Last week the disappointing outcome of a major study made the news.  Here are some quotes from an article in the Washington Post titled Moderate weight loss alone doesn’t lower heart disease risk in diabetics, study shows:

Losing a small amount of weight doesn’t appear to lower the risk of heart attacks and strokes in people with diabetes who are already getting good medical care, according to a long and expensive clinical experiment whose results were announced Friday.

While modest weight loss has benefits in how overweight diabetics feel, sleep and move, whatever benefit it may confer in preventing cardiovascular disease — which is what most diabetics die from — is too small to measure, the study found.

“We were hoping that a weight-loss program would help reduce cardiovascular disease, but now we have the answer that it doesn’t,” said Mary E. Evans, a physician at the National Institute of Health’s National Institute of Diabetes and Digestive and Kidney Diseases, which paid for the study.

The researchers recruited 5,145 people with Type 2 diabetes, which is the form that generally comes on in adulthood and is strongly associated with being overweight. Type 1 diabetes, an auto-immune disease, is the opposite. It comes on in childhood, and its sufferers are usually thin.

Half of the people were randomly assigned to get intensive dietary counseling on how to limit their calories. They were provided meal substitutes such as Slimfast drink. They were also urged to exercise more and instructed how to do so safely. They met weekly in support groups and once a month with a counselor, although that amount of attention was eventually reduced to a monthly visit and a monthly phone call.

In the first year, the people with the intensive counseling lost 8 percent of their weight. They gained some back, but over the decade of the study maintained an average 5 percent reduction from their starting weight — about 10 pounds. The people in the less-intensive “arm” of the study lost, on average, about 1 percent of their body weight.

By the end of 11 years, there was no difference between the two groups in the rate of heart attack or stroke.

When I read this story, I of course immediately wondered what kind of intensive dietary advice these people were given.  I followed some links and eventually found a copy of the study protocol online.  Here’s the section on diet:

Restriction of caloric intake is the primary method of achieving weight loss. In order to aim for a weight loss of 10% of initial weight, the calorie goals are 1200-1500 kcal/day for individuals weighing 250 lbs (114 kg) or less at baseline and 1500-1800 kcal/day for individuals who weigh more than 250 lbs. These goals can be reduced to 1000-1200 kcal/day and 1200-1500 kcal/day, respectively, if participants do not lose weight satisfactorily. These calorie levels should promote a weight loss of approximately one to two lbs/week.

The composition of the diet is structured to enhance glycemic control and to minimize cardiovascular risk factors. The recommended diet is based on guidelines of the ADA and National Cholesterol Education program and includes a maximum of 30% of total calories from total fat, a maximum of 10% of total calories from saturated fat, and a minimum of 15% of total calories from protein.

BINGO!  It wasn’t losing weight that failed to prevent cardiovascular disease, it was losing weight on the ADA’s crappy low-fat, calorie-restricted diet.  If participants were indeed consuming 30% fat and 15% protein, that leaves 55% of their calories from carbohydrates – just what a diabetic needs, eh?  Hope Warshaw would approve.

Diabetics are three to four times more likely to die of heart disease than non-diabetics.  Thanks to the arterycloggingsaturatedfat theory, this sad fact causes so-called experts like the medical wizards at the ADA to recommend exactly the wrong diet.  The logic goes like this:  Well, since we know a fatty diet causes heart disease and diabetics are prone to heart disease, they need to eat a low-fat diet.

They can’t seem to bring themselves to consider an obvious alternate theory:  What if diabetics are prone to heart disease because high blood sugar causes heart disease?  What if heart disease begins with damage to a coronary artery and high levels of blood glucose can cause that damage?

If you look at it that way, then it’s clear that diabetics absolutely, positively should not be eating the kind of high-carb, low-fat diet the ADA recommends.  They should be eating a diet that keeps their blood sugar down – every day, every hour.  Since fat is the only macronutrient that doesn’t raise blood sugar, that would be a moderate protein, high-fat diet.

