In response to my first post, Dr. Ludwig responded with his own. I have recopied it here in full, with his permission. Additionally, for illustration, I have added figures from several of the papers that he references in the appropriate places in the text.

(Originally posted January 10, 2018 on Medium: https://medium.com/@davidludwigmd/hi-kevin-appreciate-the-scholarly-debate-58a6b7df1bff. Copied in full, with added figures in the text.)

Dr. Ludwig:

Hi Kevin, appreciate the scholarly debate. Just a few brief comments. First, to be clear, I said your statistics were misleading, not that you’re wrong.

Ok, so what’s misleading? First, food availability data (see the bottom left caption in most of your figures) do not accurately reflect what is actually consumed. Nor do added oils, the focus of your comments elsewhere, reflect total fat intake. We know that the food supply contains about 3,900 kcal per person. Though actual calorie intake has gone way up, it’s nowhere near that level. Also, we need to be careful of self-report data, which has much selective bias.

Admittedly, data on dietary intakes can be problematic, but the long term trends are clear. Stephen and Wald summarize data in the US during the 20th century, estimating that in 1960 the proportion of calories as fat was about 40%.

The CDC has good data that proportion of dietary fat decreased to about 33% by 2000 (ie, near the government recommended level). The 2 figures in that report tell the story at a glance.

Yes, fat consumption in gram amount has remained about the same, but that’s just the point. We’re eating more of everything — arguably in part due to being hungrier from all the highly processed carbohydrates. As you say: “according to NHANES data, carbohydrates went up dramatically” from 1980 to 2000, consistent with the government advice to eat a high-carbohydrate, grain-based diet (those 6 to 11 servings a day!).

Of note, the “American Paradox” of decreasing proportion of fat as obesity rates rose was described by Heini and Weinsier 20 years ago — though it’s really no paradox at all considering the metabolic effects of processed carbohydrates.

Indeed, multiple recent meta-analyses show that high carbohydrate diets as actually consumed are demonstrably inferior to all higher fat diets for weight loss. Unfortunately, this high carbohydrate intake is also strongly linked to mortality among US cohorts. [Click here for the most relevant table from this paper. — KB]

So let’s certainly continue exploring this, but I don’t think that concerns about the low-fat diet recommendations are based on myths that need killing.

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Enjoy this article? Proceed to Part 3 of the macronutrient series, here [to be added].

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As an MD/PhD student, my passion is for communicating the cutting edge of medical science and fighting misinformation. If this post is of use to you, please consider donating to my Patreon account. Your contribution will make a significant positive impact, and I will be greatly personally appreciative.

You can sign up as a patron at my page, here.

You can also find me on Twitter at @kevinnbass.

There is a narrative, circulating for the past decade or longer, that Americans have gotten fat because of the dietary guidelines. This narrative has been circulated above all by Gary Taubes, author of Good Calories Bad Calories and other best-selling works. Gary is a masterful storyteller.

This image has an empty alt attribute; its file name is Screen-Shot-2019-05-04-at-3.53.09-PM.png
Reference: Good Calories, Bad Calories by Gary Taubes

And the story he has told has echoed throughout the online nutrition world like wildfire. It is repeated by the likes of Tim Noakes, Nina Teicholz, Jason Fung, and the rest of the who’s who of low-carbohydrate dieting. Nina Teicholz, in particular, has taken Gary’s claims to an special extreme, giving many talks around the world on how the Dietary Guidelines caused the obesity pandemic. Her book, which was centered around this idea, was highly praised by both the Wall Street Journal and the Economist.

Here is a link to a popular presentation by Nina Teicholz on just this subject: https://www.dietdoctor.com/introduction-dietary-guidelines-start-obesity-epidemic

The problem? The story that Gary and Nina tell isn’t true.

Let’s dissect through the main points of this story, piece by piece.

For one, Americans never really consumed a low-fat diet, and they never followed the Dietary Guidelines to try to consume one. Here are food availability data from both the Food and Agricultural Organization and the United States Department of Agriculture.

Below is the above data, but with a breakdown for each nutrient class.

Now let’s look at percentage of fat in the diet, with cutoffs prescribed by USDA:

Indeed, if we look at total fat (the first two graphs in this article), it seems not to have decreased at all after the dietary guidelines. If we look at % fat, it decreased from 41% to 37% (in 1997), only 4% and nowhere near the value prescribed by the guidelines of 30%. Moreover, even at its lowest level of 37% in 1997, it was still higher in absolute grams (see below) than in 1980 when the guidelines were released. And after 1997, the absolute dietary fat intake increased to its highest ever.

