Tuesday, July 05, 2005

Atkins Low-Carb Quandry Update

You may recall that I recently wrote about a European television series, Diet Trials, that followed dieters on four diets - Atkins, Weight Watchers, Rosemary Conley and Slim Fast - for six months. The show was followed with great interest by viewers who watched, week after week, as those following Atkins lost more weight while their triglycerides plummeted (a good thing) significantly more than those on other diets.

The very public demonstration that an Atkins diet can help one lose weight and lower cardiovascular risk factors left the medical establishment in Europe in a quandry - without solid long-term safety questions answered, how can they recommend low-carb diets for weight loss?

As I said in my previous article, it is short-sighted to limit options to those who are overweight and obese today while waiting for research data that both clinical case studies and anecdotal evidence suggests is safe and effective for at least six months. Barring any major metabolic issues, the vast majority of individuals will not need to remain at very limited carbohydrate levels for the long-term.

Who in Europe listens to me though?

I was not surprised at all by the follow-up Op/Ed letter in IC-Wales today - Healthy diet, lifestyle change and more exercise key to losing weight - from Dr. Nadim Haboubi, a consultant physician and Sian Jones, a specialist dietitian.

Without missing a beat or departing from the low-fat dogma, they make it clear they are alarmed about the article...regarding the safety and the efficacy of Atkins diet.

Their first issue with the Atkins diet is that [t]he principal aim of weight management is...to introduce a negative energy balance to reduce body weight.

I whole-heartedly agree!

And what the research shows is that those who are placed on a low-carb diet - both in controlled settings and in "free living" conditions - eat less calories without having to count calories. So, what's the problem when even they admit the low carbohydrate diet is quite popular currently as it achieves a short-term weight loss mainly through reducing appetite. (emphasis mine)

Well, they continue onto their second issue, that one has to maintain a lower body weight over the longer-term.

Imagine that, I agree again!

I do find it amusing that they felt they had to state the obvious. What we know, again from the research, is that regardless of diet used to lose weight, people have a hard time keeping weight off for the long-term. Why, you might ask. It's simple - they too often return to the very eating habits that caused the weight gain in the first place. The ONLY surefire way to assure weight maintenance is to make a permanent change in your eating habits for the long-term.

This is something that, when reviewed from Induction to Maintenance, Atkins (and other low-carb diets) try to do for the long-term. This is also where I believe many are missing the "big picture" of low-carb diets. I'll get to that in a moment though since there was another issue they felt necessary to include in their letter.

In the long-term, they contend that it is important to ensure that people who are obese are following a healthy balanced diet that is low in saturated fats and high in complex carbohydrates.

Ready for a "really big" problem now?

To date, research has never exclusively followed two controlled-groups, over the long-term, to determine if only a diet low in saturated fats compared with a diet "higher" in saturated fats is 1) safe, 2) healthy, 3) cardio-protective, 4) reduces risk of cancer, 5) lowers cholesterol, 6) reduces incidence of degenerative disease, 7) enables better weight management long-term or 8) improves quality of life and/or life expectancy long-term.

But wait you say - everyone points out research over the years that shows that those who follow a diet that is lower in saturated fats are healthier!

Here's what I say...The research used as evidence does indeed make that correlation.

Keep in mind though, correlation is not causation.

When you look at the evidence, something important keeps returning to make the data hard to use as "proof" - confounding factors.

So, what are "confounding factors?"

They're things in a study that impact the results, for better or worse, and make determining exactly what caused the results difficult to tease out of the data with certainty.

For example, much of the data used as "proof" are from lifestyle intervention studies where multiple "lifestyle problems" are addressed and remedied all at once - change diet, add medication to lower cholesterol and/or blood pressure, require smoking cessation, include an exercise program and even teach relaxation techniques.

So the question begs, at the end of such a study, what exactly caused the results?

Anywhere you have multiple interventions, you have confounding factors - unless, at the start, a way to account for each is established and each is accounted for in the final results. And while some studies have sought to address the above confounding factors, there are still other confounding factors to consider too.

Other confounding factors - and ones that I think are more important - what types of foods are included in the diet change versus the control group? What level of trans-fats are in both diets? What about fried foods and the potential HNE's? How much "junk food" is in each diet?

All of these things impact health and they have not been adequately tracked in the studies used as "proof" that low-fat diets are healthy because they are lower in saturated fats.

In fact, at the end of the day, it may just be that it's the lower trans-fats, HNE's and junk food that results in better health and the level of saturated fat may have nothing to do with it. We simply do not know or can state with certainty that it's lower saturated fat because no one has actually looked at these other confounding factors when determining results for different dietary interventions.

You may be thinking, that's outrageous, she's nuts, no one debates the issue of saturated fats or thinks they're even healthy!

To such doubt I ask you remember that I look at evidence...and here are some eye-opening numbers for you.

As of this year, 2005, the United States once again experienced an uptick in life expectancy, now reported to be 77.7 years on average, up from 77.4 years in 2002. Impressive, huh?

During that same period, the United States fell in its worldwide ranking for life expectancy, when compared with other countries, from 28th to 48th. We barely remain in the top-50 countries in the world for life expectancy. [CIA World FactBook]

Just some food for thought to start with as I present some more interesting numbers.

