ago to 10 thousand years ago) are optimal foods for humans. The Paleolithic (Paleo) diet includes grass fed beef and other lean meats, fish, shellfish, fruits, vegetables,  eggs, nuts, but no grains, no dairy, no salt, no refined fats (butter or margarine) and no sugar or high fructose corn syrup.

Fanatical Diet (Lifestyle types)
There are three things one should never discuss in polite company, religion, politics, and diet. Getting into an argument with proponents of diets is like a democrat trying to convince a republican that Obama is ok. Each side will quote their own studies, statistics, and population studies. But the key to scientific study of the various diets is not what we presume from correlation, but from what we learn when that diet is placed into patients – in this case, the laboratory values of those who have the diet.

Diet proponents become fanatical about their diet (lifestyle) to the point of religious fervor. Seeking to prove that their diet is backed by science, proponents use population studies with associations that are only suggestive and not proof of causation. These associations become propaganda as the associations are repeated over and over, morphing from a suggestion to “proof.”

The Flaws of population studies or Correlation does not equal causation
The foundation of many diets are based on the correlation of what a population eats and what diseases they suffer from. In the Paleo diet the assumption about what they ate and the diseases they suffered from is a spurious correlation at best, and far from causation.

Population studies are flawed, as often we find that we don’t know as much about the population as the data might suggest. Take the Pima Indians of the Southwest. In 1990 a paper came out stating that the Pima Indians had a low incidence of fatal coronary heart attacks in spite of having a high rate of diabetes. The Pima Indians were called among the most studied populations, with an NIH post in Phoenix, and lots of studies showing the highest rate of diabetes in the world. When the population was examined more carefully, the Pima Indians had plenty of heart disease.

Step back from the most studied group in the United States with great statistics and physicians trained in modern medicine and then imagine making conclusions about what Chinese eat, or Mediterranean’s, or French. Those assumptions are more flawed, as are the statements about what diseases they do or do not have. Now step back further trying to determine what people of the Stone Age ate, what diseases they had, and we leave the tenuous role of suggestion and enter the role of outright guessing. Even if we have reasonable data (and often we don’t – even for the best studied people in the United States) the correlation between what people eat as a cause for what diseases they have is a fundamental flaw. Correlation does not equal causation.

The Best Diet or Lifestyle is?
When it comes to the best diet plan for a person – we just don’t know enough to say that one is better than another. There isn’t enough evidence to state that the Paleolithic (also called Paleo) diet is better than the Ornish, Southbeach, Pritiken, or pick one, or better than how you currently live your life.

We cannot broadly say that any given diet will prevent heart disease, cancer, arthritis, or even obesity. When someone tells you a diet can prevent such, they have gone from the realm of science to the realm of bs.

The Paleo Diet Premise:
The Paleo diet premise is that we should avoid certain foods because our body is not evolved to process those foods, and if it does process them it will lead to the chronic diseases of modern man – heart disease, strokes, cancer. Cavemen didn’t have those diseases, so we should eat like cave men. Of course, we don’t know about what diseases that cavemen had – especially when it comes to organ and soft tissue diseases, we just have a few fossils that we examine and look for evidence of known diseases. Would coronary artery disease show up in a fossil – nope? Would cancer show up in the fossil – bone cancer would (kind of a rare cancer) or cancer that went to the bone might – but it would be hard to tell if the fossil evidence.

We do know, from many hunter-gathering societies, that they live a short life, and not long enough to develop the diseases we associate with aging. All a person has to do to pass on their genes is make it into puberty, and to be effective to nurture the young, into the 30′s, and to see grandchildren and help child raising – into the early 40′s. That is what a simple civilization needs. After that, in any primitive society, the elderly become a burden – perhaps to be placed on an ice flow. People who live into their 40′s and 50′s may die of cancer, heart disease, or obesity- but they will have passed on their genetic code.

