Fiona Godlee: Panel discussion on “Low carb high fat diets: Public controversies and opportunities”

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

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

I also am the medical director and founder
of the obesity program at Indiana University Health, and I'm an Aspin health innovator
fellow. And I'm thrilled to be here, and so I have
to think both Swiss Re and the BMJ for organizing this. I think this is absolutely fantastic, and
I love the opportunity to have a dialogue about some really important issues affecting
both the health and the financial viability of not only the United States but around the
globe. So I'm thrilled to be here. So as far as type II diabetes, and I just
want to make it clear that I'm going to be focusing on type II diabetes, 'cause that
is what I do and what I am interested in, and first I just want to walk through some
incredibly basic, agreed upon things that then somehow escape even intelligent people
when we move those things into guidelines, okay? And that is type II diabetes is what? It's a problem of elevated blood sugar.

And although humans are different, and heaven
knows we need to respect the differences, we cannot utilize a one size fits all approach. We do have to understand that there are some
things that are the same. And again, associations like the American
Diabetes Association readily acknowledge, in a disease where the problem is elevated
glucose, that the macronutrient that elevates glucose is carbohydrates, okay? So problem, elevated glucose, macronutrient
that the American Diabetes Association acknowledges is the cause of elevated glucose, especially
postprandial, which we know is a risk factor for coronary artery disease. If we want to not just manage with another
pill, but reverse out of the disease process, we have to take away or significantly limit
what is causing the problem. And so that's why the approach that I utilize
is a low carbohydrate, and therefore, because there's three macronutrient, we have to balance
this out, become a high fat diet.

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

There are three things that work. And what I would love to see is consensus
that reversal should be a goal, that patients should be given the choice of which of these
three proven methods they would like to initiate and manage in their own life, because Patient
A may choose surgery, and I applaud Patient A, that they're going to take control and
do something. Patient B may want to calorie restrict forever.

Fantastic, that is great for them as well. And a lot of patients, I think the majority
of the patients, and again, that's just my opinion, are going to choose a non-calorie
restricted method of just reducing carbohydrates, and one of the main criticisms we get is that
this is not sustainable. But again, we published our one year data,
83% still adhering, and we actually have proof of adherence through beta-hydroxybuterate
levels, which is unlike any nutrition study in the past. We always guess at their adherence and we
use the unreliable food diaries. We can show that they adhered.

And we are going to be publishing our two
year data soon, and I will tell you, adherence is fantastic. So again, I think the most important take
home thing is people have choices. Patients with diabetes have choices. They need to be educated that the choices
exist and that the goal of reversal is real. They need to be explained all three choices
that are evidence based, and then the patient needs to be able to be the one to take control. Fantastic. Four minutes, thank you very much. Okay, so if the other panel members, and I'll
come back to Sarah for a minute as well, could give us a minute, on your position on low
carb, high fat diets. Michael? Thank you, yes. I am a physician, I've been around a long
time as a diabetologist and I don't have strong feelings one way or the other, but what I
recognize is that the whole epidemic of type II diabetes has developed during my lifetime. The prevalence when I began my career was
around about half a percent in many countries, up to 1%. Now it's running at 10%, 15%, Saudi Arabia
30%, 40%.

And that has happened because of weight gain. With relative risks of 80, 90, 100. That's why it has happened. The mediators to get into the state of being
diabetic has been driven by weight gain. I think we now understand that the level of
blood glucose, that's a marker of this disease, which is doing massive damage to every organ
system in the body, and that the way to get rid of it is to get rid of the weight, as
Roy pointed out, removing the head at the top. If you didn't gain weight in the first place,
you wouldn't have this disease, whatever your genes, and it doesn't matter to me whether
you do that weight loss using a high carbohydrate or a low carbohydrate diet, but it has to
be something which you are prepared to stick into and then you must look at the long course. As a physician, I've used drugs, as all of
us have for many years. They have covered up the disease, and I worry
a little bit that if you haven't got rid of that liver fat then you're just covering up
the disease.

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

Okay. Thank you very much indeed. So Jenny? Okay. Have I got one minute or five? You've got one minute. One minute? Because we heard from you earlier. Forgive me. Okay. And I'm hoping there will be lots of questions
from the audience in about three minutes' time. Go Jenny. Okay, so I guess I want to sound a note of
caution. Low carbohydrate diets today are not the same
as low carbohydrate diets during human evolution. So I'm wary on the basis of at least four
observational studies that low carbohydrate diets are associated with higher risk of total
mortality, and higher risk of cardiovascular disease mortality. That caution should also apply to the most
vulnerable group in our population, and that is women of reproductive age. We're talking about women who can fall pregnant
on a low carbohydrate diet and go through pregnancy on a low carbohydrate diet. What is the effect on the fetus? So that group has been traditionally kind
of regarded as a special group, and not a group that we should take into account all
the time. Well, sorry, I think they should be the lowest
common denominator, and we should be very, very careful what we say.

