Monday, January 31, 2011

Gluten-free January Participants: Take the Survey!

Matt Lentzner, Janine Jagger and I have designed a survey for participants of Gluten-free January, using the online application StatCrunch. Janine is an epidemiologist who studies healthcare worker safety at the University of Virginia; she has experience designing surveys for data collection so we're glad to have her on board. The survey will allow us to systematically gather and analyze data on the results of Gluten-free January. It will be 100 percent anonymous-- none of your answers will be connected to your identity in any way.

This survey has the potential to be really informative, but it will only work if you respond! The more people who take the survey, the more informative it will be, even if you didn't avoid gluten for a single day. If not very many people respond, it will be highly susceptible to "selection bias", where perhaps the only people who responded are people who improved the most, skewing the results.

Matt will be sending the survey out to everyone on his mailing list. Please complete it, even if you didn't end up avoiding gluten at all! There's no shame in it. The survey has responses built in for people who didn't avoid gluten. Your survey will still be useful!

We have potential data from over 500 people. After we crunch the numbers, I'll share them on the blog.

Thursday, January 27, 2011

The Diabetes Epidemic

The CDC just released its latest estimate of diabetes prevalence in the US (1):
Diabetes affects 8.3 percent of Americans of all ages, and 11.3 percent of adults aged 20 and older, according to the National Diabetes Fact Sheet for 2011. About 27 percent of those with diabetes—7 million Americans—do not know they have the disease. Prediabetes affects 35 percent of adults aged 20 and older.
Wow-- this is a massive problem. The prevalence of diabetes has been increasing over time, due to more people developing the disorder, improvements in diabetes care leading to longer survival time, and changes in the way diabetes is diagnosed. Here's a graph I put together based on CDC data, showing the trend of diabetes prevalence (percent) from 1980 to 2008 in different age categories (2):

These data are self-reported, and do not correct for differences in diagnosis methods, so they should be viewed with caution-- but they still serve to illustrate the trend. There was an increase in diabetes incidence that began in the early 1990s. More than 90 percent of cases are type 2 diabetics. Disturbingly, the trend does not show any signs of slowing.

The diabetes epidemic has followed on the heels of the obesity epidemic with 10-20 years of lag time. Excess body fat is the number one risk factor for diabetes*. As far as I can tell, type 2 diabetes is caused by insulin resistance, which is probably due to energy intake exceeding energy needs (overnutrition), causing a state of cellular insulin resistance as a defense mechanism to protect against the damaging effects of too much glucose and fatty acids (3). In addition, type 2 diabetes requires a predisposition that prevents the pancreatic beta cells from keeping up with the greatly increased insulin needs of an insulin resistant person**. Both factors are required, and not all insulin resistant people will develop diabetes as some people's beta cells are able to compensate by hypersecreting insulin.

Why does energy intake exceed energy needs in modern America and in most affluent countries? Why has the typical person's calorie intake increased by 250 calories per day since 1970 (4)? I believe it's because the fat mass "setpoint" has been increased, typically but not always by industrial food. I've been developing some new thoughts on this lately, and potentially new solutions, which I'll reveal when they're ready.

* In other words, it's the best predictor of future diabetes risk.

** Most of the common gene variants (of known function) linked with type 2 diabetes are thought to impact beta cell function (5).

Two Wheat Challenge Ideas from Commenters

Some people have remarked that the blinded challenge method I posted is cumbersome.

Reader "Me" suggested:
You can buy wheat gluten in a grocery store. Why not simply have your friend add some wheat gluten to your normal protein shake.
Reader David suggested:
They sell empty gelatin capsules with carob content to opacify them. Why not fill a few capsules with whole wheat flour, and then a whole bunch with rice starch or other placebo. For two weeks take a set of, say, three capsules every day, with the set of wheat capsules in line to be taken on a random day selected by your friend. This would further reduce the chances that you would see through the blind, and it prevent the risk of not being able to choke the "smoothie" down. It would also keep it to wheat and nothing but wheat (except for the placebo starch).
The reason I chose the method in the last post is that it directly tests wheat in a form that a person would be likely to eat: bread. The limitation of the gluten shake method is that it would miss a sensitivity to components in wheat other than gluten. The limitation of the pill method is that raw flour is difficult to digest, so it would be difficult to extrapolate a sensitivity to cooked flour foods. You might be able to get around that by filling the pills with powdered bread crumbs. Those are two alternative ideas to consider if the one I posted seems too involved.

Tuesday, January 25, 2011

...towards a m a n i f e s t o

Some thoughts on happiness...

