Dr. José Carlos Souto - 'Low-carb: myths that refuse to die'

[Music] first of all i would like to thank dr gerber and dr tyler for the opportunity it is an honor to be here talking to you so what i'm going to be addressing is low carb and the myths that refuse to die so most dietary guidelines as you know are focused basically on reduction of fat fat especially saturated fat but they are very liberal with carbs especially grains they actually push you to eat more of them so this very carb-centric approach is obviously not helping you just look around we have an epidemic of obesity metabolic syndrome and diabetes and there is no shortage of high quality studies just as ninotaishas were saying uh before me that a low carb approach is effective and yet it struggles to be accepted by the mainstream so the question is why there is so much resistance to a low-carb approach the current guidelines were developed developed with a single focus which is ldl cholesterol so anything that increases it should be avoided and anything that lowers it we should embrace but in a in addition there are several myths and these myths are being perpetuated by doctors and dietitians alike regarding imaginary dangers to the kidneys liver bones etc now this is a nice segue to what nina taisho swords was just telling us and see this was written uh about the last guidelines in 2015 uh and stephen nissen the the doctor that is writing about it in 2016 uh he's not a low-carb doctor he's he's as mainstream as it gets but yet he saw that a detailed review of the new guidelines again he's talking about the last one confirms a disturbing reality the nearly complete absence of high quality randomized controlled clinical trials studying meaningful clinical outcomes for dietary intervention unfortunately the current and past u.s dietary guidelines represent a nearly evidence-free zone it's a strong statement but it's true and it seems to be true for the next one so he continues we reduced dietary fats but binged on carbohydrates and became increasingly obese type 2 diabetes grew into an epidemic that is now threatening to reverse decades of progress in coronary heart disease incidents the obsession with low-fat diets has resulted in some extraordinary and bizarre food marketing practices yes indeed so why so much resistance to change because we know low carb is better to achieve and maintain weight loss it is better to control type 2 diabetes and it's an obvious dietary solution for the metabolic syndrome so i'm going to propose to you that the biggest problem is not insulin resistance is evidence resistance a piece of the puzzle as to why this happens has to do with the many myths surrounding low carb so let's take a look at them there are many uh for the sake of time i selected just four that i think are the most important it will harm your kidneys it will harm your liver it will harm your bones and you it will give you gout because it raises uric acid all that protein so patients with chronic kidney disease they actually have trouble excreting many substances including those that are derived from protein metabolism so it is true that those people in end stage kidney disease should not be put on a high protein diet however we should keep in mind that a low carb diet is not high protein by design although it can be now just for the sake of discussion let's suppose it is a high protein diet okay i like to do an analogy with heart failure and exercise a patient that has a late stage heart failure cannot tolerate exercise like for example going to flights of stairs he may die okay but that does not mean that exercise is bad for the heart so it is a logical fallacy very sick heart equals low exercise tolerance that is true but exercise does not cause heart disease likewise very sick kidneys they can't tolerate a high protein diet but a high protein diet does not cause kidney disease okay now this is one randomized control trial of a low carb high protein diet it is not the only one there are many okay but here for example we have a very low carb high protein diet compared to a high carb diet and this is the conclusion this study provides preliminary evidence that long-term weight loss with very low carb diet does not adversely affect renal function compared with a high carb diet now some people will object this is a study that lasted just one year but what if it's not bad for your kidney for one year but it will explode it in five years so next we are going to look at an observed observation of study of patients with type 2 diabetes that are deemed to be at high risk of kidney disease now we are talking about 6 000 patients followed from 2002 to 2008. in this graph what is to the left is protective and what is to the right is associated with a higher risk of progression to kidney disease in these patients and i'm going to highlight animal protein because we all have heard that animal protein is especially bad but see those that consumed the most animal protein were actually less likely to progress to kidney disease and basically the only two kinds of foods that were associated with a bad outcome were high carbohydrate foods and deep fried fast food which shouldn't be a surprise because those patients are diabetic and diabetic patients why are they losing renal function