Rules to Maintain a Balance

Sometimes when we first start a low-carb diet, our bodies react in ways that might seem off, so the next rule addresses the "potty problems" that some find when they're starting on a new low-carb diet.

Rule 12:

• If you are constipated, mix a tablespoon or more of psyllium husks in a cup or more of water and drink daily. Or mix ground flaxseed into a shake or sprinkle wheat bran on a salad or vegetables.

This rule compliments rule 11 - that is it helps with strategies to avoid and counteract constipation. Water and high-fiber supplements are recommended to help maintain regularity. With any changes to your daily diet your body may experience short-term bouts of constipation and the above rule helps get you through this. It also reinforces for the long-term what works for constipation naturally rather than chemically processed products or sugar-laden fiber mixes that are commercially available.

The secret of this rule is that it is providing you with natural ways to alleviate constipation, not only in beginning, but in the long-term as you look to maintain your goal weight if you still have occasional issues.Important in this rule is to understand what it is to be constipated.

Constipation is not just not having a bowel movement for a couple of days - it is having the urge to have a bowel movement and being unable to go to the bathroom! When you do finally go, the feces are dry and hard. While not going for a day or two may be alarming, if you are not uncomfortable, you are probably not constipated. When you are constipated it is important to be sure you are getting plenty of water and increasing your fiber so that you are able to go without straining. Drinking water as instructed in the previous rule along with this one give you the tools to regulate yourself naturally.

The last rule we'll look at speaks directly to the recommendation to take, at minimum a good multivitamin with minerals. It's pretty much a universal given no matter what type of diet you eat that you should include a vitamin each day, and the same is true for those starting a low-carb diet.

Rule 13:

• At a minimum, take a good daily multivitamin with minerals, including potassium, magnesium and calcium, but without iron.

Many people starting out on a low-carb diet with both feet and take a large number of supplements.

In this rule, Dr. Atkins makes it clear that at minimum you need a good multivitamin each day. Also specifically mentioned are minerals, which are important to maintain electrolyte balance, especially when you're starting a low-carb diet and will experience a metabolic shift to burn fat primarily instead of glucose, which releases a lot of water from stored glycogen.

Much like the rule on water (fluid) intake is universally agreed as a "good rule", so too is this rule. While some people will benefit from additional supplements to their daily multi-vitamin, it is not necessary to start with more than a good multi-vitamin with minerals.

In the long-term, maintaining this habit of taking a good multivitamin is also a good idea no matter what diet you follow.

It is important to note with this rule that the multi-vitamin must have potassium, magnesium and calcium - these control and keep in balance your electrolytes (your body salts), so chooing one with a good balance and ratio of these minerals is important. Important too is to use a multi-vitamin not packed with iron (unless you have a medical reason to take additional iron) since your diet will now contain enough iron (if you follow it correctly) each day without additional supplementation of iron. Too much iron is as deterimental to your health as too little. Unless you have a reason to take more iron, find a good multi-vitamin without iron!

The secret within this rule is to learn to keep a balance - insure you're getting all the nutrients you can with real food and have a multivitamin each day to be sure if you missed somewhere along the way, you had it in your vitamin.

This rule and the one before it aren't about extremes - it is about balance.

By taking care of potential "potty problems" and including a good multivitamin each day, you're developing a habit that will enhance your ability to get all of your nutrients each day - even on those days you may not eat "well".

Rules to Drink it Up!

Three rules specify the importance of adequate hydration and choosing beverages wisely.

Rule 9:

• Avoid foods or drinks sweetened with aspartame. Instead, use sucralose or saccharin. Be sure to count each packet of any of these as 1 gram of carbs.

Rule 10:

• Avoid coffee, tea and soft drinks that contain caffeine. Excessive caffeine has been shown to cause low blood sugar, which can make you crave sugar.

Rule 11:

• Drink at least eight 8-ounce glasses of water each day to hydrate your body, avoid constipation and flush out the by-products of burning fat.

Starting with the last one, drinking eight 8-ounce glasses of water, provides direction to make sure we consume enough fluids each day.

It's universally accepted that water is important; with disagreement as to whether fluid intake must be water itself or any beverage that helps provide hydration. I tend toward the belief that all fluids count toward water intake - if someone wants to drink water, great!; if someone wants to consume iced tea with lemon or a diet beverage, great! It's all good as long as we also are mindful of the other rules which have important considerations when choosing what to drink.

Rule nine limits consumption of artificial sweeteners and specifically suggests that we avoid aspartame (NutraSweet, Equal) because evidence suggests it stimulates insulin and may cause lowering of blood sugars. This in turn would trigger hunger and leave one open to eating more than desired. Else where in Atkins book he provides an allowance of three packets of articifical sweetener each day of the two he recommends. This limit isn't to say you can't have something sweet, but rather forces selection and limitation as you're starting a low-carb diet.

That one must count each packet of any artificial sweetener as 1g of carbs - this alone places a limit on how much you can have in a day, without stating it, if you're following rule three and getting the majority of your carbs from vegetables and salads. Long-term, into maintenance, this is an excellent rule - it limits your exposure to chemical sweeteners and lessens the chance you'll use them in excess if you continue to follow this rule for the rest of your life.

The potential of caffeine to affect insulin and blood sugars is also included in the rules. Each time you have caffeine, your body has an insulin response and the potential for cravings to be triggered. In addition to the potential for cravings being induced by caffeine, there is also the risk of feeling more hungry and eating more than you would had you not had the caffeine. While initially caffeine may supress the appetite, later after its effects are waning, you may actually feel more hungry than you would have had you not had the caffeine.

It is especially important in the first two weeks to do all you can to limit your cravings; as you can see from the above rules that are in place, many of them aid in limiting the cravings to keep you on track. It is also important to begin to fully understand "hunger" and how much sates your appetite rather than leaving you stuffed. By avoiding caffeine, limiting artificial sweeteners and keeping yourself hydrated you're accomplishing this goal.

Dehydration when following a low-carb diet, due to ketosis, is to be avoided. It will increase the concentration of ketones in your body and the result is less efficient buring of fat for energy. You'll also run a greater risk of getting constipated, as well as, a greater risk of painful headaches. Proper hydration while you're in ketosis will help to eliminate the ketones from your body in your sweat, urine and respiration - you need the water intake to accomplish this each day.

As an aside, I've found caffeine has little effect on me. Over the years I've noted that it's a "your mileage may vary" type thing and usually recommend an individual see how they feel with and without caffeine in their daily menu.

Rule Eight: Keep it Real

A low-carb dietary approach is easy to maintain almost anywhere you can eat - at home, on the road or in a restaurant. The key is to carefully consider your options available and understand where carbs are most likely to be found in things "allowed" when they're prepared by others. When you're cooking at home, you know what ingredients you're using; on the road or in a restaurant, odds are high that the chef is using ingredients you won't be including in a controlled-carb diet.

Rule 8:

• Eat out as often as you wish but be on guard for hidden carbs in gravies, sauces and dressings. Gravy is often made with flour or cornstarch, and sugar is sometimes an ingredient in salad dressing.

In an effort to keep it real, rule eight establishes that it's perfectly reasonable to eat out, with a caution to be aware of ingredients used in food preparation. As one more rule, it again repeats an underlying theme within all the rules - take responsibility for what you do eat.

Simply put, do not assume anything in a restaurant is acceptable unless you ask or ingredients are clearly stated on the menu! Where ingredients are not disclosed on a menu, learning how to ask and actually taking the time to ask about ingredients and food preparation is something you'll become accustomed to over time - and in the long-term will be an invaluable asset in your tool-box of strategies to insure you're eating controlled-carb for life!

