Interview with Adele Hite

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I came across Adele's blog shortlyafter 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 whileconverting to a backup computer and getting everything functioning tokeep my blog moving. Then her October 9, 2012 blog reached out andfinally let me know what I was reading and that it was not thestandard nutrition blog. Yes, I had ideas before that, but this onereally made me sit up and take notice. Now I am rereading many ofher blogs with a new insight and understanding. Keep up the goodwork Adele!
It is with enthusiasm that I am happyto have an interview with Adele Hite and a person that doesunderstand the needs of people with type 2 diabetes.
Bob: Please tell us whom AdeleHite 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 thatis truly and deeply outraged at what is going on in our food-healthsystem. I mean really angry. I try to be morecalm and circumspect in my writing and in my talks, because there isa whole big food-health establishment that needs to change anddiplomacy is important. But in person I can get really upset aboutthe issue, especially when it comes to diabetes, because that hitshome for me. My father was diagnosed as prediabetic a number ofyears ago; his doctor was “old school” enough to give him theoptions of either eliminating sugars and starches or startingmedication (which is a reminder that the way everyone treateddiabetes before the widespread use of insulin was to have patientsreduce the sugars and starches in their diet). My dad chose theformer and enlisted my help. I gave him a glucometer and some basicnutrition biochemistry information. That was all he needed to figureout a diet that keeps his blood sugars in check and his HbA1c normal(not “diabetes-normal,” but truly normal). The diet he settledupon is not one that the American Diabetes Association or the Academyof Nutrition and Dietetics would recommend, although in every respectit is very nutritious, filled with lots of veggies and adequateprotein with natural fat at every meal.
When I did my hospital internship, Iwas horrified to see so many people with diabetes who were losingtheir bodies bit by bit—a few toes here, a foot there, eventually alower leg, then the whole leg—with failing kidneys, failingeyesight, and lives that were defined almost entirely by theirdisease state. They weren’t near death but they were dying, quiteliterally, piece by piece, It was like some awful science fictionmovie; it felt as if we were keeping these folks alive just enough tokeep a steady supply of them coming into the hospital, dialysiscenter, and wound clinic where, as health professionals, we couldmake a show of treating them and get paid well for doing that—butwe weren’t going to give them the opportunity to stop the progressof the disease by being willing to let them eat (gasp!) eggs orsteak. Every day, as I saw these folks hooked up to wound suctionmachines or dialysis, I was profoundly grateful for my dad’s doctor(the now-retired Dr. Ronald Moore of New Bern, NC) and for theopportunities I had to learn that there was a different way. I amjust as profoundly angered that we, as health care professionals andpublic health policymakers, give these patients and their families noother choice. I look at my dad and I know that there is a differentending to his story with diabetes that is not such a happy one. Icould be losing him a little bit at a time, watching him suffer foryears and years. I could be watching him have toes and feet becomeblack with infection and then chopped off. He could be blind andcrippled and enduring the painful process of dialysis multiple timesa week. But he had a choice. And I am sickened by the knowledge thatthere are sons and daughters that have no other choice than to standby helplessly and watch as those things happen to a mother or fatherthat they love.
Whew. When I’m not outraged andangry, I’m a mom with three dangerously smart and funny childrenwho forbid me to talk about nutrition in front of them, which is finewith me. I do have other interests! I have been teaching yoga forabout a dozen years now, although my students teach me far more thanI teach them. I also write songs with my husband, who is not only100% supportive of my work, but who makes sure I have a life awayfrom nutrition. He’s an incredibly talented musician who playsguitar and sings in multiple bands. Sitting in an audience watchingpeople dance to a song I wrote or hearing them sing along is justabout the coolest thing ever. I love being outdoors. I walk trailsnearby with my husband and friends at least once a week. We go tothe beach or to the mountains in NC frequently. I love camping bymyself and cross-country skiing with my family. These things keep mesane 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 lookforward to the day when everyone has the choices my dad had and myefforts are no longer needed.
Bob: What drew you to nutritionand 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 wesay, in self-defense. I liked cooking and became interested in thenutrition aspects of food when the low-fat, vegetarian agenda tookhold of the nation in the 1980s. Embarrassingly enough, I climbed onthat bandwagon with little skepticism at the time. It worked finewhen I was younger, but as I got older and had kids, I found myselfin a constant battle with my weight. At 60+ pounds over my normalweight and officially “obese,” I was valiantly trying to get myweight under control, but the harder I tried, the harder it was tolose. Finally, I was eating about 1200 calories and exercising 2hours a day—and not losing any more weight. What was worse is thatI was miserable. I was hungry and exhausted. My hair was fallingout. When I went to my family physician for help because I was sure Ihad some kind of weird metabolic condition, he told me I was fine butthat I needed to lose some weight because my blood pressure and bloodsugar numbers were going up. He suggested I eat less and exercisemore. To my everlasting credit, I did not kill him on the spot.