because high blood sugar is affecting the kidney so it's of course high carbohydrate foods that should be bad for them it's not by eating beef that you make your diabetes worse uh and this is not the single cherry picked uh study here we have another one this it has more than eight hundred six thousand patients uh eight thousand six hundred patients followed for six and a half years and you can see that renal function does not change according to the level of protein intake but if we look at the all-cause mortality those that eat very little protein actually die more there is something funny about this paper because if you look at the title it's high protein intake associates with cardiovascular events but not with loss of regular function so they needed to find something bad about protein okay so these events they are not cardiovascular death okay you actually die more if you eat less protein but i think that the peer review would not take it without changing the title now this is a special paper it is special because it is the only randomized control trial i could find that is actually testing a higher protein diet on patients that have already established kidney disease the diet they were trying cut carbs by half but protein was not restricted it is a multiple intervention diet so there is also reducing uh iron on the diet and they are also increasing polyphenols in the diet so it's hard to say what is actually doing good here because it's several interventions but keep in mind it's half the carbs but it's liberal on the protein side and the control diet was the standard low protein diet usually prescribed for this kind of patients so almost 200 patients the mean creatinine was 1.8 which means these guys had at least moderate kidney disease and they were randomized and the end points here were hard endpoints by which i mean dialysis or death and the mean follow-up was four years now 65 percent carbohydrates and the diet that was being tested was 35. protein was 25 to 30 percent so it's it was actually pretty high protein and they drank wine so the results are stunning this is a 19 absolute risk reduction so uh keep in mind that usually when people take statins for primary prevention we are talking about at most a one percent risk reduction one percent this is a 19 risk reduction for dialysis or death with a diet that did the opposite of what the guidelines tells you to do it is free in terms of protein it restricts carbs and you can see the difference this is a very recent paper it is not a randomized control trial but it's interesting because they were trying a very low calorie ketogenic diet and this diet was 1.4 grams of protein per kilogram weight so it was considered a high protein diet now interestingly 27 percent of patients with mild renal failure reported normalization of glomerular filtrate after dietary intervention so this paper is hinting to us that some patients as they lose weight as they be make their metabolic syndrome better they can actually reverse a mild uh renault failure with diet so it seems that not only a low-carb diet is not bad for your kidneys but it may may be actually good in terms of reversing disease so i think we slashed that one liver there is a persistent myth that a low-carb diet will somehow force or harm your liver you probably heard that the funny thing is there is nothing in the peer-review literature that even hints at that possibility and it you should do it if you are in in the health profession just do a pubmed search put the relevant uh keywords you won't find anything implying a low carb or even a high protein diet in harming the the liver okay on the contrary when you look at the animal studies there are many but it can you can summarize them uh like this excess sugar fructose in the diet leads to fat production and accumulation in the liver and dr lustig has looked and told us in exquisite detail about that less carbs means less fatty liver more protein also means less fatty liver but what about in humans then again dr lustig showed us a lot of data in his presentation i encourage you to look back at that presentation if you are looking from home you can look at his video also this is the his website where you will it will take you a while just to browse through all the papers that he's published we are looking at the seventh seventieth one okay he showed in his presentation that adolescence with fatty liver could have a big reduction in the fat content of their liver in less than 10 days with a low sugar diet i'm going to show you just one trial because this trial made all a lot of news it was published in cell metabolism and the thing to keep in mind here is uh as it was said before in this conference many times people will argue okay your fatty liver got better but it's because you lost weight as if it was a bad thing okay but anyway it's because you lost weight so here they did a isocaloric diet and made their best effort to keep people with uh weight stable okay uh in a diet that is low carb and high protein so according to the myth this should be bad for your liver it's low carb and high protein and what we saw was a dramatic reduction of liver fat in two weeks so the weight was although some people lost a little bit of weight and it was hard to keeping them from losing weight