Paleo™ ~ Still a Fad Diet in 2014, and Destined for More of the Same

Whoa boy! Did you hear? US News & World Report listed the Paleo Diet dead last in their "Best Diets of 2014" round up ... AGAIN! I warn you, dear readers, that I'm in a mood, and my snark and sarc levels are quite high as I write this.

Now, I give exactly ZERO credence to these sorts of lists, but I find it pretty darned hilarious that even the vegans and Atkins bested Paleo.  Heck, Dukan!  But there it is ... the nemesis of paleobros and brahs everywhere (especially those who've ever done a WOD) ...da da.h DAAAH ... (cue movie announcer) The ZONE.

Nothing makes the loin clothes bind and chafe more than Zone besting Paleo, even if it's some bunch of loser know-nothing "experts" making the proclamation.   There's nothing like getting dissed, yet again, in the mainstream press to bring out an official Loren Cordain rebuttal followed by a blog post from his petulant "former student", and thus far, 2014 has not disappointed.  First up Cordain goes through a statistical counting rule exercise of all the experiments one would have to do to test each diet head-to-head with each other diet.  I guess he didn't have much to add from the previous rebuttal, so why didn't he just recycle that one?

Whenever something like this comes out, there are generally three kneejerk responses from the paleo community:

• They misrepresented the paleo diet
• They ignored all the studies showing that it works
• Their nutritional science is bad

That middle bullet point usually decried after complaining how they ignore all the thousands of anecdotal testimonials, making both the first and third complaints wildly hypocritical.

First things first, here's the USNWR page specific to the Paleo Diet.  It seems that they are working off of the following macro proportions:  Protein = 38%, Carb = 23%, Fat = 39% though I'm not sure which paleo diet these come from.  Certainly not the Eaton & Konner consensus "smoothie".   So perhaps one of the various paleo clinical trials, that the evaluators did look at.  Here we get a total fat consensus of sorts that is sort of inline with USNWR's 39%, but only one eeks out over the recommended 10% saturated fat.  But protein is consistently lower and carbohydrate is pretty consistently higher.  

is THIS your paleo diet?

We are, once again, back to square one trying to get some sort of definition of the paleo diet.  WHAT IS IT?????   It is hilarious that WAPF's Sally Fallon Morell complains that the paleo diet is too low in fat -- to which the various and sundry paleos protest -- but then when the mainstream complains it is too high in fat ... noooooooooooooooooooooo!  It is not!   

Ahhhh!  Now I see where USNWR gets their ratios!  From The Paleo Diet author himself, as highlighted on page 218 of Robb Wolf's book.  Let me repeat.  This is THE sample diet in The Paleo Solution:  The Original Human Diet   by Robb Wolf, 2010,  that he copied with attribution from the author of trademarked *The* capital-P paleo diet.  

Alrighty then!  So it seems that USNWR basically did a C&P from their eval of the paleo diet from at least two and a half years ago.  The one Cordain rebutted.

It is obvious that whoever wrote this piece did not do their homework and has not read the peer review scientific papers which have examined contemporary diets based upon the Paleolithic food groups which shaped the genomes of our ancestors. Accordingly the conclusions are erroneous and misleading. I feel strongly that it is necessary to point out these errors and make this information known to a much wider audience than those reached by the readers of the U.S. News and World Report.

He lists the studies: 