When you eat out, in addition to the food you get, you're paying for a service - to have your food prepared - so be fully prepared to expect to be served acceptable food for your diet. Start by asking that things be prepared in a way that is acceptable for you or ask for guidance as to what else is acceptable if the chef cannot prepare something without particular ingredients. The basic ingredients, at minimum, you must insist are not included in your meal because of carbohydrate content are sugar, corn starch, arrowroot, potato starch and flour. The standard food ingredients to not be included are bread crumbs, breading, rice, pasta and potatoes, sugar based marinades, high carbohydrate salad dressings, etc.

In addition, you also want to be careful to avoid dishes prepared with shortening, margarine and other fats high in trans-fats. This isn't explicit to the rule above, but given our current knowledge, it's something to avoid when eating out.

If a restaurant is having a difficult time accomodating you, choose a simple salad wth oil and vinegar for your dressing, have a basic protein grilled (no marinade) baked or broiled, and some steamed vegetables.

In all the years I've restricted carbohydrate in my diet, I've never been unable to find something on a menu that's acceptable. Sometimes it means being a bit creative, but as long as a restaurant has basic foods, you can find something to eat as a meal while you're there.

Life Gets in the Way

Just a quick post to let readers know that life has gotten a wee-bit hectic here and this week time is short for writing the continuation of the series in progress. I'll be back on Friday morning with the next installement - hope you'll come back then as we continue looking at the rules of induction (Atkins) and how they provide us with insights for long-term success!

Study: Pediatricians Failing our Kids!

Earlier this week the Buffalo News carried Pediatricians slow to treat childhood obesity; an article critical of pediatricians - they were found in a survey to be "failing in large numbers to take Step 1 in the manual of fat prevention — calculating a child’s body mass index, or BMI." [emphasis mine]

Here readers are led to believe that Americas pediatricians are negligent in their basic duties of standard care for children - they're not calculating out BMI to "prevent" obesity in children.

Never mind the fact that the large majority are indeed weighing and measuring children at their routine well-child visits; ignore they have eyes to see and recognize a child who is too heavy; and heck, let's just forget they have experience, experience, experience, with years of taking care of kids to recognize the difference between an obese child and a normal child in their care.

Nope, let's just chastise them for exercising clinical judgement in their practice of medicine because they're not in lock-step with the additional recommendation to now calculate and chart BMI to "prevent obesity."

**sigh**

Some days I'm just tired of the misinformation and misleading of the public.

Calculating a BMI is data collection - nothing more; nothing less - and like any data collection, its usefullness is only as good as what one does with the data in hand.

Data such as a calculated BMI does not prevent disease (obesity); it is only a piece of a larger picture, and is a piece of data that is considered by many to be highly unreliable as a predictor of health.

Imagine for a moment you're a doctor, a pediatrician, and you've just weighed and measured this child:




















He's five, stands 3'10" tall and you've determined he weighs 54-pounds, thanks to the nurse who weighed and measured him then added those figures to his chart before you entered the exam room.

You give him the once over and note he's lean and healthy; his mother tells you he's very active, quite a little monkey outside climbing, running and jumping whenever he has a chance - and you note too that he is itching to get out of your office as quickly as possible, laughing gleefully as you continue along with your physical of him.

Do you calculate his BMI at this point in time?

No? No you say?

Why, you've missed this healthy and active kid is at the 95th percentile according to the BMI - in children, that's "overweight," the politically correct way of classifying a child who registers obese on the BMI chart.

In this example, this child is one of the roughly 15% in our nation classified as "overweight" for age.

So much for your clinical judgement - you failed to recognize the fat kid in need of intervention to improve their diet and activity levels before they develop other diseases correlated with obesity!

**sigh**

So what are we to make of the survey?

How about some context.

The researchers reviewed the charts of 400 children and found pediatricians calculated BMI in roughly 1 in 20 children; while 91% did actually weigh and measure height in kids.

Somehow the researchers failed to ask or look at those who were calculated to compare to those not calculated - perhaps these pediatricians fail not in their care, but rather fail to see the usefulness of calculating each and every child, especially those obviously a healthy weight.

Let's do math!

According to the IOM, it's estimated that roughly 15% of children this age are at or above the 85th percentile for BMI. A closer look defines an estimated 10% are at or above the 95th percentile for BMI.

Children who hit the 85th percentile for BMI are said to be "at risk for overweight" and those who reach the 95th or higher are said to be "overweight."

Stated another way, 85% of kids are well within normal weight, and some are underweight (as problematic potentially as obesity) with BMI calculated below the 85th percetile; another 5% may be "at risk" for becoming overweight/obese because they fall between the 85th and 94.9th percentile for BMI.

Simply put - 90% of children today are not obese; 85% are not obese or at risk for overweight.

But we don't hear or see that much in the media, do we?

The media and authorities, it seems, are working really hard to scare the beejeebers out of parents these days.

Yes, the prevalence of children who are calculated as having a BMI at or above the 85th percentile has indeed increased. Where in the 70's roughly 5% of children were at or above the 85th percentile, today roughly 15% are.

But we're communicating the increased prevalence in terms designed to make the increase an issue for every parent to not only worry about, but do everything in their power to change, when the fact is that 85% of children are normal weight (or underweight).

We're not just targeting adults with the message we have a problem in the United States - today every child is being targeted - with messages about diet, exercise, risks to future health, and even the potential of premature death; hearing, repeatedly, they'll die at an earlier age than their parents because kids today are too fat.

We really need to ask ourselves, must we target all children in our attempts to reduce obesity in some children, or are our resources and time better spent when they're directed and focused on the children who really do need some help?

While it may seem useful to chastise pediatricians, whom are quite competent in their daily practice of medicine, for not calculating every child's BMI - maybe a better question is why are they being asked to when 85% of the kids walking into their office each day are not too heavy?

Do we really think pediatrians are so daft they'd visually miss recognizing an obese child?

Do we really want to require a doctor to spend time calculating out the BMI for all children s/he sees and chart they actually did calculate it out too, when 85% of the patients are likely to be below the 85th percentile?

Add to this, a percentage of the children falling at or above the 85th percentile are not really overweight or obese - by the simple BMI they are, but as the above picture illustrates visually, the BMI is not always an accurate measure of true fatness that should cause concern.

How useful is it really, in the long-term, to have every parent in America wondering if their pediatrician is failing their child because they're not calculating BMI at the office visit?

Impact of Community Based Diet Intervention, More than BMI

There's been a lot of fuss over the publication of the Shape Up Somerville: Eat Smart Play Hard.™, initiative results in the May issue of Obesity. (abstract)

As noted in the abstract, the objective "was to test the hypothesis that a community-based environmental change intervention could prevent weight gain in young children" as reflected in the change in BMI z-score.

In total, 1,178 children were enrolled - 385 in Somerville (the intervention group), and two control communities, one enrolling 561 children to be followed, the other 232 children to be followed. All the children were in grades 1 through 3 at the beginning of the study period, school year 2003-2004 (September to June).

The intervention was intensive, and expensive.

Overall, the researchers started with a $1.5-million dollar CDC grant. And, if that were not enough, the Tufts website notes the grant "received supplemental support from The US Potato Board, Dole Food Company, Blue Cross and Blue Shiled of MA. It is also supported through generaous donations by Whole Foods Market, WGBH, New Balance, Gaining Ground, Annie’s Homegrown, Stonyfield Farm, Organic Valley, White Wave, Earthbound Farms, Shaw’s Supermarkets, Cabot Creamery, Friendship Dairies, Newman’s Own, The Vermont Bread Company, and the Kashi Company."

