These are the slides I presented at the 'low carb downunder' conference in Sydney on the 24th of November 2012.

1. Has nutrition research helped
us with our food choices?
Simon Thornley (Epidemiologist)
University of Auckland

2. Summary
 What is science/epidemiology?
 A brief history of human nutrition
 I get involved… diversion into tobacco
 Food addiction?
 What next?

3. My view
 Yes, but many nutrition scientists are not
listening to the data
 Fructose, sugar, carbohydrates are often
overlooked

4. What is science or research?
 “In God we trust, all others bring data”
 William Edward Deming
 “First establish the facts, then seek to
explain them”
 Aristotle

5. Science
 Anarchistic; consensus not useful
 Hypothesis and argument
 Disproof over proof
 Uncertainty over absolutes
 Integration

6. A basic epidemiological study…
Disease Subjects
What we eat
Focus on statistical over biological evidence…

8. Error…
 Many contradictory studies
Not included in CI or p-value Accounted for by 95%
[Quantitative bias analysis] Error confidence interval and
p-value
Selection bias
recruitment %
Information Systematic Random
bias
Accuracy of measures?
Unmeasured False +ve False –ve
~5% ~10 to 20%
confounding
RCT? From literature?

9. Confounding…
Sugar
consumption
Coronary Heart
Dental caries
Disease

10. Bradford-Hill Criteria
 Strong  RCT better than
association? observational study
 Consistent?  Makes sense
 Does cause come
before effect?
 More
exposuremore
disease?

11. Salt restriction
 Salt restriction ↓ blood pressure
 Observational studies show both ↑ and ↓
survival (unmeasured confounding)
 Only randomised study shows benefit in
group that didn’t restrict salt.
 Taylor, R. S., Ashton K. E., T. Moxham, L Hooper, and S. Ebrahim. "Reduced Dietary Salt for the Prevention of Cardiovascular
Disease." Cochrane Database of Systematic Reviews, no. 7 (2011).
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD009217/frame.html .

13. Is the idea falsifiable?
HOW DOES SCIENCE GO
WRONG?

14. How it works in theory…
Idea Experiment Interpret New Idea
Generate Test Inferences from Refine
hypothesis hypothesis experiment hypothesis

15. In reality…?
Experiment Interpret New
Idea
Generate Test Inferences from Idea
hypothesis hypothesis experiment Refine
hypothesis

16. Some history…
NUTRITION IDEAS OVER THE
LAST 100 YEARS…

17.  Museum photo…

18.  Dairy photo

19. What happened in the 1960s?
 Diet-heart hypothesis
 Heart disease caused by saturated fat
 Response: reduce fat (↑sugar or carb.)
 Cheap sugar (HFCS in USA)
 American Heart Assoc  other English
speaking countries
Taubes G. The Diet Delusion. New York: Vermilion; 2007.

20. Brain washing?
THE ACCEPTED STORY

21. Nutrition to the rescue…
A–B=C
A = Energy in (food)
B = Energy out (burned, metabolism)
C = Energy stored (as fat)
Cause
↑A/↓B→↑C – obesigenic environment (↑energy
in/ reduced energy out)

22. What’s ok...
THE GOOD!

30. It’s not OK... Ever!
THE BAD

32. http://longwhitekid.files.wordpress.com/201
1/08/anchor-best-new-zealand-butter-
380h-x-270w-heavy-card-21.jpg

33. Salt

36. WE ALL LIVED HAPPILY
EVER AFTER?

38. AN ALTERNATIVE VIEW
EMERGES…

39. My thoughts on obesity…
Medical training Public Health Research Research
Traditional Tobacco Similarities Critique of
Nutritional theory addiction between energy density
- Energy density obesity and Focus on sugar
smoking
1994 2005 2007 2011

40. Why does a smoker smoke?

41. Withdrawal
Symptoms Duration (weeks)
Irritability <4
Depression <4
Restlessness <4
Poor concentration <2
Increased appetite >10
Craving to smoke >2

42. Automatic behaviour
Rational Automatic Addiction
breathing Automatic,
behaviour withdrawal, harm
Mid brain/brain
Cortex
stem

43. Subconscious learning…
Withdrawal
discomfort
Puff
cigarette
Nicotine
metabolised
Withdrawal
More relief
puffs

44. How do cigarettes work...?

45. FOOD ADDICTION?

46. Carbohydrate?

47. Eating and addiction?
 Atkins Diet
 An executive who had tried obesity surgery,
laxatives, diets, everything…
“Often I would shake until I could put
some sugar in my mouth”

48.  “Ihad an hour’s drive from my office to
my home, and I knew every
restaurant, candy machine and soft
drink dispenser”

49. What about glucose?
 Is refined starch the same as nicotine?
 Are low GI foods the obese person’s
equivalent to a smoker’s nicotine patch or
gum?

