You are what your body does with what you eat

A newly published study, in the journal Lipids - Comparison of Low Fat and Low Carbohydrate Diets on Circulating Fatty Acid Composition and Markers of Inflammation - found that subjects given a low-carb diet experienced "profound alterations in fatty acid composition and reduced inflammation compared to a low fat diet."

The press release, issued from SUNY Downstate, sums it up completely:

Metabolic syndrome is a condition afflicting one quarter to one third of adult men and women and is an established pre-cursor to diabetes, coronary heart disease, and other serious illnesses. Patients have long been advised to eat a low-fat diet even though carbohydrate restriction has been found to be more effective at reducing specific markers, such as high triglycerides, characteristic of the syndrome. Now, a new study indicates that a diet low in carbohydrates is also more effective than a diet low in fat in reducing saturated fatty acids in the blood and reducing markers of inflammation.

While there have been contradictory and confusing messages directed at health conscious consumers about dietary recommendations, most researchers agree on the need to limit inflammatory agents. In a report published today in the on-line version of the journal Lipids, researchers at the University of Connecticut, SUNY Downstate Medical Center in Brooklyn, and the University of Minnesota show much greater improvement in inflammatory markers in patients with metabolic syndrome on a very low carbohydrate approach compared to a low fat diet.

Lead researcher Jeff S. Volek, PhD, RD, associate professor of kinesiology at the University of Connecticut, describes the study as “adding to the evolving picture of improvement in general health beyond simple weight loss in keeping blood glucose and insulin under control.” The work is part of a larger study (currently under review) showing numerous improvements in blood lipids.

The current work concludes that “lowering total and saturated fat only had a small effect on circulating inflammatory markers whereas reducing carbohydrate led to considerably greater reductions in a number of pro-inflammatory cytokines, chemokines, and adhesion molecules. These data implicate dietary carbohydrate rather than fat as a more significant nutritional factor contributing to inflammatory processes.”

Richard Feinman, PhD, professor of biochemistry at SUNY Downstate Medical Center, adds, “The real importance of diets that lower carbohydrate content is that they are grounded in mechanism: carbohydrates stimulate insulin secretion which biases fat metabolism towards storage rather than oxidation. The inflammation results open a new aspect of the problem. From a practical standpoint, continued demonstrations that carbohydrate restriction is more beneficial than low fat could be good news to those wishing to forestall or manage the diseases associated with metabolic syndrome.”

One of the remarkable effects in the data presented that may have contributed to the results is that despite the three-fold greater saturated fat in the diet for the low carb group, saturated fat in the blood turned out to be higher in the low fat group due to the process known as carbohydrate-induced lipogenesis.

Dr. Volek points out that “this clearly shows the limitations of the idea that ‘you are what you eat.’ Metabolism plays a big role. You are what your body does with what you eat.”

How Do You Feel on Low-Carb?

An interesting short-term study published in this month's American Journal of Clinical Nutrition, Low- and high-carbohydrate weight-loss diets have similar effects on mood but not cognitive performance, sought to assess differences in mood following a high-carbohydrate diet compared with a low-carbohydrate diet.

In the study, ninety-three subjects were randomized into two groups:

• The high-carbohydrate dieters consuming a calorie restricted diet with 46% carbohydrate, 24% protein and 30% fat. Women consumed approximately 1429-calories each day, or 164g carbohydrate, 48g fat and 86g protein. Men consumed approximately 1667-calories each day, or 192g carbohydrate, 56g fat and 100g protein.
  
• The low-carbohydrate dieters consuming a calorie restricted diet with approximately 4% carbohydrate, 35% protein and 61% fat. Women consume approximately the same calories as above (there was no statistically significant difference for calories consumed in the study), or 15g carbohydrate, 97g fat and 125g protein. Men consumed approximately the same calories as above, or 17g carbohydrate, 113g fat and 146g protein.

Throughout the study, over the course of eight weeks, foods were provided to subjects and every two-weeks weight was taken and mood measured. Compliance by those following the low-carb diet was verified by measuring urinary ketone levels.

Both diets resulted in statistically significant weight loss.

