FAKE NEWS: 40 years of prevention through low fat dietary advice by Prof Iain Broom | PHC 2018

[Music] welcome Professor Ian broom well thanks Sam and thanks for the invitation to this say all I can see is quite an amazing conference and I've never been at a conference where the audience has been so enthusiastic it's unbelievable I mean it's really great but I really can't thank Sam but also the audience as well from better active participation that's really really good now I've entitled this fake news and it's about the only thing I can see is come out of Donald Trump that's actually good and that's the phrase fake news I hope that I'm no Donald Trump supporters around but I did give him the benefit of the doubt in the beginning but I'm a bit worried about what's going on now a little bit about my background in relation to low-carbohydrate approaches I actually I'm a biochemist by training and a physician by adoption and indeed had three quite strange training because I was a physician working as a lecturer in surgery and then senior lecturer in surgery so I worked with the surgeons and Tim put up a paper this morning with two names on it that I recognized Bruce Istrian and Jorge Blackburn they're responsible for my getting involved in low carbohydrate diets not in relation to diabetes or obesity but in relation to problems occurring after surgery where surgical patients might develop sepsis and we use a post-operative ketogenic approach to monitor for sepsis and patients who were deemed to be at risk of their junction of whatever they've put together breaking down and causing sepsis so that was my introduction into that and the reason I got to know George and Bruce is that Aberdeen University has a joint program with from within the department of surgery to transfer in junior staff across for a period of a year so that's how I got to know this George is also involved in bariatric surgery or was and one of our fellows went across there and came back started bariatric surgery in Aberdeen in 1982 long before bariatric surgery was done anywhere else in the UK with the exception of wheels so prior to having patients ready for bariatric surgery usually their livers are pretty large and they get in the way of the surgery so you have to have a way of reducing a liver science and we do this by simply putting them on to a low-carb ketogenic diet for two weeks before surgery now most of these patients BMI was well above 40 and they have been totally unsuccessful and reducing their weight but when they went on to this diet we were amazed that the week just appeared to drop off and a lot of these patients actually refused surgery and that's how my obesity clinic started that was that which ended up being huge as your pardon the pun in addition I always had an interest in diabetes and specifically in obese type 2 diabetes so I apart from working in surgery I also worked a diabetic rank and consequently because of my interest I got all the complicated type 2 diabetics referred to me and I thought why are we fitting these patients carbohydrate when their main problems Cara behind rate intolerance why don't we why don't they use as ketotic approach and it made a huge difference as you'll see later so anyway enough of my background I better go on to what really is 40 years of really good diabetes and associate CVD management and prevention through a low fat carbohydrate dietary advice that is the fake news is absolute rubbish the low-fat high-carbohydrate diets were originally proposed to reduce coronary heart disease mortality and prevention of Corey Humphries and cholesterol was the primary target and low-fat high-carbohydrate diets were not designed to deal with either weight or diabetes management not at all no again everyone talks about randomized control clinical trials these were designed specifically for drug therapy assessment where there is only one variable the drug or a placebo this is actually a very pure structure to look at dietary studies because there is always more than one variable if you change one macronutrient you alter the other match in nutrients you can't take account of patients preference you can't take account of peer pressure there are lots of variables that impact on an RCT becoming appropriate and because of problems relation to patients under peer group the dropout rate from RC cheese and dietary studies is huge if you had the same dropout rate in drug studies the drug the whole study would be dropped we'd be just cancelled out because it seemed not to be appropriate since 30 percent or more of patients can't tolerate the drug so never leave that a patient acceptability problem in terms of adherence to specific dietary therapy and diet and disease is very complex it's not a simple issue unfortunately most of our medical graduates since the last World War but very little training in nutrition prior to the Second World War it was a huge amount of nutrition in the training and Hippocrates said if you don't understand the foods but man is eating you will ever never understand the diseases that will affect him so it's it's I think we've lost the way in terms of our medical training with nutrition we do not get sufficient training in nutrition right low carbohydrate diets weight loss of metabolic control look a behind alike so important yes the role cause weight loss but they're much more important because the input the improvement metabolic control is completely independent of weight loss you get improved insulin sensitivity because of the removal of ectopic fat this was discussed yesterday with the various MRI pictures wool fat diets have said that low carbohydrate diet just as a improved control in dependence of weight loss bariatric surgery again clearly demonstrated an independence between weight loss and improved control patients achieving very athletic we've had bariatric surgery they're diabetic