That’s not all. While some claim that the food availability data presented above are flawed, the survey data present their own problems. Here are the survey data:

Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4598942/figure/F1/

So far, so good. Until one plots macronutrient trends not as a percent, but as absolute grams/day:

Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4598942/figure/F1/

Strange, because all we see here are an increase in intake of carbohydrate, not a reduction in fat. What could have caused this? In a recent paper, Edward Archer notes that this apparent increase might have been caused by artifact. Indeed, the methodology of the survey changed between the second and third surveys:

Reference: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0076632

In addition, obesity trends also seem to contradict the claim that dietary guidelines caused the obesity epidemic. As we can see below, obesity has been steadily increasing since at least the 1880s–a century before the Dietary Guidelines.

Reference: http://www.nber.org/papers/w16252.pdf

Not unimportantly, USDA does have a food availability dataset that goes back almost this far, using a different methodology to document years prior to 1970. The parallels between the increase in obesity and this dataset are striking. (Look at the two graphs side-by-side.)

What’s more, the above graph is roughly consistent with the food availability data. If we look closer (below), we see that calories also inflect at roughly 1960–20 years before the Dietary Guidelines.

It is likely that many factors account for the recent explosion in obesity, but whatever they are, the above evidence suggests that the seeds were planted in the 1950s or 60s or even the 1870s or 80s–not the 1980s.

If you would like to read more about macronutrient trends, please see my upcoming macronutrient trend series.

But let’s get back to the question at hand.

What exactly are Americans eating today? How close are they to the Dietary Guidelines for Americans?

For instance, what percentage of Americans fail to consume the foods recommended by the Dietary Guidelines?

These values were reported in a 2010 study:

80% fail to get the recommended total fruits
75% whole fruits
89% total vegetables
96% green leafy vegetables
98% orange vegetables
96% legumes
61% starchy vegetables
58% other vegetables
85% milk
99% whole grains
48% meat and beans
80% oils

The percent of Americans consuming more than their maximum discretionary energy allowance from solid fats and added sugars?

Solid fats 95%
Added sugars 77%

Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2937576/

How far are Americans from meeting the recommendations laid out in the actual Dietary Guidelines, on average? Data are available on this as well.

They are eating about half as many total vegetables, half fruits, adequate grains (we’ll return to this in a moment), half dairy, and generally adequate protein as recommended by the dietary guidelines:

Reference: https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/

Americans are eating a quarter of recommended dark green vegetables, a third of red and orange, a third of recommended legumes, half of starchy vegetables, and inadequate “other vegetables”:

Reference: https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/

They are overconsuming refined grains almost two-fold and consuming only about 25% of recommended unrefined grains.

Reference: https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/

Men are eating too much meat, and women have an adequate intake. Seafood is under consumed. Nut consumption is generally adequate.

Reference: https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/

Solid fats are overconsumed, while oils are underconsumed:

Reference: https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/

Added sugars are overconsumed–by between 20-80%, depending on the age group:

Reference: https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/

The average American intake of saturated fats exceeds the maximum recommended intake:

Reference: https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/

The sodium intake is double the recommended intake in many age groups:

Reference: https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/

That was from survey data. But how do the food balance data look?

Not great.

Americans still consume less than half of recommended fruit, less than 70% of recommended vegetables, and half of recommended dairy:

Reference: https://www.ers.usda.gov/amber-waves/2017/july/us-diets-still-out-of-balance-with-dietary-recommendations/

They overconsume total grains, with most of the recent increase from corn. (Remember that they vastly underconsume whole grains, which means that these grains that they are overconsuming are refined grains.) They also over consume protein foods relative to recommendations.

Reference: https://www.ers.usda.gov/amber-waves/2017/july/us-diets-still-out-of-balance-with-dietary-recommendations/

Americans massively overconsume sugar, consuming almost double that recommended by the dietary guidelines:

Reference: https://www.ers.usda.gov/amber-waves/2017/july/us-diets-still-out-of-balance-with-dietary-recommendations/

What kinds of foods do Americans eat? According to a recent study, nearly two-thirds are ultra-processed.

Reference: https://blog.aicr.org/2017/06/13/processed-foods-calories-and-nutrients-americans-alarming-diet/

What are the major sources of calories in the American diet? A 2012 study cleanly summed this up in a single table:

Reference: https://www.mdpi.com/2072-6643/4/12/2097

It is worth noting that critics often point to the large quantity of grains in the American diet as indicating that Americans are somehow following the dietary guidelines. Yet it is worth looking (again) at what kinds of carbohydrates (and grains) Americans actually eat:

Reference: https://www.mdpi.com/2072-6643/4/12/2097

Scarcely a whole grain to be found, consistent with the above 2010 paper showing that only 1% of the American population, yes 1%, consumed the recommended whole grains.

