Welcome all seeking refuge from low carb dogma!

“To kill an error is as good a service as, and sometimes even better than, the establishing of a new truth or fact”
~ Charles Darwin (it's evolutionary baybeee!)

Wednesday, October 24, 2012

Looking AHEAD to a day when Intent to Treat is a thing of the past ...

... it's not a competition, the compliant/successful are analyzed separately, and while we're at it, perhaps we can do away with this notion that any single outcome or cluster of outcomes is somehow more important because we've designated them as "primary" ahead of time.

Such is where I find my thoughts wandering as the Look AHEAD diabetes trial passes in and out of my head as I absorb the discussions of it here and about the web.  

{This rambles, sorry!}

I understand the scientific basis behind intent to treat (ITT), I just think it mostly destroys the meaningful/actionable information us "consumers" (including doctors wishing to provide the best advice possible based on such information) might hope to get from many of these studies.   I think back on my questions when in 2009 I had plateaued out and was eating pretty low carb (induction levels)  most of the time with the occasional "cheat" (which was never a binge).  I wanted to know what the long term healthfulness of such a diet was in maintenance, which in my case involved substantial losses but still remaining excess weight.  I have never found the answer in the science because such a trial does not exist.  Which is why the next best thing is to look at those who have been eating such a diet for long periods and at least attempt to gauge from their results, and ... well ... you know what I think there by now.  But back to ITT and related issues, and let's start with one of those first.

These diet trials always seem to be stacked up as competitions between various means to get to an end.     With the possible exception that such contests might sway both dieters and those doling out diet advice towards trying more effective approaches, the contests are pretty meaningless in the larger picture.   Despite boasts that LC diets are easier to stick to for longer periods, the various studies are wholly inconclusive on these points.  In the end, it matters to me that *I* can stick to a certain diet or lifestyle or whatever euphemism you want to use, and not how many out of 30 subjects in some randomized study were able to stick to their's.  BUT, and here's the biggie, I'm VERY interested in how the 25 subjects who did stick to Diet XYZ fared.  I might not see the same results, but if 25 people stuck to XYZ, lost weight and had improvements in various metabolic markers, and those persisted for years in those who maintained the weight loss, that's what I want to know.  And if those who adhered to the more controversial LMNOP diet lost weight but had worsening metabolic profiles after several years despite maintaining their weight losses, that is important to me too.  In the end, most of these studies belong more in the behavioral journals than the nutrition/biochem/physiology ones.

I get very tired of the Destruct ELMM Street movement out there who seem to think if they repeat it enough it will magically become true ... ahem that pool noodle wielding hustler Gatewing ... that caloie accounting methods are failed approaches to weight loss and the answer lies in the his IONOsphere.

This is simply not true.  Imagine if you will, a "perfect" blood pressure lowering medication is developed.  It is inexpensive and has no known side effects, but you had to take it religiously every 8 hours.  You conduct a trial on this drug vs. placebo, but after the first month, only 10% of the study group has gotten into the groove of taking their pill on time, and 40% have dropped out because their compliance was too poor to maintain sufficient BP control to satisfy the ethics board.  What you're left with are data dominated by 50% of the original group that is complying only well enough to stay in the study that swamps out the performance of this drug in the 10%.  Personally, if I needed BP meds, something like this would not be my option, but I've known enough people taking these who don't like the side effects that might just be motivated enough to set an alarm for every 8 hours, pop their pill and then go about their merry way.  This med works beautifully for them and their blood pressure is flawlessly controlled.  This is the same thing with ELMM -- because deliberate efforts to alter ones diet and/or activity level require work in many cases.  This is why some people do well on Jenny-style plans and the low carb community seems dominated by those (me included) who have difficulty with the sort of structure required for long term implementation of a standard CRD.  To say that ELMM doesn't work because not everyone can stick to it long enough to see results or because long term adherence and permanent habit changes required for maintenance are difficult is just wrong-headed.

Now it is fair to say that ELMM may be bad advice to give to the masses because it is so difficult to implement, just as it would be fair to say that my wonder BP drug might not be highly recommended for the same reason.  But the efficacy of the treatment remains valid.

