Nyungar Diabetes: Australian Dietary Genocide?

NOTICE

Aboriginal and Torres Strait Islanders to should use caution viewing this post, as it contains images of dead persons. Nothing in this post should be taken as criticising or diminishing the efforts of the Nyungar or Aboriginal and Torres Strait Islander communities in pursuing their health or be construed as criticism of them for an unfortunate situation.   The Nyungar have a deep and rich oral culture of which I am not a part. Therefore, I hope to be excused for any error due to the interpretation of things via the written words of mainly white historians. It is worth the risk to be wrong because this issue deserves highlighting and, as always, my comments are open to people to improve the information on this blog.

Nigerian Musings

In my last post, I talked about the phenomenal success of the ketogenic diet in Nigeria where hundreds of thousands of Nigerians were using a Facebook group to solve their obesity, diabetes and PCOS health problems with a ketogenic diet. Then I saw an article on Siberian health problems from carbohydrate consumption and other lifestyle change in Russia. It got me to thinking, how are Aboriginal and Torres Strait Island Australians faring?

A Diabetes Emergency in Aboriginal Australia

It is, unfortunately, no secret that diabetes is out of control for them and this crisis was seen as that many years ago. Even when compared to lower socio-economic Australians the statistics are horrifying. Whereas among other Australians, type 2 diabetes is virtually unknown in people under 25, the rate for Aboriginal Australians is 1.5% for people aged 15 to 24, and 0.5% for children aged 2 to 14! After that, the rates are about four to five times other Australians until age 55+ where 40% have diabetes.  In general, Australian Aborigines develop diabetes twenty years earlier than other Australians and are about twice more likely to be hospitalised.

Why is it so bad?

Indigenous peoples in other places like the Arctic and the Pacific Islands experience similar problems with obesity and diabetes. This was blamed on ‘thrifty genetics’ that predisposes them to weight gain.

While the existence of a thrifty gene is now disputed, the common thread is that their hunter-gatherer lifestyle has changed to a Western diet. As concluded from this study, that change results in health problems linked to insulin resistance. The fat deposition is very noticeable in aboriginal people. They tend to put on weight around the middle yet can remain quite lean elsewhere, and this is backed up by the cited study. 

There is a predominantly central pattern of fat deposition in both men and women, which is associated with greater insulin resistance and cardiovascular risk than is peripheral fat deposition.

Past Research into Diet

Prof. Kerin O’Dea undertook pioneering work into traditional aboriginal diets, obesity, diabetes and heart disease. In her study from 1988, it was noted that even in underweight subjects still adhering to a more traditional way of life; there was higher fasting insulin and elevated triglycerides (signs of insulin resistance) even though their diet was low fat and comprised of lean meat. 

In a book chapter from 1988 “The hunter-gatherer lifestyle of Australian Aborigines: implications for health.” Prof. O’Dea looked precisely at what we could learn from a ‘Paleo’ type diet of aborigines. In summary:

  1. Aboriginals become obese and develop diabetes (along with high blood pressure and heart disease) when they stop eating traditional food.
  2. Before European contact, they were lean and physically fit, and there was no evidence of chronic disease. They were ‘underweight’ with low BMI (13.4 to 19.8 kg/m²) without having signs of malnutrition.
  3. There was a lack of literature and nutritional data on an entirely traditional diet, and so she studied people living mostly traditionally.
  4. One group she studied had “a traditionally oriented diet” with a BMI of ~17kg/m² and exhibited low fasting glucose (3.8±0.4 mmol/L) but still showed other diagnostic signs of insulin resistance.
  5. Referred to her previous seven-week study of a traditionally oriented diet (about 1200 calories). It had two-thirds of calories from meat, 13% from fat, 54% from protein and 33% from carbohydrates when the group were inland where tubers and honey were more plentiful. The carbohydrate quantity dropped to a level estimated at less than 5% when on the coast with protein at about 80% and fat at about 20%. The trial showed a normalisation or improvement of the metabolic factors associated with diabetes. 
  6. She concluded that a traditional aboriginal (Paleo) diet could reduce primary diabetes and cardiovascular risk factors in the general population but noted it was unlikely to be popular with nutritionists.

This type of diet is also unusually rich in animal protein and high in cholesterol- characteristics not generally favoured by nutritionists in making recommendations for better health.

Other Research

Prof. O’Dea performed other ground-breaking research regarding diet, diabetes and Australian aboriginals.  These included:

  • A 1980 three-month cross-over study that compared an aboriginal urban diet and traditionally oriented diet (50% protein, <20% carbohydrates, >30% fat) with a Caucasian control group that showed aboriginal people exhibit a stronger insulin response to glucose than Caucasians which was less pronounced after a traditional diet. This was likely to be a major factor in their predisposition to diabetes.
  • A study in 1982 on the effect of a high protein, seafood based, very low carbohydrate ketogenic diet for two week period. This showed a significant but small improvement. Most other trials of ketogenic diets have proceeded for longer periods as two weeks is about the time required for initial ‘fat adaptation’. It can be wondered what might have been the result had this trial been longer. 

The Nyungar

My armchair research is not as ground-breaking, but I do want to add. I decided that I would like to focus this blog on one particular group.  The Nyungar (or Noongar) whose lands I dwell upon in South Western Australia. Why? The Nyungar were lean and healthy eating a traditional diet until relatively recently, and much of that diet is well recorded.

It is unknown exactly when the Nyungar came to these lands, but there is evidence dating to at least 30,000 years- or greater than 1,500 generations ago.  History records that Europeans did not first settle here until 1826. Along with European settlement came new foodstuffs, disease and farming practices previously unknown to the Nyungar. Flour became especially attractive to them as they had nothing as starchy in their traditional diet. Some of the trouble with settlers was for stealing flour however despite new found foods, the traditional way of eating is said to have existed until the 1960s. Allowing some leeway, it was only three to five generations ago that the Nyungar changed their diet.  

Many things changed with the coming of settlers, but I will focus on their food. It is common sense to do so as obesity is roughly 80% metabolism and diet and only 20% exercise and other lifestyle factors. The Nyungar did not run marathons for fun. Like other hunter-gatherers, their activity was low level for long periods and aimed at surviving. If you doubt that common sense, remember that it takes a 6.8km run to burn off a serve of coca cola and takes little effort to drink a few serves.  I do not know why people confound themselves with other factors and think that we are obese because people just aren’t moving as they used to. It is a factor, but you cannot outrun a bad diet- contrary to the favoured myth of the fitness industry.

Nyungar Diet Today

So what was their diet like then and what is it like now? Some of the information I am about to present comes from this paper from 2010.  It suggests that the current diet is high in fat, sugar, fast food and carbohydrates and that it is given to infants at an early age. 

The majority of infants had received ‘fast foods’ by 12 months of age with 56.2% had been given coca cola, 68% lemonade and 78% fried chips.

Unsurprisingly, many are on the same poor Western diet that causes diabesity all around the world. The same one that results from giving advice to the populous to minimise salt, fat, sugar, avoid saturated fat and to eat 45 to 65% of dietary intake from carbs (Australian Dietary Guidelines) and the food industry adjusts its products to match. The diet exacerbated by the fast food industry with its fattening mix of carbohydrates and polyunsaturated seed oils.

Traditional Diet

What was their diet? Well, the account of foods is quite detailed in this paper too. It was a meat based diet rich in meat, offal, but low in green vegetables with some tubers with limited grains, fruit and sugars. The effect of that diet is apparent below.  

Traditional aboriginals
Obesity and diabetes were unheard of on a traditional diet. Courtesy Wikimedia Commons

Respectfully, I have not put any pictures here of today’s Aboriginals and Torres Strait Islanders following (as best as they can) the Australian Dietary Guidelines but you can do your own google search. You are likely to find that, along with all Australians, people are not as lean. It is important to remember however that research showed that even lean Aboriginal and Torres Strait Islanders were predisposed to diabetes.

I think it is important that a reader gets some context of the ‘bush tucker’ food available here- especially the carbohydrates. The exceptional skill that the Nyungar had to live on this land is hard to appreciate unless you have spent time here. We do not have natural forests of edible nut trees with an undergrowth of berries. There was no farming, and everything was taken in season leaving enough to replenish naturally. Surviving on meat and fish here is one thing, determining the edible plants among the majority that are toxic belongs to Nyungar knowledge won over millennia that is foreign to me. Let us look more closely at the carbohydrates in their diet. These were said to be from the zamia palm, seeds and nuts (primarily wattle seed), fruits, nectar, honey and tubers.

Sugars: Nectar, Honey and Fruits

Banksia Nyungar Food
Banksia nectar was a Nyungar treat

Nectar from plants like the Banksia was seasonal at the flowering time. The nectar would obviously form a seasonal treat or snack in their diet- much like when Europeans suck on a honeysuckle.

 

There was no organised cultivation or production of snack products. As you might imagine too, just like these available for all Australians at my local supermarket, such snack treats would not form the mainstay of their diet.

