Update on my complaint about the NHS Choices article on carbohydrate: more questions than answers

In February, I wrote a blog post which aimed to draw attention to, in my view, the bias and lack of balance in an article on the NHS Choices website entitled ‘The Truth About Carbs’. I complained about this article, and had filled out the requisite form here. You’ll see that any complaint can be no more than 1500 characters. I had to aggressively prune back my original complaint to comply with the space allowed and, in the end, my complaint came in at less than 250 words. Hey ho.

Here’s the wording of the complaint I was able to submit:

I’d like to complain about this article: http://www.nhs.uk/Livewell/loseweight/Pages/the-truth-about-carbs.aspx. The article tells us that that carbohydrates are a major source of energy. Even on a very low-carb diet, individuals are able to get energy fat and protein, and the absolute requirement for carbohydrate in the diet for energy is actually none at all (if we’re going to be accurate about it). Regarding weight control, there is no recognition in this article of the influence of hormones such as insulin and leptin on fat storage, and the differing effects of the major macronutrients here.

I believe that the idea that ‘fibre is filling’ is also misleading. In fact, there is evidence to show that when individuals adopt a low-carb diet, they very eat several hundred calories less each day quite spontaneously. The article cites one study as evidence of the fact that low-carb diets do not produce better weight loss in the long term, though attrition rates (and possibly adherence) was poor.

See here http://authoritynutrition.com/23-studies-on-low-carb-and-low-fat-diets/ for a comprehensive review of 23 studies which demonstrates superior results achieved by low-carb diets with regard to weight loss and disease markers. To my mind, dietician Sian Porter and the NHS Choices website have done a bad job of communicating the facts and summarising the evidence. I wish to formally complain about the inaccuracies in this article and its (to me) clear bias and lack of balance.

I stated in the blog that I had not had a response to the piece after 2 months. I tweeted to this effect, and was assured by one of the editors of NHS Choices that I had been sent a reply. When I questioned this, it turned out no response had been sent. The confusion was put down to ‘Human error’.

Shortly after, I did get a response, which I posted as an addendum to the blog. I felt the response was inadequate. The Managing Director of NHS Choices (Jonathan Carr-Brown) agreed, and eventually got back to me with a more fulsome response on 25 February, which I have pasted below. I’ve also added my response to the points Mr Carr-Brown makes.

Response from NHS Choices

Taking your points into account, we stand by our article “The Truth About Carbs” [http://www.nhs.uk/livewell/loseweight/pages/the-truth-about-carbs.aspx].

This article is part of a package of healthy living content on NHS Choices and abides by our standard editorial process [http://www.nhs.uk/aboutNHSChoices/aboutnhschoices/Aboutus/Pages/Editorialpolicy.aspx]. It provides a balanced and informed view to the general public, not any particular interest group (for example, it is not aimed at diabetics in general, although it does offer some information on carbs and diabetes). It is also not written to undermine any individual, any group, or any lifestyle choice – in fact it was written with the aim of helping people taking their own informed, healthy choices.

Turning to the specific points you raise – you are right – people can survive with little carbohydrate. However, this does not change the facts as we have presented them. This article is information about healthy diet for most ordinary people, it does not explore every possible avenue of diet.

This is also the case when it comes to hormones. We know they affect people, but there is little that we can credibly say to a general readership that will be of particular help when trying to maintain a healthy diet and/or achieve healthy, sustainable weight loss.

We have used the term “Fibre is filling”. Obviously, feelings of fullness are subjective, but the statement is subjectively true – in this sentence it is shorthand for “foods containing high levels of fibre tend to be more filling”. That is not to say that people who are eating a low-carb diet will not experience satiety.

Our “The Truth About Carbs” article is balanced – it provides links to studies that found that low-carb diets produced better weight loss than low-fat diets in the populations studied and in the particular circumstances of those studies. It is not the case that the article cites one study as evidence of the fact that low-carb diets do not produce better weight gain. If you read it as a whole, you will see that it has approached the research fairly.

In fact, it presents three systematic reviews of other studies that suggest that low-carb diets may produce better results than low-fat diets. It then cites a single systematic review suggesting that low-carb diets may not be demonstrated to have more effect than low-fat at 12 months, and another systematic review suggesting that low-carb diets were no more effective in the long term.

And we go on to say, “The weakness of current research is that most studies are short term and of varying quality and there is a recognised need for longer-term, rigorous evaluation. Moreover – and this applies to most research on diets – it is notoriously difficult to study the effects of diet on health because people don’t live in labs, they live in the real world and are exposed to different lifestyle and environmental factors, which can influence the results.”

The AuthorityNutrition.com article cited does indeed link to 23 peer-reviewed studies, but as with the NHS Choices article, it is not a systematic review. On examination of the studies presented these appear to have been picked for their favourability towards results for low-carbohydrate diets, and there does not seem a balancing view. For this reason, we view it with caution.

Having looked briefly at the studies themselves – these largely appear to be short-duration, small or modestly sized randomised trials. Many of them look only at specific populations (eg. diabetics, adolescents, postmenopausal women), and for a considerable number of them, the weight loss effects of the diet (while reported) are not the primary outcome of the research. Some of them find a difference, but not a statistically significant one.

We also view it with caution because the “Weight loss” graph presented in the article portrays the average weight loss of the patients combined without taking into account sample size, study participant characteristics (eg. initial weight). This has the effect of distorting the apparent significance of these studies, and has not been done with the kind of comparative rigour as you would find in a standard box-diagram commonly used in meta-analyses.

These points are the kinds of issues that we consider when we critically appraise the evidence. As such, AuthorityNutrition.com’s article does not constitute evidence, but a cherry-picking of science to prove a particular point.

