Some confusion about macronutrient divisions in Direct meals

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Docb

Docb

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Relationship to Diabetes
Type 2
Moderator Note: The following dicsussion was split away from a newbie’s thread here: https://forum.diabetes.org.uk/boar...nd-a-little-grumpy.106777/page-2#post-1269845

Burylancs said:
4. The ludicrous DiRECT study in 2017 of Roy Taylor claimed to have operated on 50% of calories from carbs, 10-20% from Protein and 20-30% from fats. Which means Taylor's guinea pigs were getting upto 20% of their calories from Fresh Air. His figures have 100 recommended combinations of carbs, protein and fats of which 99, Ninety-nine ! of them are mathematically impossible e.g. 50 +15+25 adds up to 90% not 100%. It's amazing that this stuff is taken so seriously especially by Diabetes UK, although they've ploughed £millions into it so feel that they have to keep plugging it.
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You have me at a disadvantage because I have not looked at the detail of the direct trial - I am not inclined to set aside the several days it would need to gather together the information and even begin to understand it, let alone critique it.

I do however note that the authors (and there were an awful lot of them of which R Taylor was one) interpretation of the outcome of the trial was...

Our findings show that, at 12 months, almost half of participants achieved remission to a non-diabetic state and off antidiabetic drugs. Remission of type 2 diabetes is a practical target for primary care.

Are you suggesting that because some of the experimental detail looks a bit odd, that this overall interpretation is unjustified? If so then that seem to me to be a bit harsh.
 
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Docb said:
Are you suggesting that because some of the experimental detail looks a bit odd, that this overall interpretation is unjustified? If so then that seem to me to be a bit harsh.
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I think when giving the necessarily approximate distributions of macronutrients in the varied meals, they just made sure they didn’t go OVER 100%.

I don’t have any difficulty in recognising that approximately 50 + (10-20) + (20-30) ties in well enough with slides 14-15 here


which suggest

weight loss 61 carbs + 13 fat + 26 protein
and
maintenance 50 carbs + 35 fat + 15 protein

I don’t have a source for @Burylancs quoted ranges, but to dismiss the trial on the basis of the approximate indication of macronutrient splits between different shakes (and then maintenance meal plans) feels a bit ‘baby and bathwater’ to me.
 
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everydayupsanddowns said:
I think when giving the necessarily approximate distributions of macronutrients in the varied meals, they just made sure they didn’t go OVER 100%.

I don’t have any difficulty in recognising that approximately 50 + (10-20) + (20-30) ties in well enough with slides 14-15 here


which suggest

weight loss 61 carbs + 13 fat + 26 protein
and
maintenance 50 carbs + 35 fat + 15 protein

I don’t have a source for @Burylancs quoted ranges, but to dismiss the trial on the basis of the approximate indication of macronutrient splits between different shakes (and then maintenance meal plans) feels a bit ‘baby and bathwater’ to me.
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The figures for carbs/fats/protein proposed in DiRECT are just a plausible looking set of numbers jotted down on the back of an envelope. They don't make sense and no actual trial could have taken place using them. It's thoughtless stuff and an insult to the T2 community - but we're used to that ! DocB they are few if any details of what went on, how it was organised, what the actual results were ( And Breathe has asked for facts and figures, and what did he actually measure, and complained that Taylor 'hypothesises about stuff' ). Many of Taylor's claims and assertions exist in an evidence-free zone which in turn suggests that much of what we hear about his work on Forums such as this is Mythology.
 
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@Burylancs, forgive me for persevering but I am trying to get a perspective on this.

From my limited understanding, the trials, in which a lot of people were involved both as researchers and participants, essentially showed that if somebody was obese and had a diabetes diagnosis then losing weight was beneficial in terms of blood glucose measurement. Indeed for a statistically significant number of participants, the weight loss reduced HbA1c levels to below the diagnosis level. Are you questioning that?

In my time I have seen lots of dodgy science but I cannot recall a programme the size of DiRECT, with so many participants in two centres coming up with something that is hopelessly wrong in its basic findings.

What I have seen is lots of dodgy reporting of very good science where what the scientists say in the technical papers is cherry picked to support a particular point of view by those more interested in the PR value of the work rather than technical accuracy. Is that the thing you are concerned about?
 
Docb said:
@Burylancs, forgive me for persevering but I am trying to get a perspective on this.

From my limited understanding, the trials, in which a lot of people were involved both as researchers and participants, essentially showed that if somebody was obese and had a diabetes diagnosis then losing weight was beneficial in terms of blood glucose measurement. Indeed for a statistically significant number of participants, the weight loss reduced HbA1c levels to below the diagnosis level. Are you questioning that?