And then, it is worth looking at the guidelines themselves:

Reference: https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf

Americans are not consuming anything remotely close to what the Dietary Guidelines for Americans recommends. Suggesting otherwise—as such people as Nina Teicholz, Jason Fung, Tim Noakes, Zoe Harcombe, and many more do—is dishonest. But it’s all part of the same old game.

The purpose of making such a claim is sensationalist. It turns the diet wars into a battle of David against Goliath. Of truth-telling rebels against corrupt bureaucrats. This is the kind of story that sells. And when you need to sell a story to make a livelihood in the Internet age, it can be a very tempting story to tell indeed.

The real truth is that the self-styled truth-tellers are in fact fabulists exploiting an obesity pandemic to make money and get attention. They do not have a side of the story. They do not have an opinion informed by evidence. Theirs is not an unpopular point of view. They have simply made a career of fooling others–and some of them have even fooled their own selves.

This is not without precedent. Echo chambers and cult-like behavior are the norm in human society throughout history. Think of the entire civilizations that have fallen victim to group-think and then self-destructed. In fact, think of the first major Western such civilization: ancient Athens. Now imagine such group-think taking place among an even smaller group of people. This is exactly what has happened among this group of low-carbohydrate diet advocates. They are Athens before waging war on Syracuse. They are clueless and hopeless–yet endlessly optimistic. They can stir up great crowds. But time and again, when one takes a moment to actually scrutinize most of their claims, it is clear that they are waging wars on the flimsiest of hopes and building castles on foundations of sand.

I do not mean by this that nothing from the low-carbohydrate diet proponents is useful. Some is useful, and I wholeheartedly support that. Fortunately, what is useful has been stripped from the useless, and responsible people, some of whom I consider my teachers, are in charge of developing these ideas further to help rather than mislead patients.

It is worth noting that the major website responsible for propagating the above false claims about the dietary guidelines and many videos associated with these claims over the past 5 years–dietdoctor.com–is in fact a storefront that uses criticism and inflammatory rhetoric directed at the medical establishment as a launching point for a business worth tens of millions of dollars. Among its targets are the United States government, individual scientists, cancer research, and life-saving statin drugs. Of the latter, the website promotes individuals who claim that these drugs harm patients, while statin scientists believe that these drugs have saved the lives of hundreds of thousands or millions of people. It is hard to not notice that this overall inflammatory approach and business model eerily follows the precedent trail-blazed by anti-vaccination groups.

This does not mean that the Dietary Guidelines are without flaws. They are not. They are poorly communicated. They are technocratic and difficult to understand. They are couched in politispeak and clearly the result of a painstaking consensus process–good procedurally, but terrible science communication. They need to explicitly recommend reducing consumption of ultraprocessed foods. The USDA, whose mandate is also to promote agriculture, probably should not be in charge of formulating them.

But make no mistake about it, what is abundantly clear is this: Americans do not follow the Dietary Guidelines. Given that, it is hard to believe, as claimed by Gary Taubes and Nina Teicholz, that they caused the obesity pandemic. Diets in the wealthy world are in many ways worse than ever–by almost every metric.

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As an MD/PhD student, my passion is for communicating the cutting edge of medical science and fighting misinformation. If this post is of use to you, please consider donating to my Patreon account. Your contribution will make a significant positive impact, and I will be greatly personally appreciative.

You can sign up as a patron at my page, here.

Lipoprotein(a) is a lipoprotein particle. Like the LDL particle, it increases the risk of cardiovascular disease. Before diving into details about just what Lipoprotein(a) is, let’s get a handle on just how much of an impact high Lipoprotein(a) levels can have.Lp(a) blood level show a dose-response relationship to cardiovascular disease risk in multiple studies, and Lp(a) is now widely considered a reliable marker for CVD risk.

Here is a graph showing ~4-fold increased risk at >95th-percentile Lp(a) level:

[Above is adjusted for age (left) and multifactorially (right). The multifactorial adjustment is for age, total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, apoB, BMI, hypertension, DM, smoking, lipid-lowering therapy, and, for women, menopause and HRT.]

Here are the same data represented with a Kaplan-Meier curve.

As we can see, the unadjusted, >95th percentile Lp(a) associates with >2x lifetime incidence of myocardial infarct (heart attack).

At 80-years-old, 15% at the 22nd percentile or below but 30% at 95th percentile or above will have had a myocardial infarction.

30% of people at below the 22nd percentile but 40% at above the 95th will have cardiovascular disease (CVD).

