There’s a hold up in the Bronx,
Brooklyn’s broken out in fights.
There’s a traffic jam in Harlem
that’s backed up to Jackson Heights.
There’s a scout troop short a child,
Kruschev’s due at Idlewild!
Car 54 where are you?
Anyone who watched TV in the early sixties no doubt remembers the hilarious show Car 54 Where Are You? starring Fred Gwynne and Joe E. Ross as New York uniformed police officers Francis Muldoon and Gunther Toody. Muldoon and Toody were well meaning but hopelessly inept, always screwing things up in outrageous fashion, causing no end of grief and embarrassment to their precinct commander Captain Block, who had to sort out the idiocy and try to make things right.
Now comes the medical equivalent of Muldoon and Toody in the persons of in-training physicians Tsuh-Yin Chen, M.D. and William T. Smith, M.D. The role of precinct commander in this production is played by one Klaus-Dieter Lessnau, M.D., who, unlike Captain Block, only adds to the problem with another layer of ignorance and stupidity. And whereas Car 54 Where Are You? left its viewers with their sides hurting from laughter, the repercussions of our medical drama will be felt painfully in the world of nutrition for years to come. A well-respected medical journal will have a blot on its record in much the same way CBS did after rushing to air the discredited George Bush Air National Guard story before it was authenticated, and, lastly, the whole episode will serve as a cautionary tale to anyone considering going to the emergency room of a teaching hospital.
Our drama unfolds not on the TV screen but in the emergency room of Lenox Hill Hospital in New York. The script for this show is contained in an article in the current issue of The Lancet titled A life threatening complication of Atkins diet. Let’s tune in.
First, a brief synopsis of what happened–a treatment as they say in Hollywood–then we’ll review the case in more detail to see what really happened.
An obese woman who had been on the Atkins diet for the previous month came to the emergency room complaining of shortness of breath. The resident physicians who saw her found evidence of elevated ketone bodies in her blood, diagnosed her with ketoacidosis, admitted her to the intensive care unit, gave her IV fluids, tested and x-rayed everything, and discharged her four days later after a complete recovery. The resident physicians along with their attending physicians wrote this case up as an example of what could happen to someone following a low-carb diet and got it published in a prestigious British medical journal, accompanied with an editorial issuing a further warning as to the risks of low-carb dieting. The press was all over the story and one of the attending physicians issued statements to anyone who called.
Let’s look a little deeper. This is the patient’s history:
In February, 2004, we saw a 40-year-old obese white woman who complained of dyspnoea (shortness of breath). 5 days earlier, her appetite had decreased, and she had felt nauseous and had since vomited four to six times daily. She became increasingly short of breath, and presented to us as an emergency.
She had strictly followed the low-carbohydrate high-protein Atkins diet, eating meat, cheese, and salads for the previous month.
This lady was truly on the Atkins Diet:
She took vitamins recommended by the diet: chromium picolinate, Atkins Basic3 (multivitamins; Atkins Nutritionals, Inc, USA), Atkins Essential Oils (omega fatty acids), Atkins Dieters’ Advantage (electrolytes and extracts), and Atkins Accel (a “thermogenic” formula). As instructed by the original Atkins diet book, she monitored her urine twice daily, with dipsticks strongly positive for ketones. She reported a weight loss of about 9 kg over this 1-month period.
Here is her presentation and the doctors’ physical findings along with my commentary:
On presentation to the emergency department, our patient was in moderate distress, with a respiratory rate of 20-30 breaths per min.
‘Moderate distress’ breathing at a rate of 20-30 breaths per minute? I don’t think so. A normal respiratory rate is between 12-20 breaths per minute, but obese people tend to breath a bit faster since they have a lot going on metabolically and need a little more oxygen. I wouldn’t say that an obese person breathing 20-30 times per minute was in distress, especially in view of the rest of the physical exam, which we’ll see in a moment. The resident physicians are trying to make a case for severe metabolic acidosis with this patient. If the patient truly was in severe metabolic acidosis (as type I diabetics can be if they go into ketoacidosis) she would have been demonstrating a type of breathing called Kussmaul breathing, which is characterized by rapid, deep, labored, sighing breaths familiar to anyone who has ever seen a bad case of ketoacidosis. We’re this patient exhibiting Kussmaul breathing, I’m sure it would have been identified as such in the published case report.
On examination, her bowel sounds were hyperactive and she had mild epigastric tenderness. Otherwise, clinical examination was unremarkable with normal vital signs.
Okay, when the resident physicians listened to this patient’s abdomen they heard more active, louder bowel sounds than normal and when they pushed on her abdomen she told them it was mildly tender. And her clinical examination was ‘unremarkable’ and her vital signs (blood pressure, heart rate, etc.) were normal. It doesn’t sound like someone in distress to me. When patients are in distress, their heart rates and/or blood pressure readings are usually elevated.