I found this section of the NIH press release about the study interesting:

“Look AHEAD found that people who are obese and have type 2 diabetes can lose weight and maintain their weight loss with a lifestyle intervention,” said Dr. Rena Wing, chair of the Look AHEAD study and professor of psychiatry and human behavior at Brown University. “Although the study found weight loss had many positive health benefits for people with type 2 diabetes, the weight loss did not reduce the number of cardiovascular events.”

Why was a psychiatrist chairing the study?  Probably because the NIH believes overeating is a psychological problem.  People are gluttons, being gluttons makes them fat, and being fat turns them into diabetics.  Then they get heart disease because they’re diabetics.  Cure their gluttony with intensive dietary counseling, and they’ll lose weight and suffer fewer cardiovascular problems as a result.

Except it didn’t work out that way, did it? After 11 years and $220 million spent, this large study failed to show that the diet promoted by the ADA, the USDA and countless doctors prevents heart disease in a population prone to heart disease.  With that in mind, perhaps the psychiatrist can come up with an explanation for this quote in the Washington Post article:

The results will probably surprise many physicians and patients but are not likely to change the advice they give and get.

Well, of course not.  You wouldn’t want failure to inspire a change in your beliefs, much less in your strategy.

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33 Responses to “Another ‘Heart-Healthy’ Diet Study Fails”
  1. CeeBee says:

    They gave them SLIMFAST!!!! Full of such “heart healthy” fats like canola oil and hydrogenated soybean oil – with a little high fructose corn syrup added to help it go down better. Oh please.

  2. Stefan says:

    Hi Tom,
    in May 2008 a study was published which deals with LCHF intervention in diabetics: http://www.nutritionandmetabolism.com/content/5/1/14
    Doesn’t say how much they spend but I would guess… lots less. Note the conclusions on cardiovascular events…
    Stefan

    That’s the study that should have made the big headlines.

  3. Good work Tom. That was a nice piece. Limit fat and especially limit saturated fat, but apparently, carbohydrates can be eaten at will.

    Here is my favorite quote from the article on the study:
    “The Look AHEAD (Action for Health in Diabetes) trial involved hundreds of doctors, nurses, dieticians and exercise therapists at 16 medical centers. It cost about $20 million a year, or about $220 million over its 11-year-life.”

    It took that many resources to uncover this fact – low fat diets aren’t effective.

    And yet that’s not likely to be the conclusion the researchers make.

  4. Kevin says:

    Tom, here’s an article from some time ago (really hard to believe 2005 is 7, almost 8 years ago) on Halle Berry’s condition.

    http://www.dailymail.co.uk/health/article-371528/Halle-Berry-My-battle-diabetes.html

    I’m not sure if she has Type I or Type II diabetes (the reports are all over the place) but this did catch my eye: According is, by her own admission, her stance on how her diet has helped her tremendously:

    “”I started to eat loads of wonderful fresh vegetables, chicken, fresh fish and pasta. I cut out red meat and cut back on fruit because it can contain quite a lot of sugar.
    “Now one of my favourite dishes is something simple but tasty such as grilled tuna and garlic mashed potato.”

    Cut out the red meat, load up on pasta, potatoes, but cut back on fruit because it contains sugar.

    Do you know of any studies that show the efficacy of Paleo (or, heck, I’ll take Paleo-esque diets) on Type II diabetic patients? I’ve heard the body’s ability to recover from this is truly amazing… without a single pill.

    Love the blog, keep up the great commentary.

    There have been quite a few studies on low-carb diets for diabetics. Here are a few samples:

    http://diabetes.diabetesjournals.org/content/53/9/2375.short
    http://www.biomedcentral.com/content/pdf/1743-7075-2-34.pdf
    http://www.biomedcentral.com/content/pdf/1743-7075-5-36.pdf
    http://www.nutritionandmetabolism.com/content/5/1/14

  5. Sue D says:

    There is some hope sometimes. I was very surprised and happy that my mother, who has Type II diabetes and other issues including a heart problem, was put on a low carb diet after her recent back surgery. Apparently, the rehab center where she spent the last five weeks truly understood what was best for her.

