From Measure for Measure by Wm Shakespeare

The web has been alive with commentary the past few weeks since Denise Minger lobbed her first cannonball of a critique across the bow of The China Study, the vessel T. Colin Campbell, Ph.D. rode to fame and bestsellerdom.  Seems like everyone is now jumping into the fray and gunning for poor Dr. Campbell, who early on in the fracas made a few halfhearted attempts to fight back but has now fled the scene.  I’ve been laying low watching it all play out, and so now figured it’s about time I add my two cents worth to the debate. But first a little history.

I met Dr. Campbell about ten years ago (five or so years before the publication of the popular book The China Study) when we both spoke at the same conference.  He was a nice enough man who spoke about the work he and his team had done in China gathering the data published in the massive 894 page monograph Diet, Life-style and Mortality in China (pictured above left).  As Dr. Campbell presented his data ‘demonstrating’ the superiority of a plant-based diet and demonizing protein of animal origin, I didn’t think much about it because the data was all in the form of observational studies, which, as all readers of this blog should know by now, despite often showing correlation don’t prove causation.  My lecture, which followed Dr. Campbell’s, was, as you might imagine, a lecture of a different sort.  Then we both sat on a panel after our talks and fielded questions.  And were both cordial to one another.

A few years ago, I became vaguely aware that Dr. Campbell had written a popular book on his work in China titled, appropriately enough, The China Study.  I assumed it pretty much mirrored his presentation I had watched, so didn’t rush out and grab a copy.  Over the past few years a number of people have asked about The China Study through the comments section of this blog, and I’ve typically answered that the data are all observational and so not really meaningful in terms of causation.

(Note: Throughout this post whenever I refer to the popular book Dr. Campbell wrote, I’ll call it by it’s title The China Study, and when I refer to the large study Dr. Campbell was involved with in China and was the basis for the monograph Diet, Life-style and Mortality in China, I’ll call it the China study.)

About a year ago, I wrote a guest post for Tim Ferriss’s The Four Hour Workweek blog.  It actually wasn’t a guest post as much as it was an excerpt of a chapter from our book The Six-Week Cure for the Middle-aged Middle extolling the virtues of saturated fat.  It was a popular post that has garnered to date 520 plus comments, many of them fairly spirited.  I agreed to answer a number of the comments and did so.  I noticed as I sifted through them that a handful were absolutely fawning of Dr. Campbell and The China Study.  Here is a sampling:

The number one study of diet and disease is the China Study. All other data points are slivers compared to the volume of data and statistical correlations that came from the China Study.

Have you read The China Study? Dr. Campbell points out repeatedly that none of the weight loss studies such as Atkins or South Beach diet follow any type of peer reviewed scientific method.

Tim…and to think I was such a big fan of yours. This is by far the weakest (and least cited) argument I have ever read on diet–especially increasing saturated fats. Half knowledge is a scary thing in the hands of influential people. Maybe it’s another genius marketing ploy (like the myth riddled protein Atkin’s diet)–people love to feel good about their personal yet poor decision making–and diet is very personal. Check out researchers that actually meant to study nutrition–like Dr. T. Colin Campbell’s The China Study comes to mind.

It was pretty apparent that the disease of non-critical thinking was at epidemic proportions.

After reading a number of these, I decided I had better take a look to see what Dr. Campbell had going on that had attracted such devotees.  I pulled up his book on Amazon and read through a few comments, most of which were even more nauseatingly gushing than the above.  I ordered a copy of The China Study.

I knew that both Anthony Colpo and Chris Masterjohn had done their own critiques of the original data, so I figured, what the hell, I’ll take a look at the ‘real’ China study (as opposed to the popular book of that name) and do one too.  And I’ll critique the popular book, which I figured was a rehash of the China project, while I’m at it.

I tracked down a copy of the 894 page book in a bookstore in the UK and forked over $240 to purchase it and have it shipped.  As I was awaiting its arrival I told Gary Taubes what I had done, and he replied that he had done the same thing himself a few years earlier.  And that I could have borrowed his.  And, even worse, that most of the data was available online for free.

When the book arrived, I was amazed at the size of it.  Not only was it the 894 pages as advertised, it was in a large format.  Much larger than a volume of the Enclyclopaedia Britannica.  It wasn’t at all what I thought it would be.

Here are a couple of photographs shamelessly using our own book to show the size of this behemoth

Of the 894 pages, the first 82 are a study overview, description of methodology and author commentary.  It is written in the form of a scientific paper with half the page in English and half in Chinese (which, presumably, is a translation of the English half).  The remainder of the 894 pages are raw data and correlations.  Page after page after page of correlations.  I didn’t bother counting them, but Dr. Campbell says there are 367 variables, each of which is compared with every other variable.  I don’t doubt him.  This study was a massive undertaking, requiring thousands upon thousands of man hours and God only knows how much money.  No one can possibly accuse the team members of not giving it their all.

Here is one page of correlations.  This one between stearic acid and all the other variables studied.

But in the end it is still only an observational study.  And even though – again, according to Dr. Campbell – there are over 8000 statistically significant correlations, correlations are not causation.  Any scientist worth his/her salt will tell you that all you can do with data from observational studies is use them to form hypotheses that can be rigorously tested in randomized, controlled trials.  Then and only then (assuming the study results show it) can you even begin to talk about causation. The whole enterprise, costly and time consuming though it was, was described perfectly by Shakespeare in the words of MacBeth:

…it is a tale
Told by an idiot, full of sound and fury,
Signifying nothing.

Once I saw that the original China study was nothing but a huge number of correlations, I quickly lost interest.  What is the point in going through the brain damage of ferreting around in these to see if Dr. Campbell interpreted them correctly when he tries to make his case that a plant-based diet is optimal.  It doesn’t really matter whether he interprets them correctly or not, they are only correlations.  Repeat after me one last time: Correlation is not causation, correlation is not causation, correlation is not causation…

I wondered why Dr. Campbell and his group didn’t spend a fraction of the time and money they spent on this behemoth of a spreadsheet full of correlations on a real study that could provide hard evidence.  Why not randomize subjects into two groups and provide one a plant-based diet and the other a meat-based diet or something similar.  Lock them down as Ancel Keys did if they had to.  Surely the money spent on the China study could’ve covered that.  Get some real data.  I discovered later that I wasn’t the only one who wondered that.  Even some of Dr. Campbell’s own colleagues abandoned him to this study and told him it would be worthless.  More about this later.

So enough for me.  I stuck my copy of the $240 book of correlations in my library and forgot about it.  Until Denise Minger’s critique hit the net.

Upon reading her blog post, my first reaction was This is great; someone took the time to do what I was going to do. I figured Dr. Campbell had cherry picked his correlations to  make the case he wanted to make, and I had seen Colpo and Masterjohn catch him on it.  Ms. Minger went even further and really caught Dr. Campbell with his pants down, correlation-misinterpretation speaking.  I continued to read with mounting glee Ms Minger’s successive critiques and a few other bloggers who had critiques of their own.  (Believe me, there is no dearth of material here for people to attack without any two attacking the same data twice.)

After this went on for a while, I had my second reaction to the whole affair.

Which was that I had fallen victim to the confirmation bias.  My bias was that Dr. Campbell was wrong, so I was more than happy to uncritically accept evidence confirming his error without lifting a finger to double check said evidence myself.  I knew that if a blogger somewhere had come out with a long post describing an analysis of the China study demonstrating the validity of all of Dr. Campbell’s notions of the superiority of the plant-based diet, I would’ve been all over it looking for analytical errors.  But since Ms. Minger’s work accorded with my own beliefs, my confirmation bias ensured that I accepted it at face value.

Once the fact that I had succumbed to my confirmation bias settled in around me, I became suffused with angst.  I had tweeted and retweeted Ms. Minger’s analysis a number of times, giving the impression that I had at least minimally checked it out and had approved it.  I had emailed it to a number of people, many of whom, I’m sure, had forwarded it on.  I’m sure I played a fairly large role in the rapid dissemination of the anti Campbell/China study info.

(It didn’t really make me feel better to know I wasn’t alone in falling into the confirmation bias quicksand.  Take a look at this post from Richard Nikoley’s Free the Animal blog.  I doubt that all these people checked Ms. Minger’s calculations before posting.)

My angst wasn’t because I had possibly fed the flames of a misinformation wildfire – I wasn’t particularly worried about that because mountains of other data (including first hand data from my own clinical practice) have persuaded me that Dr. Campbell is dead wrong in his ideas about the superiority of a plant-based diet.  No, my angst arose for two other reasons: first, because I was distressed that I so easily fell prey to the confirmation bias, and, second, because I felt I needed to go through all the calculations  myself to make sure Ms. Minger and others whose work I had circulated were truly correct in their analyses.

As I was wallowing in self pity over all this, I didn’t realize that salvation was at hand. And that my savior was none other than Dr. T. Colin Campbell himself.

Yep, his first response to Denise Minger’s critique of his work appeared on the Tynan.net website and rescued me from my pit of self-loathing.  In it, Dr. Campbell wrote:

But she suffers one major flaw that seeps into her entire analysis by focusing on the selection of univariate correlations to make her arguments (univariate correlations in a study like this means, for example, comparing 2 variables–like dietary fat and breast cancer–within a very large database where there will undoubtedly be many factors that could incorrectly negate or enhance a possible correlation). She acknowledges this problem in several places but still turns around and displays data sets of univariate correlations.

In other words, the China study is an observational study comparing one variable to another (univariate correlations) and, as such, meaningless.  And this from the man’s own pen.

Since these observational studies are meaningless in terms of causality, it doesn’t really matter how one slices and dices the data because meaningless correlations by any other names are still just as meaningless.  All this falderal over whether or not Dr. Campbell had his interpretations right was tantamount to the medieval theological argument over how many angels could stand on the head of a pin.  And my participation certainly wasn’t required.

I’d known this all before, of course, but somehow had lost my focus on it.

I was ready to wash my hands of the whole affair when I came across another statement Dr. Campbell made in his response to Ms. Minger’s critique.  Writing of her, he said:

One further flaw…is her assumption that it was the China project itself, almost standing alone, that determined my conclusions for the book (it was only one chapter!). She, and others like her, ignore much of the rest of the book.

Only one chapter? As I mentioned above, I always figured The China Study was simply Dr. Campbell’s tale of the China study and the conclusions he had drawn from it.  Now he says that only one chapter is about the China study, leaving me to conclude that the rest must be about something else.  I found the book, which I hadn’t yet taken from the pack it came in from Amazon, opened it and started reading.

Wow!

In 1976 author Mary McCarthy famously said live on the Dick Cavett show of her rival Lillian Hellman:

Every word she writes is a lie, including ‘and’ and ‘the’.**

I feel much the same way about The China Study.  Except it’s not really a lie, it’s an obfuscation.

In fact, in my studied opinion, The China Study is a masterpiece of obfuscation.

It is obfuscatory in so many ways it could truly qualify as a work of obfuscatory genius. It would be difficult for a mere mortal to pen so much confusion, ambiguity, distortion and misunderstanding in what is basically a book-length argument for a personal opinion masquerading as hard science.

Let me take just one tiny section of the book, one that is in no way atypical, and show you what I mean.

In Chapter 3 titled Turning Off Cancer, Dr. Campbell is starting to hit his stride in his anti animal protein jihad.  He has described the three stages of cancer – initiation, promotion and progression – and is setting the stage for his description of his laboratory work implicating animal protein in all three stages.

Here is his setup paragraph starting on page 50:

At the start of our research, the stages of cancer formation were known only in vague outline.  But we knew enough about these stages of cancer to be able to structure our research more intelligently.  We had no shortage of questions. Could we confirm the findings from India that a low-protein diet represses tumor formation?  More importantly, why does protein affect the cancer process?  What are the mechanisms; that is, how does protein work?  With plenty of questions to be answered, we went about our experimental studies meticulously and in depth in order to obtain results that would withstand the harshest of scrutiny.

The “findings from India that a low-protein diet represses tumor formation” were the results of a rodent study published in the Archives of Pathology in 1968 that Dr. Campbell wrote about 14 pages earlier in the book.  He mysteriously refers to the Archives of Pathology as an obscure journal when it is anything but.  It was published then by the American Medical Association and still is today under the new name Archives of Pathology & Laboratory Medicine.  But the notion of the paper initiating his quest being discovered by Dr. Campbell in an “obscure medical journal” fosters the impression of him as a leave-no-stone-unturned kind of guy.  Even the little throw away but incorrect phrase “obscure medical journal” is part of the greater picture of obfuscation that maintains throughout the book.

The study from India showed that rats given aflatoxin along with a high-protein diet got liver cancer while rats given the same amount of aflatoxin while consuming a low-protein diet didn’t.  Aflatoxin is a substance released from a fungus often found in peanuts, corn, other grains and even hay. It is converted in the liver to a much more toxic compound and is often used in laboratory experiments with animals to induce cancer and other problems.

Moving on, here is what Dr. Campbell has to say about protein and cancer initiation:

[I] How does protein intake affect cancer initiation?  Our first test was to see whether protein intake affected the enzyme principally responsible for aflatoxin metabolism, the mixed function oxidase (MFO).  This enzyme is very complex because it also metabolizes pharmaceuticals and other chemicals, friend or foe to the body.  Paradoxically this enzyme both detoxifies and activates aflatoxin.  It is an extraordinary transformation substance.

[II] At the time we started our research, we hypothesized that the protein we consume alters tumor growth by changing how aflatoxin is detoxified by enzymes present in the liver.

[III] We initially determined whether the amount of protein that we eat could change this enzyme activity.  After a series of experiments, the answer was clear (Chart 3.2).  Enzyme activity could be easily modified simply be changing the level of protein intake.

[IV] Decreasing protein intake like that done in the original research in India (20% to 5%) not only greatly decreased enzyme activity, but did so very quickly.  What does this mean?  Decreasing enzyme activity via low-protein diets implied that less aflatoxin was being transformed into the dangerous aflatoxin metabolite that had the potential to bind and to mutate DNA.

These four little paragraphs and accompanying chart take up less than a page in space, and are tiny glittering gems of obfuscation.  Let’s deconstruct.

First, take a look at how subtly these four paragraphs are written, especially II.  Note how he writes “the protein we consume”?  I’m sure many people took these paragraphs to mean that the studies were done on humans.  That’s almost the implication.  Reread them to see if they indicate anywhere that the author is talking about rat studies.

As Dr. Campbell progresses through this chapter, he does ultimately tell the reader he is talking about rat studies and not human studies, but he doesn’t mention the word rat for another two pages after the above paragraphs. By this time it’s probably implanted in the minds of many readers that he’s talking about human studies.

He describes experiments showing that rats getting diets high in casein (a milk/animal protein) develop more cancer at the same dose of aflatoxin than do rats getting a lower-casein diet.  The implication: animal protein causes cancer.

Dr. Campbell then gave his rats diets of varying amounts of plant protein (wheat gluten) and found that they did not get cancer after exposure to aflatoxin irrespective of protein dose.  Same thing happened with soy.  Implication: plant protein protects against cancer.