Hedonic well-being?
Let Sunshine Win the Day
or Cynicism: it’s healthy and it makes me happy

The North West m a n i f e s t o events came about as a response to societal changes and as a way of artists and health allies expressing their frustrations and articulating shared passion. As a piece of work, it’s less about strategising and more about connecting and moving forward, and very much in the tradition of artist’s manifestos: its about shouting from the roof-tops.

Last week’s event in Liverpool was planned to give voice to practitioners across Merseyside to come together and exchange ideas and vision to inform the manifesto and celebrate some of the unfolding activity across the area. So, as part of a series of events, exploring shared aspirations for the field, this was a bit of a hybrid event, and with over fifty people in the room was vocal, buoyant and inspiring.

I introduced the session by framing our practice in relation to wider national and regional activity and placing the arts at the heart of society, both in reflection and reaction.

Artistic Director of FACT, Mike Stubbs went on to give a Liverpool context, painting a picture of a thriving and engaged cultural sector and challenging us to think about how we evidence our impact.

Punctuated with artist’s interventions, the session drew some significant thoughts and insight from participants that can be found on the dedicated m a n i f e s t o /merseyside blog pages (only available to that sessions participants, but all the m a n i f e s t o sessions will be drawn together leading up to June 2011).

The only off-note, was in Nic Marks’ rounding-up of the morning. Marks, of the new economics foundation (nef), mistakenly forgot he was at an arts event and not a happiness forum, missing, as he did the cynicism, experience and discontent in the room, (and perhaps wider society).

Whilst many of the people in the session had eloquently described how the arts are, by their very nature political, and I’d opened the session by expressing frustration at societal acceptance of blame for government mismanagement and the crimes of the bankers, Marks focused on what he saw as ‘cheap shots’ at the happiness agenda.1

Now I may be mistaken, but at all the m a n i f e s t o events, I’m mindful of ensuring a couple of things; keeping what I say as consistent as possible, for parity’s sake across the region, and focusing on the long (and rather obvious) history of the arts being more than little baubles and trinkets to pacify people, but as exciting, provocative, subversive and again, political.

By suggesting that cynical politicians may just be hijacking the happiness agenda and arguing our work wasn’t just about making people happy, I apparently blinded Marks to why he was there: to look at the arts in relation to well-being.

And the Five Ways to Well-being by nef are pretty much accepted as good, common-sense ways of looking at day-to-day actions to promote well-being. By connecting with people: being active: taking notice of things beyond our day to day: keeping learning and giving. So no argument there, in fact this ‘latest scientific evidence’ is blindingly obvious.

That’s why we asked Marks to round things off; we thought that all these actions might in fact, contribute towards more fully engaged members of society who connect with others and actively debate and question the status quo: take more than a passing interest in the sound-bites of the popular press and see the potential of shared voices and practice as being part of something bigger: contributing to wider civic society.

Surely then, the result of being a fully engaged citizen might just lead to a more cynical and less superficially ‘happy’ society. Describing my comment about our work not just being about making people happy, as being a ‘cheap-shot’ typical of the media, and for a ‘quick laugh’ Marks risked skewing the whole flavour of the session and devaluing the contributions made.2

I doubt that anyone taking part in the session would question the impact of the arts on well-being, that’s why we’re all involved, we weren’t there to explore the damage we can inflict on each other with our practice.

The point is, that the arts offer so much more than hedonic gratification, and through participation give voice to frustration, anger and cynicism; in other words, art is more than the blind pursuit of happiness (whatever that is) that we’re all told we must aspire to.

Like flat-screen TVs, 4x4 cars or celebrity spray-on tan, it seems happiness is being peddled on the consumerist must-have shopping list. Well, with 2.5 million people unemployed and counting, it looks like the only quick-fire state route to happiness will be through prescription drugs, no doubt on offer through our local National Health Franchise.

Whilst we’re on our way to understanding well-being, (and I’d suggest that the arts and cultural engagement play a big part in that journey), I find it increasingly difficult to imagine how subjective happiness can be identified let alone measured.

And yet as far back as the 2006 Conservative Party Conference, David Cameron has muted the idea of a happiness index, commenting, ‘Let optimism beat pessimism, let sunshine win the day..." Five years later, the NHS, Education and Cultural sectors are undergoing fundamental changes and the banking crisis has thrown the global economy into turmoil. Under the instruction of Cameron, a happiness index is being prepared as I type.