The Evolution of Homo Sapiens:
When Homo Erectus came out of Africa, they encountered a world that was much more varied in food sources than Africa. The brain of the human (H. sapiens) evolved, becoming much larger, and utilizing far more energy than the brains of the Australopithecus – about 10 percent more. More than any other species, humans evolved a brain that required more calories- and our brain metabolism accounts for up to 25% of our energy needs. Bigger brains and its increased requirements mean a richer diet- and modern hunter gathering species derive about half of the energy from animal foods – in contrast with other primates that have far fewer animal foods. While our ancestors the Australopithecus dined on plant foods, and had large mouths to grind up fibrous plants – humans are built, with smaller faces and jaws, to dine on energy rich animal foods.

The reconstructed skull of Lucy, Australopithecus- large jar and muscles for eating plants

The Human skull is larger, larger brain- and jaws for more energy rich foods

Humans were successful, as the fossil record shows, because they were “flexible” eaters, using a wide variety of dietary strategies. If there were a lot of Elk, then we ate elk- berries, we picked berries. To state that our digestive system evolved only to eat some few items found in the Stone Age – has been disproven on the face of it. Our ancestors in Africa didn’t encounter Arctic char, whales, seals, salmon – and yet when they moved from that warm climate to the frozen north, they adapted quite well to a very high fat diet of primarily animal based diet that was clearly not available in Africa. The findings of starch grains from wild plants in grinding tools from sites in Italy, Russia, and the Czech Republic from the mid-upper Paleolithic era suggest that the production of flour was present 30,000 years ago.

Contrary to what Paleo proponents state: people made flour 30,000 years ago

How to eat like a caveman
There are some things about the Paleo diet that people avoid:

Excess sugars including fructose
Excess Omega 6 oils – including soy
Processed wheat, grains, and gluten
Dairy

What is the scientific evidence for this? It’s the simple premise that modern man has lifestyle illness from altering food, taking in too many calories, and if we would return to our ancestors roots (pun intended) we would avoid these highly processed foods and not suffer from the holy trinity of diabetes, obesity, heart disease, and maybe even cancer. There is not a single shred of evidence to support the premise of this diet.

An entire dietary regimen has been formed with plenty of books and websites to guide you through this. It has become so popular that the question becomes not the flawed premise for the diet, but rather how the diet would compare to other diets. If you want to eat like a caveman, then shop on the outside of your grocery store.  Everything on the inside of your grocery store is generally processed foods, and everything on the periphery of the grocery store is generally not processed.  On the periphery you will find the vegetables, fruits, meat counter, fish counter – although you might get in trouble with dairy, and before you check out they might have a cookie or two – or there might be a bakery (a big no no among the non-Geico types). But lets be clear- whatever the caveman could get that they could eat- they would eat, and if a caveman were to be around today- wait, we have them – well, they eat Poptarts.

In one real scientific study patients with known heart disease who were randomized to either the Mediterranean-like diet (based on whole grains, low fat dairy products, fish, fruit, and vegetables) or the Paleolithic diet (no grains or dairy but plenty of lean meat, fish, fruits, vegetables, root vegetables, eggs, and nuts) and those who undertook the Paleolithic diet were satisfied with less food. There was also a decrease in leptin in the Paleolithic group by 31% and by 18% in the Mediterranean group.

There have been other studies that show that people who go with this diet have improved laboratory values – less triglycerides, lower blood pressure, some weight loss, that the diet has a better glycemic index (the food doesn’t increase blood glucose levels as much). This diet compared to a standard diabetic diet did better. Those studies are short term, with small numbers of individuals, and hints of laboratory values.

So before one assumes I am putting this diet plan into the trash bit along with Ornish- there is clearly some data here that shows good nutritional sense in the food.

While highly processed carbohydrates transiently increases blood glucose levels more than whole grains – it does not mean that bread is bad for a person. At least we don’t know enough about this to state that today. Clearly, people who eat a lot of flour based products can get fat quickly, and getting off the bread and bakery products will help reduce weight, decrease hemoglobin A1C levels, decrease triglycerides, and overall be healthy.  Some people need to be told to never eat them again – as some alcoholics must never drink again- and some people are able to moderate them so they do minimal damage to the body.