control of the metabolic control improves within the first 10 days long before have actually lost any weight now this is probably this is history and you probably know all about this Ancel Keys is the main protagonist for this and he was a very good physiologist nutritionist and he's probably done the best study of starvation ever published in two volumes in the 1950s he couldn't do now what he did then because he would never get ethical permission to do it but basically he was determined that fat was the problem in relation to coronary heart disease he sat it off initially with total fat and then rolling that back to saturated fat now he had a number of countries that you'd look at but it didn't match his hypothesis so he told he chose seven countries to prove his hypothesis and he ignored all the data that was there from sugar now in the 1970s when this new dietary change came about I was actually in touch with professor Adams at the Rockefeller and he was strongly against this absolutely and he said if she bought down this route Ansel you will end up with an epidemic of obesity and type 2 diabetes that's what he said in 1977 before the guidelines came out he was ignored and you heard about John you didn't he said exactly the same thing and John was piloted by Ancel keys the finished dietary study was a very complex this is the North Karelia project was a very complex program and there was a lot more factors altered than simple dietary fat and again coronary heart disease was the target illness and cholesterol was what was being targeted and this was thought to be if you reduce saturated fat this would have that effect an increase unsaturated fat you would get a beneficial effect I'm not sure what the weight of the finished population is at the moment but I'm sure that's higher than it was in 1983 the evidence against the 22 country studies which as well please had the data for and could have used he didn't use what did the 22 countries studies show no evidence of fat being associated with coronary heart disease refined carbohydrate consumption and tobacco were suggested is linked factors for the 22 country study the Nurses Health Study no effect of dietary fat and cardiovascular disease the Women's Health Initiative 49,000 premenopausal woman fat reduction was affected saturated fat was affected no effect on cardiovascular disease 2008 and FAO review no convincing evidence for fat 2012 Cochrane review 24 studies no effect on CVD or total mortality by reducing fat intake low fat diets are here to call the heart disease and cholesterol high carbohydrate diets will lead to inappropriate increased insulin levels and to drive adipose tissue fat synthesis and again this type of diet also drives nutrient partitioning if your insulin resistance and that frequently that effect roughly 40% of the circadian population believe it or not if your insulin resistance yes the muscles are resistant to the effects of insulin the Ilsan still binds to the muscle membrane it's the intracellular signal that causes the problem if you look at effect of insulin on adipose tissue there is not so much influence so therefore if you drive high carbohydrate you drive fat synthesis and you drive wait up and then patience goes up the appropriate genetic disposition you will drive up ectopic fat and make insulin resistance worse and eventually end up with type 2 diabetes now you've seen these things before this is intrahepatic bile and this is subcutaneous fat these two patients in the same BMI and same waist circumference look about pressure differences cholesterol there is a difference but the main difference is actually in the HDL and the triglycerides well a high carbohydrate diet does is to drive HDL down and drive triglycerides up now I know you may not believe in cholesterol but cholesterol does have an effect and especially when the LDL cholesterol it's in a specific form and when the values are here it is in a specific form and I'll come back to that in a minute obesity still is the primary risk factor for type 2 diabetes as you go up the BMI scale the risk of developing type 2 diabetes increases interesting enough once you go above 40 which is a much smaller proportion of the obese population that that link is not quite so strong and then likewise in women but again it's it's twice as dangerous in women than it is men in terms of the likelihood of developing type 2 diabetes and as was mentioned earlier we have a big problem in terms of the numbers of patients that are proposed to be becoming type-2 diabetes it's big enough in the developed world but in the developing world this is huge and this was again talked about this morning in relation to Africa but it relates to all industrializing countries it's a huge problem the we need to try and sort out and we can sort it out by changing the dietary guidelines now alteration to mat condition dietary composition you're talking about high and low fat high and low carbohydrate standard them high protein V LCDs LCDs or combinations of these but the real debate is all about moving to a low carbohydrate diet that is well that is what we're trying to do that's the outcome they really want now this is a diet that I used in the Vista clinic to try and get patients to bring the weight down it was adapted somewhat for type 2 diabetics it took me a long time in any Chess Champion to persuade my Dietetic colleagues that this was a good approach to managing both obesity and type 2 diabetes yeah I won however because NHS could ampion at one point one time was the only NHS authority within the UK to issue a low-carbohydrate leaflet to patients to allow them to maintain this program and the dieticians themselves would support it I changed my diabetic clinic dietitians approach to managing type 2 diabetes and their use of low carbohydrate diets I made I think a big impact on the junior staff coming through the