Clive Parkinson
Blue Monday: January 24th 2011

1. In his summing up, Marks said that Cameron and the Government don’t talk about happiness, whereas in reality, there is a wealth of coalition rhetoric on the subject.
2. Rounding off the event and from the lectern, Nic Marks looked me squarely in the eyes and asked, ‘Isn’t happiness the most important thing for our children?’ (Like Ricky Gervais, but without the irony). I wanted to scream, ‘Of course it is, you twerp!’ but I applauded politely thinking, ‘I’d like my children to have a healthy degree of cynicism too; oh and food and shelter, oh and education and love...’

Monday, January 24, 2011

Blinded Wheat Challenge

Self-experimentation can be an effective way to improve one's health*. One of the problems with diet self-experimentation is that it's difficult to know which changes are the direct result of eating a food, and which are the result of preconceived ideas about a food. For example, are you more likely to notice the fact that you're grumpy after drinking milk if you think milk makes people grumpy? Maybe you're grumpy every other day regardless of diet? Placebo effects and conscious/unconscious bias can lead us to erroneous conclusions.

The beauty of the scientific method is that it offers us effective tools to minimize this kind of bias. This is probably its main advantage over more subjective forms of inquiry**. One of the most effective tools in the scientific method's toolbox is a control. This is a measurement that's used to establish a baseline for comparison with the intervention, which is what you're interested in. Without a control measurement, the intervention measurement is typically meaningless. For example, if we give 100 people pills that cure belly button lint, we have to give a different group placebo (sugar) pills. Only the comparison between drug and placebo groups can tell us if the drug worked, because maybe the changing seasons, regular doctor's visits, or having your belly button examined once a week affects the likelihood of lint.

Another tool is called blinding. This is where the patient, and often the doctor and investigators, don't know which pills are placebo and which are drug. This minimizes bias on the part of the patient, and sometimes the doctor and investigators. If the patient knew he were receiving drug rather than placebo, that could influence the outcome. Likewise, investigators who aren't blinded while they're collecting data can unconsciously (or consciously) influence it.

Back to diet. I want to know if I react to wheat. I've been gluten-free for about a month. But if I eat a slice of bread, how can I be sure I'm not experiencing symptoms because I think I should? How about blinding and a non-gluten control?

Procedure for a Blinded Wheat Challenge

1. Find a friend who can help you.

2. Buy a loaf of wheat bread and a loaf of gluten-free bread.

3. Have your friend choose one of the loaves without telling you which he/she chose.

4. Have your friend take 1-3 slices, blend them with water in a blender until smooth. This is to eliminate differences in consistency that could allow you to determine what you're eating. Don't watch your friend do this-- you might recognize the loaf.

5. Pinch your nose and drink the "bread smoothie" (yum!). This is so that you can't identify the bread by taste. Rinse your mouth with water before releasing your nose. Record how you feel in the next few hours and days.

6. Wait a week. This is called a "washout period". Repeat the experiment with the second loaf, attempting to keep everything else about the experiment as similar as possible.

7. Compare how you felt each time. Have your friend "unblind" you by telling you which bread you ate on each day. If you experienced symptoms during the wheat challenge but not the control challenge, you may be sensitive to wheat.

If you want to take this to the next level of scientific rigor, repeat the procedure several times to see if the result is consistent. The larger the effect, the fewer times you need to repeat it to be confident in the result.

* Although it can also be disastrous. People who get into the most trouble are "extreme thinkers" who have a tendency to take an idea too far, e.g., avoid all animal foods, avoid all carbohydrate, avoid all fat, run two marathons a week, etc.

** More subjective forms of inquiry have their own advantages.

Thursday, January 20, 2011

Eating Wheat Gluten Causes Symptoms in Some People Who Don't Have Celiac Disease

Irritable bowel syndrome (IBS) is a condition characterized by the frequent occurrence of abdominal pain, diarrhea, constipation, bloating and/or gas. If that sounds like an extremely broad description, that's because it is. The word "syndrome" is medicalese for "we don't know what causes it." IBS seems to be a catch-all for various persistent digestive problems that aren't defined as separate disorders, and it has a very high prevalence: as high as 14 percent of people in the US, although the estimates depend on what diagnostic criteria are used (1). It can be brought on or exacerbated by several different types of stressors, including emotional stress and infection.

Maelán Fontes Villalba at Lund University recently forwarded me an interesting new paper in the American Journal of Gastroenterology (2). Dr. Jessica R. Biesiekierski and colleagues recruited 34 IBS patients who did not have celiac disease, but who felt they had benefited from going gluten-free in their daily lives*. All patients continued on their pre-study gluten-free diet, however, all participants were provided with two slices of gluten-free bread and one gluten-free muffin per day. The investigators added isolated wheat gluten to the bread and muffins of half the study group.