Only a few studies have examined the effects of the Paleolithic diet on laboratory values that we associate as increased risk for disease – but again, those were laboratory values, not a long-term follow up for disease.

The premise for the Paleo diet may be flawed, but here are the parts of the Paleo diet that most would agree with:

(a) Highly processed grains – white flour, rolled oats- do cause a rapid increase in blood glucose levels and the body responds to that by increasing triglycerides and ultimately fat.
(b) Fish – as long as it is not contaminated with mercury, is a protein source that is high in Omega 3 fatty acids, which have been shown to be beneficial. If you have some great fish three or four meals a week it works out well.
(c) Vegetables and fruits are the basis for most diets- thus a vegetarian could participate in a Paleo diet easily. Too many people do not eat enough fruits or vegetables or look to them as snacks.
(d) The trend away from cattle feedlots and desire to have grass fed rather than grain fed beef. Grain fed beef is fatter and more prone to being infected with Salmonella or E.Coli than grass fed beef.  There is a wider variety of taste with grass fed beef, and most who find grass fed beef end up preferring its flavor. Grass fed beef is best cooked with Sous Vide cooking.
(e) If you eat more calories than you burn you will gain weight. But it is more than just calories – it is also the types of calories. Eating high glycemic index foods mean you will spike glucose pushing it into cells, where it will be quickly transformed and stored as fat. Low glycemic index foods will be slowly burned  - thus, calorie for calorie with the Paleo diet plan you will tend to burn the fuel from the food as opposed to store it.
(f) If you eat a majority of your food with highly processed grains instead of whole grains you will have a faster rise in blood sugar. Some attribute this rise to increased obesity and an increased load on the pancreas.

Overall- this is not a bad diet program. Nothing in it would appear to cause nutrient deficiencies and there is some preliminary evidence that this diet keeps a person more satisfied with less food. It is a low-carbohydrate diet, and those diets, in comparison to other diets, tend to produce faster and longer weigh loss.

Here are a few scientific references- I’m sure we will add more as time goes on

Low incidence of fatal coronary heart disease in Pima Indians despite high prevalence of non-insulin-dependent diabetes. RG Nelson, ML Sievers, WC Knowler, BA Swinburn, DJ Pettitt, MF Saad, IM Liebow, BV Howard, and PH Bennett
Circulation. 1990;81:987-995

Food for Thought: Dietary change was a driving force in human evolution. Wm R Leonard. Scientific American. December 2002: 107-114.

A Paleolithic diet is more satiating per calorie than a Mediterranean-like diet in inviduals with ischemic heart disease. Jonsson, et. Al. Nutrition & Metabolism 2010, 7:85

Thirty thousand-year-old evidence of plant food processing. A Revedin, et al Proc. Nat. Acad. Sci, November 2010: 107:18815-18819

Dr. Esselstyn noted the risk of heart disease in rural China was low in the 1970’s – and presumed that they didn’t have a “western diet.” Now there are two flaws in his population statistics: First in the 1970’s in rural China most individuals were starving to death – it was the end of the cultural revolution and any source of food that could be found and eaten was. The second issue is if you examine data from The China Study you will see that heart disease mortality was lowest in the rural communities that were able to eat more meat. In The China Study (again, I promise this will be a topic later) – they used mortality statistics from the time during the end of the Cultural Revolution. Rural China was starving then, all trees had been used for fuel, there were virtually no birds left (combination of deforestation and hungry humans) and rice was used for the army.

Dr. Esselstyn then talks about Norway during World War 2, when they were occupied by the Nazi Germany, and how that heart disease diminished as the Norske were forced to eat a plant based diet. That was a great assumption to make, but when examining the data from Norway there are a few interesting factoids – Meat consumption dropped 60% but fish increased 200 per cent. Vegetables and potatoes increased but sugar decreased by half. And when the data is put to a microscope in 1942 and 1943 when mortality declined, animal proteins were still higher than before the war. It appears that Norway suffered from increasing fish (great source of Omega 3 fatty acids) and foraged for foods such as wild greens, grew and ate a lot of potatoes, but had a low amount of sugars and almost no margarine (I don’t know a respectable Norwegian today who cooks with margarine). The sad part of the war was the increase of mortality from infectious diseases – especially pneumonia (my mother’s cousin who fought for the resistance died of this, as did many of his comrades).