The low-carbohydrate diet resulted in a statistically significant greater weight loss over the eight-week period than the high-carbohydrate diet, with low-carb dieters losing an average of 7.8kg (17.2-pounds) compared to 6.4kg (14.1-pounds) in the intent-to-treat analysis (p=0.04).

Both groups showed improvements in psychological well-being (p=0.01 for time) and there was no significant difference in working memory. The researchers noted "[t]here was some evidence for a smaller improvement in cognitive functioning with the LCHF diet with respect to speed of processing, but further studies are required to determine the replicability of this finding."

Quick Clicks to Low-Carb Rules Articles

• Handing you the Keys to Success
• Establishing Good Eating Habits: Rule One
• Rule Two: Back to Basics
• Rule Three: Vegetables & Fruits are Heart of Controlled-Carb
• Rule Four: Starches, Sweets: No Longer Staples
• Rule Five: Break Free from Contradictions
• Rule Six: Empower Yourself
• Rule Seven: Use Your Smarts!
• Rule Eight: Keep it Real
• Rules to Drink it Up!
• Rules to Maintain a Balance

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.

Keeping Our Eyes on the Ball

Today I'd like to interrupt my series on understanding the short and long-term lessons found within the Rules of Induction (Atkins) and provide space for my husband, Dr. Gil Wilshire, MD to share his thoughts in a guest commentary. So, without further ado:

Keeping Our Eyes on the Ball
Gil Wilshire, MD, FACOG

Back in 2006, Regina and I were interviewed and asked about our thoughts on the future of dietary science and policy. We speculated that carbohydrate restricted diets would be an accepted, main-stream concept by the year 2040. I believe we are well on our way to seeing our goal fulfilled well before this arbitrary temporal milestone.

I try to remain constantly vigilant with regard to new scientific information, and it seems that in every month good, new information is published. Recently, Matt Hayes and colleagues (J. Nutr. 137:1944-50, 2007) drilled deeper into out understanding of carbohydrate restriction, metabolic syndrome, and the biochemistry behind satiety. I am pleased to see that our current shared clinical experience of spontaneous caloric control and rapid reversal of metabolic syndrome is now being bolstered by more clinical data. Although the study in question was rather timid with respect to carbohydrate restriction (it was a South Beach-type protocol) I still found the information valuable.

It is another, peer-reviewed paper to the ever-growing pile of scientific evidence supporting our position.

I would also like to add that my ever-growing clinical experience in my new home of Central Missouri continues to be very gratifying. It seems that not a month goes by where something good happens very quickly after a patient begins their new life style (I dislike the thought of "diets"...this implies a temporary change, instead of a whole new way of being). In my obese, "infertile" patients, it is fairly common for women to become pregnant before instituting hormone therapies. Women who appeared destined for the bariatric surgeon are losing huge amounts of weight...and now are making appointments with the plastic surgeons!

I must say, there are many doctors in the surrounding communities who are truly scratching their heads as our mutual patients make healthy progress eating "high fat" diets. Now, after some period of suspicion, I am actually getting requests to learn more about what we do in my office!

Positive results are very persuasive.

Nothing succeeds like success.

Being married to Regina is never boring, and I am privileged to hear all the latest details occurring within the nutritional community every night when I get home from the office. We are a disparate lot in the "low carb" community, with much independent thinking and talented, innovative thought leaders. I suspect that the field of nutrition and metabolism will never be one of lock-step agreement. However, I would like to take this opportunity to reiterate our common goals and to reinforce our shared understanding:

1) Current dietary recommendations that promote low-fat and low cholesterol diets are unscientific, unproven, and fatally flawed; and,
2) The vast majority of modern humans appear to function best when eating nutritionally dense, whole foods that most closely resemble those foods on which we evolved.

I believe it is these principles that unite us all. There will always be bumps in the road, and we must always be prepared for unexpected turbulence. That's life.

Let's keep our eyes on the ball! Slow, steady progress always wins the race.

Good health to us all!

Gil
Mid-Missouri Reproductive Medicine & Surgery

Rule Four: Starches, Sweets: No Longer Staples

Rule 4:

• Eat absolutely no fruit, bread, pasta, grains, starchy vegetables or dairy products other than cheese, cream or butter. Do not eat nuts or seeds in the first two weeks. Foods that combine protein and carbohydrates, such as chickpeas, kidney beans and other legumes, are not permitted at this time.