Honey

Honey is a product of the concentration of nectar by bees. Unlike the European bees that arrived with settlers, most Southwest Australian bees are solitary and small.  You just don’t get the same prodigious quantities of honey from them. Australia’s honey producing stingless native ‘sugarbag’ bees are not native to South Western Australia.

Fruit

Native peach is of scant flesh

The fruit the Nyungar ate is typified by the native peach or ‘Quandong’. It is the size of an oversized grape and has limited meat. In fact, the ones in this picture are quite luscious compared to ones I have found in the wild. The ones I have seen have very thin flesh and a large nut with an oily kernel eaten roasted. It is a bit like a macadamia with a root beer flavour.

The Quandong has a short season of about a month over Summer in each locale ripening progressively from North to South in range over four months. It is also a small parasitic tree depending on specific compatible host trees, so both the fruit and the tree are not plentiful. The quandong is high in vitamin C but not overly sweet. If you can gather a sufficient quantity (an undertaking of some effort) and then combine with sugar, it makes a pleasant jam. Eaten fresh, the Nyungar would have had a tart treat.

While sugars were undoubtedly sought after, you would defy credibility if you were to maintain that the traditional Nyungar diet had any substantial sugar. It is recorded that the Nyungar collected nectar mixed with water for a sweet drink and also fermented it into an alcoholic drink (called Gep). Without bees to do the work, you can be assured that even when such seasonal pursuits were possible, they were well below the WHO stretch target of 5% of calories from sugar. You can be fairly sure that due to local availability and seasonality, most days would have no sugar intake at all.

Starches: Wattle, Tubers and Zamia

Wattle seed was probably the dominant seed that was eaten. In season it was ground and made into cakes cooked on an open fire and qualifies as the primary Nyungar grain. It would have been typical of the seeds that the Nyungar ate. Nutritionally, it was very high fibre (54%), and with a net carbohydrate content of 10.5%, 20% protein and about 6% fat, it is a very low carbohydrate grain compared to wheat (~70% carbohydrate).

Tubers were the last and probably most significant of the starches, and the Nyungar diet had a varied number. While I can find no nutritional analysis for these plants, it is important to remember that they were opportunistically collected, seasonal and never farmed or selected to improve the size and nutritional content. It is also a factor that tuberous plants tend to be found inland in the forests, and not on the coast.

Zamia: Carbohydrates or Fat?

Unlike other groups in Australia, the zamia palm is said not to have been eaten by the Nyungar for its more starchy seed, but instead for the poisonous oily macrocarpam which was specially treated to make it safe to eat. Contrary to what may have been assumed, to the Nyungar this was valued as a fat and not a carbohydrate source- much like the oil palms of the tropics.

Nyungars were not Vegans

The major part of the Nyungar diet, as written in many sources, was animals, eggs, birds, fish and grubs. As previously linked:

Traditional foods from this region varied but included emu, kangaroo, possum, goanna, fresh water crustaceans (maron and gilgies), bardi grubs from under the bark of eucalyptus trees or in the roots of mallee trees, wild duck, mallee hen eggs taken from the mound where multiple eggs were found and fish for people who lived on the coast permanently or in different seasons. Everything edible on an animal carcass was consumed, including organs such as the liver, kidney, brain and intestines.

It is evident through their preference for eating the oily zamia palm and other accounts of meat eating that they did seek fat although it was also not a high-fat diet. Fat would have been mostly from animal sources, and most wild sources from meat are not as high in fat as the domesticated ones that we now eat.

A Paleo Diet?

Putting this diet into modern terms, it would be pretty close to what people call a ‘Paleo Diet’.  No dairy, but with eggs, meat and fish as available with limited vegetable content as could be foraged. Looking at the descriptions of Prof. O’Dea’s work and the descriptions above, most Nyungar would probably be on a high protein (say 75%) low fat (say 15%) and low carbohydrate (say 10%) diet with inland Nyungar probably eating more tubers for some more carbohydrates.

The actual composition would be subject to the seasonal and local availability of the carbohydrate sources like tubers; it would have been at times, a ketogenic diet- particularly if the hunt and forage were insufficient.

With so few carbohydrate and fat rich foods, there is no doubt that the Nyungar would have prized fat and carbohydrate foods as high energy sources.  This is likely to be why they took the time and trouble to detoxify oily zamia palm fruits. 

The Cause is Apparent

We have looked at some of the past research and taken a look at the likely composition of the Nyungar diet. It should be fairly obvious why the Nyungar would suffer from insulin resistance, obesity and diabetes when fed a Western diet. Even if you disregard the similar opportunistic diet that they ate while migrating to Southwest Australia they have had more than 1,500 generations to adapt to the low carbohydrate, low-fat food in their country. We have given them three to five generations to adjust to a high carbohydrate, high-fat Western diet. The effect of our dietary advice has tripled obesity since the 1970s for all Australia. It even gives us the diabetes epidemic that Australia now faces. No wonder the Nyungar have been so severely affected by it.

I am of Northern European descent. My ancestors have had over one hundred generations to adapt to a higher carbohydrate diet made possible through agriculture, but even that is not long enough. No wonder I developed diabetes in my forties while some Nyungar get it in their twenties. Doesn’t that make perfect sense?

The Australian Dietary Guidelines

Even if the diet that Australians ate was exactly to the Australian Dietary Guidelines (essentially low-fat with 45 to 65% of energy from carbohydrates with multiple meals spread throughout the day), it still is far from their traditional diet of one main meal, low in carbohydrates, after the hunting and foraging were completed.

Now we hit the great conceit. You see with all of our science and technology we have worked out that the ‘perfect’ diet for Australian humanity is expressed in the Australian Dietary Guidelines. The Nyungar and other groups should eat our perfect diet born of science because to do otherwise would be to deny them health. It would be discriminatory to have them follow a different diet.

If I were to espouse their original low-carb, low-fat, high protein diet, people would say: “Yes but in their primitive way of life they died young”. To that, I would say: “That is why we have modern medicine including antibiotics, sterile surgery, vaccinations, pre and ante-natal care, effective drug therapies and more”. Further, as obesity and diabetes were completely unheard of on their traditional diet, no-one would likely die of diabetic complications, suffer diabetic induced cardiovascular disease, diabetic blindness, kidney failure and amputation. Isn’t that what we are seeking to fix?

No one is suggesting that the Nyungar must go back exactly to their traditional diet and lifestyle. There is no reason though why healthy eating of similar composition to their traditional diet cannot be recommended.  It is not, though. In fact, the diet that I am on is denied as an option for the Nyungar by Diabetes Australia and Diabetes WA. My diabetes effective low carb healthy fat diet would be pretty close to their traditional diet. It is safe, maintainable and gives me normal blood glucose that means I will avoid diabetic complications.

Most importantly, it has reversed my diabetes.

Calling it Out

No Facebook groups are helping the Nyungar, or other groups achieve low carb weight loss and curing their diabetes as the Nigerian ladies have achieved through self-organisation. Our First Australians are depending on not-for-profits who are failing them. 

Advice from Diabetes Australia for Aboriginal and Torres Strait Islander’s with diabetes may include the call to eat more bush tucker, but it is otherwise much the same as for all Australians. In particular, it does not suggest limiting, total carbohydrate. The CSIRO has recently proven this to be effective, and actually, Prof. O’Dea’s studies also showed its efficacy some forty years ago. It seems unfortunate that it was not a favoured message of the nutritionists either now or then.

This issue has to be called out, and so I am doing so. To continue pushing the Australian Dietary Guidelines for people with diabetes, and in particular for the First Australians like the Nyungar, is tantamount to Australian Dietary Genocide. It is making us all, white fella and black fella, very very sick.

My next post will examine this issue further.

Nigeria: Sisters are Doin’ it for Themselves

Our Shame

In Australia, our fat-cat bureaucrats, egghead scientists, over-lobbied politicians, salivating not-for-profit CEOs, conflicted dietitians organisations, greedy pharmaceutical companies and over sweetened food industry CEOs are debating obesity strategy and sugar or health taxes. The government has already dispensed a National Diabetes Strategy that this motley crew put together that wouldn’t even make it onto the fiction best seller’s list, let alone solve the problem, as it fails to contemplate changing dietary recommendations as solutions. Taxing us to tackle obesity? Unfortunately, they take themselves too seriously.

As a health consumer, what do you think? Before you answer, I’ll tell you that you should simply not give a damn (or insert your favourite four letter word here). Sorry for the language but when you realise that other than your statistic, it is not about you. Not one of these is truly advocating for you with your chronic obesity or diabetes. It is all to do with their interests like funding for their members and organisations, research buckets of money or profits. They have forgotten you and the experts are dead. After all, if they actually fix your chronic diabetes or obesity, what would they do with themselves?

Meanwhile, In Nigeria…

A quiet revolution is underway. Let us look at something that really should matter to you much more than the business plans and career advancement of all those types above.

