Jerome Burn

UK ‘Fat Wars’: Martin Luther moment for medicine?

Award-winning British journalist, Jerome Burne, believes the UK’s ‘Fat Wars’ herald a much-needed ‘Martin Luther moment’ for medicine. He explains why in a shortened version of his blog on the topic (click here for a full version). It’s a riveting read.

Last week the front page of The Times carried a story that was an opening shot in a revolution: I’m sure the editors didn’t intend it as that and the readers didn’t see it that way either. It was a story about shifting from the long recommended low-fat diet to one that cut back on carbohydrates instead.

Standard fare for the cuddly lifestyle pages, hardly material for social upheaval.

I don’t think it is too fanciful to suggest that this may come to be seen as a “Martin Luther moment” for medicine. It may not split the profession as Luther’s divided the church. It does have the potential to dramatically change the way medicine is practised. 

To begin with, it is significant that doctors were involved; nutritionists would never have made the front page. Insiders, such as the monk Luther or the aristocrats who signed the Tennis Court Oath before the French revolution, are often key to giving revolutionary change lift off.

The doctors had largely been convinced of the benefits of low carbs by trying it themselves and seeing the effect on their patients. But this is more than just another of those irritating nutritional U-turns: “Last year we had to avoid eggs because they were packed with cholesterol, now we can safely have six a week. Can’t they make up their minds?”

If there is a U-turn in official advice about fat/carb quantities, and the physiological case seems to me unarguable, the knock on effect would be far reaching – the tug on a loose strand of wool that unravels a whole sweater.

To begin with it would involve admitting that nutrition can be a safe, effective and cheaper treatment for some lifestyle disorders than drugs.

Such developments seem sensible and unthreatening but they carry a revolutionary charge.  At the moment, diet is regarded as a useful but relatively ineffective handmaiden to real medicine.

But if diet is going to start growing medical muscles, that raises fascinating regulatory problems, that doctors, who may well have emerged from medical school with only a few hours of nutritional classes, are probably unaware of.

First there is what might be called a legal falsehood about food. The official position is that it cannot modify physiology – ludicrous and patently untrue but that’s fundamental assumption about diet that all nutritionist have to learn to tip-toe around.

Officially the only substances that can prevent, cure or treat are drugs/medicines. The implication is that if you do demonstrate the effectiveness of a diet, food or supplement – say curcumin for inflammation or B vitamins to lower the homocysteine linked with Alzheimer’s – then it is logically a drug.

This claim requires a greater leap of faith than transubstantiation – the Catholic doctrine that the bread and wine given in communion literally turn into flesh and blood when eaten, which Luther thought profoundly wrong .

But then the substance has to be licenced which involves large and expensive trials, which are almost never done because food and natural substances are not patentable. Even doctors cannot properly prescribe non-drug remedies, however good the evidence.

So the revolutionary potential should be becoming a bit clearer.

Suppose a 100 or so GPs started using nutrition to treat their diabetic patients? Could they all be hauled in front of the GMC for using unlicensed treatments or might the common slogan that you can get all the minerals and vitamins you need from a healthy balanced diet start to look as implausible as the low-fat orthodoxy? 

But talking about a low-carb diet and suggesting some supplements along with specific exercise regimes is still just splashing about on the surface of lifestyle treatments. If a growing number of doctors stay on the low-carb path they will start to encounter much more interesting and unfamiliar dietary territory.

How low, for instance, should you go with your carbs? At the moment, the definition of low carbs is pretty elastic. Compared to 300 or more grams of carbs that a conventional diabetic diet can provide, getting that down to 100 grams seems pretty low. But what if you go down to 50, 20 grams?

We know for certain that once you get below about 20 your metabolism makes a step change, like the transition from water to ice. It stops relying on carbohydrates (blood sugar) for energy – because you aren’t getting enough – and it starts to release fat from your fat stores (you can see why this would be popular) to provide a different source of energy. The fat is transported to the liver where it is turned into ketones which the brain and muscles can also use as fuel.

I’m going ignore (debates around this) for now and just mention a very radical but very plausible idea: the ketogenic diet might help you fight cancer.

The princes of the medical church will disapprove of such heresy; the parishioners’ response seems much more favourable.

A full version of this blog appears on HealthInsightsUK