In other words, Lp(a) = more frequent, more severe cardiovascular disease.

Why did investigators adjust for those variables in the first graph? Because risk factors go together: smoking goes with bad diet, lack of exercise, low income, etc. So if you do a study and conclude smoking causes X, it could actually be all those other things causing X.

So what investigators do is use statistical methods to estimate what the data would look like with all variables of non-interest equal, and just the variable of interest changing.

This multifactorial adjustment usually causes the risk attributed to the variable of interest to decrease relative to the unadjusted risk. Yet in this study, the risk doubled after adjustment. This is unusual, and investigators noted this but couldn’t explain it.

Could it be that somehow Lp(a) protected participants from diabetes, stopped them from smoking, reduced cholesterol, caused lower blood pressure? We may look at this more later in the thread.

Here is one more study (2016) showing the same epidemiological trend, using two different assays for Lp(a), analyzing data from the UK, showing the same results.

Again, we see a 2- to 4-fold increase in risk in CVD. Most people have ~1/3 chance of dying from CVD. CVD probably increases Alzheimer’s risk as well. This means that at the upper quintile for Lp(a) blood levels, we expect a large increase in absolute risk of both CVD and other diseases. It’s a really big deal.

That concludes our introduction to the importance of Lipoprotein(a). We will revisit all of this and more as we unpack our discussion about this marvelous and terrible lipoprotein.

Willpower is substantially genetically determined

The willpower versus genetics dichotomy in discussions of behavior is bizarre. Personality traits like willpower are substantially genetically determined. To the degree they are not, why do we assume that they are not determined by something else out of the person’s control?

Some people are blessed with a lot of inborn willpower. Some people need more prodding. Some people are in poor health for reasons they do not understand, and this saps and undermines their willpower. Some people were educated poorly and given bad examples of behavior.

All of these things, at least in the short-term, are not in people’s immediate control. They can all determine a person’s willpower.

The question is: can a person use willpower to increase their willpower?  Possibly, but why would they use willpower to increase willpower? What motivates the original use of willpower in the first place?

It’s clear, to me anyway, that something besides willpower, some external event or some epiphany must cause this. Such things just happen; they are out of a person’s control.

To the extent that free will does not exist, personal responsibility is necessary

This does not imply that I think people are not responsible for their behavior. They are. They are responsible for their behavior because by making people responsible for their behavior, we encourage good behavior.

Imagine a situation where we made nobody responsible for their behavior, because everything is ultimately caused by a mix of environmental and genetic determinants. What would happen? Well, people who are inclined to do bad things would do them.

And since they were immediately forgiven because it is not their fault, and because they were not educated not to do bad things because nobody really chooses to do bad things anyway, people’s bad tendencies would be allowed to run riot, and more bad things would happen.

Deterrents like the law, moral conditioning such as an early education appropriate to civilized society, and “softer” enforcement of social norms as occurs among communities of adults (who gets invited to parties, who wins company accolades, etc.) are all external incentives that shape behavior. It is in fact because in many ways were so externally determined that social norms, rewards and penalties for moral and immoral behavior, a legal system, etc. are so important.

It is exactly because we are not fully internally in control of our behavior that we must hold each other morally and social responsible for our respective good and bad behaviors.

If each of us operated entirely according to an internally decided willpower, that would be when we would not hold each other responsible for anything.

Because in that case, why should we? Our holding each other responsible could have no impact on each other’s behavior.

If internal willpower de novo determined everything, then moral responsibility would in fact have precisely no meaning or utility.

It is precisely because human beings are so determined by things outside their control that holding each other morally responsible is important and useful.

Moral characteristics are unequally distributed

Each of us are born with a different set of character traits with moral valence. Some of us will be intensely motivated. Others quite unmotivated. Some of us will be more predisposed to eating a lot. Others less. Some of us will be intelligent, others dim.

Some of us will be imbued with a sexual drive that can, if not controlled, cause us difficulties. Others the opposite. Some of us will have a drive, a craving for physical activity, up to dozens of hours per week. Others will want to be couch potatoes.

Some of us are relaxed. Others anal retentive to an extreme. For some of us, being on time is a real challenge, as we become consumed with other activities and lose track of the time. Others of us will not comprehend how such people could do this.

Many of these inborn characteristics will incline us to behave in ways that will be at odds with our own interests.

Realizing this is also to a degree dependent on inborn characteristics (such as intelligence). Reshaping behavior is to a degree depending on inborn characteristics (such as motivation). And things are likely far, far more complicated than even this.

But external feedback from society is also likely to play an important role, since it can bypass intelligence and motivate us in ways that we might not be intrinsically motivated.