During the six weeks of the intervention, patients receiving the gluten-free food fared considerably better on nearly every symptom of IBS measured. The most striking difference was in tiredness-- the gluten-free group was much less tired on average than the gluten group. Interestingly, they found that a negative reaction to gluten was not necessarily accompanied by the presence of anti-gluten antibodies in the blood, which is a test often used to diagnose gluten sensitivity.

Here's what I take away from this study:
  1. Wheat gluten can cause symptoms in susceptible people who do not have celiac disease.
  2. A lack of circulating antibodies against gluten does not necessarily indicate a lack of gluten sensitivity.
  3. People with mysterious digestive problems may want to try avoiding gluten for a while to see if it improves their symptoms**.
  4. People with mysterious fatigue may want to try avoiding gluten.
A previous study in 1981 showed that feeding volunteers a large dose of gluten every day for 6 weeks caused adverse gastrointestinal effects, including inflammatory changes, in relatives of people with celiac disease, who did not themselves have celiac (3). Together, these two studies are the most solid evidence that gluten can be damaging in people without celiac disease, a topic that has not received much interest in the biomedical research community.

I don't expect everyone to benefit from avoiding gluten. But for those who are really sensitive, it can make a huge difference. Digestive, autoimmune and neurological disorders associate most strongly with gluten sensitivity. Avoiding gluten can be a fruitful thing to try in cases of mysterious chronic illness. We're two-thirds of the way through Gluten-Free January. I've been fastidiously avoiding gluten, as annoying as it's been at times***. Has anyone noticed a change in their health?

* 56% of volunteers carried HLA-DQ2 or DQ8 alleles, which is slightly higher than the general population. Nearly all people with celiac disease carry one of these two alleles. 28% of volunteers were positive for anti-gliadin IgA, which is higher than the general population.

** Some people feel they are reacting to the fructans in wheat, rather than the gluten. If a modest amount of onion causes the same symptoms as eating wheat, then that may be true. If not, then it's probably the gluten.

*** I'm usually about 95% gluten-free anyway. But when I want a real beer, I want one brewed with barley. And when I want Thai food or sushi, I don't worry about a little bit of wheat in the soy sauce. If a friend makes me food with gluten in it, I'll eat it and enjoy it. This month I'm 100% gluten-free though, because I can't in good conscience encourage my blog readership to try it if I'm not doing it myself. At the end of the month, I'm going to do a blinded gluten challenge (with a gluten-free control challenge) to see once and for all if I react to it. Stay tuned for more on that.

Thursday, January 13, 2011

Does Dietary Saturated Fat Increase Blood Cholesterol? An Informal Review of Observational Studies

The diet-heart hypothesis states three things:
  1. Dietary saturated fat increases blood cholesterol
  2. Elevated blood cholesterol increases the risk of having a heart attack
  3. Therefore, dietary saturated fat increases the risk of having a heart attack
To evaluate the second contention, investigators have examined the relationship between blood cholesterol and heart attack risk. Many studies including MRFIT have shown that the two are related (1):

The relationship becomes much more complex when you consider lipoprotein subtypes, density and oxidation level, among other factors, but at the very least there is an association between habitual blood cholesterol level and heart attack risk. This is what you would want to see if your hypothesis states that high blood cholesterol causes heart attacks.

Now let's turn to the first contention, the hypothesis that dietary saturated fat increases serum cholesterol. This idea is so deeply ingrained in the scientific literature that many authors don't even bother providing references for it anymore. When references are provided, they nearly always point to the same type of study: short-term controlled diet trials, in which volunteers are fed different fats for 2-13 weeks and their blood cholesterol measured (2)*. These studies show that saturated fat increases both LDL cholesterol ("bad cholesterol") and HDL cholesterol ("good cholesterol"), but typically the former more than the latter.  These are the studies on which the diet-heart hypothesis was built.

But now we have a problem. Nearly every high-quality (prospective) observational study ever conducted found that saturated fat intake is not associated with heart attack risk (3). So if saturated fat increases blood cholesterol, and higher blood cholesterol is associated with an increased risk of having a heart attack, then why don't people who eat more saturated fat have more heart attacks?

I'll begin to answer that question with another question: why do researchers almost never cite observational studies to support the idea that dietary saturated fat increases blood cholesterol? Surely if the hypothesis is correct, then people who habitually eat a lot of saturated fat should have high cholesterol, right? One reason may be that in most instances, when researchers have looked for a relationship between habitual saturated fat intake and blood cholesterol, it has been very small or nonexistent. Those findings are rarely cited, but let's have a look...