It is important to view this article as one of thousands on the NHS Choices website. It is aimed at a broad audience, not just those who wish to, or are trying, one particular diet. This is demonstrated by the fact that the article was visited more than 15,000 times in January alone and nearly 30,000 times since its publication in November 2013.

If you have any further, specific points that you would like to raise about this article, please get in touch with us again. Having said that, in reviewing the content again and although you didn’t raise it, we have changed a part of the article that described ketones as “toxic chemicals”, which was factually incorrect. The rest of the article was factually correct.

We are proud of our content, and if this has given you a chance to reconsider your view, you may be interested in syndicating NHS Choices content onto your own personal site. For information about syndication, visit http://www.nhs.uk/aboutNHSChoices/professionals/syndication/Pages/Webservices.aspx

If you wish to continue to formally complain about NHS Choices’ content, please read about our complaints process here: http://www.nhs.uk/aboutNHSChoices/aboutnhschoices/Aboutus/Documents/120117-nhs-choices-complaints-policy-v2-D01.pdf

Regards

 

Jonathon Carr-Brown

Managing Director

NHS Choices

Health and Social Care Information Centre

My Response to NHS Choices

Dear Jonathan

Thank you for your email of 28th February. You kindly invited me to get back in touch with any further issues I had regarding the article The Truth About Carbs. I would like to take this opportunity now.

The response states that the article provides a balanced and informed view, and was not written to undermine any individual, any group, or any lifestyle choice. We’ll get to the issue of balance and the relevant evidence later on. Whether there was an intention or not to undermine anyone or anything, readers can be left in little doubt that the piece came down strongly in favour of carbohydrate-rich diets and against lower-carbohydrate regimes. Whatever the intent, I think the end result is clear.

The response that the article “was written with the aim of helping people taking their own informed, healthy choices.” Whether or not the article did this is a moot point (see below). My impression is that the article was less about people taking their own informed choices, and more about telling people what to eat (i.e. a carb-rich diet).

In the article, the essential nature of carbohydrate is alluded to more than once. For example “Carbohydrates are one of three macronutrients (nutrients required in large amounts)”, “Why do we need carbs?” and “Carbs are important to your health for a number of reasons.”

But, as I pointed out in my original complaint, the dietary requirement for carbohydrate is zero. The response states that the article is factually correct (other than your prior assertion that ketones are ‘toxic’). However, it is not factually correct to assert that carbohydrate is needed by the body.

The response appears to acknowledge the effect of hormones on weight and health, but says “there’s little that they can credibly say to a general readership that will be of particular help”. I find this patronising. My experience is that the general public is generally very capable of understanding biochemical and physiological information and its relevance to health and wellness.

The response states: “We have used the term “Fibre is filling”. Obviously, feelings of fullness are subjective, but the statement is subjectively true – in this sentence it is shorthand for “foods containing high levels of fibre tend to be more filling”.

This may be “subjectively true”, but I’d say that we should be relying more on objective evidence, where it exists. And it does. In this 2013 review of 44 studies assessing  the effect of increased fibre on appetite and food intake [Clark MJ, et al. The effect of fiber on satiety and food intake: a systematic review. J Am Coll Nutr. 2013;32(3):200-11] concluded:

•    Most acute fiber treatments (61%) did not enhance satiety.
•    Most acute fiber treatments (78%) did not reduce food intake.
•    Neither fiber type nor fiber dose were related to satiety response or food intake.

I suggest the subjective observation that ‘fibre is filling’ is not evidence-based and that the article should reflect this.

The article concedes that “That is not to say that people who are eating a low-carb diet will not experience satiety.” In fact, there is good evidence that lower–carb diets lead to a spontaneous reduction in calorie intake, and that the more fat is eaten, generally the less is eaten quite naturally [Johnstone AM, et al. Effects of a high-protein ketogenic diet on hunger, appetite, and weight loss in obese men feeding ad libitum. AJCN 2008;87:44-55].

The ability of lower-carb diets to lead to a spontaneous reduction in food intake received scant attention in the article, in stark contrast to the (inaccurate and misleading) information on fibre. This suggests, to me, bias in the article.

The response states, “it provides links to studies that found that low-carb diets produced better weight loss than low-fat diets in the populations studied and in the particular circumstances of those studies. It is not the case that the article cites one study as evidence of the fact that low-carb diets do not produce better weight gain. If you read it as a whole, you will see that it has approached the research fairly.”

I’ve copied the relevant part of the article below. Then I’m going to list the studies (I’ve added reference numbers for ease), and comment on them.

•    A 2013 review of 13 studies involving 1,569 participants concluded that those assigned to a very-low-carbohydrate ketogenic diet (VLCKD) achieved greater long-term (at least a year) reductions in body weight and certain cardiovascular risk factors than those assigned to a low-fat diet [1]. The authors concluded that a VLCKD “may be an alternative tool against obesity”.
•    Another review from 2013 of 17 studies involving 1,141 obese patients suggested that low-carb diets “had favourable effects on body weight and major cardiovascular risk factors”, although the effects on long-term health were unknown [2].
•    A 2009 study comparing low-carb diets with low-fat diets examined 13 studies involving 1,222 participants, concluded that low-carb diets were “more effective at six months” and were “as effective, if not more” as low-fat diets at 12 months [3].