Nigeria’s population is pushing 190 million. The traditional diet is quite high in carbohydrates with palm oil and other fats, and it used to be a sign of affluence to be chubby- but not anymore. It has upwards of five percent of those people with diabetes, many more pre-diabetic and far too many are obese. The obesity rate climbed eight times from 1.3% in 1974 to 10.3% in 2014.  Fertility is impacted by PCOS. Yessiree, Nigeria has an insulin resistance problem.

Is Nigeria Lacking Dietetic Advice?

How can this be? Surely most people are not so affluent as to be obese? Nigerians probably have a good deal of plant-based diet as meat is more expensive. They have national dietary guidelines that are just as good as ours. Those guidelines recommend that Nigerians have a rich carbohydrate diet, limit fat and avoid saturated fat. Those guidelines say they should have lots of fruits and vegetables and not eat too much red meat. They have a dietitians association that gives them the same advice as everyone else in the world gets. Perhaps Nigerian Dietitians have the same problem as the DAA in that they have the same fantastic dietary guidelines, but no one follows them. Strangely this is an epic fail in every country, but we keep on doing the same thing and hearing the same excuses.

Perhaps it is all the new sedentary jobs in Nigeria that have caused these health problems? The Internet penetration is at about 52%- approximately 97 million people and about 16 million of those are on Facebook. Of course, to think of Nigeria as a poor, backwards country is not only insulting, it is untrue. There is one key technology statistic they lead in. I noticed that they even beat the United States.

Google Trend

If you search for the term ‘ketogenic’ on Google Trends, you see that Nigeria beats all other places in the world. “It must be some mistake,” you say? It is not. While our societies are nauseatingly debating sugar taxes, how to prevent obesity, coming up with ineffective national diabetes strategies and suppressing low carb for greed under a thin veneer of philanthropy, the ladies of Nigeria are transforming their health and the health of their country.

Now the low-carb deniers are probably going to suggest some tin-foil hat conspiracy. Maybe Prof. Tim Noakes has been commuting North every week spreading his vile message? No. It is a grassroots revolution.

In Nigeria, the low-carb diet is best known under the term ‘ketogenic’ diet, and so it has slipped under the radar compared to terms like Paleo, LCHF and Banting.  

Nigeria Ketogenic search trend
Nigeria Ketogenic Diet Rapid Growth

The Google trend search also shows that adoption has been extremely rapid. From a near standing start, it accelerated in about August of last year. It had the usual January bump that we see in diet trends. What is driving this? No surprises folks. It is because it works and the ladies know it.

Ketogenic Lifestyle

One of the largest groups on Facebook is called “Ketogenic Lifestyle”.  It started posting its ketogenic information in August of last year when the surge happened. It has about 316,000 members and has grown very fast. What may surprise you is that this group caters to provide support for Nigerian low-carbers. Almost all of the members are Nigerian, and the majority are women. How the three admins manage a Facebook group with over 300,000 people is probably worthy of a separate post (and a gold medal)!

This group was started by Joy Aghogho whom some of the members refer to as “Aunty Joy”. Joy is exactly what they feel every time a sister, infertile in the past from PCOS, announces their pregnancy. The posts are a procession of advice and information and then beautiful ladies. Beautiful and large before, beautiful and healthier after keto. They know the keto diet is a therapeutic diet that can counter the health scourges of their country (diabesity) as well as PCOS and epilepsy. There is not a dietitian in sight. These are ketogenically educated ladies, and they seem to know it better than most Australian APDs!

The Numbers

Let us just run some numbers for the bureaucrats and CEOs who may happen to come across this health consumer’s blog. 316,000 Nigerian Facebook users can actually be doubled when you consider that their partners are probably eating keto too. That is four percent of the Facebook user population. Given that societies like Nigeria have very dynamic and active personal networks radiating from each user, that figure may well be a good proxy for the penetration of the ketogenic diet into Nigeria itself. This figure is significant as the official rate of diabetes in Nigeria is 5%, and the ketogenic diet normalises and reverses type 2 diabetes and offers type 1s normal blood glucose. There is likely to be a great crossover between the obese and diabetic population (10.3% and 5%) and the ketogenic diet population.

The Implications

So here are some questions and implications for various people from the ketogenic health explosion in Nigeria.

For Government Health Ministers and Health Bureaucrats:

Will Nigeria beat diabesity before your country even considers the right move? It looks like you need to get away from the noisy lobbyists and interest groups and investigate what is happening for health in our own Facebook communities.

For Pharma CEOs:

Nigeria is probably not even a blip on your sales figures, but you now have a duty to your shareholders to inform them of the risk from other country populations adopting low carb- particularly at the rate of growth seen in Nigeria.

For Pharma Shareholders:

Along with the Credit Suisse report, time to reassess your long-term investment unless your CEO has communicated a clear strategy to manage dietary change to low carb.

For Diabetes Not-for-profits:

Are you really committed to innovation to improve the lives of people with diabetes? If not then find another job.

For Food and Drink Industry CEOs:

Time to stop resisting with marketing that will damage your future brand. Consider what your products will be in a low carb future and like pharma executives- consider your projections carefully.

For Food and Drink Company Shareholders:

Along with the Credit Suisse report, time to reassess your long-term investment unless your CEO has communicated a clear strategy.

For Dietitians and their Not-for-profits:

Even if you STILL think this is a diet fad, shame on you to force health consumers to fix themselves via Facebook. Ignoring this health revolution is making you irrelevant.

For the higher carb chronic disease sufferer:

Time to try what these smart Nigerian ladies know.

For the researcher:

Plenty of epidemiological data here about the mass-effect of ketogenic diets on weight loss, POCS, Diabetes and health. Time to pull out your head and head to Abuja or talk nicely to Joy.

For the existing low-carber:

See what the low carb community can do.
Keep calm and keto on with our Nigerian sisters!

Health Networking for Chronic Disease

The Usual Channels

We have accepted that your regular networking channels for health may offer some relief, but they won’t offer you anything approaching a cure.  For example, If you are looking to reduce your dependency on medications? Avoid any ‘lifestyle information’ that has the seal of approval from pharmaceutical companies. 

If you have diabetes and might try to reduce your carbohydrate, Diabetes Australia tells you to eat to the Australian Dietary Guidelines like the rest of the population (45 to 65% of calories from carbohydrates) when it is common sense that pharmaceutical use rises the more carbohydrates you eat. Eli Lilley supports the awards for diabetes educators in Australia and so is it a curious coincidence that their educator gave advice to me to eat more carbs?

We saw that Sanofi has a website to send you to chemists that they have educated to use their product. Dietitians Associations have breakfast manufacturers as partners.  They continually tell you not to skip breakfast and to eat whole grains like it is a religion. Despite this, in Australia, your doctor will refer you to dietitians, and the government pays your fee to see them!

Unchain Yourself

You don’t need to chain yourself completely to this mess. Just accept that it is full of possible conflicts and corporate marketing and interests. You would go crazy trying to get to the truth while understanding this is just the chronic health industry that you want to leave behind.

Our quest to get some low carbohydrate dietetic advice looks bleak. Can it really be hard and dangerous to do it yourself? Worse than any danger from a short-term dietary change would be to do it incorrectly, not see any benefit and miss out on future good health.

Health Networking

Health Networking by Facebook can help
Health Networking Pays Dividends

So the big hint that came out of our PCOS analysis was that we saw in the Facebook comments on the DAA press release that there were Facebook comments from people who were doing low carb and who did not agree with the press release.

However, before we go there it is critical to understand the Macrofour principle:

The experts are dead!

If you don’t get that, then go back and re-read my blog from the beginning.  Without that understanding, you may be seduced by all of the rhetoric of the people who have not walked a mile in your shoes. When they say ‘build your health team’ it really means ‘learn how to depend on us’. When they say ‘learn how to manage your disease’, it means ‘learn how to get comfortable with our products and services for life’. There is no conspiracy here.  It is all just good business. After all:

There is not profit in healthy people and there is no profit in dead people. The chronically sick are the most profitable.

So as I said before, take the best that system can offer to buy you time, but do not accept that it is your best solution.

Finding the Right Experts

When I say the experts are dead, it doesn’t mean that all experts are useless and all expert knowledge is useless. Quite the contrary. The solution to your problem is likely to be underpinned by science and experts.  They are just not the experts that would have you manage your chronic condition until you die. Equally, you need to avoid the snake oil salesmen who dishonestly offer you a product or cure. It seems a difficult road to navigate but there is a solution.

The Internet and Facebook are part of your ‘Health Team’

Social media is social networking. Social media health groups are health networking.  If a better solution is being practised somewhere in the world, then somewhere on the internet is a forum or group that is exercising it and sharing the knowledge. You just need to find it. 

Start by talking to people. Were they like you? What have they done? What worked and what didn’t work. Remember, your N=1 is not their N=1; but it might be N=2!

