1. In a recently published case report, we see a West Virginia hospital strive toward a new standard of care for approaching patients with type 2 diabetes. What therapeutic agent is at the center of this inpatient intervention? A ketogenic diet. Dr. Mark Cucuzzella is the change agent at this community hospital, supported by open-minded administrators and countless hospital employees. The publication of this case report is an important step toward establishing a new standard of care for reversing type 2 diabetes with carbohydrate restriction.

2. Can lower-carb eating lead to the common heart arrhythmia atrial fibrillation? Headlines might lead you to believe this is the case, but cardiologist Bret Scher explains why an observational study of this sort is weak evidence. When you layer a compromised definition of low-carb itself, unreliable food frequency questionnaires, a weak association, and many potential confounding variables, the concerning headlines fade away.

3. The New York Times reports that a new, observational study suggests a meaningful increased incidence of diabetes onset in patients taking a statin, regardless of brand and dose. Although the quality of this evidence is weak, other research — some of it from randomized clinical trials — confirms that this risk is real and meaningful, but puts the absolute increase in risk of diabetes at a much lower level than these headlines suggest. 

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1. A lengthy article in The Mail on Sunday calls out three UK experts for publicly questioning the efficacy of statins. The article suggests that thousands of people who could be helped by statins are not taking them because of these “statin deniers.” But the record of statins to meaningfully protect allpatients from cardiovascular disease is spotty. Cardiologist Bret Scher unpacks the bitter controversy between the pro- and anti-statin camps.

2. A new study compared a pork cheeseburger to a plant-based burger, but with an added twist: a sugary drink was added to the pork cheeseburger but not to the other meal. This study design suggests obvious bias, yet it got through peer review. It’s just another reminder of how agendas can impact otherwise “scientific” studies and their results.

3. You may have seen multiple online articles about the perils of “keto crotch” — a condition featuring unpleasant vaginal odors purported to be caused by the keto diet. Dr. Evelyne Bourdua-Roy, a family doctor who treats patients with low-carb diets, looks into the rumors, and concludes that “keto crotch” is perhaps misinformation or misdiagnosis, but is NOT a chronic or significant ongoing problem women experience when in ketosis.

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1. A new op-ed published in Minnesota’s largest newspaper, the Star Tribune, christens the keto diet as “The risk-reversal diet.” With a very engaging style, the author focuses on the type 2 diabetes epidemic, including its shocking scale and crippling cost. He builds a strong case for his thesis: “Errant beliefs about food and health engineered a diabetes crisis, and a simple, sustainable way of eating can end it.” That way of eating is keto. A must read.

2. According to CNN, Weight Watchers is “getting crushed by keto.” A surprisingly poor quarter led Weight Watchers’ CEO to mention a “keto surge” as one of the company’s challenges. Her company’s stock has tanked, down almost 80% from its high less than a year ago. Even bigger news: CNN also reports that a Wall Street analyst named Diet Doctor as part of the reason she is concerned about Weight Watcher’s future performance. Another must read!

3. Headlines about a new, randomized study out of China suggest that a higher level of dietary fat is bad for the gut. Fear not. The diet in the experiment was not low carb, and the added fat was mostly soybean oil, rather than healthy, real-food fats. Dr. Bret Scher explains all of the red flags in this new study.

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1. A post-PREDIMED world… Agarwal and Ioannidis weigh in (via this analysis in the journal BMJ) on lessons learned from the retraction of a landmark Mediterranean diet study, and the repercussions and way forward. Also, Vox asks how researchers will reassess the revised and reissued study, and raises questions about how other medical journals will deal with their newer studies that cite and rely on the old PREDIMED.

2. MedPage reports on a new observational study, just published in Neurology, that finds elevated inflammation in midlife is associated with steeper cognitive decline, particularly memory decline. The subjects with the highest quartile of blood levels of a systemic inflammation marker experienced 11.6% steeper decline in memory than the subjects in the lowest quartile. This data comes out of Atherosclerosis Risk in Communities cohort study, and suggests that midlife inflammation may pose a greater cognitive risk than midlife hypertension.