If you’re worried about cancer – and who isn’t – you’re now starting to look at animal protein a little differently.  Which is what Dr. Campbell wants.  But he hasn’t told you the complete story.

As I’ve written often in these pages, rodents aren’t just furry little humans.  They are a distinct species separate and apart from humans.  The rodents usually used in lab experiments are Sprague-Dawley rats, and inbred strain that has a tendency to develop cancer easily. (See Abelson, PH. (1992) Diet and Cancer in Humans and Rodents, Science 255(5041); Jan 10: 141)  In fact, these rats can develop cancer just from a change in diet.  I ran quick checks on a bunch of the studies referenced in The China Study, and all checked used Sprague-Dawley rats.

And think about this.  If you were to visit a farm and search for rodents, where do you think you would be most likely to find them?  In the grain or in the milking area?  Like Dr. Campbell, I grew up in a rural area and spent a lot of time on a farm.  Rats and mice are in the hay and in the grain.  You have a helluva time keeping them out of the animal feed, which they eat, too.  Grain and hay are common places for growth of the fungus that produces aflatoxin.  Since rodents spend most of their days in this stuff (grains), and since they eat it as well, I would bet that most have adapted over the generations to  the combination of plant protein and aflatoxin.  If this did them in regularly, there wouldn’t be the rodent problem on farms that there is.  So, in my opinion, making a huge issue of the fact that rats didn’t get cancer after dosing with aflatoxin irrespective of how much plant protein they ate is pretty disingenuous.

Most disingenuous of all in the above four paragraphs and chart is the lack of full disclosure in these paragraphs of the very study Chart 3.2 is made from. Let me explain.

Certain enzymes in the liver convert aflatoxin into a more toxic substance that Dr. Campbell claims can initiate the formation of cancer.  He demonstrates in rat studies that giving the rats a lower protein diet decreases the activity of this enzyme, meaning that the lower the protein intake, the less conversion of the aflatoxin into the really nasty stuff.  Chart 3.2 above and on page 52 of his book shows this graphically.

When I pulled the study from which this chart was adapted (Mgbodile MUK and Campbell TC. (1972) Effect of protein deprivation of male weanling rats on the kinetics of hepatic microsomal enzyme activity, J Nutr, 102: 53-60.) and read it, I found a little disclaimer Dr. Campbell didn’t bother to mention in The China Study.  You can read the last paragraph of the study (highlighted in yellow) below:

Nice, eh?  He hits the nail on the head.  Protein utilization may be influenced by what is eaten along with the protein.  Sucrose (table sugar) was eaten along with the protein used in this experiment.  In other experiments corn starch was used instead of sugar and the effect of the protein on the enzyme was diminished, meaning that the protein along with starch did not have nearly the same effect as protein with the sugar.  Who knows whether or not it’s even the protein that has the effect and not the sugar?  It can’t be shown from this study. That caveat certainly didn’t make in into The China Study.

See what I mean about a masterpiece of obfuscation?

I could go on and on, but I’ll quit after I give you just a couple more examples.

On page 107 of The China Study Dr. Campbell writes:

At the end of the day, the strength and consistency of the majority of the evidence is enough to draw valid conclusions.  Namely, whole plant-based foods are beneficial, and animal-based foods are not.

Then one inch below (literally) he writes the following:

The China Study was an important milestone in my thinking.  Standing alone, it does not prove that diet causes disease. [Italics in the original]

So, the China study produces valid conclusions as to causality, i.e., “whole plant-based foods are beneficial, and animal-based foods are not.”  Yet the China study “does not prove that diet causes disease.”  Say what?

Don’t believe me, take a look at a scan of my copy:

On page 73 Dr. Campbell dons the mantle of prestige conferred by one of America’s most august newspapers.  Writes he referring to the China study:

We had a study that was unmatched in terms of it’s comprehensiveness, quality and uniqueness.  We had what the New York Times termed “the Grand Prix of epidemiology.”

A quick search of that phrase in the online version of the NY Times reveals that it came from an opinion piece by none other than Jane Brody, a kindred spirit to Dr. Campbell.  Brody, a lipophobe of the deepest hue, has written a number of low-fat cookbooks and is a believer in the plant-based diet. So she hardly qualifies as an unbiased commenter.

And speaking of the so-called plant-based diet, when Dr. Campbell responded to Ms. Minger’s critique, he took her to task for mentioning the words ‘vegan’ and ‘vegetarian’ as it applied to his work.

One final note: she repeatedly uses the ‘V’ words (vegan, vegetarian) in a way that disingenuously suggests that this was my main motive. I am not aware that I used either of these words in the book, not once. I wanted to focus on the science, not on these ideologies.

Just for grins, I turned to the index of The China Study to see if ‘vegan’ or ‘vegetarian’ were indexed.  Here’s what I found on page 417:

vegetarianism or veganism. See plant-based diet

When I flipped over  to ‘plant-based diet’ on page 414, I found a long grocery list of references.

Even in his online response to his opponents, Dr. Campbell apparently can’t resist obfuscating.

Okay, just one more, then I’ve got to draw this to a close.  Let’s go back to the bottom of page 52, the page the paragraphs above and Chart 3.2 appear on.  Dr. Campbell shows in Chart 3.2 how protein is involved in stimulating the liver to convert aflatoxin to the toxic product that he implies is involved in cancer initiation.  He then reports how he wanted to see if animal-based protein was involved in the other phases of the cancer progression cascade.  So he and his grad students started to look.  He writes:

As time passed, we were to learn something quite remarkable. Almost every time we searched for a way, or mechanism, by which protein works to produce its effects [on cancer formation and progression], we found one!

That, my friends, is almost the dictionary definition of the confirmation bias summed up in one sentence.

This tiny bit of the book that I’ve chosen to lay bare is truly the tip of the iceberg.  I could go on and on and on, but I’m sure you get the picture.

Before I finish, I want to get back to something I mentioned earlier about how one of Dr. Campbell’s own colleagues bailed out from the China study because he recognized it for what it was: a giant observational study that was meaningless.  Here is how Dr. Campbell describes it on page 105-106:

When we first started this project we encountered significant resistance from some people.  One of my colleagues at Cornell, who had been involved in the early planning of the China Study, got quite heated in one of our meetings.  I had put forth the idea of investigating how lots of dietary factors, some known but many unknown, work together to cause disease.  Thus we had to measure lots of factors, regardless of whether or not they were justified by prior research.  If that was what we intended to do, he said he wanted nothing to do with such a “shotgun” approach. [i.e., a big, meaningless observational study]

This colleague was expressing a view that was more in line with mainstream scientific thought than with my idea [i.e., a randomized, controlled trial that might demonstrate causality would be a better use of the funds.] He and like-minded colleagues think that science is best done when investigating single – mostly known – factors in isolation. [He and like-minded colleagues are correct.] An array of largely unspecified factors doesn’t show anything, they say. [They are right.] It’s okay to measure the specific effect of, say, selenium on breast cancer, but it’s not okay to measure multiple nutritional conditions in the same study, in the hope of identifying important dietary patterns.

I prefer the broader picture, for we are investigating the incredible complexities and subtleties of nature itself…

So I say we need more, not less, of the “shotgun approach.” We need more thought about overall dietary patterns and whole foods.  Does this mean that I think the shotgun approach is the only way to do research?  Of course not.  Do I think that the China Study findings constitute absolute scientific proof?  Of course not.  Does it provide enough information to inform some practical decision-making? [No.] Absolutely.

Dr. Campbell uses an impassioned written speech to persuade the scientifically untrained that the China study carries vastly more scientific value than it actually does. Once again, it’s a large observational study, but an observational study nonetheless.  And as such, it is useful only in developing hypotheses to be tested with randomized, controlled trials.  The entire 894 page study proves not a shred of causality.

What saddens me about all this is that hundreds of thousands (probably millions) of people who can’t (or won’t) read critically have fallen for the premise of The China Study without even thinking about it.  Believing that the entire book is based on the greatest and most important nutritional study ever completed.  What happened to the ability to read critically?  Has it vanished from the populace?  Based on the comments on The China Study on Amazon it would seem so.

In my opinion, there really isn’t much of substance in the entire 400 plus page book.  But I encourage you to buy it and read it to test your own critical reading skills.  If you don’t want to test your critical reading skills, you’ll at least enjoy coming across some real howlers such as this one believed only by the vegetarian/vegan zealots out there (oh, sorry, plant-based diet followers):

As you will see in this book, there is a mountain of scientific evidence to show that the healthiest diet you can possibly consume is a high-carbohydrate diet. [italics in the original]

I wonder if Gary Taubes, who wrote a vastly more scientific book, would agree?

Lest you think I’m being too hard on poor Dr. Campbell, let me tell you a few things.  First, as I mentioned earlier, the few sections of The China Study I dissected are just a tiny fraction of the whole.  I could go on and on. Second, Dr. Campbell mentions Protein Power by name on page 19 and labels it a modern protein fad diet that “continue[s] to inflict a great variety of dangerous health disorders.”  Third, he is absolutely and unnecessarily brutal in his treatment of Dr. Robert Atkins.  He has an entire section on Dr. Atkins starting on page 95 that runs for almost three pages.  After quoting from one of Dr. Atkins’ books, he writes the following about the deceased diet doctor:

There are snake oil salesman, who have no professional research, professional training or professional publications in the field of nutrition, and there are scientists, who have formal training, have conducted research and have reported on their findings in professional forums. Perhaps it is a testament to the poser of modern marketing savvy that an obese man with heart disease and high blood pressure [here he inserts a citation for an article discussing Dr. Atkins’ death] became one of the richest snake oil salesmen ever to live, selling a diet that promises to help you lose weight, to keep your heart healthy and to normalize your blood pressure.

A way below-the-belt commentary when you consider that Dr.Atkins was a trained cardiologist who took care of thousands of real, live patients throughout his career – he wasn’t, like Dr. Campbell, a bench scientist doing rat studies in a lab.  Bob Atkins and I have had our differences, but were he still alive, I would vastly prefer to put my own care in his hands than I would those of Dr. Campbell, who has never treated a patient in his life.

You may ask if I took anything of value from my reading of this book?  I did.  On page 107 Dr. Campbell writes the following:

The results of this study…convinced me to turn my dietary lifestyle around. I stopped eating meat fifteen years ago, and I stopped eating almost all animal-based foods, including dairy, within the past six to eight years, except on very rare occasions,  MY cholesterol has dropped, even as I’ve aged; I am more physically fit now than when I was twenty-five; and I am forty-five pounds lighter now than  was when I was thirty years old.  I am now at an ideal weight for my height.

I have no reason to doubt Dr. Campbell’s own medical and dietary history (except maybe for the part about being more physically fit than he was at age 25 – that’s a tough act for someone who is 73), so I’ll assume it’s all true.  As I recall, he had a trim physique when I met him 10 years ago, which, assuming nothing has changed, is probably the same.  And I’m going to take Dr. Campbell at his word about what he eats.

Granted, I’m younger than Dr. Campbell, but I follow almost the opposite diet as he does yet I, too, have low cholesterol, very low blood pressure and am ideal weight for my height.  What this all tells me is how wonderfully adaptive the human species is where diet is concerned.  It’s no wonder we took over the earth.

** Lillian Hellmann was predictably furious over McCarthy’s comment and adopted the typical American response: she sued.  In one of those turns in which the law of unintended consequences jumps up and bites one, many of her untruths came to light in the courtroom as McCarthy was forced to defend her statement.  Hellmann disengaged by dying during the proceedings.

It’s worse than I thought.

Not long after posting, I came across a McClatchy column in our local paper pushing the perspective of most dermatologists, a perspective that’s so unbelievable that it almost reaches comedic proportions. (Our local paper requires paid registration, so I’ve linked here to a paper that doesn’t.) The piece serves to show in spades the way dermatologists think (if that’s what you call it), and lets us know why their advice should be taken with a huge grain of salt.

The piece was written by a health writer, but her go-to experts were a couple of academic dermatologists:

We’ve got the skin-care basics from two experts in the field: doctors Nancy Thomas, associate professor at the University of North Carolina’s Department of Dermatology Lineberger Comprehensive Cancer Center, and Kelly Nelson, assistant professor at Duke University Medical Center’s Department of Dermatology.

As I started reading this article I was preparing myself for all the normal admonitions to slather with sunscreen, wear a big hat, avoid sun bathing, etc., but even I – who am used to reading idiocy in the press about things medical – was stunned at the levels of caution recommended by these brain-dead dermatologists.

Both of these doctors agree that everyone needs sun protection, and needs it apparently all the time. If you listened to them, you almost wouldn’t walk by an open window without using sunscreen first.

Even if you’re inside much of the day, you’re exposed walking to your car, into the grocery store or into work.

So, if you go to the mall, don’t forget your sunscreen for that long walk from the  car to the door.  And don’t forget to reapply before you walk back to the car if you happen to stay in there for a couple of hours.

But what about vitamin D?  A lowly SPF 8 reduces vitamin D synthesis by 90 percent, so your sunscreen-slathered walk from the car to the store gains you no vitamin D. Where should you get it?  Well, if you ask the question, the good doctors start finger wagging.

And don’t make the vitamin D argument, which says sun exposure is necessary to absorb the highly important vitamin. Just take a vitamin supplement

Okay.  But Dr. Holick writes

when you are exposed to sunlight, you make not only vitamin D but also at least five and up to ten additional photoproducts that you would never get from dietary sources.

What about these additional photoproducts?  I’m sure nature didn’t endow us with the ability to make them for no reason.  And you can’t get them from supplements, so where do you get them if you don’t get some sun exposure?  The answer is, you don’t.

Plus, vitamin D supplements are just that: supplements.  They supplement the vitamin D you make yourself – they don’t replace it.

If, God forbid, you actually do go out in the sun, the good doctors recommend a sunscreen with a SPF 30 if not higher.  And don’t just smear a little on, they recommend at least two ounces of the stuff (about a shot glass full).  Plus they want you to put it on at least 20 minutes before going outside and re-slather yourself with another shot glass of the stuff every two hours.

Just this week, New York Times health columnist Jane Brody jumps into the rolling river of mainstream dermatologic nonsense and is swept along to her own idiotic conclusions.  Her greatest fear is sun-exposure-driven skin cancer, not just premature aging and skin spots, although she does comment on those.  Using anecdotal information she would decry in others, she brings her own relatives in as examples.

My paternal grandmother, who lived a block from the beach in Brooklyn and swam daily in the years before sunscreens, had what we called “elephant skin” by her 50s.  But my 90-year-old Aunt Gert, who lives nearby and winters in Florida but never went to the beach or sat in the sun, has the skin of a 60-year old.

Well, I guess that settles that.  And I’ve got a great uncle, still going strong at age 87, who drank like a fish and smoked two packs a day for most of his adult like.  According to Jane’s logic, maybe we should adopt Unc’s lifestyle.

