Category: dietitians

The Superfood Your Dietitian Probably Won’t Tell You to Eat

What is a Superfood?

Superfood
Definition of a Superfood

Nutrient density is defined as the nutrients divided by the calories in a food. The higher the number, the closer a food would be to being a superfood. I saw a table of these in this article which sets out reasons to become vegetarian. The table shows that raw leafy green vegetables are probably superfoods:

http://www.businessinsider.com/reasons-to-go-vegetarian-in-charts-2013-10
ANDI Nutrient Density of foods list purportedly from Dr Joel Fuhrman

I don’t disagree that kale and spinach are high in nutrients for their calories, but something was missing from this table. It was a class of food that I believed was very nutrient dense. Within that class there was one particular food that I thought would meet the definition of a ‘superfood’- but it was missing. Why was it missing? That question started a journey that I hope you will find as interesting as I do.

Superfoods (Eye Roll)

Like me, you probably roll your eyes at the ‘superfood’ term. Cynicism aside, it is a common term for foods regarded more highly than others for their nutrition. After a bit of media research, I found that none of these internet articles, which were the top hits in google for ‘superfood’ mentioned the missing food. I found that extraordinary when gram for gram it:

  • Has about three times the iron of red meat
  • Has about three times the protein and iron of black beans
  • Twice the vitamin A of carrots with far more bioavailability
  • Kills quinoa & whole grains for B vitamins, some of which are associated with a lower risk of cancer
  • Is a significant source of phosphorus, potassium, copper, selenium, and zinc
  • Has so much more….

What is this missing ‘superfood’ and why is it not listed with others? Well, the answer lies in the definition. You see if it is not considered very beneficial for health and well-being by ‘experts’, then it is not a superfood.

The Ignored Superfood?

So while some dietitians and nutritionists wax lyrical about goji & acai berries, kale, blueberries, quinoa, broccoli, salmon and (of course) whole grains, this ‘superfood’ it seems, is not regarded as healthy. They tell you to eat ‘this and that’ in endless articles to spruik their dietetic prowess. They, and a chorus of others on the Internet, give you scientific reasons to eat less or more of all sorts of things. We are told about: fibre, low-fat dairy, high-fat dairy, eat eggs, don’t eat eggs, eat fish but don’t eat animal meat, free-range, grass-fed, non-GMO, stress-free, wild, Patagonian, rare, exotic, antioxidant, phyto-, anti-aging ingredients, but hardly anyone seems to pay any attention to this ‘superfood’.

Right about now you probably think I am trying to get you to eat more of this food. Maybe I have a supplement to sell you? That is NOT what this post is about. I care what I eat because I have had success using diet to reverse my diabetes. While I have incorporated this ‘superfood’ more into my diet, you can eat whatever you want. Do this for whatever reason of belief or science- but please don’t get those reasons mixed up!

The Superfood not a Superfood

The superfood ‘in waiting’ is liver. Chris Kresser and Chris Masterjohn, have called liver a ‘superfood’. They and Zoë Harcombe make a good case for its nutritional qualities; but irrespective of their reputations, it does not make it much more a superfood. You see the term superfood is a social term deemed by consensus of more than a few people. The really interesting question, and subject of this post, is why there is little fanfare from other nutrition experts to give it superfood status.

But for that recognition, liver should be the king of superfoods.  Unless you are very young, your mother or grandmother would have told you how healthy liver is. Hunter-gatherer cultures used to eat it first after killing an animal. Carnivores are said to also eat it first when they kill their prey. It was the original super food so why are so many nutritionists and dietitians reticent to confer superfood status today? Why were organ meats and liver omitted from the nutritional density table in the vegetarian article? Why are they routinely omitted from other lists of ‘superfoods’?

Do Superfoods need to Taste Bad?

Liver is not a superfood just because many find it unappetizing although some may joke that tasting bad is almost a necessity for superfood status. Just look at kale or broccoli! Liver can be eaten as liverwurst or paté and disguised and included in ground meat dishes. Chicken livers are even a traditional ingredient in Bolognese. I am sure these tips could be told to us by dietitians to encourage the consumption of a superfood. Its common practice in newspaper pieces from health experts for other superfoods.

High Cholesterol?

Little has been written about liver’s fall from grace but like eggs, it is high in cholesterol. It may be inferred from the fate of eggs that it fell out of favour due to cholesterol being a nutrient of concern. Unlike eggs, it has not received redemption. It seems it has no friends to make its case. Why is that?

