Good Calories, Bad Calories (83 page)

Such a trial would not be ideal, because many dietary variables would differ between the two groups—calories and fats among them. The subjects would also know what diet they’re consuming, and so the study would not be done blindly (although, ideal y, the physicians who treated the subjects and the investigators themselves would be unaware). Nonetheless, it would be a good starting point. Would those eating the carbohydrate-rich diet be more likely to become glucose-intolerant, hyperinsulinemic, and insulin-resistant? Would they be fatter and have a greater incidence of obesity, metabolic syndrome, and Type 2 diabetes? Would they have more heart disease and cancer? Would they die prematurely or live longer? These are the questions we need to answer.

Another question that needs to be addressed urgently regards the health effects of sugar and high-fructose corn syrup alone. Since the 1980s, as we discussed (see Chapter 12), sugar and high-fructose corn syrup have been exonerated as causes of chronic disease on the basis that the evidence was ambiguous. Since then, virtual y no studies have been funded; there have been no attempts to clarify the picture. Today I can imagine no research more important to the public health than rigorous, control ed trials of the long-term health effects of sugar and high-fructose corn syrup.

For the past decade, the National Institutes of Health has been funding trials that test whether “lifestyle modification” wil prevent diabetes and metabolic syndrome. But these trials are done only in the context of the conventional wisdom on diet, obesity, and disease. In the largest of these trials to date, the $150 mil ion Diabetes Prevention Program, the lifestyle modification included 150 minutes of exercise each week and a low-fat, low-calorie diet. The results confirmed that such a program of diet and exercise wil indeed prevent or delay the appearance of diabetes and metabolic syndrome, but they said nothing about what aspect of this lifestyle modification was responsible. Was it the reduction in fat calories or total calories? Was it the exercise? Or was it a change in the type of carbohydrates consumed or a reduction in the total amount of carbohydrates? As we discussed (see Chapter 19), even if the goal of a diet is to reduce calories by preferential y reducing fat, it wil inevitably cut back on carbohydrates as wel , and usual y sugars in particular.*138

The NIH is currently spending $200 mil ion on a decade-long trial cal ed Look AHEAD to test the hypothesis that if obese diabetics lose weight they’l be healthier for the effort. This is “the largest, most expensive trial ever funded by NIH for obesity outcome research,” says the Baylor University psychologist John Foreyt, who is one of the trial’s principal investigators. But once again, the trial tests only the conventional wisdom. The goal of Look AHEAD is to induce five thousand obese diabetics to lose weight by the same lifestyle modification used in the Diabetes Prevention Program: cutting calories and fat calories, and exercising. If these obese diabetics do lose weight, and if they do end up healthier for it, we stil won’t know whether it was the calories, the fat calories, the exercise, some combination of al three, or maybe just the carbohydrates or the sugar that made the difference. And we won’t know whether, if they restricted carbohydrates alone and ate protein and fat to their hearts’ content, they would have been healthier stil .

Because these trials are planned as a test of only one hypothesis—and a poorly defined hypothesis at that—the research ensures that we won’t have the kind of reliable answers that we so desperately need. If the Diabetes Prevention Program had included a test of the carbohydrate hypothesis, the investigators could have compared the effect of a low-fat, low-calorie diet and exercise to the effect of carbohydrate restriction alone, and that would have told us whether it’s the carbohydrates or the calories and the sedentary behavior that cause these chronic diseases. If Look AHEAD were to include a test of the carbohydrate hypothesis, we might at least know the answer in another decade. It doesn’t, and we won’t.

The scientific obligation, as I said in the prologue, is to establish the cause of obesity, diabetes, and the chronic diseases of civilization beyond reasonable doubt. By doing so, we can take the necessary steps to prevent these disorders, rather than trying to cure them or ameliorate them after the fact. If there are competing hypotheses, it does us little good to test one alone. It does little good to continue basing public-health recommendations and dietary advice on association studies (the Framingham Heart Study and the Nurses Health Study are prominent examples) that are incapable of reliably establishing cause and effect. What’s needed now are randomized trials that test the carbohydrate hypothesis as wel as the conventional wisdom. Such trials would be expensive. Like the Diabetes Prevention Program and Look AHEAD, they’l cost tens or hundreds of mil ions of dol ars. And even if such trials are funded, it might be another decade or two before we have reliable answers. But it’s hard to imagine that this controversy wil go away if we don’t do them, that we won’t be arguing about the detrimental role of fats and carbohydrates in the diet twenty years from now. The public wil certainly not be served by attempts of interest groups and industry to make this controversy go away. If the tide of obesity and diabetes continues to rise around the world, it’s hard to imagine that the cost of such trials, even a dozen or a hundred of them, won’t ultimately be trivial compared with the societal cost.

PROLOGUE: A BRIEF HISTORY OF BANTING

Epigraph. “Farinaceous…”: Tanner 1869b:219.

“…corpulence notoriety”: Anon. 1864b. “…size or weight”: Banting 1864:14.