Instead, I gave up dieting andexercising 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 andfewer carbohydrates, I did lose weight and I’ve kept my weight in anormal range for over a decade now. But that’s not why I madenutrition a career.
Because Dr. Eric Westman of the DukeLifestyle Medicine Clinic knew that I’d lost weight using the sametype of diet he was using to treat patients in his clinic (our kidswent to the same school and we’d been in the PTA together), heasked me to join him in his work. I ended up as the PatientEducator, helping patients learn how to adapt their shopping, eating,and cooking habits to a reduced-carbohydrate diet.
As I got to know these wonderfulfolks who were struggling with overweight, obesity, and diabetes, Ikept hearing the same story over and over again. It was veryfamiliar because it was my story too. They had tried to lose weightby lowering fat and calories and exercising, but it didn’t workvery well, or very long—or, for some folks, at all. After findingsuccess with the clinic’s diet, the patients kept asking the samequestions. Why were we told that eggs and meat are bad for us andbread and cereal is good for us when we feel so much better on thisdiet? Most of all, they wanted to know: Why weren’t we given thischoice before? I didn’t have an answer, but their own outrageabout how this option was never presented to them convinced me to goback to school to try to figure it out what was going on in nutritionand health care.
Bob: Is there a differencebetween nutrition and dietetics and is this important?
Adele:Yes and no. Both fields are centered around finding ormaintaining health through food. But the scope of nutrition is muchwider than dietetics, and there are many ways to study or practicenutrition in addition to being a dietitian; you could say thatdietetics is a subset of nutrition. Almost by definition, if youare in dietetics, your training and education has been dictated bythe Academy of Nutrition and Dietetics (AND) which has a particularagenda shaped by its close association with food and pharmaceuticalmanufacturers and with the USDA.
The difference between nutrition anddietetics is important because the AND has been leveraging itsfinancial backing to lobby state by state for restrictive licensurelaws that allow only Registered Dietitians to practice nutrition. This is a bad thing for the consumer because it would furtherrestrict our already-restricted choices about nutrition information. People deserve the option of hearing a perspective on nutrition thatis not influenced by one particular organization. Iam fully committed to the idea that dietitians and othernutritionists should be held to high professional standards, butother nutrition professionals actually have higher educationalstandards than RDs. You can become an RD with only a 4-yearBachelor’s degree plus internship hours, as compared to a CertifiedNutrition Specialist which requires Master’s or PhD level training. I also believe that nutrition professionals should be at theforefront of preventive medicine and health care reform—butdietitians cannot be the only nutrition professionals allowed topractice. 
Unfortunately,as long as the AND is chained to USDA guidelines, food manufacturers,and pharmaceutical companies, the interventions and advice ofdietitians will be ineffective at best, damaging at worst.  And,as result, dietitians will be poorly paid, our motivations willbe suspect, our advice will be (as it should be) disregarded, and asprofessionals we will be marginalized.  We will remain on thesidelines, as we saw when RDs were denied Medicare/Medicaid coveragefor intensive treatment of obesity. If we want to be active playersin healthcare, dietitians will have to raise their own standards, andwe will have to disengage ourselves from industry influence. Wewill also have stop treating the policy guidelines that emanate fromthe USDA as if they are actually science, since they aren’t.
Bob: Is there hope for peoplewith type 2 diabetes that listen to members of the Academy ofNutrition and Dietetics (AND)?
Adele: Well, yes, depending on who those members are! All RDsare not necessarily members of the AND (just as all MDs are notmembers of the AMA), and even those who are may have progressive,science-based views on nutrition. At the North Caroline DieteticsAssociation (an affiliate state-level organization of the AND)conference, I heard a colleague discuss the merits ofcarbohydrate-restricted diets at a question & answer session—andno one contradicted her! Times are changing and those RDs are outthere. But you are right that the AND “party line” is probablynot the best choice for those with type 2 diabetes. During mytraining, I was appalled at how much RDs and other diabetes educatorsrely on educational materials from insulin companies to teachpatients about living with diabetes. These are not materials thatare going to help patients minimize their insulin consumption,which—along with overall blood sugar control—should be a goal oftreating diabetes.
Bob: In rereading your first twoblogs (often these set the parameters of things to come), you havespelled out an agenda and I think rightly or correctly laid thegroundwork for the blogs that follow. Have you changed any thoughtssince?
Adele:Your question prompted me to re-read those blog posts. Iwill readily admit that I shift my position on matters of food andhealth all the time, but I still feel pretty good about those posts. The primary shift that has occurred is that, every day, I becomeincreasingly oriented towards looking at the whole food-health systemand its dysfunction as an extension of social, cultural and economictrends that have been with us as long as the Guidelines have. Although I would stand by the assertion that the Dietary Guidelinesare very much at the center of that dysfunction, in some ways theymay be—like obesity—more of a manifestation of other trends thana cause in and of themselves.
