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Tuesday, June 20, 2006

Feinman: ADA Is 'Trying To Back Into' Supporting Low-Carb


Dr. Richard Feinman teaching medical students about low-carb diets

Have I got a treat for you today.

One of the nation's foremost leaders in the field of metabolic and nutritional research is a man by the name of Dr. Richard D. Feinman. He is a professor of biochemistry at SUNY Downstate Medical Center in Brooklyn, New York and the editor-in-chief of the scientific journal Nutrition & Metabolism.

I had the privilege of meeting Dr. Feinman in person for the first time in January this year at the Nutritional & Metabolic Aspects of Carbohydrate Restriction conference and found him to be a most fascinating individual when he talks about livin' la vida low-carb from the scientific vantage point.

Sometimes those of us who support the low-carb lifestyle get so caught up in the semantics and politics of low-carb that we simply forget about the amazing advances that have taken place with this way of eating through diligent and deliberate research studies by men like Dr. Feinman.

Be prepared to learn from this man who has dedicated his life to not only teaching his students about the health benefits of carbohydrate-restriction, but to spread that message to virtually anyone who would listen to what his years of experience and personal research have shown him.

Class is now in session...

1. We have with us one of the world's most renowned scientific experts in the world of livin' la vida low-carb, Dr. Richard Feinman from the SUNY Downstate Medical Center. Dr. Feinman, tell us briefly what you do and why you became interested in the science behind the low-carb/controlled-carb nutritional approach.

I am a professor of Biochemistry at SUNY Downstate Medical Center and I have been teaching metabolism to medical students for many years. I am primarily interested in the underlying biochemistry in nutrition and in our teaching, we use low-carb diets as a way of illustrating various principles of metabolism – the role of insulin, ketosis, gluconeogenesis (the method by which your body supplies glucose in the absence of dietary carbohydrate). Whereas I am not strictly speaking as an advocate of any diet, I am primarily interested in low carbohydrate approaches because they are grounded in metabolism (e.g., high carbohydrate, high insulin, fat storage rather than oxidation) in a way that low fat diets are not.

2. Studies have been coming out in droves over the past couple of years even as the media and those self-proclaimed health "experts" continue to assail the low-carb lifestyle as just a passing fad. Do you feel there is hope for a revival in low-carb living if the preponderance of the evidence continues to point people to the effectiveness of low-carb diets on weight loss and improved health?

I think people have already understood the importance of avoiding excessive carbohydrate consumption and even organizations that claim to be opposed to low-carb diets are backing into acceptance with the approximations of diets based on glycemic index and the notion of avoiding refined sugars and starch. So yes, I do feel there is a lot of hope.

I see as the real problem that the media and “experts” continue to have exaggerated warnings about fat even in the face of contradictory evidence such as the recent Women’s Health Initiative. The dialog is not on a good track: it is not really low-carb or low fat, it is a question of whether you substitute one for the other.

We have known for some time that, for most people, if you replace fat with carbohydrate, cardiovascular risk goes up and probably weight gain is increased. That would seem to the message of the obesity epidemic where fat went down and carbohydrate went up. Everybody agrees that if you are overweight and you remove fat from your diet as a way to reduce calories, that is a good thing. It is only if you replace the fat with carbohydrate that you get into trouble.

Conversely, replacing carbohydrate with fat improves things. This is hard for most people to understand because we are trained to look at fat as inherently bad. I think there is hope because people have so much access to information and as the data is made clear, people will change their opinions. I think it is equally important that we not let the contentious atmosphere created by the “experts” to blind us to those areas where they may be correct; we do not have a monopoly on the truth.


3. Diabetes has become as big an epidemic these days as obesity, with 1 in 3 Americans currently who are either already diabetic or pre-diabetic. Many studies are coming out this year showing how a ketogenic diet is helping diabetic patients to greatly reduce and sometimes completely come off of their medications. What is it going to take to get organizations like the American Diabetes Association and family doctors to stop prescribing more and more drugs and give low-carb a chance to work?

First of all, Jimmy, I don’t think we know about family doctors. Most doctors are primarily interested in their patient and their patient’s outcomes and may not even know what the ADA thinks. I think the study that led to this interview, done by Jorgen Vesti Nielsen (available free of charge by clicking here ) is very informative because, although it is a small study, it was done for 22 months and has a clear clinical flavor to it.