1. Frassetto LA, Schloetter M, Mietus-Synder M, Morris RC, Jr., Sebastian A: Metabolic and physiologic improvements from consuming a paleolithic, hunter-gatherer type diet. Eur J Clin Nutr 2009.
2. Jönsson T, Granfeldt Y, Ahrén B, Branell UC, Pålsson G, Hansson A, Söderström M, Lindeberg S. Beneficial effects of a Paleolithic diet on cardiovascular risk factors in type 2 diabetes: a randomized cross-over pilot study. Cardiovasc Diabetol. 2009;8:35
3. Jonsson T, Granfeldt Y, Erlanson-Albertsson C, Ahren B, Lindeberg S. A Paleolithic diet is more satiating per calorie than a Mediterranean-like diet in individuals with ischemic heart disease. Nutr Metab (Lond). 2010 Nov 30;7(1):85
4. Jonsson T, Ahren B, Pacini G, Sundler F, Wierup N, Steen S, Sjoberg T, Ugander M, Frostegard J, Goransson Lindeberg S: A Paleolithic diet confers higher insulin sensitivity, lower C-reactive protein and lower blood pressure than a cereal-based diet in domestic pigs. Nutr Metab (Lond) 2006, 3:39.
5. Lindeberg S, Jonsson T, Granfeldt Y, Borgstrand E, Soffman J, Sjostrom K, Ahren B: A Palaeolithic diet improves glucose tolerance more than a Mediterranean-like diet in individuals with ischaemic heart disease. Diabetologia 2007, 50(9):1795-1807.
6. O’Dea K: Marked improvement in carbohydrate and lipid metabolism in diabetic Australian aborigines after temporary reversion to traditional lifestyle. Diabetes 1984, 33(6):596-603.
7. Osterdahl M, Kocturk T, Koochek A, Wandell PE: Effects of a short-term intervention with a paleolithic diet in healthy volunteers. Eur J Clin Nutr 2008, 62(5):682-685. 

Let's match those up to my table other than the obvious Frassetto and Osterdahl. Lindeberg is #5, but also #3 which was simply a different write-up from the same trial comparing paleo to a Mediterranean diet in ischemic diabetics. Thus, Jonsson is #2. Ryberg is missing from Cordain's 2011 list because it was a 2013 publication. I've addressed these: Frassetto, Lindeberg & Jonsson, Ryberg, Osterdahl

You'll note that #4 is missing from my list.  This is because, last I checked, pig trials don't qualify as human trials.  Also #6 is not on my list.  This is because this wasn't a clinical trial.   It was more of a documented field trip to see what occurs if you take some unhealthy urban Aboriginals and have them hunt and gather for food for several weeks.  Interesting for sure, and blogged on  here  but paleo is not about hunting and gathering, and no, fighting for the last jar of coconut butter at the specialty store doesn't count.

You can go read Cordain's full rebuttal, but he basically takes issue with USNWR using terms like "unknown" and referring to studies as "tiny" and pointing out that the studies are short.   Ummm ... they are!  And yes, the long term benefits are indeed unknown despite the claims being made.

Now, this is not to say that all or even most of the other diets have been studied in any greater detail, but the sum total of paleo to date 2011 was 5 human trials ranging from 9 to 15 subjects testing the paleo diet, for durations as short as 10 days and up to 3 months.  Further, only two of those were controlled, but neither controlled for caloric intake.  But paleo doesn't count calories you say?  Well that's all fine and dandy, but in those controlled trials, which just so happened to be the two, and only two, that lasted 3 months the control groups ate about 300 and 450 calories more than the paleos.  To say *it works* and it can cure a zillion disorders and diseases and has no drawbacks, even if what the *IT* is could be defined and standardized, is truly dishonest.  When you can't even settle on what *IT* is, even among the "pure paleo" diets implemented in this handful of studies, you're in deep trouble in terms of scientific grounds.  I'll return to this in a bit, because now let's look at the Paleo Baby Jesus weighing in with his particular brand of outrage over this repeat diss.

New Year, New News Same Old Shit

So, my twitter and FB feeds have been more backed up than an Elvis impersonator on a two week heroin binge. The topic? US News and World Reports 2014 “Best Diets” ranking, which places the crusty old Paleo Diet a dead, fossilized…corpralite-esque…LAST. Now, the PD was not just last, it was behind such hard scientific contenders as the Slim Fast and Medifast diets! (Those are diets built around shakes folks…)

inspiration 

Well, he did mention shakes ...  