“Knowing too that…”: Harvey 1872:69–70.

Banting began dieting: Banting 1864:18–19. “I have not felt better…”: Banting 1869.

United States, Germany: Banting 1869. “the emperor of the French…”: Anon. 1864c. “If he is gouty…”: Quoted in “banting” entry, OED 1989.

A paper was presented: Anon. 1864f. See also Anon. 1864d; Anon. 1864a. “is tolerably complete…”: Anon. 1864g. Banting responded: Banting 1869.

Banting acknowledged: Banting 1869. Alfred Wil iam Moore: Anon. 1864g. John Harvey: Harvey 1864.

Bril at-Savarin: Bril at-Savarin 1986 (“fat…,” 237–39; “…rigid abstinence…,” 251).

Dancel: Dancel 1864 (“Al food…,” 59; “The hippopotamus…,” 54).

“We advise Mr. Banting…”: Anon. 1864g.

“fair trial” and “…starchy elements…”: Anon. 1864e.

“To attribute obesity…”: Mayer 1968:6.

Sir Wil iam Osler: Osler 1901:439–40. Oertel prescribed a diet: Oertel 1895. See also French 1907:951. Bismarck lost sixty pounds: Schwartz 1986:103

–4. Ebstein insisted: Ebstein 1884 (“of meat every kind…,” 33).

“Foods to be avoided…”: Greene 1951:348.

“The great progress…”: Bruch 1957:352.

“The overappropriation…”: French 1907:14. Rony reported: Rony 1940 (“…marked preference…,” 59; “an extremely obese laundress…,” 62).

“In Great Britain obesity…”: Davidson and Passmore 1963:382.

“On the day of the races…”: Tolstoy 2000:200. “the dearth of proteins…”: Lampedusa 1988:255.

What Dr. Spock taught: Spock 1946:361; Spock 1957:436; Spock 1968:449; Spock 1976:493; Spock 1985:536; Spock and Rothenberg 1992:380. 50

mil ion copies: Pace 1998. “Al popular ‘slimming regimes’…”: Davidson and Passmore 1963:389. “The first thing…”: Brody 1985:18.

Brody recommending potatoes, etc.: Brody 1985:18–20. “We need to eat…”: Brody 1981a:97. “…at the height of fashion…”: Brody 1985:78. “the previous nutritional advice…”: James 1983:20. Footnote. See Barr et al. 1953b; Eppright et al. 1955; Blix 1964; Wilson 1969; McLean, Baird, and Howard 1969; Apfelbaum 1973.

“bizarre concepts…”: Anon. 1973:1419.

Charlotte Young: C. M. Young 1976 (“The diets developed by Ohlson…,” 364; “No adequate explanation…,” 365).

“people who cut down…”: Squires 1985.

“sparingly”: USDA 1992.

“There is always an easy solution…”: Mencken 1982:443.

Less red meat, fewer eggs: Putnam et al. 2002. Fat intake has dropped: USDA Center for Nutrition Policy and Promotion 1998. Fal in cholesterol levels: Gregg et al. 2005.

Ten-year study of heart-disease mortality: Rosamond et al. 1998. See also Rosamond et al. 2001; McGovern et al. 2001. AHA statistics: Thom et al.

2006.

Percentage of smokers has dropped: National Center for Health Statistics 2004.

Incidence of obesity increasing: National Center for Health Statistics 2005:9, 275 (table 73). Diabetes rates: Fox et al. 2006; Cowie et al. 2006.

“What we see instead…”: Interview, Wil iam Harlan.

Best-sel ing diet books: Mackarness 1958; Tal er 1961; Stil man and Baker 1968; Atkins 1972; Tarnower and Baker 1978; Sears and Lawren 1995; Eades and Eades 1996; Steward et al. 1998; Agatston 2003.

Fixated on cholesterol: This idea came from David Kritchevsky, who, among other accomplishments, authored the first textbook on cholesterol, published in 1958.

Series of expert reports: USDA and USDHEW 1980; USDHHS 1988; NRC 1989; U.K. Department of Health 1994.

“Each science…”: Whitehead 1980:14–15.

“If science is to progress…”: Feynman 1967:148.

PART ONE: THE FAT-CHOLESTEROL HYPOTHESIS

Epigraph. “Men who have excessive faith…”: Bernard 1957:38.

CHAPTER ONE:

THE EISENHOWER PARADOX

Epigraph. “In medicine…”: Bernard 1957:55.

The details of Eisenhower’s heart attack: Lasby 1997:70–80.

White’s press conference and Ike’s recovery: Ibid.:83–93.

Eisenhower’s weight, cholesterol, and blood pressure: Ibid.:257–58; interview, George Mann.

Ten times a year: Lasby 1997:70. Eisenhower’s diet and Snyder’s responses: Ibid.:258–59.

“He eats nothing…”: Ibid.

“He was fussing…”: Ibid.:260.