The Studies

It's difficult to do a complete accounting of these studies, but I've done my best to round them up. I can't claim this post is comprehensive, but I doubt I missed very many, and I certainly didn't exclude any that I came across. If you know of any I missed, please add them to the comments.  [UPDATE 4-2012: I did miss several studies, although they're basically consistent with the conclusion I came to here.  I plan to update this post with the new references at some point.]

The earliest and perhaps most interesting study I found was published in the British Medical Journal in 1963 and is titled "Diet and Plasma Cholesterol in 99 Bank Men" (4). Investigators asked volunteers to weigh all food consumed at home for 1-2 weeks, and describe in detail all food consumed away from home. Compliance was good. This dietary accounting method is much more accurate than in most observational studies today**. Animal fat intake ranged from 55 to 173 grams per day, and blood cholesterol ranged from 154 to 324 mg/dL, yet there was no relationship whatsoever between the two. I'm looking at a graph of animal fat intake vs. blood cholesterol as I write this, and it looks like someone shot it with a shotgun at 50 yards. They analyzed the data every which way, but were never able to squeeze even a hint of an association out of it:
Making the most out of the data in other ways- for example, by analysis of the men very stable in their diets, or in whom weighing of food intake was maximal, or where blood was taken close to the diet [measurement]- did not increase the correlation. Because the correlation coefficient is almost as often negative as positive, moreover, what is being discussed mostly is the absence of association, not merely association that is unexpectedly small.
The next study to discuss is the 1976 Tecumseh study (5). This was a large cardiovascular observational study conducted in Tecumseh, Michigan, which is often used as the basis for comparison for other cardiovascular studies in the literature. Using the 24 hour dietary recall method, including an analysis of saturated fat, the investigators found that:
Cholesterol and triglyceride levels were unrelated to quality, quantity, or proportions of fat, carbohydrate or protein consumed in the 24-hr recall period.
They also noted that the result was consistent with what had been reported in other previously published studies, including the Evans county study (6), the massive Israel Ischemic Heart Disease Study (7) and the Framingham study. One of the longest-running, most comprehensive and most highly cited observational studies, the Framingham study was organized by Harvard investigators and continues to this day. When investigators analyzed the relationship between saturated fat intake, serum cholesterol and heart attack risk, they were so disappointed that they never formally published the results. We know from multiple sources that they found no significant relationship between saturated fat intake and blood cholesterol or heart attack risk***.

The next study is the Bogalusa Heart Study, published in 1978, which studied the diet and health of 10 year old American children (8). This study found an association by one statistical method, and none by a second method****. They found that the dietary factors they analyzed explained no more than 4% of the variation in blood cholesterol. Overall, I think this study lends very little support to the hypothesis.

Next is the Western Electric study, published in 1981 (9). This study found an association between saturated fat intake and blood cholesterol in middle-aged men in Chicago. However, the correlation was small, and there was no association between saturated fat intake and heart attack deaths. They cited two other studies that found an association between dietary saturated fat and blood cholesterol (and did not cite any of the numerous studies that found no association). One was a very small study conducted in young men doing research in Antarctica, which did not measure saturated fat but found an association between total fat intake and blood cholesterol (10). The other studied Japanese (Nagasaki and Hiroshima) and Japanese Americans in Japan, Hawai'i and California respectively (11).

This study requires some discussion. Published in 1973, it found a correlation between saturated fat intake and blood cholesterol in Japan, Hawai'i but not in California. The strongest association was in Japan, where going from 5 to 75 g/day of saturated fat (a 15-fold change!) was associated with an increase in blood cholesterol from about 175 to 200 mg/dL. However, I don't think this study offers much support to the hypothesis upon closer examination. Food intake in Japan was collected by 24-hour recall in 1965-1967, when the diet was roughly 3/4 white rice by calories. The lower limit of saturated fat intake in Japan was 5g/day, 1/12th what was typically eaten in Hawai'i and California, and the Japanese average was 16g, with most people falling below 10g. That is an extraordinarily low saturated fat intake. I think a significant portion of the Japanese in this study, living in the war-ravaged cities of Nagasaki and Hiroshima, were over-reliant on white rice and had a very peculiar and perhaps deficient diet.  Also, what is the difference between a diet with 5 and 75 grams of saturated fat per day?  Those diets are probably very different, in many other ways than their saturated fat content.

In Japanese-Americans living in Hawai'i, over a range of saturated fat intakes between 5 and 110 g/day, cholesterol went from 210 to 220 mg/dL. That was statistically significant but it's not exactly knocking my socks off, considering it's a 22-fold difference in saturated fat intake. In California, going from 15 to 110 g/day of saturated fat (7.3-fold change) was not associated with a change in blood cholesterol. Blood cholesterol was 20-30 mg/dL lower in Japan than in Hawai'i or California at any given level of saturated fat intake (e.g., Japanese eating 30g per day vs. Hawai'ians eating 30g per day). I think it's probable that saturated fat is not the relevant factor here, or at least it's much less influential than other factors. An equally plausible explanation is that people in the very low range of saturated fat intake are the rural poor who eat a  diet that differs in many ways from the diets at the upper end of the range, and other aspects of lifestyle such as physical activity also differ.