The real meat of Jane’s piece is that since the sun makes us feel better and look better (the vast majority of people surveyed say a tan is more aesthetically pleasing than fish-belly white), people are becoming addicted to the sun.  And, as with any addiction, sun addiction is tough to break.

Jane worries that sun addiction leads first to overexposure then to skin cancer.  She quotes the oft-cited statistic that this year will see

3.5 million new cases of superficial but often disfiguring skin cancers, and an estimated 68,720 melanomas

I think she’s overstating the case for these superficial skin cancers being “disfiguring.”  Most are basal cell or squamous cell skin cancers, which are virtually non-malignant and can be removed without leaving much – if any – evidence of their ever having been there. Both MD and I have had basal cell cancers removed from our foreheads in minor office procedures without any evidence they were ever there.

The 68,720 melanomas, which are malignant, are much more attention getting.  But, there is no evidence that excess sun exposure causes melanoma, while there is data showing that chronic sun exposure and vitamin D seem to prevent it.

Just for grins, let’s go along with Jane and assume that melanoma is caused by the sun.  If we go to the latest cancer statistics from the American Cancer Society (ACS), we find that 8,700 people died last year from melanoma.  We know that sun exposure and vitamin D (along with maybe the other 5-10 photoproducts we synthesize from sun exposure) help prevent breast, colon and prostate cancer.  If Jane is correct and we avoid the sun, we run less risk of being one of the 8,700 people who perish from melanoma. But what about the other side of the coin?

According to the same ACS statistics, last year 40,230 people died from breast cancer, 32,050 from prostate cancer and 51,370 from colon cancer. So, on the one hand, we have 8,700 people die of a disease that probably isn’t related to sun exposure while on the other we have 123,650 who died from cancers known to be related to lack of sun exposure.  I don’t know about you, but I’ll go with the sun exposure, “disfiguring” superficial skin cancers be damned.

Plus, we didn’t even mention the devastating disease multiple sclerosis, a disease much more common in those with little sun exposure.  There are between 250,000-350,000 new cases of MS diagnosed each year. I’ll be happy to accept the risk of a few minor cancers to significantly reduce my risk of developing MS.

The danger of too much sun is minimal – the danger of too little sun is enormous.  I know which side I come down on.  The health trade offs remind me of a corny joke I heard when I was a kid that made such an impact on me that I’ve remembered it since.  The joke (or parable) was about economic issues, but it applies to sun exposure as well.

Did you hear the one about the guy who took big steps to save his twenty dollar shoes and ripped his 50 dollar pants?

It’s just another way of saying don’t be penny-wise and pound foolish.  In terms of our current discussion, we could say, Don’t be skin-cancer-wise and colon-breast-prostate-foolish.  Which is exactly what the misguided perspective of most dermatologists would have us be.

Painting: Olive Trees with Yellow Sky and Sun by Van Gogh

During the whirlwind that has been my life of late, I managed to make my way through Dr. Michael Holick’s terrific book The Vitamin D Solution from which the above quote comes.  Before I get started on my review, in the interest of full disclosure, I’ve got to tell you that of all the books I’ve reviewed on this blog since its inception, this is the first and only one that I’ve been sent gratis by the publisher.  It was strange how it came about.  I learned of this book long before it was published and had pre-ordered it through Amazon.  A few weeks or so after my pre-order, I received an email from the publisher’s PR agent for this book asking if I would like a pre-publication copy for possible review.  I sure would, said I, and promptly canceled my Amazon order.

I’ve been a fan of Dr. Holick’s for years now, reading every paper he publishes, which is a considerable job given his prolific output.  I’ve corresponded with him a time or two on a few issues and he has always been very generous with his advice.  I consider him THE authority on vitamin D.  So, I was eager to dig into his book.

I wasn’t disappointed.

I figured that somewhere along the way, Dr. Holick had gotten intrigued with vitamin D, had pursued his interest and had become sort of a guru.  But in reading his book, I learned that he is much more than that.  He began studying vitamin D as a graduate student and ended up being the person who actually discovered 1,25 (OH)D, the major circulating form of vitamin D in humans.  This was back in the early 1970s, and he’s been studying vitamin D without letup since.  His book is the most up-to-date source of all the science available about this amazing nutrient.

Dr. Holick sums up the importance of vitamin D to human well being in this single sentence from early in the book:

The sun is as vital to your health and well-being as food, shelter, water and oxygen.

Which seems reasonable since every morsel of energy we consume originates with the sun.  No sun, no plants.  No plants, no animals.  No plants and animals, no us.  As Sir Karl Popper noted, we eat the sun. We evolved in the sunlight, so it makes sense that the sun offers other benefits as well food.

Dr. Holick begins his book with a fascinating comparison of a ten-year-old girl growing up somewhere along the equator to a ten-year-old girl growing up in the United States or Europe.  The former will probably never learn how to use a computer, never go to a mall, never learn to drive a car and will probably end up spending most of her life outside tilling the soil as did her parents and grandparents.  She will probably experience periods in her life of poverty and poor nutrition.  By contrast, her US or European counterpart will always have plenty to eat, will learn to shop, order pizza, operate a computer, Game Boy, Wii, and God only knows what other kinds of electronics.  She will have her doting parents slather sunscreen on her to protect her skin from birth until she’s old enough to do it herself.  She will come of age in a different world, filled with the latest in medical technology.

And she will pay for it with her health.

Her equatorial counterpart will be only half as likely to get cancer in her lifetime.  She will have an 80 percent reduction in risk of developing type I diabetes before the age of 30.  And she will live longer.  If she can avoid trauma or an untreated severe medical condition, the girl growing up in the more primitive but sunny circumstances will have an overall 7 percent greater longevity than her US/European counterpart.  She will have stronger bones, lower blood pressure, fewer cavities in her teeth, a greatly reduced risk for heart disease, type II diabetes, obesity, arthritis and most of the other diseases that will plague her more Westernized sisters.

Why the difference?  According to Dr. Holick, the equatorial girl has vastly more exposure to natural sunlight over her lifetime than does the other.

But, you might ask, why don’t the children in the US and Europe play outside more in the sunshine and reap its many benefits?  A couple of reasons.  Most of the US and Europe are too far north to get enough sun exposure to generate the production of adequate vitamin D during a large part of the year.  And, second, most parents are so fearful of sunburn that they slather their kids with sunscreen if and when they let these children play outside during the part of the year they can make adequate vitamin D.  Since a sunscreen with an SPF of only 8 reduces the synthesis of vitamin D by 95 percent, think of how little vitamin D children with sunscreens of SPF 30 or 45 are making.  Zero.

Why?

Heliophobes.

Readers of this blog know that I refer to people who have an unreasoning fear of fat as lipophobes, fat fearers.  Well, since Helios was the Greek god of the sun, I’ll call those who have an unreasoning fear of the sun heliophobes.

Why do people become heliophobes?  Same reason they become lipophobes: they refuse to think.

Just as lipophobes see a heart attack in every morsel of fat, heliophobes see skin cancer in every ray of sunshine.

To give them their due, the heliophobes have at least a smidgen of data to bolster their point of view.  Unlike the lipophobes, who have no reliable data demonstrating that saturated fat causes heart disease, the heliophobes can point convincingly at the data showing sun exposure causes problems for the skin.

Unquestionably, excess sun exposure causes premature aging of the skin and a couple of types of skin cancer.  Of this there is no doubt.  But, lack of adequate vitamin D appears to be related to an entire host of serious problems including melanoma, the most dangerous and deadly form of skin cancer.  The most common type of skin cancer from overexposure is basal cell carcinoma, which is just about the least malignant of all cancers, and if treated (by removal) results in virtually no mortality.  The same can’t be said for prostate, breast and colon cancers, all cancers thought to be sun (or, more correctly, lack of sun) related.  These cancers are much more prevalent the farther north one goes and almost non-existent at the equator.

The trade off, in my opinion, is well worth it.  Especially when it’s possible to have the best of both worlds and avoid both the premature aging, minor skin cancers AND the breast, prostate and colon cancers (not to mention multiple sclerosis, osteoporosis, and the host of other disorders laid at the doorstep of too little vitamin D) by sensible sun exposure.

Dr. Holick tells you how.  He provides charts and tables telling you how much sun exposure you require for adequate vitamin D synthesis depending upon where you live in the world.  And he describes how you can make up any difference by taking vitamin D supplements.

Why not just take the supplements and forget about the sun?

Vitamin D made in the skin lasts at least twice as long in the blood as vitamin D ingested from the diet.  When you are exposed to sunlight, you make not only vitamin D but also at least five and up to ten additional photoproducts that you would never get from dietary sources or from a supplement.

Old Mother Nature is pretty parsimonious with her creations, and I suspect she wouldn’t have five to ten photoproducts circulating around if they didn’t do something good for us.  Just because we aren’t advanced enough yet to figure out what it is they do, doesn’t mean they don’t do something.  Thus Dr. Holick’s recommendation to hit the sun if at all possible instead of the supplement bottle.

Plus, there are some downsides to indiscriminately throwing back the supplements without monitoring your 25 (OH)D levels.  See here and here, for example.

One of the few criticisms I have of this exceptional book is that Dr. Holick goes way overboard in his obvious worry about the opinion of the heliophobes.  Throughout, he repeatedly warns against overexposure as if getting a little too much sun from a day at the beach could lead to one’s body becoming wrinkled and having skin cancers the size of buboes popping out all over within a week.  But we can’t be too hard on the poor Doc because the water in which he swims professionally has a high SPF indeed.  His colleagues are primarily dermatologists and Dr. Holick works hard not to gain their total opprobrium.  As cardiologist wage their misguided war against fat, dermatologist wage theirs against the sun.  And just as many cardiologists haven’t figured out that fat can be a good thing, dermatologists apparently haven’t learned of the good sunshine can do.  Or if they have learned it, they’ve chosen to ignore it to their patients’ detriment.

The dermatologists are a pretty vocal group and are constantly issuing press releases about the dangers of sun exposure.  So sun phobic are dermatologists that in their minds, the perfect place to vacation would be inside a cave.  I’m not really exaggerating – they are heliophobes of the deepest dye.  And they don’t tolerate dissent.  Ask Dr. Holick.

In 2004 I was forced to give up my position as a professor of dermatology at Boston University Medical Center, a position I had held for nearly ten years.  My stalwart support of sensible sun exposure just didn’t jibe with the views of the chair of the department.

Since this time the scientific literature has exploded with articles about the benefits of vitamin D and the widespread epidemic of vitamin D deficiency.  (I just ran a PubMed search for vitamin D and found 48,552 citations.) I wonder if this silly woman who fired him and was so pompous and cocksure now feels any sense of remorse?  Especially since she still labors in obscurity while Dr. Holick is an academic rock star.

Another point I would take issue with is Dr. Holick’s statement in the book that there is no difference between vitamin D2 and vitamin D3.  He says he’s performed studies looking at these two versions of vitamin D and found both of them to maintain vitamin D levels in the appropriate range.   Since he’s done the studies and seen the data, I don’t have any reason to disagree with him on his findings.  But, there have been a number of anecdotal reports showing that people with problems due to vitamin D deficiency seem to have better symptomatic improvement if they take vitamin D3 (the real vitamin D) than if they take equivalent doses of vitamin D2.

Since these are anecdotal reports, we can’t put absolute faith in them, but I would still recommend vitamin D3 over vitamin D2.  In these situations where one supplement is supposed to perform better than another, usually the one that allegedly performs better, costs more.  So you end up in a risk reward situation: Do I want to pay more to get a better effect or do I want to pay less and hope for adequate results?  In the vit D3 versus vit D2, we don’t have this circumstance.  Both are dirt cheap, and, if anything, vitamin D3 is less expensive.  So if they both create the same blood levels, but one engenders more anecdotally positive reports, why not go with it.  My advice is to buy vitamin D3 and avoid the D2.

One more criticism I have of the book (might as well get ‘em out early) is Dr. Holick’s aligning with the mainstream in criticizing saturated fat.  I’m sure he hasn’t looked at the literature on saturated fat, because if he had, he wouldn’t have written what he did.  But I can’t really hold that totally against him since he is, after all, a mainstream guy (in all but his defense of sunshine), and, as such, would be expected to be marinated in the mainstream biases.

Unfortunately, for a century now, the American diet has been getting higher in fat–especially in the extra-unhealthy saturated fats.  This may partly explain why skin cancer rates have gone up, as well as diabetes and heart disease.  The average American diet is about 16 percent saturated fat, whereas most qualified dieticians [sic] will tell you it should be no more than one third of that.  To make matters worse, there has been a trend toward fad weight-loss programs advocating high fat content (the Atkins diet is probably the best known of these).

Leaving aside whether these diets actually work in the long term to help people keep weight off, diets high in saturated fat may cause a variety of life-threatening health problems and probably contribute to skin cancer, not to mention all other types of cancer.  But you don’t necessarily have to go on a traditional ‘diet’ to achieve the results you’re looking for.  You just need to start moving toward foods lower in saturated fat and try to limit or evict those foods that contain excessive amounts of fat–which is typically found in processed products (which also usually contain lots of salt and sugar) and marbled meats.  There are several excellent eating plans out there that advocate eating this way.

It’s beyond the scope of this book to offer specifics on the perfect diet, but I’ll say that a healthy eating regimen calls for plenty of fresh fruits and vegetables, high-quality proteins (“high-quality” meaning they are low in saturated fat but can be high in healthy monounsaturated fats, as is the case with wild salmon), and whole grains.

Jesus wept.

Fortunately, aside from a few small mentions here and there, this is about the extent of his saturated fat bashing.

For a while now, I have been worried about the long-term effects that will come about from the heliophobes and their constant sunshine bashing. (In fact, MD and I wrote a whole chapter about it in The Protein Power LifePlan back in 2000.)  But after reading The Vitamin D Solution, I’m greatly concerned.  Conscientious parents have no idea of the future damage they may be causing by never letting their children play outside without slathering them with sunscreen.  Today’s children have weaker bones are are much more prone to fracture than children of a few decades ago.  As Dr. Holick reports

Even more alarming is a new epidemic in which bone formation in children appears normal but is actually much softer than is should be.  Girls today break their arms 56 percent more often than did their peers forty years ago.  Boys break their arms 32 percent more often.

I’m sure the girls and boys of forty years ago were much more rough and tumble than the ones of today, yet the kids of today suffer more fractures.

While writing this post I got an email notifying me of a recent study showing that melanoma, a virulently malignant form of skin cancer is occurring with frighteningly high frequency in today’s teens.  These are the adolescents at the leading edge of the great heoliophobe movement, the very ones whose parents, in an effort to protect them, coated these kids liberally with sunscreen every time they walked out of doors.  Did their well-meaning parents set them up for this terrible disease?  Are the chickens coming home to roost?  It’s difficult to say for sure, but, in my opinion, it’s more than likely.  Here’s what happened.