even with more than 3 000 calories a day on a low carb diet but the liver fat went down like 25 okay what about bone health it's another urban legend that low carb which is supposedly high protein would lead to osteoporosis and why should it because all this protein they tell you will result in an acidic metabolism and that acid needs to be tempinated needs to be controlled by calcium and phosphorus which reside in our bones well one fact and this is a physiology physiology fact is that body weight does not significantly change your blood ph which is kept at a very narrow range actually the the ph needs to be at this very narrow range those that work in icus know very well that larger fluctuations will lead to pretty bad outcomes okay so our body cannot be influenced in terms of ph by what we eat and important what controls that ph are the kidneys in the lungs not the bones so why was this myth put forward in the first place the thing is people with chronic metabolic acidosis they do lose bone mass but those people they have kidney disease it's not because they ate a steak okay again when the kidneys are functioning fine they regulate the body's ph by modifying the urine's ph so that it won't make your blood blood either acidic or alkaline now look at this graph it shows you that yes indeed if you put people on a high protein diet after they were on a low protein diet there is an increased excretion of calcium in the urine so people say aha see when you eat more protein you are losing calcium and the calcium is coming from where obviously from the bone not really because if you look at how they absorb calcium from their diets what people found out is that once you put someone in a high protein diet it increases the absorption of calcium so you become more efficient in absorbing the calcium that you are eating and if you are absorbing more calcium it's obvious that you're going to excrete more so this highlights a problem with nutrition people extrapolate from mechanisms like nobody cared to actually look if the calcium was coming from the bones or not they just assumed it was from the bones and then you have this myth that low carb is going to give you osteoporosis i like this paper because it has the most descriptive title ever a diet high in meat protein and protein and potential amino acid load increases fractional calcium absorption and urinary causing excretion without affecting microsoft bone resorption or formation you don't even need to need to read the the abstracts right now this is as mainstream as it gets this is the national osteoporosis foundation and it's a systematic review and meta-analysis which should put the myth to the rest okay although the scientific literature is somewhat limited with regards to the beneficial effects of protein intake our analysis does not indicate the presence of any adverse relations and the body of evidence shows that if the effect of dietary protein on a skeleton appears to be favorable and the conclusion is no adverse effects of higher protein diet and diets intakes and positive trans positive trends on bone mass density at most bone sites so it's actually good for you okay what about gout gout as you know is very painful it's a painful condition it's an arthritis that occurs because uh you have uric acid crystals that precipitate that form inside the joint and it is said to be due to much red meat and seafood patients are told to avoid too much protein hence there is a myth that a low-carb diet will worsen or cause gout well first we need to understand that a high uric acid level is common in people with gout but people with a high steric uric acid will some of them will never develop the disease so to have a high uric acid level is necessary but not sufficient for you to have gout now i went to the uk gout society to see what they recommend for you not to eat you should avoid organ meats you should avoid game you should avoid oily fish and seafood and meat so basically you cannot eat anything that is nutrient dense now what should you eat instead plenty of fruit at least five a day plenty of bread other cereals and potatoes and moderate amounts of meat fish and alternatives so it's the road to obesity and diabetes it's basically that okay now it is interesting because all physicians know that gout is very very closely associated with the metabolic syndrome so why on earth would i tell somebody with the metabolic syndrome to eat this and expect him to get better so what about science because all we have been telling is people say this organization says but you know what about science the evidence to avoid meat is purely epidemiological again nutritional epidemiology something akin to astrology the great majority of appearance purines are the uh the things there are the precursors of the uric acid the great majority of the purines are endogenous meaning they are made by your body just like cholesterol and the purine restriction the diet that i showed you we reduce uric acid by no more than 1.5 milligrams per deciliter which is clinically irrelevant when people actually follow it which is never because it's basically impossible to follow that that diet now this is very interesting look at this dietary management of gautama is the evidence there were only three randomized control triads