Toxins?

It could perhaps be said that there is a fear that liver may concentrate toxins like heavy metals. Indeed now banned arsenic compounds have been used in factory chicken farming and accumulate in chicken livers. That really is a food safety issue. If liver is not safe to sell then warn the public and don’t allow it to be sold or change farming practices. We did not stop eating spinach when there were e-Coli deaths or stop eating berries when there were cases of cholera from frozen berries. If that is the reason then it is inconsistent.

Dietitians seem more likely to warn you not to eat liver than extol its virtues. Liver is so high in bioavailable vitamin A that in the UK, pregnant women are told to avoid it by dietitians because of the risk of birth defects. Rather, they should also take iron, folate (and now B6) supplements to prevent birth defects when all are in high amounts in liver! So effective is the message that pregnancy forums are full of mums-to-be frantically worried about an accidental meal of liver as though it will kill their unborn child!  It is more likely that your mother or grandmother was told to eat it when she was pregnant with you or one of your parents, and that she did so. I suppose it is lucky you are here!

Superfoods are Mostly Plant-Based

Looking at the prominent superfood lists that I quoted, there are few animal-based superfoods and even fewer that are meat. Most of the lists of superfoods are exclusively or near exclusively plant-based. Since livers’ fall from grace as a cholesterol filled organ meat, meat (in general but not liver specifically) has been associated with cancer in a number of studies. Liver has about a quarter of its fat as saturated fat, but is not in itself a very high-fat food so fat is not a sound reason to avoid liver given its other nutritional virtues. Why else could it be neglected?

Recently, in a lecture, Dr Gary Fettke noted that at its foundation, the science of dietetics had a perspective of vegetarianism because of the involvement of Seventh Day Adventists. Seventh Day Adventists have a core belief in a vegetarian lifestyle. Those dietary beliefs were recorded to have been received from God by Ellen G. White in the 1860s in visions. They included the view that meat is unhealthy and causes cancer and that grains, fruits, and vegetables are especially healthful (superfoods). Medical evangelism, a stated goal of Seventh Day Adventists, appears to extend to dietetics and ‘lifestyle medicine‘. Sanitarium, a company owned by the Seventh Day Adventist Church, promotes soy and whole grains as superfoods and promotes vegetarian eating and has strong links to the dietetic profession. Seventh Day Adventists believe that modern science has vindicated her visions but is it instead that her visions that have influenced ‘modern dietetic science’? Could it be that proving your prophet and improving the profits of your church create an unholy conflict of interest?

Some may say this is a conspiracy theory however in the field of anthropology and the social sciences, unlike the say the science of physics, what humans believe provides a prima facie case for associated outcomes.

Vegetarian Agenda?

Is liver being unfairly denied superfood status because of a belief-based vegetarian zeitgeist? One that started with the introduction of dietary guidelines and has progressed through to today?

Here is what seems readily apparent:

  1. On the basis of nutritional elements including proteins, vitamins and minerals, liver is clearly a superfood and one which outperforms others.
  2. Liver was likely to have been your grandmother’s and/or mother’s superfood. It was probably your paleo ancestor’s go to food- if available.
  3. It rarely (if at all) appears in lists of superfoods. Those lists are dominated by plant-based foods.
  4. It is high in cholesterol but this is no longer a nutrient of concern. It is not particularly high in either fat or saturated fat.
  5. I could not find any studies even associating the eating of farm animal liver to cancer or adverse health. (If you know of any, then please add to the article comments.)
  6. Liver may not taste great to everyone, but this is not a reason to deny it superfood status.
  7. Unlike eggs, liver has never recovered from the concern over dietary cholesterol. It seems it has had few friends to redeem its name.
  8. Liver may be, without good evidence, tarred by associational studies of other meat products.
  9. There is no nutritional benchmark for a superfood. It is a status conferred by social consensus.
  10. Liver does not have that consensus and is mostly ignored as a superfood by the nutritional and dietetic professions.

Liver: A Fistful of Supplements

What good reason is there for liver not to be a superfood when a serving clearly replaces a fistful of supplements? Why are offal, organ meats and liver as a food absent from our food guidelines altogether? Maybe liver is omitted from our guidelines for the same reason it is omitted from a table in an article convincing you to be vegetarian?