Other research suggests that over periods of 12 months and beyond, low-carb diets fare no better than low-fat diets and there is some concern about the long-term health impact. There is strong and consistent evidence that reducing your calorie-intake is more important for losing weight than changing the proportion of carbs, fat and protein in your diet:

•    A 2013 report [4] on the safety of low-carb diets reviewed 17 studies involving more than 272,000 people and found low-carb diets were “associated with a significantly higher risk” of death and no reduction in the risk of cardiovascular disease.
•    A 2006 review comparing low-carb diets with low-fat diets examined five studies involving 447 individuals found that those on a low-carb diet had lost more weight than those on a low-fat diet at six months but not at 12 months [5].
•    A 2004 review of the long-term benefits of various weight loss methods analysed 26 studies and found no evidence that low-carb diets resulted in greater weight loss than low-fat diets over the long term [6].

1.    Bueno NB, et al. Very-low-carbohydrate ketogenic diet v. low-fat diet for long-term weight loss: a meta-analysis of randomised controlled trials. Br J Nutr. 2013;110(7):1178-87.

2.    Santos FL, et al. Systematic review and meta-analysis of clinical trials of the effects of low carbohydrate diets on cardiovascular risk factors. Obes Rev. 2012 Nov;13(11):1048-66

3.    Hession M, et al. Systematic review of randomized controlled trials of low-carbohydrate vs. low-fat/low-calorie diets in the management of obesity and its comorbidities. Obes Rev. 2009 Jan;10(1):36-50

As is alluded in the article, all of these reviews provide evidence that low-carb diets produce better weight loss and disease marker changes than low-fat diets.

4. Noto H, et al. Low-carbohydrate diets and all-cause mortality: a systematic review and meta-analysis of observational studies. PLoS One. 2013;8(1):e55030.

As the title of this review states, this is based on ‘observational’ (or epidemiological) studies. These studies may indeed have found a link between lower-carbohydrate intakes and increased risk of death, but this does not mean that low-carb diets cause death. It is possible, for instance, that those in the poorest health tended to adopt lower-carb diets in order to improve their health. In fact, the authors of the review state this: “the relation may not necessarily be causal, particularly in the observational studies because of possible confounding factors and biases that may not have been fully adjusted for, which may have rendered the results less valid.”

Another major issue with these sorts of studies is that they are usually based on self-reporting of the diet which is notoriously prone to error.

While intervention studies may have issues too, it is generally accepted in scientific circles that they are superior to epidemiological studies.

5. Nordmann AJ, et al. Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Arch Intern Med. 2006;166(3):285-93.

Here’s what the authors concludes as regard to the effect on weight loss: “Low-carbohydrate, non-energy-restricted diets appear to be at least as effective as low-fat, energy-restricted diets in inducing weight loss for up to 1 year.”

Again, the balance of evidence favoured low-carb over low-fat, and yet this study is listed in a part of article that purports to provide evidence that low-carb diets have no particular merit.

6. Avenell A, et al. What are the long-term benefits of weight reducing diets in adults? A systematic review of randomized controlled trials. J Hum Nutr Diet. 2004;17(4):317-35.

The article states that this review ‘found no evidence that low-carb diets resulted in greater weight loss than low-fat diets over the long term’.

Actually, none of the studies in this review compared low-carbohydrate diets to low-fat diets, explicitly. No explicit claim is made by the authors to this effect either.

The review did assess the impact of ‘low-carbohydrate protein sparing modified fast’ diets. But these are generally very low calorie diets (often on 300-500 calories a day) that are consumed in the short term. These diets in no way represent ‘low carbohydrate diets’ that are usually ‘ad libitum’ (unlimited quantities of prescribed foods are permitted). The Avenell review is simply not relevant to the debate here.

So, to summarise, the evidence cited by the article is comprised of:

1.    Four reviews [1,2,3,5] of intervention studies that are broadly supportive of low-carbohydrate eating as superior to low-fat dieting.

2.    One epidemiological review which links low-carbohydrate eating with increased risk of death which is based on unreliable dietary data and from which no causality can be inferred.

3.    One review [6] which is misrepresented in the article and is not relevant to the discussion.

Despite the fact that the evidence cited is overwhelmingly in favour of low-carbohydrate diets, the tone of the article is clearly disapproving of this way of eating. I suggest that the article does not reflect the balance of evidence at all.

The review of the literature in the article is followed by the following paragraph, which is also reproduced in your response response:

“The weakness of current research is that most studies are short term and of varying quality and there is a recognised need for longer-term, rigorous evaluation. Moreover – and this applies to most research on diets – it is notoriously difficult to study the effects of diet on health because people don’t live in labs, they live in the real world and are exposed to different lifestyle and environmental factors, which can influence the results.”

I don’t dispute this, but if “there is a recognised need for longer-term, rigorous evaluation”, then how can NHS Choices and its dietician confidently tell us that a third of our diet should come from starchy foods? The advice is strong and certain, and I’d like an opportunity to assess the quality of the evidence on which this advice is based. I do hope that you will respond with the specific research that supports this position.

As regards the piece that I linked to at Authority Nutrition, I accept this was not a systematic review in the conventional sense. I also accept some of the shortcomings of the research. However, all of the studies cited provide evidence that, overall, lower-carb diets are superior to low-fat ones.

Rather than criticising the article and accuse it of ‘cherry-picking’, maybe you could respond with a list of studies that support the dietary approach you advocate. I note that none of the reviews of clinical evidence cited in the article support the dietary approach it advocates.

I am glad you have seen fit to remove the word ‘toxic’ in relation to ketones. I note, though, that the relevant part of the article now reads:

“When you are low on glucose, the body breaks down stored fat to convert it into energy. This process causes a build up of ketones in the blood, resulting in ketosis. Ketosis as a result of a low carbohydrate diet can be accompanied by headaches, weakness, nausea, dehydration, dizziness and irritability particularly in the short term.”

