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Monday 26 May 2014

Diabetes as an Iatrogenic Disease - the Indian Experience

Diabetes and dairy fat in India.

     The epidemics of diabetes, cardiovascular disease and related conditions in India have been called iatrogenic (Raheja B.S. 1994), a product of diets high in linoleic acid as a result of “chasing the phantom of cholesterol” (Raheja et al. 1993). The traditional Indian diet (39% fat) supplied 20.3%E as saturated fats, mainly from ghee, with 5% from linoleic acid. Concerns that this diet is atherogenic have resulted in replacement of ghee with high-linoleate oils; the modern urban diet being 31.9% fat, with 5.6%E as saturated fat, and 16.9% linoleic acid (Raheja, B.S. et al. 1993).
     In children and young individuals, a high intake of n-6 PUFA is correlated with fasting hyperinsulinaemia, and dietary supplementation with n-3 PUFA leads to an improved lipid profile but not insulin sensitivity. In adults, high-carbohydrate meal consumption was reported to cause hyperinsulinaemia, postprandial hyperglycaemia and hypertriacylglycerolaemia. (Misra, A. 2009).

The association of ghee consumption in the Indian diet with a lower rate of diabetes is consistent with the correlation between serum markers of dairy fat consumption and reduced diabetes risk (Mozaffarian et al. 2010, 2013). The NZ Ministry of Health currently recommends a wide range of linoleic acid and alpha-linolenic acid in the diet; the lower recommended intake of LA being 4%, the upper being 10%, and the lower recommended intake of ALA being 0.4%, the upper 1% (the omega 6-3 ratio at median intakes thus being 10:1). Saturated fat intake below 10%E is recommended. (Food and Nutrition Guidelines for Healthy Children and Young People (Aged 2–18 years): A background paper. 2012 MOH).

     The message from the Indian researchers into the causes of their diabetes epidemic is that higher consumption of dairy fat protected marginal dietary omega-3 intake from abrogation by excessive intakes of omega-6 fatty acids. Replacing highly saturated dairy fats with diets higher in linoleic acid and refined carbohydrate, which is the same effect that the campaign against saturated fat has had among more disadvantaged New Zealanders, has increased the rate of diabetes, which is consistent with the New Zealand experience, suggesting that the increased incidence of diabetes in New Zealand has been in large part an iatrogenic phenomenon.

he present epidemic of DM and ACVD in Asian indians and possibly in other communities is iatrogenic resulting from what may be called modern malnutrition due to increased intake of total and n-6 fats and decreased intake of n-3 fat and antioxidants. Such a diet induces oxidative stress and activates the immune system. Imbalance between n-6 and n-3 fats result in inappropriate immune response. It also leads to increased and unbalanced biosynthesis of metabolites of n-6 fats. These are immune suppressive, proinflammatory and thrombogenic. They also contribute to insulin resistance and dyslipidemias. This makes DM and atherosclerosis as malnutrition related oxidative immune inflammatory disorders. Various risk factors are also the result of the same inappropriate response. Our intervention studies give considerable support to this hypothesis. It is suggested that simple correction of diet defects can reverse the disease process and thereby offer a simple, practical therapeutic option not only for the primary prevention of each of these disorders or their complications but also for the so called risk factors for these diseases. It is suggested that the real remedy for DM, ACVD and all the risk factors lies not in drugs or surgery but in the kitchen."
- B. S. Raheja

Misra, A. et al. (2009). South Asian diets and insulin resistance. Br J Nutr. 2009 Feb;101(4):465-73. doi: 10.1017/S0007114508073649

Mozaffarian, D. et al. (2010). Trans-Palmitoleic Acid, Metabolic Risk Factors, and New-Onset Diabetes in US Adults. Ann Intern Med. Dec 21, 2010; 153(12): 790–799. doi:  10.1059/0003-4819-153-12-201012210-00005

Mozaffarian D. et al. (2013). Trans-Palmitoleic acid, other dairy fat biomarkers, and incident diabetes: the Multi-Ethnic Study of Atherosclerosis (MESA). Am J Clin Nutr. 2013 Apr;97(4):854-61. doi: 10.3945/ajcn.112.045468.

Raheja B.S. (1994). Diabetes and atherosclerosis as immune-inflammatory disorders: options for reversal of disease processes. J Assoc Physicians India. 1994 May;42(5):385-90, 395-6. PMID:7829439

Raheja, B.S. et al. (1993). Significance of the N-6/N-3 Ratio for Insulin Action in Diabetes. Annals of the New York Academy of Sciences, 683: 258–271. doi: 10.1111/j.1749-6632.1993.tb35715.x

Food and Nutrition Guidelines for Healthy Children and Young People (Aged 2–18 years): A background paper. (2012) New Zealand Ministry of Health.

Monday 19 May 2014

Uffe Ravnskov, Zoe Harcombe and Aseem Malhotra on the New Censorship

This is just a bookmark for three responses to two recent incidents of press censorship.
ABC withdrew the two episodes of "Heart of the Matter" Catalyst show, despite nothing substantial in the complaints being upheld, and the BMJ retracted some comments critical of statins, including those of Dr Aseem Malhotra, which were opinion based on his clinical impression, and had been presented as such.

[EDIT: This BMJ comment thread supplies all the information anyone might need to know about statin side effects. The patients' stories in particular.]