I realize nothing I write here will ever change a darned thing about how studies are analyzed, but a girl can dream.  And this goes as much for the various medications I may one day have to weigh the risk/benefits of.  For those actually taking some medication as prescribed, what are the outcomes?  Yes, I am concerned about the incidence of side effects, especially ones so severe as to force discontinuation of the med.  But at that point that data point is useless, unless you really think it's worthwhile studying the effects of writing a prescription for a medication and syndrome management, and nothing else in between.  This, sadly, seems to all-to-often be how clinical data is treated.   And this is exactly what's concluded when ITT analyses muddy the waters.  You'll have 30 who start out in a year long study, perhaps 28 of whom "complete the study".  At 93% that's a rather impressive retention rate.  But all that means is that they showed up for and completed all meetings and assessments.  If I'm assigned to the XYZ Diet, I can follow it for a week and so long as I show up for everything, my data gets put in the ITT mix just like the person who takes to XYZ like a duck to water and follows it to the letter for the entire year.  My results are ultimately meaningless as to the efficacy/safety/healthfulness of XYZ except for the fact that I'd be a data point against the practicality of such a plan based on ease of compliance.  To make matters worse, if I'd dropped out at 6 months, my 6 month data would often be carried forward to the end of the study and included in all subsequent time points in ITT.  

Rarely is the compliance bar for "adherence" set very high.  When one looks at the dietary intake data from Shai, for example, we are to believe that in the second six months of year one, the low carbers ate the same or even a little less and gained back some lost weight.  In the Ebbeling study where all food was provided, daily diaries were apparently kept, but we're not made privy to any accounting of some sort of percent (by number of participants) or degree of compliance.  Often compliance is so poor as to render the study results rather moot.  Such was the case in a diabetes study I blogged on back in May (here) pitting LF v. LC.  The table at right shows the targets in blue and the actual intakes.  Whatever the results there, that study did not end up comparing the diets it purported to be testing because very few actually followed the assigned diet.  They did do a separate analysis here for those who complied best, but this was still lacking (see my original post for a more detailed discussion on that).  

It may well not be practical to present, or the numbers so small as to be inconsequential, but I always want to know about the fate of the subjects assigned to XYZ who complied and completed.  Then it's sort of up to me to decide if XYZ is a protocol I could comply with for any length of time or if I want to chance the negative outcomes the dutiful XYZers encountered along with their impressive results in other areas.  But when all I can see is that 30 XYZers lost an average of 5 lbs in a year -- a number hopelessly influenced by dropouts carried forward and those who didn't eat the XYZ diet after all -- there seems to be little value in the outcomes.  I, personally, cannot consider long term VLC diets anything but "do at your own risk" until I see some hard data -- including organ fat scans -- on people actually eating that way in maintenance for several years ... and don't give me the Inuit!

And so here we are again, for the third time in as many days, back to the Look AHEAD diabetes trial. Here we have all the "bad things" listed in the title and opening sentence of this post in one tidy decade long package of a study.  The study purpose was quite narrowly defined -- it was to pit usual diabetes education against "intense" lifestyle (diet and exercise) intervention to see if it reduced the CVD-related outcomes.   It's not all that far from testing whether giving advice improves CVD risk!  Further, the CVD outcomes were severe "events" -- heart attacks, strokes and/or CVD related death.  To put this in perspective, my father-in-law is in his 80's and has had heart disease since I've known him for 20 years now.  I'm not quite sure how long he's been on at least one BP lowering med, but likely at least a decade more than I've known him.  He's had a couple of angioplasties, triple bypass, has some new/returning blockages currently and had a pacemaker put in a couple three years back.  Yet he's never had a heart attack or a stroke and he's still around now 20 years after he enrolled in my study (e.g. came with the hubby package).  He's not a diabetic, but his doctors have always been on him for his weight, which has increased 10% or so as well.  As Stephan Guyenet mentioned in comments here, this study was halted because they weren't seeing enough "events" to distinguish between the two groups.  Which is good news for those considering signing up for such trials -- it probably doesn't hurt to have some degree of accountability/attention/etc. on a regular basis.   

The "dud" here is that they defined the parameters so narrowly -- pitting A v. B and measuring outcome X and looking for differences between groups.  Classic ITT with single minded focus on the primary outcome.   It's set up as a contest -- intensive lifestyle intervention vs. status quo advice -- which is better?   Since Phase I defined goals for the intervention, the ITT analysis of all patients assigned to this group just muddies the water.  At the very least you have two major confounders here:

  • Both groups used various pharmaceutical interventions 
  • Some members of both groups both lost or gained weight in amounts in line with the weight goals of Phase I of the ILI 
This in the context of there appearing to be very little in the way of documenting/reporting compliance in any meaningful way.   