clinic because they could see how this was working and I know that some of them who are no consultants are using this approach in their own clinics albeit north of the border but effectively we have attended to use a higher-protein hundred 20 grams a day giving 41 percent energy carbohydrate maximum of 40 grams a day 16 percent energy and the fat was 43 grams 43% energy now at this at the same time the standard amount of fat in standard healthy eating suggested by Diabetes UK with the six of the calorie deficit diet and it was actually giving 51 to 59 grams of fat so we this is actually a low-fat diet despite the fact it's a low carbohydrate diet so I'm perfectly in keeping with the diabetes UK's situation at that time except I'm using a lot more of the total energy as fat no patient acceptability I said is very important and it has been stated that patients will not accept a low carbohydrate diet again all the evidence is totally against this these are various randomized control trials despite what I said about randomized controlled trials where these are the dropout rates right so the low carbohydrate much higher much higher much higher much higher all it's highly significant levels so there is a complete fallacy that patients will not tolerate a low carbohydrate approach they tolerate it much better than a low fat approach and low fat means obviously high sugar palatability in terms of a diet is very important if you reduced the fat in the diet to very low levels it becomes completely unpalatable and the only way to get it palatable is to add sugar and that's what the food industry does it adds sugar it has preservatives the preservatives themselves of effects and on the dietary intake affect an appetite effects on society the food industry know about this it won't tell you I've not been sued yet and I'm for seeing out said several things again this is what you might expect in a typical uncontrolled poorly controlled type 2 diabetic hemoglobin a1c 10% the patient had a BMI of 40 he was a troller skipper couldn't obviously go as a stroller out on the ship he was on 400 units of insulin perdy he had severe angina the cardiac surgeons wouldn't look at him in terms of doing a bypass he was referred to me by the cardiac surgeons I put him on a low carbohydrate diet and you can see within three weeks he dropped his hemoglobin a1c 10% to 8.5% and it continues to draw and a year after this he had his coronary artery bypass graft and ten years later he was still very much alive and kicking he's greater gone up slightly but he was still maintaining his low carbohydrate intake and was also an extra benefit for me because he was a troller skipper so therefore if a couple of weeks or so I get a huge portion of fish on my desk at the clinic for several years in fact until I retired again it doesn't matter in terms of weight loss with the exception of one year there is always a much greater benefit of low carbohydrate approaches to low-fat approaches in terms of actual weight loss at three months at six months now the problem is that at at six months most dietary therapies tend to fail we don't really know why they tend to feel that patients tend to come off their diet at six months and that's why the feel but why do the patients come off with it six months that we don't know and don't understand which really explains why at six months six months is the usual maximum now the other thing about the weight loss is that you get much better weight loss and what and it's very consistent this is my Ilion Robertsons was my dietician the diabetic clinic here and you can see we get really quite considerable weight loss and you would expect you're looking at 5% this is 8% roughly 9% Foster again very similar results in Sam AHA again similar results and if you'd a systematic review which one of my students carried out many years ago clearly demonstrated an improvement with a little carbohydrate in virtually all studies at six months it wasn't quite so clear and the fewer fewer studies at this particular time at one year so there are perhaps problems with this sustainability but then I think the sustainability requires apart from the change in diet a behavior modification program along with the diet now the other thing that is always said is that once you have diabetes it is much more difficult to lose weight of course it is if you use a high carbohydrate diet you are pushing fat deposition so that's quite more difficult they have a huge problem of insulin resistance and this is wing study where she use type 2 diabetics and non diabetics boxes and the weight loss that we achieved in exactly the same environment exactly the same food but diabetics lost exactly half of what the non diabetics did right and this has always been a problem no matter what you actually how you look at managing obesity if you look at the the real studies and the real diabetes you've got the diabetes placebo my dad which is a mountebank you've got a good difference then you've got the non diabetes placebo again the weight loss in the placebo group and non diabetics is twice as much as the diabetics why because the dietary advice that was given to these patients with a 600 calorie deficit diet based on high carbohydrate what happens if you go on to a low carbohydrate diet now this is a bit extreme because this is a V LCD and you can see there is absolutely no difference in the rate of weight loss between diabetics and non diabetics these patients were all on a ketogenic diet they had maximum of 15 grams of carbohydrate input and they lost weight at exactly the same rate again if you look at all the drug trials and the placebo group create changes in type 2 diabetes - two point four it's six months two point six eight twelve months twelve month weight change in the various drug trials four point six to seven point six so roughly you get an expected forty percent weight