Thank you very much indeed. And Roy? Just in general, I think a low carbohydrate
diet is entirely reasonable, provided it's not extreme. The point we need to bear in mind is the body
really sees very little of the food that's put into it. We're all hung up on what goes in the mouth,
but in fact it goes into the stomach, the liver is actually controlling for very large
periods of the day exactly what fat's being seen, exactly what glucose is being seen. So we need to grasp that fact, and it leads
directly on to the important fact that Mike alluded to, that in fact once you start accumulating
excess fat, the metabolic factors are against you. So the approach Sarah's outlined, yes, if
it works for the individuals concerned, that is absolutely fine. I would have no theoretical hang ups. I'm coming from the position of being a practical

You've got to be pragmatic. What works for the individual is what we're
after. So conceptually, no issues provided it's not
extreme, but remember, it's metabolism that calls the shots, and that metabolism gets
wrong-footed mightily when it has to struggle with too much fat in the system. Thank you very much. Sarah, one minute. Okay, so let me just address the pregnancy
one. So I will tell you that what my feeling, when
you put those graphs up, was horror, that somehow we would see this big postprandial
spikes in pregnancy as acceptable, because if there's one risk we know, it's hyperglycemia
in pregnancy.

So you talk about damaging the fetus, I mean,
I don't think anybody is going to dispute that. When you have elevated blood sugar in pregnancy,
you've got a problem pregnancy, and therefore, you make epigenetic changes that we are going
to struggle for decades and generations to back out of. And so to me, that graph was totally unacceptable,
and I wanted to say, "Where is the flat glucose curve? Where is the pregnancy with the flat glucose
curve?" Because I want my patients that I care for,
who are pregnant, to have a flat glucose curve. And you don't have to be in ketosis to have
a flat glucose curve, when you're pregnant. You just have to still be restricting carbohydrates
significantly, and you can get that much better flat glucose curve in an unbelievable critical,
not only for that patient, not only for that patient's baby, but what about the next generation
after that? So pregnancy is so important and it's going
to be our key of backing out of this epigenetically.

So critical. And then the next thing I would say is there
are plenty of studies on a low carbohydrate, high fat, and I'm happy to send you some of
Jeff Volek and Steve Phinney's work on this, but as far as the
liver fat and the fat accumulation, the thing that's a shock to the body is a derange metabolic
system. And when we limit the carbohydrates and we
can bring the glucose down, what we can see is postprandial lipids fall and we see many
of these positive aspects from a body composition standpoint too, and we'll be publishing our
[inaudible 00:12:44] data as well, so that we can see that, because I think it's very
important and I think that the 2011 paper that was published on this that looked specifically
at this is very important, but I don't think that we should fool ourselves to think that
the only way we can get there is through significant calorie restriction. Thank you very much. So we're going to have questions from the
audience now.

I just want to ask, how many people in the
audience would consider themselves to be currently on a reduced carbohydrate, increased fat diet. You got them all. Okay. That's pretty good. Well, is that pretty good? I might put my hand up slightly tentatively. Is anyone in the audience who considers themselves
to be on a high carbohydrate, reduced fat diet? A few people. Goodness me. And that's through just because that's the
nature of the eating or because that's what you've chosen to do for health? We'll have to find out. Do feel free to grab the microphone and give
your justification. So I'd like hands up please, and I'll take
three at a time if that's alright. So have we got three microphones or just two? No, we've got three. Oh, we've got three. So one there, one there just behind. Where's the other microphone? Oh, yes, just give it to someone looking attractive
in the audience, and then someone else, where's the third microphone? [inaudible 00:14:08] just to the lady there.

Okay. Could you make your questions quite short
and comments short and introduce yourself? [inaudible 00:14:15] Yeah, thank you. [inaudible 00:14:16] from Tufts. So first, Michael, I don't not believe in
the calorie balance importance. It's extremely important, but it's not the
solution. It would be like somebody coming with a fever
and you say, "Well, we have to fix your fever imbalance. We have to make you produce less hot and less
cold," rather than actually finding out the cause of the fever.