Moral feedback and social norms can be harmful

External feedback from society can also be incredibly demoralizing and painful.

Imagine that you are a psychopath with sadistic tendencies and you had a tough upbringing. You might have the strong internal drive to become a serial killer, or you might want to kidnap and torture small children.

Society would tell you not to do this, and it would punish you severely if you did. Your life would likely not be a good one.

People like this exist, and other well-meaning people have decided to try to rehabilitate them. Jon Ronson talks about this in the Psychopath Test.

And Ronson notes that rehabilitation programs for such people have been an abysmal failure. They don’t work. These people are permanently bad apples.

What to do? Well, if such people are permanently bad apples, that is a very sad thing for everyone. The victims of such people and the people themselves.These people could simply be isolated, or they could be made an example of to encourage others who are less extreme cases not to behave in this way.But what is clear is that externally motivating such extreme cases not to misbehave won’t work. We should abandon such an approach, as it is likely to be fruitless and unnecessarily painful.

Even though moral feedback and social norms can be harmful, they should still be rationally enforced

When we can identify such hopeless cases, we should. The problem is that this is very hard to do for almost any person or any behavior. But when we can, we should.

Deciding when and how to act to motivate others morally, in other words, is an empirical question. We study what the odds are that x, y, or z course of action will change a, b, or c behavior, and we then implement that course of action when appropriate.

Sometimes we will miss the mark and exert pressure on someone whose behavior will not be alterable. Other times, it will require a great deal of discomfort for a person who is amenable to change to actually make that change. In still other cases, change will be easy to induce.

What we need are ways to understand where, when, and how to change others’ behavior in a way that produces net benefit rather than net harm.

Conclusions and a final question

A few things seem clear:

  1. Moral characteristics like willpower are to a degree inborn and may be largely determined by things outside our control, so the dichotomy between willpower and genetics is nonsensical;
  2. Even if we are entirely determined by genetics and environment, this says nothing about the usefulness of holding others morally responsible;
  3. Holding others responsible requires that they do not have complete free will, or else it would be useless to hold them responsible;
  4. Some people are going to be more or less amenable to change by being held responsible—the way that we hold them responsible and try to change their behavior is important;
  5. It is very challenging to identify which people will be amenable to behavior change before trying;
  6. Nonetheless, a rational and evidence-based way of holding others responsible and trying to elicit change would be useful to avoid unnecessary effort and pain and maximize benefit.

To all this might be added a question: How much pain justifies change, if it is achievable?

In latest news, Jason Fung presents a sobering graph on increasing death from cancer, blaming doctors and “Cancer Incorporated” for the rise.

That is, until the last 20 years are included.

Source: Center for Disease Control (CDC)

Age-adjusted death from cancer rapidly declining?! Oops!

The United States is actually currently experiencing among the lowest rates in age-adjusted death from cancer in the past 100 years.

How come? Well, let us look at the cancer mortality breakdown among males.

What was responsible for the swift rise and then swift drop? Yep! Cigarettes. Who was responsible for reducing cigarette smoking? Yep! The medical and public health establishments. And their damned treatments and health recommendations that Jason Fung wants to discredit.

What about females?

Same dealio. Only difference is females adopted smoking later and peaked later. But when you look at the other cancers? They’re either stable or falling. For both sexes

Let’s look at more detail, broken down by age, shall we?

Source:

The rate of death from cancer has declined dramatically from 1950-2015 in all age groups except those older than 85. This is due to a dramatic improvement in cancer treatments at younger ages and a drop in lung cancer at older ages.

But we wouldn’t know that from Jason Fung’s narrative, based, as it is on a research article that is more than 20 years old:

Yep, Jason Fung is basing his conclusions on data that are 25 years old.

What about cancer treatments? We have already seen that among younger people, there has been a dramatic decline in cancer deaths, indicating massive success in modern cancer treatment. But let’s look at a breakdown in 5-year survival by cancer type (right-hand column):

Source: Summary of Long Term Changes in Cancer Mortality and 5-Year Relative Survival – sect_01_table.04.pdf

A far cry from the claims of Jason and his publisher Andreas Eenfeldt (owner of the popular low-carbohydrate diet website www.dietdoctor.com).