    Now, I have to work back and find out why she gained nearly 40 pounds the year before surgery and discover what her doctors were allowing her to eat! At least I do know that the occasional meals I brought to her the last few months before surgery (which she really enjoyed) were low carb so her blood sugar stayed level. But apparently, her dietitian was clueless, especially telling her that a McDs egg biscuit every morning is just fine as were the hamburger w/sour creme & chives fries at lunch. Even with eating those meals, however, an 80 year old woman should not gain 40 pounds in one year

    Now that she’s home, I’m probably beating my head against a wall because to her it is back to random points allocated to each bit of food rather than good science and since she’s getting the right points she doesn’t care if she is getting really bad advice. The doctor will tell her what a good little girl she has been. Really sad.

    Forty pounds in a year? Something is definitely wrong there.

  6. Jana says:

    It seems the more I read about this stuff the creepier it gets. I don’t get why they insist on beating a dead horse. They won’t ever get the results they want with low-fat, high-carb, reduced calories out of a bunch of gluttons who are lazy. I wish the scientists doing this research would find new jobs researching nutrition in the right direction.

    It is stunning to see researchers try the same diet over and over, despite persistent failure.

  7. Claude Benshaul says:

    Yet another proof that Barbara Tuchman conclusions in her book “The March of Folly” were right on the money.

    When confronted with compelling evidences that a strategy isn’t producing the desired results or produces results that are the opposite of those it was seeking to achieve, a government will never assume that the strategy was wrong, instead it will find reasons to explain that the strategy is correct but the implementation was flawed.

    You can expect lengthy analysis studies to follow this study report that will try to show that calories needed to be more severely restricted, subject forced to exercise until fainting from exhaustion and harsher methods should have been employed to enforce compliance instead of relying on counseling.

    Or as Milton Friedman put it, governments interpret failure as evidence that they need to do the same thing again, only bigger.

  8. Jesrad says:

    We could have saved them $220 million: here in France the government has mandated an uniquitous, pretty intensie nutritional counseling of the exact same sort that was tested in the study, but on a diverse population of 67 million people, for the past 12 years. Its results are that obesity rates, diabetes rates, hypertension rates and CVD death frequency have been continuing to rise on perfectly unchanged trends.

    If the French start copying our government’s dietary advice, that French Paradox will be gone soon.

  9. LeonRover says:

    How could “look AHEAD” ever work?

    Even tyro control engineers know ya’ gotta “look BEHIND” to see what’s been happening, so as to adjust the way AHEAD.

    Canny photographers knew that Pippa Middleton had lost weight for the Royal Wedding because they photo-papped her BridesMaid’s posterior walking up the aisle.

    The Dukan Diet worked by using “look BEHIND”.

    Of course, one needs a flat, not a parabolic reflector.

    Slainte

  10. desmond says:

    Unfortunately, for most people, failure does not change beliefs — I guess many scientists are no different. A couple of years ago, a parenting guide pointed out something very insightful to me. Let’s say your son is shy. You decide you want to help him change his ways. The natural inclination is to tell him, “Johnny, I noticed you can’t make friends easily; let’s work on it.” Guess what, you just helped him BELIEVE that he IS BAD at making friends. Instead, wait until he actually does interact well with another child, and soon after casually mention, “Johnny, I saw you laughing with Steve. You seem to be making a friend. I like that.” Now Johnny probably won’t immediately believe that he is gaining some social skills; but after a couple instances of that he will start to believing. Before you know it, he is actually is less shy.

    So… guess what all this “American’s are fat and lazy, and you need to change” emphasis is doing? Thanks right, convincing us that we are lazy. That is not a good way to motivate change. Feeding us diets that are doomed to failure will only convince us that we are hopeless. Just what this nation needs, a citizenry convinced that they are lazy failures.

    Spot-on. When I was failing over and over to lose weight on low-fat diets (which I usually began every January), I blamed myself. Everyone said this works, it’s not working, so I must not have the discipline to make it work.

