Fiona Godlee: Panel discussion on

We've been given a very non-controversial topic of low carb, high fat diets Because you've heard from four of our panel, I'm going to give Sarah, who you haven't yet met, a first chance to introduce herself and to give us five minutes, Sarah, on your pitch, and then I'm going to ask each of the remaining panel members to give us a one minute pitch on what their position is on low carb, high fat diets

And before you speak, I just wanted to recognize what I found a helpful point, that Roy just made, which is the fact that we can talk about this in the context of diabetes and diabetes reversal, type II, in the context of weight management in people who have overweight or obesity, and also in the context of maintaining healthy life in the general population I think we slightly need to remember those three areas for consideration So Sarah, five minutes Okay My name is Sarah Holberg and I am one of the medical directors at Verda Health

That would be my conflict of interest statement, and I'm also on the advisory board at Atkins I also am the medical director and founder of the obesity program at Indiana University Health, and I'm an Aspin health innovator fellow And I'm thrilled to be here, and so I have to think both Swiss Re and the BMJ for organizing this I think this is absolutely fantastic, and I love the opportunity to have a dialogue about some really important issues affecting both the health and the financial viability of not only the United States but around the globe So I'm thrilled to be here

So as far as type II diabetes, and I just want to make it clear that I'm going to be focusing on type II diabetes, 'cause that is what I do and what I am interested in, and first I just want to walk through some incredibly basic, agreed upon things that then somehow escape even intelligent people when we move those things into guidelines, okay? And that is type II diabetes is what? It's a problem of elevated blood sugar And although humans are different, and heaven knows we need to respect the differences, we cannot utilize a one size fits all approach We do have to understand that there are some things that are the same And again, associations like the American Diabetes Association readily acknowledge, in a disease where the problem is elevated glucose, that the macronutrient that elevates glucose is carbohydrates, okay? So problem, elevated glucose, macronutrient that the American Diabetes Association acknowledges is the cause of elevated glucose, especially postprandial, which we know is a risk factor for coronary artery disease If we want to not just manage with another pill, but reverse out of the disease process, we have to take away or significantly limit what is causing the problem

And so that's why the approach that I utilize is a low carbohydrate, and therefore, because there's three macronutrient, we have to balance this out, become a high fat diet And we have a study that I'll be excited to talk about later that shows that this works very well Now, that being said, I'm also going to say to Roy that I'm a huge fan, and I think that what we can say is that there are three ways that we can reverse out of the huge epidemic of type II diabetes, that the entire world is facing Okay? There are three proven ways to reverse this Bariatric surgery, a significantly calorie restricted diet and a low carbohydrate, high fat approach

There are three things that work And what I would love to see is consensus that reversal should be a goal, that patients should be given the choice of which of these three proven methods they would like to initiate and manage in their own life, because Patient A may choose surgery, and I applaud Patient A, that they're going to take control and do something Patient B may want to calorie restrict forever Fantastic, that is great for them as well And a lot of patients, I think the majority of the patients, and again, that's just my opinion, are going to choose a non-calorie restricted method of just reducing carbohydrates, and one of the main criticisms we get is that this is not sustainable

But again, we published our one year data, 83% still adhering, and we actually have proof of adherence through beta-hydroxybuterate levels, which is unlike any nutrition study in the past We always guess at their adherence and we use the unreliable food diaries We can show that they adhered And we are going to be publishing our two year data soon, and I will tell you, adherence is fantastic So again, I think the most important take home thing is people have choices

Patients with diabetes have choices They need to be educated that the choices exist and that the goal of reversal is real They need to be explained all three choices that are evidence based, and then the patient needs to be able to be the one to take control Fantastic Four minutes, thank you very much

Okay, so if the other panel members, and I'll come back to Sarah for a minute as well, could give us a minute, on your position on low carb, high fat diets Michael? Thank you, yes I am a physician, I've been around a long time as a diabetologist and I don't have strong feelings one way or the other, but what I recognize is that the whole epidemic of type II diabetes has developed during my lifetime The prevalence when I began my career was around about half a percent in many countries, up to 1% Now it's running at 10%, 15%, Saudi Arabia 30%, 40%

And that has happened because of weight gain With relative risks of 80, 90, 100 That's why it has happened The mediators to get into the state of being diabetic has been driven by weight gain I think we now understand that the level of blood glucose, that's a marker of this disease, which is doing massive damage to every organ system in the body, and that the way to get rid of it is to get rid of the weight, as Roy pointed out, removing the head at the top

If you didn't gain weight in the first place, you wouldn't have this disease, whatever your genes, and it doesn't matter to me whether you do that weight loss using a high carbohydrate or a low carbohydrate diet, but it has to be something which you are prepared to stick into and then you must look at the long course As a physician, I've used drugs, as all of us have for many years They have covered up the disease, and I worry a little bit that if you haven't got rid of that liver fat then you're just covering up the disease It's going to come back Sarah, I'm going to give you a chance to come back on all four of these

Matthias? Thank you, Mike Yeah, I also don't have very strong feelings of or low carb versus low fat in terms of weight management I think as you have presented the studies show either way would work for many The question is how is adherence and what are the personal preference, actually? In the long term In terms of longer term perspectives, among initially healthy, normal weight, I think that's a different question, and we don't have very good evidence that low fat or the carbohydrate or the [inaudible 00:07:42] composition per se is a major relevant factor for chronic disease beyond weight management, and I think that this discussion of low fat or low carb actually distracts from other points of diet quality which are more essential in this regard, I think