Norway in WW2 ate a lot of fish- and this roe was popular

He followed these patients for up to 12 years – his numbers are confusing as he started with 24 patients and six dropped out (leaving 18). One of the 18 died from his heart disease (leaving 17). At ten years there were 11 patients. They did angiography and reported a regression of 11 lesions with 14 remaining stable.

Angiogram- xray - of a plaque. Not enough to do surgery on though

When any study talks about a “cardiac event” it means to most of us a heart attack. If you have a small lesion in a coronary artery and then that lesion accumulates a blood clot that is what a heart attack is. The blood clot (from platelets – a sticky component of blood that helps you clot ) blocks the flow of blood to the heart muscle. If the clot blocks blood flow for a long time then the heart muscle dies and you have a myocardial infarction, if it opens up then all you have is a heart attack. This has little to do with the size of the lesion, and more to do with the complex chemistry of the coagulation system. Hence, taking aspirin a day or Plavix is more beneficial.

The other major problem with the study is that these individuals were on lipid lowering medications. Dietary reduction of lipid level (Cholesterol and lipoproteins such as VLDL, HDL) is about ten per cent on average, but never more than twenty per cent. However, lipid-lowering medications – such as Crestor – can remarkably lower levels of the lipids. In addition, lipid-lowering medications are best for reducing inflammation. They are anti-inflammatory to blood vessels, meaning in addition to lowering the lipids and cholesterol, their main effect is to reduce the chance of having a “coronary event.”

Crestor shown to be effective at decreasing the plaque in arteries

One of my cousins, preventing heart disease and eating fat

There is a lot of pseudoscience in medicine, and the reason that we have medical treatments that are quackery is because of the industries built around them.  This was made evident by the recent issues with the HCG diet. Contrary to what reasonable people would think, the new FDA ban on over-the-counter HCG did not shut down the industry built around HCG. The FDA states “HCG has not been demonstrated to be effective adjunctive therapy in the treatment of obesity. There is no substantial evidence that it increases weight loss beyond that resulting from caloric restriction, that it causes a more attractive or “normal” distribution of fat, or that it decreases the hunger and discomfort associated with calorie-restricted diets”

There is an entire HCG diet industry kept alive by those who make their living promoting this weight loss method.  What has gone away is the ability of non-physicians to sell the drops, tablets, troches – all HCG must be prescribed by a physician. Within two miles of my home there are five places that advertise HCG diet. None of these places is a physician’s office. Whether the FTC or FDA cracks down on these is another matter.

These weight loss clinics sell the HCG –either by breaking the law and prescribing without a license, or they are finding a physician who will write the script without seeing the patient.   For a physician to write a prescription without seeing a patient is not only bad medicine it is unethical- and, at least in Arizona, would probably result in the physician being sanctioned by the medical board.

Because the FDA has, without equivocation, stated that HCG is not useful for weight loss, proponents of HCG are now circulating “articles” of “studies” showing that HCG works. But the HCG controversy provides a microcosm of how proponents of woo-woo medicine (medicine that is based on pseudoscience) use “studies” to promote their treatments.

The article that should have put the nail in the coffin of HCG was written in 1976 in the Journal of the American Medical Association. The paper was a study of 202 patients treated with either HCG or saline placebo.  The physicians administering the medicine did not know if they gave the patient HCG or if they gave the patient the saline (salt water). The patients did also not know.  All patients were placed on the 500 calorie diet.  At the end of the study, there was no difference between those who were given HCG and those who were given placebo in terms of weight loss. There was also no difference in fat loss. There was no evidence that those who had received HCT were more or less satisfied, and the dropout rate was the same. Thus, they could not prove what the advocates of HCG said- that people who use HCG along with the diet will feel better and adhere more to the diet, and that there was no more or less fat loss among those patients. This was the article that, temporarily, put the nail in the coffin for HCG.