Keys made the cover of Time: Anon. 1961 (“…know the facts,” 52). First official endorsement: AHA 1961.

Eisenhower’s half-dozen heart attacks: Lasby 1997:293–323.

“great epidemic”: White 1971:220.

“drastic development…”: Mayer 1975a:138. Decline in deaths due to eating less fat: See, for instance, Sykowski et al. 1990; Hunink et al. 1997; NCEP

2002:I –26.

Osler wrote in 1910: Cited in Cassidy 1946. “If it had been common…”: White 1971:52. “part and parcel…” and “…cripples and kil s…”: White 1945:475.

Herrick, the ECG, and the early history of cardiology: Liebowitz 1970:146–76. “Medical diagnosis…” and “…after the publication…”: Levy 1932.

Census numbers: Cooper 1972; Preston et al. 1972. Fortune article: Anon. 1950. Cassidy’s point: Cassidy 1946.

Mitigating against the “epidemic”: Levy 1932. See also Tunstal Pedoe 1984.

AHA 1957 report: Page et al. 1957 (“great difference…,” 165).

Between 1949 and 1968: Harper 1996. See also Harper 1983. Proportion of heart-disease deaths dropping: Harper 1996; interviews, Harry Rosenberg, chief of mortality statistics, National Center for Health Statistics, and Thomas Thom, a statistician at the National Heart, Lung, and Blood Institute. WHO

committee report: Lozano et al. 2001 (“…the apparent increase…,” 14). About the situation in the United States, see also Woolsey and Moriyama 1948.

NHI 1949 al ocations: Haseltine 1949. NHI 1960 research budget is from NIH, n.d., NIH Almanac.

“a private organization…”: White 1971:114. 1945 charitable contributions: Anon. 1945. Rome Betts: Moore 1983:57.

AHA fund-raising campaign and its success: Anon. 1948a; Anon. 1948b; Davies 1950; Moore 1983:77. “great epidemic…”: White 1971:220.

Compel ing arguments: Mann 1957; Page et al. 1957; Harper 1983. “unobserved publications”: Kritchevsky 1992. “They don’t fit…”: Interview, David Kritchevsky.

“The present high level…”: Keys 1953.

“The simple fact…”: Select Committee 1977a:1. CSPI pamphlet: Brewster and Jacobson 1978. “Within this century…”: Brody 1985:2.

Keys’s argument: Keys 1953.

History of food disappearance statistics: USDA 1953; Cal and Sanchez 1967.

“Until World War I …”: Interview, David Cal .

Historians of dietary habits: See, for instance, Schwartz 1986:46; Cummings 1940:10–24. One French account: Levenstein 1999. USDA 1830s estimate: Appen 1933, cited in Cummings 1940:15. “with plenty of beef-steaks…”: Trol ope 1932.

“considered by the general public…”: Ward 1911.

FTC report: FTC 1919 (“…the amount of meat consumed…,” 84).

“nationwide propaganda…”: Stiebeling 1939.12 The Jungle: Sinclair 2003 (“overlooked for days…,” 91). Meat sales dropped by half: Young 1981. “The effect was long-lasting…”: Root and de Rochemont 1995:211.

Trends for vegetables, fruits, etc.: USDA 2000.

“The preponderance of meat…”: Clendening 1936:7.

Food consumption from the end of World War I : Friend et al. 1979.

“medical vil ain cholesterol”: Blakeslee and Stamler 1966:28.

“biological rust…”: Ibid. 1966:24.

Anitschkow reported: Anitschkow and Chalatow 1913. The problem with rabbits as animal models: See, for instance, Ahrens, Hirsch, et al. 1957; Altshule 1966. “…‘cholesterol disease…”: Leary 1935.

Stamler’s chicken experiments: Blakeslee and Stamler 1966:36. Natural y occurring atherosclerosis: Altshule 1966; Lindsay and Chaikoff 1963. In baboons: McGil et al. 1960.

Exercise lowers it: Goldberg et al. 1984; Heath et al. 1983; Huttunen et al. 1979. Weight gain raises it: Anderson, Lawler, and Keys, 1957. Weight loss lowers it: Milch et al. 1957; Jol iffe et al. 1962. Fluctuate seasonal y: Bleiler et al. 1963; Antonis et al. 1965. Change with body position: Tan et al. 1973.

Stress wil raise cholesterol: Frideman et al. 1958. Male and female hormones: Laskarzewski et al. 1983. Diuretics: Ames and Hil 1976. Sedatives: Wal ace et al. 1980. Alcohol: Fraser et al. 1983. 20 to 30 percent: Kritchevsky 1958:181.

“Some works…”: Gofman and Lindgren 1950.

One out of every three women: Stone et al. 1974. Rarely die of heart attacks: Discussed in Ahrens, Hirsch, et al. 1957.

Sperry and Landé’s research: Landé and Sperry 1936.

Heart surgeons and cardiologists: See, for instance, James 1980; interview, Alan Sniderman. Debakey reported: Garrett et al. 1964.