50. Bread: white v. wholegrain

51. Glucose: glycemic index?

52. What about sugar?
 Sugar is actually low/moderate GI

53. I TAKE A LOOK AT SUGAR?

55. The medical gurus say sugar is
OK?
 “Excess sucrose has largely been
exonerated as an important dietary factor in
the aetiology of type-2 diabetes...”
J. I. Mann and A. S. Truswell
Diseases of overnourished societies and the need for dietary change: in the
Oxford Textbook of Medicine, 4th Edition.
 Postprandial glycemia (GI) used to
exonnerate sugar…

56. Sugar: traditional views
 30% increase over last 30 years
Popkin BM, Nielsen SJ. The sweetening of the world's diet. Obesity Research 2003;11(11):1325-32.
 “Empty calorie”
Nestle M. Soft drink "pouring rights": marketing empty calories to children. Public Health Reports
2000;115(4):308-19.
 Fructose not mentioned
 Something is missing?

59. Update...
 AHA turns around.
 “Fructose... has been indirectly implicated
in the epidemics of obesity and type 2
diabetes”
Circulation 2009;120;1011-1020

60. Fructose: what has changed?
 GI ignores fructose
 Sweeter than glucose
 Linked to:
 Gout, diabetes, weight gain, metabolic syndrome
 Hypertension, rotten teeth
 High triglycerides, dyslipidaemia, CVD
 Tends to ↑ hunger
Johnson, R.J., et al., Hypothesis: Could Excessive Fructose Intake and Uric Acid Cause Type 2 Diabetes? Endocr Rev, 2009. 30(1): p. 96-
116.
Segal, M.S., E. Gollub, and R.J. Johnson, Is the fructose index more relevant with regards to cardiovascular disease than the glycemic index?
European Journal of Nutrition, 2007. 46(7): p. 406-17.

61. What about saturated fat?
 Recent summaries
 no association with heart disease.
Skeaff CM, Miller J. Dietary Fat and Coronary Heart Disease: Summary of Evidence
from Prospective Cohort and Randomised Controlled Trials. Ann Nutr Metab
2009;55:173–201
Mente A, de Koning L, Shannon HS, Anand SS (April 2009). A systematic review of the
evidence supporting a causal link between dietary factors and coronary heart
disease. Arch. Intern. Med. 169 (7): 659–69.

62. Food addiction: evidence
 Addiction pathways
 Eating is automatic
 Rats
 sugar induces withdrawal; not fat.

63. In the headlines…

64. My inbox...
 “For three weeks I cut all sugar and
flour…
 then…
 mood swings…,
 depression…,
 stomach pain…,
 joint and muscle pain…,
 the shakes….”

65. “People who knew me started thinking I was
hiding a drug problem.”

66. Overeater’s Anonymous
 “When you are addicted to drugs you put
the tiger in the cage to recover;
 When you are addicted to food, you put the
tiger in the cage, but take it out three times
for a walk”
Kerri-Lynn Murphy Kriz

67. Critique: Academia
 “Any addictive … hypothesis can't explain
the rise that we've seen over the last …
30 years of obesity.”
Prof. Boyd Swinburn, Professor of Population Health,
Deakin University 13 Jan 2009

69. SO WHAT?

70. Synopsis
 Nutrition focuses on energy not hunger
 Low fat idea predates obesity epidemic
 Sugar intake continues to ↑
 Likely subtle addiction
 Likely cause of major risk factors for heart
disease
 Many nutrition researchers stuck in
energy paradigm (cf. some pop science)

71. More details

72. Thank you!
Slides and my articles are
available at:
www.slideshare.net/sithor