I came across Adele's blog shortly
after the March 1, 2012 post and I have been reading it ever since.
Yes, when I had a computer crash, I missed a couple of weeks while
converting to a backup computer and getting everything functioning to
keep my blog moving. Then her October 9, 2012 blog reached out and
finally let me know what I was reading and that it was not the
standard nutrition blog. Yes, I had ideas before that, but this one
really made me sit up and take notice. Now I am rereading many of
her blogs with a new insight and understanding. Keep up the good
work Adele!
It is with enthusiasm that I am happy
to have an interview with Adele Hite and a person that does
understand the needs of people with type 2 diabetes.
Bob: Please tell us whom Adele
Hite is that we cannot find on your websites.
Adele: Interesting question.
The Adele that is more difficult to find on the web is the one that
is truly and deeply outraged at what is going on in our food-health
system. I mean really angry. I try to be more
calm and circumspect in my writing and in my talks, because there is
a whole big food-health establishment that needs to change and
diplomacy is important. But in person I can get really upset about
the issue, especially when it comes to diabetes, because that hits
home for me. My father was diagnosed as prediabetic a number of
years ago; his doctor was “old school” enough to give him the
options of either eliminating sugars and starches or starting
medication (which is a reminder that the way everyone treated
diabetes before the widespread use of insulin was to have patients
reduce the sugars and starches in their diet). My dad chose the
former and enlisted my help. I gave him a glucometer and some basic
nutrition biochemistry information. That was all he needed to figure
out a diet that keeps his blood sugars in check and his HbA1c normal
(not “diabetes-normal,” but truly normal). The diet he settled
upon is not one that the American Diabetes Association or the Academy
of Nutrition and Dietetics would recommend, although in every respect
it is very nutritious, filled with lots of veggies and adequate
protein with natural fat at every meal.
When I did my hospital internship, I
was horrified to see so many people with diabetes who were losing
their bodies bit by bit—a few toes here, a foot there, eventually a
lower leg, then the whole leg—with failing kidneys, failing
eyesight, and lives that were defined almost entirely by their
disease state. They weren’t near death but they were dying, quite
literally, piece by piece, It was like some awful science fiction
movie; it felt as if we were keeping these folks alive just enough to
keep a steady supply of them coming into the hospital, dialysis
center, and wound clinic where, as health professionals, we could
make a show of treating them and get paid well for doing that—but
we weren’t going to give them the opportunity to stop the progress
of the disease by being willing to let them eat (gasp!) eggs or
steak. Every day, as I saw these folks hooked up to wound suction
machines or dialysis, I was profoundly grateful for my dad’s doctor
(the now-retired Dr. Ronald Moore of New Bern, NC) and for the
opportunities I had to learn that there was a different way. I am
just as profoundly angered that we, as health care professionals and
public health policymakers, give these patients and their families no
other choice. I look at my dad and I know that there is a different
ending to his story with diabetes that is not such a happy one. I
could be losing him a little bit at a time, watching him suffer for
years and years. I could be watching him have toes and feet become
black with infection and then chopped off. He could be blind and
crippled and enduring the painful process of dialysis multiple times
a week. But he had a choice. And I am sickened by the knowledge that
there are sons and daughters that have no other choice than to stand
by helplessly and watch as those things happen to a mother or father
that they love.
Whew. When I’m not outraged and
angry, I’m a mom with three dangerously smart and funny children
who forbid me to talk about nutrition in front of them, which is fine
with me. I do have other interests! I have been teaching yoga for
about a dozen years now, although my students teach me far more than
I teach them. I also write songs with my husband, who is not only
100% supportive of my work, but who makes sure I have a life away
from nutrition. He’s an incredibly talented musician who plays
guitar and sings in multiple bands. Sitting in an audience watching
people dance to a song I wrote or hearing them sing along is just
about the coolest thing ever. I love being outdoors. I walk trails
nearby with my husband and friends at least once a week. We go to
the beach or to the mountains in NC frequently. I love camping by
myself and cross-country skiing with my family. These things keep me
sane and calm (most of the time) and help me to maintain perspective.