So, while you concede that ketones are not toxic, the remaining paragraph gives the distinct impression that they can have toxic effects in the body.

For the reasons explained above, I believe the article remains misleading and not evidence-based. I disagree that the article is balanced (and something to be proud of). I would be very grateful if you could respond point-by-point to the issues I raise here.

Kind regards

John Briffa

I got an almost immediate response from Mr Carr-Brown, who suggested we discuss the issues when we meet. I said I’d like a formal response, and that the complaint should be escalated to what is known as the ‘Clinical Information Advisory Group’. We shall see what comes of this in due course.

In the meantime, as for the suggestion that I syndicate NHS Choices content on my own site, I think I’ll pass: Disseminating unscientific, non-evidence-based, misleading and potentially dangerous dietary advice is not a business I want to be in.

56 Responses to Update on my complaint about the NHS Choices article on carbohydrate: more questions than answers

  1. Jack 22 May 2014 at 10:12 am #

    people like Carr-Brown are embedded throughout the academic, research, administrative and political systems that should be providing us with sensible and accurate information on the choices we need to make. It is as important to be clear and honest about what is not known as much as what is incontrovertible. They are slowly undermining the credibility of the whole system. This battle for the truth is not going to be won any time soon. Keep up the fight Dr John. Your country needs you.

  2. Vicente 22 May 2014 at 10:52 am #

    Hi John,
    they say that their article provides a balanced and informed view? My godness!
    It is one false statement after the other!

    “Research suggests low-carb diets don’t result in greater weight loss over time than healthy balanced diets” … LIARS

    “Carbs should be the body’s main source of energy in a healthy balanced diet” … LIARS

    And they go on and on…

    It is really really sad to read articles like the one from NHS.

  3. NM 22 May 2014 at 12:39 pm #

    In their attempt to demonise ketones, they inadvertently give the game away: “When you are low on glucose, the body breaks down stored fat to convert it into energy”.

    So in an article about weight-loss (ie: marshalling stored fat and converting it to energy), they castigate the very behaviour they admit, explicitly, is most effective at so doing!

    Imagine this conversation:

    Patient: Hello NHS Choices, I want to lose weight.

    NHS Choices: Losing weight? Ok, what you actually mean is “breaking down stored fat to convert it into energy”. After all, you don’t want to lose bone or muscle!

    Patient: True. What’s the best way to liberate all that stored fat as energy?

    NHS Choices: Be “low on glucose”.

    Patient: Ok. I guess that means I should make sure I eat foods that primarily don’t increase my glucose, so that my fat stores can be liberated?

    NHS Choices: NO! MAKE SURE YOU EAT LOTS OF GLUCOSE!

    Patient: But I thought you said that the best way to lose fat is to have low glucose so you can liberate your stored fa..

    NHS Choices: SHUT UP AND EAT YOUR WHOLEGRAINS!

    • Pingo 22 May 2014 at 1:21 pm #

      You are so right!

    • Vicente 22 May 2014 at 1:40 pm #

      Funny, but sadly real.

      They know that eating low-carb can lead us to severe health “problems”, like significant decreases in body weight, body mass index, abdominal circumference, systolic blood pressure, diastolic blood pressure, plasma triglycerides, fasting plasma glucose, glycated haemoglobin, plasma insulin and plasma C-reactive protein, as well as an increase in high-density lipoprotein cholesterol [1]. You can also see how your NAFLD [2] and GERD improve [3].

      And they know there is another risk with low-carb diets: when you abandon the diet and add carbs you could gain weight! [4]

      But the people at NHS Choices know the “Truth about carbs”: we should eat more carbs because they advise so, “The Government’s healthy eating advice, illustrated by the eatwell plate, advises that a third of your diet…”. Why is eating carbs healthy? Because they say so.

      Completely balanced, no bias, they say. The facts say the opposite.

      [1] Systematic review and meta-analysis of clinical trials of the effects of low carbohydrate diets on cardiovascular risk factors. Obes Rev. 2012 Nov;13(11):1048-66. Epub 2012 Aug 21.

      [2] The effect of a low-carbohydrate, ketogenic diet on nonalcoholic fatty liver disease: a pilot study.Dig Dis Sci. 2007 Feb;52(2):589-93. Epub 2007 Jan 12.

      [3] A very low-carbohydrate diet improves gastroesophageal reflux and its symptoms. Dig Dis Sci. 2006 Aug;51(8):1307-12. Epub 2006 Jul 27.

      [4] Comparison of the Atkins, Zone, Ornish, and LEARN Diets for Change in Weight
      and Related Risk Factors Among Overweight Premenopausal Women. The A TO Z Weight Loss Study: A Randomized Trial

    • Jonathan Bagley 23 May 2014 at 4:39 pm #

      That’s very clear. A good explanation.

    • jake3_14 26 May 2014 at 11:43 pm #

      +1, sir/madam!

    • MMartin 16 July 2014 at 10:28 pm #

      Well put

  4. Charlie - a biochemist 22 May 2014 at 3:11 pm #

    As Jack above says “keep up the fight…..” It really is imperative that all people, especially diabetics, are given the correct dietary advice.

    What is amazing is that 1st year biochemistry textbooks (for example, Harper’s Illustrated Biochemistry, 27th edition, 2006) lay out quite clearly the role of insulin in the promotion of the storage of fat and the restriction of its release from the adipose tissue. Harper’s also points out that insulin switches on the pathways in the liver that convert excess dietary carbohydrate into triglycerides and cholesterol. These end products are then released into the bloodstream in the form of particles, vLDLs. These are then, of course, converted into LDLs on the transfer of the fat (triglycerides) to the adipose cells – again under the direction of insulin.