Bob: You have two statementsthat have intrigued me. The first one is this - “Frequentlythose arguments (leptin insulin ghrelin, oh my!) boil down to acollection of snapshots from experimental data that may or may notcreate a physiologically significant or practically useful collage.” What is the significance of these three hormones in thediscussion?
Adele:One of the effects of the intense amount of funding andattention that has been poured into obesity research is that we havebeen learning, as they say, more and more about less and less when itcomes to obesity. I love biochemistry, but in nutritionalbiochemistry, our knowledge level sometimes becomes so detailed thatwe forget to climb back up the ladder and put all the piecestogether. This may be what is happening with some of ourinvestigations into hormones having to do with appetite, like leptinand ghrelin. Investigations into hormones that regulate appetite is,underneath it all, predicated on the assumption that people who areobese eat more than people who aren’t, or at the very least, eatmore than they “should”—whatever that means. The fact that wedon’t actually know whether or not this is true (or when it is trueand when it isn’t)—there is plenty of evidence that people withobesity often do not consume more calories than others—means thatthis has turned our attention away from trying to figure out why somepeople utilize the same number of calories differently than others;some store those calories as fat, while others burn them for fuel oruse them to build and repair the body.
Leptin is the hormone that issupposed to regulate appetite by telling the brain how much storedenergy we have. It was theorized that a leptin deficiency is whatprevented appetite from being “turned off” in people withobesity, who by definition have large amounts of stored energy. Whenwe discovered that people with obesity had the same levels of leptinas people with normal body fat levels, we had to start looking at theproblem in a different way. Dr. Robert Lustig has been doing a greatdeal of work with regard to leptin in human subjects, so I wouldcheck out his new book, Fat Chance, for a thorough discussion of thishormone.
Ghrelin is a hormone that stimulateshunger, but is also involved in regulating growth, learning, andmemory. It is usually talked about as the counterpart to leptin, andlike leptin, is linked strongly with insulin activity.
Insulin is very much at the centerof our current concerns about health, but you’d be surprised at howlittle we know about it—and what we do know we seem to haveforgotten. Insulin is a master hormone whose effects are feltthroughout many metabolic pathways, but it has three very basicfunctions: 1) to clear glucose from the bloodstream by ushering itinto cells where, if it isn’t used as energy, it is eventuallystored as fat; 2) to “turn off” glucose production by the liver;and 3) to “turn off” the process that allows body fat to be usedas energy. This last function is frequently forgotten in our hasteto treat people with diabetes. A Duke endocrinologist who wasmystified by the fact that her patients on insulin kept gainingweight—even though she told them to eat less and exercisemore--couldn’t even dredge up the fact that preventing“fat-burning” is a primary role of insulin!
Although it is hard to make anysweeping generalizations about people with obesity and ourinvestigations into leptin and ghrelin have shed little light on theissue, we do know one thing about people who are obese: theirinsulin levels have been elevated. We don’t know how often, or towhat extent, or in what fashion, or even why. But we do know thatmuch. Insulin, ghrelin, and leptin are strongly linkedphysiologically and we are just beginning to untangle thoserelationships, but at this point I would say that it is rare to haveleptin or ghrelin dysregulation without the upstream effects ofinsulin dysregulation.
We also know that the effects ofelevated insulin are not limited to increased fat storage. There isalso increased inflammation which may help explain the fact thatinsulin levels are a strong independent predictor of heart disease. But we haven’t really investigated that relationship because wehaven’t developed the tools to do that. The scientific developmentsthat allowed researchers to easily measure serum cholesterol levelsdrove the investigations into the relationships between diet, serumcholesterol and heart disease—which turned out to be a ratherfruitless path until we could start to further break down cholesterolmeasures 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 primaryfocus of nutrition science. But since we do not currently have aconvenient and consistent way of measuring or even talking aboutinsulin, this has not happened. I’m hoping that a breakthrough ininsulin 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, “Notethat I am not saying “Everything in moderation.” I am saying“Everything in context.”” Is this a key in the way foodshould be studied and whether a particular food is good for ourhealth at our time and period in life?
Adele:Absolutely. If I ate the way my son eats, I would store alot of body fat; if he ate the way I eat, he’d be very hungry. Ouractivity levels are about the same (I would even argue that I’mquite a bit more active than he is, as his favorite form of exerciseis to lay on the couch). But I’m a peri-menopausal female, and heis an adolescent male. We have very different internal environments,metabolic and hormonal settings, and diet histories. There is nosingle dietary approach that would make sense for both of us, unlesswe are talking about focusing simply on acquiring essentialnutrition—and even then, there are likely to be some significantvariations between his needs and mine. As a result, it makes littlesense to say this food or group of foods is “bad” and another is“good.” A dietary pattern that leads to good health for oneperson may not lead to good health for another, or even for that sameperson at a different point in his/her life.
