Time to Hire a New Watchdog for the Henhouse

There is an old saying for a failed plan that “we have been letting the fox guard the henhouse”.  Such is the case with the leadership in “nutrition”.  The “henhouse” has been our nutrition-related health, and the “fox” has been the dietetics profession.

Before I launch into the data supporting my point I have to say that I deliberated for some time about writing this as it is somewhat of an assault against the behavior of another group of people.  This is something I do not like to do.  Several dietitians I know actually practice good clinical nutrition.  The profession in its larger bureaucracy has, however, gotten us very off course through their leadership (or the lack of it in a way that would make a difference).

I was struck by two pieces of information recently.  The first was an article posted on Stone Hearth News (http://www.stonehearthnewsletters.com/dietitian-association-is-food-industry-friendly-and-dominates-usda-dietary-guidelines-healthy-nation-coalition/nutrition/).  I will come back to that a little later.  The second was a graphic about the relationship between government related guidelines and the problem of obesity that they are designed to “fix”.  Ideally there should be a declining obesity rate with progressive guidelines if these guidelines actually do what they are designed to do.  To the contrary, the relationship has been a progression of the problem with progressive guidelines to fix it.

If anyone struggles with the concept here, find a successful business person to explain it to you.  Somewhere along the line, “the plan” has to be measured against the “outcome”.   Take a look at the outcome:

The latest data projection released this week by the US Center for Disease Control shows that the problem is getting worse faster than even the most dramatic projects of a few years back.  It is now anticipated that 42% of the US adult population will be obese by the year 2030 (http://www.usatoday.com/news/health/story/2012-05-07/obesity-projections-adults/54791430/1).

The rub with the staggering rise in obesity rates is that it is the primary driving force behind the diabetes epidemic.  The remarkable correlation between the projections in diabetes increases and obesity increases is striking:

So how does all of this get back to the dietetics profession?  Back to the article in Stone Hearth News.  It seems that Congressional investigation found that the American Dietetic Association (ADA) has been receiving $1 million a year in payments from pharmaceutical companies and an undisclosed amount from companies such as Coca-Cola, PepsiCo, and Hershey.  There is not much else someone could realistically call this except “conflict of interest”. 

About the same time the Center for Medicare and Medicaid Services (CMS) announced that it will not reimburse registered dieticians to provide counseling for obesity any longer for the simple reason that there is no evidence that what they recommend works.  To the contrary, the evidence seems to suggest that it does the opposite.  This relates to the fact that ADA limits the scope of dietetic education and practice to USDA-approved recommendations.  The USDA recommendations have come under considerable criticism as they are overly influenced (inappropriately) by the largest single lobby in the Washington.  If you haven’t figured out who that is, the chart below will help.

Both groups (ADA and USDA) seem to be more industry friendly than concerned about outcome.  The USDA 2010 Dietary Guidelines “Independent Scientific Review Panel” consists of 7 registered dieticians of 8 total members.  Sounds like a family tree that does not branch enough!

Given all of this the ADA would seem to be in need of reform.  Their recent activities, however, have been to change their name to the Academy of Nutrition and Dietetics apparently to try to distance themselves from their record, and to lobby for laws throughout the US which would prohibit the providing of nutritional advice by anyone other than a dietician.  Fortunately, no one else has seen the wisdom of that idea including here in Virginia where that bill came up without success in 2012 for the second time in 3 years.

If things are to change, what we do must change.  The champions of true change in nutrition that makes a meaningful positive change are clinical nutritionists and other like-minded providers.  Do some dieticians become good nutritionists in a functional sense?  The answer is yes, but not in large numbers and by no help from organized dietetics groups.  The only way things can change is to not stay the same!