A vegetarian (plant-based) zeitgeist certainly explains it. We have guidelines and dietetics that includes the views that:

An Inconvenient Truth

I made a bet on my health-based on guidelines that appear to be written with a vegetarian agenda and lost. Call me biased, but my hypothesis is simple.

True nutritional science would not have a plant-based bias. Liver is not a superfood because that is an inconvenient truth.

We can’t trust in the nutritional establishment to answer this charge. I am throwing this open to the ‘court of public opinion’.

What do you think?

Maryke, Queen of (Vegan?) Dietitians

Hypocrisy of the Church

Religions are often accused of being hypocritical. When you set a high moral standard, you often end up with egg on your face when you do not live up to it. Whether it is paedophilia and the Catholic Church or Buddhists releasing birds as a good deed, we can prosecute, punish, amend behaviour and seek forgiveness.

But what of those who act hypocritically to begin an inquisition as did Bloody Mary?

In the context of dietitians, what if they claim to be an evidence-based organisation and then proceed to ignore scientific evidence? What if they apply their scientific knowledge inconsistently? Should there be a ‘Special Place in Hell’ for them?

Veganism

While vegetarianism has been around for a long time, its more extreme sibling, veganism, traces its named history to 1944. 

Veganism has its proponents and critics. The PCRM, related to the animal rights organisation PETA, has championed the research and arguments for the healthiness of the vegan lifestyle.

Let me state that I have no problem if you choose to follow a diet for any reason. That includes fasting if that is the informed effect that you wish to achieve. I have nothing against vegans personally, although I do not agree with them if they use ‘dodgy’ scientific reasoning to make claims that the vegan diet is superior for health.

One voice against veganism is Lierre Keith (a former vegan) who has written a book criticising veganism. Dr Zoe Harcombe has summarised that book well in her blog post if you wish to understand the case against veganism. You can read the book if you want the detailed case.

To be balanced here is a pro-vegan book and a link to a pro-vegan site.

While there is an abundance of some nutrients on a vegan diet, we learn from the pro-vegan site:

Vegans are vulnerable to deficiencies in vitamins B12 and D, omega-3 fatty acids, and calcium. …  Vegans need to supplement B12 because there is no reliable source in their diet.

So it is no secret and even the pro-vegans will tell you that a vegan diet has dietary risks and you must plan that diet well and need supplements to be healthy.

Veganism & Dietetics

We also learn from this website that a vegan diet is supported by Canadian Dietitians and Australian Dietitians among others. In fact, there is wide support for the vegan diet across dietetic organisations internationally. British Dietitians even have an alliance with the Vegan Society and an MOU.

South African dietitians (ADSA) don’t seem to have public statements about their policy on veganism however they endorse vegan nutritional science by promoting veganism and a number of their registered dietitians support plant-based diets and practice vegan dietetics. Like Canadian, British and Australian dietetics organisations, South African dietitians also belong to the International Confederation of Dietetic Organisations. The next ICDA Congress will be in Cape Town in 2020.

It should not be surprising that internationally all dietitians sing from the same hymnbook. Vegans would make very good clients for dietitians given that a vegan diet needs to be well planned and supplemented to be healthy.

LCHF & Dietetics

Unlike veganism, which has the full support of dietitian’s organisations, a low carbohydrate (Banting or LCHF) diet is labelled by them as a diet that is dangerous. I won’t repeat the volumes that have been written about the dietetic organisations’ fear and loathing of low carb. Here is just one example from the Dietitian’s Association of Australia.

What is the reason for this? Low carbohydrate diets involve avoiding starchy, sugary and vegetable oil-based processed foods from the food industry that are a regarded by many as a modern scourge to health. LCHF eaters are more likely to be shopping at the farmers’ market, cooking food from scratch, and avoiding ‘soda pop’ and boxed cereals. The case has been made that commercial interests (such as sponsorships by the food industry of dietetic associations) are behind their non-acceptance of low carb diets.

Double Standards?

Vegan diets strictly omit all animal-derived products notably meat, eggs, fish and all dairy. LCHF diets limit or avoid sugary fruits, starchy vegetables and grains but include low carb fruits & vegetables, dairy, meat, eggs, and fish. The picture below gives you an idea of just a few of the many foods that are typically included in a low carb diet.