In my time I have seen lots of dodgy science but I cannot recall a programme the size of DiRECT, with so many participants in two centres coming up with something that is hopelessly wrong in its basic findings.

What I have seen is lots of dodgy reporting of very good science where what the scientists say in the technical papers is cherry picked to support a particular point of view by those more interested in the PR value of the work rather than technical accuracy. Is that the thing you are concerned about?
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You last observation is absolutely true, what the general public gets fed is often far away from the actual evidence in the scientific research.
 
Docb said:
@Burylancs, forgive me for persevering but I am trying to get a perspective on this.

From my limited understanding, the trials, in which a lot of people were involved both as researchers and participants, essentially showed that if somebody was obese and had a diabetes diagnosis then losing weight was beneficial in terms of blood glucose measurement. Indeed for a statistically significant number of participants, the weight loss reduced HbA1c levels to below the diagnosis level. Are you questioning that?

In my time I have seen lots of dodgy science but I cannot recall a programme the size of DiRECT, with so many participants in two centres coming up with something that is hopelessly wrong in its basic findings.

What I have seen is lots of dodgy reporting of very good science where what the scientists say in the technical papers is cherry picked to support a particular point of view by those more interested in the PR value of the work rather than technical accuracy. Is that the thing you are concerned about?
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You have got to remember that Taylor is a polemicist rather than a seeker after objective truth. He has pet theories to prove and interprets every available scrap of evidence to prove himself right and ignores everything else. It's Logical Fallacy called Confirmation Bias. In addition to that he is adept at self-promotion.

Look at the quote you offered in your last post. The 2017 DiRECT trial was a failure, a year after it ended 53% of the Intervention group were not in 'remission' as defined by Taylor. So Taylor recasts that failure as a success, 'almost half' he says succeeded. It's a disingenuous hiding of the truth and your uncritical parroting of it in your other post is part of the myth-making process.

By the way the research in 1955 proved that weight loss was critical in T2 management. It's been standard advice for 70 years not a new discovery of Taylor.
 
Burylancs said:
........................................

Look at the quote you offered in your last post. The 2017 DiRECT trial was a failure, a year after it ended 53% of the Intervention group were not in 'remission' as defined by Taylor. So Taylor recasts that failure as a success, 'almost half' he says succeeded. It's a disingenuous hiding of the truth and your uncritical parroting of it in your other post is part of the myth-making process.

By the way the research in 1955 proved that weight loss was critical in T2 management. It's been standard advice for 70 years not a new discovery of Taylor.
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Three points:
1. 47% in remission isn't a failure - how many who are on medication alone are in 'remission' ?
2. There is evidence (which Taylor is also associated with) that Low carb (without calorie restriction) works for just over 50% of those who are able to do it (D Unwin et al) and that it also works for weight loss and blood pressure normalisation.
3. There is debate as to whether the effects in DIRECT were due to the extreme calorie reduction also being a reduction in carbs, though we know that the Low Carb effect is independent of calorie reduction. So although weight loss is critical, the actual method used for weight loss may not be critical.
 
Burylancs said:
You have got to remember that Taylor is a polemicist rather than a seeker after objective truth. He has pet theories to prove and interprets every available scrap of evidence to prove himself right and ignores everything else. It's Logical Fallacy called Confirmation Bias. In addition to that he is adept at self-promotion.

Look at the quote you offered in your last post. The 2017 DiRECT trial was a failure, a year after it ended 53% of the Intervention group were not in 'remission' as defined by Taylor. So Taylor recasts that failure as a success, 'almost half' he says succeeded. It's a disingenuous hiding of the truth and your uncritical parroting of it in your other post is part of the myth-making process.

By the way the research in 1955 proved that weight loss was critical in T2 management. It's been standard advice for 70 years not a new discovery of Taylor.
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My quote was interpretation statement in the Lancet paper:


and please, I am not in the habit of parroting things.

Again, I think you are being unduly harsh in describing the trial as a failure. I can accept that the relationship between diabetes and obesity predates this study but for me the most interesting thing about it is that it was a statistically based study which put numbers to the relationship.

By the way, there were 25 authors on that paper, and yes I know all about author creep in this type of document. Are you suggesting all of them were subject to confirmation bias?
 
Docb said:
My quote was interpretation statement in the Lancet paper:


and please, I am not in the habit of parroting things.

Again, I think you are being unduly harsh in describing the trial as a failure. I can accept that the relationship between diabetes and obesity predates this study but for me the most interesting thing about it is that it was a statistically based study which put numbers to the relationship.