The Wall Street Journal included some idea of this supplemental support in quantifiable terms...

"...the Tufts researchers helped the city win a grant from the Robert Wood Johnson Foundation for a bigger-ticket item, an extension of a bike path that will eventually go all the way to Boston. "

"...the City Council came up with its own ideas: reimbursements on gym membership for city employees and dozens of new bike racks for schools and streets."

"...Dr. Economos persuaded a Whole Foods store to donate about $35,000 in fresh produce."

"...a Department of Homeland Security grant is providing fitness equipment at fire stations and chefs to train the firefighters about nutrition and healthy meals."

"...a doctor sponsors the community fun run."

So, it's hard to add up all the additional monies and in-kind donations to know the true cost of the initative, but Somerville has secured an additional $1.5-million dollars to continue the efforts.

What exactly happened in Somerville that so much attention is focused on this small town?

Throughout the city of Somerville, the efforts to place the towns children on a diet and increase activity included:

• School lunches, classroom snacks and fundraisers revamped


• Teachers were trained to implement the new health curriculum, called The HEAT Club (Health Eating and Active Time)


• School Staff Role Modeling implemented


• After school program policies created for snacks


• After School policies for physical activity developed


• Increased time for recess, lunch, and physical education


• Annual height and weight data collected with reports for parents


• Monthly newsletter was sent to parents


• Monthly community newsletter to community members


• Parent education forums held for non-english speaking parents


• Area restaurants developed "Shape Up Approved" menu items


• Safe Routes to School maps were created


• Crosswalks were re-painted in thermoplastic material


• Bike racks installed at elementary schools


• School nurses and area Pediatricians were educated about taking weight and height of children

I don't think they missed an opportunity to intervene, do you? No Child Left Behind - heck, this was an "in your face" intervention, with no one left behind.

Throughout Somerville, it was impossible to escape the Shape Up Somerville messages.

So you'd think the results would be impressive given the media's attention the last few weeks.

The researchers trumpted "A community-based environmental change intervention decreased BMI z-score in children at high risk for obesity. These results are significant given the obesigenic environmental backdrop against which the intervention occurred. This model demonstrates promise for communities throughout the country confronted with escalating childhood obesity rates."

Based on their results that found over eight months, "At baseline, 44% (n = 385), 36% (n = 561), and 43% (n = 232) of children were above the 85th percentile for BMI z-score in the intervention and the two control communities, respectively. In the intervention community, BMI z-score decreased by –0.1005 (p = 0.001, 95% confidence interval, –0.1151 to –0.0859) compared with children in the control communities after controlling for baseline covariates."

Simply put, the kids in the intervention group gained about 1-pound less than the kids in the two control towns who received no intervention.

They didn't lose weight, they just gained less, which is expected - growing children gain weight each year (or are supposed to).

Within the full-text we find a curious table designed to highlight the effect of this intervention, Estimated intervention effect over 8 months on a child at the 75th percentile BMI z-score, which seems contrary to the objective of reducing the incidence of overweight and obesity, which is defined as a BMI that places a child in the 85th percentile or higher.

Nonetheless, the researchers included it to show how the intervention would effect children at the 75th percentile - children, it should be noted, already within the definition of a "healthy weight" for age.

It seems to have escaped many that with or without intervention such a child would remain within "normal, healthy" weight, as evidenced in the table data included.

Case in point - highlighted in the table - a boy, at baseline 8-years old has a BMI of 17 and is in the 75th percentile. Eight months later, without intervention (it's hypothesized) he might grow about an inch-and-a-half and gain 5.07 pounds; with intervention, just 4.25-pounds (a difference of 0.82-pounds, or about 12-ounces).

Without intervention the child's BMI is now 17.4; with intervention it is now 17.17 - in both instances the BMI increased, right?

But in both instances the child in this scenario fell on the charts, going from the 75th percentile to the 73.9 percentile without any intervention and the 71.1 with intervention, and at a cost of $1.5-million to keep this hypothetical child well within "normal" when he would have remained there anyway?

I wondered, what happened to the kids who were overweight or obese to start - the 170 of 385 children in the intervention.

As I combed through the data, another curiosity - no data was provided to show the intervention was effective for this particular subset of children within the intervention group.

Why was that data not provided?

I would think that would be the icing on the cake for the researchers to highlight the benefit of such an intense intervention, wouldn't you?

So, I got to thinking, what changes, based on the data provided, might happen for a child within this group?

The researchers neatly summed up the hypothetical child within normal, so how about we create the same table for a child who was at the 95th percentile at baseline to see what might happen.

Johnny is 8-years old, he stands 4' 2.25" and weighs 72-pounds - BMI 20.1, 95th percentile.

In eight months, like the scenario presented by researchers, he now stands 4' 3.75" (growing 1.5") and without intervention is likely to weigh 77-pounds (gained five pounds); with intervention he'd weigh about 76-pounds (gained four pounds).

Without intervention he's fallen to the 93.8 percentile; with it he's fallen to the 93rd percentile.

Yes - with or without intervention this hypothetical child went from "overweight" to "at risk for overweight" - which begins to explain the absence of data on the subject of where the children were on the charts at the end of the study period.

I'm not trying to say we shouldn't try to help children engage in more activity or eat a healthier diet, but quite frankly, these results are not as impressive as we're being led to believe.

We have no data to look to in our understanding of how this type of aggressive community-based intervention impacted children already underweight or at the bottom of "normal, healthy" weight; we have no clue as to how this type of intervention impacted those children who were well within "normal, healthy" weight; and without the hard data we don't know that any of this helped those children at risk for or already overweight!

I'd like to see the data and also see someone investigate impacts in other areas of life, like reading and math scores. Sandy Szwarc, over at Junkfood Science, pointed out that "While the school year was absorbed in diet and exercise, (after the Shape Up program was completed in 2005) the average reading test scores among Somerville kids are 15.4% below state average, and their math test scores are a whopping 26% below those of kids in the rest of the state."

I did some poking around and found the Somerville MCAS testing stats online; in the 2003/04 school year, third grade reading scores indicated that 44% needed improvement or were failing; in the 2004/05 school year - these same students, now 4th graders, tested in ELA (english language arts) showed 63% now needing improvement or failing, and 73% needed improvement or were failing math (not tested in 3rd grade).

Just some food for thought, and a hat tip to Sandy for the educational impacts that may be part of the intiatives overall impact not recorded in the results that are focused on BMI z-scores.

Diet for Diabetes Mired in Half-Truths

"A half-truth is a whole lie."
Yiddish Proverb

If you want to see a truly stupendous exercise in smoke-and-mirrors and misdirection, look no further than people like Hope Warshaw, or organizations like the American Diabetes Association -- they've practically cornered the market on rhetorical tricks and red herrings.

Of course, that's almost understandable since everything recent scientific studies have to say about their most popular punching bag, carbohydrate restricted diets, directly contradicts their doom-and-gloom predictions that no one can eat that way, or should.

Case in point, the recent Diabetes Health article penned by, none other than, Hope Warshaw, The Optimal Eating Plan for Type 2 Diabetes?

Let me first say, Ms. Warshaw is quite proud of her accomplishments and offers visitors to her website the following information in her biography detailing her direct work with "McNeil Nutritionals, LLC, a Johnson & Johnson Company; Mead Johnson Nutritionals, a division of Bristol-Myers Squibb; Roche Diagnostics and Novo-Nordisk Pharmaceuticals. She writes consumer and professional materials for brochures, newsletters and websites. Hope has worked with PR [public relations] companies on nutrition-related campaigns, such as Barkley Evergreen & Partners, Fleischman Hillard, Inc., Paine PR, Edelman, RF Binder and Hunter Public Relations."