So calorie balance is important, but what's
driving calorie imbalance is what's missing from calorie counting. That's good that you listened to my talk,
then. Thank you [inaudible 00:14:43]. So I agree with that. And the second comment I think is that Michael
also said that these changes in these trials are fairly small. They're usually around half a kilogram or
a kilogram, and most of these trials are about a year long. The obesity epidemic globally is from changes
in the population of about half a kilogram per year, so in fact, those small changes
are what is actually happening in the entire population to explain obesity.

There's not massive changes going on. They're very, very subtle things going on
in the population. Just in 30 years we've shifted our calorie
imbalance by half a kilogram per year, and so my question is for everybody, but I think
especially for Michael, since he brought this up. What has caused the obesity epidemic in the
last 30 years? If it's just about calories and not anything
about the quality of the food that's driving that imbalance, what has actually changed? Because the 60s and 70s were not a golden
age of lifestyle, right? Anybody see Happy Days in the US, right? So what has changed? And I think what's changed is starch and sugar,
predominantly, along with some other things. Thank you very much. Hi, my name is Nina [inaudible 00:15:47] and
I'm a journalist and author. So I just want to call attention to the fact
that there are more than 70 randomized control clinical trials on the low carb diet, and
that the review papers, the ones that were shown, were a little bit selective, but the
one by [inaudible 00:16:03] internal medicine that was done show that low carb outperforms,
is equal to or outperforms the low fat diet in this systematic review of all trials, and
so given that, I think that the question that I have, and there were a number of the presenters
who favored a higher carbohydrate diet or plant based diet, a plant based diet is naturally
high carbohydrate, so recognizing that epidemiological data is not as strong as randomized control
clinical trials, what is the scientific justification then for supporting a higher carbohydrate
diet when there is no randomized control trial that I know of really showing that to be superior? What is the scientific justification for choosing
epidemiological data over randomized control trial data? Thank you very much.

So Campbell Murdoch, GP, also chief medical
officer for, also work for Public Health England, promoting for selectivity
and for the NHS on health and wellbeing. My question really relates to human beings
being a complex system, and I think everyone alluded to this, and also live in a complex
environment. Just focusing on the human for a moment though,
we have many homeostatic systems running in us. Some of those are probably working on a local
level, and some of them are overlapping across the body. One of the key areas that I think would be
useful to clarify is around the first principles of what's causing the problems, and one of
the thoughts I always have around obesity as a cause, and if we pick that as an excessive
body fat, then we need to stop and think, "Actually, we have different fat stores,"
as alluded to in the pancreas and the liver and the subcutaneous tissue, and my patients
teach me that some of them are fantastic at putting on subcutaneous fat stores and protecting
the body, whereas others are not so good at that and they can't mitigate their lifestyle.

What's the question here? Just get to the question. Sorry, so the question is, should we be actually
saying obesity doesn't cause the problem, obesity is a marker of a problem? Very nice, thank you very much. So if people could raise their hands and the
microphone people just choose three other people, that would be most helpful. So we have the panel of is obesity the cause
or a marker of a problem, how do we justify high carbohydrate support for that diet when
there's no randomized trial, and what is the cause of the obesity epidemic? So I ask you to volunteer your answers. Yeah, Roy? Maybe I could comment that obesity can't be
said to be the cause. If you look at people who are severely obese,
BMI over 40, what proportion don't have diabetes? 70%. So clearly it's not the obesity per se, it's
the matter of the individual who is unable to cope with that much fat … Section 1 of 3 [00:00:00 – 00:19:04]
Section 2 of 3 [00:19:00 – 00:38:04] (NOTE: speaker names may be different in each
section) Of the individual who is unable to cope with
that much fat that's in their body at the time.

So I think we can disentangle these two things. We're looking at a global measure, obesity,
if you like, but we're not looking at the individual susceptibility factors. Now, one reason we're able to cut through
confusion and come to a clear answer from that first study was that we didn't look at
the general population and try to work out what was causing the diabetes.

We looked at the people who were 100% susceptible
and dealt only with them, and that's why we were able to come to a clear answer. So we need to see through group data to understand
that it's composed of individuals who don't bear any obvious external labels of susceptibility
and lack of susceptibility. Thank you. Mike? Yes, I'd add to that that the weight loss
that we found indirect was able to reverse the diabetes no matter where it started. So if you had type II diabetes and you're
unlucky enough to get it with a weight of 80kg, then 10kg, 15kg does the job.