    It is therefore not surprising that Westman et al (The Effect of a Low-Carbohydrate, Ketogenic Diet Versus a Low-Glycemic Index Diet on Glycemic Control in Type 2 Diabetes Mellitus. Nutr Metab (Lond) 2008, 5(36)) found that low carbohydrate diets drastically lower the level of triglycerides in the blood by around 60%.

    Is it not ironic that the prevailing dietary advice tells us not to eat fat because you will have a heart attack because you will clog up your arteries with fat, but the very thing that increases the amount of circulating fat in our arteries is – carbohydrate.

    Further, a Harvard-lead study author reported – “High triglycerides alone increase the risk of heart attack nearly three-fold. And people with the highest ratio of triglycerides to HDL had 16 times the risk of heart attack as those with the lowest ratio of triglycerides to HDL in a study of 340 heart attack patients and 340 of their healthy same age counterparts.”

    Since Westman also found that low carb diets also increase the levels of HDL, you would have thought that the medical profession would have jumped at the chance to use these predictors of heart disease – rather than use total cholesterol which is supposedly made up of both good and bad cholesterol. As someone once said that is like trying to tell who won a game of football when you only know the total score.

    I also totally agree with the notion that carbohydrate is not required in the diet – unlike fat and protein. This is because we can synthesise all the glucose we need (together with the other essential sugars such as ribose) from the amino acids produced on the hydrolysis of dietary proteins – by a process termed – gluconeogenesis. Again, all is revealed in a first year text such as Harper’s – in other words, it is not the latest research – it is not rocket science – it is simple basic biochemistry.

  5. Ash Simmonds 22 May 2014 at 3:31 pm #

    Everything goes out the window as soon as they say it’s evidence based, then tell you that you require something that is categorically not required.

    Unless of course they’ve updated all these biochemistry sources in the mean time:

    –> http://highsteaks.com/carbohydrates/

    Dunno, maybe *I’m* the one in a fantasyland…

  6. Nancy M 22 May 2014 at 6:08 pm #

    Good for you for tackling them on this. Hope you can keep hold of their eel-like squirming and get them to swim straight.

    I admire your patience!

  7. Auggiedoggy 22 May 2014 at 7:16 pm #

    The fact remains, populations that are the healthiest and longest-lived do not follow low carb diets. losing weight is great but it is not the be-all and end-all of good health. I’ve done the LCHF fad diet and it was a disaster. Fortunately I had the good sense to drop the butter, full fat dairy, bacon, fatty meats, etc., and move on to a healthy diet with plenty of fruits and vegetables.

    • Tyrannocaster 23 May 2014 at 1:13 am #

      Thanks for that; I needed something amusing to lighten up my day.

    • mike 23 May 2014 at 7:21 am #

      I wonder if you’d be kind enough to illustrate what the ‘disaster’ was and what proportions of macro nutrients have you moved to having dropped what appears to be largely fat?

      • Dr John Briffa 23 May 2014 at 7:35 am #

        The lack of detail in Auggiedggy’s comment, coupled with the hackneyed portrayal of a low-carb diet and the use of the word ‘fad’, leads me to conclude that in all likelihood there was no disaster (as Auggiedoggy probably didn’t ever eat this way).

        It smacks of the sort of hysterical rhetoric that comes from many dieticians or others who base their nutritional ideas more on ideology than science.

        • NM 23 May 2014 at 9:23 am #

          I do believe that Auggiedoggy is indeed on a strict vegan diet. The paucity of the rhetoric and the feeble obviousness of the straw-man lie suggests a brain starved of essential fatty and amino acids.

    • Laurie 23 May 2014 at 7:46 am #

      I’m sorry for your loss, of the facts.

    • Thomas Murphy 23 May 2014 at 9:52 am #

      Hmm. Fruits and vegetables. As a Type 2 diabetic, I have a blood sugar monitor which gets very alarmed when I eat a “healthy diet with plenty of fruits and vegetables”.

      Are you telling me, then, that:

      a. high levels of sugar in my blood are not a long term threat to my health, despite the fact that the NHS kept me in hospital for two days when they saw how high my suagr levels were?

      b. the recent laser surgery and current course of injections into my eyes for diabetic retinopathy were completely unncessary and the NHS just wants to spend its budget on frivolous medical interventions?

      c. I should simply increase my oral medication to the maximum (the only advice I had – from a senior hospital consultant after a 120 second “interview”) and just live with the nasty gastro-intestinal side effects (you really do not want to know)?

      Until I discovered Dr. Briffa and started making changes to my lifestyle and diet in accordance with his principles and those advocated by many other doctors around the world who are beginning to realise that we have been led astray, the most I had to look forward to was years of “managed decline”.

      Now?

      My sugars are improving and I take medication less often. I still have a way to go to lose a couple of stone and get rid of the abdominal fat which, though I am not seriously overweight, is proving to be a stubborn little sod to remove. Even so, for the first time since diagnosis, I feel I am taking control and making measurable improvements to repair the hidden long term damage I did not even realise was happening to my body.

      Fortunately, I had the good sense to listen to Dr. Briffa and others and decrease my intake of carbohydrates significantly. I’d like to say thank you to him and the many others in this field who daily challenge the conventional wisdom.

    • Jonathan Bagley 23 May 2014 at 4:43 pm #

      Auggiedoggy, I’m interested in why it was a disaster. I don’t treat moderating carbohydrate as a religion, so if you’ve got some useful information, please elaborate.