  11. eddie watts says:

    wow just wow. i should not be surprised any more!
    and it seemed to start so well with this at the start “strongly associated with being overweight” rather than causes etc etc

    but to end with “The results will probably surprise many physicians and patients but are not likely to change the advice they give and get.”

    would be hilarious if not for the fact that this problem is literally killing people.

    And faced with failure, they’ll probably decide to do it again, only bigger.

  12. LCNana says:

    Well, Tom, thanks for another head banger. So frustrating eh? You do so much good works posting this stuff…just wish we could convince those who need convincing.

    Among our friends we see this kind of thinking every day. And there is just NO talking to them. “My doctor told me…” that’s what we hear. Statins, low-fat – all this is “saving my life” and I would never want to endanger my own life – that’s the mantra.

    Thank God the sun is shining today otherwise…….

    The nation’s health would take a giant step forward if people stopped assuming doctors know anything about anything beyond which pill to prescribe or which surgery to perform.

  13. Pierce says:

    If the math and science behind the caloric restriction in the study was correct, wouldn’t the patients have lost 52-104 pounds in the first year?

    Maybe that should have been the real take away here: “‘Science’ behind caloric restriction has no basis in reality.”

    I wonder if they got 1-2 pounds per week based on any kind of experiment with actual people or if it’s just a back of the napkin calculation assuming that human metabolism behaves in exactly the same fashion as does burning food in a test tube.

    It’s the napkin calculation.

  14. js290 says:

    Religious nut jobs, the lot of them…

  15. elduderino says:

    Obvious one. From the statistical/logical perspective, there is another easy way to dissect the failure of this study. Being overweight and obese do correlate with type II diabetes (T2D) – 60% of obese people have T2D. But you can have T2D without being overweight, called diabetes type IIA. 40% of T2D patients are lean. So the problem in diabetes clearly is one of disturbed metabolism, and one possible *symptom* is being obese; being obese is not the *cause* of T2D. So the obvious strategy is fixing the metabolism.
    The patronizing indoctrination with ADA and NCEP guidelines instead of an array of n=1 experiments with food diaries, continous blood glucose monitoring, at least weekly bloodwork and use of body analysis scales is disgusting and dehumanizing.
    Instead of listening to the patient and his/her body, the doctors in this study listened to some random guideline, which is not even scientifically validated (the why here is a long story). If I was asked to participate in such a study, I would decline flat out. I can’t treat my patients like that.

    Fixing the metabolism certainly ought to be the starting point, but of course the researchers believe gluttony is the cause of the metabolic issues.

  16. Dave, RN says:

    “Look honey, losing weight is pointless. This study says so”!

    “Now pass me those chips”…

    I’m afraid that could be the takeaway message for some people.

  17. Troy Wynn says:

    Everybody is looking at the glass is half empty. This spot on study is another black swan for testing the efficacy of a calorie restricted low fat diet. The hypothesis again fails. No real weight loss, no improvement in metabolic markers, no improvement in CVD rates.

    Conclusion? Stay the hell away from this diet, diabetic or not! Now the next step:

    Test the efficacy of a low carb (less than 50gms ) diet for 10 years, we all know they have the time, right?

    We’ll see if they ever try that one. I’m not holding my breath.

  18. Marilyn says:

    NIH press release:
    “Look AHEAD found that people who are obese and have type 2 diabetes can lose weight and maintain their weight loss with a lifestyle intervention,” said Dr. Rena Wing, chair of the Look AHEAD study and professor of psychiatry and human behavior at Brown University. “Although the study found weight loss had many positive health benefits for people with type 2 diabetes, the weight loss did not reduce the number of cardiovascular events.”

    What jumped out at me when I first read about this fiasco was the positive spin on nothing, and the regurgitation of “…many positive health benefits…” Maintaining a piddling 5% weight loss after all that physical and mental abuse for 11 years proves more than anything that the human body will struggle to survive in the face of significant odds. And what’s this “. . .many positive health benefits. . .”? That’s the same line they always give about “healthyfruitsandvegetables.” I’ve never known anyone to positively identify those “positive health benefits” in either case.

    Well, I guess they couldn’t bring themselves to announce that they wasted $220 million.