The most recent study was the Health Professional Follow-up study, published in 1996 (12). This was a massive, well funded study that found no relationship between saturated fat intake and blood cholesterol.


Of all the studies I came across, only the Western Electric study found a clear association between habitual saturated fat intake and blood cholesterol, and even that association was weak. The Bogalusa Heart study and the Japanese study provided inconsistent evidence for a weak association. The other studies I cited, including the bank workers' study, the Tecumseh study, the Evans county study, the Israel Ischemic Heart study, the Framingham study and the Health Professionals Follow-up study, found no association between the two factors.

Overall, the literature does not offer much support for the idea that long term saturated fat intake has a significant effect on the concentration of blood cholesterol in humans. If it's a factor at all, it must be rather weak. It may be that the diet-heart hypothesis rests in part on an over-reliance on the results of short-term controlled feeding studies.  It would be nice to see this discussed more often (or at all) in the scientific literature.  It is worth pointing out that the method used to collect diet information in most of these studies, the food frequency questionnaire, is not particularly accurate, so it's possible that there is a lot of variability inherent to the measurement that is partially masking an association.  In any case, these controlled studies have typically shown that saturated fat increases both LDL and HDL, so even if saturated fat did have a modest long-term effect on blood cholesterol, as hinted at by some of the observational studies, its effect on heart attack risk would still be difficult to predict.

The Diet-heart Hypothesis: Stuck at the Starting Gate
Animal Models of Atherosclerosis: LDL

* As a side note, many of these studies were of poor quality, and were designed in ways that artificially inflated the effects of saturated fat on blood lipids. For example, using a run-in period high in linoleic acid, or comparing a saturated fat-rich diet to a linoleic acid-rich diet, and attributing the differences in blood cholesterol to the saturated fat. Some of them used hydrogenated seed oils as the saturated fat. Although not always consistent, I do think that overall these studies support the idea that saturated fat does have a modest ability to increase blood cholesterol in the short term.

** Although I would love to hear comments from anyone who has done controlled diet trials. I'm sure this method had flaws, as it was applied in the 1960s.

*** Reference cited in the Tecumseh paper: Kannel, W et al. The Framingham Study. An epidemiological Investigation of Cardiovascular Diseases. Section 24: The Framingham Diet Study: Diet and the Regulation of Serum Cholesterol. US Government Printing Office, 1970.

**** Table 5 shows that the Pearson correlation coefficient for saturated fat intake vs. blood cholesterol is not significant; table 6 shows that children in the two highest tertiles of blood cholesterol have a significantly higher intake of saturated fat, unsaturated fat, total fat and sodium than the lowest tertile. The relationship between saturated fat and blood cholesterol shows no evidence of dose-dependence (cholesterol tertiles= 15.6g, 18.4g, 18.5g saturated fat). The investigators did not attempt to adjust for confounding factors.

Wednesday, January 12, 2011

Bits and Bats…an Arts and Health Networking Miscellany
27th January, 6:00 – 8:00
Venue at MMU: Details will be emailed to you at least 48 hours in advance

Just to remind you that at this networking evening, I’ll be sharing some very quirky films from the early days of the NHS, purely for our fun and conversation. They are wonderful. If you have any film/new media at all that you’d like to share, please let me know in advance.

m a n i f e s t o update…
For those of you who have been involved in these events to date, a big THANK YOU. There’s another event at the Bluecoat Gallery on the 19th.

Its part m a n i f e s t o and part celebration of work underway in Merseyside and if you want to attend, please get in touch with Polly Moseley at  

Following the first stage m a n i f e s t o work which has seen a gathering of passion, vision and aspiration of those involved, I’ll be drawing all the strands together for a second stage of activity which will see us coming together and refining what it is, where it goes and what we do with it. By June 2011 we’ll have something very public to share.

The North West Arts and Health Network is past 1500 members…but what does it all mean?

In reality, our reach is potentially far wider than this, as a number of you email this to your networks on my behalf (thank you)!

Remembering that this network is informal and free…what is it that you’d like to see happening? How can we support each other and what would be useful to have online…most anything is possible.

It would be easy for me to put a survey out and ask you all the obvious questions; but what would the point be? Because if I’m asking the questions, I’m steering things just a bit too much.