    • Simon Shorrock 23 May 2014 at 4:45 pm #

      Oh dear, I’m sorry the diet our ancestors thrived on didn’t suit your dietary requirements.

  8. Liz 22 May 2014 at 9:47 pm #

    Well actually I think they do eat Low carb. They eat a lot lower amounts of carbs than we do, and not quantities of processed refined carbs, like the SAD diet (Standard American Diet). The problem of which is that years of abuse ie over-ingestion of unhealthy carbs, leads to carbohydrate intolerance and metabolic syndrome, and this needs drastic action in many individuals, meaning they may need to go to as little as 20-30g carb (healthy carbs) per day for the rest of their lives, to regain their health. What do you mean by a disaster – you felt ill? didn’t enjoy the food? Perhaps you were suffering carb addiction and had severe withdrawals, or perhaps couldn’t manage to ditch them at all? Or your metabolism was switching from glucose as its fuel to Ketones, in many people this makes them feel ill or strange for up to a month, everyone is different. But once you are ketone, or fat,-adapted, you should feel on top of the world. The worst thing is to call LCHF a fad diet, it is the diet that sustained the human race until about 10 000 years ago. The SAD diet (or SUKD) began its onslaught about 150 -100 years ago and is spreading its diseased fingers to every developing or indigenous nation it touches.

    • Maggie 23 May 2014 at 7:23 am #

      *applause*

    • LouiseB 23 May 2014 at 9:19 am #

      Well said Liz

  9. Mark John 22 May 2014 at 10:21 pm #

    Liz, you said everything I was going to say!

    Only a few short decades ago, what we now consider to be a low carb & high fat diet, was normal. Today’s “normal” or “healthy plate” diet is completely and totally abnormal and most people can’t handle it metabolically. This is precisely why the western world (and spreading) is suffering from the onslaught of metabolic problems and diseases.

    We don’t need new drugs, we just need an old diet.

  10. Christoph Dollis 23 May 2014 at 5:21 am #

    Not irrelevant to this post: Latest Medical Mea Culpa: Carbs Kill

  11. Kate Holland 23 May 2014 at 8:50 am #

    I have been lo carb over a year, I did it because I was at the point of no energy, and taking the max amount of metformin, scared they would put me on insulin. I lost 4 stone, regular glucose levels without drugs, blood pressure normal, we still have “discussions” about cholesterol levels, but I refuse statins. It’s not really that overly high…according to THEIR standards. I find when I have an indulgence meal on the odd occasion, I feel more hungry the rest of the day…carbs having their way with my addictive centre! When I am my usual 50 carbs or under there are no feelings of hunger. I test my blood glucose level if I eat something unusual, just to make sure it’s not spiking my levels, so far, so good. I never have the almost painful, stomach churning hunger/cravings I used to get when I consumed lots of carbs. But no researchers have come and asked me about it!

    • Liz 23 May 2014 at 9:04 am #

      Fantastic Kate, well done you. Please feel welcome to come and look at my FB page – I Love My Cholesterol!! And where are those researchers when you need one??

    • Thomas Murphy 23 May 2014 at 11:42 am #

      Kate:

      My partner and I have been working our way to your sort of diet and have been experiencing almost the same things as you – to the extent that carbs we used to crave simply do not interest us any more.

      We planned to allow ourselves “carb days” where we were allowed to stuff ourselves. We did that exactly twice and felt so bloated, uncomfortable, de-energised and generally out of sorts that, after the second time, we realised that there was something more than correlation going on – there was cause and effect. We don’t have carb “blow-out” days any more because we don’t actually enjoy them.

      Incidentally, a lot of people who comment on this forum are diabetic (as I am). When I was diagnosed, we discovered through my glucose monitor that my partner is actually hypo-glycaemic. She used to suffer food panic attacks for years but it was only when we had a monitor that we realised why.

      Dr. Briffa’s recommendations with respect to healthy eating apply equally to hyper and hypo glycaemics. My other half no longer suffers from low blood sugar panic attacks or from urgent cravings. She also has more energy whilst eating less and, as she remarked to me yesterday, even her skin is looking healthier than it has done for some time now. High fat, moderate protein and low carbs is helping me to keep my sugars down and helping my partner to keep her energy levels up without the sudden and sometimes quite frightening crashes she used to suffer.

    • Leaf Eating Carnivore 23 May 2014 at 6:18 pm #

      Anybody concerned about Total Cholesterol levels and/or statins ought to wander over to:

      http://highsteaks.com/cholesterol/#mortalitychart

      for some good commentary and an eye-opening graphic (just enlarge the pic for detail).

      If I lived in your vicinity, Dr. Briffa, I would do my best to be your patient. Thanks for the good fight.

  12. gez 23 May 2014 at 9:47 am #

    can’t help feel you are cherry picking your evidence – for example other systematic review have found negligible beneficial effects (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3392894/) that has to be measured against the side effects of a high protein diet, such as bad breath, body odour and constipation

    You also ignore the issue of sustainability – are people going to stick to a low-carb diet for their rest of their live – as well as quality of life – its not just about weight loss, but holistic wellbeing

    • Thomas Murphy 23 May 2014 at 10:04 am #

      Dr. Briffa doesn’t advocate a high protein diet but a high fat, moderate protein, low carb one – so not really relevant.

    • Dr John Briffa 23 May 2014 at 10:07 am #

      gez

      The paper you link to is not primarily about carbohydrate intakes, but intakes of protein (the clue is in the title of the paper, gez).

      In any case, it clearly shows that high-protein diets are superior to lower ones in terms of weight and other markers of health. Even when you cherry-picked, gez, you did an awful job of it.