Maternal Use of Acid Inhibiting Drugs Linked to Childhood Asthma

The list of problems associated with the use of stomach acid inhibiting drugs (PPIs) continues to grow.  The list already contains osteoporosis, increased infection rates, low blood magnesium levels causing heart rhythm abnormalities, muscle cramps, and others.  These adverse effects are really pretty predictable as the acidity in the stomach plays very important roles in human function including the facilitation of the absorption of minerals such as calcium and magnesium, destroying bacteria introduced by food and helping digestion in general.

There is now a new problem to be added to the list, the induction of asthma in the offspring of PPI users.  A study of the issue in about 200,000 children in Denmark(1) showed it was found that maternal use of PPI during pregnancy was associated with a 40% increased risk of asthma in the child.  The scientific debate about the study suggests that the association does not prove direct cause of the offspring asthma by the PPI drugs.  It may relate to the drug altering the maternal digestive tract bacteria and/or causing digestive tract yeast growth.  The infant develops their normal healthy bacterial populations directly from the mother.

Whether it is a direct effect caused by the drug or a secondary effect caused by the drug altering the maternal environment, it still is a problem caused by the maternal use of the drug.  The lesson from this study appears to be that maternal use of PPIs should be cautiously considered both over concerns about the mother’s own health and over concerns about creating asthma risk in the child. 

Every normal human function serves a purpose and simply shutting it down as the simple way to treat a symptom is not the best approach.  People develop digestive symptoms such as indigestion for a reason.  If the reason is found and the mechanism is corrected, the symptoms typically resolve.  This seems like a better approach for both generations.

1)  McGrath KW et al. Am J Respir Crit Care Med 2012 Mar 15; 185:612.

The Future for Many Children:Complicated Type II Diabetes

Type II diabetes was formerly called adult onset diabetes.  It is the type of diabetes where diet and weight eventually wear down the body’s ability to handle sugars and carbohydrates. Fifty years ago, the amount of sugar and refined carbohydrate in our diet made this type of diabetes rare before 50 years of age, hence the term adult onset. Children rarely developed diabetes then; it was exclusively an autoimmune disease where something stirred up the immune system. The autoimmune disease turned around and destroyed the pancreas and its ability to produce insulin (juvenile onset or type I). My pathology textbook (study of disease) in grad school only referred to adult and juvenile onset diabetes.  

By the 1980’s, everything was beginning to change. Up to that point, only about 3% of all new cases of diabetes in children where Type II.  The latest statistics show that by 2005, 45% of all new diagnoses of diabetes in children are type II. It is not that type Ii diabetes is simply replacing type I but rather an explosive increase in the percentage of children with diabetes. It is now estimated that one in three, or 33% of children born since 2000 will develop diabetes in their lifetime!

Once many of us get over the shock of these statistics, we tend to try to mentally minimize them by an poorly founded belief that modern medicine will save them from the ravages of diabetes with some better combination of drugs. A new study just published in the New England Journal of Medicine proves that that hope is more of a myth. The study looked at three different drug and lifestyle regimes in children with type II diabetes. The reality is that with the study definition of “successful treatment”, its failure rate in children is an alarming 40-50%. 

Three different treatments were used; the single first-line drug, metformin, metformin with lifestyle intervention and metformin with another drug, rosiglitizone or Avandia. The single drug was able to achieve the target blood sugar control in less than 50%. The combined drug treatment and the drug with lifestyle intervention were successful in 40-45%. Any way you look at it, about half of all diabetic children could not be controlled well with these treatments.

The definition of “control” needs some explanation. The goal used was a hemoglobin A1C of 8% or less for 6 months. This test is a measure of the percentage of hemoglobin that is damage by the attachment of sugar, a process called “glycation”. Our hemoglobin being glycated is not a real problem, but it serves as a simple marker of the extent that other proteins in the body are being damaged. 

The ones of great concern are those in blood vessel linings, the retina of the eye, nerves and the kidney filtering membrane. Damage of these areas result in the common complications of diabetes namely vascular disease (heart disease, stroke, peripheral vascular disease), vision loss and blindness, neuropathy, and kidney failure. 