The reasons physician-scientists consider this article a good article are: (a) The study was randomized so the patients did not know what they were getting.  This eliminates bias of the patient. (b) The physicians did not know what the patients were getting – eliminating the bias of the physician (c) The results were reviewed by non-bias staff (d) the study was prospective- meaning the subjects were followed ahead of time so the authors could not manipulate the data either way. (e) the article appeared in a journal that is peer reviewed, meaning editors read the article for its content, have the ability to ask the authors to submit raw data, and can spot bias.

That article, along with others, put away the HCG diet industry for a while, until 2007. In 2007 a book was written about HCG – by Kevin Trudeau, called “The Weight Loss Cure ‘they’ don’t want you to know about.”  The Federal Trade Commission fined Trudeau 37 million dollars for making false statements in this book. Oddly enough book is still sold, and many of the “HCG weight loss coaches” make money selling it.  The book is bunk, by the way – total, complete and utter nonsense promoting HCG.

This silly book resurected a bad diet

Contrast the great article in JAMA with an article that the HCG coaches are currently recommending, by Dr. David Bryman, an osteopath from Scottsdale, who published a non-randomized study with a higher protein low calorie diet- showing the HCG had more weight loss (The Bariatrician – 2010 Vol 25, page 11). The problems with this study are several: first there is no randomization, second there is no control, third there is no blinding, and fourth there is a clear bias, fifth the article is retrospective  – so it can come to the conclusion it likes. The article is worthless.

Having “journals” gives people who practice pseudoscience (be it chiropractic, acupuncture, homeopathy) a sense of legitimacy. Sadly, those journals do not follow scientific principles of research, evidence or science-based medicine.

Confirmation bias is a bias hard to overcome. This is seen in the HCG diet industry. If you attribute weight loss to HCG, then everyone who loses will confirm your bias that it was the HCG.  It is clear that it is the diet – whether it is a high protein 800 calorie, or the original 500 calorie diet, that will provide the weight loss.  However, the people who sell it, or the books and meal plans, are convinced that the HCG is doing the work- in spite of the lack of science supporting their claim.  Much like acupuncture, or homeopathy – if someone believes it, and then is confirmed by placebo effect, it is difficult to overcome that bias.  Add in that a part or all of one’s living is made by some pseudo-scientific endeavor and the pseudoscience becomes a religion.

It is difficult to convince someone their “experience” is not accurate or even that their “experience” isn’t what they think it is.

HCG shows the ultimate “placebo” effect.  A placebo is a pill or injection that has no active substance in it – commonly a sugar pill or a saline injection.  Placebo comes from Latin, meaning “I shall please.”  To test whether a chemical, hormone, or some agent works, you have to test it against a placebo. Some people, 35-55% of them, with some diseases, will have an equal effect with a placebo as with the hormone tested (in this case HCG). Placebo works best with nebulous things that cannot be measured- like appetite. As was shown in the JAMA study when HCG was compared with saline injections, there was no difference.  HCG works by placebo effect.

The problem is that HCG is not a placebo.  HCG is a hormone, one that has effects that can be long lasting and harmful. We don’t know if the hormone has a tumor promoting effect as other hormones do (estrogen with breast and uterine cancer and testosterone with prostate cancer, HCG may have tumor promoting effects – it certainly can increase venous thrombosis). The other problem is physicians who prescribe this are giving legitimacy to a treatment that does not work, and can cause harm. They are also placing themselves at risk by stating they have evaluated a patient

As with all pseudoscience- there are people who firmly “believe” in this without a shred of legitimate evidence. Proving that having a degree (MD, DO, RN) does not make one a skeptic, and clearly degrees do not teach people how to think and apply the scientific method. Many in pseudoscience use the logical fallacy of an appeal to authority – e.g.- a doctor prescribed the HCG, and a nurse is my coach so it must be good.