When I was a kid, I played outside all the time.  So did all my friends.  We were outside, especially during the summer, from the time we got up until it was dark.  Since we played outside most all the time, as summer approached and the suns rays became more direct, we had already developed the base of tan from being outside all during the spring when it was difficult to get sunburned.  Our tans protected us from the effects of the sun, blocking both UVA and UVB light.

UVB rays are those that burn the skin and the ones that drive the synthesis of vitamin D.  UVA rays are those that mobilize the melanin (the pigment in the skin) and bring it to the surface.  When enough melanin comes to the surface, our skin gets darker, i.e., we develop a tan.  The tan then protects us from the harmful effects of the sun, allowing us to stay out all day without getting a sunburn and without getting too much UVA, which is important since excess UVA exposure is thought to be the cause of melanoma.

Although many sunscreens available today claim to block both UVB and UVA, when today’s teens were young children, virtually all of the sunscreens on the market then blocked UVB only.  Which is probably the root cause of the increase in melanoma in adolescents today.  Here’s what happens.

People who don’t use sunscreens and who have good sense get out of the sun when they begin to burn.  Avoiding the sun limits the exposure to both UVB, the burning rays, and UVA, the melanoma-stimulating rays.  When people slather on sunscreen that blocks UVB only, they can then stay out in the sun for a long time without burning.  The price they pay for this is that they end up with an extremely large dose of UVA, which doesn’t cause pain but sows the seeds for later melanoma development, a fate that has in the past befallen many a vacationer to the sunny areas of the world.

Many people labor away in offices for 50 weeks of the year then escape for a couple of weeks of fun in the sun.  Since they have limited time, they don’t want to spend it with graduated sun exposure while they develop a tan.  They pile on the sunscreen in copious amounts, hit the beach and stay out all day, stopping only long enough to put on more sunscreen.  During this process, they accumulate the effects of huge exposure to UVA and often pay the price years later by developing melanoma.  Those hardy folk who work outdoors all year long and have constant sun exposure almost never develop melanoma.  Why?  Because they develop a tan that blocks the UVA.  Plus, thanks to their constant sun exposure, they receive the benefit of plenty of vitamin D synthesis, which has been shown to be protective against melanoma.  The poor schmucks on vacation who broil in the sun while basting themselves with sunscreen get way too much UVA and don’t get any vitamin D because sunscreen blocks virtually all of the vitamin D synthesizing rays.  They are the victims of a true double whammy.

And that is what I suspect is driving the increase in melanoma in teens today: their poor misguided parents attempting to do the right thing.  Very sad, indeed.

Along with the increase in melanoma, the huge epidemic of fibromyalgia we are seeing today is in great measure a consequence of vitamin D deficiency.  Without enough vitamin D, bone doesn’t harden as it should.  It grows, but is softer and mushier and less supportive than it should be.  The body continues to make more bone to try to remedy the problem and the bones actually enlarge.  This enlargement presses against the periosteum, the fibrous sheath that surrounds the bone and through which the nerves run.  As the pulpy bony growth presses against the periosteum, it stimulates the nerves in the periosteum and causes the deep bone pain common to sufferers of fibromyalgia.  Doctors who are up to date on their vitamin D knowledge will press the breastbone to try to elicit pain.  And if they do, their patient is probably suffering from a vitamin D deficiency.  If that’s what the blood test shows, then the fibromyalgia can be treated with a course of sunshine and/or vitamin D supplementation.

A couple of weeks ago, I was reading The Vitamin D Solution on a plane, and the guy sitting across the aisle from me was reading Predictably Irrational, which I had read and enjoyed a while back.  I kept looking to see where he was in his book, and he kept glancing at mine.  After we had landed and were taxiing in, he asked me if I had ever known anyone who had responded medically to vitamin D.  He then told me that he had been experiencing severe, debilitating pains in the bones in his chest, back and legs.  He went to his doctor, who checked his vitamin D levels, found them way low, and started my new friend on a course of vitamin D supplements, which, in due course, had gotten rid of his problem.  He was a pretty tan guy, so I asked him about his sun exposure and wondered why he would be vitamin D deficient.  He then told me he was a kidney transplant patient, which explained everything.  As you will learn when you read Dr. Holick’s book, the kidney converts the inactive form of vitamin D circulating in the blood to the active form.  This gentleman’s transplanted kidney obviously wasn’t doing it for him.  Vitamin D supplements did the trick, however, and his pains had vanished.

The subject matter I’ve covered in this post barely scratches the surface of what’s there in Dr. Holick’s new book.  I heartily recommend it to all.

Before I sign off here, though, I want to relate a funny story.  Funny to me at least.  It involves a character who was a running dog of mine back when I was in medical school.  Any of you who read The Protein Power LifePlan already met this guy in another humorous adventure of his I related in the section on iron overload.  He’s the guy who dated the pig lady.

This guy was, in Billy Bob Thornton’s memorable words to Woody Harrelson in the movie Indecent Proposal, a “real poon hound.”  This guy would relentlessly go after anything with a skirt.  And, as often happens with those types, he came down with a bad case of herpes.  As soon as he got his diagnosis he went into a depression for about a week and then began reading everything he could read on herpes.  He discovered that herpes was typically a local infection but that in some patients (mainly immunocompromised ones) herpes could go systemic, which means it could spread through the bloodstream and and create a hellish infection everywhere, often with fatal consequences.  His affliction was never far from his mind, which led to the tale that follows.

In those days Zovirax hadn’t been developed, so the only remedies for this loathsome disorder were OTC products that didn’t really work.  At that time the main OTC med was Stoxil, which my friend purchased by the car-load lot and coated himself (or at least his infected parts) with at the least sign of an outbreak.

One day he came down with some kind of upper respiratory infection and called me to get something for it.  He was prone to these infections, which responded well to minocycline, a tetracycline-derivative drug.  I called him in a course of the drug and forgot about it.

Unbeknownst to me, my friend was planning a day at the lake with his latest inamorata.   Complexion-wise, he was lily white and usually avoided the sun.  A day at the lake was not his typical recreation, so I can be excused from not telling him not to go out in the sun; it would have never occurred to me that he might do so. The sun can be a problem because tetracycline drugs have a propensity to give people who take them a photosensitivity reaction when they get too much exposure.  These photosensitivity reactions cause the skin to swell and become discolored and blistered.

My friend took his meds as prescribed, had a great day at the lake, came home with the girl and hit the sack.  After he had been asleep for a few hours, he woke up needing to relieve himself.  On his walk to the toilet, he passed the bathroom mirror and glanced at the mirror wherein he saw the Elephant Man staring back at him.  His face red, blistered and swollen, eyes just slits.  He had obviously had a bad photosensitivity reaction (obviously that is to those who knew about such things) after his day in the sun while on minocycline.  But he didn’t know this.  He flew into a blind panic because the first thing that sprang to his mind was that his herpes was swarming on him: that he had developed systemic herpes.  He immediately grabbed the Stoxil and practically bathed in it.  Then he put in an emergency call to his dermatologist, whom, I’m sure, found it strange since dermatologists rarely — if ever — get emergency calls.

When he told me about it later in the day, I burst out laughing and have laughed about it any time I thought of it up to this moment.  In fact, I’m having trouble typing these words because I’m still laughing so hard remembering.  Who says doctors are humorless?  My friend even laughed about it later, though admittedly not to the same degree I did.  What I found so funny was not his condition but the fact that he was so obsessed with his herpes that the first thought that jumped to his mind was that his disfigurement was his herpes going wild.  Maybe you just had to be there.

Don’t let my semi-off-topic detour make you forget about picking up a copy of Dr. Holick’s book.  Despite my few minor criticisms, it is an excellent book that provides a wealth of useful information.  Just the Q&A is worth the price of the book because in that section Dr. Holick answers all the questions anyone might think of about vitamin D, including the one I’ve been asked numerous times: If you shower after sunbathing, does it wash away the vitamin D.  The answer is No.  Then he explains why.

There is something for everyone in this book, from studies showing sun bathing works as well (if not better) than medications for lowering blood pressure to discussions of vitamin D and its effects on obesity and leptin secretion.  It doesn’t matter if you’re depressed, have multiple sclerosis, psoriasis, osteoporosis or even PMS, you can learn how vitamin D will help you out. Grab a copy and start reading.

Since the last time I posted (which, admittedly, was a while ago), I’ve flown about 8 billion miles, so I’ve had plenty of time to read while in the air.  Here is a list of the books  on my nightstand right now.

Pandora’s Seed: The Unforeseen Cost of Civilization by Spencer Wells.  I’m about a forth of the way through this book describing the problems we hunting/gathering humans have had in adapting to agriculture.  So far, so good.  A couple of medical missteps already, but nothing major.  But I haven’t gotten to the real meat of the part on disease, so I’ll reserve my judgment until then.

The Upside of Irrationality: The Unexpected Benefits of Defying Logic at Work and at Home by Dan Ariely.  This is the follow up book to Predictably Irrational, which I posted about earlier.  While the first book explained how predictably irrational we humans really are, this second one teaches us how to benefit from it.

Manthropology by Peter McAllister.  A fun book written by an Australian anthropologist discussing what wimps modern men (and women) are compared to their Paleo ancestors.  According to McAllister, today’s elite athletes would have trouble competing with our ancient predecessors in any events requiring speed or strength.  Unfortunately this book won’t be available in a US edition until Oct 2010.  If you want it before then, you can get it on Amazon, but you’ll have to pay through the nose for it like I did. I couldn’t resist the title.

The First Cut, Cut to the Quick, and The Deepest Cut all by Dianne Emley.  The careful reader can probably detect a theme in these books, which are are police procedural mystery novels set in Pasadena, CA.  The protagonist, Nan Vining, is a single mom and has recovered from a near death experience after having been stabbed in the throat while on duty.  These have been my escapist books over the past couple of weeks.  I’m running out of mysteries to read because it seems that I have read everything written by US and UK (and even Australian) authors.  Help!  Any and all suggestions will be appreciated.

36 Arguments for the Existence of God: A Work of Fiction by Rebecca Goldstein.  A literary novel if there ever were one.  Probably not everyone’s cup of tea, but I enjoyed it immensely.  It has so many moving parts that it’s hard to describe.  Read the Amazon review if you’re interested.

The Rational Optimist: How Prosperity Evolves by Matt Ridly .  I was curious to see how Matt Ridly, an excellent science writer, would approach a more soft science than usual.  His thesis is that collective human intelligence will save us from the fates all the Erhlich’s and Malthusians fear await us.

Decoding Reality: The Universe as Quantum Information by Vlatko Vedral. Another book that is no doubt not everyone’s cup of tea, but I’m a physics/quantum mechanics geek so I enjoy this kind of book.  It explores the idea that information is the basic element making up the universe.

Cro-Magnon: How the Ice Age Gave Birth to the First Modern Humans by Brian Fagan.  Dr. Fagan is an Emeritus Professor of Anthropology at the University of California, Santa Barbara and a fellow member of the Santa Barbara Yacht Club. This book, his latest, explores the time that Cro-Magnon man and Neanderthals co-existed in Europe and how the superior intellect of the former allowed them to survive the Ice Age.  Until I read this book, it hadn’t occurred to me that the Cro-Magnons, who were identical to us genetically, roamed Europe for about 30,000 years, a length of time vastly longer than all of recorded history.  And yet it seems we know less about them than we do most of the other primitive beings.

The sous vide project has gone wild.  Instead of watching from the sidelines and showing up at board meetings, which heretofore has been my chief activity vis a vis the company, I am now in charge of the entire direct-to-consumer operation.  Consequently, I have been on the road and will continue to be a road warrior for a while.

Tomorrow, in fact, will find MD and me in San Francisco at the Sur La Table store for a Sous Vide Supreme demonstration.  Richard Blais, the chef pictured above with the two us (he’s the one with the faux hawk), will be doing the demo, but MD and I will be in attendance.  So, if you want to drop by and meet us, have a chat or just see how much older we look in person than in our photographs, come on down to the Ferry Building Marketplace in San Francisco tomorrow (May 8th) from 10 ‘til 2.  Hope to see you there.

And I hope to be back to some sort of regular blogging schedule maybe next week.  I don’t have to leave until the end of the week.

Sad to say, but this wasn’t the first time I’ve ever labored in the back end of a restaurant.  Both MD and I are very familiar with those duties.  One of the truly bad moves of my financial life was investing in a franchise restaurant years ago.  I still don’t know what came over me, but whatever did, it cost me a lot of money.  I distinctly remember how it all happened.  I was sitting in the kitchen of our house in Little Rock going through the mail and came upon a magazine buried in the pile.  I don’t remember now what magazine it was, but it had an article on hot new restaurant concepts.  One of the hottest, and one that was taking Dallas by storm, was a Mexican restaurant franchise called ZuZu.  ZuZu Handmade Mexican Food, to be exact.

I read the article and inexplicably reached around behind me, picked up the phone and dialed the number to get more info.  (A phone call, I might mention, that cost me hundreds of thousands of dollars before it was all over.)  The person on the other end – a honcho from ZuZu corporate office in the Rolex Building in Dallas – painted a wonderful picture of restaurant ownership, and before I knew it, MD, our eldest son and I were headed to Dallas to see a ZuZu restaurant in the flesh and try the food.

The food was dazzlingly good – all fresh, all handmade.  We tried just about everything and didn’t find anything that we didn’t love.  And much of it was low-carb, to boot.  Our eldest was just out of college and looking for something to do and our middle son was going to graduate soon.  After discussion with them, we decided to take the plunge.  Bad, bad, bad mistake on many fronts, but we learned a lot.  And that’s about the best face I can put on it.

The kids all went to Dallas and underwent the training program.  MD and I purposely avoided learning how to operate the cash register or do anything in the front of the house.  We had a large medical practice in Little Rock (a relatively small city) and didn’t want to be doing a pelvic exam or a rectal exam on someone in the morning, and then greet them that evening wearing a ZuZu hat and a big smile with ‘For here or to go?’

Consequently, whenever things went crazy – as they always do in the restaurant business – MD and I got dragooned into working the back of the house where we could do our part yet stay out of sight. One day during the first couple of weeks of being open was particularly memorable. MD and I both had presentations to make to a large medical meeting in Seattle, but the day before those presentations, we were scheduled to be on CBS The Early Show and the day before that on the Sally Jesse Raphael show.  I was busy putting together my slides for the medical presentation while MD was working on patient charts when we got the call.  MD headed to the restaurant while I stayed at the office and finished my slides.  By the time I got to the place, it was a true hellhole. MD was surrounded by piles of dirty plates, glasses, pots and pans and was deep into catching up on the dish washing so I jumped in and started prepping by chopping tomatoes, limes, onions, cilantro, you name it.  As soon as the dish washing was caught up (which took over six hours), MD started helping me prep. I was on a roll with all the stuff I was slicing and dicing, so she grabbed the peppers that I hadn’t gotten to yet and began.