3. A new, National Institutes of Health funded and American Heart Association sanctioned analysis of old, observational data finds subjects with type 2 diabetes who ate at least five servings of nuts each week experienced 20% less heart disease and about a third less premature death than those who ate almost no nuts. This sort of weak, observational finding doesn’t mean much, but regardless, the popular press is scrambling to cast nuts as a “better for you” substitute for foods high in saturated fat rather than a replacement for refined carbohydrates. 🙄

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1. Women with a diagnosis of polycystic ovary syndrome (PCOS) should definitely be on the lookout for type 2 diabetes. The American Diabetes Association publishes a new study in its journal Diabetes Care that finds normal weight women with PCOS have a 3.2X chance of developing type 2 diabetes. For overweight and obese women with PCOS, risk is 4.7X and 8.8X, respectively. Research shows that a low-carb diet can often reverse both PCOS and type 2 diabetes.

2. MedPage Today reports on a new study, published in JAMA Network Open that demonstrates huge individual variability in (non-diabetic) blood sugar responses to the same foods. For example, “a standard meal consisting of a bagel and cream cheese, glycemic excursions ranged from just 6 mg/dL up to 94 mg/dL.” This informs the question of why some people may do well on a low-fat diet and others may struggle. In addition, it speaks to the power of continuous glucose monitors (CGMs) to inform individuals about their personal tolerance for specific foods.

3. ABC News reports on a new analysis in the journal The Lancet that reveals that six cancers linked to obesity (colorectal, endometrial, gallbladder, pancreatic, kidney, and multiple myeloma) are “increasing in a stepwise manner in successively younger birth cohorts in the USA.” Translation: researchers are seeing a younger and younger onset of these obesity-related cancers in successive generations.

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1. The much anticipated EAT-Lancet report dropped last week, and it said pretty much what it was expected to say — that the world population must drastically cut meat and dairy consumption, replacing those calories with legumes, seeds, whole grains, fruits, and vegetables. This switch is purportedly necessary for both personal and planetary health. Countering this sweeping pronouncement are those interested in adequate nutrition and regenerative agriculture. Like Dr. Georgia Ede writing in Psychology Today and Diana Rogers, RD writing on her blog, Sustainable Dish. This is just the beginning of a long and contentious conversation, so read up and buckle up.

2. How important is fiber? And fiber-packed whole grains? A highly publicized analysis released last week in the journal The Lancet looked at carbohydrate quality and found that dietary fiber is protective against cardiovascular disease, type 2 diabetes, colorectal cancer and breast cancer. It shouldn’t surprise any of us that cutting out processed foods like white bread, cookies, cakes and sugary beverages and replacing those foods with high-fiber carbohydrates like whole-grain, unsweetened cereal or wheat berry pilaf will lead to health improvements. That says nothing about swapping out whole-food, low-carb staples like vegetables, olive oil, and meat or fish with whole-grain products. (Pssst… most low-carb diets aren’t low in fiber.) 

3. A new study published in JAMA (and out of the University of California San Diego and Emory University schools of medicine) shows that adolescents with diagnosed fatty liver disease who cut out added sugars, but do little else to change their diets, can quickly improve their health, reducing liver fat by 31% on average in just two months. How wonderful that children’s health can recover so quickly from some of the damage done by sugary foods.