In other words, it is really about patients on low-carb diets. Most important, it shows patients coming off of drugs. Of course, many people may prefer drugs to a change in lifestyle but it should be the patient’s choice. Also, many clinicians don’t have total control and their patient may be under the guidance of a dietitian whose training may not be particularly up-to-date or enlightened. I don’t know what it will take to change the nutrition curriculum.

With diabetes, carbohydrate restriction has been a traditional treatment and because the underlying physiology is obvious and accepted. Since low carbohydrates stabilize glucose and insulin excursions, we can expect progress pretty soon. Even the ADA is probably trying to back into carbohydrate restriction with a minimum of losing face.

The coverage of Nielsen’s paper by WebMD has the remarkable statement: “While agreeing that carbohydrate restriction helps people with type 2 diabetes control their blood sugar, ADA spokesman Nathaniel G. Clark, MD, tells WebMD that the ADA does not recommend very low-carb diets because patients find them too restrictive. ‘We want to promote a diet that people can live with long-term,’ says Clark, who is vice president of clinical affairs and youth strategies for the ADA. ‘People who go on very low carbohydrate diets generally aren't able to stick with them for long periods of time.’"

The admission of the value of carbohydrate restriction is the important thing and the fact that the ADA would promote their diet which has no demonstrated high compliance is obvious to a careful reader. The article includes the usual concerns that dietary fat will increase but at the point at which the literature catches up with Dr. Clark and he discovers that replacing carbohydrate with fat reduces risk, he will change his mind, or at least will have to put further strain on his cognitive dissonance.


4. Why has the low-fat dietary approach monopolized what is considered "healthy" in America for the past quarter century? What is going to change that perception to include other methods of eating, especially low-carb?

Low fat is a simple intuitively appealing idea: dietary fat will show up in your body as body fat, or blood lipid. You have always heard it in the phrase: “you are what you eat.” Unfortunately, it is just way too simple and in many cases, completely wrong. Instead, it should be you are what you do with what you eat because metabolism is the key.

But, of course, not everybody wants to study metabolism and if there is an easy answer people may go for it. Again it is about relative components of the diet. If for some reason -- taste, ethnic upbringing, personal style -- you eat a lot of carbohydrates, you may well do better reducing the fat in your diet. For most people, however, it is going to be better to replace carbohydrate with fat (and/or protein). I do think, though, that the perception is changing, at least to the extent that people are recognizing the limitations of a high carbohydrate diet.


5. One of the popular criticisms of livin' la vida low-carb is that the research is all short-term and very little long-term. How much longer are we going to have to wait to begin seeing some long-term studies of the Atkins/low-carb approach?

Well, long term studies are going on but the question is what criterion such studies are expected to meet and, here, we first have to accept the general failure of the low fat approach. We have big population studies like the Women’s Health Initiative which shows that a low fat approach is a pretty poor strategy for weight loss and cardiac health. In some sense, the obesity epidemic is still prima fascia evidence that reducing fat and increasing carbohydrate is a bad idea. The disclaimers about reduced exercise probably are relevant but can’t be considered a major effect. On comparison studies, though, the ONLY data we have of any length comparing diets are comparing low carbohydrate and low fat and low carbohydrate does at least as well and usually better.

6. Who are some of the more notable low-carb researchers that people need to keep an eye on in the coming years?

The group at the University of Connecticut, Jeff Volek and Maria-Luz Fernandez and their students, Cassandra Forsythe, Rich Wood, Riccardo Silvestre form one of the most active in low-carb research and one can expect continuing interesting work. Additionally, Eric Westman and Will Yancy at Duke University head another strong center.

But beyond low-carb per se, I would look at the general drift of biological research. To take one example, Barbara Kahn’s group at Harvard has produced some remarkable studies in which genes are knocked out in animal models. Of particular interest is the so-called FIRKO (fat insulin receptor knock-out) mouse, which is genetically engineered so that fat cells specifically cannot respond to insulin. The FIRKO mouse winds up weighing about half as much as the normal mice even though they eat the same amount of food.

