Atkins Diet: Several articles:

Subject:  The Atkins Diet may promote temporary rapid weight loss over the short term. Long term effects are still unknown.

The Atkins Diet

As the Atkins Diet has moved from obscure curiosity, to fad, and now to national obsession,  I find myself troubled.  The Atkins' Diet, as you must all know by now, is an extreme low carbohydrate diet, to the degree that followers consume more meat, poultry and fish than anyone would have imagined healthy a few years ago.  For a long time the only people who thought this diet could be a good idea had a commercial interest in meat production. This focus on eating meat, protein and fat rather than the multitude of complex carbohydrates, fruits and vegetables favored by traditional dieticians is so contrary to the accepted model of good diet that most professionals thought Atkins' claim that the diet promoted weight loss were either delusional or an outright scam.  Over the years frequent articles have made light of Dr Atkins' purported claims.  Yet in the last year several studies have supported using this diet.  Patients do lose weight faster and surprisingly their cholesterol
  profile
has improved.

Cool, so it wasn't a scam.  Yet there are still basic questions that haven't been answered and theoretical concerns of risk versus benefit that may take long term studies to answer.

Look at it this way, if you changed your dog's diet drastically, say you switched dog food brands, and the dog started to lose weight, you might wonder if this was OK.  But if we find a new diet that for some unclear reason forces our bodies to lose weight, we not only find it acceptable, we accept it like a new religion.

What do we really know about the Atkins' diet? Not nearly as much as you'd think for how popular it is.  A review article published in April, 2003 looked at all the studies to date using low carbohydrate diets and suggested that these diets might lower weight in a manner similar to other diets. [1]  Caloric reduction below expenditure produces weight loss.   A thousand calories of lean beef produced weight loss equivalent to 1,000 calories of say oat bran, blueberries, and carrot juice. Sizeable portions of meat are filling and perhaps it is easier to feel satiety on fewer calories of meat than of granola? But the data weren't good enough to say much more than their conclusion: "There is insufficient evidence to make recommendations for or against the use of low-carbohydrate diets, particularly among participants older than age 50 years, for use longer than 90 days, or for diets of 20 g/d or less of carbohydrates."   
An older study from Switzerland half a dozen years ago summed it up like this: "The results of this study showed that it was energy intake, not nutrient composition that determined weight loss in response to low-energy diets over a short time period." [2]  The low carbohydrate dieters did show interesting improvements in blood profile, lowering, fasting plasma glucose, insulin, cholesterol, and triglyceride concentrations.

