Four-letter Words

A well-loved and much followed doctor on twitter mused recently that he was considering blocking anyone who used the word 'crap' in a tweet about diet. 'Nutrition Twitter' is a pretty wild place, much of it a roiling cauldron of ill-feeling, self-promotion, ad-hominem attacks and bizarrely misleading and misinformed contributions. In other ways it can resemble the Western Front of 100 years ago - opposing armies dug in, lobbing artillery and random salvos at each other, memories of the Christmas Truce fading fast. It's all very matey behind the lines, but the zone between the trenches is a waste-land. Yet as in any war-zone (or perhaps in this case a culture-war-zone) there are sane voices trying to inject some manners, and reliable data into the mix, like conscientious objectors, bravely bearing stretchers. Something about Twitter makes this hard to do well, at least that's my experience of trying in my small way. It is almost as if they want us all to fight ...

Back to the point: is the word 'crap' just a bit, well, crap? I've used it somewhat tongue-in-cheek as an acroynm for Calorie Rich And Processed. And although 'processed' isn't a four-letter word I recently took up almost 2 sides of A4 trying to explain what this could mean for patients who might be curious.

The four letter words suffer from all the drawbacks of their longer cousins - words aren't a terribly reliable means of communication until most of us agree pretty well what they mean. The four-letter variety are also often quite punchy, and the more of an emotional-payload a word packs, the harder it is to keep the conversation calm. Words can be used as weapons as well as a means of communication. Crap - like Quack - is just a term of abuse in most contexts.

As is Junk.

Oddly my least favourite four-letter word in nutrition isn't sweary or dismissive at all, but routinely used by many thoughtful and sensible colleagues.

Carb.

There is much that can be said about the short-comings of this word, a good book could be written on how it might be serving to obscure as much as it reveals about diet, and one of the biggest problems with it was revealed in a recent experience in the Surgery.

It was another day of phone-based General Practice and one of my patient's call details on my screen read "concerned may need diabetes test as has eaten a lot of carbs during lockdown". My expectations were that I’d hear a tale of weight gain during lockdown, brought on an orgy of ice-cream, crisps, biscuits, cake and pringles, all eaten in front of endless TV, or at the very least a tale of heroic consumption of stockpiled white pasta.

Instead I discovered that this guy, having been identified as being at risk of diabetes a year back, had since been steadily loosing his excess weight, including during lockdown, by increasing activity levels and improving the quality of his diet. Looking at his previous results, and hearing he was feeling great, and that he'd managed to drop 10% of his body-weight, I felt confident there was no need to be worried at all. But the mystery remained - what exactly had prompted the call?

"My wife is worried I've been eating too many carbs and it could bring on diabetes".
"OK, so what is it you've eaten that is making her concerned?"
"I've had a slice or two more wholemeal bread a day since lockdown"
"Anything else?"
"No"

There was little left to do except congratulate him on his excellent progress, reassure him that he was doing the right thing to continue excluding sugar, white flour products and processed foods from his diet, not to worry about the wholemeal bread, and that the well organised routine monitoring arrangements would be more than adequate.

It was a small incident, but just one more example of the difficulties caused by that simple word "carb".

As it happened I only had to wait a further few days before catching up with a paper published in the BMJ which provide a different type of evidence suggesting that simple talk of 'carbs' may be unhelpful. This paper showed that risk of developing diabetes falls with the first two servings of whole-grain foods a day, and then remains lowered from there on in.

“That surprising graph in full”

Hu, Yang, Ming Ding, Laura Sampson, Walter C. Willett, JoAnn E. Manson, Molin Wang, and others, ‘Intake of Whole Grain Foods and Risk of Type 2 Diabetes: Results from Three Prospective Cohort Studies’, BMJ, 370 (2020) <https://doi.org/10.1136/bmj.m2206>

What most surprised me was that some the types of foods counted as 'whole-grain' in this study were quite processed: including wholemeal bread and wholemeal pasta. These are foods that would be confidently included by many proponents of low-carb diets in their definition of 'carbs' to be avoided. Others view them as 'inbetween foods' with grains being best eaten genuinely whole (like brown rice) or only part-processed (like porridge oats or bulghur wheat). One was left wondering what the results would be in a study with a stricter definition of 'whole-grain'.

What seems to get so easily lost is that nearly everyone agrees that sugar and foods made with sugar and refined grains are prone to be over-eaten, and also lack nutrients and fibres that were present in their whole-food state, and that provided one has the option to avoid them, then they are best avoided. Are there any sensible diet plans for general health and disease prevention that don’t encourage a reduction in these foods? We know that a wide range of encouraging improvements in body-weight and composition, insulin resistance, progression to and through diabetes have been demonstrated with diets that reduce or eliminate these foods.

But then there's a narrative that goes much further: it goes "'carbs' cause obesity and diabetes" (full stop), next that "all grain-foods are carbs, along with root vegetables", some versions of the narrative include legumes too before reaching the next full stop. Next we learn that "insulin resistance and obesity and diabetes are caused by carbs and lack of exercise" (another full stop here).

But if people who eat whole-grain foods, even quite processed whole grain foods, are protected from the key condition at the centre of this narrative - type-2 diabetes - what then? It looks as if we’ve boxed ourselves into a narrative that tells people who eat protective foods that these foods are harmful.

All those full stops and closed sentences need opening up. The story is almost certainly a lot more interesting and complex that that.

In the meantime "carb", like "crap" and "junk", is increasingly showing up as a term of abuse, and seems to be doing little to improve the quality of conversations about food and health. Isn't it time change the story, upgrade the language and to recognise that 'carb' is going to be a problematic term until we all agree a meaning that is not only transparently understandable by patients, but also supported by the overall evidence.