I don’t want the food-health issue to be all I do because I look
forward to the day when everyone has the choices my dad had and my
efforts are no longer needed.
Bob: What drew you to nutrition
and making this a career?
Adele:
I’ve always been interested in food. My mom was a terrible cook
(sorry, mom) and my brothers and sister and I learned to cook, as we
say, in self-defense. I liked cooking and became interested in the
nutrition aspects of food when the low-fat, vegetarian agenda took
hold of the nation in the 1980s. Embarrassingly enough, I climbed on
that bandwagon with little skepticism at the time. It worked fine
when I was younger, but as I got older and had kids, I found myself
in a constant battle with my weight. At 60+ pounds over my normal
weight and officially “obese,” I was valiantly trying to get my
weight under control, but the harder I tried, the harder it was to
lose. Finally, I was eating about 1200 calories and exercising 2
hours a day—and not losing any more weight. What was worse is that
I was miserable. I was hungry and exhausted. My hair was falling
out. When I went to my family physician for help because I was sure I
had some kind of weird metabolic condition, he told me I was fine but
that I needed to lose some weight because my blood pressure and blood
sugar numbers were going up. He suggested I eat less and exercise
more. To my everlasting credit, I did not kill him on the spot.
Instead, I gave up dieting and
exercising and took up research in my local Health Sciences Library,
which turned out to be a much more productive way to lose weight!
When I finally figured out that I needed more protein and fat and
fewer carbohydrates, I did lose weight and I’ve kept my weight in a
normal range for over a decade now. But that’s not why I made
nutrition a career.
Because Dr. Eric Westman of the Duke
Lifestyle Medicine Clinic knew that I’d lost weight using the same
type of diet he was using to treat patients in his clinic (our kids
went to the same school and we’d been in the PTA together), he
asked me to join him in his work. I ended up as the Patient
Educator, helping patients learn how to adapt their shopping, eating,
and cooking habits to a reduced-carbohydrate diet.
As I got to know these wonderful
folks who were struggling with overweight, obesity, and diabetes, I
kept hearing the same story over and over again. It was very
familiar because it was my story too. They had tried to lose weight
by lowering fat and calories and exercising, but it didn’t work
very well, or very long—or, for some folks, at all. After finding
success with the clinic’s diet, the patients kept asking the same
questions. Why were we told that eggs and meat are bad for us and
bread and cereal is good for us when we feel so much better on this
diet? Most of all, they wanted to know: Why weren’t we given this
choice before? I didn’t have an answer, but their own outrage
about how this option was never presented to them convinced me to go
back to school to try to figure it out what was going on in nutrition
and health care.
Bob: Is there a difference
between nutrition and dietetics and is this important?
Adele:
Yes and no. Both fields are centered around finding or
maintaining health through food. But the scope of nutrition is much
wider than dietetics, and there are many ways to study or practice
nutrition in addition to being a dietitian; you could say that
dietetics is a subset of nutrition. Almost by definition, if you
are in dietetics, your training and education has been dictated by
the Academy of Nutrition and Dietetics (AND) which has a particular
agenda shaped by its close association with food and pharmaceutical
manufacturers and with the USDA.
The difference between nutrition and
dietetics is important because the AND has been leveraging its
financial backing to lobby state by state for restrictive licensure
laws that allow only Registered Dietitians to practice nutrition.
This is a bad thing for the consumer because it would further
restrict our already-restricted choices about nutrition information.
People deserve the option of hearing a perspective on nutrition that
is not influenced by one particular organization. I
am fully committed to the idea that dietitians and other
nutritionists should be held to high professional standards, but
other nutrition professionals actually have higher educational
standards than RDs. You can become an RD with only a 4-year
Bachelor’s degree plus internship hours, as compared to a Certified
Nutrition Specialist which requires Master’s or PhD level training.
I also believe that nutrition professionals should be at the
forefront of preventive medicine and health care reform—but
dietitians cannot be the only nutrition professionals allowed to
practice.
