January 21, 2013

Interview with Adele Hite

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.

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