I point this out to highlight the fact that Ms. Warshaw is well schooled in media and marketing, or should I say "spin"? Simply put, she's no novice when it comes to creative persuasion, that is how to craft a message that hits on all cylinders of your emotions.

Keep in mind as we move on, feelings do not change facts.

In her recent addition to the media fodder attempting to discredit carbohydrate restricted diets, she sets the stage quite brillantly to avoid fact by littering her piece with half-truths designed to appeal to fear.

Bottom line - statements with half-truths are deceptive; they're partly true, but not the whole truth; they present a verifiable piece of information that is true, but in context is not representative of the truth. Some might say they're lies, others might say they're stretching the truth, and still others may say that a half-truth is really just being economical with the truth.

They've been with us for generations. We find them littering food packaging and in advertisements for many different things; sometimes stated, sometimes implied, and sometimes even admitted to in the fine print no one reads. Half-truths are so prevalent in our daily lives, is it any wonder that when one appears in an article about health, no one seems to notice?

Ms. Warshaw sets the stage by setting readers minds to believe her article is the truth about the "optimal" diet for those with diabetes; and uses a number of literary tricks - rhetorical statements, imaginative prose and pursuasive words to trigger a desired response in readers. She leads with our base knowledge that dieting is hard and we should "be realistic and take a long-term perspective in this “which diet is best” debate, rather than wasting time quibbling over extremes - from low-carb to vegan."

With this one sentence she's already working hard to influence readers by bringing them into her world while employing empathy, *we all know* it's a waste of time to quibble over diet, that vegan and low-carb are *extreme* diets, and that, as the title of her article hints, *we know* the optimal diet for those with diabetes.

Forget about data, there isn't even room for debate.

Since that isn't quite enough, she then adds a message driver, a logical fallacy to drive this message home by appealing to fear, one of our strongest emotions.

Fear of being a loser, on the losing team, on the team that no one wants to be a part of anyway, the team that everyone quits because it's so bad.

"A Team’s No Good If All the Players Quit"

Think about that statement for a moment.

A Team’s No Good If All the Players Quit.

It conjures up cliches we all know - quitters never win, be a team player, teamwork works, winners never quit...and it stirs up fear - the fear of failure.

So with that in play, she then moves in with the half-truths - "A number of studies that compare low carb diets to conventional diets demonstrate early initial weight loss and improvement in other health parameters, such as blood glucose control. But studies of low carb diets that last longer than six months do not show significantly more weight loss. They do show that many study subjects drop out of the study and are unable to stick with the diet."

She cites two studies to support her assertion and show veracity of her statements:

1. Foster GD, Wyatt HR, Hill JO, McGuckin BG, Brill D, Mohammed S, Szapary PO, Rader DJ, Edman JS, Klein S.: A randomized trial of a low-carbohydrate diet for obesity. NEJM 348(21): 2082-90, 2003.

2. Bravata, DM, Sanders L, Kuang J, Krumholz HM, Olkin I, Gardner CD, Bravata D: Efficacy and safety of low-carbohydrate diets: a systematic review. JAMA 289: 1137 – 1850, 2003.

When we review these studies, we find her statements are accurate, but more accurately they are smoke and mirrors because they do not present the whole truth since the two studies are not trials specifically investigating dietary approaches for those with diabetes.

Indeed the studies she cites - one is an investigation comparing low-carb and low-fat diets for obesity, the second is a meta-analysis reviewing some of the published studies up to one year comparing low-carb and low-fat diets for obesity. So while weight loss was a key part of the studies cited, they are not the most relevant available to us to examine for those with diabetes.

You see, the two studies above, while they included subjects who were obese, they were not diabetic subjects; and the second was not a research study, but a meta-analysis review of studies that included the first study cited.

But a casual reader wouldn't know that - they only see two references which lends credibility to her statements and makes them appear to be important in determining dietary recommendations for those with diabetes.

Now consider this - how would her statement need to change if she included Beneficial effects of ketogenic diet in obese diabetic subjects?

In this study, subjects with and without diabetes, were grouped by blood sugar levels and the study lasted 56-weeks (one year, one month) and there were no drop outs - that is all who started the study completed it. With across the board improvements in total cholesterol, HDL, LDL, triglycerides, and fasting blood sugar in both groups, along with significant weight loss over the period of a year (a 54-pound average weight loss for both groups!) is it any wonder she didn't cite this one?

Or how about Low-carbohydrate diet in type 2 diabetes. Stable improvement of bodyweight and glycemic control during 22 months follow-up, a study over a period of almost two years that compared a low-fat diet to a low-carb diet in those with diabetes; and at six months, those following the low-fat diet abandon it when they saw the results of those following the low-carb diet? Oh, yeah, there were also significant improvements to risk factors including blood sugars (with elimination of medications) and weight loss and weight maintenance.

Two longer term studies, both ignored for this particular article. But a casual reader doesn't know they exist and Ms. Warshaw isn't going to tell.

So she moves on to the statement "Low-carbohydrate diets are not recommended by the American Diabetes Association for two key reasons. First, avoiding carbohydrate, as some low carb diets suggest, does not entirely return blood glucose levels to the normal range after meals. Second, an adequate amount of carbohydrate is an important component of a healthy eating plan, providing essential fuel, vitamins, minerals, and fiber;" and offers two more citations to support her words, both references are ADA statements.

So again we find half-truth, but not the whole truth.

This is because Warshaw sees the world though the prism of ADA truth making it impossible to take her seriously on any level.

Does she really believe someone with diabetes will not, or more accurately, can not give up consuming sugar or excessive carbohydrate that she feels it necessary to portray the dietary approach as one where "avoiding carbohydrate" is a problem rather than the solution?

Many, if not all, carbohydrate controlled plans restrict total carbohydrate each day, but no plan says you must avoid all carbohydrate or eliminate it completely. Maybe she has a problem with a diabetic avoiding sugar and foods that quickly raise blood glucose?

Second, her statement that avoiding carbohydrate..."does not entirely return blood glucose levels to the normal range after meals" implies that what she's going to present to readers will do just that - just ignore the smoke, just ignore the mirrors, as she continues with "an adequate amount of carbohydrate is an important component of a healthy eating plan, providing essential fuel, vitamins, minerals, and fiber."

Ignore the fact that all carbohydrate restricted plans include and encourage a high intake of non-starchy vegetables (rich with nutrients, fiber and minerals); no the message by now is clear - low-carbohydrate diets are for losers, they're unhealthy, nutrient deficient, make you avoid something with no reward for the effort (normal blood sugars after meals) and you're not going to lose weight with a low-carb diet anyway, move along now and don't pay to much attention to the fact she opened with two "extremes" low-carb and vegan but only attempts to discredit one.

Afterall we can't have anyone consider a low-carb diet, because "diets that force people to dramatically change their eating style are not maintained over the long haul. These diets require too dramatic change compared to the common, albeit not healthy, eating habits of the 21st century."

Take a good look at the last sentence - it's too big a change from the "unhealthy" eating habits we have, but by golly, a person with diabetes deserves to eat whatever they want and they can continue on with their common ways!

What she is saying is that no person with diabetes is willing to change their unhealthy ways, so why bother.

She then has the nerve to present to readers more rubbish - "Research from numerous studies, including the Diabetes Prevention Program and the National Weight Control Registry, show that people can lose weight and keep it off successfully for three years and five years, respectively, by reducing dietary fat and total calories."

Two is not "numerous" it's a couple.