As closing time approached, we began preparing the stuff for the next day.  In doing so – and I don’t remember now how I did it – I burned the bejesus out of my hand and had an enormous half-dollar size blister pop up.  After closing, MD and I got home and got into bed to get a few short hours of sleep before our 6 AM flight the next morning.  As we lay there recounting the day and wondering about our sanity for ever embarking on such a folly, MD said that her hands were starting to burn.  In just a few minutes, her hands were on fire.  She had been chemically burned by the juices from all the peppers she had prepped, and, like a sunburn, it had taken a few hours before she started feeling the effects.  She jumped up, held her hands under the cold water for about five minutes, then slathered them with a cortisone cream we had at the house.  She came back to bed and worried all night that her hands would end up red and grotesquely swollen by the morning, and that she would have to appear on national TV with lobster hands along with her husband with his giant blister.  What a nightmare!

Her hands were okay by morning – a little red, but nothing all that noticeable.  I still had the enormous blister I was trying to keep intact so that the skin would act as a dressing, but I figured I could probably keep it out of sight of the cameras.  We caught our flight, went on with Sally Jesse that afternoon and the CBS morning show the next day without incident.  Then it was off to Seattle for that gig.

In addition to our labors on the above-mentioned disastrous day, MD and I have both washed thousands and thousands of dishes using the commercial dishwasher, which has a lot of hands-on effort that goes along with it.  It seemed that it always fell to me to do the prep work.  I’ve sliced and diced rosemary, cilantro, garlic, onions, tomatoes and peppers by the car-load lot. ( And along the way I developed pretty good knife skills without sacrificing any of my fingers in doing so.)  So the two of us have spent plenty of back-breaking time in the bowels of a commercial kitchen.

But never in an enormous kitchen designed to service a fairly high-end restaurant like the one we found ourselves in the other night.  I was eager to see how it all worked.

I learned plenty.  For one thing, it’s really easy to cook in a big commercial kitchen because you have everything at your disposal.  And you don’t have to dig all the stuff out when you need it – it’s already there.

If you need to quick chill something, the giant ice bath is right there.  If you need to throw an entire tray of stuff into a big fridge, you’ve got it available without having to rearrange everything so it will fit.  If you need to quickly blanch something, there is the giant strainer and the pots of boiling water are at the ready.  It really makes cooking much more hassle free than it is at home.  And the best part of all is that you have (or at least we did during this event) staff who clean up behind you.

In between my various tasks assigned tasks, I snooped around, and my worst fears were confirmed.  Before we get to that, though, let me tell you what I’ve learned about chefs.  What I’m about to say doesn’t apply to every chef who cooks, but I would guess it applies to most.

Chefs are not particularly health conscious. They cook for flavor, not for health.  If there is a choice between making something taste a little better or making it a little more healthful, taste will win every time.  Which is a good thing in many cases because chefs – like most other people – have been brainwashed as to what is healthful and what isn’t.  Most doubtless believe that saturated fat is unhealthful, but, fortunately, that doesn’t deter them from using butter, heavy cream, bacon, and all the other tasty high-saturated  fat foods in their cooking. If butter tastes better – that’s what they use.

But many things are deep fried and cooked using vegetable oils and shortenings because these products don’t impart much of a taste.  That was the big advantage of Crisco when it came out: it was pure and while and left no taste the way lard did.  Same with processed vegetable oils today, so chefs use the heck out of it.

Part of my job was to make some egg rolls for an appetizer.  I filled them with shredded chicken, shredded crab, a snow pea, some ginger and a little salt and pepper.  Then I deep fried them.  I asked the main chef, who was keeping a watchful eye on all of us pretend chefs, what kind of oil he used in the deep fryer. (The deep fryer, like everything else in the kitchen, is running all the time, and people pop stuff into it all night long when the restaurant is busy.)  He told me it was canola oil.  I asked him if canola was commonly used in deep fryers; he said that canola was used in every restaurant he had ever worked in.

I was surprised because I wouldn’t think canola oil would hold up to a deep fryer.  I asked how often they changed the oil – he told me they did so once a week. I made a note to research it a little when I got home.

I knew polyunsaturated fat made up somewhere around a third of the fatty acids in canola oil.  Polyunsaturated fatty acids (PUFA) are the ones most harmed by heat and oxygen, so it really made me wonder why anyone would use an oil containing so many PUFA for deep frying.  I just imagined all the oxidized fats in the oil I was dropping my newly made egg rolls into.

(There is a misconception in the minds of most people about what happens to PUFA when they are kept hot and bubbling for a long time as they are in deep fryers.  A lot of people think the PUFA convert to trans fats.  They don’t.  It requires heat, pressure and a catalyst to transform normal PUFA to trans fats.  What does happen, however, is that the PUFA become oxidized.  Then when you eat them, you are consuming oxidized fats that your body has to deal with.)

When I got home after our dinner, I went to the USDA Nutrient Database to look up canola oil to see if I had remembered correctly about the percentage of PUFA. I found the following entry:

Oil, industrial, canola (partially hydrogenated) oil for deep fat frying

When I looked up the fatty acid breakdown, I discovered that this industrial canola oil made for commercial deep fat frying contained almost a third of its fatty acids (27 percent to be exact) as trans fats.  Which is why it worked for the deep fryer.  During the processing of this oil, most of the PUFA had been converted to trans fats.

I looked at the other canola oils listed in the USDA list and found this one:

Oil, industrial, canola with antifoaming agent, principal uses salads, woks and light frying

Sounds just like what you would want to eat on your salad, doesn’t it?

This particular canola oil had just a couple of grams of trans fats per 100 grams of oil, so it wasn’t nearly as bad as the deep fryer canola oil, but it still doesn’t sound particularly appetizing.

At most of the stations in the kitchen there were containers of a salt and pepper mix and containers of oil with ladles.  If frying (not deep frying, but regular frying) were to be done, you threw a ladle of oil on the grill or in the skillet.  If you were whipping up a salad dressing, you started with the oil and worked from there.  This oil is the industrial oil with the antifoaming agent.

So, the take-home message from my experience is that if you eat in a restaurant you are going to get a lot of oils that you would probably rather not have.  At worst, you’re going to get a load of trans fats; at best, you’re going to throw back plenty of omega-6s. Omega-6 fats are, for the most part, pro-inflammatory, and we get way, way too many of them in our diet as it is. Most of the readers of this blog know how harmful omega-6 fats are in large quantities, so I won’t go in to it here.  Suffice it to say, however, that the medical literature is full of articles pointing out the hazards of too many omega-6 fats.  Then there is the American Heart Association that has inexplicably come out in support of omega-6 fats for heart health (Harris, WS), which advice you can put up on your shelf right beside the advice to avoid saturated fats.

In the 6-Week Cure we wrote about how vegetable oils – at least in lab animals – drive the development of fatty liver.  Researchers give rodents large regular doses of alcohol to get them to develop fatty livers.  They have found that if they give the rodents vegetable oils, they can accelerate the development of liver disease.  If the rodents get saturated fats, however, they almost can’t get fatty livers no matter how much alcohol they take in.  Does this apply to humans?  Who knows?  These kinds of studies would be unethical to do in humans, so we can’t test to find out.  But, the evidence is clear enough in rodents that I’m not all that eager to go face down in the vegetable oil.

I suspect that one of the reasons non-alcoholic fatty liver disease is reaching epidemic proportions worldwide is the ubiquitous substitution of vegetable oils for saturated fats every where.  When we were doing research for the book, I scoured the literature to find studies in which people with fatty liver disease were treated with diet and found only two such studies.  In both of them the fatty livers of the subjects reversed quickly – in just a matter of a few days – when the subjects went on low-carb diets.  I suspect that the increase in saturated fat helped things along markedly.  And, I suspect the unwarranted avoidance of saturated fats by our bamboozled fellow citizens is one of the reasons there is so much fatty liver disease.

If you prepare your food in your own kitchen, you control exactly what goes into it.  If you go out to eat, you lose that control.  I suspect most restaurants operate about like the very upscale one I just played chef in, and so if you go to even a nice restaurant, you’re going to be consuming stuff you would probably rather not consume.  In the old days (when I was a kid, for example), going out to eat was a big deal, and it almost never happened. Everything was prepared at home.  Now people eat out more than they eat at home.

According to the National Restaurant Association, more people are dining out than ever, even in tough economic times.  On a typical day, restaurant sales in the US average $1.6 billion. The average household spent $2,698 for restaurant food in 2008.  Forty percent of adults say that eating out or getting take-out food makes them more productive in their lives. The majority of adults – 78 percent – believe that dining out with family and friends is a better way to make use of their leisure time than cooking and cleaning up.

To the left is a graph from the USDA Economic Research Service showing the increase in the home budget dollar spent on food away from home.  It just about parallels the graph showing the development of the obesity epidemic.  I’m not necessarily making the case that eating out has caused the obesity epidemic, but I’m not sure it hasn’t played a significant role in it.  Especially now that I know what kind of oils restaurants use.

One of the statistics I read while researching for this post was that 73 percent of adults say they are trying to make more healthful choices at restaurants now than they did just two years ago.  Assuming this is true, it probably means they are ordering more salads, which seem to equate in everyone’s mind with a more healthful choice.  But if the dressings are made for the salad with the oils used in bulk in most restaurants, it’s probably not the best thing you can eat where your health is concerned.  But I always ask for my dressing on the side so that I can control how much I put on, you say?  That’s the big joke among chefs.  It’s been shown that when salads are tossed by the chef, much less dressing is used as compared to when people ask for it on the side and add it themselves.

The point of all this is that when you go out to eat, no matter how upscale the restaurant, you lose control over what goes in your mouth.  Short of bulling your way into the kitchen, you are clueless as to what oils are going into and onto your food.  If you eat out a lot, you are doubtless taking in a fair quantity of trans fats and oxidized fats and plain old omega-6 fats – all fats you can stand to do without.  The only way you maintain control is if you do the cooking yourself.  Plus, you’ll save a lot of money because it’s almost always less expensive to prepare it yourself.

One of the best things you can do for your health (and your pocketbook) is to spend more time in your own kitchen.

ADDENDUM:  Geez, one post later and I’ve already forgotten about the book list.

Since the last post, I’ve polished off Predictably Irrational, the Kate Atkinson novel and the Shenk book on genius.  I’m still working on the others.

I’ve added the following to my list:

I See Rude People by Amy Alkon.  The subtitle says it all: One woman’s battle to beat some manners into impolite society.  Amy is a friend of mine who writes an advice column, and I can tell you after spending a lot of time with her, that she is unfailingly polite and gracious herself to everyone she meets…except for boors.  I’ve dipped into her excellent book numerous times, but now I’m reading it from front to back.  I wish I had the gumption she does to confront the rude people I’m (we all are) confronted with daily.  With this book, I can do it vicariously.  An excellent read.

Naked by the Window by Robert Katz.  A book about the death (was is murder, suicide or accident?) of the diminutive Cuban artist Ana Mendieta, who plunged 34 stories to her death in 1985.

The Invention of Air by Steven Johnson.  I hope I love this book as much as I loved his The Ghost Map.

The quarterly Meatpaper was founded by a couple of vegetarians who made the conversion to meat eating a few years back.  (The founders say that when vegetarians cross over to the meat-eating dark side, bacon is the most common conversion food.)  It’s a difficult magazine to pigeonhole.  One would think it would revel in meat eating, and, in a way, it does.  But it does it in a daredevil sort of way, much in the way a magazine on skydiving might portray the thrill of that sport while still noting that certain death is only a chute failure away.  My take is that the writers and editors believe that meat-eating is a perilous undertaking, but one that many people choose for the taste despite the risks involved.  As anyone who had read this blog for anytime knows, my beliefs don’t quite fall that way.

The most recent issue contains a couple of articles I want to tantalize you with.  One that describes an almost unbelievably scrumptious food that I’ve yet to eat, at least knowingly, and another article I find deeply disturbing.

First, to the scrumptious.

In “Schmaltz Redux,” Daniella Cheslow briefly describes the history, disappearance and resurgence of a staple of Jewish cooking: schmaltz.  For those of you who don’t know what it is (and I was in that category until I read this article), schmaltz is basically chicken lard. Small pieces of chicken fat are cooked slowly until they resolve into an oil.  Throw in a few pieces of onion during the process, and you’ve got schmaltz, which can be used much as lard or duck confit.

To give you an example of what I mean about daredevil writing focusing not on just the delicious and nourishing virtues of schmaltz, but on the risks (non-existent, in my opinion) of consuming it.

“I love schmaltz.  But it’s very unhealthy, it’s all saturated animal fats.  I stopped eating schmaltz when my grandmother died in 1972,” said Susan Rosenthal, 59, a physician from East Brunswick, New Jersey. “I have a master’s degree in nutrition [a dead give away that the woman knows almost nothing about nutrition], so if I would have given my children schmaltz, that would have been shameful.”

Shameful indeed.

I’m sure this enlightened woman would have no qualms about giving her children all the olive oil they wanted.  But according to the USDA nutrient database of foods, olive oil contains 14 grams of saturated fat per 100 g whereas chicken fat contains 20 grams in the same amount. But 100 g is 3.5 ounces, and since schmaltz is used as a cooking oil, I suspect most people don’t eat much more than an ounce at a time, which would mean the schmaltz would give the children a little over 5 g of saturated fat while the olive oil would contain 4 g.  A difference of under two grams.  Not a huge difference in my opinion.  And since the schmaltz also contains a lot of both monounsaturated fat and polyunsaturated fat, it can’t really be characterized as “all animal saturated fats.”  But such misinformation is what comes from a master’s degree in nutrition.

The article goes on to detail a little more of the history of schmaltz and its resurgence but, at the end of the piece, once again the specter of early death from eating schmaltz rears its head.

To bring her article to a close, Cheslow offers a quote from David Sax, author of Save the Deli:

There’s something these days that’s sexy about it [making food from scratch].  I think [schmaltz] is coming back for that reason, and also people appreciate the taste, and they realize that it’s going to provide a richer experience.  Literally, figuratively, tastefully, and spiritually, it’s a heart stopper. [my italics]

Jesus wept.

I have elicited a promise from MD that when our brutal travel schedule over the next month and a half comes to a close, she will make us some schmaltz, an event I will dutifully record photographically.  Until then, however, you’ll have to make do with photos and instructions I found online.  The schmaltz in the photos in this blog post look great, but the uses the blogger makes of the schmaltz are not my cup of tea.

Now to the disturbing.

When you think Argentina, you think beef.  The Pampas, gauchos and endless herds of cattle.  For years Argentina has been one of the great beef reservoirs of the world.  But unless things change, that all may be coming to an end because the cattle are being displaced by a more profitable commodity: soy.

“Plowing the Pampas,” an article written by Nicholas Kusnetz, describes how many Argentinian ranchers are hanging up their bolas and picking up a plow.  Why?  Because soybeans are a vastly more profitable use for the land than raising cattle.

Kusnetz spoke about the switchover with scientists at a government research station in the Pampas.