In countries often cited as the "picture of health" with low rates of obesity, cardiovascular disease and other degenerative diseases, who live longer than we do - here is the level of saturated fat they eat as part of their daily calories (these statistics are from the British Journal of Medicine, WHO and CIA World FactBook):
  • France
    Total Fat: Men 37.7%; Women 40%
    Saturated Fat: more than 15%
    Obesity rate = 11%
    Life Expectancy Rank = 16th, 79.28 years
  • Spain
    Total Fat: Men 39.2%; Women 38.9%
    Saturated Fat: 13%
    Obesity Rate = 8.6%
    Life Expectancy Rank = 19th, 79.23 years
  • Italy
    Total Fat: 34.7%
    Saturated Fat: 12%
    Obesity Rate = 6.7%
    Life Expectancy Rank = 14th, 79.4 years

I've made a point to look at three countries often highlighted as examples of the "Mediterranean Diet" lifestyle. While the media tries hard to convince us those in these countries are eating a low-fat diet, the statistics point to another reality.

Not only do people in these countries outlive us and suffer less from a variety of degenerative diseases, their diets are markedly different than ours - the majority of their meals prepared at home from fresh, whole foods; there is significantly less reliance on packaged processed foods; they liberally use natural fats and oils in cooking with significantly less trans-fats in their diet; and they consume much lower levels of added sugars in their diet.

So tell me again, without any doubt, it's the saturated fat that's deadly and must be kept low in the diet if one wants to be healthy long-term...and then go tell those who are living longer, healthier lives in a true Mediterranean diet that they're eating too much saturated fat. Convince them that our recommendations in the US are better for long-term health and longevity.

Which now brings me back to the editorial...where yet another additional assertion was made.

It is important to note that those who are on the Atkins diets do restrict their intake from protective foods (such as fruits and wholegrain cereals). This is of concern as research has shown a clear association between poor fruit and vegetable intake and bowel cancer.

The point often lost in the whole debate - restriction is not elimination.

The fact is that even during the most restrictive period on Atkins, some fruits are included.

Yes, tomatoes, pumpkin, avocado, lemons, limes, squash and even macadamia nuts are all really fruits and all are allowed during the first two weeks of Induction. After the first two weeks all berries (strawberries, blueberries, raspberries, blackberries, etc.), along with honeydew melon, cantelope and other low glycemic-index fruits are not only allowed, but encouraged.

Ahhh, but what about grains - surely we need those, don't we?

Need to eat and like to eat are two different things. While it is true that grains and grain products are restricted initially - and fiber intake really is the issue for including them - I often wonder why no one points out the fact that non-starchy vegetables are higher in fiber and more nutrient-dense?

Throughout both Induction and Ongoing Weight Loss, the volume of non-starchy vegetables is high, and one is expected to maintain that level of intake for the long-term as they add more carbohydrate selections, including whole grains.

Let me be clear here - the foundation of low-carb is non-starchy vegetables and that remains the foundation as one moves along and modifies their diet to be controlled-carb long-term.

This is something that those stuck in the low-fat dogma fail to acknowledge in their quick dismissal of low-carb and controlled-carb diets. Many also lose sight of the fact that in the long-term, whole grains are allowed and re-introducing them is encouraged as one is still losing weight. Are you starting to see how, over time, low-carb diets are trying to teach new eating habits long-term? You don't just diet and then try to maintain a diet. Instead you start by restricting particular foods and slowly but surely adapt your diet along the way so that by the time you've lost the weight you now have a lifestyle pattern of eating you can continue with long-term.

But of course there is the issue of foods that are higher in saturated fats, right?

Keep in mind that allowing a food is not requiring a food.

While Atkins and other low-carb diets often include foods typically banished in low-fat diets, like beef, lamb, natural cheese, cream and eggs, there is no requirement one eat them or ever eat them in excess.

In fact, eating anything in excess is strongly discouraged because one goal in low-carb weight-loss diets is to learn new eating habits while one is losing weight and learning to listen to satiety signals the body sends when you eat. By allowing selections often deemed "unhealthy" by low-fat doctrine, one is given an opportunity to actually learn how to eat the very foods that tempt them later after they lose weight and are now trying to maintain weight!

How anyone misses this is beyond me.

How anyone can say, with a straight face, that eliminating trans-fats, avoiding refined carbohydrates and junk food and significantly reducing added sugars is unhealthy long-term is beyond me. Oh, yeah, those aren't things that the critics often ignore too.

Anyone who can think that a diet of mostly whole foods - non-starchy vegetables, legumes, whole grains, meats, eggs, cheese, poultry, fish, natural fats and oils, fruits, nuts and seeds, herbs and spices, and even moderate amounts of starchy vegetables - is unhealthy needs to rethink the connection between diet and health.

In the United States we have a crisis on our hands and to summarily dismiss low-carb diets is missing an opportunity to help those who are obese now.

By remaining focused on the first few weeks of restriction in low-carb diets, we're missing the point of long-term lifestyle modification, long-term changes in eating habits and the potential for better long-term health by ignoring the fact that long-term, low-carb diets are modified slowly, as one continues to lose weight, to reduce fat intake while increasing carbohydrate intake.

One only needs to open Dr. Atkins' New Diet Revolution or Atkins for Life to see that, plain as day, in black and white - as carbohydrate intake increases, fat intake decreases.

At maintenance, controlled-carb diets, like Atkins for Life, are not "low-fat," but they're certainly not excessive in fat calories either. In fact, controlled-carb starts to look very similar to the real life eating habits in France, Italy and Spain for macronutrient mix and foods encouraged in the long-term.

Tell me again that's not healthy!

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