He also writes:  "The aforementioned rebuttals are quite technical and detailed, I’m not going to rehash that material, " ... Has Robb ever really "hashed" those studies?  I mean really looked at them?  It would appear not, because had he, he would not be so wont to cite them left and right ... well not if he was intellectually honest about the diet he promotes anyway.  He goes on to cite Dr. Mat Lalonde's nutrient density work complete with video from AHS12, he didn't analyze the nutrient content of ANY of the paleo diets, and (~19 min) come to find human breast milk scores very low ... uh oh!    The sample diet is in your book Robb, have you ever put it in a program?  Skull sweat needed ...

Next up, Robb belittles people who think paleo is "too hard" by presuming it is a necessary step towards better health:

Some people make diet and lifestyle changes easily, others prefer to smoke through a trach-tube and scare little kids with their electronically synthesized voice vs changing behavior.

Yeah, as if there are only two ways to eat, mythical paleo or total crap.  You get much the same brand of condescending lovely in his book.  Ironically, he has developed a line of supplements to help people transition to paleo ... because as everyone knows, healthy diets are notorious for making you feel like total Robb before you feel better.  Put the Paleologix copy side by side sometime to the diet propaganda put out by its developers.  Sigh.

Ahh but Google Trends.  I'm sorry but has anyone seen anything about Zone in eons?  That paleo bests Zone is so Crossfit (and the competitive CFers don't do paleo).   I wasn't all that familiar with the paleo peeps a couple of years ago, but I followed LC goings on quite closely.  The "any day now this thing is going mainstream" came and went in low carb, and you keep hearing it in paleo circles.  Sorry, I couldn't help myself with the Smally meme, I keep getting this guy in my mind whenever these back patters go into rally the troops mode.  (Oh c'mon, it's harmless fun).

Off to Google Trends we go ... You can always click to enlarge.  I thought I'd add in a fad diet like Dukan to Zone and paleo just to see what happens.  On the left are the search terms, and we see that in January paleo has managed to spike up past Dukan's peak popularity.  However, when you put terms in, you are given choices, and while paleo has no such choices pop up to select "diet"or "topic", Zone and Dukan do.  It's just interesting is all, that's below right.  The red there is "Dukan Diet" as topic.  

One needs to look at some other things to put this massive popularity of the paleo diet in perspective.  Below left is what happens when you throw Atkins into the mix coming down the tail of it's popularity in 2004 it kinda puts the diet noise in perspective.  Just for fun I did a head to head for carbsane and ancestral health.  Not too shabby, and those peaks in the red ancestral health there are August.  That's some pretty cool stuff!  :-)

I even hold my own against Whole9, though I get squashed by Whole30 ... I'm going to be losing sleep over that ... LOL (actually the fact that I register at all is pretty cool ;-).).   Overall paleo seems to still be trending upwards, but given how Google doesn't distinguish between positive and negative headlines and stories, on balance, I'd say the paleo peeps are probably more than a little concerned in this regard.  But enough of the truly meaningless stuff unless you're in the marketing biz or trying to convince your cult that all's well in the world.  

So let's get back to Robb's delightful take on USNWR and the paleo diet. He writes:

3-There is no science supporting the Paleo Diet.

This one absolutely crushes me…is it too much to ask that folks go to PubMed and search for Paleo Diet? I guess I should look at this not as annoying, but as job security. Well, the rebuttals are a good resource for peer reviewed literature around this topic but here is a snippet from an email I received from Prof. Cordain:

There have been 8 RCT of The Paleo Diet. The endpoints including CV risk factors, satiety, weight loss indices show Paleo to be superior to diabetic diets, the Mediterranean Diet and to be more trace nutrient dense than the USDA food pyramid/now the Food Plate. References are as follows:

This is the same list as above, adding:

8. Ryberg M, Sandberg S, Mellberg C, Stegle O, Lindahl B, Larsson C, Hauksson J, Olsson T. A Palaeolithic-type diet causes strong tissue-specific effects on ectopic fat deposition in obese postmenopausal women. J Intern Med. 2013 Jul;274(1):67-76

I would think that Robb learned a thing or two about over-reaching with the paleo science schtick, or at least he might have learned, finally, what RCT stands for, and how there are more than two types of studies out there.  If one were to take Robb at his written word, one would think there are only two:  randomized controlled trial or observational study.  Cordain (and Wolf and all the rest of them) need to recognize the relative paucity of research on *any* paleo diet to begin with.  This isn't a list of 8 RCT's, it's not even a list of 8 clinical trials in human beings.  Here's the more appropriate list:

1. Lindeberg http://www.ncbi.nlm.nih.gov/pubmed/17583796
2. Frassetto http://www.ncbi.nlm.nih.gov/pubmed/19209185
3. Jonsson http://www.ncbi.nlm.nih.gov/pubmed/19604407
4. Ryberg http://www.ncbi.nlm.nih.gov/pubmed/23414424
5. Osterdahl http://www.ncbi.nlm.nih.gov/pubmed/17522610

This is a Twitter exchange between Robb and myself from almost a year ago.  

Is it just me, or has Robb been promising more and more studies for years now and we never seem to get them?  In his "don't poo poo the science" rant, Robb goes on:

So, we provide material like this to the detractors and get a response ” That’s not much research, we can draw NO conclusions from this.” Um, ok. So, we just keep doing what is not working? Another common dissent in this story is much of what we talk about in Paleo Land is anecdotal. Yes, most clinical findings, are observational. Most if damn near all scientific findings START observationally, cause someone to say something to the effect “hm…what the heck is going on here? I wonder if this is what’s happening?” Observation–>hypothesis–>testing–>accept/reject/refine. The Evidence Based Medicine crowd somehow forgets this process…but in an entirely selective and self serving way. When I finally get this cert done I have at least six LOOOONG posts I will do expanding on this. For now we have what has been done, and we have a number of things in the pipeline:

A healthy diet with and without cereal grains and dairy products in patients with type 2 diabetes: study protocol for a random-order cross-over pilot study – Alimentation and Diabetes in Lanzarote -ADILAN

Firstly, someone please explain to Robb that lack of control in an experiment still makes it an experiment, not an observational study.   Let's use cholesterol as an example.

1. Observational Study:  Measure levels at baseline, measure levels at 5 years, see if there is any correlation.  (e.g. do high or low levels withing normal range at baseline predict future levels outside of normal range?)
2. Uncontrolled Experiment:  Measure levels at baseline, prescribe a diet and exercise regime, measure levels at 5 years, see how they change.  This is an experiment because a "treatment" is applied.  However if levels change we cannot definitively attribute them to the treatment as there was no control.  "Further studies needed" after a pilot like this.
3. Randomized Controlled Trial:  Recruit subjects and measure baseline levels.  Randomly assign them to either (1) or (2) above, and measure levels at 5 years.  (1) serves as a control group for (2).  Now if the groups differ, the effect can likely be attributed to the treatment.

How is the EBM crowd somehow forgetting the scientific process?  How are they being self serving?  I can't wait for the half dozen or more LOOOOOOOOONG (too many O's) posts to come expanding on this!  But check out the single study in the pike Robb links to:

We intend to include 15 adult patients with a medical diagnosis of type 2 diabetes mellitus with or without medication and with an increased waist circumference (≥ 80 cm for women and ≥ 94 cm for men) in a random-order cross-over diet intervention study during two periods of four-weeks separated by a six-week washout period. Patients will be instructed to eat two healthy diets according to official dietary guidelines with respect to macro/micronutrient composition and fiber content, but differing in the type of food included, with one diet being without cereal grains and dairy products.

Ummm ... he's getting his papers mixed up, but how is this going to "plug some of the holes in Prof. Lindeberg’s original Paleo Diet in humans study"????  Both Lindeberg/Jonsson (#5/3) and Jonsson (#2) involved 12 week trials.  Lindeberg a head to head with two groups of 15 and 14 following paleo or Mediterranean diet for 3 months, Jonsson involving 13 subjects following each diet for 3 months in randomized cross-over fashion.  It may plug a few holes but it will open more if there are any results to be had.  They will fix calories so the subjects remain weight stable throughout.  I hope they plan on using true whole grain cereals ("real food").  But how is this really groundbreaking?  Do the paleos REALLY intend to take on the clinical data/literature of the Atkins diet and other lower carb approaches that incorporate dairy?  After all, that's what primal is .....