Five years ago, one of the researchers told me, I would have been surrounded by pasture.  Now, nearly all the cows were crowded into feedlots.  The land was a tricolored patchwork as far as the eye could see: thousands of acres of deep green corn leaves, lighter green soybeans, and the straw-colored stubble of cornstalks that had been sprayed with Roundup to ready the field for soy.

At the station, two soil specialists showed me where they experiment with different crop rotations.  They have found that their most productive “rotation” is just the opposite: all Roundup Ready soy, all the time.  They don’t know why, they tell me, but it grows well.  They don’t see any reason to grow anything else.

“If I were a farmer,” I ask, “and I came to you for advice, what would you tell me?”

“Pure soy,” they say. “The more soy you have, the better your profits will be.”

The article goes on to describe how the economic realities are driving the ranchers to become soy farmers.  I don’t have a problem with this; you’ve got to expect that people will follow the money.  What does trouble me is that a crop with such a disastrous effect on health could be more valuable than cattle, which have been providing humans food for millennia.  But the herds are shrinking, and soon, if things don’t change, in a few years Argentina could become an importer of cattle.  An almost unthinkable proposition.

Should this disastrous end come to pass, I wonder if the grand ranches of the Pampas will still raise a few cattle along with thousands of acres of soybeans.  And will these few beef grazing in a small lot allow the farmers to continue to refer to themselves as ranchers despite the vast majority of their income coming from soy?  Probably.  I’ve seen it happen in Arkansas.

The delta lands east of Little Rock are made up for the most part of vast soybean growing operations.  The farmers who own and farm the land were descended from cotton farmers.  Cotton farming was the tradition, but economics won out, and most of the cotton fields were replanted in soy.  But old traditions die hard, and most of these farmers still keep a small patch of cotton on their land, and if asked what they do, they reply that basically they’re cotton farmers but they grow some beans on the side.

I suspect that if things continue in Argentina, many self-proclaimed ranchers will be growing a few beans on the side as well.

Sad. Very sad.

I would encourage you to subscribe to Meatpaper to keep up with what’s new and edgy in the world of meat.  I have no affiliation with the magazine nor do I get any click-through income if you subscribe.  I just like the idea of former vegetarians writing a magazine on meat and making a go of it.  And I want to help.

I’m going to start a new tradition with this post.  As anyone who reads this blog regularly knows, I read a lot.  People often ask me what I’m reading, so I’m going to start putting my current reading list at the bottom of the posts so those of you who are interested can keep up.

Survival of the Fattest by Stephen Cunnane

Atlas Shrugged by Ayn Rand.  (This isn’t a reread.  I’ve never read the thing, so I figured it was about time.)

The Plague by Albert Camus  (I’ve never read this one either, and it’s taking me forever to get through it.  But I’m almost finished.)

Predictably Irrational by Dan Ariely

One Good Turn by Kate Atkinson

The Genius in all of Us by David Shenk

The Girl who Kicked the Hornet’s Nest by Stieig Larsson (This one won’t be available in the U.S. until May 25.  A friend who visited me from the UK, where it has been available for months now, brought me a copy.)

The number one winner going away was Lierre Kieth’s brilliant The Vegetarian Myth.  If you haven’t read it, grab a copy ASAP.  For those of you who don’t know, Lierre was recently the victim of an assault at a San Francisco reading.  Masked thugs came out from behind the stage and smashed her in the head and face with pies laced with cayenne pepper.  After the assault took place, while Lierre was trying to get the burning pepper out of her eyes, the audience (of mainly vegetarians) cheered.  It was truly disgusting.  Richard Nikoley and Tom Naughton reported on the assault here and here.  Jimmy Moore has a  interview with Lierre about the attack here. Tom Naughton proposes a rationale for such behavior here.

It appears that militant vegans have secured  Lierre’s name and other versions of her name on Twitter and are mounting a vicious smear  campaign against her.  Purchase her book to fight back.  Success is her best revenge.

Here are the books in descending order.

#1 The Vegetarian Myth by Lierre Kieth.  My review here.

#2 Mistakes Were Made (But Not by Me) by Carol Tavris and Elliot Aronson.  My review here.

#3 Good Calories, Bad Calories by Gary Taubes.  My review here.

#4 Lucy: The Beginnings of Humankind by Donald Johanson. My review here.

#5 Control Theory by William Glasser My review here.

#6 The Brain Trust by Larry McCleary, M.D. My review here.

#7 500 Low-Carb Recipes: 500 Recipes from Snacks to Dessert, That the Whole Family Will Love by Dana Carpender

#8 Natural Hormone Balance for Women by Uzzi Reiss.  A mention here.

#9 How to Cook Everything by Mark Bittman.  MD’s review here along with her entire list of essential cookbooks.

#10 Crucial Conversations: Tools for Talking When Stakes are High by Kerry Patterson et al.  My review here.

#10 Primal Body-Primal Mind by Nora Gedgaudas

#10 The Great Cholesterol Con by Malcolm Kendrick.  My review here.

#10 The Happiness Hypothesis by Jonathan Haidt My review here.

The last four books on the list sold exactly the same number of copies, so they all tied for 10th on the list.  I listed them alphabetically.

Although not a book, sales of the DVD of Tom Naughton’s brilliant film Fat Head would have put it at #2 on the list.  If you haven’t seen this film, order it today.  Here’s my review.

I want to thank all of you who have ordered not just books but all kinds of things through this site.  And I want to encourage you to continue.  The small commission I make on each order helps underwrite the maintenance on this site, which is much higher than I would have thought it would be.  Plus, I’m still paying off the recent redesign.

For those of you who don’t know what I’m talking about, any time you order a book or a DVD or a CD or anything (groceries, supplements, tee-shirts, whatever) through Amazon.com, I get a small commission on your order.  But I get this only if you go through one of the Amazon portals on this blog or MD’s blog or anywhere on the website.  What is an Amazon portal?  If you click the picture of The Six-Week Cure for the Middle-Aged Middle at the upper right of this post, you will be taken to the Six-Week Cure page on Amazon.  If you’re looking for something else, just type it in the search window, click the ‘Go’ button to the right, and you will be taken to wherever you want to go, and anything you purchase once you get there will earn me a tiny commission.

This whine for help with Amazon is my own version of those awful PBS fundraising telethons.  The difference is that here it doesn’t cost you anything; you simply have to purchase whatever you were going to purchase through Amazon anyway by going through one of the portals on this blog.  And your free programming will continue.

As some of you may have noticed, I finally removed the tacky Google ads that were at the bottom of each post.  I didn’t even realize they were there until I was having lunch with Mark Sisson one day, and he asked me what my relationship with Atkins Nutritionals was.  I told him I had no relationship with them.  He told me he figured I did because a fairly prominent banner ad for Atkins Nutritionals appeared at the bottom of each of my posts.  I checked myself, and, sure enough, there were the ads.  I looked into it and found out that I was making about $45 per month for these ads (not all were Atkins, but most were) so I ditched them altogether.  Had I been making $1500 per month on these ads, I may have had second thoughts, but as it was, I had no problem giving them the ax.

So, at this point, no ads are cluttering the pages of my blog or MD’s blog.  Other, of course, than those for our own books, which are the previously mentioned Amazon portals.  Order early and order often.

What gives is that I’m stuck in the airport in Seattle – my flight to Chicago is delayed for almost four hours because of bad weather in the Windy City.  I figured I would use this time to stick up a quick post about thermodynamics and provide a long quote from Robert McLeod, who writes Entropy Production, a physics (sort of) blog.  As you can see below, he pretty much trashes Bray and other nutritional researchers who blithely use the 1st Law of Thermodynamics to prove the old a-calorie-is-a-calorie notion.  To show the way the average nutritional writer looks at this law, I needed to find a quote.  As it works out, the only thing I have with me is Anthony’s book The Fat Loss Bible, which just happens to have the perfect quote.  So, sorry AC, I’m not really trying to pick on you.  And you certainly aren’t the only nutritional writer who thinks this way – you’re just the only one who has a quote handy I can use.

The First Law of Thermodynamics states that energy can neither be created nor destroyed. It can only be converted from one form to another. In other words, energy just doesn’t just magically disappear; it must be converted to something else. In the case of any excess calories you ingest, they will be stored as fat, used to accommodate an increase in lean tissue mass, or dissipated as heat through thermogenesis. Manipulating the proportion of protein, fat and carbohydrate you eat each day will not excuse you from the Law of Thermodynamics.

This is the way just about all nutritional scientists and writers look at the First Law.  Let’s take a look at how a physicist sees it.  Robert McLeod wrote a long post a while back reviewing Gary Taubes’ Good Calories, Bad Calories.  Near the end of the post, he discusses the energy balance equation and one of our old friends, Dr. George Bray, who gave Gary’s book a bad review in an obesity journal.  (I posted on this same review a couple of times here and here.)

Here’s what he says:

I was somewhat confused to see this [a nutritional description of the energy balance equation] Surely the nutritional scientists did not not really believe this, right? I mean, any idiot undergraduate students knows that the 1st Law is only useful in a closed system, and humans live on the planet Earth, not in an insulated box. Right?

Enter a rebuttal by G. Bray in the journal Obesity Reviews. Bray is a to be a major obesity researcher and one of the 2nd tier villains in the book. Taubes relates a story of Bray excising a section of a British report on obesity, where Bray removed the material pertaining to the relationship between insulin and obesity. He clearly has editorial support to make his case. Bray is one of the second-tier villains in Taubes’ book. Taubes has a footnote (p. 421), which suggests that Bray actively suppressed the carbohydrate-insulin hypothesis.

“According to Novin, when he wrote up his presentation for the conference proceedings Bray removed the last four pages, all of which were on the link between carbohydrates, insulin, hunger, and weight gain. “I couldn’t believe he would make that kind of arbitrary decision,” Novin said.”

Unfortunately, to a physicist this energy balance hypothesis looks like a silly hand-waving exercise, not a serious argument. Frankly I was flabbergasted when I first read this article. This conservation of energy argument is on the same scientific level as the ridiculous “drink cold water to lose weight” idiocy. A human organism is:

1. Not in thermal equilibrium with their environment. Last time I checked I have a body temperature around 38 °C and spend most of my time in 21 °C rooms.
2. Capable of significant mass flows (e.g. respiration).
3. Capable of sequestering entropy (e.g. protein synthesis).

Is wearing a sweater fattening (by insulating you from your environment)? Here’s a quote from the rebuttal,

“Let me make my position very clear. Obesity is the result of a prolonged small positive energy surplus with fat storage as the result. An energy deficit produces weight loss and tips the balance in the opposite direction from overeating.”

According Bray’s thermodynamics argument, wearing sweaters makes you fat. This illustrates the greatest fallacy of trying to apply the 1st Law to a human: it makes the implication that living organisms consume kilocalories for the purpose of generating heat rather than perform useful work (i.e. breathing, contracting cardio and skeletal muscle, generating nervous action pulses, etc.). In reality heat is the waste product of basal metabolism. The first law does not distinguish between different types of energy. Heat, work are all equal under the First Law of Thermodynamics.

Applying the 1st Law to living organisms is Proof by Tautology. Yes, 1 + 1 = 2, but this tells us absolutely nothing about the underlying mechanics. The 1st Law does not (I repeat N-O-T) tell us whether you store excess energy in the form of fat, or bleed it off into the atmosphere by dilating blood vessels next to the skin, sweating, etc. To do so would require an accounting of entropy.

What would a semi-rigorous description of the thermodynamics of a human organism look like? Look at the title strip on the top of the page. See that equation in the background?

[The above is the background of the header of Robert McLeod's blog]

This type of equation would be a bare starting point for energy balance in a complex system like a living organism. Good luck actually accounting for all the terms. Those Σs are sums.

We all fall victim to the confirmation bias and have to fight it constantly.  Gary Taubes thinks I may even have succumbed a little in the earlier post on AC and the metabolic advantage.  He emailed me saying he had read the post and thought it was great up to the point right at the end where I wrote that the data on the whole showed that, if anything, there was a metabolic advantage.  Gary thought the data presented in all the studies in AC’s chart was ambiguous and that I was going out on a limb a little in making the statement that I thought, if anything, that the papers argued for a metabolic advantage.

I disagree.

I decided to base this critique not on the scientific literature at large, but instead on only the papers that AC mustered for his argument.  I intended to make the critique much like a court case in which one side presents the information and the other attempts to counter it.  I didn’t want to go out myself and gather a bunch of papers that confirmed my viewpoint, because then we would have had nothing but a bunch of dueling Ph.Ds, a  bunch of he saids, she saids, that wouldn’t prove anything.  I stuck with the papers AC used and presented my arguments as to why I didn’t think his papers proved his case.  After going back and rereading the post, I still feel that if this ‘evidence’ were presented to a jury, the verdict would come back in favor of my arguments.  If anything, AC’s own ‘evidence’ argues for the existence of a metabolic advantage, and, at worst, certainly doesn’t ‘prove’ that one doesn’t exist.

Since I posted the first part of my critique, AC has responded using his customary restraint and understated gentility designed to appeal to his sort of reader.  His response – as I figured it would be – is merely a listing of even more papers he believes substantiate his claims.  Instead of undertaking a serious scientific inquiry, he is looking for more white swans.  Let me explain.

I wrote a long post a couple of years ago on Sir Karl Popper and the metabolic advantage.  Popper set the standards by which hypotheses should be structured.  A well-stated hypothesis should be able to be falsified.  That doesn’t mean it will be falsified, but it should be structured in a way that it can be.  And real scientists – of which, sadly, there are all too few in the field of nutrition – don’t try to confirm their hypotheses: they try to refute them.

One of the examples Popper used in explaining how a hypothesis should be established involved swans – white and black.  He used the following as an example of a good hypothesis:  All swans are white.  He made the case that this hypothesis cannot be confirmed by simply pointing out more and more white swans.  The hypothesis can be strengthened by doing so, but it can’t be proven.  It can, however, be disproved by the discovery of even a single black swan.  Popper argued that scientists should be working to find black swans instead of simply adding more and more white swan sightings to their data.  The more effort scientists expend to find a black swan without finding one, the more their hypothesis is strengthened.  Diligently searching for black swans is a much more valid scientific endeavor than simply looking for more white swans.

Many scientists don’t want to hunt for black swans, however, because they don’t want to blow up their hypotheses.  The easy way to bolster their hypotheses is to continue to tally up all the white swans they find and forget about looking for black ones.

Which, of course, is what our young friend AC has done and written about in his latest missive.  He tallies up a bunch more white swans and ignores the black ones, even the black ones in hiding in plain sight in his own list of papers.  This failure of his to try to puncture his own hypothesis leads me to believe there exists a large chasm of incomprehensibility between the way AC thinks and the scientific method.

To give but one example of this, AC argues in his book that the studies by Rabast that clearly show a metabolic advantage aren’t valid because, as AC puts it,

Regardless of whether Rabast et al’s findings were the result of water loss from glycogen depletion, pure chance, or some other unidentified factor, they should be regarded for what they are: An anomaly that has never been replicated by any other group of researchers. For a research finding to be considered valid, it must be consistently reproducible when tested by other researchers. As proof of the alleged weight loss advantage of low-carbohydrate diets, the findings by Rabast and colleagues fail dismally on this key requirement.