Okay Thank you very much indeed So Jenny? Okay Have I got one minute or five? You've got one minute One minute? Because we heard from you earlier

Forgive me Okay And I'm hoping there will be lots of questions from the audience in about three minutes' time Go Jenny Okay, so I guess I want to sound a note of caution

Low carbohydrate diets today are not the same as low carbohydrate diets during human evolution So I'm wary on the basis of at least four observational studies that low carbohydrate diets are associated with higher risk of total mortality, and higher risk of cardiovascular disease mortality That caution should also apply to the most vulnerable group in our population, and that is women of reproductive age We're talking about women who can fall pregnant on a low carbohydrate diet and go through pregnancy on a low carbohydrate diet What is the effect on the fetus? So that group has been traditionally kind of regarded as a special group, and not a group that we should take into account all the time

Well, sorry, I think they should be the lowest common denominator, and we should be very, very careful what we say Thank you very much indeed And Roy? Just in general, I think a low carbohydrate diet is entirely reasonable, provided it's not extreme The point we need to bear in mind is the body really sees very little of the food that's put into it We're all hung up on what goes in the mouth, but in fact it goes into the stomach, the liver is actually controlling for very large periods of the day exactly what fat's being seen, exactly what glucose is being seen

So we need to grasp that fact, and it leads directly on to the important fact that Mike alluded to, that in fact once you start accumulating excess fat, the metabolic factors are against you So the approach Sarah's outlined, yes, if it works for the individuals concerned, that is absolutely fine I would have no theoretical hang ups I'm coming from the position of being a practical doctor You've got to be pragmatic

What works for the individual is what we're after So conceptually, no issues provided it's not extreme, but remember, it's metabolism that calls the shots, and that metabolism gets wrong-footed mightily when it has to struggle with too much fat in the system Thank you very much Sarah, one minute Okay, so let me just address the pregnancy one

So I will tell you that what my feeling, when you put those graphs up, was horror, that somehow we would see this big postprandial spikes in pregnancy as acceptable, because if there's one risk we know, it's hyperglycemia in pregnancy So you talk about damaging the fetus, I mean, I don't think anybody is going to dispute that When you have elevated blood sugar in pregnancy, you've got a problem pregnancy, and therefore, you make epigenetic changes that we are going to struggle for decades and generations to back out of And so to me, that graph was totally unacceptable, and I wanted to say, "Where is the flat glucose curve? Where is the pregnancy with the flat glucose curve?" Because I want my patients that I care for, who are pregnant, to have a flat glucose curve And you don't have to be in ketosis to have a flat glucose curve, when you're pregnant

You just have to still be restricting carbohydrates significantly, and you can get that much better flat glucose curve in an unbelievable critical, not only for that patient, not only for that patient's baby, but what about the next generation after that? So pregnancy is so important and it's going to be our key of backing out of this epigenetically So critical And then the next thing I would say is there are plenty of studies on a low carbohydrate, high fat, and I'm happy to send you some of Jeff Volek and Steve Phinney's work on this, but as far as the liver fat and the fat accumulation, the thing that's a shock to the body is a derange metabolic system And when we limit the carbohydrates and we can bring the glucose down, what we can see is postprandial lipids fall and we see many of these positive aspects from a body composition standpoint too, and we'll be publishing our [inaudible 00:12:44] data as well, so that we can see that, because I think it's very important and I think that the 2011 paper that was published on this that looked specifically at this is very important, but I don't think that we should fool ourselves to think that the only way we can get there is through significant calorie restriction Thank you very much

So we're going to have questions from the audience now I just want to ask, how many people in the audience would consider themselves to be currently on a reduced carbohydrate, increased fat diet You got them all Okay That's pretty good

Well, is that pretty good? I might put my hand up slightly tentatively Is anyone in the audience who considers themselves to be on a high carbohydrate, reduced fat diet? A few people Goodness me And that's through just because that's the nature of the eating or because that's what you've chosen to do for health? We'll have to find out Do feel free to grab the microphone and give your justification

So I'd like hands up please, and I'll take three at a time if that's alright So have we got three microphones or just two? No, we've got three Oh, we've got three So one there, one there just behind Where's the other microphone? Oh, yes, just give it to someone looking attractive in the audience, and then someone else, where's the third microphone? [inaudible 00:14:08] just to the lady there

Okay Could you make your questions quite short and comments short and introduce yourself? [inaudible 00:14:15] Yeah, thank you [inaudible 00:14:16] from Tufts So first, Michael, I don't not believe in the calorie balance importance It's extremely important, but it's not the solution

It would be like somebody coming with a fever and you say, "Well, we have to fix your fever imbalance We have to make you produce less hot and less cold," rather than actually finding out the cause of the fever So calorie balance is important, but what's driving calorie imbalance is what's missing from calorie counting That's good that you listened to my talk, then Thank you [inaudible 00:14:43]

So I agree with that And the second comment I think is that Michael also said that these changes in these trials are fairly small They're usually around half a kilogram or a kilogram, and most of these trials are about a year long The obesity epidemic globally is from changes in the population of about half a kilogram per year, so in fact, those small changes are what is actually happening in the entire population to explain obesity There's not massive changes going on