Dietitians Examples

Back to getting dietetics advice.  A recent change in Australia is the formation of a group of independent dietitians.  They were set up to form a register of consultant dietitians who had no other conflicting commercial interests.  There are similar organisations of dietitians through Facebook groups. In the very next days, dietitian Matthew O’Neill is running an online seminar on low carb aimed at reconciling mainstream dietetics advice.  They may still not be the experts you are looking for, but the reason that I know of these options is through social networking on Facebook, Twitter and the Internet.

In a similar fashion, we saw that Dietitian Franziska Spritzler favours a low-carb approach for PCOS and other ailments. Feng-Yuan Liu had an article written about her on Foodmed.net and Metro Dietetics where she works, understands the therapeutic low carb approach and has better information (based on my analysis) than the DAA for PCOS.

If you have diabetes and need intensive help, then Jennifer Elliott has a program that can be undertaken with doctor support. While being deregistered from the DAA might seem a bad thing, in the opinion of the low carb community on Facebook, she is very competent and knows her stuff. Especially when we have examined the DAA’s poor PCOS press release, it may be that being deregistered from the DAA is actually a badge of competence and innovation.

Of course, if you are in Tasmania, you could probably not go past the Nutrition for Life Team. Started by ‘silenced’ orthopaedic surgeon, Gary Fettke and run by his wife, Belinda.  It seems that being deregistered, banned or silenced is almost a pre-requisite for credibility. We may look at that more closely in the future.

The point is that I know about these dietetic resources from networking in the low-carb community.

Where Else?

This is not exhaustive. There are these and many other resources. You can discern the worth of these by using your extended health team and the wisdom of crowds. You need to learn from people who have walked a mile in your shoes and hopefully have achieved a better outcome.

In a coming post, I will collate a list of Facebook groups and other resources for people to examine. These may have dated by the time you read this blog, but others will have taken their place. You will need to find them.

If you have low carb services or run a facebook group or other forum and may not be represented in the channels I may use or want to check that you are included, then please contact me.  To be perfectly clear I do not accept payment for mention in my posts and any inclusion is at my complete discretion after having regard for your standing in the low carb community.

Can We Get Low Carb Help From Dietitians?

Can We Trust Dietitians?

Not to re-invent the wheel as Foodmed.net did an in-depth series of articles on the Dietitians Association of Australia (DAA). These reports questioned in particular whether food industry sponsorship skewed their advice, whether their spokespeople were in touch and not influenced by industry, how there was likely to be dubious media information from such involvement and how there was apparent suppression of opposing views. The author, Marika Sboros, was not the first investigative journalist to report on the issue of possible industry influence in the DAA. She did not pull punches in suggesting that they engaged in fake news and disclosed that significant amounts of their revenue came from industry sponsorship. The DAA’s only response (that I am aware of) was this statement on their website.

What is the reality?  Can we trust the DAA and its dietitians in general for their advice? It is an important question for health consumers and not just Australian ones.  DAA is part of an international organisation, and they all appear to sing from the same dietary hymn sheet (standards).

In our analysis of the paper behind the DAA press release we discovered that the women with PCOS were part of a self-help charity and were probably following a lower carb approach out of the ‘wisdom of the crowds’. That said it did not appear to be a very low carbohydrate diet being on average 42% carbs by energy. The DAA seemed to recommend increased carbohydrate consumption when we found that there was no evidence for that from the cited study.

In fact, from reviewing the literature and interpreting the evidence, the advice should be that PCOS sufferers would benefit by reducing carbohydrates starting with sugar.

Press Release Review

Now considering the press release analysis, I note that among other things the DAA:

  • Did not make it clear to a largely uninformed public that this was not an intervention study. In other words, there was no experiment to put equally sick subjects a low carbohydrate diet and evaluate their health improvement.  At best it is a small epidemiological study.
  • Did not clearly disclose that the reason for the reduced carbohydrates was likely to be due to self-help information. This made it appear to the health consumer that the lower carbohydrate intake could be causing their problems.  This type of study cannot be used that way, but this would not be known to a health consumer.
  • Recommended the consumption of whole grains which was an untested outcome. Again, for the health consumer who did not read and interpret the full paper, this would be misleading. The study made no reference to whole grains whatsoever.
  • Did not disclose that the reduction in carbohydrates was significantly from a reduction in sugar. Sugar reduction is in line with WHO and Australian Dietary Guidelines, and the PCOS cohort was statistically closer to the WHO target.
  • Did not disclose that neither the PCOS nor healthy women were complying with dietary guidelines or physical exercise recommendations.
  • Made no comment on the relative good health of the PCOS women.

Now the DAA might say that some of this were the author’s responsibility. However, I also note that they managed the peer review and accepted the quality of this paper for publication in their journal, so they also bear that responsibility.

I cannot find a sound evidence-based reason why the DAA would produce such a press release from that paper.

Industry Influence?

In the DAA example, I cannot say that this paper was influenced by the desire to ‘market’ whole grains for the food industry as Marika Sboros’ articles might suggest, but that is one possible reason. Many dietitians work in food manufacturing, and the commercial pressure to maximise profits for shareholders look to be at odds with the consultant dietitian’s advice that consumers need. How does one organisation properly reconcile these very different aims?

Dietitians Association of Australia Spokesperson Margaret Hays
Margaret Hays looking through a collection of cereals after suggesting not to skip breakfast (C) Copyright 9 News

I note that one of the corporate partners of the DAA is the Australian Breakfast Cereal Manufacturer’s Forum. They would have something to gain if more women eat wholegrain cereal for breakfast because they are fearful for their fertility.  It would be scandalous if that were the aim of the DAA in producing this press release.

Other Explanations?

Another possible explanation is that they are incompetent to interpret research and apply an evidence-based approach. If that is the case, it makes it hard to recommend seeing their members (APD dietitians) carte blanche as the DAA is responsible for monitoring their ongoing training and providing information.

Another possible explanation is that they have dogma and dietary beliefs rather than science and have simply used this research to push pre-conceived dietary information on the public. That would also be quite scandalous if it were true.

It could just be an advertisement to drive concerned women, trying to conceive, to see their APD members. The need to see their members indeed featured as a media message.

It could be just due to very poor management of this organisation or even just one dumb mistake.

The circumstances around this paper and press release, coupled with questions that Marika Sboros has raised about the DAA, also call into question the very peer review process of this paper and subsequent use of it as a consumer health message. I am not a nutrition scientist, but to me, it raises questions about the integrity of the DAA’s journal to be free of industry influence. It is one thing for the authors to declare conflicts of interest (and I do not suggest that the authors of this study have any undeclared conflicts); but what about the journal owner (the DAA) itself?

It is speculation because we do not have all the facts, and I don’t think there is much point in speculating further. My comment section is, of course, open to the DAA, its staff, its dietitians or the public to comment. If you are a whistleblower or do not want your comment published, I will also respect that. If we can definitively answer this, I would be happy to update in this or a future post for the many health consumers out there that would be bewildered, like me, about this issue.

Ripple Effects

Whatever the reasons and motivation, unfortunately, among the media to pick this up were the Huffington Post and News. You can see that if you read those articles, you would not find an alternate view. You might take the advice as those news outlets appear to have done no critical analysis of the DAA press release.  Their many female readers may have taken this message to heart.

Dietitians Association Facebook Post
Facebook Post of PCOS Press Release

It also appeared to generate social media activity and some women ‘tagged’ their friends to read this article. Did those friends have extra grainy bread or cereal after reading it?

As a health consumer, I find this unsatisfactory. It does demonstrate how the media ends up reporting health advice that misleads the public. We can partially blame the media for this.  They should have sought alternate views rather than taking a press release and just reporting it and only speaking to the DAA.  However, the journalists apparently relied on the science in a press release from the DAA to be fair, evidence-based and accurate.

The Outcome for PCOS Women

The net effect of the press release is to give the exact opposite advice that they should have. If anything, the message should have been to reduce carbohydrates starting with sugar. The effect could be child-denying for a woman with PCOS trying to conceive and potentially life-threatening. It is horrific to me, and I am appalled that the DAA has not yet corrected this of their own volition. 

I call for this press release to be retracted and for better advice to be given. The DAA should also make efforts to contact every woman who may have read this press release. In fact, in my opinion, it is appropriate for any woman with PCOS who read this to be offered free dietetic sessions with the corrected advice lest it spawns a future class action.

I note though that they tried to diminish Marika Sboros’ work by calling them blog posts and calling her a blogger when she has had a distinguished journalistic career spanning decades.  They also make the point that she is not Australian based with the implication that it diminishes her journalism.  That approach indicates both arrogance and a tendency to run on spin rather than facts. That behaviour is akin to the arrogance of Donald Trump’s handling of Whitehouse reporters. DAA, health consumers, deserve answers, not dietetic spin; but why would you listen to an Australian consumer health blogger like me?

DAA management, if you feel you don’t owe health consumers a public explanation, how about coming clean to your dietitian members? After all, they pay most of your salary. Your training, advice and alleged intimidation of those with new ideas may be exposing them to lawsuits and liability. We can vote by not engaging your members’ services, and they can vote to sack you if your answer to them is unsatisfactory.