A valid criticism of these studies is that they were looking at low carbohydrate diets and not necessarily as low as what Dr Atkins' may prescribe.  Since Spring 2003, a series of articles have come out showing value in the Atkins' routine.
An April, 2003 study followed women eating a similar total calorie but low carbohydrate versus a more typical diet.  The low carbohydrate participants, lost lots more weight over a 6 month period, an average of 8.5 Kilograms compared to 3.9 Kilograms. [3] This allowed the exciting conclusion, "Based on these data, a very low carbohydrate diet is more effective than a low fat diet for short-term weight loss and, over 6 months, is not associated with deleterious effects on important cardiovascular risk factors in healthy women."  This is probably when Atkins' books implanted itself on the best seller lists. 
A study in the New England Journal of Medicine a month later produced somewhat similar results but this time used severely obese patients as test subjects, again over a six month period.  Weight loss was less for both groups but again the low carbohydrate group did better with a weight loss of 5.8 versus 1.9 Kilograms. [4]
The same journal published another similar study at about the same time.  This one looked at obese men and women, found a similar advantage in weight loss over a three and six month period; low carbohydrate patients lost 6.8% versus 2.7% of their body weight during the first six months.  What was different is they ran the study for a full year. [5]
In running the study longer they found something very interesting that had not shown up in the shorter studies.   By twelve months the differences in weight loss between diets were no longer significant.  Low carbohydrate dieters stopped losing weight and started to regain. What happens after a year? If one extrapolates this leveling off and the loss of ground seen at 12 months to an imaginary 18 month point, the weight loss has evaporated.  The patients weigh as much after 18 months as they did at the start of the study. 
So why bother? What have people gained following this diet?  Over the short term they lose weight quickly.  Perhaps a non obese person could use this diet to lose enough weight that they could start an exercise program and keep the weight off.  At this time there is no evidence that any of these dieters keep the weight off for the long term.
Living on protein is more expensive than living on carbohydrates which of course are cheaper.  The Atkins Diet is for the affluent not the destitute.  Someone actually did publish a study confirming what seems rather obvious.  [6]
The basic blood numbers which we associate with risk for coronary vascular disease seem to improve more on the low carbohydrate diet. Can we equate this with fewer heart attacks?  The studies didn't last long enough to tell us this.  So at this point we don't know and I wouldn't want to make the same mistake Premarin did and promise heart disease protection without real data
Severe caloric restriction of any kind slows the metabolism making it progressively more difficult to lose weight.  In a way, the body learns to hibernate to protect itself from starvation.  Carbohydrate restriction has an even stronger effect, shifting the conversion of thyroid hormone (T-4) to Active hormone (T-3) toward the production of an inactive hormone (Reverse T-3), leading to a pseudo hypothyroid state. 
The focus on high caloric fat and protein seen in the Atkins' Diet drastically reduces fruit and vegetable consumption.  High meat consumption is associated with increased cancer rates.  High fruit and vegetable consumption is protective against cancer.  Combining the effects, begs the question, are we trading a few months of weight loss for a significantly increased risk of developing cancer?  We may be duplicating the tradeoff we thought we had using hormone replacement therapy for menopausal women:  we reduce the risk of heart disease only to increase the risk of cancer.  As everyone knows now the benefit of reduced heart disease turned out to be a myth and hormone replacement only increased cancer risk without changing heart disease risk appreciably.

Clearly fat consumption is not the simple cause of obesity.  People are able to lose weight on high fat diets. At the least, our national pursuit of low fat foods may be on the wane.  Total calories consumed may still be the best measure of which diets will produce weight loss.  Total carbohydrates and especially simple sugars may be the best measure of effect on blood fats.  The more sugar in the diet the higher the blood fats.

Obesity is a disease that is having a significant health impact on people in our country.   Though due to many reasons, one of the major reasons is the consumption of excessive amounts of simple carbohydrates.  Shifting from simple carbohydrates to complex carbohydrates makes sense.  Reducing total carbohydrates to a level seen in primitive, prehistoric diets makes theoretic sense.  That a significant portion of the population has taken it upon themselves to experiment with such a drastic diet still leaves me marveling at the way we think.

It is only in recent years that certain populations have had the affluence to even ponder how to lose weight.  Before now and in most of the world, the goal is still the opposite.  We do not have a long historic tradition of weight reduction diets to draw on.  Evolution has shaped our physiologies to survive in a hungry world.  It has not molded us to live in a world of excess.  We have reached a point in which we have choices in diet.  Our choices go beyond edibility, availability, simple economics and taste preferences.  We are trying to understand and design diets that promote health, happiness and longevity.  This is a challenge when the successful genetic programming that allowed our ancestors to survive directs us to consume and store excess calories as efficiently as possible.

The Atkins' diet adds another important piece to our understanding of dietary interventions.  What its long term effects will be, we don't know.  At this point we think that it helps obese people lose weight over the short term.  What effect it will have on cancer rates and other diseases over the long term? I don't know. 


references:

  1 Bravata DM, Sanders L, Huang J, Krumholz HM, Olkin I, Gardner CD.Efficacy and safety of low-carbohydrate diets: a systematic review.
 JAMA. 2003 Apr 9;289(14):1837-50. 
  2 Golay A, Allaz AF, Morel Y, de Tonnac N, Tankova S, Reaven G. Similar weight loss with low- or high-carbohydrate diets. Am J Clin Nutr. 1996 Feb;63(2):174-8.
  3 Brehm BJ, Seeley RJ, Daniels SR, D'Alessio DA.A randomized trial comparing a very low carbohydrate diet and a calorie-restricted low fat diet on body weight and cardiovascular risk factors in healthy women. J Clin Endocrinol Metab. 2003 Apr;88(4):1617-23.   
 4 Samaha FF, Iqbal N, Seshadri P, Chicano KL, Daily DA, McGrory J, Williams T, Williams M, Gracely EJ, Stern L. A low-carbohydrate as compared with a low-fat diet in severe obesity. N Engl J Med. 2003 May 22;348(21):2074-81. 
  5 Foster GD, Wyatt HR, Hill JO, McGuckin BG, Brill C, Mohammed BS, Szapary PO, Rader DJ, Edman A randomized trial of a low-carbohydrate diet for obesity. JS, Klein S. N Engl J Med. 2003 May 22;348(21):2082-90. 
   6 whoops! I don't think I kept a copy of this reference.  I'll have to find it again.


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Subject:  I stand corrected on certain statements I made regarding the Atkins Diet

      In a lecture last August, Dr Tori Hudson mentioned a bumper sticker she'd seen.  It said, "Don't believe everything you know."  Dr. Hudson was lecturing on the ever changing research on hormone replacement therapy (HRT).  Imagine what it must be like for MDs who have prescribed HRT for decades under the premise that it protected women from heart disease to adjust to our new understanding that it doesn't.  For a while I couldn't remember the wording of the bumper sticker and came up with several versions meaning more or less the same thing.  "Not everything you believe is true" was my best guess until I looked at my notes from the lecture.  It is with this little mantra floating in the back of my mind that I have received an email that asked me to reconsider some belief's which I have taken for granted. 

     It was while pondering this disconcerting thought that I received a response to the email I sent out about the Atkins Diet taking me to task for some of the things I thought were true.  It was from a gentleman who has done exceedingly well following this diet. 

     In his words, "I am in no way associated with the Atkins Center or any of its products.  I am just one its success stories.  Over the last 2 years, I have dropped 65 pounds with a restricted carbohydrate approach.  I am now on maintenance consuming loads of fruits and vegetables as well as meats and I have never felt better.  I mountain bike and climb Fourteeners and I am now in the best cardio vascular shape of my life.  My lipid profiles have improved dramatically and I am no longer a victim of the blood sugar roller coaster ride that affects so many others. I have been dealing with weight management since I was ten years old.  Years of low-fat dieting was a total disaster."

   So my first question is does this information change anything I think or have said about the Atkins' Diet. Perhaps. The Atkins approach is one of the best at directly changing hyperinsulinemia which contributes to many people's weight problems.  Of course it is not the only diet that seeks to lower insulin production, both Sears' Zone Diet and Heller's Carbohydrate Addict's Diet have similar goals though with differing techniques. This is what I have thought and continue to believe.

      Several studies have shown that the Atkins diet is superior to low fat diets at producing weight loss over a six month period. The one long term study I found, which only went a year, did seem to indicate that many people might have trouble maintaining the weight loss and that after an average of 18 months may have been back up to their original weight.  Yet this isn't the case with this gentleman so I commend him. It is clear that he has changed more than his diet and he exhibits the evangelical zeal that can lead to long term life style changes.

     Is the Atkins better than Zone or Heller or Whatever Beach Diet?  I don't know.   Diets that lower insulin production seem to be the trick for many people. The bottom line is which diet can they follow the easiest for the longest time?

     This fine gentleman brought up another point.  I had questioned the risk versus benefit of Atkins based on the assumption that the higher fat and meat consumption would increase cancer risk for adherents. 
     Again to quote the letter,
"One of your statements is misleading. Your statement 'High meat consumption is associated with increased cancer rates' I think is based on a study which showed higher cancer rates with increased meat consumption while in the presence of almost every type of carbohydrate.  There was no studies conducted, that I am aware of, that studied increased meat consumption without the presence of excessive carbohydrates.  If there were, I'd like to know about them.  The entire basis of the Atkins approach focuses on the physiology and response of the body when not under the influence of insulin invoking carbohydrates which is exactly why you lose weight eating a quantity of protein and fat that would actually cause you to gain weight if that same quantity of protein and fat were consumed with carbohydrates."