Sample of Low Carb Foods (dietdoctor.com)
Sample of Low Carb Foods (dietdoctor.com)

If there were any valid concern over the healthiness of LCHF diets then surely such a diet could be well planned by a dietitian just as a vegan diet is? If the diet was perhaps deficient in a vitamin surely it could be supplemented as vitamin B12 must mandatorily be on a vegan diet? Are dietitians competent with the vegan diet and clueless to deal with other diets that do not include certain foods? It seems unlikely. Instead, it smells like hypocrisy and I was not the first to notice this.

Complaint Against Prof. Tim Noakes

You may be aware that Claire Jusling Strydom, the former ADSA president, lodged a complaint with the Health Professions Council of South Africa (HPCSA) against Prof. Tim Noakes, a distinguished South African scientist and medical doctor. This was because of this tweet that he made three years ago suggesting that babies can be weaned onto LCHF foods. The tweet was in response to a question by a lady who was asking on twitter about the best foods given that she was breastfeeding and some elements of her food might come through her breast milk. The lady in question was not his patient. The resulting inquiry has been described as the nutrition trial of the century. If you wish you can read more of the details here.

The ADSA stated about its complaint:

The complaint was prompted by a tweet from Professor Tim Noakes offering low carbohydrate and high fat complementary feeding advice to a mother. This advice is considered unconventional advice that is not evidence-based nor in line with the current paediatric food-based dietary guidelines for South Africa or any international paediatric dietary guidelines.

In summary, during and after an inquiry lasting three years:

  1. The ADSA usurped responsibility for the complaint from its former president.
  2. Well before a ‘verdict’ had been reached, the HPCSA falsely pronounced Prof. Noakes ‘guilty’ in a press release.
  3. An investigative journalist has written that the food industry may be behind this trial.
  4. Prof Noakes was actually found ‘not guilty’ on all ten points.
  5. During the trial, he presented the evidence-base for an LCHF diet and why it is healthy. You can review that substantial evidence-base conveniently divided into 80 short videos of testimony on youtube.
  6. The HPCSA has now appealed the decision of its own tribunal and this debacle is set to continue.

Common Sense Check

As a quick check, look at the picture above showing a small subset of foods that would commonly be understood to be LCHF by the public. It was taken from one of the prime consumer websites for LCHF (dietdoctor.com). Do those foods look unhealthy for a young infant as they transition to solid food? A quick common sense test tells you something more than the salmon in the picture is fishy with this whole affair.

Let us have a closer look at the critical part of SA’s paediatric guidelines for a child after six months of age as they begin complementary feeding and start the move to more solid foods:

PAHO and WHO provide the following guidelines with regard to complementary foods that can provide adequate nutrients to meet the growing breastfed child’s nutritional needs: • Provide a variety of foods to ensure that nutrient needs are met. • Meat, poultry, fish and eggs should be eaten daily, or as often as possible. At this age, vegetarian diets cannot meet nutrient needs, unless nutrient supplements or fortified products are used. • Vitamin A-rich vegetables and fruit should be eaten daily. • Provide diets with an adequate fat content. • Use fortified complementary foods or vitaminmineral supplements for the infant, as needed.

Again, look at just the small subset of LCHF foods in the picture.  Do you see a major problem? To me, this looks compliant with the guidelines yet the ADSA was not satisfied. Note the text in green above. You may well ask that if a vegetarian diet is explicitly called unsuitable, then what of its more extreme sibling the vegan diet?

SA Dietitians and Vegan Diets for Infants

Well, you may be surprised to learn that registered South African dietitians do not seem to have a problem with the vegan diet for infants.

In an article in defence of a vegan diet for infants (in response to concerns over the death of an Italian child fed vegan food) South African registered dietitian Jessica Kotlowitz was quoted as saying:

So if any of the people quoted in this article really want to make a difference and prevent childhood deaths from malnutrition, they will promote the adoption of vegan and vegetarian diets.

I am not a dietitian but sorry Jessica, that is not consistent with SA’s paediatric guidelines for complementary feeding. Please see the text in green.

In an article posted on the ADSA’s own website, SA registered dietitian Cheryl Meyer says:

Contrary to common belief, a properly planned vegan diet is proven to be healthy and nutritionally adequate for people of all ages.