Media Manipulation or Setting Journalism Standards?

I note that the DAA gives out a cash and in-kind award for what it regards as good nutrition journalism. The award can be majority decided by the CEO, who presumably approved that PCOS press release, and their media manager who wrote it. Should the award be meaningful when its own press release standards appear to be so poor or if it has an agenda to push particular nutrition dogma rather than evidence-based science? If the journalists who won the award, wrote favourably of nutrition advice that marries with DAA sponsors or favours the DAA’s views, it could be seen as a cash incentive for having promoted its sponsors interests or dietary dogma. While it has sponsors of any kind, it seems a very ethically-sensitive undertaking for the DAA to be doing this.

Lessons from this Case Study

I think you need to make up your own mind about all of this. The bottom line is that, as health consumers, we need to be mindful that organisations can be influenced by many factors. Those factors can be other than for our health. My suggestion is that as health consumers we should boycott not-for-profit organisations that have industry sponsorship or donations. Otherwise, at least have very low regard for their advice.

While the DAA looks to be quite poor about communicating evidence-based nutrition science, it would be unfair to say that all their members or dietitians are useless to give low-carb dietary advice. These are highly trained nutrition specialists. They know more about metabolism than we are likely to. If well trained and of an open mind, they should also be able to learn and grasp new concepts. They should interpret them rather than being mired in their organisation’s dogma or other interests.

There is something we can learn from this if we are looking for help. There was some public outrage at the press release. Some people posted negative Facebook comments. Many of these people appeared to share an alternative view towards low carb. As an idea, perhaps you could try communicating with them to ‘health network’ for a solution.

In my next post, we will look further at how we could perhaps find helpful dietitians and other advice.

Finding Advice for a Very Low Carb Ketogenic Diet

Where Can we Get Advice?

If you have read my previous posts, you may have decided to trial a Very Low Carb Ketogenic Diet. In my last post, I thought I would start to give you some practical advice to achieve that.

Before we start looking at that, I would like to state the Macro Four principles of chronic disease management.

The Experts are Dead!

The experts do not care about N=1 but you do!

And now I introduce the third and probably the most important one.

Find people who have walked a mile in your shoes.

Why do I say this? Well, suppose that there is a cure out there and that people have discovered it.  Let us say that cure is effective and people have been quietly taking benefit from it for a while. Let us say that cure has not been given the official anointment in your country or local area but has been widely practised in another- officially or unofficially.

The official channels of your health system may not offer you that cure for decades. However, there would exist a pocket of people quietly benefitting from that cure but because they are probably ‘unofficial’ you may not hear of it.  You could perhaps find a group of fellow sufferers and talk to them. Alternatively, lets say you have decided to try a ketogenic diet, find a large group and ask- Has anyone found this has helped condition X? You have little to lose from this approach. It is just talking to people.  

Health Networking

Health networking is your surest way to find that is to find a group of fellow sufferers and talk to them. 

Seeking advice. Hope or Despair
How will you find advice?

Before we talk about where you may find those people to get some advice, let us talk about the common places that you won’t find those people. After all, your time without relief is time suffering.  You want to spot the time wasters.

Not-For-Profit Advice?

You are unlikely to find someone with a advice for a better solution at a self-help group educated by your local, not for profit organisation for your chronic condition.  That is because those ‘experts are dead’ and they will offer you conventional therapies that mean that you will remain chronically sick. Their advice may be complementary to a path you choose to take, or they may even discourage you from an alternate solution.

Why would they do that? The reasons are many and varied.

  1. They follow the standard treatment.
  2. You probably won’t find ‘cured’ people there.
  3.  Their mission statement probably perpetuates the ‘learned helplessness‘ that you want to leave behind.
  4. That standard treatment might be as preferred by outside interests like the pharmaceutical or food industries.

If that seems strange to you it isn’t. Let me state that I do not believe in ‘conspiracy theories’. On the other hand, there is almost always an explanation for human behaviour however, nonsensical or odd. Most of the time it can be understood by looking at the flow of money.

Earlier, I focussed on PCOS because I expect that by the time many of you read this blog, the example of type 2 diabetes will seem so obvious in retrospect. Then again, maybe not!

Following the Standard Treatment

Nonetheless, here is my experience as someone with type 2 diabetes.  I was diagnosed with type 2 diabetes about five years ago. I duly followed what Diabetes Australia recommended. Without repeating some of my earlier blogs, it was a disaster. My health deteriorated.

After some three months on a VLCKD and with greatly normalised blood glucose, I rang up their help line to see what advice they would give.  Sure enough, the CREDENTIALED DIABETES EDUCATOR told me to eat more carbohydrates. That would have been a disaster.

You Won’t Find ‘Cured’ People

Me ringing up was an oddity.  I am just the kind of contrarian individual who would do that. I have toyed with the idea of going to one of the self-help groups to spread the word but who wants an ugly scene with the group expert? So once someone has found a solution, they won’t frequent those social circles.  You need to find the people who have the ‘cure’ and talk with them!

They Mean Well but Teach Learned Helplessness

Chronic disease charities do say they want to end their illness.  In the end, they accept donations for a mission and are a corporation in their own right. They probably honestly want to give you help and advice. Take it. Check it. Then discard any notion that is the end of it. Avoid any learned helplessness that may come from depending upon them and seek to do better.

The Influence of Industry

Now we get onto the thorny question of the influence of industry on not-for-profit entities. There are no conspiracy theories on this blog. It is normal corporate behaviour to protect and maximise a revenue stream for shareholders by spending budget to create profits. That is just business. When was the last time you heard a CEO say: “We think there is a better solution than our product.  Please use that solution.”?  Primarily for the health and pharmaceutical industries, the expenditure to protect a revenue stream comes under the ‘marketing budget’ and the ‘Research and Development’ budget.

Not-for-profit’s too are still corporations. They do not have to look after your health although they may state that they do.  It would be rare for a government to legislate that. If a not-for-profit says that they are there to look after your health, it is (in most countries I know of) pure self-regulation. They are more likely to take care of their member’s interests, but they are not even obliged to do that!

Will Your Local Pharmacy (Chemist/ Drug Store) Provide Advice?

You might bump into someone at your local chemist who has a solution but will they talk to you to tell you? So here is a story. I had just gone to the chemist to buy some glucose testing strips after I had ceased my diabetes medication due to going low carb.  There was a lady about 70 years old. She was filling her prescription for the diabetes drugs that I had just ceased. I almost spoke to her to tell her that there was another way but then realised that she would probably think I was crazy.  I was not her doctor or dietitian.  Now I am no shrinking violet, so your chances are not good for that to happen. On the other hand, if you are that person who is told this by some ‘crazy’, maybe you should give it some consideration?

Pharmaceutical Marketing

But there is another reason your chemist may not provide advice. I give you a ‘wonderful’ website to manage your diabetes if you are Australian. Now you have to look hard to the copyright message at the bottom to see that this site is owned by Sanofi- a pharmaceutical company. It is a standard commercial behaviour to protect revenue streams so, while their advice is probably valid to help you manage your diabetes through their medicines, don’t expect to find any therapies to get you off them on this website. Want proof? Have a look for any mention that, with diabetes, you should avoid sugar or reduce carbohydrates.

Also, do not expect to get such advice at the chemists that they point you to. They tell you that they have educated these pharmacists. Education is usually part the marketing budget. So if you want advice on how to manage a lifetime of medications, then those chemists and their pharmaceutical company education will suit you well. Alternatively, if your desire is to eliminate or reduce your dependency on medicines, I would now be asking my pharmacist if they have any pharmaceutical company training in my medication and be aware that may cause bias. I do not know what else the pharmacist receives in this arrangement (if anything), but maybe one of them or Sanofi could tell us in the comments below. Still, that website could be useful to tell you which chemists to avoid.

Does this shock you?  Maybe mildly?  Well, get used to it health consumers with some dollars to spend. This is normal commercial behaviour. In this blog, we will examine many other examples as we find out how we might find that elusive cure for our chronic disease.

Next, we will consider whether you may get a solution from Dietitians.

Is a Very Low Carb Ketogenic Diet (VLCKD) Safe?

Reconciling Strange Advice from Dietitians

If you are reading these posts, you will remember that we started this journey because we saw a media release that seemed odd. The Dietitian’s Association of Australia (DAA) recommended that ladies with Poly Cystic Ovarian Syndrome should eat more ‘grainy bread’. We found that advice not to be supported by the evidence and discovered that a Very Low Carbohydrate Ketogenic Diet (VLCKD) might be a solution. If you have come straight to this post, I recommend you read the previous three posts first.

So if the weight of evidence supports lowering our carbohydrate intake, is this going to harm our health and particularly, will it be harmful to undertake a VLCKD?

Revisiting the Evidence from the Studies

Our starting point is the very study that the DAA cited to suggest that ladies with PCOS (who reduced their carbohydrates) were harming their health and chances of fertility.

We note that these ladies only cut their carbohydrates by 5% and this appears to be cut by reducing sugar mostly.  Did that harm their health?