    I have little doubt that there is an association between high meat diets and cancer just as there is an association between high fruit and vegetable diets and a protection from cancer.  But my good correspondent brings up an interesting question.  All of the epidemiological studies were on free living people who probably ate a typical amount of carbohydrates.  Are there studies looking at people following Atkins and their cancer rates?  Unfortunately, no.   A quick PubMed search for "carbohydrate consumption and cancer risk" did not provide any straight forward arguments supporting the idea that cancer was triggered by carbohydrates. In fact I did find data suggesting the opposite.  Yet this does not say the theory is wrong.  That meat is only cancerous in the presence of high carbohydrates is still an  intriguing belief.  The Atkins Diet does in many ways resemble what we call a Paleolithic Diet.  The cultivation of grain goes back only about 10,000 years at most.  Throu
 gh most
of evolutionary history and even until very recently most of humanity lived on diets that were more similar to what Dr Atkins suggested than our current high sugar and grain diet. 

    What do we know about the changes in health as this new modern diet was introduced?  Probably the best work to look at isn't recent but was done by Dr Vincent Price, almost a century ago now.  Dr. Price, a dentist documented via photos and dental records the deterioration brought about as Modern diets were introduced into 'primitive cultures.'  If you haven't looked at the before and after pictures of what a modern diet has done to people you should check out the website of the Price-Pottinger Foundation.  It is accepted that these primitive cultures had lower cancer rates than ours.  So perhaps there is something to this idea.

    Yet was it the addition of wheat and sugar that caused the increase in cancer or was it the decrease in plants, fruits, fish, nuts or other nutrients?  Or was it simply the increase in total calories? These are not easy questions to answer.  It is well accepted that the more fruits and vegetables people consume the lower their cancer risk.  One common misunderstanding about the Atkins Diet of which I was reminded is that it is not always as extreme as it is during the initial phase. 

     Again to quote my writer, "I also noticed you made the same mistake discussing the Atkins approach that almost every other article ever written has made in the past.  The extreme low carbohydrate intake is only part of the induction segment of the dietary plan.  As you progress on the diet, more carbohydrates are recommended until you reach the maintenance part of the diet where upwards of 80-100 grams per day of carbohydrates are acceptable as long as the participant does not begin to gain weight back.  This is the part of the Atkins diet that never gets spoken about and is a huge injustice.  No where in the Atkins Diet guidelines do they instruct people to stay on the induction part of the diet permanently."

    If 80-100 grams of carbohydrate are allowed over the long term in the Atkins Diet will this allow adequate fruit and vegetable consumption?  The government's goal of five a day should probably be our minimum when talking about cancer prevention and does not include nuts.  A better goal might be ten a day of fruits, vegetables and nuts. A serving of fruit typically has about 10 grams of carbohydrate, a serving of vegetables about 5 grams.  The Atkins' 80 gram carbohydrate allowance could allow 3 fruits (at 10 grams each) and 10 vegetables (at 5 grams each) per day. So in theory the Atkins diet, over the long haul, allows more than adequate amounts of carbohydrate for cancer protection.  Thus my concern that the Atkins' Diet was a trade off between weight loss and cancer is not really valid. I stand corrected.

   In all this debate the best summary I have found comes not from a peer reviewed journal but from October, 2003's edition of Gourmet. 

     Writer Michelle Stacey sums up the situation like this:
"Never mind that The Washington Post calls the Atkins diet "a classic" and "practically gospel" among the fashionistas, or that The New York Times claims that a "healthy slice of New York's high society is hooked on Atkins," or that New York magazine has declared a general "carb panic" or that your best friend lost 25 pounds on Atkins.  Our bodies don't read magazines, and our taste buds aren't style conscious. Maybe on some cellular level we want slices of baguette on which to place our chevre, potatoes with our marbled steak, a tarte Tatin to finish a great meal, and the occasional bagel or bowel of cereal for breakfast.  There must be reasons why man cultivated grains and created dessert --- reasons beyond cultural and purely physical..
"The body also craves sweetness - the first taste a newborn human recognizes--- which is only one reason why Paris without patisseries is unthinkable. If the Atkins juggernaut ends up slowing America's mindless pursuit of tasteless carbs---the nonfat frozen yogurts, the pillowy muffins and cinnamon buns and hubcap sized pretzels that line deli windows--- it deserves its place in culinary history.  But for the sake of our national cuisine and of our chef's let's hope it is accompanied by the return of the risotto, the yeasty bread, even the silly slice of toast under the poached egg, that we're born to love."