Cheryl, that advice (at 131 characters) is equal to a tweet. You didn’t mention breastfeeding as long as possible which ADSA criticised Prof. Noakes about after the trial but you had room in the article to do so. The essential need to supplement B12 is not mentioned at all in the entire article! Again, I am not a dietitian but I am sorry Cheryl, but that is also not consistent with SA’s paediatric guidelines for complementary feeding. Read the text in green above. Especially, not mentioning the need for B12 supplementation at any age is a dangerous omission for the public who read your article.

What Should Vegan Babies Eat?

So what should vegan babies be weaned onto? Well the SA dietitians don’t say but their US cousins give us the following advice:

Wean vegan infants with soy milk fortified with calcium and vitamins B12 and D. Milk alternatives, such as soy, rice, almond, hemp, etc., are not recommended during the first year of life as a primary drink because it is low in both protein and energy.

Wow! Do dietitians really think that is a healthy option? They also do not mention how the baby will get critical omega 3 fatty acids commonly supplemented to kids in fish oil. It certainly flies in the face of South Africa’s paediatric dietary guidelines.

When parents get this wrong the results are horrific. Aside from the Italian case mentioned above, there was this more recent case in Belgium. Here is yet another warning.  More here and this paper gives a case study of what happens when a vegan breastfeeding mother does not supplement adequately.  Where was that advice from the dietitians?

Unlike LCHF, a bad vegan diet is a proven risk to infant health, however, dietitian organisations tolerate that risk. It appears that the ADSA has not counselled, cautioned or complained about its dietitians to the HPCSA or had them retract their public statements nor has it issued a clear policy on vegan paediatric nutrition. At the same time, they have set off a nebulous complaints process over LCHF that has dragged on for three years against Prof. Tim Noakes and which now is going to appeal. How can this be reconciled?

ADSA Noakes Aftermath

In their press release after the not-guilty verdict, the ADSA expanded the detail of their concern about Prof. Noakes’ tweet. Among their criticism was that Prof. Noakes did not emphasise that breastfeeding be continued. This was not emphasised by either Jessica or Cheryl either and they had much more space to use than the 2 spare characters that Prof. Noakes had in his tweet. That press release also makes much of the uncertainty caused by twitter but the vegan advice given by its own dietitian’s remains unaddressed and it is in more conventional media than twitter.

The ADSA further expanded their concern (post-verdict) with the following text:

When foods rich in carbohydrates such as whole grains and legumes are avoided and other carbohydrate food sources such as dairy, fruits and vegetables are restricted, thediet can become deficient in certain essential nutrients, such as vitamin C, B1, B3, B6, folate, magnesium and fibre. Because infants and young children are considered a vulnerable group, the potential for nutrient deficiencies is a serious concern. Deficiencies can compromise growth, and cognitive and physical development. 

It is a bit late to expand to this after the trial. If you didn’t say that in the trial and it is a material criticism then why expand now? If it was said and considered during the case then its sour grapes after a verdict where it must have been considered.  Let us see how their text looks if properly worded for concerns over a vegan diet for infants:

When foods rich in protein such as meat, fish, eggs, and dairy are restricted, the diet can become deficient in energy and certain essential nutrients, such as vitamin B12, D, Omega-3 fatty acids and calcium. Because infants and young children are considered a vulnerable group, the potential for nutrient deficiencies is a serious concern. Deficiencies have caused death and can compromise growth, and cognitive and physical development. 

I think you can see that a vegan diet presents at least an equal risk, and more likely a greater risk than an LCHF diet for infants.

This hypocrisy has its parallel with (Bloody) Mary Tudor who issued a proclamation that she would not compel her subjects to follow Catholicism and then proceeded to put the senior clergy on trial.

Effective Leadership or Piousness?

The press release by the ADSA following the verdict can be described as extraordinary for both its lack of leadership following the events that they themselves created and the lack of any concrete response to a three-year nutrition inquiry.

blind leading blind
Is there Ineffective Leadership in Dietetics Organisations?

The ADSA would do well to learn about the failure of Mary Tudor’s ‘inquisition’ to bring back the Catholic faith to England. Unlike the successful Spanish Inquisitions, the failure of Mary’s effort is attributed to the inability to conduct trials in secret. The truth came out to the public. Of course, Dr Gary Fettke has suffered the fate of a successful secret LCHF trial in Australia allegedly vexatiously instigated by its dietitians.