      • gez 23 May 2014 at 2:23 pm #

        Plus heard reports that a low-carb diet can make people grumpy and irritable

        • PhilT 27 May 2014 at 12:29 am #

          Seems it’s you that’s grumpy and irritable gez – a symptom common in carb eaters when they haven’t eaten for an hour or two and their blood sugar has crashed (again).

          Find us five quality studies showing better health outcomes or markers and weight loss with a low fat high carb diet and we can have a conversation.

    • Vicente 23 May 2014 at 11:50 am #

      Please, think a little about sustainability: because of years of eating SAD I had GERD, NAFLD, 25Kg more than I have now and my physical performance was ridiculous. That wasn’t sustainable.

      So yes, I can eat low-carb in the long term. That is sustainable. Being sick is not.

      Think again about “quality of life”: now I have quality of life.

    • Liz 23 May 2014 at 2:56 pm #

      I’m sorry, I always laugh when I see these “symptoms” touted as side effects to this diet!!.

      A) I don’t think they always are experienced, but some individuals may “suffer” these while their metabolism changes from glucose burning to fat burning, and then will subside with time,

      and
      B) they are ludicrously minor when compared to the possible side effects of a carb-based diet, for example metabolic syndrome, inc. being overweight, heart disease, high blood pressure, cancer and Alzheimers, the list goes on.

      Hmm… risk of cancer or risk of constipation – that’s a hard choice!!

    • Diane Smith 23 May 2014 at 4:36 pm #

      I have been sticking, very easily, to a low carb diet for 4+ years now and I know of many people who have stuck at it for many more years than that too. Eating this way does increase my quality of life and wellbeing. As well as weight loss, my blood pressure has gone back down to normal from being high, I now have consistent high levels of energy throughout the day, I no longer suffer mood swings and feeling trembly and shaky from blood sugar highs and lows, my heartburn has cleared up, my IBS has cleared up and my acne has cleared up, oh, and I no longer have painful period cramps. I feel better now than I did 10 years ago when I ate according to the recommended Eat Well plate. Sure, not everyone will stick to it but many, many people do and many more would once they tried it and experienced the amazing health benefits, if they were not constantly being dissuaded by articles such as the one on NHS Choices. I do believe that if people were encouraged to try it and stuck with it, it would save the NHS a lot of money from treating the diseases caused by obesity and uncontrolled blood glucose.

  13. David Bell 23 May 2014 at 11:06 am #

    Keep up the excellent work! As a diabetic initially wrongly diagnosed as T2 I was given the usual NHS nonsense about balanced diets, eat normally and so on including a local NHS booklet with the Eat Well Plate and so. My glucose meter soon told me the truth. When I went onto insulin as a late onset T1 my nurse gave me a Roche carb-counting leaflet showing plates of typical food items and their carb content and how much insulin to use for each. So somehow the NHS evidence base changed from ‘carbs are OK’ for T2 to ‘carbs need more insulin’ (to convert them to useable energy) when confronted with the inescapable truth for T1.

  14. Sonia Lancaster 23 May 2014 at 12:39 pm #

    Thank goodness for people like Dr Briffa who aren’t prepared to be a sheep

  15. Diane Smith 23 May 2014 at 12:46 pm #

    Thank you Dr Briffa for all your hard work and all you do.

  16. Mark John 23 May 2014 at 5:48 pm #

    A lot of what’s written about LCHF is about losing weight, then maybe improved health markers. What’s the best thing about LCHF in my opinion is not the weight loss per se, but the change in body shape it delivers. It spares muscle. I am a 6’2″ competitive athlete and didn’t consider myself particularly overweight. However, starting LCHF about one and a half years ago (out of curiosity) resulted in a weight loss of about 21lbs but at the same time increased muscle mass and strength. Waist size decreased by about 4 inches! I entered my last competition a bit concerned about not “carbing up” like I would have done in times gone by and was very tempted to consume a glucose type drink just before the race but decided to stay true to what I’d done for the previous year. I felt great throughout the race, the extreme lactic burn which is excruciating for the last two or three minutes didn’t seem as bad and despite being the oldest in my category, I came just behind the gold medal winner.

    LCHF isn’t about losing weight but changing body shape and composition. It’s about effective training, muscle building, competitive advantage in athletic competition etc. Eating what I used to eat just doesn’t interest me anymore when I can have such vitality for free. And yes, I did feel a “bit odd” for about the first month or so.

  17. George Henderson 24 May 2014 at 4:06 am #

    Noto et al. is the worst paper I have ever read. It has nothing to do with low-carb diets, there is no dose response, and RCTs of real low-carb diets were excluded in the selection process.
    It fails to meet basic standards of candour and clarity.
    Being observational is the least of its problems.

  18. Lori Miller 24 May 2014 at 4:13 am #

    @augiedoggy & gez, I’m donating $1 to Heifer International for every troll post I see. Heifer International provides livestock to underprivileged people all over the world for income, self-sufficiency and more of that dreaded protein in their diets.

    I’ve been on a LC diet for over four years and have had to give up GERD medication, visits to the chiropractor, getting cavities filled, four-hour naps, and a whole lot of hours of exercise. But if a different diet works for you, that’s awesome.

  19. Digby 26 May 2014 at 3:35 pm #

    Thank you for your perseverance! With physicians like you and a few solid science reporters like Gary Taubes working to get the truth out, there are finally cracks forming in the concrete wall of the carbs-based nutrition platform. The fact that suddenly there is so much push-back about low-carb diets and gluten sensitivity shows that big-ag is nervous.