Some have pointed out in comments that perhaps this is just one more depressing study on how difficult it is to lose and maintain significant amounts of weight.  There are some other more encouraging outcomes here.  First, thanks to Stephan's comments, we learn from Dr. Sharma that the reason the study was halted in terms of the intervention was because:  
"... given a remarkably low incidence of ‘hard’ endpoints in both the interventions and control groups, it became evident the the study would stand little chance of demonstrating superiority of the lifestyle intervention in terms of preventing cardiovascular complications." 
Perhaps they needed to enroll sicker patients to begin with, but as my own n=1 example of my father-in-law demonstrates, standard medical care has done a good job of preventing "hard" endpoints, if not preventing all progression of his heart disease.  But the guy is in his 80's, fully in control of his faculties, mobile and self-sufficient.  Perhaps what this study shows is that some of the newer medications out there, and/or better diagnostics for self-monitoring of blood glucose, insulin pumps, various insulin formulations, etc.etc. are improving the quality of life for diabetics.  I know there are the self righteous out there who consider the bulk of those "burdening" the rest of us with their medical costs as just that -- burdens.  I know there are the conspiratorial out there as well, who think the government, medical establishments, pharma and food manufacturers have proactively acted to make lifestyle intervention next-to-impossible while hooking us on expensive medications.    The irony here is that folks heralding this study as the death of ELMM lifestyle intervention, and even speculating that somehow the researchers are hiding a bodycount of ELLMers who died of other causes from the harm of the intervention, are falling right into the trap set by the conspiracy if there is such a thing.  

I absolutely do not get why the low carb and paleo communities are SO antagonistic towards other ways of eating.  Period.  I will never forget the time, early on at Jimmy's forum, when I wondered out loud if I should try a WW or NS style approach to lose more weight since LC had stopped working for me.  Oh my the nastiness!!  "Good luck with that!"  and basically "don't come crying back to us when you gain all your weight back".  Paleo is literally littered with former vegans and vegetarians who look down their noses at practitioners of that lifestyle -- or gawd forbid someone goes back to eating that way (Don & Tracy).  Honestly, don't admit you ever eat grains, you are an inferior being for not "duh" seeing the light that Wheat Belly hath shone on the evil that is the seed of a grass.  If you want a really good lashing for eating anything grain, dairy or legume, have a gander at   Replace your peanut butter with, I'm not making this up, coconut oil spread on raw veggies, and eschew hummus because garbanzos aren't paleo.   I probably don't need to even bring up the bashing that goes on of folks like Melissa M. and Go Kaleo which begins with the fact that neither follows the Primal Directive (TM).  

But the exact nature of the intervention aside, what I would like to know were I diabetic is whether or not weight loss is something necessarily health improving.   What I hear in the medical world is that "losing as little as 5% of one's body weight can reduce the risks".  This comes from studies on recently diagnosed diabetics and/or studies on pre-diabetics and/or groups at risk (family history) who may or may not have early signs of diabetic progression such as IR, IGT, etc.  But forestalled progression or reversal of recently detected diabetes is different than reversing longstanding disease.

I do not think there is much of any doubt that for a large proportion of those predisposed to diabetes, it is obesity that ultimately "causes" the disease to manifest.   If we can swallow the argument that the human genome hasn't changed in the 10K or so years of the Neolithic, surely we can agree that the human genome hasn't changed much in the past half century.  Classic T2 has tracked right along with obesity, and as obesity hits younger populations, we see the disease develop earlier in life.  It is not even in question that Americans eat more.  But what do you tell the 55 year old who is 50 lbs overweight 5 years into his/her diabetes diagnosis?   I think this WAS the goal of Look AHEAD.   

So I hope they'll look at the data another way because I believe there may yet be some valuable information in there.  It may not be one intervention vs. another and whether or not you'll drop dead of a heart attack, but how about this.  Lump it all together and break it out into quartiles or quintiles of weight loss percents.  Who cares how they got there, let's look and see if just the weight changes things.  If losing 10% by whatever means (and keeping it off) makes a difference, that might be a motivating factor.  I realize that if the result is still "no difference",  the tendency may be to dissuade diabetics from making lifestyle changes in favor of pharmaceutical interventions.  Here is where that judgment comes in.  Be honest, most reading this will think less of the person opting for pharmaceutical intervention.   How many times do we need to hear "if only they'd just eat a low carb diet" ... from people who have been doing so and become more and more insulin resistant and, in my opinion, unhealthy (by their own admissions of maladies).  