Unfortunately,
as long as the AND is chained to USDA guidelines, food manufacturers,
and pharmaceutical companies, the interventions and advice of
dietitians will be ineffective at best, damaging at worst. And,
as result, dietitians will be poorly paid, our motivations will
be suspect, our advice will be (as it should be) disregarded, and as
professionals we will be marginalized. We will remain on the
sidelines, as we saw when RDs were denied Medicare/Medicaid coverage
for intensive treatment of obesity. If we want to be active players
in healthcare, dietitians will have to raise their own standards, and
we will have to disengage ourselves from industry influence. We
will also have stop treating the policy guidelines that emanate from
the USDA as if they are actually science, since they aren’t.
Bob: Is there hope for people
with type 2 diabetes that listen to members of the Academy of
Nutrition and Dietetics (AND)?
Adele:
Well, yes, depending on who those members are! All RDs
are not necessarily members of the AND (just as all MDs are not
members of the AMA), and even those who are may have progressive,
science-based views on nutrition. At the North Caroline Dietetics
Association (an affiliate state-level organization of the AND)
conference, I heard a colleague discuss the merits of
carbohydrate-restricted diets at a question & answer session—and
no one contradicted her! Times are changing and those RDs are out
there. But you are right that the AND “party line” is probably
not the best choice for those with type 2 diabetes. During my
training, I was appalled at how much RDs and other diabetes educators
rely on educational materials from insulin companies to teach
patients about living with diabetes. These are not materials that
are going to help patients minimize their insulin consumption,
which—along with overall blood sugar control—should be a goal of
treating diabetes.
Bob: In rereading your first two
blogs (often these set the parameters of things to come), you have
spelled out an agenda and I think rightly or correctly laid the
groundwork for the blogs that follow. Have you changed any thoughts
since?
Adele:
Your question prompted me to re-read those blog posts. I
will readily admit that I shift my position on matters of food and
health all the time, but I still feel pretty good about those posts.
The primary shift that has occurred is that, every day, I become
increasingly oriented towards looking at the whole food-health system
and its dysfunction as an extension of social, cultural and economic
trends that have been with us as long as the Guidelines have.
Although I would stand by the assertion that the Dietary Guidelines
are very much at the center of that dysfunction, in some ways they
may be—like obesity—more of a manifestation of other trends than
a cause in and of themselves.
Bob: You have two statements
that have intrigued me.
The first one is this - “Frequently
those arguments (leptin insulin ghrelin, oh my!) boil down to a
collection of snapshots from experimental data that may or may not
create a physiologically significant or practically useful collage.”
What is the significance of these three hormones in the
discussion?
Adele:
One of the effects of the intense amount of funding and
attention that has been poured into obesity research is that we have
been learning, as they say, more and more about less and less when it
comes to obesity. I love biochemistry, but in nutritional
biochemistry, our knowledge level sometimes becomes so detailed that
we forget to climb back up the ladder and put all the pieces
together. This may be what is happening with some of our
investigations into hormones having to do with appetite, like leptin
and ghrelin. Investigations into hormones that regulate appetite is,
underneath it all, predicated on the assumption that people who are
obese eat more than people who aren’t, or at the very least, eat
more than they “should”—whatever that means. The fact that we
don’t actually know whether or not this is true (or when it is true
and when it isn’t)—there is plenty of evidence that people with
obesity often do not consume more calories than others—means that
this has turned our attention away from trying to figure out why some
people utilize the same number of calories differently than others;
some store those calories as fat, while others burn them for fuel or
use them to build and repair the body.
Leptin is the hormone that is
supposed to regulate appetite by telling the brain how much stored
energy we have. It was theorized that a leptin deficiency is what
prevented appetite from being “turned off” in people with
obesity, who by definition have large amounts of stored energy. When
we discovered that people with obesity had the same levels of leptin
as people with normal body fat levels, we had to start looking at the
problem in a different way. Dr. Robert Lustig has been doing a great
deal of work with regard to leptin in human subjects, so I would
check out his new book, Fat Chance, for a thorough discussion of this
hormone.