Her body-mass index was 41.6 kg/m2.
Interestingly, the case report doesn’t tell us this patient’s height or weight, only her body mass index (BMI). I assumed a height of 5′ 5″, which, when run through the BMI calculator, gives a weight of 250 pounds.
So, let’s see what we’ve got so far. An obese, 40 year old lady who has been nauseated and vomiting (4-6 times per day) for the past five days shows up in the emergency room. She is breathing a little faster than normal, but, given her weight, probably not by much. She doesn’t appear to be in any distress and all her vital signs are normal. Her abdomen is a little tender (whose wouldn’t be after vomiting for five days?) and her bowel sounds are hyperactive (think of the last time you got some kind of abdominal flu; I would be willing to bet that you could hear your own bowels gurgling without the aid of a stethoscope). Every doctor who has taken care of patients for any length of time has seen this same picture countless times. It’s a diagnosis that can be practically made from across the room.
The patient has gastroenteritis, an infection (probably viral) of the gastrointestinal tract. She may be a little dehydrated if she hasn’t been able to keep any fluids down, but she has probably been able to hold some fluids on her stomach or her blood pressure would be low and her heart rate rapid from the dehydration. If you’re the physician taking care of this patient you might want to run a couple of other tests just to make sure, which you do and find out that her blood sugar is normal (so you know she isn’t a diabetic in ketoacidosis) and her amylase is okay (so she doesn’t have acute pancreatitis) and her liver enzymes are normal (so she probably isn’t afflicted with hepatitis) and her white blood cell count is elevated, which goes along with an infection. You then might drip a liter of fluid into her intravenously to rehydrate her and make her feel better, give her a shot to reduce the nausea and vomiting or maybe a prescription for a suppository for the same thing, tell her to drink only clear fluids, and come back if she doesn’t get any better. In virtually all cases the patient will get well.
Then as you’re discussing all this with the patient, you find out that OH MY GOD, SHE’S BEEN ON THE ATKINS DIET! Now, if you’re an experienced physician, you tell her to not worry about her diet for a while until she gets over her nausea and vomiting, but that once she’s recovered she can return to her low-carbohydrate weight-loss efforts..
If you’re Muldoon and Toody, however, you panic. Low-carb diets cause ketosis, you think. Maybe she’s in ketoacidosis, which can be fatal. Since you’re an idiot, you ignore her normal blood sugar level, which should tell you that she’s making plenty of her own insulin. As the level of ketone bodies rises in the blood, it stimulates the release of insulin from the pancreas. The spurt of insulin then shuts down the process that makes ketones. Ketones only rise to dangerous levels in people who have type I diabetes and can’t make their own insulin. If the system didn’t work this way, people who starved would die from ketoacidosis relatively quickly, but they don’t; they live for weeks without food before they succumb to protein malnutrition, not ketoacidosis. The idea that this patient, who had a normal (or probably an elevated) insulin level was in dangerous ketoacidosis is absurd, but Muldoon and Toody don’t realize this because the patient HAS BEEN ON THE ATKINS DIET, FOR GOD’S SAKE.
In their frenzy of misdiagnosis, the panic-stricken Muldoon and Toody check the patient’s blood levels of beta-hydroxybutyrate, a specific ketone body, and find it to be high. They, of course, don’t bother to realize that, the Atkins diet notwithstanding, elevated levels of ketones would be expected since the patient hadn’t been able to hold anything on her stomach for five days, and when people don’t consume food they break down body fat for energy and produce ketones in the process. Nope, that would be way too rational. These doctors-in-training have the diagnosis of ketoacidocis burned into their brains thanks to the red herring of the Atkins diet, and they’re looking for anything to confirm it. They check a bunch of other labs that don’t really show anything all that earth shattering (and, in fact, don’t even really compute–but that’s a technical issue beyond the scope of this post) and admit the patient to the intensive care unit. Car 54 Where Are You?
In a typical teaching setting, the next morning the resident physicians would present their patient who is now resting comfortably in the intensive care unit at about $5,000 per day, and whom, in their own minds at least, they had just snatched from the jaws of impending death from ketoacidosis, to their attending physician. In a typical teaching hospital, the attending physician, who would have had a number of years of patient experience, would gently (or maybe not so gently) tell the residents that they had overreacted a little and would walk them back through the situation with a Socratic-type dialogue that would probably go something like this:
‘You checked this patient’s blood sugar and it was normal, right? Okay, now, what does that blood sugar tell you about the condition of the patient’s pancreas? Uh huh, that’s right, it’s making plenty of insulin. Okay, now, if the patient is making plenty of insulin, is it really possible that she could be in life-threatening ketoacidosis? Okay, guys, let’s review how ketones are made…’ You get the picture. I know how these little dialogues go because I was a resident at one time, and I was on the other end of a number of them. In fact, I had an attending physician in surgery, famous for his sarcasm, who, had I done something like these two had done here, would have led me through the whole Socratic-dialogue process so that I could see every misstep I made along the way, then would have shaken his head and said, “Well, Doc, which is it? Are you stupid or do you just not care?”