Suffering from failure due to the effects of the truth, Mary Tudor, had a propaganda letter published entitled “A Godly Treatise concerning the Masse, for the Instruction of the simple and Unlearned People” and this press release is reminiscent both of its necessity and tone. 

ADSA president Maryke Gallagher stated:

We have no personal gripe with Professor Noakes. Our concern has always been about the health of babies.

If ADSA’s concern was about the health of babies, then why have you not acted against your vegan dietitians who have committed dietetic indiscretions that at least equal Tim Noakes’?  It certainly makes this appear to be a lie and the complaint an inquisition. I note that the public already has the ADSA pegged as liars from the press release.

Hypocrisy and Denial?

With apparent hypocrisy over the acceptance of veganism as safe for infants and denial to confront the science of LCHF, why should we not see the ADSA as a religion with anointed clergy? A anti-scientific religion running an inquisition that didn’t burn Prof. Noakes at the stake the first time. 

Maryke, Queen of Dietitians, concludes with:

South Africans have also been confused by the ebb and flow of this divisive nutrition debate and the inconsistent nutritional advice provided over many years. That is unfortunate. I’m pleased this is over and we can now focus on other urgent nutrition challenges we have in South Africa.

What could be more important than addressing South Africa’s diabesity crisis with a weight normalising dietary change? One that your actions forced a scientist and doctor to provide testimony about to show as healthy?

An evidence and science based organisation cannot just ignore 80 videos of Prof. Tim Noakes’ scientific evidence.  Prof. Noakes is the real A1 rated scientist here and at least that was begrudgingly acknowledged.

This seems the kind of arrogance that we would expect from a monarch having failed in an inquisition.  “There is nothing to see here, move along and keep faith in the anointed.” In the meantime, the inquisitors continue to try and burn the heretic with an appeal that could have stopped by admitting it was a scientific mistake.

No Maryke, Queen of Dietitians, this is not over and the ADSA cannot continue like nothing happened. The ADSA is not blameless- dietitians are the instigators of this inquisition. It seems despite publicly brushing your hands, the HPCSA is determined to keep your complaint going and that was within your power to remedy.

A Special Place in Hell

I asked the question at the beginning if there was a special place in hell for hypocritical science-based organisations that ignore scientific evidence. If there isn’t then there should be.

As a health consumer, I ask you to consider carefully whether your health is worth risking with anti-science anti-evidence organisations. Choose your dietetic advice and dietitian wisely and that applies even if you are vegan and in any jurisdction in the world.

Consumer imposed hell by voting with your feet is the best message you can send and if you cannot find a dietitian, there is plenty of more scientific advice on the Internet.  Errr yes, the horror of truth from ‘Dr Google’ is something that the Spaniards unfortunately never had.

What happened to Mary Tudor? Well, every school girl and boy knows that history did not treat her kindly and despite her many machinations, the truth won and England chose the Anglican way.

Diabetes: A Tale to my Daughter of Lions and Sheep

My Daughter’s Angst

I want to tell you a true story about my diabetes and it is also about lions and sheep.

Recently I rolled my ankle while exercising and as a result, I had a sore foot. I was hobbling around at home and my daughter noticed.  She didn’t say anything but a few days later my wife relayed a conversation that she had with another mother from my daughter’s school about my diabetes. That mother was a nurse.

You see my daughter had been picked up from school by the nurse with her daughter. During the car ride, my daughter had said that I had diabetes. My daughter was really worried that my foot was going to be amputated because that is what happens to people with diabetes. The mother, very concerned, proceeded to tell my wife about possible treatments for diabetic feet.

What Would you Say About Diabetes Complications?

Do you have diabetes? What would you say to your daughter or loved one? I’ll tell you what I told her. I hope it is useful for you if you are in a similar situation.

“Firstly,”, as I explained to my daughter. “you need to be aware that retinopathy is diabetic blindness, neuropathy is diabetic nerve disease (a precursor to diabetic amputation) and nephropathy is diabetic kidney disease that usually leads to dialysis.”

“Now a measure of your diabetes severity is called HbA1c or A1c for short. Your A1c is a measure of the sugar in your blood cells. This is useful because your blood cells are renewed every three months so you kind of get an average of the sugar level in your blood over that time.”

A Dirty Little Secret

“Below 5.8% you are normal, and above that, you have pre-diabetes until 6.5% when you have full diabetes.  Diabetes organisations tell us to aim for an A1c of between 6.5% to 7.0% but darling there is a dirty little secret there. You see eating carbohydrates (as they recommend) it is hard to get that low. If fact many people do not get below 7.0%!”