They're very, very subtle things going on in the population Just in 30 years we've shifted our calorie imbalance by half a kilogram per year, and so my question is for everybody, but I think especially for Michael, since he brought this up What has caused the obesity epidemic in the last 30 years? If it's just about calories and not anything about the quality of the food that's driving that imbalance, what has actually changed? Because the 60s and 70s were not a golden age of lifestyle, right? Anybody see Happy Days in the US, right? So what has changed? And I think what's changed is starch and sugar, predominantly, along with some other things Thank you very much Hi, my name is Nina [inaudible 00:15:47] and I'm a journalist and author

So I just want to call attention to the fact that there are more than 70 randomized control clinical trials on the low carb diet, and that the review papers, the ones that were shown, were a little bit selective, but the one by [inaudible 00:16:03] internal medicine that was done show that low carb outperforms, is equal to or outperforms the low fat diet in this systematic review of all trials, and so given that, I think that the question that I have, and there were a number of the presenters who favored a higher carbohydrate diet or plant based diet, a plant based diet is naturally high carbohydrate, so recognizing that epidemiological data is not as strong as randomized control clinical trials, what is the scientific justification then for supporting a higher carbohydrate diet when there is no randomized control trial that I know of really showing that to be superior? What is the scientific justification for choosing epidemiological data over randomized control trial data? Thank you very much So Campbell Murdoch, GP, also chief medical officer for diabetescouk, also work for Public Health England, promoting for selectivity and for the NHS on health and wellbeing My question really relates to human beings being a complex system, and I think everyone alluded to this, and also live in a complex environment

Just focusing on the human for a moment though, we have many homeostatic systems running in us Some of those are probably working on a local level, and some of them are overlapping across the body One of the key areas that I think would be useful to clarify is around the first principles of what's causing the problems, and one of the thoughts I always have around obesity as a cause, and if we pick that as an excessive body fat, then we need to stop and think, "Actually, we have different fat stores," as alluded to in the pancreas and the liver and the subcutaneous tissue, and my patients teach me that some of them are fantastic at putting on subcutaneous fat stores and protecting the body, whereas others are not so good at that and they can't mitigate their lifestyle What's the question here? Just get to the question Sorry, so the question is, should we be actually saying obesity doesn't cause the problem, obesity is a marker of a problem? Very nice, thank you very much

So if people could raise their hands and the microphone people just choose three other people, that would be most helpful So we have the panel of is obesity the cause or a marker of a problem, how do we justify high carbohydrate support for that diet when there's no randomized trial, and what is the cause of the obesity epidemic? So I ask you to volunteer your answers Yeah, Roy? Maybe I could comment that obesity can't be said to be the cause If you look at people who are severely obese, BMI over 40, what proportion don't have diabetes? 70% So clearly it's not the obesity per se, it's the matter of the individual who is unable to cope with that much fat

Section 1 of 3 [00:00:00 – 00:19:04] Section 2 of 3 [00:19:00 – 00:38:04] (NOTE: speaker names may be different in each section) Of the individual who is unable to cope with that much fat that's in their body at the time So I think we can disentangle these two things We're looking at a global measure, obesity, if you like, but we're not looking at the individual susceptibility factors

Now, one reason we're able to cut through confusion and come to a clear answer from that first study was that we didn't look at the general population and try to work out what was causing the diabetes We looked at the people who were 100% susceptible and dealt only with them, and that's why we were able to come to a clear answer So we need to see through group data to understand that it's composed of individuals who don't bear any obvious external labels of susceptibility and lack of susceptibility Thank you Mike? Yes, I'd add to that that the weight loss that we found indirect was able to reverse the diabetes no matter where it started

So if you had type II diabetes and you're unlucky enough to get it with a weight of 80kg, then 10kg, 15kg does the job If you are lucky enough to wait until you get it with 150kg or 160kg, still, it's 10kg or 15kg that seems to do the job So what we're looking at is taking away the last bit of fat that got stored, which has gone over what we're now calling the personal fat threshold, the point at which you start putting it into the ectopic sites, developing the signs of a metabolic syndrome So I think that's a very important concept Should I answer Darius's point? Yes

You know, you're asking that wonderful question, "What's caused this epidemic of obesity?" Well, in the United States, there has been an increase in starch and sugar consumption There has also been an increase, and I showed the slide from Adam [inaudible 00:20:47] in fats In terms of calorie provision, the fats slightly outweigh the carbohydrates, but I don't think that's the answer either I think the answer lies in this extraordinary change in our behaviors, and I mentioned the eating between meals, the snacking, the fact that you can buy snacks in launderettes and petrol stations and you know, it's an extraordinary change in the whole species behavior has been enacted through clever marketing I mean, the marketing companies have been very, very clever, and they're very effective and they have led us to eat more of these foods

There's also this issue that, in animals, if you give experimental animals a sweetened drink, it doesn't have to be sugar, it can be artificially sweetened, they will automatically go and look for more sweet foods to eat, solid foods And if you have this profusion of sweetened foods, and of course, you don't eat starch and sugar, they taste horrid You have to mix them up with some fat to make them palatable It works both ways But if you give people nothing but, and many people in the west of Scotland, there's in a line in Scotland goes from Motherwell, and we call it the Irn Bru line, because on the west of that line, people don't drink anything except Irn Bru, and they're exposed to this sickly sweet stuff from childhood onwards, and they are driven to eating more snacks that than the right hand side, sorry, the east side, which is where we drink tea