A little thought tells you this is a beautiful abstract picture of what one is shooting for in carbohydrate restriction – get your fat cells not to respond to insulin by lowering the total amount of insulin available. There are now so many outstanding sources on the Internet that one can learn a good deal about biochemistry at just about any level. Obviously, I recommend our journal Nutrition & Metabolism in which Nielsen’s paper was published because we are an open access journal (no subscription required). We are not specifically a low-carb journal but we do get some important papers in this area and you can register for free and will be alerted when new papers come out.


7. How do you respond to your critics who say your support for the low-carb approach shapes your conclusions to fit a predetermined mindset?

Well, I am not strictly speaking a supporter of any particular diet. Low carbohydrate diets have a rationale in basic metabolism and that is my main interest. All science, however, has to start from a predetermined mind set but I always like the definition of science described by Izja Lederhendler at the NIH: “In science you make a hypothesis and then you try to shoot yourself down.”

In a literature review, Jeff Volek and I tried to test the idea that carbohydrate restriction was beneficial for metabolic syndrome by looking at some of the experiments performed by people who are proponents of low fat, or at least testing the validity of a low saturated fat approach. We were perfectly prepared to accept the outcome of their studies but, in fact, on metabolic syndrome the controls did better than the low fat intervention groups (available without subscription by clicking here).

My mindset is ready to be shot down. Show me the data. Also, whereas it is common for people to say that one size does not fit all, the nutrition literature continues to publish averages and group statistics. Our journal often won’t accept a paper that doesn’t show individual data. An interesting example where individual data tells the story is Volek’s paper in our journal which shows some knockout results for some people on low carbohydrate diets but also shows that some people do better on low fat diets.


8. What is going to be the ultimate breaking point for the medical community to begin taking low-carb seriously enough in the treatment of obesity and disease?

We have many different medical communities. I think many practicing physicians already see it as a choice. The public may actually lead the way. A recent survey we took of an online low-carb support group showed that physicians were generally supportive of patients who wanted to pursue a strategy based on carbohydrate restriction. The paper is still in peer review but I can tell you that of the 3000 answers we got, about half had seen a physician or other health professional before or during a low-carb diet. More than half said the physician was supportive. Another third said that the physician had no opinion but was supportive when they brought in good results.

9. The average Joe out there has had it hammered into their head that low-carb is dangerous, unsafe, and even harmful to their health despite the fact that it can produce remarkable weight loss and health improvements. Combat these assertions and make the case for low-carb, or, to put it another way, is there anything you would like to express to those of us who support the low-carb lifestyle to encourage us as we talk to people about this life changing way of eating?

I’m a biochemist and naturally I would emphasize experiments and I always like the French word for experiment -- experience. I think that if you encourage people that you talk to, to trust their experience rather than the “expert on television,” you can transmit your message.

If people are willing to try to throw away the bun and just eat the hamburger and see if that isn’t an actual improvement in how they feel, they can learn something. But conversely, if people have actually tried the low carb lifestyle and don’t like it, you should listen to them and you may learn something.

We don’t have all the answers and we don’t want to make the same mistake as the lipophobes. Also, the scientific literature is still a surrogate for experience and there is much information that can make the case for carbohydrate restriction. In talking to people who have no experience of low carbohydrate diets and don’t keep up on the literature but are sure that it is bad for you, you can make the arguments from your own experience, especially if you have some kind of taste for eating your heart out.


THANK YOU for being willing to share your wealth of wisdom and knowledge with my readers today, Dr. Feinman. You can e-mail Dr. Richard Feinman at rfeinman@downstate.edu.

4 Comments:

Blogger Lowcarb_dave said...

Jimmy - Great Interview!

It's good to have guys like this on 'our side'!

6/21/2006 12:59 AM  
Blogger Science4u1959 said...

Excellent, wonderful, and HEART WARMING, Jimmy. A Big Thank You for this - you just made my day! Keep up the good work! Fantastic!

6/21/2006 2:30 AM  
Blogger LCforevah said...

I just love the way that Dr Feinman refers to the mainstream "experts" as "backing into acceptance" of low carb by using the glycemic index.

I have a visual of an army of little gray men in lab coats shuffling backwards at the same time, clipboards in hand!

Any method to acknowledge the need to restrict sugars is good for the national health at this point.

6/21/2006 11:07 AM  
Blogger Rob said...

Excellent interview Jimmy!

6/21/2006 9:14 PM  

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