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DNC News:  And still more on Atkins Diet.

Subject:
A letter from someone critical of the Atkins Diet


It seems I opened a can or worms when I began a discussion of the Atkins Diet. Recall that several weeks ago I wrote a newsletter reviewing the research I could find on the Atkins Diet which suggests that it is an effective way to lose weight for several months.  I expressed concerns about the long term consequences of following it.  I then sent out another letter quoting heavily from a letter sent by one of my readers who has done very well following this diet.  I can not in all fairness stop now, but must print a rebuttal sent in by another reader.

Then I am going to change the subject. Last week I read an article in the paper about the growing shortage of safe drinking water in the world.  When a significant portion of the world's population can't find a safe drink of water, it gets difficult for me to fixate on the pros and cons of these diets. 

OK here is the letter:

"I think it is important to point out that there are definite downsides to the Atkins diet that many people never hear about. Since the "studies" that are frequently quoted in support of the Atkins diet were based on non-scientific surveys sponsored and paid for by Atkins, I think it is important to note that independent studies, and new medical technology, have shown that while Atkins may have been onto something for some people, the diet is certainly not appropriate for all, and has some disturbingly unhealthy drawbacks.

"Independent studies have been finding that while the overall level of blood lipids improves on the Atkins diet, the improvement may be due more to reduced
girth than to the diet itself. What is disturbing about it is revealed in further use of technology on the part of the developer of the South Beach Diet; that is that a diet high in saturated animal fats produces serum cholesterol molecules that are smaller and "stickier" (and therefore likely to clog arteries despite the reduced volume of serum cholesterol) than a similar diet that gets its fat from unsaturated, non-hydrogenated vegetable sources. While Dr. Agatston compliments Atkins on "his" diet, which is really only a recycling of one that has been around since the 1800s and has enjoyed periodic fad popularity from time to time ever since, he does point out that because of the cholesterol molecule size, Atkins needed to refine his diet. By reducing carbohydrate of the refined type along with cutting saturated fat, Agatston found that the cholesterol molecule produced by people on SBD was larger and "slipperier" and less likely to stick to artery walls.

"While many born again dieter disciples who follow Atkins belittle the South Beach Diet with puzzling zeal as being "Atkins Lite," they fail to recognize that SBD is not low carb, and does not include the saturated animal fat so abundant in the Atkins plan. Unfortunately, the failure to recognize this distinction may ultimately prove devastating for their cardiac health. Disturbing anecdotes from Atkins dieters who experienced cardiac problems after adhering to it for long periods of time are starting to emerge with disturbing regularity.

"Another of the aspects of the Atkins diet that many do not recognize because they do not avail themselves of emerging technology, is the devastating effect it can have on metabolism for moderately active to active people. I have been having my metabolism tested periodically for a couple of years. I made the mistake of trying the Atkins diet for about three months last year. I quickly pleateaued after losing only six pounds.

"At the start of Atkins, my Resting Metabolic Rate (RMR) was 1850 calories a day. When I plateaued on Atkins, I found that my RMR had dropped to only 1350 calories, in spite of my cardio exercise and strength training. I was not getting enough carbohydrate in my diet, and my body was burning muscle for quick energy. Our bodies have a more difficult time burning stored fat than muscle when there is not enough glycogen available in the liver--my body got it from muscle rather than fat.

"I stopped Atkins immediately, and reintroduced adequate carbohydrate. In  a couple months of concentrated strength training effort, I have managed to increase my metabolism by 330 calories a day. Now that I am back on track with a so-called "high carb" diet, I have started losing fat again--ten pounds in the last month, and my RMR is still humming along.