But that wasn’t how this one must have gone there at the Lenox Hill Hospital. Instead of Captain Block gently reading Muldoon and Toody the riot act, our leader, Dr. Klaus-Dieter Lessnau, must have fallen into the OH MY GOD SHE’S BEEN ON THE ATKINS DIET trap. Instead of showing his underlings the folly of their ways, he jumped right in there with them, wallowed in their stupidity, kept this poor patient in the intensive care unit for four days, and may have even said, ‘let’s write a paper on it.’ After the paper was published and made the news, our attending was ever so eager to bask in his 15 minutes of fame and talk to any reporter that called and further memorialized his own boneheadedness. See here and here. Had members of the press possessed even a smidgen of medical knowledge or had they checked with anyone other than Dr. Lessnau himself, the many pieces appearing about this fiasco might have been entitled something along the lines of:
Buffoons misdiagnose mild gastroenteritis, cost patient thousands.
Unfortunately, however, the press, afflicted with its own pro-low-fat bias, has been more than happy to take this opportunity to lambaste low-carb diets. Car 54 Where Are You?
In a perfect world, after this idiocy had consumed both the residents and their attending physician, and was then written up and sent out to journals for publication, someone, somewhere, with good sense, doing peer review would see it, realize it for what it was, and reject it. I have no way of knowing, but I suspect from the dates involved that that is exactly what happened. These events took place over two years ago in February of 2004, and were, I’m sure, written up shortly thereafter, and shipped off to some medical journal. I seriously doubt that The Lancet was the first choice. I would imagine that these authors received a number of rejections, but kept sending the paper out. It finally fell on fertile soil with The Lancet where not only did the editors fall for this ignorance hook, line, and sinker, they saw fit to publish a supporting editorial written by a dietitian turned PhD at the University of Minnesota. Car 54 Where Are You?
The editorial goes through the following argument. Although a number of studies have shown the low-carbohydrate to be superior to the low-fat diet in oh so many ways, we’ve got to be concerned about dieter safety. The report by Muldoon and Toody shows what can happen to a dieter on a low-carbohydrate diet. This patient could have died. The Atkins diet (and by extension all low-carbohydrate diets) are unbalanced. If you don’t believe it, compare the Atkins diet to the 2005 US Dietary Guidelines (and we all know how perfect those are). We’ll even provide the table. There, you see:
Clearly, the Atkins diet is not nutritionally balanced.
And they finish off with:
Special care needs to be taken when formulating the best prescription for weight loss, because people choosing to lose weight range from being marginally to significantly overweight, and might have a wide range of disease risk factors with varying levels of severity. As researchers and clinicians, our most important criterion should be indisputable safety, and low-carbohydrate diets currently fall short of this benchmark.
So, with this paper and accompanying editorial all the low-fat zealots have gotten what they’ve been waiting for. For years when MD and I and Robert Atkins and Ron Rosedale and Robert Crayhon and Jonny Bowden and a host of others have extolled the virtues of the low-carbohydrate diet, all the naysayers said: Where are the studies? All your clinical experience is simply anecdotal; we want to see the science. Show us the studies.
Well, over the last three or four years these folks have been deluged with studies showing the superiority of the low-carb diet over the low-fat diet for not just weight-loss, but for lipid lowering, blood sugar control, and blood pressure reduction as well. In any head to head challenge, the low-fat diet hasn’t been able to lay a glove on the low-carb diet.
Now that the low-fatters have been bloodied with all these studies they have been demanding for years, they haven’t given up, they’ve only changed their strategy. Since they can’t successfully argue on the merits, they’re resorting to scare tactics. Sure, they’ll say, you’ll lose weight alright, solve your lipid problems, and all the rest, but look at that poor lady who almost died. It was written up. That could happen to you, you know.
And to think that The Lancet has been a party to this travesty is almost beyond belief until it is recalled that it was The Lancet that published the Dean Ornish I’ve-proved-that-my-diet-has-reversed-heart-disease paper back in 1990. Like the current paper, the 1990 Ornish paper, in my opinion, was not worthy of publication without some serious rewriting. But, it is obvious that the powers that be at The Lancet have a bias in favor of low-fat dieting. And, based on the publication of these two papers, not just a mild bias, but a totally slanted perspective. In fact, I think that the name of the journal should be changed the The Slantcet.
Car 54 Where Are You?