Personally, the rapid reversals of diabetes in the early days following GBP and that crash diet study will always occupy a box seat in my mind when thinking about these things.  This is not to say that everyone's diabetes can be reversed, or that everyone should consider GBP when all else fails or even before all else fails.  But it serves as a reminder that even the weakest beta cells amongst us are rather more resilient than we've been led to believe, and that diabetes need not be a progression.  Oddly enough, though I believe there are other health-damaging implications of doing this, more dramatic yo-yo dieting may be better than half-hearted modest attempts at losing weight.  Periodically draining the cellular swamp sufficiently so as to restore pancreatic function buys time even if weight is gained back -- provided the draining has been sufficient so as to restore proper sequestration of excesses where they belong -- the fat tissue.  

What's most demoralizing to me here is that in the interests of personal dietary agenda, many are too eager to throw very reasonable lifestyle changes out the window as useless, and worse yet, potentially harmful.  (Please, let's not encourage the Jonathan Bailors out there with claims that one can be doing more harm than good, and yes, even Paul Jaminet seems to be insinuating that if the exercise involved walking one's dog at a brisk pace in the evening this could even be harmful???!!!!).    I will note that most of those I'm seeing doing so generally have no clue what it is to be "simply" obese ...  And I will also note that those suggesting other dietary intervention is superior have NO data to back it up with, only rank speculation by many who still believe carbohydrate consumption causes diabetes.  


ProudDaddy said...

Another problem with these kinds of trials are the control group members who do the same things as the intervention group. I'm in the control group for the PLCO Cancer Screening Study. Periodically, I am asked if I have been diagnosed with cancer. What I am never asked is whether I have taken any of the screening tests that the intervention group is given. Since I take all the screening tests I can on my own volition, I'm really a member of the intervention group, but my results will be considered control.
Similarly, in the Look AHEAD trial, there must have been a lot of controls who took it upon themselves to lose weight and reduce caloric intake. Were they identified? If so, how would you score them? So far, this study has only shown what we all knew already - it is hard to lose weight and maintain it in the real world, and compliance outside of the metabolic ward gets lousier as the study term increases.
One other point: It may be almost as important to correlate weight gained or lost during the last year as that during the entire study period.

Paul Jaminet said...

Evelyn, I didn't say the exercise could be harmful, I said the exercise they recommended was so minimal as to be homeopathic/ineffective at improving health even if it was followed ... but at least it couldn't do any harm.

I do think an "eat less" prescription is potentially dangerous if the diet quality is poor.

Unknown said...

Re antagonism and vehemence, some people derive a feeling of self-worth through their lifestyle so when you question their dietary choices to them it is an attack on their self-worth.

Vegan, Primal, Paleo etc. become lifestyles, give people a feeling of inclusiveness, just look at the comments posted at MDA. People get the dopamine flowing not on account of what they are eating but on the feeling of virtue they derive from what they are eating.

When someone comes along and raises issues like factual accuracy it's a major buzz kill.

George Henderson said...

Evelyn, I think you and Dr Feinman are in concordance on the ITT issue.
If anything, AHEAD falsified the usefulness of giving the ELMM advice, not necessarily ELMM itself.
We may find that those who followed the advice most scrupulously did in fact prove the hypothesis, even if the alternative hypothesis, that giving the advice was beneficial in and of itself, was disproved.

Evelyn aka CarbSane said...

Hi Paul,

I read your post before I read some of the additional info on the study linked to in comments on my first post. I gotta say, I found myself scrolling up to double check that the blog I was reading was indeed yours because the overall impression I got from the post was that you thought the intervention arm likely backfired and not only did it not help, it may have actually harmed. How did I get that impression?

Well, for starters, under the subtitle Was “Eat Less Move More” Harmful? you wrote:

A few Paleo bloggers are not surprised; indeed, Peter Dobromylskyj speculates that all-cause mortality – which Ms. Kolata and the NIH press release do not report – may have been higher in the “eat less, move more” intervention group: {quote Peter} It seems very likely to me that more people died in the intervention group than in the usual care group, but p was > 0.05. Call me a cynic, but I think they stopped the trial because they could see where that p number was heading. {end quote Peter}. Peter may be a cynic but cynics are sometimes right, and I will bet that he’s right about this. In general, calorie restriction and exercise are better attested against cardiovascular disease than against other health conditions, so if death rates from CVD were identical in the two arms after 11 years, it’s quite likely death rates from other causes were higher in the intervention arm.