To finish, it is worth understanding the sleight of hand at play with Fung’s final presented graph:

How does this graph square with what we have seen earlier? Let’s recall:

This image has an empty alt attribute; its file name is Screen-Shot-2019-03-10-at-6.39.50-PM.png

So why is cancer mortality going up in Fung’s graph while age-adjusted mortality is going down? Here’s why:

Source: https://www.census.gov/newsroom/releases/archives/2010_census/cb11-cn192.html

And because cancer mortality is greater among older people…

Source: SEER*Explorer

Because the population is aging, and older people die of cancer at higher rates than younger people, presenting the statistics in a non-age-adjusted form and calling that “an increase in cancer” is seriously misleading. Jason Fung knows this, but presenting the data as they really are would destroy his narrative.

It gets worse. Let’s look at three charts. The last one is a whopper. But take a brief look at the next two first.

Let’s look at those aged 65 and younger.

Source: SEER*Explorer

Declining for the past 40 years.

What about those aged 65 and older?

Source: SEER*Explorer

Even among those whose risk of death from cancer goes up exponentially with age, death from cancer for the past 20 years has been declining.

Now let’s look at the cancer mortality for those aged 50 and younger.

Source: SEER*Explorer

A halving of the rate of death from cancer in the past 40 years in people aged 50 and younger.

If these three graphs do not demonstrate resounding success in the war against cancer, I don’t know what does.

So what’s up with Jason Fung’s article? What is his… goal? The same as everything else he writes. He hopes to instill fear and stir up and then capitalize on resentment and anger. He wants to paint the medical establishment and government as having failed the American people.

And then? And then… he wants you to take him as the authority. He wants to replace them… with him and his friends. And then he wants to sell his shitty books that also peddle an endless stream of deceit using exactly the same tricks that I have detailed here. And he wants to sell you bullshit supplements and fake science conferences.

Don’t let him.

The true story is that the drop in cancer deaths is directly attributable the very institutions that Jason Fung tries to discredit. Jason Fung is a fraud and his goal is nothing other than social corrosion for his own profit.

Don’t fall for his crap.

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As an MD/PhD student, my passion is for communicating the cutting edge of medical science and fighting misinformation. If this post is of use to you, please consider donating to my Patreon account. Your contribution will make a significant positive impact, and I will be greatly personally appreciative.

You can sign up as a patron at my page, here.

You can also find me on Twitter at @kevinnbass.

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1. The Role of Medicine by Thomas KcKeown
McKeown's book had an extraordinary influence on the discussion of what we now call the "social determinants of health." The central argument of The Role of Medicine was that the vast majority of improvements in health through the 20th century have not been due to medicine--but due to social factors promoted by reformers, activists, and philanthropists. Although his hypothesis that nutrition undergirded much of the gains in 20th century health is now usually disregarded for one favoring cleaner water supply, McKeown's arguments are persuasive and they haven't been entirely set aside by many prominent social scientists. McKeown's enduring legacy is in having shown that the epidemics that had hitherto plagued civilization were not defeated by antibiotics or vaccination--but by improved environmental factors. (This does not mean that antibiotics or vaccination are not useful or have not helped--it just means that the majority of progress in the reduction of mortality was not made by use of them.)

Some recent counterarguments to McKeown claim that, in fact, statins, antihypertensives, and open heart surgery have made similar progress in recent years as McKeown's environmental revolutions made at the turn of the 20th century. Both views are likely right: historical developments in medicine are likely overblown, yet rapidly advancing medical technology is likely to make such feebleness a thing of the past. Yet still, for improving our countries' health environments, much work remains to be done.
2. Bad Science by Ben Goldacre
In this riveting book detailing quackery both within medicine and outside, Goldacre takes a scalpel to bad science and in doing so, lays open both the underbelly of the modern medical-industrial complex and suggests a better way. Goldacre while inclined almost to polemics at times provides a necessary corrective to Whiggish tendencies to falsely regard modern medicine or the quackery that stands against it as the solution to our health problems. Often, in terms of effective treatments, we are on our own. And that fear, not the effectiveness of quacks or of medicine, is probably why we run headlong into the open embrace of the reassurances of modern medicine or of the quacks who decry it. If we choose the more difficult path, it does not have to be this way. Most of us won't.
3. The Omnivore's Dilemma by Michael Pollan
The book that self-deluded quacks and shills alike can agree is, at the least, fairly well written, TOD is possibly one of the greatest books written about food in our generation. Covering different styles of eating, from the industrial to the agricultural to the hunter-gatherer, Pollan eviscerates the madness of the modern food system but tries to search for a middle-ground between the reckless ingenuity of man and the maddening and sometimes inhospitable vicissitudes of nature. Monsanto is, as always, singled out as a monster, spawning a cottage industry of green activists mistakenly obsessed with the toxic threat of pesticides to the purity of our food--and of a simpler way of life. Wendell Berry's quixotic and imaginary vision of a life of community based in agrarian values laid out in Culture and Agriculture features strongly. Pollan is a master storyteller but often places a folksy, modernity-anxious ideology ahead of science in his quest for coherent narrative. The Omnivore's Dilemma, more than any book, started my journey into the world of food. May people enjoy it and take it seriously, but not too.
4. In Defense of Food by Michael Pollan
Responsible for bringing the concept of nutritionism to modern consciousness (at least in book form), in this work Michael Pollan coined the now famous phrase, "Eat food, not too much, mostly plants." Food in this sense is meant in opposition to what Pollan calls "food-like substances," which are ingestible food-like items that are industrially produced but "would not be recognized by your grandmother" as food.