Well, we need to remember that PCOS is a serious disease that can often progress to diabetes.  Sufferers may have worse cardiovascular health.  The case-control study cited by the DAA shows us something kind of interesting.

Despite the PCOS ladies all being sick, there was no significant difference in their health markers except for some of those indicating PCOS!

All of the following were not significantly different from the healthy ladies: Fasting glucose, Fasting insulin, HOMA2-β, HOMA2-IS, HOMA2-IR, All Cardiovascular risk factors, SHBG, DHEA-S and FSH.

By that information, dropping carbohydrates by 5% and increasing saturated fat appears to have done these ladies little harm when compared to the control group.  That is especially the case for cardiovascular risk. We need to be mindful however that a VLCKD cuts carbohydrates much more aggressively.

We have the other studies cited by us that showed insulin resistance markers improved, cardiovascular markers remained insignificantly different or improved, and the ladies lost weight. It does not appear that any of these studies support that lowering carbohydrates has worsened the health of study participants. This was so even when they were following a VLCKD.

Evidence of Danger of a VLCKD

If you google “dangers of a ketogenic diet” you may see some issues raised.

  1. You may have low blood sugars
  2. You may have flu-like symptoms for a few days
  3. Concern over a life-threatening condition called “Diabetic Ketoacidosis” or DKA
  4. Acidosis (a more acidic body chemistry)
  5. Kidney Stones
  6. Thyroid problems
  7. Nutrient Deficiency
  8. Constipation

Should you consider these? Yes, of course, you should. Will all of these apply to you? Almost certainly not. For example, DKA is almost exclusively a concern for type 1 diabetics.  Even then, you are reducing your blood sugar, and this is a condition of high blood sugar.

Should you be concerned that you may have low blood sugar for example? Of course you are as one of the effects you are seeking is precisely this. The health effects of too high blood sugar are well documented.   However, if you are on blood glucose-lowering medicine this may be of concern as some types of medicine (although not metformin which you are likely to be on for PCOS) could cause hypoglycemia (dangerously low blood sugar).

If you are on any medications, obviously you need to discuss this with your doctor and be mindful that this is a therapeutic diet and your medication may need adjustment. For example, if you were on a diet to reduce your blood pressure and it was effective, you would need to adjust medication you were using to lower blood pressure.

Other Information on Risks and Safety

The Diet Doctor website has an extensive array of information about low carb and keto diets and particularly some of the concerns that there may be. I won’t cover those here on my blog because I don’t want to reinvent the wheel.

VLCKD and cycling
Is a VLCKD safer than cycling?

Now if I were to recommend to you to start cycling for your health and give you public advice to do so, I would need to run through all the things that you should consider.  You should respect other traffic, wear a helmet, pump up your tyres to the right pressure, ring your bell to warn pedestrians, wear bright clothing, eye protection from dust and glare, adequate footwear, etc.  Does that mean you should not try cycling for your health? I think you probably get the idea.

Long Term Considerations

I have seen “authorities” (including the DAA) warn that a VLCKD is dangerous because it has not been tested in the long-term. The implication is that you should not try it in the short term for this reason. I find that logic a little strange. It is important to realise that we are not committing to this diet long-term.  A VLCKD is something that we are potentially going to to try for three to six months- about the length of those studies. We could expect that our results may not be too different from the study participants; but if they are, then like all trials we can re-assess from what we have learned.

So to be clear the approach is to do the N=1 trial on ourselves.  If a medical professional monitors us, we will have N=1 results from relevant tests. Assuming that our health improves, we can continue. If there are adverse changes, then we can reassess and look for other reasons why our outcome differed from that expected.

Your N=1 Trial

Now if someone wishes to make headlines of the fact that I am advocating “self-experimentation” they obviously haven’t walked a mile in the shoes of someone with a chronic condition. The alternative is the following process.  We could wait to have:

  1. Experts do all the experiments on hundreds or thousands of people.
  2. The experts write it up.
  3. It accepted by a reputable journal.
  4. That study peer reviewed.
  5. The paper accepted by peers and published.
  6. It further accepted by the research community.  Acceptance may take a very long time- particularly if it is against orthodoxy.
  7. The study converted into treatment protocols.
  8. Bureaucrats anoint the treatment protocol as effective and safe.
  9. Clinicians accept the treatment protocol as effective and safe.
  10. Your doctor now advise you to make the change to stop eating some foods.

You are looking at a process that takes multiple years or decades.  We will probably come back to this in a later post. Now if that is a new drug with potentially toxic side effects I would, in almost all circumstances, want that process to be robust.

Wait or try now?

Standing in your shoes, however:

  1. If you are trying to conceive, your biological clock is running down.
  2. You are probably suffering from side effects and symptoms that are unpleasant.
  3. An unresolved condition like PCOS is likely to progress to more serious health concerns.
  4. We are talking about reducing, avoiding or eliminating certain foods from our diet.  We aren’t looking to take an experimental cancer drug!

What is a significant and risky change for the ‘system’ to recommend to the general population for N=millions is a different decision for N=1.  Is it safe to for millions of people to try a VLCKD? If it were cycling and I recommended it, some people would die as a result of that recommendation. Is it safe for you and is the risk worth the potential benefit?  I think we can both agree that you are capable of making that decision.

It is your decision. Do you take it?

Assuming that you do, then next we will look at some of the practicalities of doing your trial.

The Case for a Low Carbohydrate Diet for PCOS

We are moving through some questions to determine if we should try a Very Low Carbohydrate Ketogenic Diet (VLCKD) to help with PCOS.  If you have not read them, then you should read the previous posts before this one.

In previous posts, we examined the Dietitian’s Association of Australia’s (DAA) press release recommending that ladies with PCOS increase their carbohydrate intake with ‘grainy bread’.  We concluded that the evidence cited by the DAA did not support that recommendation.

The next question we will look at is:

Is there Other Evidence that Supports Lowering Carbohydrate Intake?

Here, with appropriate cautions, we can leverage the work of an expert.  I point you to this post by Franziska Spritzler a dietitian who favours a low-carb approach for PCOS.

To be clear, we should be as sceptical of Franziska as we are of the DAA and need to be of all experts when ‘the experts are dead’.

In summary, she says:

  1. Her opinion is that standard carbohydrate amount, and timing advice for people with diabetes and PCOS is unhelpful.
  2. Women with PCOS are likely to have metabolic problems, type 2 diabetes and cardiovascular disease.
  3. She mentions the VLCKD pilot study that interested us.
  4. She focuses on hyperinsulinemia and insulin resistance (IR) as core problems for PCOS. The previous study and DAA the press release that we examined also noted that.
  5. She puts forward that the usually recommended carbohydrate diets are not helpful for those conditions whereas a low carbohydrate approach is.
  6. A study looking at the best dietary approach (examining six) was inconclusive; however, none of those was a VLCKD.
  7. She is in favour of a very low carb diet to address PCOS.

I don’t feel that it’s enough to simply encourage weight loss without providing guidance on how to do so in a sustainable way that  has been shown to improve IR and insulinemia — i.e., limiting carbs to 50 net grams per day or less.

What is the Common Ground?

But now I recall that the DAA referred paper put forward that saturated fat caused insulin resistance.

So it seems that most dietitians would agree that a diet that addresses hyperinsulinemia and insulin resistance is best for PCOS; however, they differ over whether those conditions cause (or remediate by the removal of) saturated fat or carbohydrates. Also diets for weight loss are recommended.  Now we are getting somewhere! 

The DAA referred paper cites this study to support that saturated fat (expressed here as fat quality) is the villain.  That study concludes:

Most studies (twelve of fifteen) found no effect relating to fat quality on insulin sensitivity. However, multiple study design flaws limit the validity of this conclusion. In contrast, one of the better designed studies found that consumption of a high-saturated-fat diet decreased insulin sensitivity in comparison to a high-monounsaturated-fat diet. We conclude that the role of dietary fat quality on insulin sensitivity in human subjects should be further studied …

It is inconclusive to me from this study that saturated fat causes insulin resistance.  Further, we find this study which found that in laboratory testing, saturated fat did not cause insulin resistance.  It said about that conclusion:

We acknowledge that this does not agree many epidemiological reports supporting the notion that diets high in saturated fats are associated with insulin resistance and an increased prevalence of type 2 diabetes [1].

It appears that saturated fat causing insulin resistance is far from proven.

More Evidence to Lower Carbohydrates for PCOS?

So back to carbohydrate restriction for PCOS and there is this study.

An 8-week low-starch/low-dairy diet resulted in weight loss, improved insulin sensitivity and reduced testosterone in women with PCOS.

I note that this was a low carb diet, but not necessarily low enough to be ketogenic.  It was also not a randomised control trial as there was no control group. Most participants would have been on less than 130 grams of carbohydrates per day. At 79g of fat (19.5g saturated), this is a high fat, high saturated fat diet.