In terms of the other scams in medicine- Homeopathy is one that actually has a board sanctioned by the State of Arizona. It isn’t odd that Arizona is so backward, after all, it is the wild west. But I like the quote from Dr. Zina Pitcher, when the State of Michigan tried to force the University of Michigan to have a homeopathic school:

…shall the accumulated results of three thousand years of experience be laid aside, because there has arisen in the world a sect which, by engrafting a medical dogma upon a spurious theology, have built up a system (so-called) and baptized it Homœopathy? Shall the High Priests of this spiritual school be specially commissioned by the Regents of the University of Michigan, to teach the grown up men of this age that the decillionth of a grain of sulphur will, if administered homœopathically, cure seven-tenths of their diseases, whilst in every mouthful of albuminous food they swallow, every hair upon their heads, and every drop of urine distilled from the kidneys, carries into or out of their system as much of that article as would make a body, if incorporated with the required amount of sugar, as large as the planet Saturn?

The power of the purse did cause the school to come to the University of Michigan, although eventually the Supreme Court did state that the Regents of The University of Michigan were not answerable to the legislature.  The homeopathic school was merged into the medical school in 1920′s – and homeopathy was gone for a while. Sadly- it is back.

Heart artery plaque- low fat diet doesn't prevent this

Never has it been more clear that publishing a paper in a respected journal can lead to a career. Even if the science has changed it. It has been 15 years since Dean Ornish published his data showing a 3 percent reduction in the plaques seen by coronary angiograms on a select group of patients who followed his diet and “lifestyle” plan.  To be exact: they found 1.75% improvement after one year and 3.1% improvement after five years.  Where the control group increased by 2.3% in one year and 11.8% at five years. This was a group of 28 patients who followed his diet to the letter.

In 15 years no one has reproduced that data. No one. In medicine we see a lot of data come through, when it is not reproduced, or unable to be reproduced by others we look at it with a very jaundiced eye. Or to be blunt – we don’t believe it. Yet, his data, with all the issues it has- is still touted by a few in the popular press as “proof” that the “low fat” works. We have levels of evidence in medicine, and while Ornish attempted to get to the highest level of evidence, by having a control group – he fell short with several major statistical issues: (a) his study does not contain enough people to be anywhere nearly significant (b) one cannot rely on angiographic photographs which are interpreted in many different manners (c) one cannot control outside factors, exercise, BMI, smoking cessation.

In contrast, we now have an entire group of lipid medications. A recent study in New England Journal of Medicine showed how that Crestor had produced a regression of plaque in 63% of the individuals.

Lets be clear- the medication data is using far more sensitive instruments to measure plaque. Intra-vascular ultrasound where they thread a tiny ultrasound probe into the artery and  measure the plaque precisely.   In the Ornish data, he used photos of angiograms ( show two cardiologist the same angiograms and you will get two different interpretations of it – angiograms are not precise). The medications show specific reductions in plaque- not everyones – unlike Ornish. It is rare that anything does 100 per cent to everyone.

When looking at angiograms- like Ornish did- the interpretation of them is so variable, that no scientific publication today would accept that data, or its interpretation. The small amount of plaque reduction is too small to be anything but observer bias.

Two views of the same image- angiogram interpretation is flawed

Still, from one old paper- Dean Ornish has made a career, being the anti-Atkins, and riding the anti-cholesterol, low-fat band wagon with the same religious fervor as Keyes did thirty years ago (see my earlier post about that).

The difficulty is this: science has caught up with us, and we know a lot more about how plaque forms and doesn’t form. We know that dietary cholesterol is far less important that what the liver makes. We know that the dietary component may be far more related to the triglycerides – and they are raised far more by the grains and pastas that Ornish loves.

Still, Ornish is the lead health-blogger for Huffington Post, has influenced Bill Clinton (see the previous post) and is favorably mentioned by Dr. Oz. He still argues against those who advocate any “low carbohydrate” solution, based on his “empiric” data.

Personality, the willingness to believe in  your hypothesis no matter what science says, and the desire by the public to see “natural” leads to a great career in politics, and entertainment. For most scientists, Ornish’s paper isn’t a breakthrough, but borders on confabulation.