This is from Uffe Ravnskov's newsletter:

Why are the media afraid of revealing the greatest medical scandal in modern time?
In my October 2013 Newsletter I told you about the Australian TV program "Heart of the matter" produced by Maryanne Demasi, a PhD in medical science and a science reporter and presenter with  Australian Broadcast Corporation (ABC)¨s catalyst. In the program she interviewed several experts about their view on the effects of cholesterol-lowering diets and statin treatment. As far as I know this is the first TV program in the western world where critics of the cholesterol campaign have been allowed to present their view in detail. The shrewish reactions from the National Heart Foundation and from the drug companies were therefore predictable. 
In accordance with their Code of Practice and the editorial policies ABC asked the Audience and Consumer Affairs (A&CA) to examine the critical comments. Eleven critical points were examined, but although ten of them were cleared of bias, the ABC declared that the programs have been removed from the ABC website, because the A&CA has concluded that some parts of the program breached ABC standards on impartiality. 
Their decision is most curious because the A&CA did not find any factual information wrong. For instance, in their report you can read the following about the first episode “The dietary villains”:

1. The factual information in the program was accurately presented and the reporter has demonstrated that she diligently sought and considered a variety of views on the subject. No material inaccuracy has been demonstrated by any complainant.
2. The principal perspectives were presented.
3. Neither position was endorsed by the program.
4. Neither perspective was misrepresented.
5. The nature of the program necessitated that the unorthodox theory was given more time and explanation. The Code does not require that they receive equal time, nor that every facet of every argument is presented. 
With one exception similar conclusions were made about the second part. I shall come back to the exception that breached the ABC standards. 
The objections reveal that either the complainants have an alarming lack of knowledge or that they consciously try to mislead. Here come a few examples; in a complicated 49 pages document from ABC you can read all of them. 
The hypothesis that eating saturated fats can increase cholesterol levels which in turn can cause heart attacks is widely accepted by the medical community.”
It is true that it was accepted many years ago, and most doctors and lay people still think it is true. However, more and more researchers have realized that it is totally wrong. Furthermore they would have known it already sixteen years ago if they had read my review about this issue, or my review from 2010  or a more recent one by Robert Hoenselaar or the recent meta-analysis by Chowdhury and coworkers
Sadly, as it appears from the following, the complainants seem to be unfamiliar with the most simple facts of biochemistry. 
"It was mentioned that those molecules which contain long chains of single carbon bonds are more stable than those containing numerous double bonded carbon groups. Students doing high-school chemistry will be able to tell you the fault in this statement.”
As I told you in my February 2013 newsletter this is a fact. Any well-informed student will also be able to tell you that, and if anyone still thinks that the authorities cannot be wrong, any textbook in biochemistry can tell you that they are. 
Several complainants argued that the viewers were misled because some of the interviewees “had businesses promoting nutrition based products, diets, books and supplements that constitute conflicts of interest”.
But as Dr. Demasi pointed out, everyone interviewed had a conflict of interest including Ass. Professor David Sullivan who is a member of several advisory panels within the pharmaceutical industry and he has also received research grants from several statin-producing drug companies. Furthermore Dr Robert Grenfell, another supporter of the cholesterol campaign who was interviewed in the program, is Director of the National Heart Foundation, which has received millions of dollars from pharmaceutical companies for research, scholarships and fellowships.
“The pharmaceutical industry was accused of ‘criminal’ conduct akin to ‘organised crime’. Medicines Australia strongly rejects such accusation and feels that it is unfair (sic) characterisation of Australia’s medicines industry.”
Haven´t they read Peter G√łtzsche´s book Deadly Medicines and Organized Crime? Or the recent article in The Independent? Have they forgotten the VIOXX scandal? Have they forgotten the criminal behavior of Pfizer
Most pages were about the questioning of the benefit of statin treatment. As one of the complainants wrote: It is a fact that appropriate cholesterol interventions are very powerful in preventing cardiovascular disease. And in a letter to Dr. Demasi the National Heart Foundation wrote: The mass of evidence suggests that…statins reduce the risk of death or cardiovascular events in populations without a history of CVD, irrespective of age and gender and across a wide range of cholesterol levels.
If you think this is a fair statement, read my newsletters from May 2013August 2013September 2013 and November 2013 The simple fact is that no statin trial has been able to prolong the life for women or for people without coronary heart disease. Therefore, if you are a doctor and you have a heart-healthy patient who want to lower jhis/her cholesterol, tell the patient the following: “Your chance not to get a non-fatal heart event during the next five years according to Cochrane is about 97 per cent. You can increase your chance to 98 per cent if you take a statin every day. But then your risk of suffering muscle problem is at least 20 per cent unless you never exercise; your risk of becoming sexually impotent is about 20 per cent; your risk of suffering from diabetes is about 4 per cent, and you also run a risk of memory loss, liver damage, peripheral neuropathy, cataract, and even cancer, but we do not yet know how large these risks are. And don´t forget than many non-fatal events may heal with little future discomfort or none at all.”
Now to the reason why the program was removed.

One of the rules in ABC´s Code of Practice is the following: Do not unduly favour one perspective over another. But how could Dr. Demasi be able to do otherwise???  I mean, if the members of A&CA acknowledge that all the critical remarks from the opponents of the cholesterol campaign were true, and If the proponents are unable to present any relevant counter-arguments, how could A&CA state, as they did, that some parts of the program breached ABC standards on impartiality?

A&CA suggested that Catalyst should add extra information to the website to provide more balance. They did not recommend to strip the stories off the website. This decision was made by ABC management. The question is why? Some speculate that it was political pressure from the drug industry or the Heart Foundation or it was an action to avoid more controversy.Fortunately both programs are still available on Youtube. Here is part one, and here is part two.
Uffe Ravnskov, MD, PhD, independent investigator
Spokesman of THINCS, The International Network of Cholesterol Skeptics
Magle Stora Kyrkogata 9, 22350 Lund, Sweden

Assem Malhotra's response to the BMJ statins censorship is here:

And Zoe Harcombe's analysis of both matters is here