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

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

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

And Mike, in response to Nina's point about
the high card, what's the justification for high carb? I kind of lost the point here, but I think
Matthias had an answer to that. Oh, Matthias, yep? Yeah, I also did not completely understand
the question. And I understand it, but Nina, tell me if
I'm wrong. You were basically saying that there's no
randomized control trial of a high carb diet, so on what basis can one justify? Have I got that right? There are randomized trials comparing low
carb and low fat diets, so I think that's not the issue. Say it again Nina, sorry. You can lose weight on both diets. But there's so much evidence for low carb
diets in terms of being preferable for weight loss and also clearly for diabetes reversal. For diabetes? No. Yes. [inaudible 00:22:46] Sarah Holberg studies
show diabetes reversal on a low carb diet, so 60% of the population reversed their diabetes
in one year, with 84% adherence. In a randomized trial? No. In a controlled clinical trial. It was not [inaudible 00:23:01]. It was a controlled clinical trial. Well, Sarah should speak to it herself.

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

Well, again, randomization, I know Laura [inaudible
00:23:55] was in the audience, so her study is a perfect example of one of the problems
with randomization in that people come in knowing they want to do a low carbohydrate
diet because they see people that it works, and when you randomize them to the low fat
[inaudible 00:24:10] what happened right away in the trial? People dropped out. And so we were trying to do a good quality
study where we believe, and again, I will argue this with anyone, which is that the
ability to acknowledge and prove adherence is much more important than the lack of randomization. But the other thing I want to point out from
our study too is that our average time with diabetes was eight years, and in fact, on
other studies, they much more recent diagnosis and they exclude insulin, and a huge percentage
of our patients came to the study on insulin and diabetes up to 20 years. So we took sick people. Mike, your response to that? Yeah, I was just going to say a couple of
things. Measuring ketones has become popular. Your ketones go up if you're losing weight,
so this is a completely circular argument.

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

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

Hang on, Sarah. Right, and I said that was an option, calorie
restriction is. But can I just make one point? No, no. Hold your fire. I'm going to give three, where are three microphones. Just give me a sense? Who's got the microphones? One there, one there and where's the third
one? I conquered a microphone in the first round,
so … [inaudible 00:26:31]. One quick point and then a question related
to … Just say who you are, please. Seymour [inaudible 00:26:36], [inaudible 00:26:35]
cardiologist. So disappointing what [inaudible 00:26:38]
and what Mike has said. When you look at the issue of ultraprocessed
foods, 50% in the UK of consumption is ultraprocessed food linked to obesity. A recent publication in the BMJ linked ultraprocessed
food to cancer, independent of BMI. You look at the make up of that ultraprocessed
food, it's come from starch, sugar, sugary drinks, ultraprocessed fruit and vegetables.

That's 77% of the ultraprocessed food is coming
from that. So starch is and sugar is a major issue. In relation to that, and the question to the
panel here, there's one thing that's a real bugbear for me. We know obesity is a major issue, but the
bigger issue of the insulin resistance syndrome, metabolic syndrome, and some studies suggest
up to 40% of people with a normal BMI have metabolic syndrome or [inaudible 00:27:18]
metabolic syndrome.

A third of people with type II diabetes in
the UK [inaudible 00:27:21] had a normal BMI. Can we have a consensus of agreement today
that there is no such thing as a healthy weight and only a healthy person? Ah, interesting. Hold on, I just want to [inaudible 00:27:31]
the second microphone. Sir? Could you say who you are? My name is [inaudible 00:27:33], I work at
the Liggins Institute at the University of Auckland. That's if you drill a whole here and come
out on the other side. We are working on perinatal nutrition and
health, and I wanted to make three remarks. First I want to support Jenny's remark that
I think we can only win the race against obesity and diabetes when you think about prevention,
especially when you look at the limited success in intervention studies in adult populations. So perinatal nutrition is key, avoiding gestational
diabetes is key.

The second remark I would like to make up
for discussion is about evidence, and that relates a little bit also to the previous
panel. I think we are facing the issue that we have
a broad range of differently designed studies that are still mostly carried out in caucasians. So still rather than doing different studies
in the same population, we should do the same studies in different populations that we can
compare them and assess their relevance for ethnicity. And the third quick remark is about relevance. We were discussing going back to organically
grown food and the luxury of having gardens in northern California and maybe Switzerland. Whether we like it or not, 80% of the world
population will soon live in megacities with more than 10 million inhabitants. So if we don't bring the solutions into these
cities, it's statistically irrelevant. Thank you for that, and the third microphone
is with someone there. I'm Dr Mark Hymen, the director of the Cleveland
Clinic Center for Functional Medicine, and I found it very interesting that in a group
of very educated people about nutrition, most of us preferred a higher fat, lower carb diet,
and only one person was on a low fat diet.