  19. Christopher says:

    A couple good quotes come to mind with each head-bang.
    Bang
    ‘To those who believe, no proof is neccesary. To those who don’t, no proof is possible’
    Bang
    ‘The definition of insanity is doing the same thing over and over and expecting a different result’
    Bang
    ‘We’re Americans. We don’t admit we were wrong. We just keep on doing the wrong thing until we’re right’ (this one is actually not a famous one, it’s from the show ‘The Boondocks’)

  20. Marilyn says:

    Do you think they’ll set up a support group for all those survivors?

    Well, a psychiatrist was in charge of the study.

  21. johnny says:

    The study clearly showed that even at the lowest calorie level of 1,000, at 55% carbohydrates that equal 550 calories or 137.5 grams, there were no health benefits and the weight loss was pathetic.

    Any intelligent person would conclude that carbohydrates are too high!

    But that would be anathema to the USDA, Big Agra, the AMA and Big Pharma.

    Thus, more suffering to fill the coffers of the vested interests!

    How much longer will this go on?

    I wonder how many people actually stuck to such a low calorie count.

  22. gollum says:

    Yeah it would be funny if people were not suffering horribly. Area woman (in Dresden I believe) gets surgery for tumor. Tumor has to be wheeled away in a wheelbarrow. Her GQ — I mean, GP had told her to eat less.

    As to the result of the study, it is still surprising. Weight loss is hard to lie yourself with too or to fudge, and weight tends to increase with age, so it’s not a freebie effect. Also, losing weight is supposed to increase glucose control, simply because there is more free space in storage. That’s what I thought (at least in the case of obese DM2). So either these people lost muscles and water, but not fat — gee, how could this happen on the best of diets? Or heart disease is caused by unrelated factor. Didn’t peter from hyperlipid have some interesting ideas how glucose overrides fatty acid burning, fatty acids which unfortunately the heart runs on?
    Total mortality would also be interesting.

    It wasn’t much of a weight loss. I didn’t see any figures on mortality.

  23. Carole W says:

    “The nation’s health would take a giant step forward if people stopped assuming doctors know anything about anything beyond which pill to prescribe or which surgery to perform.”

    Tom, Tom, you know better than that! Pills? Surgery? Statins! Gastric bypass! Sadly, we are at the point of having to stop assuming that most doctors know anything *about* anything at all! Most of them only know HOW to prescribe pills and HOW to do surgery.

    Which really is such a sad state of affairs…so many book-smart people spending so many years of their lives in school, just to end up parroting bad science and ultimately hurting the people they want to help. I do believe most of them mean well (or at least don’t mean harm), but meaning well doesn’t actually accomplish anything without critical thought.

    So we must ignore (most of) the doctors, and pity the people who won’t.

    And thank our lucky starts for Tom Naughton, bastion of good science and smart thinking! :)

    True, some doctors prescribe pills and surgeries that I’m against. But pills recently saved me from a serious infection after a sting and surgery is the reason I was able to walk around the property today, so I’m not against either when necessary.

  24. Darren Doyle says:

    Man, the concluding paragraph is ridiculous!

    “It may turn out that because of changing norms of medical practice, along with the attention of being in the study, the people in Look AHEAD reduced their risk so much that the benefit of modest weight loss — if it exists — was too small to see.”

    You see! The control group, because of advances in medicine during the study period AND just because they were in the study at all lowered their risk so that the differences between the control and study group was negligible!!! … Wait, wouldn’t those forces have acted equally on both the control and the study group? Doesn’t that still just prove the point that the diet had no effect?! How brain-numb do you have to be to come up with this argument let alone make it your summary thought on the subject?!

    They have to explain these results away. It’s known as covering your @$$.

  25. Charlie says:

    Wasn’t wasted money they got the results they wanted; you know “diet doesn’t work”; just take your damn pill and injections you are going to die anyway. They really do not dare to test if a well design low carb diet that controlled blood sugar lower that what they consider normal A1C >6% without the use of risky medications like the sulfonylurea drugs that raise heart disease are much better for the diabetic.