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1. A new study, published in the American Journal of Physiology demonstrates that a strain of rats, bred to be prone to high blood pressure when fed salty rat chow, also appear to become hypertensive when fed high-fat rat chow. Although relatively unimpressive in terms of the relevance to humans, these rodent-study results generated some impressively misleading headlines like this one: “High-fat diets appear bad for blood pressure in younger males and females.” Argh…

2. Oh, Canada! A leading newspaper, the Toronto Star, runs a op-ed from an organization, Canadian Clinicians for Therapeutic Nutrition (CCTN), which boasts a membership of over 4,500 Canadian doctors who recommend low-carb eating. The piece was entitled “Are steak and cheese healthy? Doctors group says Canada’s Food guide is wrong on diet.” How’s that for direct, eh? But wait… there’s more from up north. The Vancouver Sun ran a myth-busting op-ed entitled, “Anne Mullens: Here’s why I’m excited about the ketogenic diet and why some of you might want to try it.”

3. ABC News Australia reports on an unusual shortage of ketone strips (both blood and urine) due to increased demand for them as keto eaters buy them in unprecedented quantities. Although informative and motivational (and even fun) for ketogenic dieters, these strips can be crucial for patients with diabetes who are at risk of ketoacidosis, a life-threatening condition. So if you are buying strips for motivation not safety where there are shortages — in Australia or the UK — please refrain from additional purchases until supply catches up with the new keto-inspired demand.

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1. Each year, U.S. News and World Reports ranks the top diets. Unfortunately, low carb and keto are at the bottom of the list. Again. How bad was it? Atkins landed the 37th spot in the ranking, and keto tied for 38th place. 🤨 Regardless of this lost opportunity to spread the word, many people — about 45% of would-be dieters — are planning to try low carb or keto in 2019! When something works, the word spreads quickly, even without much help from establishment channels like U.S. News.

2. Another study looks at the downsides of some diabetes medicines. This one, just published in JAMA Open Network, links both insulin and sulfonylureas with more cardiovascular events. Although observational, the insulin users experienced more than double the risk of the control group, so the finding is worthy of further attention.

3. More bad news about diabetes. A new study published in the journal Metabolic Syndrome and Related Disorders finds that diabetes is associated with more memory and executive function troubles in middle age. Although many observational studies have shown links between diabetes and dementia in older adults, this is the first study to link early cognitive decline (in middle-aged adults) with diabetes status.

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1. A new, well-controlled and carefully executed study adds to the evidence that diets high in red meat lead to higher blood levels of a metabolite, trimethylamine N-oxide, or TMAO. However, the evidence about the effect of higher TMAO levels is mixed, with several studies showing no association with elevated TMAO and heart events. Cardiologist Bret Scher recommends a focus on basics like a real food diet, and attention to blood sugar, blood pressure, and inflammation rather than a focus on this uncertain marker.

2. The New York Times calls out the lack of evidence for the efficacy of low-salt dietary regimens. When it comes to heart failure, the evidence is shockingly thin — only nine clinical trials with a total of just 479 subjects. Worse, “there were no data that showed that salt restriction reduced mortality or cardiac disease” in heart failure patients. Wow… please pass the salt. 🙂

3. Last week, a study published in JAMA looked at the costs of unnecessary blood sugar testing in patients with type 2 diabetes who are not at risk of hypoglycemia (dangerously low blood sugar levels). But glucose strips can be used to monitor more than just dangerously low blood sugars… they can help people identify dangerously high blood sugar, too, and modify their eating patterns to avoid reoccurrence.

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1. In a well-placed and easy-to-read article in The New York Times Magazine, Pulitzer Prize-winning cancer doc Sid Mukherjee makes the case that we should be doing more to investigate the impact of diets on our bodies and the ability of foods to help with healing. He writes about his large new research project, which pairs a promising yet thus-far-unsuccessful drug with a keto diet in hopes of boosting the drug’s efficacy and delivering life-saving results to cancer patients in the trial.

2. Might there be a magic pill to fight obesity? Something you can take that allows you to overeat and not gain weight? In spite of hopeful headlines, the real answer is “Not anytime soon.”

3. Evidence is emerging to show ketogenic diets help relieve chronic pain. Promising science suggests ketones reduce neuron excitability and inhibit pain pathways, blunting arthritis-related chronic pain. 