Ghrelin is a hormone that stimulates
hunger, but is also involved in regulating growth, learning, and
memory. It is usually talked about as the counterpart to leptin, and
like leptin, is linked strongly with insulin activity.
Insulin is very much at the center
of our current concerns about health, but you’d be surprised at how
little we know about it—and what we do know we seem to have
forgotten. Insulin is a master hormone whose effects are felt
throughout many metabolic pathways, but it has three very basic
functions: 1) to clear glucose from the bloodstream by ushering it
into cells where, if it isn’t used as energy, it is eventually
stored as fat; 2) to “turn off” glucose production by the liver;
and 3) to “turn off” the process that allows body fat to be used
as energy. This last function is frequently forgotten in our haste
to treat people with diabetes. A Duke endocrinologist who was
mystified by the fact that her patients on insulin kept gaining
weight—even though she told them to eat less and exercise
more--couldn’t even dredge up the fact that preventing
“fat-burning” is a primary role of insulin!
Although it is hard to make any
sweeping generalizations about people with obesity and our
investigations into leptin and ghrelin have shed little light on the
issue, we do know one thing about people who are obese: their
insulin levels have been elevated. We don’t know how often, or to
what extent, or in what fashion, or even why. But we do know that
much. Insulin, ghrelin, and leptin are strongly linked
physiologically and we are just beginning to untangle those
relationships, but at this point I would say that it is rare to have
leptin or ghrelin dysregulation without the upstream effects of
insulin dysregulation.
We also know that the effects of
elevated insulin are not limited to increased fat storage. There is
also increased inflammation which may help explain the fact that
insulin levels are a strong independent predictor of heart disease.
But we haven’t really investigated that relationship because we
haven’t developed the tools to do that. The scientific developments
that allowed researchers to easily measure serum cholesterol levels
drove the investigations into the relationships between diet, serum
cholesterol and heart disease—which turned out to be a rather
fruitless path until we could start to further break down cholesterol
measures into sub-particles. Because of its central role as a
“master hormone,” unpacking the relationships between diet,
insulin activity, and disease should be, in my opinion, the primary
focus of nutrition science. But since we do not currently have a
convenient and consistent way of measuring or even talking about
insulin, this has not happened. I’m hoping that a breakthrough in
insulin measurement will drive research in a long-overdue direction.
I know a couple of gentlemen who are working on that now.
Bob: The second is this, “Note
that I am not saying “Everything in moderation.” I am saying
“Everything in context.”” Is this a key in the way food
should be studied and whether a particular food is good for our
health at our time and period in life?
Adele:
Absolutely. If I ate the way my son eats, I would store a
lot of body fat; if he ate the way I eat, he’d be very hungry. Our
activity levels are about the same (I would even argue that I’m
quite a bit more active than he is, as his favorite form of exercise
is to lay on the couch). But I’m a peri-menopausal female, and he
is an adolescent male. We have very different internal environments,
metabolic and hormonal settings, and diet histories. There is no
single dietary approach that would make sense for both of us, unless
we are talking about focusing simply on acquiring essential
nutrition—and even then, there are likely to be some significant
variations between his needs and mine. As a result, it makes little
sense to say this food or group of foods is “bad” and another is
“good.” A dietary pattern that leads to good health for one
person may not lead to good health for another, or even for that same
person at a different point in his/her life.
As I see it, the biggest problem in
nutrition right now is that we think we know—for all Americans
regardless of race, gender, or age—what foods are (and are not)
going to lead to good health. Not only do we not
know (which makes us out of line when we tell people we do
know), but it causes us not to question the effectiveness of any diet
that we’ve already determined is a “healthy” one. When this
happens, we stop listening to the messages our bodies send us about
our health. It doesn’t matter what kind of diet it is, if it does
not lead to you waking up in the morning and experiencing a day where
you feel healthy—whatever your definition of that is—it isn’t
a healthy diet for you. It is the height of presumption for public
health leaders to think they know better than your body does what
kind of diet that might be.