  26. “They can’t seem to bring themselves to consider an obvious alternate theory: What if diabetics are prone to heart disease because high blood sugar causes heart disease? What if heart disease begins with damage to a coronary artery and high levels of blood glucose can cause that damage?”

    The UKPDS (United Kingdom Prospective Diabetes Study) showed that the greatest risk for microvascular complication and to lesser extent macrovascular complications was HbA1c, that is cumulative blood sugar, best lowered by lowering dietary carbs.

    Diabetes Care http://care.diabetesjournals.org/content/25/suppl_1/s28.full said that the UKPDS “results confirm previous conclusions that lowering blood glucose would be beneficial based on observational studies, pathological studies, and on three randomized clinical trials: the DCCT, the Stockholm Diabetes Intervention Study, and the Japanese study.”

    I think it might be appropriate to ask at what point not offering low-carb as one option becomes malpractice or maybe depraved indifference.

    I believe we passed that point years ago.

  27. Marilyn says:

    Tom wrote: “Well, I guess they couldn’t bring themselves to announce that they wasted $220 million.”

    My hunch is this isn’t the end of it. They’re going to spend many millions more digging through the refuse looking for, and publishing, ways the trial really did succeed.

    That’s probably true.

  28. Rich says:

    On the other hand:

    http://care.diabetesjournals.org/content/35/6/1252.long

    Trends in Death Rates Among U.S. Adults With and Without Diabetes Between 1997 and 2006

    CONCLUSIONS Death rates among both U.S. men and women with diabetes declined substantially between 1997 and 2006, reducing the absolute difference between adults with and without diabetes. These encouraging findings, however, suggest that diabetes prevalence is likely to rise in the future if diabetes incidence is not curtailed.

    Diabetes has been associated with an average 10 years of life lost for individuals diagnosed during middle age (1). Fortunately, numerous evidence-based interventions exist, ranging from glycemic and cardiovascular disease (CVD) risk factor control to early screening for diabetes complications (2). These have been paralleled by population-wide improvements in glycemic control, CVD risk factors, and rates of several diabetes complications (3–5). Despite these improvements, it remains unclear whether longevity has increased uniformly among diabetic populations. Studies in specific diabetic cohorts in Framingham, Minnesota, and North Dakota suggest mortality declined during the 1990s (6–8). Analyses of consecutive cohorts of the U.S. population from the 1970s through the 1990s, however, found that all-cause and CVD death rates declined among diabetic men but not diabetic women (9,10). However, no national studies have examined mortality trends among the U.S. diabetic population since the 1990s, and the intervening years have been a period of continued advances in treatment approaches and risk factor levels. Newly available mortality follow-up data linked to the National Health Interview Survey (NHIS) provide a unique opportunity to determine whether CVD and all-cause mortality has improved among the U.S. population during recent decades as well as whether the excess mortality associated with diabetes has declined.

    Sure, treatment has improved. Same with heart disease. Fewer heart-attack victims die now, but it’s not because of the low-fat diet advice handed out by our government. It’s because of stents, pacemakers, bypass surgery, clot-busting drugs, etc.

  29. Ricardo says:

    They should Slim fast Die Fast and Glucose is deadly for all kinds of Free Radicals Advanced Glycation End Products. Gums up are circulatory system so blood cant flow well to.

  30. Mike P says:

    This will probably fund an even BIGGER study to prove the same theory. Typical government approach; advice is given, doesn’t work, so advice must be given BIGGER/LOUDER/STRONGER.

    Doing the same repeatedly and expecting a different result is the definition of insanity.

    I’m afraid you’re probably right.

  31. Tim says:

    I heard on the radio of a study with fast food breakfast sandwiches were “unhealthy” and “lead to fat coating your arteries”
    Anyone familiar with this “study” ?

    I didn’t hear about that one.

  32. Nicole says:

    Diabetics who don’t take care of themselves generally wind up destroying their kidneys. THIS causes all manner of knock-on effects that include heart attacks and strokes.

  33. Ricardo says:

    Slim Fast = Die Fast.

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