  20. Debbie flint-carter 26 May 2014 at 5:51 pm #

    John -
    Can we pls have an email or twitter address where we can lobby for him to remove the misleading info and radically overhaul the relevant parts of the site?

    Maybe you should just rewrite it, offer it to him together with the citations and links to your source research, then perhaps it would be easier for him to just run it by a few people and just replace the wrong one with your one!

    It may save your time in the long run too! :-)

    Ps keep up the great work.
    Debbie flint-carter

  21. jake3_14 26 May 2014 at 11:53 pm #

    Dr. Briffa,

    Thank you for fighting the good fight. Since we come from the minority viewpoint, however, it behooves us to hew to the facts in support of our position even more strictly than our opposition. It is in that spirit that I raise a few objections to your critique.

    “But, as I pointed out in my original complaint, the dietary requirement for carbohydrate is zero…it is not factually correct to assert that carbohydrate is needed by the body.”

    I’d be extremely cautious with sweeping generalizations like this. Paul Jaminet, author of The Perfect Health data, can point to a mountain of evidence that the majority of the population needs to have 20% of their calories from starches for structural elements (glycoproteins), proper thyroid function, just to name two aspects of health. I won’t summarize his arguments, because he does so eloquently on his site, perfecthealthdiet.com.

    “Another major issue with these sorts of studies is that they are usually based on self-reporting of the diet which is notoriously prone to error. While intervention studies may have issues too, it is generally accepted in scientific circles that they are superior to epidemiological studies.”

    The vast majority of clinical low-carb trials have this *exact same* problem: self-reporting of food intake. Even the ABC study, conducted by Chris Gardner, which is widely cited by low-carb advocates, suffers from this limitation. Frankly, until there’s a body of studies, all necessarily short-term, conducted in locked metabolic wards, there will be no credible scientific data for the superiority of either low-fat or low-carb diets.

    “As regards the piece that I linked to at Authority Nutrition, I accept this was not a systematic review in the conventional sense. I also accept some of the shortcomings of the research. However, all of the studies cited provide evidence that, overall, lower-carb diets are superior to low-fat ones.”

    If you accept the inherent shortcomings of short-term research and that the body of clinically-based literature supporting low-carb is quite small, you have no basis for your conclusion. Neither does NHS Choices, but that’s their problem. At best, all you can say is that there’s limited evidence that a low-carb food plan produces better health markers than a low-fat food plan.

    • Lori Miller 28 May 2014 at 2:58 am #

      But isn’t Jaminet’s evidence mostly anecdotal and based on correlation studies, or have I heard wrong? If food reporting is inaccurate in studies, it’s almost non-existent if you’re using anecdotes. Jaminet recommends 20% to 30% carb even for diabetics (that’s 100 to 150g on 2000 calories a day), and made up a high-carb, high-fat diet that’s been shown in intervention studies to lead to increasing small LDL. In a population where heart disease and diabetes are major problems, it’s unclear why most people would benefit from such a diet.

    • NM 29 May 2014 at 2:47 pm #

      Jaminet has no evidence. He has anecdotes and suppositions. He ignores our millions of years of history as a species that had access to very little accessible carbohydrate for much of its evolution. Indeed, the recently-discovered preserved European from just 8000 years ago could not digest any starch AT ALL. Poor chap must have had terrible thyroid problems and no mucous to speak of!

      • Debbie flint-carter 31 May 2014 at 12:10 pm #

        Nm don’t suppose u hav a link for that 8000 yr old European info do you? Fascinating.
        d

  22. PhilT 27 May 2014 at 12:33 am #

    Keep up the good work, I made similar complaints and got similar responses – word for word in places.

    The article still contains rubbish like :-

    “Can we survive without carbs?

    While we can most certainly survive without sugar, it would be quite difficult to eliminate carbs entirely from your diet. Carbs are the body’s main source of energy. In the absence of carbs, your body will use protein and fat for energy.”

    An unbiased article would point out that calories can be obtained from any of the three macronutrients and that your body has the largest energy store in the form of fats, not carbs.

  23. JanC 27 May 2014 at 4:24 pm #

    Hi John,

    Thank you for all you do to get some clarity and discussion about this into the open.

    ‘A 2013 report [4] on the safety of low-carb diets reviewed 17 studies involving more than 272,000 people and found low-carb diets were “associated with a significantly higher risk” of death and no reduction in the risk of cardiovascular disease.’

    I looked on the website for this report and found the following comment with a link to Denise Minger’s critique of the study:

    Some highlights:
    The meat eaters group daily carb diet ranged between 37-65% of their calories. Any Paleo or Keto person would tell you that you are doing it wrong. THAT IS NOT A LOW CARB DIET! A low carb diet is less than 7-10% of your daily caloric intact. If I were to eat 65%, it would be about 150-200 carbs a day.

    Also people who smoked and had higher BMIs were in the meat eaters group, you think that had ANYTHING to do with the outcome more than a diet?

    And finally The veggie group and the meat group had almost equal amount of protein from animal products (eggs, cheese for example), so PROTEIN HAD NO EFFECT.

    Here’s the link:

    http://www.plosone.org/annotation/listThread.action?root=61529

    And here for Denise Minger:

    http://rawfoodsos.com/2010/09/08/brand-spankin-new-study-are-low-carb-meat-eaters-in-trouble/#more-580

    Best wishes,

    Jan

    • JanC 27 May 2014 at 5:54 pm #

      Just to clarify. All of the section from ‘Some highlights’ to ‘PROTEIN HAD NO EFFECT’ is quoted material, but my quotation text didn’t come out in the above.

  24. Christoph Dollis 29 May 2014 at 8:41 pm #

    Good on you for pressing for an open and transparent process.

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