This assumption means that we have
not paid attention to bioindividuality and how that intersects with
public health policy. The truth is we don’t know what kind of
diet—other than one that provides essential nutrition and helps you
maintain a weight that is appropriate for you—will lead to good
health for you this year, much less 30-40 years from now.
Bob: What advice can you share
for those of us with type 2 diabetes whether they are taking oral
medications or using insulin?
Adele:
I think the most important thing to remember is that type 2
diabetes does not manifest itself the same way in every person.
People have different levels and varieties of insulin production and
insulin resistance that contribute to an elevation in blood sugar,
which is the metabolic situation that results in a type 2 diabetes
diagnosis. Although everyone with type 2 diabetes has low insulin
production, just how low can vary significantly. Everyone can reduce
the work the pancreas has to do by reducing dietary carbohydrate.
But people whose pancreases still make some insulin can reduce or
eliminate medication this way, while others with less insulin
production cannot.
Insulin resistance occurs throughout
the body, but can specifically affect the liver’s ability to “turn
off” the production of glucose. If there is insulin resistance in
the liver and the liver continually produces more glucose than the
body needs, lowering dietary carbohydrate will only get you so far
and some sort of medical intervention is almost always necessary.
That said, there is no known
physiological need for dietary carbohydrate in the presence of
adequate intakes of protein and fat, and dietary carbohydrate is the
food group with the most significant impact on blood glucose levels.
We also know that there is no known relationship between foods we’ve
been told to avoid—meat, eggs, butter, and cheese—and any chronic
diseases. At this point, we need to put the burden of proof where
it belongs: public health policymakers and advocacy groups need to
prove that these nutritious, whole foods are truly as dangerous to
our health as we’ve been told before they tell us to avoid them.
Whether you are on oral medications, insulin, or controlling your
diabetes through diet alone, your overall health will be best served
by feeding your body the nutrition it needs, and there is a lot of
nutrition to be found in foods we’ve been told not to eat.
Bob: Have you followed the
activities and the websites for Gary Taubes and Peter Attia and will
they be a help for you, that is, the Nutrition Science Initiative
(NuSI)?
Adele:
I do follow the activities of Gary and Peter, and I’m
thrilled about the developments at NuSI. The work that NuSI is doing
will, I believe, support the changes that need to occur in public
health nutrition policy. At the same time, science is only part of
the problem. The Dietary Guidelines came into existence—and have
remained virtually unchanged for 30+ years—due not only to theories
being promoted by some in the scientific community, but to political,
economic, and social pressures. If this were really all about
science, well, the science is inconclusive on most matters of
nutrition. If the Dietary Guidelines had been based primarily on
science in the first place, they would say two things: 1) get your
essential nutrition and 2) maintain a weight that is healthy for you.
That’s all we really knew in 1980 when the first Dietary
Guidelines were created, and that’s all we really know now. But
the Dietary Guidelines are not based on solely on science, and it
will take more than science to address the changes needed in our
food-health system. However, the efforts of NuSI will certainly help
to make the case that the one-size-fits-all dietary paradigm that
we’ve been using since 1977 is inappropriate, which it most
certainly is.
Bob: I like your last paragraph
of your first blog and hope that all of us can do our part. “At
the same time, I’m not here to wring my hands in anguish. I’m
actively trying to figure out what to do about this mess we’re in.
I’d love all the feedback and help and ideas I can get from anyone
with enough time on their hands to wade through my musings. Let’s
save the world & have fun doing it.”
Adele:
Thanks! The work you do educating people with diabetes
about their options is essential to the changes we want to make in
reforming the system. The current approach to nutrition in treating
people with diabetes is probably the weakest link in the chains
holding back progress. Your efforts will surely help to break that
link.
Bob: Thank you, Adele! It is a
pleasure to publish this and there is a wealth of information that
needs to be digested and expanded upon.
Her blog is
here. Then with
Adrienne
Larocque they founded Healthy Nation Coalition
and that website is
here. Adele asked me to list an important person, Pam Schoenfeld, another founder and without whom the site would not exist.