Nonetheless, the results showed improvements in weight, testosterone and insulin sensitivity (insulin resistance) and an improvement in vitamin D levels, blood lipids (triglycerides, VLDL) with no adverse effects to ‘cholesterol’ overall.

Finally, a third study is this study, which might be missed by many because the 15 PCOS participants were in the cohort of sixty people.

Patients with polycystic ovary syndrome lost 14.3%+/-20.3% of TBW (P=.008) … at 24 and 52 weeks, respectively, without adverse effects on serum lipids.

The diet in this study was a ketogenic diet. The results were similar to the last study. They lost weight, reduced fasting insulin and had no adverse effects on their ‘cholesterol’.

I think it is significant enough to comment that anecdotally, women have a hard time losing weight with PCOS yet the experts are unanimous that overweight women with PCOS should lose weight.  These studies all demonstrated weight loss by carbohydrate reduction for women with PCOS was significant and effective.

Decision Time

But at about this time I come back to the point.  Do I cut my carbs or not or do I I wait for the boffins to settle their argument?

Well this is where I invoke another macrofour principle: 

The experts do not care about N=1 but you do!

In case you are not familiar “N=1” is the retort from an expert to refute an anecdote that someone was cured by doing something. You see they need a lot more evidence than one person before they will agree with or recommend it.  You don’t because you care about your N=1. So at this point, it is simple. You are not getting advice because scientists haven’t solved their arguments in time to advise you now.  You can make this decision for yourself- or it may be years for them to settle their argument. 

corn flake box carbohydrate
Cure please, not cereal

Personally, I am uninterested in scientist’s careers, egos and the various other distractions that could come into it like pharmaceutical profits or that someone wants to sell me a box of cereal.  I just want to get well.

If you have followed a low-fat (and particularly a low saturated fat diet) and your PCOS has not improved enough, then you have already tried the low saturated fat advice.  Did it work for you? If not then your N=1 says to favour the low-carb diet.  Alternatively, if you have been on a low-carb diet for a while and have PCOS, then try cutting saturated fat. 

Finally, if you have followed a high carbohydrate and high saturated fat diet you are either going to have to choose or cut both.  Before we move on to the safety of carb reduction, let us see whether we should lean one way or the other.

Low Carb or Cut Saturated Fat?

I think that the reader can conclude that the weight of evidence presented leans towards reducing carbohydrates, not saturated fat as having a positive effect on PCOS. We couldn’t find anything to suggest that increasing carbohydrates would help.

So despite dietitians being discordant, the weight of evidence leans towards carbohydrate restriction for PCOS.

Further, by looking behind the press release, we found that in particular, some women were reducing sugar.  So, to finish off, here is a recent post from Dr Jason Fung about sugar and insulin resistance.  Dr Fung is a Canadian kidney disease specialist. He advocates low-carb and fasting to help fix insulin resistance and to stop you losing your kidneys to diabetes.

While you read, please consider whether the wisdom of the crowds was present when the PCOS ladies in the DAA referred study chose to cut their sugar. I will prime you with the fact that sugar is the same as sucrose and each sucrose molecule breaks down into a molecule each of glucose and fructose.

Next, we will look at the safety of a VLCKD.

DAA Says Increase Carbohydrates

A Cure for PCOS?

In our previous post, it seemed there might be a dietary treatment for ‘our’ chronic condition of PCOS. The treatment was a Very Low Carbohydrate Ketogenic Diet (VLCKD). That advice lowers carbohydrate intake against the opinion of the ‘expert’ dietitians (DAA). Before we do that, it is prudent to ask a few questions to see if we could use that to aid our condition,  These are:

  1. What is the evidence for raising carbohydrate intake?
  2. Is there other evidence that supports lowering carbohydrate intake?
  3. Is a VLCKD going to be safe?
  4. On balance, is this worth trying (or should I eat more wholegrain bread)?

Let’s tackle these questions over this and the next few posts.

What is the evidence for raising carbohydrate intake?

The Dietitian’s Association of Australia (DAA) cites one study to justify that women should increase (wholegrain) carbohydrate intake.  We can read an abstract of that study at the link below. This DAA published the study in it’s journal ‘Nutrition & Dietetics’ which the DAA says is: “Australia’s leading peer-reviewed journal in its field …”.

Suboptimal dietary intake is associated with cardiometabolic risk factors in women with polycystic ovary syndrome

Let’s take a closer look, but before we start, I will uncouple comments about saturated fat. The focus here is on carbohydrate recommendations.  The reason for that is not to avoid the issue.  Saturated fat is a topic on its own, and you can have a VLCKD that is high in protein or fat. Also, any fat in a VLCKD need not be mostly saturated.

The paper concludes that:

The present study has identified suboptimal dietary patterns in women with PCOS, and highlighted dietary factors associated with cardiometabolic risk factors that warrant monitoring in both lean and obese women with PCOS.

In plain English, the authors found: Ladies with PCOS are not eating to the dietary guidelines. Dietitians should look closely at the diets of women with PCOS regardless of their weight.

How was the Study Conducted?

The study came to that conclusion by comparing the diets of 38 women who had PCOS to 30 women who did not have PCOS (control).  This type of study is a matched case-control study.  The women were matched to be roughly similar in body mass index (how overweight or obese they were). The participants recorded what they ate in a seven-day food diary, and then that was analysed and compared between the two groups.

This is not a randomised control trial (RCT) nor is it a crossover study. It is not designed to test a hypothesis about a low carb diet. It does look at the different diet and health of an average ‘healthy’ group with a sick group.

The DAA appears to have taken this study and indicated an association between the level of carbohydrate in the sick group compared to the control group. The reader might conclude that the healthy group is more healthy because they eat more carbohydrates. The reader might also conclude that the sick group became sick because they eat fewer carbohydrates.  Those would both be wrong conclusions. A problem with using this study in that way is that while there may be an association, the reason for that connection may not be apparent or even investigated. In fact, there may be no reason for the connection at all.

Food diaries are regarded as being better than food questionnaires, but still may not be accurate- especially if the seven day period does not reflect long-term eating patterns.  Some of the problems with associational studies and food diaries are discussed in more detail here.

Key Results

However imperfect food diaries and associational studies may be, though, the paper (not the abstract) is detailed about what the researchers did and what the outcomes were.  The PCOS group had 42% of calories from carbohydrates vs. 47% for the ‘healthy’ subjects. The PCOS women ate significantly less sugar (88 grams per day) than the ‘healthy’ women (114 grams per day). That is about six teaspoons per day. As sugar is a carbohydrate, that difference accounts for almost all (about 95%) of the reduction in carbohydrates!

Analysis of Sugar is Omitted

We can conclude from the study that the PCOS women were eating fewer carbs (according to their diaries), and it appeared that the reduction was mostly by reducing sugar.  Anything outside the seven days of a diary is extrapolation.  It tells us nothing about whether, if the two groups and control increased or decreased carbohydrates (sugar consumption), they got better or worse. It says nothing about the diet that women were on when they developed the condition.

DAA forgets Sugar is not a healthy food
PCOS ladies reduced sugar

The World Health Organisation recommends that a maximum of 10% of daily energy come from free sugars with a target of 5% being desirable. I note that the ‘healthy’ group were getting about 23% of their energy from total sugars compared with about 18% for the PCOS group. The study did not break down the free sugars. However free sugars are a significant proportion of most people’s total sugars. For some reason, the study made no comment whatsoever about the lower total sugar and neither did the DAA.

In the Paper, not in the DAA Press Release

There are some other things that we cannot learn from the DAA press release or abstract that are significant.  We need to read the paper to find out that:

  1. Neither of the two groups was compliant with dietary and physical activity recommendations for health!
  2. Two-thirds of the PCOS sufferers were of healthy weight.
  3. When we compare the ‘sick’ (PCOS) group with the ‘healthy’ group, the PCOS group do exhibit health markers indicating PCOS (as expected). In other health markers (such as cholesterol) they are not significantly different to the ‘healthy’ group. Given the sad progression of PCOS to affect cardiovascular risk, this is an interesting finding.
  4. The PCOS participants came from a PCOS self-help charity, and it was possible that many had lowered their carb (sugar) intake after diagnosis (joining). While the charity does not advocate a low carbohydrate diet, there were articles on their website that discussed low carb diets. This provides the most likely reason for the lower sugar intake in the diet of the PCOS sufferers.

This last point may also actually indicate that some patients have discovered that a low carbohydrate approach works. However, if more moderate carb approach after diagnosis had effectively improved or worsened their condition, then this study was simply not set up to evaluate that.

In the DAA Press Release, not in the Paper

Finally, I note that the DAA mentions the following foods that are suggested as good to eat:  (whole)grain, apples, (grainy) bread, legumes and oats and tells you to avoid: butter, coconut (oil), (fatty) meat, biscuits, cakes and pastries.  None of these was specifically mentioned in the paper, and as far as can be told from reading the paper, it is just as likely that both groups ate or avoided them all.