Like TOD, this text is shot through with modernity anxiety and a deep mistrust of established authority--an enduring theme in the genre, and of course, in American literature as a whole. But what will endure from this book is the idea that food when eaten is experienced--not studied. This concept would have a major influence in encouraging eating guidelines to abandon a focus on macronutrients, food groups, calories, etc., starting with Brazil and now Canada.

Whatever its flaws, this book can only be regarded as a masterpiece of the genre and a bedrock of progressive health culture.
5. Good Calories, Bad Calories by Gary Taubes
Largely responsible for putting hormones on the map in the popular discussion on nutrition, Taubes's impact has matched if not exceeded Pollan's, with Taubes's tendrils of impact spreading in popular culture as rapidly as Pollan's ideas are affecting government policy. Where Pollan may have impugned corporate America and the misplaced Mandarin musings of misguided researchers in a modest if sternly disapproving register, Taubes scribbled wild conspiracy-mongering screeds against the machinations of ambitious but illegitimate scientists who apparently tricked their colleagues into believing that blatantly cherrypicked research was not a grand farce. Except Taubes's claims in this respect were not true, as detailed in a recent white paper. These ideas continue to be perpetuated endlessly by conspiracy mongers and increasingly seedy participants (many of whom have extensive disciplinary records at the hands of health boards) in the keto community.

Ah, so something nice to say about GCBC. Well, it was right in saying that calories are not the end-all, be-all. Food quality is. However, Pollan said as much, so the real question is one about carbohydrate. Taubes was possibly partly right about carbohydrate but probably mostly not. The ketogenic diet may have important longevity and/or cancer treatment implications and may have caused the discovery of more than a few important metabolic regulatory steps.

I remain mostly convinced that Taubes was the master of not letting the facts get in the way of a good story. GCBC should be seen as a character study in how a brilliant mind can go wrong--akin to Newton's dabbling in alchemy or Einstein's obsessive rejection of the empirical implications of quantum mechanics--albeit at a likely lower register. As plant-based diets gain increasing popularity, Taubes's work will continue to provide the gunpowder to the counter-barrage, and mostly lacking justification. A few of its major contentions, that metabolic function can be undermined by certain kinds of foods, might be lasting in their implications, influence, and truth--in large part through the experimental verifications of David Ludwig, a Harvard professor and a Taubes spiritual (if not actual) low-carber-in-crime.

As a person, I cannot help but very much like Gary Taubes. As a science writer, I cannot help but write things that are not positive.


Professor Timothy Noakes is well known in the world of science. His work has played an important role in the world of sports science. He has published more than 400 scientific articles–a remarkable and unusual feat of scientific productivity. He has earned both a medical degree and a doctor of science and received a remarkable number of accolades.

Tim Noakes is also a kook.

In 2014, for instance, he wrote a tweet suggesting a defense of Andrew Wakefield stating that the CDC was behind a conspiracy to cover up a link between vaccines and autism. https://en.wikipedia.org/wiki/Tim_Noakes 

Also in 2014, Noakes recommended that a woman wean her baby onto a low-carbohydrate diet and became embroiled in a nearly 4-year hearing by his country’s health professionals organization. https://en.wikipedia.org/wiki/Tim_Noakes

Tim Noakes rejects that LDL causes cardiovascular disease, a central lynchpin of modern medical science. https://en.wikipedia.org/wiki/Tim_Noakes

Correspondingly, he rejects the use of statins and has a long history on social media of suggesting that statins are harmful, and of endorsing the work of fringe figure and LDL denialist Uffe Ravnskov. https://twitter.com/search?l=&q=statin%20from%3Aproftimnoakes&src=typd&lang=en&lang=en

Noakes has been known to claim that not eating carbohydrates prevents or cures cancer on multiple occasions. (Carbohydrate restriction may help treat some forms of cancer, but research is still in the preliminary stages.) Noakes also endorses the view, rejected by the large majority of professional obesity researchers, that insulin resistance precedes and causes obesity. https://twitter.com/ProfTimNoakes/status/941026898091618304 …