And one is from subjects at risk for diabetes, the other a self-selected group of dieters who are followed in a national database because they lost weight not because they have diabetes and are in good glycemic control and maintaining weight loss!

Ms. Warshaw is pretty confident you won't check or think critically, and that you'll take her half-truths and believe a low-carb diet is impossible to follow for the long-term.

She's so sure of this in fact, she has no worry saying you can't diet on your own anyway - you need help, "you need knowledge and skills to make lifestyle changes, as well as help in setting behavioral goals, not to mention ongoing and long-term support...Ask your health care provider to refer you to a diabetes education program."

Her writing is chock-full of manufactured criticism, dead-wrong assumptions, half-truth evidence, and child-like ignorance of the emotional universe inhabited by men and women with diabetes.

She hopes no one notices that what is more important is the quality of pertinent research published, not the crafty presentation.

She relies heavily on logical fallacies - appeal to authority (the ADA) and appeal to fear - to grab and hold readers' attention, then offers clever cliches to play emotions without presenting pertinent facts to help an individual with diabetes understand the hard data.

The truth is modifying your diet is difficult, losing weight may be hard, and maintaining weight after it's lost can be a challenge; having diabetes is also a challenge and managing everything that comes with a diagnosis is no small endeavor - everything from blood glucose levels to HbA1c to cholesterol to body weight is monitored, tracked and managed; not for a week or a month, but for the rest of your life.

Ms. Warshaw contends that modifying diet too is too much to ask, too much for a person to do, too much for anyone to have to do over the long-term.

She offers the status quo - the ADA position that one deserves to be able to eat normally (even though she admits this "normal" is unhealthy); afterall a low-carb diet requires "too dramatic change" in eating habits.

Notice she hasn't said a word about the dramatic change one must make to include their medication each day; self-monitor blood sugar levels; keep doctor, opthamologist and podiatrist appointments; adjust medications as complications arise; injecting insulin each day; careful wound care; and more.

Notice she hasn't said a word about what dietary modification is necessary with the ADA recommendations.

Notice she presents no evidence to support the implication that normal blood sugars are achieved when one follows this "optimal diet."

That's because normal blood sugars do not happen when one follows the dietary recommendations of the ADA.

In fact, the ADA position is that medication is the first line defense upon diagnosis because their dietary approach fails over the long-term.

Oh, Ms. Warshaw didn't include that, did she?

No, she's done a run-around the evidence, fully aware the casual reader won't know the published data well enough to spot her half-truths or question the depth of her statements.

She stays on the surface rather than digging deep and offering a compelling look at the truth.

The truth is, those with diabetes deserve to know they have options.

They deserve a full disclosure of the data to allow them to make an educated decision about what they can and cannot do with diet; what they will and will not do to manage their diabetes.

They deserve to know that not only do blood sugars normalize in many with diabetes who adhere to a carbohydrate restricted diet, but medication is often eliminated or reduced.

They deserve to know a dietary approach is available that may indeed provide normal blood sugars!

They deserve no less than full patient autonomy, something Ms. Warshaw seems to know nothing about.

They deserve the whole truth!

What's so Special about Protein Anyway?

When we hear the word "diet" we often conjure up thoughts of deprivation, hunger and the frustration of short-term attempts to lose weight. But "diet" also means how we eat on a daily basis - so the diet we eat to lose weight should, ideally, be the diet we eat for the long-term.

I agree with this idea and strongly encourage those trying to lose weight to eat a dietary pattern they'll make habit over the course of their weight loss and beyond as they then maintain their weight.

Where I disagree with this idea is in the idea that our macronutrient (protein, carbohydrate, fat) intake should be set by percentage of our calories, in strict ratios with each other, in an attempt to keep the equation "balanced" - up to 35% of calories from total fat, less than 10% (or less than 7%) of calories from saturated fat, 55-65% of calories from carbohydrate, and the remaining 10-15% of calories from protein.

We're repeatedly told a "balanced diet" remains within these percentages of calories and to maintain them while in a calorie deficit if we're trying to lose weight; going beyond those percentages and consuming too much fat, saturated fat or protein is detrimental to our long-term health.

Yesterday I closed my post with "The first, and most important rule you need to know in the "diet game" is eat your protein; and make it complete protein."

Protein is the macronutrient we take for granted, underestimate the power of, and assume we get enough of each day in our diet.

By undervaluing protein in our diet, by making the assumption that most people eat more than enough, we fail to focus on not only the building blocks of life itself, but the building blocks of our endocrine system - our hormone system.

Without adequate intake of essential amino acids, we rob our metabolism of the building blocks to function normally.

When we diet to lose weight, restrict calories and maintain the ratios suggested to keep our diet "balanced," we willfully starve our metabolism and endocrine system of the critical elements required to maintain function.

This is because our requirement for protein, for essential amino acids, is not based on a simple percentage of calories, but on how much we weigh.

If a woman, who is 5'6" tall, 30-years old and weighs 250-pounds goes to MyPyramid.gov, she'll be presented with a food plan providing 1,800-calories a day to gradually lose weight.

She will find her recommendation includes:
6-ounces of grains (Aim for 3 whole grains)
2.5-cups of vegetables
1.5-cups of fruit
3-cups of milk
5-ounces of meat and beans
Aim for 5-teaspoons of oils a day
Limit extras (extra fats & sugars) to 195-calories a day

The first critical problem with the recommendation is the calorie level - our hypothetical woman above has a Basal Metabolic Rate calculated at 1900-calories a day.

As the Discovery Health BMR Calculator page says "You expend energy no matter what you're doing, even when sleeping. Thus your Basal Metabolic Rate is the number of calories you'd burn if you stayed in bed all day...depriving yourself of food in hopes of losing weight also decreases your BMR, a foil to your intentions."

But let's set that aside for this post and look at what she is presented with as a food plan and determine if it meets her nutrient requirements, as the site contends it will.

First let's pretend she laughs off the idea of eating beans instead of meat - this makes our task of examining her protein intake easier since we'll be able to determine her intake of complete protein without having to adjust for the limiting amino acids in grains or legumes (beans).

With 3-cups of milk and 5-ounces of meat, the total intake of complete protein (if this is followed to the letter) is 56-grams.

Now, some would contend that this is above the 46g DRI (Dietary Reference Intake) established by the Institutes of Medicine for a 30-year old female. Such a contention fails to consider the IOM basis of 46g of complete protein is based on a female who weighs 128-pounds. Our hypothetical woman weighs 250-pounds!

Protein intake - that is complete protein, providing all essential amino acids in the proper ratio - is based on the formula 0.8g/kg body weight. The IOM considers this the absolute minimum required each day. So, our hypothetical woman, who weighs 250-pounds is 113.6kg, thus requires a minimum of 91g of complete protein each day.

But wait, you might say, she has other things she'll eat that provides protein!

That is true. But, with 1800-calories, planned as recommended above, she'll consume about 80-90g of total protein, and depending upon what she actually eats, she is likely to miss adequate intake of all her essential amino acids; even with careful planning and optimal selections of whole foods, she'll also likely fail to meet DRI for Potassium, Vitamin D, Niacin, Magnesium, and Vitamin E; add to this she'll likely fail to meet omega-3 requirements while consuming an excess of omega-6.

But hey, her saturated fat intake is just 6% of her calories, her cholesterol intake would be about 100mg, and her fiber intake in the neighborhood of 35g - according to the recommendations, she's eating a "healthy diet," and reducing her risk of disease by keeping her saturated fat and cholesterol intake below the maximum allowed.

On paper her diet looks just great!

In her body, in her metabolism, it's a nightmare if followed for any length of time.