By the way, there were 25 authors on that paper, and yes I know all about author creep in this type of document. Are you suggesting all of them were subject to confirmation bias?
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Read the full Lancet article, it's full of contradictions. Even this Abstract is contradictory. The opening statement says 'Type 2 diabetes is a chronic disorder that requires lifelong treatment.' But the final paragraph contradicts this by claiming that after a year nearly half the guinea pigs were in 'a non diabetic' state. Is it a lifelong condition or isn't it ?
The opening statement is wrong anyway, despite its 25 authors, because there is no 'treatment' for Type 2 only management of the symptoms in the current state of knowledge.
Also in the main article Taylor claims that his 'remission' won't stop T2s getting complications. Totally illogical - if a T2 is allegedly in 'remission' and temporarily has no connection to Diabetes ( in a 'non-diabetic state') how could they develop diabetic complications ?
And if Taylor's so called remission isn't going to stop complications, the average T2 might well ask what's the point, I might as well pop the pills and do the injections.
And it's in his main Lancet article that he claims to have fed T2s on a diet including up to 20% of their nutrition from the ether. His recommended maintenance diet at the end of the Lancet article increases the Carb recommendation from 50% in the trial to 53% in maintenance ( for no apparent reason ). So the maintenance recommendation is slightly less bizarre than the diet claimed for the experiment in that the T2 is only expected to get 17% of their nutrition from Fresh Air.
Wow ! 25 authors and not a single one of them, apparently, can add up to 100 !
 
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Unfortunately the full Lancet paper is behind a paywall and I am not inclined to pay $40 for 24hrs access to it. If you have an open access source, maybe you could post it. It would also help if you could reference the "main Lancet article" you refer to and I will try and find that.

One thing I would say is that your suggestion of contradiction between the opening in closing statements of the summary is not something that would raise concerns amongst many. It is a summary. The opening statement is a simple statement of their starting point. The final statement is a simple statement of their position after the work described. Those positions are different, not contradictory, something to be expected if the work done has provided useful additional information.

Cannot comment on the bulk of that paper or the other you point me towards for the reasons stated.
 
Burylancs said:
And it's in his main Lancet article that he claims to have fed T2s on a diet including up to 20% of their nutrition from the ether. His recommended maintenance diet at the end of the Lancet article increases the Carb recommendation from 50% in the trial to 53% in maintenance ( for no apparent reason ). So the maintenance recommendation is slightly less bizarre than the diet claimed for the experiment in that the T2 is only expected to get 17% of their nutrition from Fresh Air.
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As a reminder, if you want more detail/precision, the presentation to IDF Abu Dhabi of the primary outcomes of Direct in 2017 that I linked to above provides it.

These are the relevant slides

1686812808457.jpeg

Which would obviously have been delivered with a good deal more detail in the commentary.

I’m not sure it’s very helpful repeatedly dismiss the whole trial, or suggest that it did not take place, because of a summary range of values (albeit poorly expressed) in a paper behind a paywall?

Edit: Doc B beat me to it 🙂
 
Must admit @everydayupsanddowns that I found the assertion that the numbers did not add up a bit odd. Either the numbers do add up and @Burylancs has misread them or the numbers don't add up and it either does not matter or is a serious flaw in the work.

My approach in untangling this sort of stuff is to go right back to the source documents and see for myself what they say. Sadly it is behind a prohibitively expensive pay wall and so I cannot easily do that. Do DUK have copies of the lancet papers which I might be able to consult?
 
Docb said:
Must admit @everydayupsanddowns that I found the assertion that the numbers did not add up a bit odd. Either the numbers do add up and @Burylancs has misread them or the numbers don't add up and it either does not matter or is a serious flaw in the work.

My approach in untangling this sort of stuff is to go right back to the source documents and see for myself what they say. Sadly it is behind a prohibitively expensive pay wall and so I cannot easily do that. Do DUK have copies of the lancet papers which I might be able to consult?
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The poster called Travellor posted a link to the famous Lancet article of 2018 early last year. It's the article that pretty much kicked off the whole of the current, fashionable Remission Industry. It would be instructive to follow up in the Lancet and see what comments and rebuttals are in the following editions of the Lancet. Upto the Lancet article Taylor was talking about 'reversal' of Type 2 but there is nary a mention of that in Lancet 2018, you suspect the Editor might have banned the word, and insisted on 'remission', not wishing to make the magazine into a laughing stock.

The DiRECT trial of 2017 used the Cambridge Diet, shakes and bars, which has been around since the 60s. Perhaps Cambridge's figures for carbs/proteins and fats were casually cut and pasted into DiRECT without thought or analysis.