  

But, what, pray tell, are the other 8 large studies Robb hinted at last year?  We learn that Cordain is doing "a comprehensive study looking at the efficacy of the PD for various autoimmune conditions for which the preliminary data is very exciting.  But, it’s a retrospective survey! Bad Scientists! No RCT!!"   This is just childish really, because nobody that is serious feels this way about retrospective studies per se.  They have their pros and cons.  What *I* want to know, is where this data is coming from?  Has there even been a pilot study done on a single autoimmune disease?  Verifiable case studies even?  How can one do some sort of comprehensive retrospective study without this?  Sounds like at best we'll get a repeat of Tim Noakes SAMJ article??

What next, Reno law enforcement?  Are they doing much better than the NBA with this stuff?  We already know, thanks to Robb's own admissions, that the diet employed by Specialty Health is not a strict paleo one, or it wasn't and Robb was trying to steer it Lindeberg-ish, etc.  

Here is the bigger problem that the paleo community has with the science and the clinical trials:  They are not implementing the diets that the community as a whole follows.    It is intellectually dishonest for ANYONE to promote a high saturated fat diet based on the body of clinical evidence.  Period.  Further, the recommendations to limit fruit are in opposition to the trial diets entirely.  So you cannot have your almond flour paleo cake and eat it too here.  You can't say:

1. Lipid hypothesis is wrong thus low fat diets are wrong and limiting saturated fats are wrong
2. Look at these health bennies of our paleo diet that prove this 

When the paleo diet is, almost always lower in saturated fat and comparable or even lower sometimes in overall fat content vs. many "low fat" diets in clinical trials.  Remember this one?   That was a study comparing LFHC vs. LCHF diets for diabetes with the goals being LF = 30 and HF = 50%, but the LF dieters barely budged from baseline.  Paleo pretty much IS a low fat diet ... at least the majority of the ones implemented in clinical trials.   ALL clinical trials would meet USDA recs in practice (e.g. 11% in Ryberg is close enough!) 

Furthermore, in all but one trial, paleo has been a calorie reduced diet.  Perhaps unintentionally, but that's why people lose weight.  Those that lose weight rapidly on paleo have simply reduced intake rather significantly.  

And yet, Chris Kresser, who is Robb's business partner in paleo supplements for struggling very-low carbers, has written that fat is ideally between 40 and 70% of one's energy.   Lindeberg-style paleo?  Well that's just boring and unsustainable!  Catch Chris on Fox News and pass the chocolate over here .. thanks!!

The problem paleo has is multifactorial.

1. They can't form any sort of consensus on what the diet is
2. What consensus there is differs considerably from the diets used in the limited clinical trials
3. Lack of scientific basis
4. Lack of articulate advocacy for the diet
5. Snobbery against those for whom paleo doesn't work (so they are not paleo)

You aren't going to win fans and gain legitimacy when you use terms like nob-polishing and dick-slapping in your articles.  I have even had fans of Robb's say to me that they wish the guy would "grow up" already.  It is sad that someone with the vernacular of a frat boy is the lead voice "schooling" those EBM folks.  Especially, when for the last two years at least he's been touting his work with law enforcement that is saving Reno millions, nay, billions ... with miraculous results.  Do you know where those $$ figures come from?  Risk assessment.  And realize that Specialty Health is "treating to the lipids" and targeting those with high trigs and high LDL-P to reduce them through diet AND statins or other drugs (e.g. metformin).  So either he's saying that what SH is doing is wrong-headed, or he's happy to go along with it.   Evidence Based Medicine in action.  

In the end #5 is the most off putting.  This notion that if you don't buy in you must not care about your health.  This is the biggest turn-off of pretty much most of that community.  I don't buy into the nonsense that grains are universally bad for even a sizeable minority of people.   It's interesting that Robb is bothered so by being asked what his version of paleo is.  This was the case yet again on Facebook.  If you're going to say "see, it works", it would be helpful to define *it* in some semblance of a cohesive fashion.  At least one thing had held up until now:  GRAINS = BAD (well a small crack was made S.Boyd Eaton's presentation at AHS12, but ignoring it seems to have fixed that blip).  Oh, and white rice.  That's not really a grain like the others.  Oh and it's not processed ... oh wait it is.  But still.  It's rice and it doesn't have evil lectins and whatnot. 