The 8% target in diabetes is not a normal value, it is just the best that can safely be done with medication. Normal levels of HA1C are <5.9% and new study suggests that <5.5% is better yet. The reason that 8% is the target value for medication treated diabetes is that trying to push it down further results in episodes of low blood sugar which damages the brain and increases long-term death rates from other causes. The 8% “good treatment control” value for HA1C is simply the best that can be done with medication without causing other problems. An HA1C of 7.5-8% is associated with a more than doubling of vascular disease risk versus the normal population.

The NEJM typically invites a noted individual in medicine to write an editorial to accompany a major article like this. David B. Allen, M.D. from the Department of Pediatrics, University of Wisconsin Medical School aptly titled his editorial “TODAY – A Stark Glimpse of Tomorrow”. His added insight discussed the fact that with “well controlled (8% HA1C) diabetes, there will still be long-term complications after an incubation period of a decade or two. That used to mean at age 65-70 in 1960. It now will be occurring in 30 year olds!

Dr. Allen also commented on the failure of medication with lifestyle intervention. It was not a fair test of the value of weight loss and dietary change. With the program they used, very few participants lost enough weight to make any difference. This means that very few likely made any of the changes. The illusion of the “drugs will fix it” seems to lull most into the trap of “I don’t have to change”.

In reality, lifestyle intervention is the only realistic solution to the problem. We got here by poor nutrition and habits, and we will only get out with changes to the same. Focused nutritional therapy spends considerable time helping the family (two sets of rules in one household never works) understand the diet/lifestyle connection with type II diabetes. It provides information to allow them to make meaningful change which can reverse diabetes in many cases and improve it in every case. This type of intervention and management does not fit within the current medical disease based system, so it is unwise to expect it there or believe that it does not exist elsewhere. 

The handwriting is on the wall several years before diabetes shows up in the form of body fat which is the number one risk factor. This is the best time to get serious but good nutritional interventions are the best help available at any point in the process.

Coffee

Friend or Foe?

Coffee has been somewhat like the Rodney Dangerfield of beverages.  If you remember Rodney’s classic line, “I’ll tell ya, I don’t get no respect”.  Coffee has often been maligned by health care and the public as a health detractor.  These opinions, however, have not been based on any factual data.  Good research is finally looking at this issue and it is proving that the common speculation about coffee was wrong.

The study examined the health patterns of 42,659 adults participating in the European Prospective Investigation into Cancer and Nutrition (EPIC)–Germany study.  The study looked at the rates of the most common chronic diseases including diabetes, heart attacks, stroke and cancer.  The researchers addressed two specific questions.  The first question was, “does coffee consumption increase the risk of any of these common chronic diseases?”  The answer was no.  Comparing those who drank less than 1 cup per day, those drinking 4 or more cups had no increased risks of disease.

The second study question was, “does coffee consumption in any way decrease these disease risks?” The answer to that question was yes.  The higher coffee consumers had a 25-30% lower risk of developing diabetes than their low consuming counterparts.

The reputation of coffee likely developed from the gang it tended to “hang out with”.  Coffee consumption was often done in conjunction with a lot of cream, sugar, and donuts.  It was often done while smoking cigarettes.  If you hang out with bad characters, you will likely be assumed to be a bad kid.

Tea, in contrast, is often looked at as a “healthy” beverage which it is.  This is the result of its concentration of polyphenolic compounds which have a broad range of positive health effects.  Interestingly, coffee contains a somewhat higher concentration if it is good brewed coffee.  Some people are sensitive to too much caffeine but can drink decaffeinated brewed coffee.  This actually generated a slightly greater diabetes risk reduction than caffeinated coffee, although they were both beneficial.

The essence seems to be that coffee is a “good kid”, but it may behave badly hanging out with the wrong company.  It is best to enjoy it by itself.  Remember, the study looked at coffee, not a triple caramel mocha latte!