“Sweetie, have a look at this graph that maps those complications against HbA1c in people with diabetes.”

 

complications risk diabetes
Patients with type 1 diabetes (n=1,441) Adapted from DCCT. Diabetes 1995;44:968-43.

“You can see that someone with an A1c of 7.0% has almost double the risk of all those complications as someone at 6.0%. Someone wth an A1c of 9.0% has about five times the risk of going blind!”

My Diabetes Results

“But you said that most people struggle to hit 7.0% where they double their risk” she said: “Daddy, what is your A1c?”

I showed her my test results. “Well, when I was taking 3 different diabetes medications my A1c was 9.0%, but when I restricted carbohydrates (LCHF diet), my A1c dropped to 6.0% while taking no medications.  That took three months. Now my A1c is 5.8% and my risk is essentially the same as someone without diabetes.”

The nice ending to this story is that now my daughter’s mind is at ease AND she thinks her daddy is a ‘lion’ for beating diabetes complications.

But I am not an animal superhero. This kind of result has been repeated by many people.  It is a result based on science and results like mine must, therefore, be repeated by others.

So if you have had this awkward conversation with your son, your daughter, your wife, husband, lover or another dear relative or friend, consider backing up your assurances that you will be all right by taking control of your health. Restrict your dietary carbohydrates.

Maybe you have denial and uncontrolled diabetes and haven’t told anyone close to you. If you have not had this conversation, then still take control of your diabetes and nix your chances of complications so you can have a positive experience like I did. Better than having instead to try and explain your complications to close ones in the hospital.

Be a Lion, not a Sheep

Dietetic and diabetes associations do not want you to know this information. They have tried to silence the people that are telling you and expect you to use their services like helpless sheep. Thank God they cannot stop me telling my daughter the truth nor telling you this true story.

Consider that:

  1. The Association of Dietitians from South Africa (ADSA) complained against Prof. Tim Noakes and continue to ignore the evidence that he presented in pursuing his comprehensive acquittal. It showed that the LCHF diet was beneficial to health.
  2. Dietitians complained against Orthopaedic Surgeon Dr Gary Fettke to silence him against giving this advice to patients. How despicable to ask him to keep quiet when he can prevent amputation by diet.
  3. The Dietitians Association of Australia (DAA) deregistered dietitian Jennifer Elliott after another dietitian complained a patient was confused by her low carb advice and they reinforced their advice that results in higher risk of diabetic complications.
  4. The DAA complained against Carynn Zinn, another low carb dietitian in New Zealand where they had no authority nor any reasonable business to do so.

Why is this being Suppressed?

Low carb is actually quite simple and its safe.  On one level its just “give me a plate of healthy meat and vegetables for dinner (and hold the potatoes)” but the organisations act like you will eat rat poison.

I do not believe in conspiracy theories- but business is business. Businesses love sheep that just keep paying money for their products. As they are profitable, they have money for marketing to keep everyone buying. Marketing can pay for favourable research studies and it can sponsor dietitian’s conferences. It is worth spending marketing money to keep revenue streams going and growing. That is completely normal.

LCHF means you eat a lot less processed food (like breakfast cereals) from the food industries that sponsors dietetic associations. It appears dietetics associations are happy to ignore science and promote bad and unscientific advice from their members because it keeps you going back with a chronic condition or when their advice fails and you regain weight or worsen.

Consider too that the amount of diabetes medicine you need is almost proportional to the carbohydrates you eat.  I ate next to no carbohydrates and went to no medications. You will need less medication if you restrict your carbs- naturally if you do plan to reduce medications then talk to your doctor first.  Any reduction benefits your health and wallet but is not good for pharmaceutical companies.

Be a lion, not a sheep, and if you are still not sure I leave you with part of the testimony by Tim Noakes that these organisations do not want you to see. If this does not convince you there are 80 more short videos that the dietitians pretend to ignore that you can watch.

Whether you have type one diabetes and follow Dr Bernstein’s low carb diet or type two diabetes, if you do take this journey I know you will almost certainly have similar results. Do tell me and pay it forward by telling others, but do me a favour and don’t tell my daughter.

You see it’s nice for a daddy to be a lion to his little girl for more than just one day.

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.

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?