testing this gout diet this low purine high carbohydrate diet and known have shown benefit now let us sink in we have only three randomized control trials that have ever analyzed the diet that is widely pre-prescribed for gout and they are all negative so there's no science behind it they do say here that weight loss is good the avoidance of sugary drinks is good that regulation of alcohol is good and i couldn't agree more we cautioned about translating findings from observational and interventional studies of healthy volunteers without gout into treatment recommendations for those with established disease so this is again is the same problem with nutrition science people do nutrition epidemiology then they extrapolate by mechanisms and they never get to test if the thing actually works dr lustig showed us again in very detail a lot of biochemistry why fructose increases your uric acid it actually needs a lot of atp and this a this adenine is appearing so when the body needs to metabolize a lot of fructose it will increase your endogenous production of uric acid and this is nicely shown here this is once you ingest sugar or high fructose corn sugar and corn syrup you have an acute increase in uric acid and those things sugar and corn syrup they don't have any purines they are not protein they are not meat now this is an actual trial it's a pilot study okay it's a small one but look they were doing a modern limitation of calorie and carbohydrates and increased proportional intake of protein so according to the dogma these people with gout should become worse off once we give them more protein and less carbs so what happened basically everybody had a reduction in their uric acid after 16 weeks but what is more interesting they had a huge reduction in the number of gout attacks with more protein and less carbs now if we understand that a high uric acid and gout are associated with the metabolic syndrome then this makes sense and this is the best one because it's the atkins diet okay everybody will tell you that the atkins diet will give you gout because it's rich in protein red meat seafood very low in carbohydrates this has never been published and i wonder why okay i i found it uh as an as an abstract this is believe is the american college of rheumatology and the the data comes from a very well known paper randomized control trial the direct trial from 2008 that was published in the new england journal comparing a low carb a low fat and a mediterranean diet showing what you should expect that a low-carb diet was better but they got a subgroup of those patients and did the uric acid analysis and this is what i'm going to show you the results were more remarkable in patients that had uric acids above seven in this group the more obese and younger the greater the benefit with the atkins diet and here again you see the baseline and six months after you have a great decrease in the uric acid levels i should tell you that this is probably a biphasic thing so at first uric acid may go up and then it goes down here they're just showing you two data points and now we are going becoming uh we are starting to see news like this could a ketogenic diet alleviate gout so we have gone from this certainly is bad for you and causes gout to should we use it to treat it so can we fix the nutritional guidelines well we just saw nina taisho's making for us a dire evaluation of that brazil has since 2014 has the most revolutionary food guidelines in the world instead of focusing on particular nutrients like food pyramids or my plate its focus on processed and ultra-processed foods and the food industry and they made this 10 steps to a healthy diet and i'm going to highlight just a few of them make natural or minimally processed foods the basis of your diet limit consumption of processed foods and avoid consumption of ultra-processed foods shopping places that offer a variety of natural or minimally processed foods and be wary of food advertising and marketing so why do we care about the us or the uk guidelines in brazil we care because these guidelines have a huge influence in the way nutrition is taught around the world dietitians are still being taught that saturated fats clog your arteries that starchy food is okay for everybody including the obese or diabetics and that process low-fat food is good for you we need to fight to break the evidence-free spell of modern nutrition so in conclusion low carb is not a hyper protein diet but even if it were it would not harm the kidneys it is not a high protein diet but if even if it were it would still be good for the liver low carb is not a high protein diet but even if it were it would be good for bone health and low carb is not the only healthy approach to nutrition but it should be included in the guidelines as a tool to be offered by healthcare providers thank you [Music]

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Keywords: Low Carb Down Under, LCDU, www.lowcarbdownunder.com.au, Low Carb Denver 2020, #LowCarbDenver, #LCD2020, José Carlos Souto, Low Carb Brazil, Dietary Guidelines, Low Carb and kidneys, Low Carb and Liver, Low Carb and bones, Low Carb and gout, LCHF, Ketogenic Diet, Protein, renal function, uric acid

Id: uQYyOvCAM_E

Length: 29min 56sec (1796 seconds)

Published: Sat Jul 25 2020