And Mike, in response to Nina's point about the high card, what's the justification for high carb? I kind of lost the point here, but I think Matthias had an answer to that Oh, Matthias, yep? Yeah, I also did not completely understand the question And I understand it, but Nina, tell me if I'm wrong You were basically saying that there's no randomized control trial of a high carb diet, so on what basis can one justify? Have I got that right? There are randomized trials comparing low carb and low fat diets, so I think that's not the issue Say it again Nina, sorry

You can lose weight on both diets But there's so much evidence for low carb diets in terms of being preferable for weight loss and also clearly for diabetes reversal For diabetes? No Yes [inaudible 00:22:46] Sarah Holberg studies show diabetes reversal on a low carb diet, so 60% of the population reversed their diabetes in one year, with 84% adherence

In a randomized trial? No In a controlled clinical trial It was not [inaudible 00:23:01] It was a controlled clinical trial Well, Sarah should speak to it herself

I'll be happy to, and the interesting thing about our trial, that we published the one year data and are about to publish the two year data is it was not randomized, it was controlled, and it's because we wanted to make it real life applicable and we wanted people to be able to choose Now, you say randomization, lack of randomization is a decrease in the quality of the study Aha, I will argue with that, because ours is the first nutrition study where we can prove people stuck to it We eliminated the did they, what was their food journal? You know, these unreliable food journals We check beta-hydroxybuterate regularly on these people, so we can confirm adherence to this dietary [inaudible 00:23:47]

You could have checked that if they'd been randomized too I'm sorry, what? You could have checked that if they'd been randomized as well Well, again, randomization, I know Laura [inaudible 00:23:55] was in the audience, so her study is a perfect example of one of the problems with randomization in that people come in knowing they want to do a low carbohydrate diet because they see people that it works, and when you randomize them to the low fat [inaudible 00:24:10] what happened right away in the trial? People dropped out And so we were trying to do a good quality study where we believe, and again, I will argue this with anyone, which is that the ability to acknowledge and prove adherence is much more important than the lack of randomization But the other thing I want to point out from our study too is that our average time with diabetes was eight years, and in fact, on other studies, they much more recent diagnosis and they exclude insulin, and a huge percentage of our patients came to the study on insulin and diabetes up to 20 years

So we took sick people Mike, your response to that? Yeah, I was just going to say a couple of things Measuring ketones has become popular Your ketones go up if you're losing weight, so this is a completely circular argument Whatever diet you're on, if you're losing weight, you'll get ketones

The other thing is that the evidence on the high carbohydrate, and you notice from the show of hands, there's actually nobody who thinks they're on a high carbohydrate diet I don't know what a high carbohydrate diet is, but Jim Mann and his colleagues way back in the 1980s, Gabriel [inaudible 00:25:20] did a series on studies in competition with Jerry Rieven, because Jerry Rieven was telling high carbohydrate diets cause all the adverse effects you can imagine, they get more diabetes, their triglycerides go up, and yet when they were done in Oxford or in Italy, opposite results Everything got better including the triglycerides And the difference was that they were completely different diets The American style high carbohydrate diet is of course, was of course and probably still is, full of sugar, and the refined things that Darius is talking about, whereas what the Italians were looking at and what we were looking at in the UK was a diet with a lot of natural fiber, with a lot of legumes, and you can go up to 60% or 70% carbohydrate

So what we're going back to is glycemic load And it doesn't matter if you reduce your glycemic load by cutting carbohydrates That's fine, and there's somebody who's done it over here That's fine But an alternative way of doing that is to mix it with other foods, as I mentioned on the slide, and you reduce the glycemic load that way, or by having a lot of legumes and [crosstalk 00:26:19]

Hang on, Sarah Right, and I said that was an option, calorie restriction is But can I just make one point? No, no Hold your fire I'm going to give three, where are three microphones

Just give me a sense? Who's got the microphones? One there, one there and where's the third one? I conquered a microphone in the first round, so [inaudible 00:26:31] One quick point and then a question related to

Just say who you are, please Seymour [inaudible 00:26:36], [inaudible 00:26:35] cardiologist So disappointing what [inaudible 00:26:38] and what Mike has said

When you look at the issue of ultraprocessed foods, 50% in the UK of consumption is ultraprocessed food linked to obesity A recent publication in the BMJ linked ultraprocessed food to cancer, independent of BMI You look at the make up of that ultraprocessed food, it's come from starch, sugar, sugary drinks, ultraprocessed fruit and vegetables That's 77% of the ultraprocessed food is coming from that So starch is and sugar is a major issue

In relation to that, and the question to the panel here, there's one thing that's a real bugbear for me We know obesity is a major issue, but the bigger issue of the insulin resistance syndrome, metabolic syndrome, and some studies suggest up to 40% of people with a normal BMI have metabolic syndrome or [inaudible 00:27:18] metabolic syndrome A third of people with type II diabetes in the UK [inaudible 00:27:21] had a normal BMI Can we have a consensus of agreement today that there is no such thing as a healthy weight and only a healthy person? Ah, interesting Hold on, I just want to [inaudible 00:27:31] the second microphone