This is because chronic, habitual nutrient deficiency - whether it is a diet deficient in vitamins, minerals, or trace elements, essential amino acids, essential fatty acids, or a combination of deficiencies - places a burden on the metabolism to function without all of its needs.

Oh, you won't die with a shortfall in nutrients; atleast not immediately...no, your metabolism will continue limping along, as best it can with what you give it to work with.

But really, do you want to do that, or do you want to eat in a way that optimizes your metabolism?

How about we design a menu for our hypothetical women, one for her, that is designed specifically to meet her nutrient requirements rather than conform to a set of percentages.

Based on what we know her Basal Metabolic Rate is (what she needs for basic function before she gets moving each day), she should consume 1,900-2,000 calories and first focus on ensuring she eats 91g of complete protein each day.

If we start there, and include as part of her day 4-ounces of lean roast beef, 16-ounces of plain whole milk yogurt, 3-ounces of tuna in oil, 2 eggs, and 1/4 cup shredded natural cheddar cheese - we've included all her complete protein for the day - 91g - and started her menu with 946-calories. We have 954-1054 more calories to add to her menu.

Now we get to add in her vegetables, fruits and other foods to ensure she consumes adequate intake of the additional nutrients needed; the focus here should be first on vegetables since they're rich with vitamins, minerals and trace elements.

Let's add to her menu a salad for lunch, with 2-cups of romaine, 6 cherry tomatoes, 1/2 a sliced cucumber, 1/2 cup shredded red cabbage, and some crimini mushrooms and we'll let her top it with olive oil and vinegar; then she'll have 1-cup of steamed broccoli at dinner with her roast beef and she can indulge and include 1-tablespoon of butter to make it taste good.

As part of her breakfast, which includes the two eggs above, she'll also include 1-cup of baby spinach (raw amount to be added to egg omelet) and 1/4 cup of shredded cheddar cheese. Her breakfast will also include the one of the two cups of plain yogurt, in which she'll add 1-cup of strawberries.

Her snacks during the day will include 1-ounce of almonds with 1-ounce of sesame seeds; she'll include 1-cup of blueberries with the other 1-cup of plain yogurt, add some water and have a delicious smoothie; and she'll have 1/2 an avocado too, perhaps with her lunch or just a snack during the day.

At this point, her menu provides 1,931-calories.

But wait, she hasn't included any grains! Surely this menu is going to be deficient for essential nutrients if she isn't eating grains!

Not so fast.

The above menu provides all essential nutrients, including fiber, with one notable exception - vitamin D, the most difficult nutrient to obtain from food. She can, of course, go out in the sun for 20-minutes this time of the year each day and make all the vitamin D she needs in her skin. In months where we cannot produce vitamin D in our skin, she can add a vitamin D supplement or make different choices with foods rich with vitamin D or include cod liver oil.

But the above menu, even though it provides all essential nutrients, is a nightmare for those espousing the dietary recommendations - it's high in total fat, saturated fat and exceeds maximum allowance for cholesterol; the carbohydrate is lower than recommended (even though fiber is above recommendations), and it does not include any grains!

Which begs the question - what would you rather eat?

A menu designed to meet your calorie requirements to function before any activity but still a calorie deficit to enable weight loss - designed to provide all essential nutrients including the critical essential amino acids and essential fatty acids - or - a menu that looks pretty on paper but fails your endocrine system because it is nutritionally bankrupt?

Diet - Not a Numbers Game Afterall

When searching online for topics to write about, I often hit google news and conduct a search based on various keyword combinations - diet, health, obesity, weight, diabetes - and I'm never disappointed by the sheer number of results. On Friday I noted that the headlines are often contradictory and those I posted were all within the first five pages of results using just two keywords - diet and health - in a search of the news headlines.

So, what are we to make of dieting to lose weight? Is it a losing proposition? If it is, then why the repeated attempts to encourage the masses to diet? And, most importantly, does dieting really work?

I think it's safe to say that the most widely recommended diet for weight loss - a calorie restricted, low-fat, carbohydrate rich diet - fails the test long-term. While intially reducing weight, in the long-term, such diets do little to improve health and enable a stable, lower weight over time.

The failure of the dietary recommendations are no small matter, various agencies go to great pains to explain away the long-term failure and wind up making the issue one of personal failure rather than admit the flaw is in the recommendations.

Whether or not an individual is able to lose weight and maintain the weight loss becomes a moral issue - having willpower over hunger, taking responsibility for portions, just eat less, just exercise more, stop buying junk food, etc. When the outcome is positive, the diet worked; when the outcome is negative, the person failed to follow directions.

As Malcolm Evans summed up in his commentary, Dieting is Fine Because it is Becoming Official, "The argument goes like this - the state in its wisdom has spoken; overweight is a health issue and as such it becomes a moral issue concerning wellness, interdependencies and budgets. Weight is to be managed downwards and to disobey will result in an implicitly escalating scale of reputational and material penalties (including the denial of certain health care provision). Biomedicine currently prioritises a sense of cure over comfort. The emphasis in almost all cases is to be seen to be powerful in the chemical intervention, with much less emphasis on empathy in relation to the inevitable, or on the emotional and psychosomatic dimensions. It is a culture that allows ten minutes and the prescription of a tranquilliser. It is also a culture which disallows the complexity of overweight and seeks rapid intervention, preferably leading to the mapping of satisfactory digits to numbered targets. In the absence of a magic weight control pill (how Big Pharma would love to have one of those that was in any way remotely effective!), dieting is perpetuated despite the accumulating evidence that it is a largely ineffective alone as a long-term solution."

As I noted on Friday, Fred Hahn said it well, "Fat loss and health is NOT a numbers game - it's a hormonal game. And a game that requires full understanding of the rules."

Yet the government and leading health organizations continue to perpetuate a dietary approach based on numbers - calories, fat grams, saturated fat grams, milligrams of cholesterol, sodium intake, fiber intake, the size of portions, and the number of minutes you engage in exercise each day. It's all about counting one or more things each day in your diet and lifestyle.

All of the recommendations made to the masses come back to one single hypothesis - dietary fat is deadly and must be limited to not only keep calorie intake balanced - fat has nine calories per gram and carbohydrate and protein just four - but to prevent development of chronic disease.

Recently the obession with total fat has relaxed a bit, from strictly maintaining an intake below 30% of calories, to an allowance now of a range between 20% and 35% of calories. But this concession comes with a stricter limit on saturated fat; we're now told to limit saturated fat to less than 7% of our calories, making it next to impossible to meet nutrient requirements for essential amino acids in those who are overweight or obese.

Ah, the unintended consequences of playing, on paper, with macronutrient ratios.

You see, if we take the recommendation to consume less saturated fat to heart, and also strictly limit our cholesterol intake as also recommended, we are left with significantly less animal foods in our diet each day, now dependent on plant-based sources of protein to meet our essential requirements for amino acids.

Surely, you say, there must be strong evidence to support these recommendations? Surely we can easily meet our essential amino acid requirements with a plant-based diet? Surely a diet recommended by the government and leading health organizations must be soundly established by scientific data and be shown to lead to long-term outcomes in health and well-being?

Well, not so fast.

Here is where, as Fred Hahn called it, the "hormone game" comes into play and the rules are such that if you're not playing within them, your health suffers.

The first, and most important rule you need to know in the "diet game" is eat your protein; and make it complete protein.

Tomorrow I'll explain why and then discuss the other rules of the "hormone game" to give you insight into why everything we're told about diet is either wrong and causing more harm than good in your metabolism!

Then, throughout the week, we'll sort out what to eat if you're trying to lose weight and improve your health for the long-term.