I'm not sure how else to interpret that CVD deaths being equal you consider it *quite likely* that deaths by other causes were higher in the ELMM group, in any other way but to conclude you think ELMM was harmful. I'm not getting the clarification on your blog comments (My thinking was that ELMM should be more beneficial against CVD than other leading causes of death (notably cancer), so if there was no reduction in death or other hard endpoints for CVD, then there would likely have been an increase for the others.)

You did say that of the exercise may be insufficient, but then in the same paragraph you say:

There is another reason the exercise may have produced no observable benefit. Since I believe the health benefits of exercise occur primarily through circadian rhythm entrainment, it’s likely that daytime exercise is much more beneficial than night-time exercise. Night-time exercise might be ineffective or even harmful to health if it disrupts circadian rhythms.

Unfortunately many people find it difficult to find time during the day for exercise. If the walking was performed at night, even the modest benefits of the activity may have been lost.

Again, take-away message there would be exercising in the evening may be more harmful than sitting on your behind. Then you stand behind the contention that less of a bad diet can be worse, through the mechanism of deficiencies presumably, which I can relate to but disagree with.

Evelyn aka CarbSane said...

I think you and Dr Feinman are in concordance on the ITT issue.

I think many of us an all sides of the polygon are in agreement on this, which begs the question why it is still done. There's no law written in any submission guidelines that state ITT is even preferred. There's a huge difference between an improper omission of data and a reasoned analysis of subsets of data.

On the falsifying, the way I see it this is the insidiousness of binary Popperism in the scientific method. Things are never so cut and dried as a pair of competing hypotheses being tested where the results would support one or the other.

Pardon my bluntness, but if the researchers' true hypothesis was that giving advice should be beneficial, they are idiots! Frankly if that were true, nobody would take BP lowering meds. These work well in controlled clinical trials, but not so much in "free living" populations where some don't like how they make them feel, don't have the money to fill their scripts, forget to take their pills, decide to take different doses on their own initiative, etc. I tend to think most advice wouldn't hold up to such hypothesis tests as in this study.

George Henderson said...

Popperism; I wonder how a philosopher (who was never an experimental scientist in the short bio I read) ever came to dominate science to this extent.
Probably by providing a useful soundbite to the winning team in some old controversy.
In the year 2112 scientific questions will be settled by inductive logic. There are fashions in these things, no method is flawlessly guaranteed to reveal the truth.
The best scientific method in nutrition will be the one that stops producing anserine statements such as "we should all eat more/less of X" where X is not a toxic contaminant of the food supply.

Evelyn aka CarbSane said...

I think it's telling that it is usually MD's and not scientists who tend to fall pray to Popperism. Not sure if that's entirely relevant here except that adherence to initial hypotheses could preclude gleaning other valuable information from this study/data.

However if they were looking at advice -> outcomes, they could have stopped this after Phase I or whittled the cohort down to those who achieved the 7-10% goal. That they didn't really is mind frustrating to mind boggling proportions. By the end of 4 years it only got worse.

screennamerequired said...

There's also the annoying habit of paleo/primal/vegans basically implying that the only options out there are their diet choice or the S.A.D. (Btw, what exactly IS the Standard american diet? low fat sandwiches and fruit or high fat junk food takewaway foods?)

To vegans, some of them imply that the only options are veganism, SAD or Paleo/high meat/fat/lowcarb.

To paleo's, there's only people brainwashed by conventional wisdom into eating poison grains and low fat products or clueless misled vegans.

As a mostly vegetarian who eats muesli and yogurt I must be some kind of anomaly.

Harry said...

Hi Evelyn,

I really liked your analogy with respect to the BP medication that works flawlessly for those that self-administer it appropriately (while also being a pain in the butt to self-administer appropriately, therefore leading to low compliance).

So many useful things in life conform to this same phenomenon (i.e. they incontrovertibly 'work as advertised' but people nevertheless struggle to keep them up); examples include resistance exercises to improve body composition, financial discipline/budgeting to improve balance sheets, meditation/mindfulness to improve happiness, higher education to improve one's prospects etc.