Sir? Could you say who you are? My name is [inaudible 00:27:33], I work at the Liggins Institute at the University of Auckland That's if you drill a whole here and come out on the other side We are working on perinatal nutrition and health, and I wanted to make three remarks First I want to support Jenny's remark that I think we can only win the race against obesity and diabetes when you think about prevention, especially when you look at the limited success in intervention studies in adult populations So perinatal nutrition is key, avoiding gestational diabetes is key

The second remark I would like to make up for discussion is about evidence, and that relates a little bit also to the previous panel I think we are facing the issue that we have a broad range of differently designed studies that are still mostly carried out in caucasians So still rather than doing different studies in the same population, we should do the same studies in different populations that we can compare them and assess their relevance for ethnicity And the third quick remark is about relevance We were discussing going back to organically grown food and the luxury of having gardens in northern California and maybe Switzerland

Whether we like it or not, 80% of the world population will soon live in megacities with more than 10 million inhabitants So if we don't bring the solutions into these cities, it's statistically irrelevant Thank you for that, and the third microphone is with someone there I'm Dr Mark Hymen, the director of the Cleveland Clinic Center for Functional Medicine, and I found it very interesting that in a group of very educated people about nutrition, most of us preferred a higher fat, lower carb diet, and only one person was on a low fat diet I think that speaks a lot to what we think, not necessarily what we say or do

And the question is, the UNFAO did a survey of many countries and consumption patterns, and for every 150 calories of increased food, there was a 1 increase in type II diabetes But if that 150 calories came from soda, it was an elevenfold increase in type II diabetes So how does that sync with the idea of energy balance and that all calories are the same? Okay So back to the panel, I'm not sure I can summarize all of those, but not such thing as a healthy diet, only a healthy person, a number of comments about different populations needed, perinatal and the question of the different studies combining and the point that was just made which my brain has completely, immediately forgotten

Anyone? Mike? I can probably deal with that one That one's easy The point is the association between the sugar sweetened beverages and weight gain is much greater than any individual nutrients, and so you've just said what I think we already know [inaudible 00:30:26] asked about is there an ideal weight Well, there is an ideal weight

It's whatever weight for you, individually, and at a different age for all of you, before you get metabolic syndrome and type II diabetes, and you have to be aware of this There isn't a single figure worldwide We can't apply BMI BMI 25 or BMI 30 were epidemiological Yeah? [inaudible 00:30:48] And incidentally, I got the same text message from a patient who had become non-diabetic on a meat eating diet and word for word as the one you got

Okay Anyone? Jenny, you haven't spoken Anything you would like to add at this point? Only a small comment Kevin Hall's papers show that the actual excess calories that are needed to gain weight and explain our obesity epidemic are very small Seven excess calories a day over the course of ten years explains the obesity epidemic

So calories, in my mind, are not that important What is important is the quality of the diet But I'd just like to say something else There's a lot of demonization of processed foods, refined foods, the food industry, going on, but if you go back 40 years, which is when I started in this game, the food industry was told that there was a shortage of food, a shortage of protein and a shortage of food, and so the food industry rose to the call and said, "Okay, we'll produce lots of food, we'll increase the yield," they did exactly what we wanted, and they produced safe, cheap, palatable food So in my mind, we've just got too much of a good thing, and now we need to control ourselves

I have to say, the snacking and the marketing, there's a whole host of other stuff going on, isn't there? But I take the point Roy? I just comment on [inaudible 00:32:24] point about where's the insulin resistance syndrome, what's going on here? Just coming in on insulin resistance, it's often viewed as a pathological entity, whereas in fact we don't have insulin resistance That's a concept in the mind of man The thing in the mind of God was insulin sensitivity, which is the reality, and that's something which is evenly distributed in the population So if we look at the less insulin sensitive portion, yes, there's a lot of problems there, and so if we were to consider those people who have insulin resistance in muscle, that's the genetically inherited form, tends to run in families, naturally, and can only be changed marginally, those people are specifically disadvantaged with a high carbohydrate diet, because we know from our work following food, with magnetic resonance spectroscopy, that they can't store glucose as glycogen in muscle, immediately after meals

They have to have a bit of a boost in their daily [inaudible 00:33:28] lipogenesis So if we were to identify those people, we could perhaps follow through prospectively and actually test what I'm saying, which is only putting together notions So insulin resistance, well, let's flip it on its head and say what's real, which is a biological variation of insulin sensitivity in muscle, and yes, there is a problem at the low insulin sensitivity range Thank you Sarah, did you want to

Well, I want to put a little, one thing about ketones So ketones will rise in starvation They don't rise with weight loss

There's no data on that And so our elevated beta-hydroxybuterate, that was over twice what we see in the average population is a significant marker of adherence, again, and I'll just stress that I think puts that study above others that rely on food diaries And now I'm done with that point Thank you very much So who's got the microphones this time? There's one over there? If you could raise your hands, and the microphone people will know to come to you

But sir, you first please A retired GP from the UK with an interest in nutrition It's just that I've always been taught that Asians who have a high carbohydrate diet then come to the UK or the West and the they get diabetes because they have more meat and more protein and more fat, and I'm surprised to see this revival of the Atkins type diet, because we know that the Atkins diet increases cardiovascular disease, gallstones, kidney stones, osteoporosis and cancer Thank you very much for that Based on what data? Hold on a second