I think that speaks a lot to what we think,
not necessarily what we say or do. And the question is, the UNFAO did a survey
of many countries and consumption patterns, and for every 150 calories of increased food,
there was a .1 increase in type II diabetes. But if that 150 calories came from soda, it
was an elevenfold increase in type II diabetes. So how does that sync with the idea of energy
balance and that all calories are the same? Okay.

So back to the panel, I'm not sure I can summarize
all of those, but not such thing as a healthy diet, only a healthy person, a number of comments
about different populations needed, perinatal and the question of the different studies
combining and the point that was just made which my brain has completely, immediately
forgotten. Anyone? Mike? I can probably deal with that one. That one's easy. The point is the association between the sugar
sweetened beverages and weight gain is much greater than any individual nutrients, and
so you've just said what I think we already know. [inaudible 00:30:26] asked about is there
an ideal weight. Well, there is an ideal weight. It's whatever weight for you, individually,
and at a different age for all of you, before you get metabolic syndrome and type II diabetes,
and you have to be aware of this. There isn't a single figure worldwide. We can't apply BMI. BMI 25 or BMI 30 were epidemiological.

Yeah? [inaudible 00:30:48] And incidentally, I got the same text message
from a patient who had become non-diabetic on a meat eating diet and word for word as
the one you got. Okay. Anyone? Jenny, you haven't spoken. Anything you would like to add at this point? Only a small comment. Kevin Hall's papers show that the actual excess
calories that are needed to gain weight and explain our obesity epidemic are very small.

Seven excess calories a day over the course
of ten years explains the obesity epidemic. So calories, in my mind, are not that important. What is important is the quality of the diet. But I'd just like to say something else. There's a lot of demonization of processed
foods, refined foods, the food industry, going on, but if you go back 40 years, which is
when I started in this game, the food industry was told that there was a shortage of food,
a shortage of protein and a shortage of food, and so the food industry rose to the call
and said, "Okay, we'll produce lots of food, we'll increase the yield," they did exactly
what we wanted, and they produced safe, cheap, palatable food.

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

They have to have a bit of a boost in their
daily [inaudible 00:33:28] lipogenesis. So if we were to identify those people, we
could perhaps follow through prospectively and actually test what I'm saying, which is
only putting together notions. So insulin resistance, well, let's flip it
on its head and say what's real, which is a biological variation of insulin sensitivity
in muscle, and yes, there is a problem at the low insulin sensitivity range. Thank you. Sarah, did you want to … Well, I want to put a little, one thing about
ketones. So ketones will rise in starvation. They don't rise with weight loss. There's no data on that. And so our elevated beta-hydroxybuterate,
that was over twice what we see in the average population is a significant marker of adherence,
again, and I'll just stress that I think puts that study above others that rely on food

And now I'm done with that point. Thank you very much. So who's got the microphones this time? There's one over there? If you could raise your hands, and the microphone
people will know to come to you. But sir, you first please. A retired GP from the UK with an interest
in nutrition. It's just that I've always been taught that
Asians who have a high carbohydrate diet then come to the UK or the West and the they get
diabetes because they have more meat and more protein and more fat, and I'm surprised to
see this revival of the Atkins type diet, because we know that the Atkins diet increases
cardiovascular disease, gallstones, kidney stones, osteoporosis and cancer.

Thank you very much for that. Based on what data? Hold on a second. [inaudible 00:35:10]. We'll get to that. Sorry, I'm trying to look for you. Over here. Oh, yeah. Go, go. So [inaudible 00:35:17] from Glasgow. Sorry, just introduce yourself again. [inaudible 00:35:20] from the University of
Glasgow. So I work with Mike, so unfortunate, and Roy. So I grew up in Blantyre which is near Motherwell,
and you know, Irn Blu is from Blantyre, [inaudible 00:35:31]. So I grew up drinking lots of Irn Blu, but
I went to medical school, I was eating lots of chips, and I don't have a low carbohydrate
or a low fat diet, but what I did was change my habits, retraining my taste buds to get
rid of sugary drinks, don't eat chips as much anymore. I'll still eat the occasional ones, but I've
made proper choices. So it's neither one nor the other, and I think
most people in our community don't need to choose, if they want to stay healthy and not
become overweight, they don't need to choose one or the other. I think we're talking more about weight loss
in people who are obese, in terms of trials, and that's a different question.