The MIsadventures of Dieting in America

If you're like most Americans, you're bombarded each day with headlines that completely contradict other headlines:

• Health warning: all diets make you fat
• Diets do work... and here's how

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• Reducing Weight Without Dieting
• Lose weight or lose control

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• Good' Foods Make you Gain Weight Too
• Lose weight by eating more

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• Loosing fat without trying
• Leftovers can help you eat a third less!

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• Obesity is not just gluttony - it may be in your genes
• Get the 'skillpower' to lose weight

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• Low fat foods trick you into eating more
• Heart Association Explains The Trouble With Fats

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• Slow down at mealtime to lose weight
• Lose Weight During Dinner: Turn Off TV
• So can you REALLY lose weight just by brushing your teeth?
• Lose weight with push from a stranger
• Thinking thin can help you be thin

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• Calculating caloric intake — do the math
• It's official: diets make you fatter

Is it any wonder we're confused about how to lose weight?

I sometimes wonder if the mass confusion, conflicting headlines, contrary opinions and such is by design. No, really, I'm not a conspiracy theorist...but, keep in mind, it is highly profitable to keep people fat, and sick, and coming back for more help isn't it?

So, how do we cut through the confusion and contradictions and simply eat right?

As Fred Hahn said it in a recent reply to comments on his blog regarding calories in, calories out - "Fat loss and health is NOT a numbers game - it's a hormonal game. And a game that requires full understanding of the rules."

Monday we'll begin to lay out those rules!

There is Something Perverse About the Atkins Diet...

I've been crazy busy the last few weeks, but absolutely had to stop what I was doing to write about an article today - The Atkins Paradox: What Diet Studies Don't Reveal - by Christopher Wanjek, the "Bad Medicine" columnist over at LiveScience.com.

My headline above was taken directly from the column, "So why not go with Atkins if you can loose weight and eat bacon? The reason, most doctors say, is because there is something perverse about the Atkins diet."

I haven't laughed so hard in, well, a few days. And, what followed was even funnier...Consider the breakfast of a gentleman on the Atkins diet whom I encounter each morning on a commuter train eating an entire block of baloney right out of the package with one hand and washing it down with a diet Coke in his other hand. Between the salt, fat and artificial additives in the lunchmeat and soda, this simply can't be healthy.

Good golly Miss Molly!

I don't know about you, but when I read these stories about someone "on the Atkins diet" - or any carbohydrate restricted approach - doing it completely wrong, well all I can do is laugh. I'm not laughing because the poor fellow eating the bologna and diet coke breakfast is going about Atkins wrong, but because this columnist really, truly believes this guy is a good example to show how "perverse" the Atkins diet is.

For anyone who has not read Dr. Atkins' New Diet Revolution, he was pretty clear to avoid, or at least limit, processed meats - "Processed meats such as ham, bacon, pepperoni, salami, hot dogs, and other luncheon meats - and some fish - may be cured with added sugars and will contribute carbs. Try to avoid meat and fish products cured with nitrates, which are known carcinogens." (page 124, paperback, 1992, 1999, 2002 edition)

In fact, he specifically recommended "Always aim for unprocessed natural foods and select the freshest produce you can find. If possible, purchase organic meats and dairy products." (page 130, paperback, 1992, 1999, 2002 edition)

Not exactly a ringing endorsement of bologna for breakfast each day, huh? Then again, let's not let inconvenient facts get in the way of an article promoting low-fat diets are supreme!

And this presentation of bologna & diet coke for breakfast for an Atkins dieter really isn't the biggest problem with this article.

No, the biggest problem really is the deceptive assessment of the study published in JAMA that I previously wrote about. This is how Mr. Wanjek portrayed the results:

The Atkins and Ornish data have overlapping confidence intervals. This is a measure of statistical strength given sample size and other factors. The study implies that, with 95-percent confidence, the true weight loss could be as low as 6.8 pounds for the Atkins group and as high as 8.2 pounds for the Ornish group.

In fact, the Ornish dieters were closing the gap at 12 months as the Atkins dieters were gaining weight. This supports earlier studies suggesting that a low-fat lifestyle is better at keeping off weight in the long run.

Closing the gap? Who is he kidding? Here is the graph of each group at each measurement interval:





















Note that I've highlighted the Ornish group. I've done that because the contention that they "were closing the gap" and losing weight at 12-months is utter and complete hogwash. As a group, they were gaining weight since the two-month point in the study!

Then the suggestion that the overlapping confidence interval was masking some secret weight loss potential for the Ornish group - more utter and complete hogwash.

What Wanjek didn't say is important and it's that the range of weight loss in those following Ornish and Atkins. Here is the data:

Atkins 4.7kg [95% CI, -6.3 to -3.1kg]

Ornish 2.2kg [95% CI, -3.6 to -0.8kg]

Oh, there was an over-lap all right, but no matter how you slice it, those trying to follow the Atkins diet lost as little as 6.8-pounds (3.1kg) and as much as 13.9-pounds (6.3kg), with an average weight loss of 10.3-pounds for the group. Compare that to those trying to follow the Ornish diet - weight loss was a little as1.8-pounds (0.8kg) and as much as 7.9-pounds (3.6kg) with an average weight loss of 4.8-pounds for the group.

Put another way - the least weight loss in the Atkins group was about the best in the Ornish group. Have a look for yourself:

We're supposed to be convinced that those following Ornish were doing as well as those following (or trying to) Atkins? Oh yeah, that graphic above shows just how close the two dietary approaches were...not.

Pass the nitrite-free bacon and double cream brie, thank you very much.

Carbohydrate Restriction Seminar - Nashville, TN - May 5

It's a bit of short notice, but anyone interested in learning more about the science and research supporting carbohydrate restriction - register to attend the Nutrition & Metabolism Society Seminar at the 2007 Eastern Regional Obesity Course of the American Society of Bariatric Physicians in Nashville, TN, May 5, 2007.

Saturday, May 5
8-8:45 am Low GI and Very Low Carbohydrate Diets for Type 2 Diabetes
Eric C. Westman, MD, MHS

8-8:45 am Low GI and Very Low Carbohydrate Diets for Type 2 Diabetes
Eric C. Westman, MD, MHS

8:45-9:30 am Carbohydrate Restriction for Type 2 Diabetesin Clinical Practice
Mary C. Vernon, MD, FAAFP, CMD

9:30-9:45 am Break

9:45-10:30 am Using the Traditional Diet for Type 2 Diabetes in a Canadian First Nations Community
James A. Wortman, MD

10:30-11:15 am A Review of the American Diabetes Association Recommendations for Dietary Carbohydrate
Judy Wylie-Rosett, EdD

11:15am-Noon Panel Discussion of Morning Speakers

Noon-1:30 pm Lunch & NMS Award Presentation (lunch provided for Obesity Course & NMS attendees)

10:30-11:15 am A Review of the American Diabetes Association Recommendations for Dietary Carbohydrate
Judy Wylie-Rosett, EdD

10:30-11:15 am A Review of the American Diabetes Association Recommendations for Dietary Carbohydrate
Judy Wylie-Rosett, EdD

NMS ATTENDEES ONLY
1:30-2:15 pm Very Low Carbohydrate Diets and Serum Biomarkers of Cardiac Risk
Jeff S. Volek, RD, PhD

2:15-3 pm The Paradox of Fats in the Low Carb Diet
Steven D. Phinney, MD, PhD

3-3:15 pm Break

3:15-3:45 pm Biochemical Aspects of Carbohydrate Restriction
Richard D. Feinman, PhD

3:45-4:30 pm Panel Discussion of Afternoon Speakers

REGISTER HERE

Accreditation
The American Society of Bariatric Physicians (ASBP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The ASBP designates the NMS Seminar for a maximum of 6.5 credit hours in category 1 credit towards the AMA Physicians Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity. The program is eligible for AOA-CME credits under category 2-A.