[inaudible 00:35:10] We'll get to that Sorry, I'm trying to look for you Over here Oh, yeah

Go, go So [inaudible 00:35:17] from Glasgow Sorry, just introduce yourself again [inaudible 00:35:20] from the University of Glasgow So I work with Mike, so unfortunate, and Roy

So I grew up in Blantyre which is near Motherwell, and you know, Irn Blu is from Blantyre, [inaudible 00:35:31] So I grew up drinking lots of Irn Blu, but I went to medical school, I was eating lots of chips, and I don't have a low carbohydrate or a low fat diet, but what I did was change my habits, retraining my taste buds to get rid of sugary drinks, don't eat chips as much anymore I'll still eat the occasional ones, but I've made proper choices So it's neither one nor the other, and I think most people in our community don't need to choose, if they want to stay healthy and not become overweight, they don't need to choose one or the other I think we're talking more about weight loss in people who are obese, in terms of trials, and that's a different question

So we've got to be really careful when we actually look at this So I think the key concept, and I do clinical practice, for many of our patients, for some of them, it's clearly, we had one guy who was drinking eight liters of Irn Bru a day, and two packs of crisps Now, he lost eight kilograms when he started to go on a normal diet Most of my patients, it's snacking culture It's crisps, it's biscuits, it's cakes, which contain lots of saturated fat, and excess refined sugar, and it's a combination of things

An the key thing for them is to retrain their tastebuds And I'll give you one last example One patient I said, "Could you go and try some fruit?" He came back, next week he said, "Doc, I tried that banana, it was bloody horrible It was the first banana," and this is the reality, it's the first banana he'd ever tried So it seems to me no chips, no sweetened drinks is a Scottish low carb diet, is that right? No, so the point is it's neither one nor the other

But I take the point It's normalizing things Yeah And there's a third microphone somewhere? There Oh, so sorry, have you got a microphone? Yeah

Okay, go ahead Hello, my name is Jane Collis I've been studying diabetes for 50 years, even though I'm only 23, which I've been observing pregnancy and lipids and I've got an interesting [inaudible 00:37:18] Just bring the microphone closer That's it Sorry, various suspects of diabetes

I agree totally with the ladies talking about pregnancy We've forgotten homeostasis altogether, with fats The quality of the fat matters We can't go frying a fat and expect it not to cause damage to our body So with polyunsaturated oils, and olive oil, they're cold pressed

So unfortunately, when they're offered to us, they're very old Sometimes rancidity is covered by commercial processing So in effect, we're putting something proinflammatory into our bodies, which affects the testes and the ovaries Section 2 of 3 [00:19:00 – 00:38:04] Section 3 of 3 [00:38:00 – 00:56:04] (NOTE: speaker names may be different in each section) Which affects the testes and the ovaries Also when the baby is growing, if you should be so lucky to get pregnant with an imbalanced homeostatic function with your Omega 3 and 6, then the baby will pinch all the Omega 3 from the mother That's essential for insulin sensitivity so therefore the baby might stop growing or die

Nobody's looking at this I'm very glad to hear somebody talking about pregnancy Thank you very much Excuse my nerves No, no

You've done brilliantly So we've got the Atkins Diet, which was said, and we want to know the evidence for this, that it increases a whole lot of terrible things And why the aging population changed their profiles in coming to the UK We've got the business about the just simply stopping the bad stuff and getting back to what, in Scotland, might be considered a more normal diet And then the rancid facts and all the problems with pregnancy

So, who would like to take any of those? Sarah So, I'll just start out So, as far as the Atkins Diet, none of that is true There is not evidence for that But, more importantly here in- There you go

I agree here with, I think both of you brought up the idea of health Right? And what is a healthy diet? And I couldn't agree more That if we look at different cultures, let's look at some cultures around the world What we see is that there is a continuum that people can exist on and be healthy We have island nations who are very high carb, who have very low instances of heart disease

We have the Inuits and the Maasai who have incredibly high saturated fat intake and they are free of heart disease and healthy as well So humans can exist on this continuum very happily, until we introduce things that I believe, that we all could agree on Sugar Processed foods Once you do that, and you get a metabolically unhealthy person, there's no continuum anymore

You have to shift down to the low carbohydrate end of this continuum and whether you get there through significant calorie restriction or you just limit carbohydrates, once you have metabolic illness, your choices are limited Thank you for that Other comments on the panel? Roy That just raises an interesting point that Sarah's made It's that the way out of a problem is not necessarily exactly retracing your steps

Reflecting on the question about the South Asians moving to Britain It wasn't that Britain was such a horrible environment It was actually an affluence effect So you saw exactly the same hard rural engines move to urban centers That effect was reproduced, for instance, by George Alberti moving to Tanzania

Rurals moving to the town They became more affluent and they could afford more food As I mentioned, what's superimposed on the typical Asian diet was the increased fat and, of course meat, that they could afford So they actually put on the weight and the [inaudible 00:41:05] body was disadvantaged How you get out of that situation is a separate question

And the approach of reducing the carbohydrate for that person would be entirely reasonable Mateus Maybe I can kind of add to that I mean the issue of the nutrition transition in many countries is a major one But I think we have sometimes the idea that traditional diets are all good But, in many societies or many countries, the traditional diets are relatively poor and have little diversity, actually