As I see it, the biggest problem innutrition right now is that we think we know—for all Americansregardless of race, gender, or age—what foods are (and are not)going to lead to good health. Not only do we notknow (which makes us out of line when we tell people we doknow), but it causes us not to question the effectiveness of any dietthat we’ve already determined is a “healthy” one. When thishappens, we stop listening to the messages our bodies send us aboutour health. It doesn’t matter what kind of diet it is, if it doesnot lead to you waking up in the morning and experiencing a day whereyou feel healthy—whatever your definition of that is—it isn’ta healthy diet for you. It is the height of presumption for publichealth leaders to think they know better than your body does whatkind of diet that might be.
This assumption means that we havenot paid attention to bioindividuality and how that intersects withpublic health policy. The truth is we don’t know what kind ofdiet—other than one that provides essential nutrition and helps youmaintain a weight that is appropriate for you—will lead to goodhealth for you this year, much less 30-40 years from now.
Bob: What advice can you sharefor those of us with type 2 diabetes whether they are taking oralmedications or using insulin?
Adele:I think the most important thing to remember is that type 2diabetes does not manifest itself the same way in every person. People have different levels and varieties of insulin production andinsulin resistance that contribute to an elevation in blood sugar,which is the metabolic situation that results in a type 2 diabetesdiagnosis. Although everyone with type 2 diabetes has low insulinproduction, just how low can vary significantly. Everyone can reducethe work the pancreas has to do by reducing dietary carbohydrate. But people whose pancreases still make some insulin can reduce oreliminate medication this way, while others with less insulinproduction cannot.
Insulin resistance occurs throughoutthe body, but can specifically affect the liver’s ability to “turnoff” the production of glucose. If there is insulin resistance inthe liver and the liver continually produces more glucose than thebody needs, lowering dietary carbohydrate will only get you so farand some sort of medical intervention is almost always necessary.
That said, there is no knownphysiological need for dietary carbohydrate in the presence ofadequate intakes of protein and fat, and dietary carbohydrate is thefood group with the most significant impact on blood glucose levels. We also know that there is no known relationship between foods we’vebeen told to avoid—meat, eggs, butter, and cheese—and any chronicdiseases. At this point, we need to put the burden of proof whereit belongs: public health policymakers and advocacy groups need toprove that these nutritious, whole foods are truly as dangerous toour health as we’ve been told before they tell us to avoid them. Whether you are on oral medications, insulin, or controlling yourdiabetes through diet alone, your overall health will be best servedby feeding your body the nutrition it needs, and there is a lot ofnutrition to be found in foods we’ve been told not to eat.
Bob: Have you followed theactivities and the websites for Gary Taubes and Peter Attia and willthey be a help for you, that is, the Nutrition Science Initiative(NuSI)?
Adele:I do follow the activities of Gary and Peter, and I’mthrilled about the developments at NuSI. The work that NuSI is doingwill, I believe, support the changes that need to occur in publichealth nutrition policy. At the same time, science is only part ofthe problem. The Dietary Guidelines came into existence—and haveremained virtually unchanged for 30+ years—due not only to theoriesbeing promoted by some in the scientific community, but to political,economic, and social pressures. If this were really all aboutscience, well, the science is inconclusive on most matters ofnutrition. If the Dietary Guidelines had been based primarily onscience in the first place, they would say two things: 1) get youressential nutrition and 2) maintain a weight that is healthy for you. That’s all we really knew in 1980 when the first DietaryGuidelines were created, and that’s all we really know now. Butthe Dietary Guidelines are not based on solely on science, and itwill take more than science to address the changes needed in ourfood-health system. However, the efforts of NuSI will certainly helpto make the case that the one-size-fits-all dietary paradigm thatwe’ve been using since 1977 is inappropriate, which it mostcertainly is.
Bob: I like your last paragraphof your first blog and hope that all of us can do our part. “Atthe same time, I’m not here to wring my hands in anguish. I’mactively 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 anyonewith enough time on their hands to wade through my musings. Let’ssave the world & have fun doing it.”
Adele:Thanks! The work you do educating people with diabetesabout their options is essential to the changes we want to make inreforming the system. The current approach to nutrition in treatingpeople with diabetes is probably the weakest link in the chainsholding back progress. Your efforts will surely help to break thatlink.
Bob: Thank you, Adele! It is apleasure to publish this and there is a wealth of information thatneeds to be digested and expanded upon.
Her blog is here. Then with AdrienneLarocque they founded Healthy Nation Coalitionand that website is here.  Adele asked me to list an important person, Pam Schoenfeld, another founder and without whom the site would not exist.