So what might be a good starting point is if you email me thoughts, ideas and aspirations and I’ll put some of those questions on the BLOG, anonymously, but so others can see the sorts of things people are talking about. So feel free to email me at and we can beef up our network in ways that are useful to you.

News in from Jeremy Hunt...

… ‘Culture and sport support a range of policy priorities including, but not limited to, economic growth, health and wellbeing, and safer and stronger communities’.

Thanks for that one Jeremy.

See his letter to local authorities below.

29 December 2010

Dear Councillor

We are writing to you about our shared goal of getting better local services for people and to update you on some practical measures to help local authorities delivering cultural and sporting services when the government's overriding priority is deficit reduction, as reflected in the local government finance settlement.

We would like to highlight some of the many examples of improvement and modernisation across local cultural and sporting services. Culture and sport support a range of policy priorities including, but not limited to, economic growth, health and wellbeing, and safer and stronger communities. It is for these reasons that culture and sport are so important to communities and tend to attract significant local interest. Councils across the country have also learned that it is important to prepare for changes with evidence that can be defended.

Through the Future Libraries Programme (FLP) the Local Government Group and Museums, Libraries & Archives Council (MLA) are supporting 36 councils to find new ways to deliver library services without cutting the front line. We thought it would be helpful, ahead of the formal publication of findings from the programme, to share with you examples of the leading savings options that are emerging and our newsletter gives you more information. The MLA and Local Government Group can help if you want to find out more and are available to assist you in looking at a wider range of options and ideas for your library services that could help you save money while minimising the need for cuts to front line services.

Library authorities outside the programme are also developing innovative approaches to providing services:

* Essex County Council will be helping to improve Slough Borough Council's library service and reduce its administration costs from 1 January 2011;
* Investment by Aviva has contributed towards the transformation of York Central Library with more books, the latest technologies and new services;
* In North Yorkshire volunteers at Grassington Hub are at the heart of service delivery.

We are convinced that innovation, led by the energy and experience of councils themselves, is also going to provide the best recipes for modernising cultural services generally in a tougher financial climate.

There are also lots of examples of councils developing different approaches to providing local cultural and sporting services and responding to the economic situation by being innovative:

Many councils are successfully commissioning their cultural services to deliver more efficiently other key service priorities such as adult social care, health, better outcomes for children and young people and economic development;

* Manchester City Council has focused its culture and sport services as major drivers of economic growth, inward investment, and job creation and training;
* Leicester Comedy Festival has developed relationships with communities and the health service to respond to issues such as men's health, teenage pregnancy and healthy eating amongst children and young people;
* Suffolk Artlink manages a series of projects aimed at improving the lives of vulnerable people in Suffolk including older people and their carers;
* In Kirklees a partnership between creative arts organisations offer a range of services for people as part of their mental health and wellbeing care planning services.

There are a number of different ways by which examples such as these are shared widely across the local government sector, including:

LGID's website brings together in one place the learning that is coming out of the "Passion for Excellence" improvement work in partnership with DCMS and key public bodies.

The Living Places website is a suite of online resources developed by DCMS and key public bodies to support the contribution of culture and sport to planning http://living  

LGID has also launched two new publications outlining ways the sector can improve its efficiency through new ways of working and making better use of assets and sources of further help.  

Help and advice is available and it could assist you in providing the culture and sport local people will be looking for while making the savings that are needed.

Secretary of State for Culture, Olympics, Media and Sport

Chair, LG Group Culture, Tourism

Tuesday, January 11, 2011

Dr. Fat

A blog reader recently made me a Wordle from Whole Health Source. A Wordle is a graphical representation of a text, where the size of each word represents how often it appears. Click on the image for a larger version.

Apparently, the two most common words on this blog are "Dr" and "fat." It occurred to me that Dr. Fat would be a great nom de plume.

Monday, January 3, 2011

Paleolithic Diet Clinical Trials, Part V

Dr. Staffan Lindeberg's group has published a new paleolithic diet paper in the journal Nutrition and Metabolism, titled "A Paleolithic Diet is More Satiating per Calorie than a Mediterranean-like Diet in Individuals with Ischemic Heart Disease" (1).

The data in this paper are from the same intervention as his group's 2007 paper in Diabetologia (2). To review the results of this paper, 12 weeks of a Paleolithic-style diet caused impressive fat loss and improvement in glucose tolerance, compared to 12 weeks of a Mediterranean-style diet, in volunteers with pre-diabetes or diabetes and ischemic heart disease. Participants who started off with diabetes ended up without it. A Paleolithic diet excludes grains, dairy, legumes and any other category of food that was not a major human food source prior to agriculture. I commented on this study a while back (3, 4).