What we also do observe is that increasing diversity, even if this means you start to eat little red meat, that that is counterintuitive But it actually could be beneficial Mm-hmm (affirmative)- thank you Jenny, what about the question about pregnancy and the rancid fats and the this year round protecting the fetus? Oh, I think the idea that rancid fats are dangerous is perfectly reasonable We don't want to eat oxidized food at all

Whether it's fat or any kind of oxidated products Thank you for that And Mike, do you want to answer the business about the Scottish diet and just getting people off the bad stuff onto a more normalized? I'll tell you Yes I'll give you one

In fact, I'd like volunteers from this room I have a student who is trying to find people on low carbohydrate diets and he's been collecting hundreds of them From the internet and from Facebook and such like[crosstalk 00:42:35] And suddenly you are[crosstalk 00:42:36] But when you actually find out what they're doing, they aren't on low carbohydrate diets at all They just thought they were So I wonder what you guys are doing

Okay I've got three microphoned people If the next microphones could come to the front of the room, I would be grateful So the lady there with the microphone Yup

Go ahead My name's Rachel Stockley I'm a GP working in Brussels with English language ex-pats who are mainly working in the European Institutions Embassies and NATO Very highly educated, go onto the internet all the time about what they should and shouldn't be eating So my question is to the panel, is the influence of food processing in the carbohydrates and fats that people are eating, do you think that there is a connection between the actual levels of food processing and chronic disease? The impact of the way the food is put together or deconstructed and then put together again in some of these ultra-food processed foods? And do you think that we should be influencing food makers and providers with an index that is categorizing food according to the degree of food processing? Very nice

Thank you very much If that microphone could come up to the front here And the lady there, yes Thank you [crosstalk 00:44:00] Just introduce yourself Barbara

Just say[crosstalk 00:44:03] I like giving, I always used to give patients a choice with difficult treatments So just say your name again, Barbara Because you- I'm Barbara Boucher Queen Mary's London Maybe you've mentioned it and I've missed it, but are there any simple crossover trials of high fat and high carbohydrate trials? Which do patients prefer? Which do they find easier to stick to? And can you find any characteristics to predict which you might recommend first to a patient? Great question

Ian Oh, great Thank you My name is Ian Lake I am a medical advisor to Diabetes

codauk I am a humble GP in search of the truth And a Type I Diabetic, so I choose a ketogenic diet My question really is that if you look at most trials regarding carbohydrate and fat, most of the trials on fat are done in an environment of about 30% of the energy coming from fat

What seems to happen is that the ratios of the fats have changed within that 30% Then people are given a 24 hour recall sheet, dietary recall sheet, every year or so and conclusions are drawn from that A lot of carbohydrate gets converted to fat In fact, most of us here are probably converting our excess carbs into fat now That fat, of course, is saturated fat

So most of the diets that I've looked at regarding low carbohydrate in diabetes stick at about 40% of the carbs coming from fat 40% of the energy coming from fat So I think if I was on a high carbohydrate diet I would take a lot of care with my saturated fat Because the saturated fat that comes from carbs, I think is highly significant in this Of course the saturated fat from carbs is tagged with B100, which is quite a highly significant factor in cardiovascular disease

So that's my question Should we take that into account? Could that microphone just come here to Sarah and them we'll just have our answers to those three Which were about the importance of food processing [crosstalk 00:46:11] Oh no, I am all set I'm just going to come back to the panel

Then I'll get you in So food processing, how could we, could we get a measure of that? Get the food industry to abide by that? Has there been a crossover trial between high fat and high carb? Which the patients prefer? Which is easier to stick with? And the business about saturated fats that the body develops as a response to eating carbohydrates and how do we balance that out? Roy Just a comment on the processing of food There might be many details that may or may not deleterious, and that may require a lot of studies to sort out But the huge elephant in the room is the added sugar to processed meals

If you go into a High Street shop, anywhere, and actually read what's been added in the way of sugar, it's positively alarming Of course, this is done to improve taste and improve the chance that the consumer coming back and buying more In fact, we know from the very old experiments, that if you had sugar in a covert way, it doesn't actually change perception of society So the problem with processed ready meals is no so much the mechanism of processing, but this huge matter of added empty calories which aren't registered by appetite as having gone in Thank you

Jenny Can I just put some facts in there? If you look at the FAO, WHO website, fantastic You can plot the UK intake of sugar from 1961 all the way up to 2014 It shows a steady decline Comparable to the decline in Australia

In the intake of added sugars Fifty years ago, Mum bought a package of sugar and she made cookies and cakes and cordials Today, the food industry makes them And the food industry has allowed a whole generation of women to go out to work and to have careers Right

The problem is the structure as a population We won't disagree on that What happened over a few generations or a couple generations inadvertently is added sugar Sugar you sprinkle on your Corn Flakes and to your tea, has actually gone down markedly And has been replaced by the processed food

Now, the children really get that whack Whether it's added in the sweet and sour chicken from Marks and Spencer That leads the league of added sugar products Or whether it's added in Iron Brew, it really doesn't matter So we've got a real problem with our alarming epidemic of obesity in children