"The proof of efficacy for a diet is in my mind the track record on maintenance. The primary weakness I see of any book/food based diet is that it does not give the support needed for most people to lose and more important, maintain those losses. That takes concentrated effort for the 66 percent of all overweight people who are that way not because of the food they eat per se, but because of the emotion-spurred overeating they do on a regular basis. That takes support from others and sometimes treatment beyond an eating plan alone. It is estimated that less than 33 percent of overweight people have any chance of success without combining their weight loss program with behavior modification. Fad diet books do not focus on this or on exercise, the two most important factors for long term success.

"I took off 55 pounds on a so-called "high carb" diet and kept it off for a little over a year. When I got ready to get the rest of it off, I turned to both Atkins, which was a disaster, then SBD, which I found effective for maintenance, but not weight loss because it is only food-based, and does not incorporate nearly the level of behavior modification I found personally to be a necessary part of treatment. Now I am back on a so-called "high carb" diet, and I am losing at a regular rate, and I am addressing the rest of the very behaviors and problems that got me there in the first place.

"I would say that the single most important aspect of this was not what food I was eating, but the overall amounts of food coupled with behaviors and environmental factors that led to overeating on a daily basis. In order to address that problem, it took more than an eating plan. Eating plans like Atkins and the South Beach Diet, which promise that you can eat all you want and still have the pounds melt away, are not realistic for people who have problems with portion control and/or Binge Eating Disorder. That means they are not realistic for more than 66 percent of all overweight people.

"Each person has to decide for themselves what is right for them, but we need to go into the chosen method with open eyes. Over the last 30 years, I have known many people who tried low carbing to control their weight. None of them had long term success, for a variety of reasons. Not one. During that same time, the only people I have known who have achieved permanent weight loss have been those who had the aid of programs like Colorado Weigh, Weight Watchers or Jenny Craig, or similar programs offering long term behavior modification support. Researches by the National Weight Loss Registry (Through the University of Colorado and Mirim Hospital ) indicate similar findings. Those who achieved maintenance for longer than five years have a couple of things in common over the long term: Low fat eating (no matter how they may have initially lost the weight) and exercise.

"They are currently doing scientific research on the low carb approach to weight loss, and are debunking many of the premises upon which these plans are based. The only thing that is clear is that there are no long term scientific studies to support many of the claims made by low carb proponents, and it will be some time before the effect on long term cardiac health is known. However, early results indicate that it is probably not going to be good.

"The National Weight Loss Registry defines successful losers as those who have taken it off and kept it off for five years or more, with less than  five pounds of upward movement during that time. I don't know anyone who has eaten low carb that has achieved that. You'd think wouldn't you, that if this is such an effective method for weight control, that I would have been in contact with at least a few success stories, what with the millions who have gone on low carb diets over the last century and a half, wouldn't you?  Especially considering that I have known dozens more people that have tried low carbing than I have known who have tried the old standards?

"Truly, I think it has much more to do with what we have come to believe are reasonably sized servings over the last 20 years. Supersizing has put more than double the amounts of sugar and fat into American's diets during that time, while giving them less net nutrition. The average American diet puts more than double the amount of low quality carbohydrate and sugar inside us each year than our forebears did. What people think is a standard serving of pasta these days is four times the actual serving recommended by the Food Pyramid. The same for a single bagel. One order of Supersize french fries has four to five servings of potato and 23 g of fat--more than half the daily fat recommended and two more than the daily starch servings in just one meal item--and that doesn't include the sandwich! Throw in a Big and Tasty Cheeseburger, and you get another 37 g. of fat. That's 60 g of fat and over 1100 calories in just one meal, 520 calories of it from fat alone. That's almost doubl e the daily recommended fat in just one meal! Sorry, but I just don't buy the Atkinsized notion that the Food Pyramid is flawed because Americans have become fatter since it was initiated. Firty percent fat in a diet is not anything even approaching the recommendations of the Food Pyramid, and therefore cannot be used as some sort of "proof" that the Food Pyramid is off base. It is extremely flawed reasoning to make that assumption. The Pyramid recommends about one-fourth to half of everything the average American consumes, in all categories."


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