So we've got to be really careful when we
actually look at this. So I think the key concept, and I do clinical
practice, for many of our patients, for some of them, it's clearly, we had one guy who
was drinking eight liters of Irn Bru a day, and two packs of crisps. Now, he lost eight kilograms when he started
to go on a normal diet. Most of my patients, it's snacking culture. It's crisps, it's biscuits, it's cakes, which
contain lots of saturated fat, and excess refined sugar, and it's a combination of things. An the key thing for them is to retrain their
tastebuds. And I'll give you one last example. One patient I said, "Could you go and try
some fruit?" He came back, next week he said, "Doc, I tried
that banana, it was bloody horrible. It was the first banana," and this is the
reality, it's the first banana he'd ever tried. So it seems to me no chips, no sweetened drinks
is a Scottish low carb diet, is that right? No, so the point is it's neither one nor the

But I take the point. It's normalizing things. Yeah. And there's a third microphone somewhere? There. Oh, so sorry, have you got a microphone? Yeah. Okay, go ahead. Hello, my name is Jane Collis. I've been studying diabetes for 50 years,
even though I'm only 23, which I've been observing pregnancy and lipids and I've got an interesting
[inaudible 00:37:18] Just bring the microphone closer. That's it. Sorry, various suspects of diabetes. I agree totally with the ladies talking about
pregnancy. We've forgotten homeostasis altogether, with
fats. The quality of the fat matters.

We can't go frying a fat and expect it not
to cause damage to our body. So with polyunsaturated oils, and olive oil,
they're cold pressed. So unfortunately, when they're offered to
us, they're very old. Sometimes rancidity is covered by commercial
processing. So in effect, we're putting something proinflammatory
into our bodies, which affects the testes and the ovaries. Section 2 of 3 [00:19:00 – 00:38:04]
Section 3 of 3 [00:38:00 – 00:56:04] (NOTE: speaker names may be different in each
section) Which affects the testes and the ovaries Also
when the baby is growing, if you should be so lucky to get pregnant with an imbalanced
homeostatic function with your Omega 3 and 6, then the baby will pinch all the Omega
3 from the mother.

That's essential for insulin sensitivity so
therefore the baby might stop growing or die. Nobody's looking at this. I'm very glad to hear somebody talking about
pregnancy. Thank you very much. Excuse my nerves. No, no. You've done brilliantly. So we've got the Atkins Diet, which was said,
and we want to know the evidence for this, that it increases a whole lot of terrible
things. And why the aging population changed their
profiles in coming to the UK. We've got the business about the just simply
stopping the bad stuff and getting back to what, in Scotland, might be considered a more
normal diet. And then the rancid facts and all the problems
with pregnancy. So, who would like to take any of those? Sarah.

So, I'll just start out. So, as far as the Atkins Diet, none of that
is true. There is not evidence for that. But, more importantly here in- There you go. I agree here with, I think both of you brought
up the idea of health. Right? And what is a healthy diet? And I couldn't agree more. That if we look at different cultures, let's
look at some cultures around the world. What we see is that there is a continuum that
people can exist on and be healthy. We have island nations who are very high carb,
who have very low instances of heart disease. We have the Inuits and the Maasai who have
incredibly high saturated fat intake and they are free of heart disease and healthy as well. So humans can exist on this continuum very
happily, until we introduce things that I believe, that we all could agree on. Sugar. Processed foods. Once you do that, and you get a metabolically
unhealthy person, there's no continuum anymore. You have to shift down to the low carbohydrate
end of this continuum and whether you get there through significant calorie restriction
or you just limit carbohydrates, once you have metabolic illness, your choices are limited.

Thank you for that. Other comments on the panel? Roy. That just raises an interesting point that
Sarah's made. It's that the way out of a problem is not
necessarily exactly retracing your steps. Reflecting on the question about the South
Asians moving to Britain. It wasn't that Britain was such a horrible
environment. It was actually an affluence effect. So you saw exactly the same hard rural engines
move to urban centers. That effect was reproduced, for instance,
by George Alberti moving to Tanzania. Rurals moving to the town.

They became more affluent and they could afford
more food. As I mentioned, what's superimposed on the
typical Asian diet was the increased fat and, of course meat, that they could afford. So they actually put on the weight and the
[inaudible 00:41:05] body was disadvantaged. How you get out of that situation is a separate
question. And the approach of reducing the carbohydrate
for that person would be entirely reasonable. Mateus Maybe I can kind of add to that. I mean the issue of the nutrition transition
in many countries is a major one. But I think we have sometimes the idea that
traditional diets are all good.

But, in many societies or many countries,
the traditional diets are relatively poor and have little diversity, actually. What we also do observe is that increasing
diversity, even if this means you start to eat little red meat, that that is counterintuitive. But it actually could be beneficial. Mm-hmm (affirmative)- thank you. Jenny, what about the question about pregnancy
and the rancid fats and the this year round protecting the fetus? Oh, I think the idea that rancid fats are
dangerous is perfectly reasonable. We don't want to eat oxidized food at all. Whether it's fat or any kind of oxidated products. Thank you for that. And Mike, do you want to answer the business
about the Scottish diet and just getting people off the bad stuff onto a more normalized? I'll tell you.