Although Mendelian Randomization experiments suggest that high insulin secretion can precede obesity, such experiments suggest that only about 1-10% of obesity is explained in this way. http://clinchem.aaccjnls.org/content/64/1/192?ijkey=130c91dd6dcb0c60817738f98872ba7465543ea1&keytype2=tf_ipsecsha

Demonstrating the (unfortunate) weakness of present scientific capacity, Noakes in an editorial misinterprets this paper and indicates that he believes that it demonstrates the causality of insulin resistance for obesity. It does not. The most reasonable interpretation is that whatever Noakes’s past scientific performance, old age has likely not enhanced his abilities. Likewise, he seems at ease musing over extreme positions before a following that is not well trained to evaluate these positions.

In response to a thread that I posted on Twitter about Noakes, Jacques Rousseau, a longtime critic of Professor Noakes, sent the following very interesting link to a legendary debate that Noakes was involved in: https://twitter.com/JacquesR/status/1088902639134355456

In it, Noakes guaranteed the audience that a low-carbohydrate diet would make one immune to cancer, dementia, and diabetes. Learning this, I just had to listen to the entire debate.

As I was doing my laboratory work, I listened. Here is a point-by-point account.

At almost 20 minutes in, Noakes denied that saturated fat raises LDL. This is false, as Mensink and hundreds of studies have shown: https://apps.who.int/iris/bitstream/handle/10665/246104/9789241565349-eng.pdf. It is difficult to believe that a scientist could say such a thing. One of the only conclusions to be drawn is that he has not actually read the relevant research.

Just at 20 minutes, Noakes also claims that polyunsaturated fats are inflammatory. This is not supported by the evidence which shows that in humans polyunsaturated fats are either neutral or anti-inflammatory. Although theoretical considerations would cause people to think that polyunsaturated fats might be inflammatory, human studies have shown that these theoretical considerations have not been borne out. Yet they persist, apparently in Tim Noakes, who dismisses evidence in favor of them. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4424767/

(It is true that weight loss will reduce systemic inflammation, so one can have low inflammatory markers on a high-saturated fat diet. Likewise, one can also have high inflammation on a polyunsaturated fat diet if one’s body weight is high. Body weight and in particular body-fatness is the dominant determinant of the body’s inflammatory state, and if cutting added oils helps to reduce body fatness, good. But on an isocaloric basis, the research points overwhelmingly to oils being neutral or positive on inflammation. That is why when people lose weight, their systemic inflammatory markers decrease. When they gain weight, these markers increase. This is because being overweight is stressful on the body’s cells.)

Back to Noakes. Between minutes 20 and 50, there is much hand-waving but little actual evidence. By 50 minutes, it’s conspiracy theories: MRC and NIH won’t fund trials to test his ideas because they know he is right and want to prevent discovery of a cure for cardiovascular disease, cancer, diabetes, dementia, etc. After his claim that you won’t get dementia, diabetes, or cancer if you don’t eat carbohydrates, he then says, “Those diseases did not exist until we started eating the highly processed foods.”

This is in fact false. Dementia was documented since the beginning of recorded history: https://www.ncbi.nlm.nih.gov/pubmed/16442123.Cancer has also been documented in 1.7 million hominid ancestors: https://www.sajs.co.za/article/view/3566. (And of course “cancer” was coined by classical Greek physician Hippocrates. Oops.)

Many prehistoric animal fossils with tumors have been discovered, e.g.: https://www.sciencedaily.com/releases/2016/12/161208121323.htm So yes animals got tumors before the advent of McDonalds. (Another such report comes from Erwin Ackerknecht’s 1982 introductory chapter to his book on the history of medicine.

Diabetes is different. First documented in Egypt or India about two thousand years ago, diabetes mellitus has been remarkably rare throughout human history in the West, with physicians living in the grain-based Roman Empire rarely encountering the disease: https://en.wikipedia.org/wiki/History_of_diabetes. Some scholars have even maintained that diabetes was not first definitely documented in the West until after the middle ages (source: chapter from Burkitt and Trowell’s 1981 edited volume). This is probably because the degree of energy excess and food-processedness is indeed unprecedented today compared to the past.

Nearer the end, in response to people upset about the expense of his diet, Tim proposes that we should not be eating meat at all, but the guts, the bones, and the brain of the animal instead. He suggests that this approach will solve the problem and make his diet affordable to the poor.

An appropriate ending to this thread. Thank you for reading.

(This post is based on my January 25th, 2019 Twitter thread, here: https://twitter.com/kevinnbass/status/1088933196341960704.)

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