One of the most intriguing findings in his 2007 study was the low calorie intake of the Paleolithic group. Despite receiving no instruction to reduce calorie intake, the Paleolithic group only ate 1,388 calories per day, compared to 1,823 calories per day for the Mediterranean group*. That's a remarkably low ad libitum calorie intake in the former (and a fairly low intake in the latter as well).

With such a low calorie intake over 12 weeks, you might think the Paleolithic group was starving. Fortunately, the authors had the foresight to measure satiety, or fullness, in both groups during the intervention. They found that satiety was almost identical in the two groups, despite the 24% lower calorie intake of the Paleolithic group. In other words, the Paleolithic group was just as full as the Mediterranean group, despite a considerably lower intake of calories. This implies to me that the body fat "set point" decreased, allowing a reduced calorie intake while body fat stores were burned to make up the calorie deficit. I suspect it also decreased somewhat in the Mediterranean group, although we can't know for sure because we don't have baseline satiety data for comparison.

There are a few possible explanations for this result. The first is that the Paleolithic group was eating more protein, a highly satiating macronutrient. However, given the fact that absolute protein intake was scarcely different between groups, I think this is unlikely to explain the reduced calorie intake.

A second possibility is that certain potentially damaging Neolithic foods (e.g., wheat and refined sugar) interfere with leptin signaling**, and removing them lowers fat mass by allowing leptin to function correctly. Dr. Lindeberg and colleagues authored a hypothesis paper on this topic in 2005 (5).

A third possibility is that a major dietary change of any kind lowers the body fat setpoint and reduces calorie intake for a certain period of time. In support of this hypothesis, both low-carbohydrate and low-fat diet trials show that overweight people spontaneously eat fewer calories when instructed to modify their diets in either direction (6, 7). More extreme changes may cause a larger decrease in calorie intake and fat mass, as evidenced by the results of low-fat vegan diet trials (8, 9). Chris Voigt's potato diet also falls into this category (10, 11). I think there may be something about changing food-related sensory cues that alters the defended level of fat mass. A similar idea is the basis of Seth Roberts' book The Shangri-La Diet.

If I had to guess, I would think the second and third possibilities contributed to the finding that Paleolithic dieters lost more fat without feeling hungry over the 12 week diet period.

*Intakes were determined using 4-day weighed food records.

**Leptin is a hormone produced by body fat that reduces food intake and increases energy expenditure by acting in the brain. The more fat a person carries, the more leptin they produce, and hypothetically this should keep body fat in a narrow window by this form of "negative feedback". Clearly, that's not the whole story, otherwise obesity wouldn't exist. A leading hypothesis is that resistance to the hormone leptin causes this feedback loop to defend a higher level of fat mass.

Saturday, January 1, 2011

Annus horribilis?

Mark Wallinger
A Plea for Pessimism...
Last November I had the pleasure of speaking at the 2nd Annual International Arts and Health Conference in Melbourne. My paper; A Brightly Coloured Bell-Jar explored the relationship between our aspiration to well-being and increased dependency on medication for all our ills. You can hear a podcast of this paper at and it will be available in print in February 2011.
Polly Morgan
Two pieces of writing that echo and expand on some of the themes I raised are below.
Is this the end of the children’s decade?
Polly Toynbee questions whether voters believe David Cameron's new year's message, that: "We're tackling the deficit because we have to – not out of some ideological zeal. This is a government led by people with a practical desire to sort out this country's problems, not by ideology. When we talk of building a bigger, stronger society, we mean it." Or will they believe Ed Miliband's view that the "irresponsible pace and scale" of the cuts is a "political choice by those in power, not necessity"?

Steve Bell; The Guardian
How to Stop Living and Start Worrying.
Since when did happiness, wisdom and contentment become the cornerstones of a fulfilling life? Whatever happened to doubt? Instability? Melancholia? 

This month, Polity Press are releasing How to Stop Living and Start Worrying, a collection of interviews with Simon Critchley, which playfully parodies the conventional self-help manual. Critchley sketches an alternative view of the role philosophy plays in our lives today, covering an ambitious range of topics: from science and religion, to poetry and politics, love and humour, life and death.

…and finally

The next  M A N I F E S T O  event will be on the 19th January at the Bluecoat Gallery in Liverpool…details to follow.

...and don’t forget the first North West Arts and Health Networking session of the year on January 27th between 6:00 and 8:00 in the evening when I’ll be sharing some odd little films from the birth of the NHS in the 1940’s and I encourage you to submit material for sharing too. I’ll confirm the venue the week before, but for now, could you RSVP to