loss in the diabetics and the drug trials if you look at the actual drug itself always that with diabetes just under five non-diabetics well over eight 62% sibutramine which works slightly differently there is you can get a better effect than the diabetics than you do with the other drugs it's up at eighty seven ninety percent if you use a low carbohydrate diet in type two diabetics you get seven kilograms weight lost seven point six kilograms a year and it without severance of 100% via LCDs nineteen kilograms one hundred percent so if you drop the carbohydrate con content you will get diabetics to lose weight at exactly the same rate as non diabetics but as I said before you'll get improved glycemic control improves metabolic control even before this weight loss occurs because the insulin levels are immediately dropped and this is an immediate change on other factors let's get one thing straight insulin is an atherogenic hormone if you have high insulin levels you will develop ethyl ethyl sclerosis and all type-2 diabetic patients at the moment die from cardiovascular disease complications effectively now if you look at the lipid abnormalities in diabetics there is non diabetics there's absolutely no difference in total cholesterol between diabetics and non diabetics there is no difference in LDL cholesterol between diabetics and non diabetics the differences in the HDL cholesterol which is reduced in the choice are glycerol which is raised high carbohydrate diets push the excess glucose into triglycerides and they go up as that goes up there's a concomitant problem in terms of HDL and HDL actually goes down and this creates what is called an atherogenic profile and it relates to effectively the the LDL size but if you look at again low carbohydrates low fat 39% of population was type 2 diabetic 43 percent of metabolic syndrome weight loss six months in the little car behind it five point eight kilograms much less in the wall fat plasma try yourself little reduction 20% nope insulin sensitivity vastly improved what happens with the with the low-fat high-carb behind it it gets worse the insulin resistance gets worse now this is a little schematic that if you've consider these as LDL particles right where you have a nice high HDL cholesterol and a lower triangular slide you've got big large happy-go-lucky smiling particles that really ignore the the arterial wall on the other hand if you feed these individuals a high carbohydrate diet and their insulin resistance metabolic syndrome or type 2 diabetic you change the site of the LDL particle the same concentration of LDL is still there but you've got ten times as many particles and they're also very aggressive they do not like the arterial cell wall and the attack it they get easily oxidized and they become inflammatory processes and this is what sets up the problems with atheroma in all of the major vessels and again if you have this insulin resistance problem as David pointed out yesterday insulin acts as on the kidneys to reabsorb sodium and this will lead to effectively hypertension so you can see it doesn't take very long to actually change the particle size right pattern II is what we actually want big fat happy-go-lucky LDL particles pattern B is what we don't want but even in pattern II you get an increase in the LDL particle size and in pattern B within three weeks you're actually above the level where these particles might become might be more atherogenic and certainly that is that is also that also maintained at week six now what about dietary carbohydrates on blood pressure the only heart study upon 2005 44% of 54% of energy is carbohydrate the same total energy now this is not a huge reduction in carbohydrate it's a small reduction with the BP reduced on the 44% carbohydrate diet absolutely no change on 54% carbohydrate night so even a small reduction in carbohydrate will lead to improvement in blood pressure all this data so far has at least attempted one group of clinicians to change the country's guidelines or to try and change their country's guidelines I don't think they're quite changed yet but results of change Brazil has gone down to a lower carbohydrate intake where basically in 2013 the Scandinavian health using recommendations were to reduce carbohydrate intake increased protein increased fat and that dairy produce was healthy that's their new recommendations as I say I'm not sure that they've been implemented by the Swedish government but Brazil certainly has right what basically are the outcomes in terms of low-fat and I think the best thing is what Richard Smith said in an editorial on the BMJ is that the successful attempt to reduce fat in the diet worldwide has been an uncontrolled global experiment with absolutely disastrous results and this has led to what Adams prepare projected an epidemic of obesity worldwide an epidemic of type 2 diabetes worldwide and it starts unfortunately in our children it's you know our children that are really going to take the brunt of this and if the government is worrying about being able to afford in the future it needn't worry because the right our children are drunk my grandchildren might diet a younger age than me because of this stupid arrangement by the advisers to government as government and the government in the West to adopt a high-carbohydrate empty it's an absolute and utter disgrace I think I'll finish up with just evolution right we used to be like this when we were hunter-gatherers the Paleolithic diet and we used to worship this and if you look there are lots of these stone carvings around and now we are this and we are worshipping that I mean [Applause]

Channel: Public Health Collaboration

Views: 11,165

Rating: 4.6198349 out of 5

Keywords: diabetes, diet, nutrition, health, public health, low carb, obesity

Id: 0r9aq-nKgFc

Length: 29min 54sec (1794 seconds)

Published: Mon Dec 10 2018