No, counter to Robb's claims, this person is not me and more than one person can see the utter chaos that is "paleo" aside from "successful marketing label" at the moment.  Because you see, "bad oatmeal eater" ... I hope that was in jest, because Robb's ring leader "The Paleo Dietitian" Amy Kubal had a confession for her readers the other day.  No, not that (yes, I'll address that shortly).  No in a post about getting off the paleo yo yo go round, Amy divulged the following:

Confession time – My name is Amy, and I eat oatmeal every day for breakfast. (Disclaimer: I am by no means advocating this for everyone.) I have found that my digestion, my energy, my level of satisfaction and my mental and emotional health have all improved since I’ve found a happy balance of foods (paleo or otherwise) that my body tolerates. This flexibility isn’t going to look the same for everyone and I am by no means saying that you all need to start eating oatmeal or anything else that might make you less healthy or conflict with your goals. What I am saying is that there is no one PERFECT diet for everyone and if what you’re eating is making your body OR your mind sick, then it’s definitely not the best choice for you.

So ... Oatmeal daily is on the template?  Come on.  Improved digestion you say?  Perhaps those evil grains aren't so evil after all.

screenshot from Robbwolf.com

So which is it?  Is THE paleo diet THE healthiest way you can eat?  Is it really the ONLY nutritional approach that works?   Those are heady claims, as are the references to all the research that purportedly backs them up.

This much we know:  The diets in the clinical trials involve:

• little to no added fat
• lean meats
• NO dairy
• NO grains
• NO chocolate
• fruit 

Whereas the "evolved" paleo diets

• tons of coconut oil, ghee and/or butter
• fatty meats
• some dairy
• oatmeal
• chocolate
• limit fruit -- too fattening

It is flat out DISHONEST to use the limited science such as it is, to support anything-goes-just-don't-call-it-moderation paleo.   

Rather than panning USNWR and writing long articles bashing critics, the paleo powers that be might do better to expend resources on a cohesive, substantiated, central message.  You know Robb -- that "articles of confederacy" or whatever you called them back when YOU emailed me?   Failure to do so will only make it harder, and there will be more Paleo = BS pieces to come.  Like this one:

Paleo Diet - Just Another Fad Diet Dressed Up in Junk Science Clothes

Because it is.  The best you can hope for is that it is as enduring a fad as Atkins.  And the best everyone else can hope for is that it just goes away so we can go back to eating real foods, sleeping and moving without being recruited into the cult movement by default.

Update:  I forgot to add, that after I wrote this I noticed that USNWR posted links to Cordain's rebuttal (on RW's site) and their response.   Seems Robb and Cordain need to read before rebutting.

The author of "The Paleo Diet" comments:

The diet is described as having only been scientifically tested in “one tiny study.” Five studies, including four since 2007, have tested ancestral–or Paleo–diets and have found them superior to Mediterranean diets, diabetic diets and typical Western diets in regards to weight loss, cardiovascular disease risk factors, and risk factors for type 2 diabetes. These studies are peer-reviewed, conducted by various scientists from a large variety of institutions, and published in reputable scientific journals, including the European Journal of Clinical Nutrition, Nutrition and Metabolism, and Cardiovascular Diabetololgy. Many of the studies were not “tiny” and in fact involved the participation of numerous people. A full rebuttal is at http://robbwolf.com/2011/06/11/us-news-best-diets-rebuttal-2/.

—Dr. Loren Cordain, Professor of Health and Exercise Sciences, Colorado State University

The editors respond: U.S. News reviewed the five cited studies and referenced four of them in this profile. The studies were small and short, making strong conclusions difficult. The “one tiny study” related only to weight loss, not to the Paleo diet broadly.