Atkins Editorial Rejected

Five heathcare professionals - Dr. Stephen D. Phinney, MD; Dr. Mary C. Vernon, MD; Dr. Eric C. Westman, MD; Dr. Jay Wortman, MD; and Jacqueline A. Eberstein, RN - recently penned and submitted an editorial response to the recent media attention concerning the A to Z study published in JAMA. It was rejected by JAMA, Newsweek, Time and others. Here it is, in its entirety:

More Science and Less Zealotry, Please.

The controversy over which diet is best for all has again made headlines with the publication of the Stanford University study in the Journal of the America Medical Association March 7, 2007. Since the results are favorable to the low-carbohydrate Atkins diet, the usual criticism can be expected to follow.

Predictably, Dean Ornish has launched a tirade in which he manipulates the study findings to find fault with the low-carb approach and to deflect criticism away from his ultra low-fat diet which did not perform well in the study. Unfortunately, this is an argument based on dogma and not on science. The science speaks for itself.

As scientists and clinicians, we believe that no one dietary approach is going to be ideal for everyone. There is no doubt that, for some, an ultra-low-fat approach may be appropriate. Unlike Dr. Ornish, we recognize that there is no one-size-fits-all approach to the enormously complex problem of obesity and related conditions. Unfortunately, other authoritative sources like the US dietary guidelines also recommend a single lowered fat high-carbohydrate diet approach and have been doing so over the decades that this epidemic has grown.

Gratuitous attacks on the Atkins diet that imply it involves abandonment of wholesome vegetables and fruit for “bacon and brie” are simply wrong. Even in the most restrictive phase it meets the recommended daily guidelines for vegetables and fruits. As one advances through the phases, low-glycemic fruits, more vegetables, legumes and even whole grains are introduced based on an individual’s metabolic tolerance for these foods. One survey found that people who follow the Atkins plan over the long term eat more vegetables than they did before. Another study found that rather than increase the intake of fat and protein to compensate when carbohydrates were reduced, people simply ate less.

The unfortunate reality of today is that too many Americans are eating potato chips and fries and drinking sugar-sweetened beverages. We support the idea that wholesome foods such as meat, fish, cheese and eggs along with vegetables and low glycemic fruits constitute a healthier diet than chips and fries and sodas.

While this study examined four popular dietary approaches, what is clear is that whatever approach one takes to healthy eating, success will depend on how well you can stick to it. In this case, and in many earlier studies, it is clear that the Atkins diet is the one most people can maintain. On the other hand, the extremely low-fat diet advocated by Dr. Ornish is very difficult to follow. In this study, the subjects who were supposed to reduce their fat intake to his recommended intake of 10% could not reach that target.

Another important aspect of this and earlier studies is the beneficial effect that reducing carbohydrates has on metabolic markers. In his criticism, Dr. Ornish states that the LDL-cholesterol level fell in response to his diet, but does not mention that none of the differences in LDL-C in this study were statistically significant. This is therefore not a scientifically valid criticism. On the other hand, it is widely recognized that elevating the HDL-C, the good cholesterol, is an important factor in reducing cardiovascular risk. In this study there was a highly significant 10% rise in HDL-C in the Atkins group but no such change among those who followed the very high-carbohydrate Ornish diet.

In the same vein, the Atkins group demonstrated a significant (both statistically and clinically) greater reduction in systolic and diastolic blood pressure than the other three diets. A difference in mean arterial pressure of 5 mm Hg is about the response we would expect to see with a first-line pharmaceutical in the clinical setting. Any objective observer would acknowledge this as a major beneficial effect of the Atkins diet.

Dr. Ornish suggests that the positive findings of research such as this that supports the Atkins diet will cause problems, and that “many people may go on a diet that harms them based on inaccurate information.” This is a wildly irresponsible statement, given the consistency with which a reduction in important metabolic and cardiovascular risks are achieved by lowering carbohydrate consumption. It is simply preposterous to suggest that an approach that leads to significant risk factor reduction is unhealthy.

The seriousness of the accelerating epidemic compels us to think outside the box to find new solutions where the status quo has failed. The only approach that will be successful is one that people can actually follow. This study adds to the mounting evidence that the Atkins diet is a healthy choice which should be supported as a viable way to lose weight and improve metabolic and cardiovascular risk factors.

The Real Atkins Lifestyle

Before there was research on the Atkins diet it was commonly criticized in the belief that it would elevate cholesterol, ruin one’s kidneys and bones and cause heart disease. None of this has been borne out by the research.

What is clear from this JAMA study, and others like it, is that cardiovascular risk factors actually improve when controlling carbs. The scientific studies of this approach have shown numerous times that a pattern of rising HDL-C and falling triglycerides is the hallmark of carb restriction and that this benefit occurs even in the absence of weight loss.

Research also shows that rising HDL-C (good cholesterol) and falling triglycerides is correlated with larger LDL-C particles which are less likely to cause heart disease. Even the much touted statin drugs do not deliver this kind of improvement in LDL-C particle size. On the other hand, the research shows that eating a high-carb diet and cutting fat intake results in small dense LDL-C particles that are linked to an increased risk of heart disease.

Importance of Fat

There are other problems associated with extremely low fat diets, as well. Cutting fat intake can lead to deficiencies in fat soluble vitamins, depletion of essential fats such as EPA and DHA, and decreases in the absorption of nutrients. Studies also show that people with cholesterol levels that are too low become prone to depression, suicide and cancer and have higher overall death rates than those who have higher cholesterol levels.

When all is said and done, it behooves us to remember that the diet debate is not a horse race where there is only one winner. We know there is a great variability in metabolic and genetic factors that will determine what dietary approach is best for each individual person. Although, in this and many other studies the Atkins diet worked better for more people, it is also evident that other dietary approaches will work for some people as well. The most important thing we have learned from dietary research is that people need to find the approach that will deliver healthy outcomes for them individually. And, just as the proof of the pudding is in the eating, the proof of a diet's effectiveness is whether it can sustain those benefits over the long haul. Hopefully, the weight of the evidence will now allow the Atkins diet to be recognized and supported as a legitimate option for people who want to improve their health through better nutrition.

On a final note, Dr. Ornish’s repugnant attempt to undermine Dr. Atkins’ credibility by perpetuating the myth that he had heart disease is unconscionable. It is unbecoming of any honorable person to make ad hominem attacks on those who are departed. Enough is enough. Dr. Atkins died of a head injury. He is no longer with us, but the line of scientific inquiry that he started continues to vindicate his dietary approach. And no amount of unfounded criticism will alter the fact that this study, and the 60 others before it, clearly demonstrate that what Dr. Atkins had been telling us all along was right.

• Jacqueline A. Eberstein, R.N. Co-author, Atkins Diabetes Revolution, President, Controlled Carbohydrate Nutrition
• Stephen D. Phinney, M.D. Ph.D Emeritus Professor, Department of Medicine, UC Davis, Elk Grove, Cal
• Mary C. Vernon, M.D., CMD, Co-author, Atkins Diabetes Revolution, President, American Society of Bariatric Physicians
• Eric C. Westman, M.D. M.H.S, Associate Professor of Medicine, Duke University Medical Center
• Jay Wortman, M.D, Department of Health Care & Epidemiology, Faculty of Medicine, University of British Columbia