There is always another “fad” diet out there- and the HCG diet hopefully died when the Food and Drug Administration (FDA) and the Federal Trade Commission (FTC) issued letters to companies warning them that selling “homeopathic” HCG weight-loss drugs was not FDA approved and that there was no evidence of the claims, thus violating FTC rules.

HCG is a hormone that is produced by the human placenta during pregnancy. Clinically HCG is used as a fertility treatment, and can lead to increase in progesterone and testosterone, which have consequences of their own including deep vein thrombosis (a clot in the veins of the lower extremity) leading to pulmonary embolism and even death. This is not a benign hormone, and should only be used under the strict supervision of a physician – who knows what they are doing, not a naturopath or homeopath, or chiropractor. HCG is also elevated in some cancers, and we follow HCG levels to determine how effective our cancer therapies work with some tumors. This is also the hormone most use to determine if a person is pregnant.

This fad diet started in the 1950’s when Albert Simeons, a physician working in India, noted that pregnant women on a low-calorie diet lost fat rather than muscle and the fetus was protected. He hypothesized that the HCG reprogrammed the brain to lose fat rather than muscle, thus protecting the body against loss of muscle. Simeons went on to become an entrepreneur founding weight loss clinics, manufacturing centers, and having widespread use of his product. There was no evidence for HCG working and the diet died in 1976 after an article in JAMA showing that there was no difference between patients who received HCG and those who received a placebo. In 1976 the FTC ordered the Simeon Weight Foundation and HCG Weight Clinic Foundation to stop claiming the HCG was safe and effective, and the FTC has required labeling and advertising of HCG to state:

Albert Simeons- went from working in India to making a fortune in weight loss

HCG has not been demonstrated to be effective adjunctive therapy in the treatment of obesity. There is no substantial evidence that it increases weight loss beyond that resulting from caloric restriction, that it causes a more attractive or “normal” distribution of fat, or that it decreases the hunger and discomfort associated with calorie-restricted diets

HCG was reborn in 2007 with the book, “The Weight Loss Cure They Don’t Want You to Know About,” by Kevin Trudeau (if you watch infomercials you have seen him – the infomercial guy). Shortly after the FTC charged Trudeau with violating a court order and misrepresenting the contents of the book on his infomercials. He was ordered to pay 37 million dollars for violating their order.

This silly book resurected a bad diet

Still, that started a new industry with companies manufacturing products that could be sold out of major drugs stores, injections given in drive-by diet centers, and lots of people touting this as the cure to obesity. The manufacturers decided if they would slap the “homeopathic” label on it, they could get by with selling this over-the-counter and make even more money off consumers. The FDA stopped this nonsense- not only because this is a potentially dangerous hormone, often given without strict medical supervision, but because the very low calorie diet that goes with it should be done under the supervision of a physician also.

The reason we won’t see the HCG end is because physicians can still prescribe injections of HCG – even though this is not a diet that will work. There are still unfortunates who think getting an injection of this hormone will work- and as PT Barnum once said “there is a fool born every minute.”

The HCG proponents are filled with confirmation bias.  They lose weight, so they assume it is the HCG that suppresses appetite – although there is no evidence it does.  They then will cite articles in non-peer reviewed journal  such as Dr. David Bryman, an osteopath from Scottsdale, who published a non-randomized study with a higher protein low calorie diet- showing the HCG had more weight loss (The Bariatrician – 2010 Vol 25, page 11) . The problems with this study are several: first there is no randomization, second there is no control, third there is no blinding, and fourth there is a clear bias.  To put this in perspective- this study has less validity to it than a noted expert opining.  This study does not rise to acceptable levels of Evidence based medicine. Sadly, the HCG proponents, including health care professionals, do not understand the value of the evidence based medicine that clearly demonstrated no efficacy of HCG in any study in a peer reviewed journal.

http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm281333.htm

The action of chorionic gonadotrophin in the obese. Simeons ATW. Lancet 2:946-947, 1954.

Chorionic gonadotropin in weight control. A double-blind crossover study. Young, Fuchs, and Woltjen. JAMA. 1976 Nov 29;236(22):2495-7.