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

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

Thank you very much. If that microphone could come up to the front
here. And the lady there, yes. Thank you. [crosstalk 00:44:00] Just introduce yourself Barbara. Just say[crosstalk 00:44:03] I like giving, I always used to give patients
a choice with difficult treatments. So just say your name again, Barbara. Because you- I'm Barbara Boucher. Queen Mary's London. Maybe you've mentioned it and I've missed
it, but are there any simple crossover trials of high fat and high carbohydrate trials? Which do patients prefer? Which do they find easier to stick to? And can you find any characteristics to predict
which you might recommend first to a patient? Great question. Ian. Oh, great. Thank you. My name is Ian Lake. I am a medical advisor to I am a humble GP in search of the truth. And a Type I Diabetic, so I choose a ketogenic
diet. My question really is that if you look at
most trials regarding carbohydrate and fat, most of the trials on fat are done in an environment
of about 30% of the energy coming from fat. What seems to happen is that the ratios of
the fats have changed within that 30%.

Then people are given a 24 hour recall sheet,
dietary recall sheet, every year or so and conclusions are drawn from that. A lot of carbohydrate gets converted to fat. In fact, most of us here are probably converting
our excess carbs into fat now. That fat, of course, is saturated fat. So most of the diets that I've looked at regarding
low carbohydrate in diabetes stick at about 40% of the carbs coming from fat. 40% of the energy coming from fat. So I think if I was on a high carbohydrate
diet I would take a lot of care with my saturated fat. Because the saturated fat that comes from
carbs, I think is highly significant in this. Of course the saturated fat from carbs is
tagged with B100, which is quite a highly significant factor in cardiovascular disease. So that's my question. Should we take that into account? Could that microphone just come here to Sarah
and them we'll just have our answers to those three.

Which were about the importance of food processing. [crosstalk 00:46:11] Oh no, I am all set. I'm just going to come back to the panel. Then I'll get you in. So food processing, how could we, could we
get a measure of that? Get the food industry to abide by that? Has there been a crossover trial between high
fat and high carb? Which the patients prefer? Which is easier to stick with? And the business about saturated fats that
the body develops as a response to eating carbohydrates and how do we balance that out? Roy. Just a comment on the processing of food. There might be many details that may or may
not deleterious, and that may require a lot of studies to sort out.

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

Thank you. Jenny. Can I just put some facts in there? If you look at the FAO, WHO website, fantastic. You can plot the UK intake of sugar from 1961
all the way up to 2014. It shows a steady decline. Comparable to the decline in Australia. In the intake of added sugars. Fifty years ago, Mum bought a package of sugar
and she made cookies and cakes and cordials.

Today, the food industry makes them. And the food industry has allowed a whole
generation of women to go out to work and to have careers. Right. The problem is the structure as a population. We won't disagree on that. What happened over a few generations or a
couple generations inadvertently is added sugar. Sugar you sprinkle on your Corn Flakes and
to your tea, has actually gone down markedly.

And has been replaced by the processed food. Now, the children really get that whack. Whether it's added in the sweet and sour chicken
from Marks and Spencer. That leads the league of added sugar products. Or whether it's added in Iron Brew, it really
doesn't matter. So we've got a real problem with our alarming
epidemic of obesity in children. Sarah, can I ask you about this crossover
between high fat and high carb? Has there been or does anyone know of any
comparisons of acceptability of those two diets? Jenny or Sarah? What's Iron Brew? Can someone answer that question for me first? Is it soda, is it just soda? Yeah.

All right, all right. Sorry I had to be educated on that one. So there are a number of trials that compare
low-carb and low-fat. Well, high-carb and high-fat. Or excuse me, low-carb and high-carb. Yes. What we see over and over again is, from a
metabolic standpoint, the low-carbohydrate outperformed the low-fat diet time and time
again. Those results are much more striking when
we look at diabetes. Okay. Briefly, if you would, Mike [crosstalk 00:49:42] Can I pick up Barbara's point though, is on
individual preferences here. And if you ask people to go on a diet, which
they don't like, then they are unlikely to stick to it. So this is where it comes back to the N=1
or the N of 1 randomized trials. Which the BMJ kind of announced to the world
about thirty or thirty-five years ago. There is an hour edition to the consort program,
I don't think it's ever been used. Okay. Thanks. Jenny. CSIRO in Australia have done a lot of studies
on low-carb versus low-fat. Their parallel and up crossover. They had a long term, they had two years,
and they've looked at mood and depressive symptoms on each diet.