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1. Do genetics doom children to become and remain obese? A new, hopeful study shows that kids with a genetic propensity for obesity respond well to lifestyle intervention… just as well, in fact, as obese kids with no genetic predisposition.

2. Dr. Sarah Hallberg makes a strong case for reform of the Dietary Guidelines for Americans in her compelling op-ed just published in The Hill, a popular newspaper and website covering public policy and politics from Washington, D.C. The title? “Government dietary guidelines are plain wrong: Avoid carbs, not fat.”

3. Many of us think of ourselves as healthy, even if we know we weigh more than we should. A new study looks at five “scale-free” measures of metabolic health and demonstrates that just 12.5% of American adults qualify as healthy across all five metrics. What measures were the study authors evaluating? Waist circumference, blood sugar, blood pressure, triglycerides, and HDL cholesterol — all major markers for metabolic syndrome.

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1. Misleading headlines like “Low-protein, high-carb diet may help ward off dementia” misconstrue the findings of a small study that showed “modest effects” in mice. What headline might a candid and precise journalist write? “A low-protein, high-carb diet may have subtle brain results similar to calorie-restricted diets in mice.” Sometimes the truth is decidedly less exciting.

2. Does obesity cause diabetes or cardiovascular disease? A new systematic review and meta-analysis, published in JAMA Network Open, is the first-ever meta-analysis pooling data from studies conducted with a technique called Mendelian randomization which employs genetic markers and number crunching to mimic a clinical trial. The results showed that each five point jump in BMI increased the relative risk of a type 2 diabetes diagnosis by 67% — a substantial connection. For coronary artery disease, the association was not as strong: a five point jump in BMI increased the relative risk of coronary artery disease by just 20%. The authors of this analysis are quick to point out that Mendelian randomization studies do not prove causality. However, they do say that the study supports a causal relationship.

3. A Stanford University modeling study predicts that as global rates of diabetes surge, roughly 40 million people will not have access to the insulin they need. This shortage will be most acute in Asia and Africa. All the more reason to consider lifestyle options like ketogenic diets and intermittent fasting to reverse type 2 diabetes.

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1. VERY. Big. News. A calorie is not a calorie after all. A new, carefully-designed study, published last week in the journal BMJ, finds that participants eating a low-carb diet, compared to those eating a high-carb diet, need to eat roughly 250 more calories per day to maintain their weight. Study author Dr. David Ludwig of Boston Children’s Hospital and Harvard Medical School points out that this increase in metabolic rate among subjects in the low-carb group could translate to about a 20 pound difference (weight either lost or NOT regained) over three years. This study, funded by NuSI but designed and executed by independent researchers, was more rigorous, expensive and had a longer duration than other studies designed to test the question of whether weight control was just about energy balance or whether the composition of diet matters. It’s a big win for low-carb that should get some mainstream attention.

2. Doctors Ludwig, Willett, Volek, and Neuhouser pen a prominent consensus paper for the magazine Science special issue: Diet and health. The title? “Dietary fat: From foe to friend.” Not much new here… We see a general acknowledgement that fat can be a healthy part of our diets, especially when replacing refined carbohydrate. But many longstanding controversies remain, including concerns about the healthfulness of saturated fat. A preference for highly processed polyunsaturated vegetable oils lingers.

3. The American Diabetes Association issues new guidelines for managing type 2 diabetes in youth. (Remember, type 2 diabetes used to be called adult-onset diabetes because we never used to see cases in children.) Unfortunately, the new position statement is medication-heavy and focused on weight loss, via “eat less, exercise more” advice. It does not even mention carbohydrate restriction. Such a wasted opportunity to improve young lives. 

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1. The American Heart Association, American College of Cardiology, et. al. issued new clinical practice guidelines for the management of blood cholesterol. This revision makes progress; it individualizes care and softens some recommendations surrounding obligatory use of statins for primary prevention. Cardiologist Bret Scher takes a look at the detailed new guidelines and gives us his impressions about what they get right and where there is still room for improvement.