I think the researchers did perhaps owe us a mention of the sugar differences in their results. However, the extraordinary thing is that the DAA seems to have taken this research and used it to suggest women with PCOS should be eating more carbohydrate by promoting the eating of grains, legumes and bread in particular.

It is my understanding that there is no specific diet guideline for PCOS although dietary plans for weight loss are recommended. I would have thought that the DAA would have highlighted the reduction of sugar that the women practised before advocating people eat more carbohydrate. If the aim was weight loss, then a message about sugar reduction should also help. The WHO targets are probably being exceeded, and dietary guidelines are to limit free sugar. At best, sugar is empty calories.

No Evidence to Increase Carbohydrates

There is no clear evidence that I can find from this study that women with PCOS should be increasing their carbs. There is nothing in this study that showed increasing carbohydrates would improve PCOS symptoms.

Alternatively, this study does indicates there is likely to be a trend or practice for some women with PCOS to lower their carbs.  That seems mostly due to them lowering their sugar intake.

Although it was a little frustrating to have to go beyond the press release, I am glad that we looked into the detail and did not discount lowering our carbohydrate just yet. If anything, it is of curious interest that some women with PCOS are reducing their carbs and sugar intake while the DAA does not appear to think this is a good strategy.  Is this the wisdom of crowds?

In my next blog, we will examine the next question on our list.

Is there other evidence that supports lowering carbohydrate intake for PCOS?

Discordant Dietitians

Horrible Histories

So, if you have read the previous posts in order, you may be ready to take control of your health. Maybe not. You may not be convinced that the experts are dead or you may still be sceptical of me and my posts.  In any case, you are probably wondering what the best course of action is?  How do you decide what to do to take action for your problem? Let’s look at an example so we can understand it in more detail.

My children are fans of the TV show ‘Horrible Histories‘. If you know it you will appreciate that they are fond of their alliterative titles like ‘Terrible Tudors’ or ‘Rotten Royals’.  I think that when we look back on the period from 1970 until 2020, they would say: ‘Discordant Dietitians’. Why do I say that?  Let us take a deep dive into one example where dietitians appear to be not preaching best practice.

Polycystic Ovarian Syndrome (PCOS)

PCOS is a chronic disease.  You can read a few articles about it here.  For a woman it is heartbreaking.  Excessive weight gain, hormonal problems, difficulty conceiving and increased risk of diabetes.   I am male and therefore not a sufferer, but I note that it is related to type 2 diabetes.  You see, like type 2 diabetes, PCOS shares an underlying ‘symptom’ of Insulin Resistance which I believe is likely to be their common heritage.  I have effectively cured my type 2 diabetes by using a low carbohydrate diet.  That is why I was surprised to come across the following press release which appeared to advocate eating more carbohydrates and to avoid the low carbohydrate approach for PCOS that had worked so well for me with type 2 diabetes.

NOTE: Macrofour is in no way affiliated with the Dietitians Association of Australia (DAA)

Taking on PCOS!

Now you may or may not have PCOS.  I suggest that you pretend you do so we can use this as a beginning tutorial on why and how you might take control of your health.

I also recommend that you suspend any belief that this wouldn’t apply in your country.  There are international linkages between most of the dietetics associations, and I think it would be a mistake to assume that this is a purely Australian example.

Let us say you have PCOS and take the advice of the DAA.  You go and see an APD (Registered Dietitian) and, as the press release indicates they put you on a diet inclusive of wholegrains- under the Australian Dietary Guidelines, it would be between 45% and 65% of your recommended daily energy from (wholegrain) complex carbohydrates.

I cannot preclude that it would not make you better. I note that, as a consumer, you could always ask for a money-back guarantee if you adhere to their recommended diet and your PCOS does not resolve. Good luck!

Noting that PCOS is a ‘chronic condition’ we take the ‘Macrofour approach’.  The experts are dead, and all they promise you is a future of chronic disease. So if you have faith in an APD, still see one and do what they say. Equally, if your doctor has put you on medication you would be wise to get the benefit of that and not to vary it without discussion.

Become a PCOS Expert

But the Macrofour way is to become your own expert and do your own independent research. Maybe you ‘google’ and find this academic paper:

Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets

Finally, although we only have preliminary evidence of the positive effects of VLCKD in PCOS,77 there are clear mechanisms that are consistent with the physiological plausibility of such dietary therapy.

Let’s unpack that statement. VLCKD is a Very Low Carbohydrate, Ketogenic Diet.  Fancy talk for a diet that restricts carbohydrates to something less than 20 grams per day.  That compares with the approx. 300 grams per day that the DAA would have you on if you followed the US or Australian Dietary Guidelines.  From the press release, the DAA advises:

Ms Hays also advised women to ignore current health trends, such as shunning carbohydrate-rich grains …

A quick calculation shows that if the VLKCD was the solution, and you were very strict on your other carbs, that would be only one slice of bread for the day (allowing for some sundry other carbohydrates in your diet).  Enough for half a sandwich! I would suggest that you would indeed need to shun grains to try this therapeutic diet. Again I quote from the press release.

Margaret Hays said in food terms, this means women with PCOS are … missing out on a thick slice of grainy bread …

So the DAA says that with PCOS we should eat an extra slice of bread every day because a study showed that women who suffer PCOS weren’t eating enough carbohydrates.  That would not allow me to have a VLCKD.

Is a VLCKD a Solution?

Would this VLCKD work? Maybe we should look for more evidence? We notice that the paper linked to a reference number 77.  Two clicks away we can read that in that (small) study:

There were non-significant decreases in insulin, glucose, testosterone, HgbA1c (sic), triglyceride, and perceived body hair. Two women became pregnant despite previous infertility problems.

Wow!  On the surface, it appears to sound promising. There were only five women at the end of the trial, but two of those became pregnant!  That alone would make me start to wonder. You may not know the significance of the other reductions mentioned, but I think you can appreciate that a reduction in body hair is desirable for any woman- let alone one with PCOS.  Testosterone, glucose, insulin, HbA1c and triglycerides reductions- trust me- that is all good too- especially if you have PCOS! A VLCKD sounds like a ‘cure’, but it is a very small study.

Too Soon to Rejoice

So do we run off and change our diet against all the recommendations of the DAA?  Well, it looks promising, but I would suggest that there are some other things that we should check first.  Foremost among them is whether this VLCKD might be dangerous. Maybe there are some other things we could do to check before we change our whole diet and lifestyle?  After all, the DAA is a not for profit body that says it is interested in the health of Australians at least.  They should have something useful to say for your health.  Shouldn’t we be wary of going against their very clear public advice?

If the ‘experts are dead’ for PCOS can you guess what our next move might be?

Taking Responsibility: The Rise of Your Health

Taking Responsibility

If the metaphor is “The Death of Experts”, then its companion is “The Rise of Your Health.”  This is how you begin to take responsibility for it.

Your Support Network

In the matter of chronic disease, it is all about you.  Sure you have a support network of family and friends, but unless they have walked a mile in your shoes, the best you can hope for is sympathy. 

In my experience close family and friends, are more likely to keep you down the normal paths of medicine. It is a recommended strategy to receive the best management from conventional treatment while you find and evaluate alternatives. Not unlike your ‘medical team’, they will perceive any alternate strategy as being riskier than the standard advice.

Your Call, Not Theirs

Remember though that “The Experts are Dead.”. Unless they can offer an effective cure, all you are guaranteed is continued ill-health.  While, in general, your support network (family and friends) will point you down the most conventional path out of concern for you to get the best possible care, unfortunately, they do not appreciate that the experts are dead. As you evaluate other treatment options, it is your decision as to make whether the risk of any ‘trial’ exceeds the risk of the expected outcome. No one else will take that decision for you. It is your responsibility.

In a sense, I am advocating that you need to be your expert. You don’t need to have Albert Einstein’s intellect, but start with his attitude:

Taking responsibility the Einstein way
Albert Einstein

Learn from yesterday, live for today, hope for tomorrow. The important thing is not to stop questioning.

It’s hard to accept that you are not getting the best treatment known. Medical treatment is costly, and we have justifiable pride in the medical knowledge of our society. We expect our health systems to be on the ball, our experts up to date, and to be offered the best possible treatment. Unfortunately, health systems have one of the slowest rates of the adoption of new ideas.  We will examine some case studies and the reasons for this in future blogs.  For now, understand that it often takes decades for new therapies to be accepted into standard practice.

Medical Innovation Takes Time

In my case, at diagnosis, the solution that I now employ, a low carbohydrate diet, had already been employed for treatment for more than a decade. A major magazine had already published it as a cure! In fact, in times well past it had been a standard treatment for my problem.  The fact that nearly 20 years on it is still not the first line of therapy for type 2 diabetes seems astounding.  When you know about medical innovation, it is less astounding, but none the less still absurd causing you to ponder another of Einstein’s quotes

Only two things are infinite, the universe and human stupidity, and I’m not sure about the former.

You can live for those decades with your condition (and possibly declining health) until it is offered to you (presuming that you survive) or you can take the responsibility to actively seek a solution earlier.

Which are you going to do?