(In other words, AC is saying: that black swan over there isn’t really a black swan, because all the other swans I’ve pointed out are white.  And since all the others are I’ve pointed out are white, that one can’t be black.  It’s impossible.)

In point of fact, Rabast’s group in Germany has performed a number of studies showing a significant metabolic advantage in subjects in metabolic wards who follow low-carb, high-fat diets as compared to those taking in the same number of calories as high-carb, low-fat diets.  This group pursued this line of inquiry and published a number of studies showing this metabolic advantage.  Suddenly, however, they quit publishing on this subject and turned their attention elsewhere.

While in the research phase for Good Calories, Bad Calories, Gary Taubes interviewed Dr. Rabast about his group’s work, and here is what he said.  They were inspired by an old scientific paper (more about which later) that offered up some data they found interesting and wanted to test themselves.  They did the studies using formula diets, so they could more easily control intake and confirmed the data from the old study.  They continued to perform these studies, all with similar outcomes, until Dean Ornish published his paper on dietary fat and heart disease.  Dr. Rabast and his group decided that Ornish might be correct.  They felt that although their own data showed that high-fat diets brought about substantially better weight loss than low-fat diets of equal calories, their work might encourage people to consume more fat, which, thanks to Ornish and the low-fat movement, they had come to believe may cause heart disease.  So, they abandoned their research on high-fat diets and moved on to other interests.

The study that inspired them to study high-fat diets?  An study from the 1950s done by a couple of British researchers, Dr. Alan Kekwick and Dr. G.L.S. Pawan.  Their famous paper showed a definite metabolic advantage, a black swan writ large, as it were.  And their famous paper is well known to AC, who has a few things to say about it.  As you might suspect, given the results of this study, he declares it not worthy of consideration. Here is what he says in his book after he’s gone through his list of white swan studies, which, of course, are all worthy of mention.

Not-so-worthy mention

There is one metabolic ward trial that due to its short duration did not qualify for inclusion in Table 1a, but still warrants a mention. Incessantly cited by supporters of low-carb diets, this is the famous metabolic ward study conducted in the 1950s by Kekwick and Pawan. The London researchers conducted two experiments. In one of these, they claimed that patients maintained or gained weight on a typical mixed diet of 2,000 calories, yet consistently lost weight when placed on a 2,600 calorie low-carbohydrate diet for periods ranging from 4 to 14 days. In the second of their experiments, they had 14 patients alternate between four different 1,000 calorie diets, spending a grand total of 5-9 days on each diet: 1) 90 % protein; 2) 90% fat; 3) 90% carbohydrate, and; 4) a mixed diet. According to Kekwik and Pawan, all of the subjects in the protein, fat, and mixed diet groups lost weight, with the high-fat group experiencing the greatest weight loss of all. However, despite the very low calorie intake, many of the patients reportedly gained weight during the high-carbohydrate diet! Not surprisingly, the Kekwik and Pawan study is frequently cited by supporters of low-carbohydrate nutrition. That they ignore the studies in Table 1a, yet eagerly embrace a short-term study conducted over 50 years ago, speaks volumes about their complete disregard for rational scientific inquiry. [Italics in the original]

Here’s why: Firstly, it has long been known that in the first week or two of low-carbohydrate dieting, there is often a far greater reduction in water weight due to excretion of sodium and/or glycogen, both of which bind water in the body. Therefore, studies of such short duration are next to useless as indicators of the comparative longer-term weight loss effects of these diets.

Secondly, the Kekwik and Pawan study was a poorly controlled mess. The researchers were even driven to denigrate their study participants, writing: “The first and main hazard was that many of the patients had inadequate personalities. At worst they would cheat and lie, obtaining food from visitors, from trolleys touring the wards, and from neighbouring patients. (Some required almost complete isolation.)” [Italics in the original]

Given that protein and fat have been shown numerous times to exert satiating effects, while low-fat, high-carbohydrate diets (especially the liquid, low-fiber variety!) typically result in ravenous hunger, it’s not hard to guess during which diet the participants may have ‘cheated’ the most!

The researchers also wrote: “The results we report are selected, a considerable number of known failures in discipline being discarded”. Note how the researchers included the words “known failures”; how many failures did they not know about? How many of the patients were crafty enough to sneak extra food without being caught? Why should we trust Kekwik and Pawan’s unlikely results, given their study’s numerous flaws? The answer is simple: Unless you are a famous low- carb diet ‘guru’ who has made millions promising people they will lose extra weight at the same calorie intake by cutting carbs, we shouldn’t! At least not if we believe good science mandates a tightly controlled process of investigation. [Italics in the original]

As we shall see shortly, this commentary is all so much piffle.

(Here is the full-text version of the Kekwick and Pawan study so that you can pull it down and follow along with the rest of the discussion if you like.)

Let us begin.

It is apparent from his critique that AC read the first part of this study, found a black swan, used a bunch of incorrect gibberish and swagger to try to say it wasn’t really a black swan and moved on without ever getting to the important part of the paper. Or, an alternative explanation is that, as with the Leibel study mentioned in my first critique, he either didn’t really read the paper thoroughly or he seriously misunderstood what he read.

Drs. Kekwick and Pawan start off by explaining why they undertook this study in terms that any of us who have struggled with excess weight and found different results with different diets can understand.

Many different types of diet have been successfully used to reduce weight in those considered obese.  The principle on which most of them are constructed is to effect a reduction of calorie intake below the theoretical calorie needs of the body.  Experience with these patients has suggested, however, that this conception may be too rigid.  Many of them state that a very slight departure from the strict diet which can hardly affect calorie intake results in them failing to lose for a time.  Though it is realized that evidence from such patients is notoriously inaccurate owing to their approach to this particular condition, it is too constant a belief among them to be entirely discarded.

Drs. K & P did a number of experiments.  First they kept hospitalized subjects on diets of similar macronutrient composition but differing calories and found that reducing calories made the subjects lose weight.  And, unsurprisingly, the more the calories were cut, the more weight the subjects lost.  Next, the good doctors decided to see if changing the macronutrient composition of the diets made a difference.  They started the subjects on 1000 calorie per day diets of one of the following three structures: 90 percent of calories as carbohydrate; 90 percent of calories as protein; or 90 percent of calories as fat.  The structure of the diets made an enormous difference in how much weight the subjects lose.  As Drs. K & P wrote:

So different were the fates of weight-loss on these isocaloric diets that the composition of the diet appeared to outweigh in importance the intake of calories.

In an effort to confirm their findings, Drs. Kekwick and Pawan went on to a third series of experiments as described here:

…patients…were put on to 2000-calorie diets of normal proportions to show that their weight could be maintained while in hospital at this level and then placed on high-fat, high-protein diets providing 2600 calories per day.  It was demonstrated that these patients on the whole could maintain or gain weight on 2000-calories but, except in one instance, lost weight consistently on a 2600 daily calorie intake.

It’s easy to see why AC doesn’t like this paper.  And we haven’t even gotten to the good stuff yet, which AC doesn’t make mention of in his book.  We’ll get to that in a bit, but before we do, let’s take a look at AC’s critique of this much of the study (which is, apparently,  all he bothered to read). You can read along from the above quote in his book.

His first complaint is that the study is over 50 years old.  I find this a strange complaint, since the first study he lists in his chart of studies ‘proving’ his point was published a mere eight years after this Kekwick and Pawan study.  The Kinsell paper was published in 1964, 46 years ago.  Is there some magic cutoff date at 50 years that makes scientific papers unreliable?

Second, he claims that on low-carb diets all the weight loss from the first two weeks is water, and since these studies lasted less than two weeks, the difference was all water.

Kekwick and Pawan were a little smarter than Anthony gives them credit for being.  They understood well the notion of water loss.  (As we will see shortly, they understood it vastly better than our young friend.)  They pointed out the following:

During these periods [the different diet studies] the patients were weighed daily and in some of them balance studies were carried out in respect of water, nitrogen, fat, sodium, chloride, and potassium.  Total body-water and the basal metabolic rate were estimated weekly or at the end of each period on the diet.

If you look at the full-text version of the study I linked to above, you can see graphically how this all plays out.  In these studies the weight loss was definitely not all water.

In an effort to be meticulously accurate, not only did K & P monitor all the above carefully, they even went further.  Since these patients were not on formula diets but were on real foods instead, making it more difficult to accurately determine caloric intake, the staff would take representative samples of the foods eaten, blend them into a soup, then analyze samples to make sure the protein, carbohydrate and fat content were as estimated in the food tables.  It was hardly a “poorly controlled mess” of a study.

AC next attacks the study because the researchers admitted as to how difficult it is – even in hospitalized studies – to prevent cheating.

In such a study the difficulties are formidable.  The first and main hazard was that many of these patients had inadequate personalities.  At worst they would cheat and lie, obtaining food from visitors, from trolleys touring the wards, and from neighbouring patients. (Some required almost complete isolation.)  At best they cooperated fully but a few found the diet so trying that they could not eat the whole of their meals.  When this happened the rejected part was weighed, and the equivalent calories and foodstuffs were added to a meal later in the day.  The results we report are selected, a considerable number of known failures in discipline being discarded.

Kekwick and Pawan simply wrote of the difficulties in preventing cheating.  They were on the lookout for it, threw out data they knew was compromised, and compensated for episodes of cheating of which they were aware.  I believe the fact that they recognized cheating as going on and were keeping an eagle eye out for the cheaters makes their data more accurate, not less.

I also find it strange that AC is more than willing to toss data because of cheating in this study and is more than willing to accept data from other studies in which there was probably just as much – if not more – cheating that the authors neglected to mention either by design or because they didn’t realize it was happening.

One other thing that points to the degree into which K & P watched over this study is one that all female readers who have had trouble losing will be familiar with.

Another factor of importance which could not be eliminated was that many patients were women, in whom the retention and the losses of water associated with the menstrual cycle affected the daily weight and the estimation of total body-water.  We were surprised to find how great such factors could be, amounting in one woman to the retention of more than 3 litres of water.

Only a fool or a seeker of white swans only would think the good doctors didn’t monitor this study closely.

Now to the fun part, the part AC probably didn’t read.  And the part that really demonstrates the metabolic advantage.

The first part of this paper, the part AC has critiqued, is only a minor part of the paper.  The majority of the paper is devoted to the efforts the Drs. K & P made to determine what happened to the excess weight lost in dieters on the higher-fat diet.  They checked fat loss in the stool, they checked (as mentioned previously) water loss, they checked about everything they could think of.  You can read in the full version how careful they were.

After sifting through all the data and finding no reason that their results should have been invalid, the docs checked yet one more item.  They looked at insensible water loss.

Insensible water loss is the loss of water we all experience minute by minute that we not aware of.  We know we lose water when we urinate and/or defecate, and we know we lose some water when we visibly sweat, but we are not aware of the large amount of water we are getting rid of through our breath and via sweating that we don’t notice.  And this amount of water we lose is fairly large.

Do this experiment.  Get an accurate scale and weigh yourself immediately before going to bed.  Go ahead and urinate (and do anything else you might need to do) before weighing.  Don’t drink or eat anything, hop in the sack and sleep through the night, then get up and weigh before you urinate in the morning.  I absolutely guarantee that you’ll weigh less than before you went to bed.

If you breathe on a mirror, you will fog it from the water vapor in your breath.  This vapor is water that you lose every single time you take a breath.  You breathe approximately 12 times per minute (while resting), which means you breathe 720 times per hour and 17,280 times per day.  And that’s if you’re at rest.  If you are active, you take a lot more breaths than that.  Probably something in the neighborhood of 20,000-23,000 breaths per day, depending upon activity level.  Each one of these breaths contains water vapor that you are losing from your body, which is why you drink liquids throughout the day.  If you didn’t replace this water, you would become dehydrated.

If you have a fever or if you exercise, you breathe a lot more rapidly and lose a lot more fluid.  Thus, one of the things doctors have to be concerned about in very sick patients with high fevers is dehydration.

You also lose insensible water through constant perspiration.  When you awaken in the morning, if you’ve slept tightly covered up, you’ll notice you’re a little damp.  Not a lot, unless you’ve had a fever, but a little.  This is insensible water that you lost.

I remember how amazed I was the first time I ever looked at my own hand under a dissecting microscope.  Looking at my hand with my naked eye, it appeared normal and dry.  When I stuck it under the scope and looked, I could see little volcanoes of perspiration bubbling up from unseen pores.  It’s part of the way we regulate our temperature, and unless we work up a visible sweat, we never notice.

This loss of insensible water is why we lose weight overnight.  In eight hours of sleep, we breathe out about 5,760 breaths filled with water vapor and we sweat all night.  This water weight usually ends up being between 1 to 2 pounds or even a little more.

If I were to take a bunch of thyroid hormone or take an amphetamine, I can assure you that my metabolic rate would rise and that my insensible water loss would increase.  In fact, insensible water loss is a surrogate for metabolic rate.  If your metabolic rate rises, your insensible water loss rises.  And since insensible water loss can be easily measured, the metabolic rate can be easily estimated without having to do metabolic chamber studies.

Which is exactly what Drs. Kekwick and Pawan did with several subjects on the various diets.

They kept the subjects isolated and under supervision and weighed them on extremely accurate scales throughout the day.

Measurements were made by weighing the patient at intervals of one hour on scales specially constructed for this purpose by Messrs. W. & T. Avery Ltd. which are sensitive to 2 g. over the range of weights concerned.  During these hours no food was taken and neither urine nor faeces voided, and errors due to temperature, activity, and air draughts were avoided as far as possible.

(Scales that are sensitive to 2 g are extremely sensitive.  Two grams weighs about seven one hundredths of an ounce.)

So, here is what the researchers did.  They first fed the subjects the standard diet available to the patients on the ward and discovered what the insensible water losses were throughout the day.  You can see how this came out in the graph below, Fig. 11.

When Drs. K & P put a single patient on the different diets – 90 percent fat, 90 percent protein or 90 percent carbohydrate – and measured the insensible water loss throughout the day, the table below, Fig. 12 shows what happened. There was an increase in insensible loss with the high-protein diet as compared to the high-carb diet, and a much greater increase in insensible water loss with the high-fat diet.

The area of the chart that I colored in is the difference between insensible water loss, which represents a change in metabolism, between the high-carb diet and the other two diets.  This colored part of the chart represents the metabolic advantage of the high-protein and high-fat diets compared to the high-carb diet of the same number of calories.  The peach colored part of the chart represents the metabolic advantage of the high-fat diet as compared to the high-protein diet while the grayish color represents the metabolic advantage, as measured by increased insensible water loss, between the high-protein and high-carb diets.

The researchers wanted to make sure this wasn’t an isolated phenomenon, so they analyzed three other patients and created the graph below, Fig. 13, which mirrors the results in Fig. 12 and demonstrates that this wasn’t an outcome isolated to just one subject.