2. Newspaper headlines about the lifesaving potential of a tax on red and processed meat were plentiful last week, thanks to a thought-experiment-turned-modeling-study out of the University of Oxford, published in PLOS. A meat tax is based on the idea that red meat contributes to increased rates of chronic disease. This hypothesis relies on weak epidemiological evidence, a type of evidence that needs to be tested in randomized clinical trials to establish causation. These trials have never been conducted. There are other problems with the idea of a meat tax, like its regressive nature and likely unintended consequences.

3. The American Diabetes Association (ADA) and the American Heart Association (AHA) are teaming up to bring the connection between diabetes and heart disease into focus. The joint initiative, “Know Diabetes by Heart,” was launched last Thursday, with its own, dedicated website, including resources for patients and practitioners. Given the ADA’s medication-heavy leanings, we were not surprised that the new initiative’s sponsors — all large pharmaceutical companies — are featured prominently on the “Know Diabetes by Heart” website. Notably missing from the new website is any mention of how, for many or even most motivated patients, a low-carb diet can reverse type 2 diabetes while at the same time improve cardiovascular risk factors.

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1. The Milken Institute, a non-profit, non-partisan think tank, released a report on the real economic costs of obesity and overweight in the United States. The estimates in the report include both direct health care costs that are caused by obesity and overweight, and indirect costs associated with lost productivity borne by patients and their employers. The total number is staggering: $1.72 trillion each year. Separately, an Atkins-funded policy paper suggests that if just 20% of patients with type-2 diabetes improved their condition with low-carb nutrition, the annual savings would approximate $10 billion. 

2. In a show of knee-jerk support for all things mainstream, Sarah Bosely, the health editor of The Guardian, pens an opinion piece, “Butter nonsense: the rise of the cholesterol deniers.” Cardiologist Bret Scher unpacks Bosely’s article, pointing out that silencing healthy debate and ignoring the nuance and complexity revealed by the entirety of the scientific record isn’t the way to go, either.

3. Dr. George Lundberg, a self-described “ultimate [medical establishment] insider” and former (longtime) Editor-in-Chief of the Journal of the American Medical Association (JAMA), recently issued a Medscape opinion piece entitled, “Could it be the sugar?” In it, Lundberg explains: “The next and current big battle is over diabetes mellitus, insulin resistance, and obesity. How are they related? What can be done to stem the worldwide epidemic and prevent it from worsening? The stakes are very high, including the lives of millions of human beings and hundreds of billions of dollars.” You can watch the 7 minute video or save a little time and read the transcript provided.

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1. A new study, published in Cell Metabolism, looks at the “metabolome” — a collection of metabolic markers in blood — and finds that it is more powerful than weight for predicting future metabolic health. “Normal weight individuals with an unhealthy metabolome ‘had a 50% greater chance of becoming obese over the next ten years and had a 200-400% increased risk of heart disease’ [than those with a healthy metabolome]. They also found that overweight individuals with normal metabolome blood tests were at a much lower risk for insulin resistance and heart disease.”

2. A new Mendelian randomization study of half a million UK residents suggests elevated BMI is likely to be a causal contributor to elevated mortality. Results show that each 5 point BMI increase is associated with a 16% increase in all-cause mortality and a 61% increase in CVD mortality. The University of Bristol study was published in Obesity.

3. The American Diabetes Association (ADA) launches an elaborate-yet-misguided FoodHub with recipes, meal plans, and shopping lists. A Sweet Life provides a thoughtful critique of the ADA’s “everything in moderation, with a variety of carb levels” approach. On a related note, Diana Rodgers asks, “Why won’t we tell diabetics the truth?“

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1. In a widely reported anti-obesity move, the New York City Health Department (NYCHD) intends to lead a voluntary campaign to get food and beverage companies to reduce the amount of sugar in their products. Specifically, the NYCHD will seek a commitment from food manufacturers to reduce average sugar levels in packaged foods by 20%, and a commitment from beverage manufacturers to cut sugar in sweet beverages by 40%.