Taylor was right about one thing way back in about 2012 when he said a diagnosis of Type 2 Diabetes should be treated as a medical emergency requiring immediate intensive action. A nice contrast with GPs dismissing newbies and telling them to come back and see the nurse in six weeks.
 
Burylancs said:
The poster called Travellor posted a link to the famous Lancet article of 2018 early last year. It's the article that pretty much kicked off the whole of the current, fashionable Remission Industry. It would be instructive to follow up in the Lancet and see what comments and rebuttals are in the following editions of the Lancet. Upto the Lancet article Taylor was talking about 'reversal' of Type 2 but there is nary a mention of that in Lancet 2018, you suspect the Editor might have banned the word, and insisted on 'remission', not wishing to make the magazine into a laughing stock.

The DiRECT trial of 2017 used the Cambridge Diet, shakes and bars, which has been around since the 60s. Perhaps Cambridge's figures for carbs/proteins and fats were casually cut and pasted into DiRECT without thought or analysis.

Taylor was right about one thing way back in about 2012 when he said a diagnosis of Type 2 Diabetes should be treated as a medical emergency requiring immediate intensive action. A nice contrast with GPs dismissing newbies and telling them to come back and see the nurse in six weeks.
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If that is the diet developed by Dr Howerd, I was involved in that.
I worked for Allied Lyons in the early 70's, at their factory and labs in Market Harborough and tried out their sachets whilst under development - there were soups and also desserts which set - they were rather nice. I think that the flavours were strawberry, peach and chocolate desserts and there was beef - maybe called oxtail, mushroom and chicken soups - I think. I did storage testing, to ensure that there were no off flavours at various times after manufacture.
Using diet to treat and control diabetes is not at all recent - it was known about long before Dr Atkins was finding that his way of eating resolved many cases amongst those at his clinic.
 
everydayupsanddowns said:
As a reminder, if you want more detail/precision, the presentation to IDF Abu Dhabi of the primary outcomes of Direct in 2017 that I linked to above provides it.

These are the relevant slides

View attachment 26304

Which would obviously have been delivered with a good deal more detail in the commentary.

I’m not sure it’s very helpful repeatedly dismiss the whole trial, or suggest that it did not take place, because of a summary range of values (albeit poorly expressed) in a paper behind a paywall?

Edit: Doc B beat me to it 🙂
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Can you tell us WHEN those figures date from ? Which IDF conference in Abu Dhabi it dates from ( it's held every year).
 
Burylancs said:
Can you tell us WHEN those figures date from ? Which IDF conference in Abu Dhabi it dates from ( it's held every year).
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It is mentioned on the first slide that I linked to. Perhaps you didn’t spot it?

IDF Abu Dhabi, December 5th 2017. Presented at 4.30-4.55.

Like many of these congress / conferences, IDF seems to bounce around from place to place. I think it may have been held in AbuDhabi a couple of times?

1686852322782.jpeg
 
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@everydayupsanddowns. The link to the preprint seems to be the 2017 paper. Thanks!

It's going to take a bit of reading through to get to grips with it but I think I can see where @Burylancs uneasiness might be coming from in that I don't think anybody living with type 2 would have come up with the way in which some things are expressed in the introduction. I will need to get deeper into the paper to see if any of that affects the substance of the work - which I doubt. I also get the sense that the work started out assuming that weight loss would be a good start to getting blood glucose control for those that were overweight and their primary objective was to come up with some ideas about what level of weight loss might be beneficial and whether that could be achieved in primary care. I can see how that might have got overblown when translating the lab work in to the sort of stuff you need to get public attention and more funding. I've played that game myself so don't get upset when I see it in others.....provided the underlying science is sound.

I will read on over the next couple of days and see where I get.

Any clues about where I might find the 2018 paper?
 
Docb said:
Any clues about where I might find the 2018 paper?
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I couldn’t find that. The Diabetes UK research/info team may be able to peek behind the Lancet’s curtain, but having seen the conference slides and now the preprint of the paper (prior to Lancet publication) both agreeing on what the shakes and maintenance menu involved in the actual trial (which I believe was being queried), I can only think it must be some later extension work where the conditions were less controlled and an approximate indication of ranges was used.

I’ve looked back through forum posts mentioning Lancet, and had no luck finding the elusive 2018 article. It’s not listed in the DIRECT publications list - so perhaps some slightly more journalistic coverage?
 
@Burylancs - can you point me to the "famous Lancet article of 2018"? Do you think it was another formal paper from the DiRECT study or something from the Lancet editorial team? If I knew that it would help in hunting it down

You have set me off on another puzzle! Hope I can get further than I am with trying to make my minimalist monitor work with the mac mini running linux.
 
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