It would be rightly seen as absurd to dismiss the efficacy of any of these measures simply because it is easier to fall off the wagon than to comply, but it seems that, insofar as taking deliberate measures to eat less and move more, this is precisely what people want to do.

Imagine a world where people dismissed the efficacy of higher education in the field of physics, on the basis that it was 'hard' for most people...or that sticking to a budget is a poor financial measure because most people prefer to live beyond their means!

Eating less and moving more is the only non-surgical/non-pharmaceutical way to achieve weight management. The fact that it is hard to achieve in today's society does not speak to its illegitimacy as a solution, but rather, speaks to the wickedness of the problem we are trying to solve.

And, the romantic in me hastens to add, for many of the truly worthwhile challenges in life, ever has it been thus, and ever shall it be thus.


OnePointFive said...

Apparently they realised that there were potential problems at year 2. At that point the expected event rate in the control arm was much lower than the the 3.125% expected. They were allowed to extend the trial from 10.5 years and modify the end points.

Evelyn aka CarbSane said...

Well, if the study researchers aren't allowed to do other analyses with the data, I sure as heck hope the raw data gets made public so our tax dollars don't go totally to waste.

Evelyn aka CarbSane said...

Yep snr, I encountered that in LC as well -- it's as if you have to eat VLC or you might as well be eating bread morning noon and night.

Speaking of vegans (and vegetarians) -- I don't find that those that I know struggle to maintain that lifestyle. They don't complain of cravings and difficulties. I could never do it, but those that do don't seem to have a problem.

@Unknown, I think that community thing keeps many people sticking with things that are failing them far longer than necessary. Forget the folks who've tied their livelihoods to a dietary lifestyle, you have lots of "regular folks" who forge friendships and identify with a lifestyle. I still check in from time to time at Jimmy's to see what old friends are up to and miss support etc. In a way I'm not sure why Atkins never branched out into a Jenny style program, or why nobody's filled that vacuum in the diet world. Or perhaps that they didn't (even back during the resurgence in the early 2000's) speaks to the fact that LC was even at its height, a niche/fad diet. With it's wide reach, the internet is perfect to fill the void. But then what if you decide on a different path? I imagine it can get quite lonely out there, and for whatever reason -- perhaps because many can find the support in real life -- there's rather more a shortage of blogs and such by those following less radical approaches.

Unknown said...

@screenname: It's the same deal with exercise, they treat it like the choice is between (a) doing nothing; and (b) running marathons.

You can't go out for a three mile jog, it's marathons or nothing.

screennamerequired said...

@ Everyln. Threads on paleo/low carb forums get made everyday about their "cheating" or "falling of the wagon, you're right you defintely don't see that from vegetarians/vegans near as much which pretty much shows despite what some people think it's even more sustainable than low carb. I suspect the ultra strict vegans would have more trouble then they let on if they're the type who double checks every ingredient list for trace amounts of eggs/dairy/gelatine.

@ Unknown. Oh yes, the "right" and "wrong" exercises. I've been told how swimming laps and cycling is "pointless". WTF? I swim because I like the refreshing feeling I get when I get out and shower not, because I'm trying to sculpt some perfect body or reenact the movements of what Grok may or may not have done. Sprints and weight lifting does absolutely nothing for me personally

Don't even get me started on "chronic cardio". I thought that term was reserved for elite full time marathon runners who live as full time athletes. Now you have people referring to a 20 minute run on the treadmill as CHRONIC CARDIO.

Evelyn aka CarbSane said...

Yeah, don't get me started on the chronic cardio either. I understand that if you look closely at what the gurus actually say they aren't bashing things like this "intense" exercise intervention, but at some point it doesn't really matter the meme is out there. I can't remember who it was who once wrote an article about 5 min of intense activity being as good as a few hours. Pretty sure it was a he then said he did this and no other exercise besides cycling or walking to work daily. Hmmmm.

Back when I read at PH more, there were spates of daily questions about cheating and such. Here's where primal ala Sisson is contradictory. He writes definitive guides on whether X Y or Z is primal but what does it matter? If you're not intolerant, then dairy is OK to consider "on plan", and then there's still that 20% fudge factor. IF one believes the claims, then how can there be even 5% wiggle room?

Unknown said...

The sprinting thing chaps my ass cause if you can't run 2 miles at a slow jog what the hell are you doing sprinting?

Before I started doing speed work after losing a large amount of weight I spent 2 years jogging to get my joints and leg muscles stronger, you have to crawl before you can walk.

paleotwopointoh said...