The low-carb diet is associated with more
negative mood, even though they've lost all that weight. They don't feel as happy as the people on
the high-carb diet. Ah, interesting. [crosstalk 00:50:32] Can I just comment on that? That is, depends on the definition of low-carb
because that's actually the opposite of what we see in real low-carb. Okay. Seventy five grams. Seventy five grams of carbohydrate, exactly. [crosstalk 00:50:43] We've got literally less than five minutes. So I am just going to ask for the final three
microphone people. You can have like a ten second comment. Sorry. [inaudible 00:50:50] Willet, Harvard, Boston. This has to be a question I guess. Is there really any reason that plant based
diets need to be high in carbohydrate? I find it pretty easy to have plant based,
lots of vegetables, olive oil, nuts- Okay.

And also, Cordain, the founder of the paleo
diet was asked how many people in the world could be supported by that paleo type diet. His answer was about two hundred million people. So my question is where is the other seven
billion going to go? As someone mentioned we need to think about
the environmental consequences. Thank you. Salman, very briefly if you would. The North star in this conversation is higher
weight is bad for you. That is a weight over 25 BMI is worse than
below or in the 23-25 and over 30 is bad. There are three sets of good data that challenge
that. First a paper in the Lancet Global Health
that came out late last week or early this week. On half a million people followed for sixteen
years, from India, that shows that mortality is lower with higher BMI with no threshold. With lower BMI? No, with higher BMI. Mortality is? Is lower at higher BMI all the way up to 35. That Richard Peto is the senior author on

Got the luxury, did it. Briefly[crosstalk 00:52:16] Secondly is in Denmark, the BMI associated
with the lowest mortality has been going up by two units every decade. Item three, the tons of paper on the obesity
paradox. The sicker you are, the higher your BMI, it
protects you. What this means, there's something about BMI,
despite the fact you get more diabetes and higher blood pressure, that is counteracting
it and protecting you. So, going back to I think Haseem's comment,
people matter. BMI doesn't matter. Thank you for that. I'm sorry the final microphone person, oh
if you could be so short. I mean like a microsecond. No, sorry it's behind you. Sorry sir, behind you. Thank you. My name is Synan Mere. I am a GP from London. Just to keep it exceptionally short, in the
context of talking about either decreasing calories, caloric restriction from a thermodynamic
point of view or metabolic hormonal imbalance in the context of diabetes especially.

Where does the panel, and this is for the
whole panel, where does the panel sit on therapeutic fasting? That's not been mentioned here. Is that appropriate? Is that relevant? Is there a sustainable model? So fasting, whether it's sort of a 5/2 model
or a 16/8 model, is that something that is a feasible approach to decreasing weight and
managing glycemic control? Thank you very much. Will you let me give the panel just thirty
seconds each? Because I want to get a sense from you of
where you think the agreement is between you on this issue. I'd like to give one or two points of where
we think we've got agreement. Sarah. I think the agreement here is that reversal
is possible and I think that we need to come to a consensus and make a strong statement
about that. So that we can give patients a choice. We need to put power back into patients hands,
because I will point out Walter's comment. You can absolutely do a plant based, low carbohydrate,
high fat diet and if that's there choice, we need to all surround them and support them
for that.

Right? Because there is more than one way to skin
a cat. Three ways have been scientifically proven
to reverse Type II Diabetes. We need to talk about it and give people the
option. Thank you very much. Mike? I would just like to take a moment so Salman
you said this interesting comment here. One of the weird things is that a body mass
index of under 25 is only found in 11% of people in Scotland when they've reached the
age of 65. So we're weird. We're weird. Thin people are weird. [crosstalk 00:54:50] Whereas most people are healthy have gone
with the population. Where is the agreement Mike? In our conversation? I think that the agreement lies at the glycemic
low to high glycemic load. However you get a high glycemic load, it's
bad for you. And there's many of avoiding it. Thank you. Mateus. Along this line of plant based diets would
be the go-to to go for.

They could have a range of carbohydrate versus
fat. I would guess. Thank you. Jenny. High glycemic load diets are bad for us. I would agree that a large amount of weight
loss, of at least ten kilos or ten percent of body weight is associated with remission
of Type II Diabetes. But the next question is, for the rest of
their life, which is the best diet composition? Thank you. Roy. I would agree with all of the previous points. The individual nature of this, in other words,
the human interface with the science being talked about, is really important to recognize. So no one size fits all. Fantastic. Thank you to our panel. Thank you to the audience for their questions..

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