The ever cautious Drs. Kekwick and Pawan interpreted their findings thus:

The rate of insensible loss appears to be much affected by the type of food, provided that the water and sodium intakes are kept constant throughout the period of observation; whether this increased rate of insensible loss is a measure of bodily metabolic activity must remain in question.  Even if metabolic activity cannot be measured directly, the difference in weight responses seen with these diets does not seem to be completely due either to an altered state of hydration or to a simple deficiency of calories.  We suggest that the rate of katabolism of body-fat may alter in response to changes in the composition of the diet.

And their summary:

As the rate of weight-loss varied so markedly with the composition of the diets on a constant calorie intake, it is suggested that obese patients just alter their metabolism in response to the contents of the diet.  The rate of insensible loss of water has been shown to rise with the high-fat and high-protein diets and to fall with high-carbohydrate diets.  This supports the suggestion that an alteration in metabolism takes place.

If you haven’t already, I would encourage you to read this entire study and make your own judgment.  I’m sure you won’t find it the “poorly controlled mess” that AC does.  In fact, I suspect you’ll find just the opposite.  Unlike most of the studies published today, this one is not loaded with incomprehensible jargon, is delightfully well written and is extremely accessible to those with little medical or scientific knowledge.  You can see for yourself how precise these researchers were and now meticulously they looked for anything that might confound their results.  It would be great if more studies were done this carefully today and written this clearly.

This is the end.  I am through with AC. I’ll leave it to the readers of this post and the previous one on this subject to make their own decisions as to whether or not a metabolic advantage exists for low-carb, higher-fat diets.  I won’t be provoked again into jumping into the mud and wrestling around.  So this is my black swan song on the subject.

I read a quote a few days ago by Nassim Taleb, the author, appropriately enough, of the book The Black Swan and, for my money, the infinitely better Fooled by Randomness that is apropos to this situation:

A good foe is far more loyal, far more predictable, and, to the clever, far more useful than any admirer.

So, to you, Anthony Colpo, I raise my hat. Had you not attacked me out of the blue, I would be less knowledgeable than I am today.  I wouldn’t have bothered to dig into all the ‘white swan’ papers you posted trying to figure out why these researchers got the results they got.  I, like you, would still be mired in the notion that metabolic ward studies are squeaky clean without any hint of sullied data as a consequence of cheating.  Like you, I would still probably be confusing metabolic ward studies with metabolic chamber studies, which are horses of a much different color.  Also, I thank you because I had kind of blown off the Kekwick and Pawan papers (there are others besides this one from The Lancet) as being too old to be worth studying.  You forced me to take another look, and I was delighted at what I found.  And, sad to say, like you, I, too, had read only the first part of the these studies, the parts about the diet comparisons.  It wasn’t until your attack that I actually read this paper all the way through and found the gold mine in the latter pages.

So, AC, I sincerely hope the best for you; I thank you for pushing me into this exercise and wish you godspeed on your journey through life.

I’ve had a family medical emergency that’s been occupying my time for the past week so I haven’t really had the consolidated time I’ve needed to finish off Part II of the AC book critique, but I haven’t forgotten about it.  I should have it up in a day or two.

Until then, I’ll give you a little thermodynamics to chew on so you, too, can see that it is far from simple.

A commenter wrote the following in response to Part I of the AC critique:

Dear Dr. Eades,

I read the Feinman-Fine second-law article you cited above with interest, but found a mistake in the Figure 2 plot and the corresponding text. I didn’t notice any erratum either.

The figures in section “Efficiency and thermogenesis” should add up to 1825.5 kcal effective yield and not to the 1848 kcal given.
They seem to have interchanged the thermogenesis percentages of CHO (7%) and lipids (2.5%) in their calculation. The error source was perhaps the order in which they list the numbers: first percentages for F, C, and P from Jequier’s review, and then the diet C:F:P = 55:30:15. Go figure.

Nevertheless, it doesn’t affect the main result about metabolic advantage, weakens it a bit, though.

This came in while I was in the throes of dealing with the family problems, so I didn’t take the time to go back, pull the paper, figure out what the commenter was talking about and put my two cents worth in.  I simply posted it as it was.

Thankfully, Dr. Feinman saw it and wrote a response on another website.  I asked for permission, which he gave, to put it up here.

1. The approach taken by many that the idea of metabolic advantage has to be consistent with thermodynamics is correct.  However, one has to understand and apply thermodynamics correctly, especially as it is used in bioenergetics.

2. People who get involved in this discussion have not followed the approach in biochemistry texts and traditional bioenergetics but have not explained why that approach is wrong.  In the traditional approach from bioenergetics, for example, one usually looks at the Gibbs Free Energy, G rather than the internal energy, E.  (G includes the effect of entropy from the second law).

3. What Figure 1 of the paper shows is that metabolic advantage must exist between systems that rely to different degrees on gluconeogenesis.  You learn this in biochemistry: it costs you 6 ATP to obtain glucose from GNG but, of course nothing if you start with glucose.  So, there is a built in metabolic advantage.  Not could be.  Not debatable.  It is there.  Period.  That is an absolute biochemical fact.  So just as people thought metabolic advantage was excluded by the “laws” of thermodynamics (by which they meant the first law), “a calorie is a calorie” is excluded by the combined first and second law.  (To try to use the first law in the absence of the second law is like, actually exactly like, using gravity without considering friction).

4. Now whether you measure it [the metabolic advantage] in any particular experiment, whether the effect is great, whether it is compensated for by other processes (in low fat diets you make fatty acids which costs many ATP although the net effect may be to increase fat storage) is a different question than whether it is there or whether you want to ignore it.

5. Most of the time, as in Leibel’s experiment with the hospital patient, there is calorie balance but Leibel’s group have also done experiments with catch-up fat where there is not energy balance.  But, again, application of the theory is different than what the theory says must be true.  We have made the point that thermodynamics predicts a difference between high and low carbohydrate diets.  It when it is not found that has to be explained.  (The explanation lies in the specific homeostatic mechanisms of biological systems, not in physical law).

6. I personally believe a) Volek’s studies show the effect because the level of experimental error necessary to account for differences would be too large and, more important b) given the potential benefit in palpable metabolic advantage it would be worthwhile to try to find the conditions in which it can be seen and that this would be time better spent than in trying to disprove it with incompletely understood thermodynamics.

7. The other reason for looking for how the theory could be seen in a real weight loss experiment, is that it occurs unambiguously in numerous other biological systems: hypo- or hyper-thyroid conditions, catch-up fat in humans and animal models, animal knock-out or over-expression experiments.

8. I generally don’t pull rank on anybody and I don’t know that there is special criteria for being a scientist but you do have to understand the difference between an effect that is absolutely dictated by physical science (e.g. general theory of relativity) and the difficulty in demonstrating it experimentally (waiting for a solar eclipse and winding up with unreadable photographic plates).

9. Along these lines, like most chemists (or maybe most everybody), I have always found thermodynamics difficult and I am willing to learn from anybody who has an insight.  However…

10. I grew up in Brooklyn so I am capable of a dialogue in the style favored by Colpo and Lyle McDonald but I mostly outgrew it and don’t want to debate at that level.

11.  Relevant ideas to ponder:  I once challenged Colpo to give me a definition of the nutritional calorie (because this makes clear what the issue is), that is, not the definition of the physical calorie (raises a gram of water 1 degree C ) but what we mean when we say carbohydrate has 4 kcal/g.  His answer suggested that he had undergone spontaneous combustion but anybody else can answer the question.  The other question is that in bioenergetics we talk about calories as the free energy, G, which is a potential, analogous to gravitational potential.  When you throw the boulder off the cliff its potential energy is converted to kinetic energy and then goes to zero when it hits the bottom.  Where does the energy go?  The delta G (energy of reaction) for hydrolysis of a peptide bond is about 2 kcal.  When it reaches equilibrium (amino acids) the energy is zero.  In other words, thermodynamics talks about dissipation of energy, not conservation.  How is that possible?  Where does the energy go? 

Hope this helps.

Richard David Feinman
Professor of Cell BiologyTher
SUNY Downstate Medical Center

As a bit of lagniappe, here is a short video Dr. Feinman created on thermodynamics and irreversibility:

Click here to view the embedded video.

Addendum:

Richard Nikoley over at Free the Animal posted his take on the latest Colpo meltdown. As a part of his post, Richard dug out and put up one of my responses to a commenter from a post I wrote a couple of years ago. I had completely forgotten about it, but since it applies to the situation discussed above, I’m reprinting the comment by Ryan and my response below.  A hat tip to Richard for ferreting this out:

I have a question that may be related to this.

On several low carb forums right now, there is a debate going on about what happens to the extra fat calories if carbs are kept extra low so that insulin is kept low. Some say it will be stored as fat anyway, others say it will be burned as heat and still others say it will be excreted. One member even did near-zero carbs and very high fat for a week (4500 calories instead of a normal 2500, with an average of about 80-90 g of protein). He lost a pound off of his already lean physique.

So, where does that extra fat go? Is it excreted? The detractors say that fat is completely digested before reaching the colon but I am not sure. If it is excreted, could you go ultra high fat, zero carb for a week or so and get the same detox results as the cosmic pizza grease?

Hi Ryan–

Your comment raises an interesting question. Where does all the excess energy go?

I’ve had a number of patients and countless letters from readers who have had the same experience. They consume a ton of fat, but don’t gain weight…or even, as with the guy you described, lose a little. Mostly the letters we get are from people who complain that they are following our diet to the letter, yet not losing weight. When we investigate, we find that in virtually every case these people are consuming huge numbers of calories as primarily fat. We always ask them if it doesn’t strike them as strange that they’re eating as much as they are, yet not gaining.

In order to lose weight, one must create a caloric deficit. This can be done in a number of ways. People can burn more calories by increasing exercise; they can eat fewer calories; or they can increase their metabolic rate. Or they can do any combination of the above.

Most people going on a low-carb diet decrease their caloric intake. A low-carb diet is satiating, so most people eat much less than they think they are eating even though the foods they’re consuming are pretty high in fat. Some people, however, can eat a whole lot on a low-carb diet, and, can in fact, eat so much that they don’t create the caloric deficit and don’t lose weight. But the interesting thing is that they don’t gain weight either. They pretty much stay the same. They are eating huge numbers of calories and not gaining, so where do the calories go?

First, I don’t think they go out in the bowel. If they did, people would have cosmic pizza grease stools whenever they ate a lot of fat over a period of time, and they don’t. And a number of studies have shown that increasing fat in the diet doesn’t increase fat in the stool.

Eating a very-low-carbohydrate diet ensures that insulin levels stay low. Unless insulin levels are up, it’s almost impossible to store fat in the fat cells. With high insulin levels fat travels into the fat cell; with low insulin levels fat travels out. So, it’s pretty safe to say that the fat isn’t stored. So what happens to it?

The body requires about 200 grams of glucose per day to function properly. About 70 grams of this glucose can be replaced by ketone bodies, leaving around 130 grams that the body has to come up with, which it does by converting protein to glucose and by using some of the glycerol backbone of the triglyceride molecule (the form in which fat is stored) for glucose. If one eats carbs, the carbs are absorbed as glucose and it doesn’t take much energy for the body to come up with its 200 gram requirement; if, however, one isn’t eating any carbohydrates, the body has to spend energy to convert the protein and trigylceride to glucose. That’s one reason that the caloric requirements go up on a low-carb diet.

The other reason is that the body increases futile cycling. What are futile cycles? Futile cycles are what give us our body temperature of 98.6 degrees. Futile cycles are just what the name implies: a cycle that requires energy yet accomplishes nothing. It operates much like you would if you took rocks from one pile and piled them in another, then took them from that pile and piled them back where they were to start with. A lot of work would have been expended with no net end result.

The body has many systems that can cycle this way, and all of them require energy. Look up the malate-aspartate shuttle; that’s one that often cycles futilely.

Another way the body dumps calories is through the inner mitochondrial membrane. This gets a little complicated, but I’ll try to simplify it as much as possible. The body doesn’t use fat or glucose directly as fuel. These substances can be thought of as crude oil. You can’t burn crude oil in your car, but you can burn gasoline. The crude oil is converted via the refining process into the gasoline you can burn. It’s the same with fat, protein and glucose–they must be converted into the ‘gasoline’ for the body, which is a substance called adenosine triphosphate (ATP). How does this conversion take place? That’s the complicated part.

ATP is made from adenosine diphosphate (ADP) in an enzymatic structure called ATP synthase, which is a sort of turbine-like structure that is driven by the electromotive force created by the osmotic and electrical difference between the two sides of the inner mitochondrial membrane. One one side of the membrane are many more protons than on the other side. The turbine-like ATP synthase spans the membrane, and as the protons rush through from the high proton side to the low proton side (much like water rushing through a turbine in a dam from the high-water side to the low-water side) the turbine converts ADP to ATP.

The energy required to get the protons heavily concentrated on one side so that they will rush through the turbine comes from the food we eat. Food is ultimately broken down to high-energy electrons. These electrons are released into a series of complex molecules along the inner mitochondrial membrane. Each complex passes the electrons to the next in line (much like a bucket brigade), and at each pass along the way, the electrons give off energy. This energy is used to pump protons across the membrane to create the membrane electromotive force that drives the turbines. The electrons are handed off from one complex to the other until at the end of the chain they are attached to oxygen to form water. (If one of these electrons being passed along the chain of complexes somehow escapes before it reaches the end, it becomes a free radical. This is where most free radicals come from.)

There are two parts to the whole process. The process of converting ADP to ATP is called phosphorylation and the process of the electrons ultimately attaching to oxygen is called oxidation. The combined process is called oxidative phosphorylation. It is referred to as ‘uncoupling’ when, for whatever reason, the oxidation process doesn’t lead to the phosphorylation process. Anything that causes this uncoupling is called an ‘uncoupling agent.’

You can see that the whole process requires some means of regulation. If not, then the electromotive force (called the protonmotive force, since it’s an unequal concentration of protons causing the force) can build up to too great a level. If one overconsumes food and doesn’t need the ATP, then the protonmotive force would build up and not be discharged through the turbines because the body doesn’t need the ATP. The body has accounted for this problem with pores through the inner mitochondrial membrane where protons can drift through as the concentration builds too high and by proteins called uncoupling proteins that actually pump the protons back across. So we expend food energy to pump protons one way, then more energy to pump them back.

One of the things that happens on a high fat diet is that the body makes more uncoupling proteins. So, with carbs low and fat high, the body compensates, not by ditching fat in the stool, but by increasing futile cycling and by increasing the numbers of uncoupling proteins and even increasing the porosity of the inner mitochondrial membrane so that the protons that required energy to be moved across the membrane are then moved back. So, ultimately, just like the rocks in my example above, the protons are taken from one pile and moved to another then moved back to the original pile, requiring a lot of energy expenditure with nothing really accomplished.

This is probably all as clear as mud, but it is what happens to the excess calories on a low-carb, high-fat diet.

Cheers–

MRE