Eh, I've seen plenty of veg*ns on forums for their diet types complain of struggles to stay on the diet/lifestyle. Selection bias may play into not seeing it if someone hasn't. Plus, many vegans in particular "cheat", particularly those raising children (turns out raising a kid vegan is, well, medically questionable.) Usually it's adding in eggs or whey, but can sometimes include other dairy or seafood or even chicken.

Vegans in particular are under a huge amount of pressure within those communities (there is of course splintering there too) to not admit that there might be difficulties maintaining because veganism has such a strong moralist/ethical component for many of its adherents rather than being adopted primarily for health reasons. It dwarfs similar pressure for other diet types and is pretty well known to be an issue within that diet category.

I would take some of the anti-LC stuff more seriously if it didn't tend all too often to come right back to HCLF. It gets pretty tiresome to be told not eating 80%+ carbs, particularly as rice and grains, is unhealthy or a sign that you secretly have some medical problem.

Sanjeev said...

> not admit that there might be difficulties maintaining because veganism has such a strong moralist/ethical component
Not to mention the the religious component, preferably pre-monotheism (animism, polytheism) or "post-paternalistic/monotheistic modern alternatives" like neo-paganism and gaia worship (removed from Lovelock's technical orientation), and so on)

and never forget the "dyed-in-the-movement's wool" pervasive/endemic woo component (vaccine-demonization, acupuncture, Aryuveda, TCM, homeopathy, enemas with various noxious fluids ... and on and on)

screennamerequired said...

"I would take some of the anti-LC stuff more seriously if it didn't tend all too often to come right back to HCLF. It gets pretty tiresome to be told not eating 80%+ carbs, particularly as rice and grains, is unhealthy or a sign that you secretly have some medical problem."

Not many people are advocating 80% carbs, that is the extreme end of the spectrum and it doesn't have to be one or the other.The USDA defines a low fat diet as 30% of calories which is actually quite fat sufficient, imo. On 2500 calories a day that leaves about 700 fat calories which is more than enough to use some olive oil and eat whole eggs and some nuts. I don't advocate low fat diet, or a high fat diet for that matter. I just find myself defending low-fat diets a lot of the time because they aren't nearly as bad or evil as people make them out to be. There's many days I probably fall into the 30% fat category comfortably without even trying. When you don't add fats and oils freely, or if you're grilling instead of frying and just eating whole foods it's almost impossible to get to ketogenic percentages.

Evelyn aka CarbSane said...

In response to the same statement snr is responding to above:

(1) It is sad, IMO, that this post came off as anti LC. If anything it is in support of CW, but even there not so much as to question analytical methods in all of this.

(2) As snr points out, not many are advocating 80% carb, just as not many LC'ers are advocating 80% fat. The latter might seem that way these days, but since I have Mark Sisson on the mind from today's post, go look at his sample menu

His totals for the day: ~2500 cals 55% fat = 157g. Now that is surely not low fat, but it's not all that high fat either. Added fats (e.g. not whole foods) = 1 oz cream, 1 pat (1tsp) butter for breakfast, 2T olive oil on his salad, 1T coconut oil with dinner veggies) are less than a third of total fat and hardly excessive. Personally I don't need that much oil on salad or -- especially-- veg, but it's hardly over the top.

paleotwopointoh said...

It may be a chick thing, I don't exactly eat zero carb daily and yet have repeatedly been told by women that my children are doooomed and I must have a broken metabolism/etc. because I didn't eat 80%+ carbs (and less often <10% protein) during my pregnancies and while breastfeeding and don't eat bread or rice often.

Before I started being pregnant/breastfeeding all the time, I was pretty vlc much of the time but didn't run from potatoes and raw dairy and heard from dudes that i was totes unhealthy and not even properly paleo maaaan because i basically felt tubers and raw dairy were perfectly ancestrally valid foodstuffs and would, you know, eat them from time to time.

i got interested in paleo/primal because it offered explanations for why trying to eat, well, 80%+ bread/rice/beans was not working as a path to healthy eating for me and for why eating meat and fruit and vegetables was actually totally ok and not a path to death at 42 from clogged arteries or whathaveyou. so watching paleo (even if only a piece of it) shift into vegan-friendly high carb, low protein, low fat land is pretty disappointing, more so than the male-focused all-meat vlc thing because that has no mainstream support unlike the other.

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