Sarah, can I ask you about this crossover between high fat and high carb? Has there been or does anyone know of any comparisons of acceptability of those two diets? Jenny or Sarah? What's Iron Brew? Can someone answer that question for me first? Is it soda, is it just soda? Yeah All right, all right Sorry I had to be educated on that one So there are a number of trials that compare low-carb and low-fat Well, high-carb and high-fat

Or excuse me, low-carb and high-carb Yes What we see over and over again is, from a metabolic standpoint, the low-carbohydrate outperformed the low-fat diet time and time again Those results are much more striking when we look at diabetes Okay

Briefly, if you would, Mike [crosstalk 00:49:42] Can I pick up Barbara's point though, is on individual preferences here And if you ask people to go on a diet, which they don't like, then they are unlikely to stick to it So this is where it comes back to the N=1 or the N of 1 randomized trials Which the BMJ kind of announced to the world about thirty or thirty-five years ago There is an hour edition to the consort program, I don't think it's ever been used

Okay Thanks Jenny CSIRO in Australia have done a lot of studies on low-carb versus low-fat Their parallel and up crossover

They had a long term, they had two years, and they've looked at mood and depressive symptoms on each diet The low-carb diet is associated with more negative mood, even though they've lost all that weight They don't feel as happy as the people on the high-carb diet Ah, interesting [crosstalk 00:50:32] Can I just comment on that? That is, depends on the definition of low-carb because that's actually the opposite of what we see in real low-carb

Okay Seventy five grams Seventy five grams of carbohydrate, exactly [crosstalk 00:50:43] We've got literally less than five minutes So I am just going to ask for the final three microphone people

You can have like a ten second comment Sorry [inaudible 00:50:50] Willet, Harvard, Boston This has to be a question I guess Is there really any reason that plant based diets need to be high in carbohydrate? I find it pretty easy to have plant based, lots of vegetables, olive oil, nuts- Okay

And also, Cordain, the founder of the paleo diet was asked how many people in the world could be supported by that paleo type diet His answer was about two hundred million people So my question is where is the other seven billion going to go? As someone mentioned we need to think about the environmental consequences Thank you Salman, very briefly if you would

The North star in this conversation is higher weight is bad for you That is a weight over 25 BMI is worse than below or in the 23-25 and over 30 is bad There are three sets of good data that challenge that First a paper in the Lancet Global Health that came out late last week or early this week On half a million people followed for sixteen years, from India, that shows that mortality is lower with higher BMI with no threshold

With lower BMI? No, with higher BMI Mortality is? Is lower at higher BMI all the way up to 35 That Richard Peto is the senior author on it Got the luxury, did it Briefly[crosstalk 00:52:16] Secondly is in Denmark, the BMI associated with the lowest mortality has been going up by two units every decade

Item three, the tons of paper on the obesity paradox The sicker you are, the higher your BMI, it protects you What this means, there's something about BMI, despite the fact you get more diabetes and higher blood pressure, that is counteracting it and protecting you So, going back to I think Haseem's comment, people matter BMI doesn't matter

Thank you for that I'm sorry the final microphone person, oh if you could be so short I mean like a microsecond No, sorry it's behind you Sorry sir, behind you

Thank you My name is Synan Mere I am a GP from London Just to keep it exceptionally short, in the context of talking about either decreasing calories, caloric restriction from a thermodynamic point of view or metabolic hormonal imbalance in the context of diabetes especially Where does the panel, and this is for the whole panel, where does the panel sit on therapeutic fasting? That's not been mentioned here

Is that appropriate? Is that relevant? Is there a sustainable model? So fasting, whether it's sort of a 5/2 model or a 16/8 model, is that something that is a feasible approach to decreasing weight and managing glycemic control? Thank you very much Will you let me give the panel just thirty seconds each? Because I want to get a sense from you of where you think the agreement is between you on this issue I'd like to give one or two points of where we think we've got agreement Sarah I think the agreement here is that reversal is possible and I think that we need to come to a consensus and make a strong statement about that

So that we can give patients a choice We need to put power back into patients hands, because I will point out Walter's comment You can absolutely do a plant based, low carbohydrate, high fat diet and if that's there choice, we need to all surround them and support them for that Right? Because there is more than one way to skin a cat Three ways have been scientifically proven to reverse Type II Diabetes

We need to talk about it and give people the option Thank you very much Mike? I would just like to take a moment so Salman you said this interesting comment here One of the weird things is that a body mass index of under 25 is only found in 11% of people in Scotland when they've reached the age of 65 So we're weird

We're weird Thin people are weird [crosstalk 00:54:50] Whereas most people are healthy have gone with the population Where is the agreement Mike? In our conversation? I think that the agreement lies at the glycemic low to high glycemic load However you get a high glycemic load, it's bad for you

And there's many of avoiding it Thank you Mateus Along this line of plant based diets would be the go-to to go for They could have a range of carbohydrate versus fat

I would guess Thank you Jenny High glycemic load diets are bad for us I would agree that a large amount of weight loss, of at least ten kilos or ten percent of body weight is associated with remission of Type II Diabetes

But the next question is, for the rest of their life, which is the best diet composition? Thank you Roy I would agree with all of the previous points The individual nature of this, in other words, the human interface with the science being talked about, is really important to recognize So no one size fits all

Fantastic Thank you to our panel Thank you to the audience for their questions


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