2. CNN reports on a detailed study, published in The Lancet last week, forecasting life expectancy changes across 195 countries between 2016 and 2040. Spain is predicted to edge out Japan for the longest lifespan — 85.8 years. Study authors believe the United States is likely to fall from 43rd to 64th place in the rankings of high income countries. The authors note that although most drivers of health are forecast to improve, “for some drivers such as high body-mass index (BMI), their toll will rise in the absence of intervention.” 

3. The FDA makes it official, finalizing the complete elimination of artificial trans fats from America’s food supply. Politico reports that the FDA will “revoke all prior sanctioned uses” of partially hydrogenated oils.

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1. Very good news. The American Diabetes Association and European Association for the Study of Diabetes added a new therapeutic option for patients with diabetes: a low-carb diet. This change serves as an official acknowledgement of the strong evidence in the literature for the effectiveness of low-carb and ketogenic regimens in the fight against diabetes.

2. Another new, pro dairy fat review hits, this one out of Tufts. It shows an association between higher rates of dairy fat consumption and lower rates of type 2 diabetes. Senior author Dariush Mozaffarian states, “Our findings, measuring biomarkers of fatty acids consumed in dairy fat, suggest a need to re-examine the potential metabolic benefits of dairy fat or foods rich in dairy fat, such as cheese.” Note that this study was a large, observational analysis (a meta-analysis of prospective cohort studies), so causation is not shown. A smaller analysis that linked more dairy fat with less CVD and stroke made headlines in July.

3. Doctors in Canada publish a case report documenting how three men with type 2 diabetes used intermittent fasting to eliminate insulin and most other medications, while also improving their blood sugar control. The subjects fasted for 24 hours 3-4 times per week. On other days, they practiced time-restricted feeding, eating only lunch and dinner. Patients were monitored and medications were withdrawn under close medical supervision. This is another example of the power of diet, not drugs, to reverse type 2 diabetes. 

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1. Dr. Georgia Ede pens a thought provoking piece for Psychology Today entitled "Obesity: Stop shaming, start understanding." In it, she fingers insulin resistance as a root cause of obesity, and encourages readers to be curious enough to take a second look at the not-so-plausible mainstream assumptions about overweight and obese patients. Ede includes a companion piece for doctors where she asserts that a better understanding of insulin resistance is critical for improved patient care.

2. A new review, published in Molecular Psychology, analyzed 41 observational studies, and finds that subjects eating a Mediterranean-style diet experienced lower rates of depression. The study also finds that those eating other diets (characterized as either anti-inflammatory by the Dietary Inflammation Index or conforming with the Healthy Eating Index) also experienced lower rates of depression. Observational, of course, but interesting.

3. Both The Atlantic and The New York Times cover the latest scandal in nutrition research. High-profile and prolific Cornell Food Lab scientist Brian Wansink resigned after serious questions emerged about the scientific integrity of his work. Journals retracted over 13 of his papers. How many other researchers might also fail the careful scrutiny that Wansink received? How do we know which nutrition research should be believed?  

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1. Are there "major doubts" about the safety of keto? In spite of clickbait news headlines, there is no convincing evidence that eating carbs makes you live longer. Clinical trials show improvements in outcomes for those reducing carbohydrate intake.

2. The diabetes epidemic rages on, as evidenced by the numbers in the new report based on National Center for Health Statistics data, released this week by the CDC. A shocking 14%of American adults have diabetes. In 2014, this rate was pegged at 12.2%. Rates are worse among men (16% vs. 12% for women); worse among those over 60 (28%); worse among Hispanic Americans (20%); worse among those with obesity (21%).

3. Last week, The Houston Chronicle ran a bold opinion piece by cardiologist Bret Scher favoring low-carb diets and debunking the purported heart health risks of eating red meat.

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