Coffee consumption and risk of chronic disease in the European Prospective Investigation into Cancer and Nutrition (EPIC)–Germany study.  American Journal of Clinical Nutrition,  2012;95 901-908.  

Diet and Heart Disease

This is a concise and thoughtful discussion of the relationship between diet and heart disease. An important read for everyone!

https://www.sott.net/articles/show/242516-World-Renown-Heart-Surgeon-Speaks-Out-On-What-Really-Causes-Heart-Disease

Important Steps to Reduce Breast Cancer Risk

Some women have an increased risk of breast cancer because they have a gene variation called BRCA1 mutation or variant.  This gene is called a “caretaker gene” which is responsible for looking at the DNA inside cells that are dividing and repairing any damage.  The BRCA1 mutation or variant impairs the ability of this caretaker increasing the likelihood that a cell with damaged DNA will survive.  This is a mechanism of the production of cancer cells.

Men are not without concern here as they also have the same gene and can have the BRCA1 variant which increases their risk of prostate cancer.  In women the risk of ovarian and fallopian tube cancers is also increased. 

The degree of risk imparted by the BRCA1 gene variation is significant with 60-80% of women having it developing breast cancer by age 90 years.

While the increased cancer risks with the BRCA1 gene variation are significant, it must be remembered that 40% who have it and live to be a ripe old age will not develop the disease.  The reasons likely are the result of a more favorable combination of factors in the 40% who do not get cancer.  These reasons relate to primarily environmental differences, or differences that are largely within the individual’s control.

Two important studies have shed light on controlling risk in BRCA1 gene variant carriers.  The first looked at the ability of supplemental selenium to reduce the number of chromosome breaks (indicator of DNA damage) in carriers of the BRCA1 gene variant.  Non-carriers of the gene variant showed an average of 0.39 chromosome breaks per cell.  Those with the BRCA1 variant had a 49% increase in chromosome breaks consistent with impaired ability to repair those breaks.

Another approach to the problem is perhaps maximizing the systems that prevent the chromosome breaks in the first place.  An important one is an enzyme that prevents oxidative damage to DNA, glutathione.  Glutathione requires the mineral selenium for its generation as well as B vitamins and Vitamin C.  The above study then gave the BRCA1 gene variant patients 3 months of selenium supplementation.  At the end of the 3-month period their chromosome breaks had reduced to the same number as the control group without the BRCA1 gene mutation.

The second study concerning reducing cancer risk in BRCA1 gene mutation carriers with a phytonutrient, daidzein, which is rich in soy and other legumes.  The study looked at the ability of a product of daidzein to help the genes with the BRCA1 mutation function more normally repairing DNA damage better.  The result was an important increase in BRCA1 function in repairing DNA in the tested cell types.

There was one little “catch” in the study.  They used a metabolite of diadzein in the study, equol.  Equol is produced in the digestive tract by the metabolism of diadzein by the healthy gut bacteria.  The catch is then that it takes a population of healthy gut bacteria to metabolize daidzein to equol to get the protective effect.  Unfortunately many people do not have a healthy population of the desired bacteria in the digestive tract from a variety of factors including antibiotic use, antibiotic pass-through from commercial meat and dairy, the use of stomach acid suppressing drugs and more. 

The morals of this story seem to be:

•          That we are not doomed to be diseased by our genetics.  Even in those with a genetic risk factor, there is a lot that can be done to greatly reduce the true risk.
•          Everything connects to everything else.  We first have to consume the healthier foods (legumes, etc.), but then we have to properly digest them and have a healthy digestive tract ,as much of what helps is converted from foods by the healthy GI tract bacteria.

Health exams should be about how each body system is functioning compared to normal and ideal.  Disease exams (colonoscopies, prostate biopsies, mammograms) are just that; they see if the disease has already begun.  While important, earlier proactive steps are just as important.