For many the thought of not having a piece of bread, a side of pasta or rice, a bowl of cereal, etc. seems way too restrictive. With the low-carb products on the market, like low-carb bread, low-carb pasta, this rule seems silly - one that can be dismissed as long as they maintain rule 3 and keep carbohydrate at or below 20g net each day.

From this rule, we learn by implication - all carbohydrates are not created equal, and thus are not to be treated in a similar manner as you continue along to the long-term and maintain your weight. In baby steps, you'll be given opportunity to re-introduce many, many carbohydrate-rich foods, but for now, you're at square one and starting to learn how to eat well.

It is in this minimum two weeks period you eat those foods which are nutrient powerhouses - meats, poultry, eggs, fish, non-starchy vegetables, non-traditional fruits, good fats/oils and some dairy.

While critics focus on the limitations imposed on low-carbers - no sweets or starches in the first two weeks - often insinuating this is all one is allowed for the long-term, that's not the case.

This is a two-week period to "eat clean" from a limited selection of foods, designed to break you from the habits of old, establish good eating patterns, get back to basics that provide essential nutrients and lay the foundation of what your base diet will be later, when you are allowed to include more carbohydrate from a wide variety of foods.

By excluding bread, pasta, grains, starchy vegetables, most dairy products, nuts, seeds and legumes, this rule takes the focus off what many people consider highlights of their meals - starch; it resets emphasis on those things - protein, fat, nutrient-dense non-starchy vegetables and low-GL fruits - that in the long-term that will now be the foundation of your meal-planning well into maintenance.

Once you have a firm grip on this basic rule, and are eating in a pattern that no longer requires some sort of bread, potatoes, rice, pasta, etc. as a staple of your meals, you're on your way to understanding how these items may be re-introduced later as a complement in your habitual diet if you choose to include one or more of them.

Where before a meal may have been centered around your big bowl of pasta with maybe a small meatball or sausage, a crusty loaf of italian bread and perhaps croutons on your salad, over the long-term, as you mainatin your weight, your meals - if you learn from the rules of induction - are bulit upong your solid foundation of healthful eating - non-starchy vegeteables, quality protein, good fats and, by then, any additional foods you like and can tolerate well as a complement to your meal instead of the focus of the meal.

This rule fosters breaking the mindset that you need carbohydrate-rich foods to provide the majority of calories in each meal and at the end of each day - you don't - and by following this rule and waiting until the time is right to increase carbohydrate, you will be better able to assess what carbs you can and cannot tolerate in your meals as you progress - you'll better appreciate also how to portion your meals with these items "on your plate" in later in maintenance.

These foods, we often believe are staples will no longer be the main attractions in your meals when you're maintaining, but can still be a part of your diet in the long-term.

Trust the good doctor on this one and just don't eat anything that resembles bread, pasta, grains, etc. - no matter how low-carb they're promoted as.

During the first two weeks (minimum) avoid any and all processed products if you can.

Eat clean.

Keep it simple.

Learn.

Appreciate how good real food tastes.

Take your time.

Plan along the way.

Try new foods that are allowed.

Focus on the delicious food that is allowed.

Enjoy your meals!

Enjoy eating!

It's worth it in the long-term!

Rule Three: Vegetables & Fruits are Heart of Controlled-Carb

We hear much of a healthy diet is from eating fruits and vegetables. Research suggests there is a strong correlation between "good" health and "bad" health over the long-term when comparing the dietary habits of those eating a diet rich with fruits and vegetables to those consuming less than recommended levels.

Diets that strategically restrict carbohydrate are often criticized for lack of fruits and vegetables in the dietary approach. Much like the second rule getting lost in translation, from an allowance of a large variety of meats, poultry, fish, shellfish and game to a requirement to eat "fatty steaks, bacon, brie and cheeseburgers," by those unconvinced a low-carb diet is scientifically supported, rule three is often either ignored in the media and/or used to show how unsustainable carbohydrate restriction is in the long-term for someone to do forever.

How about we take a look, and see what the third rule actually says, and what it "pearls" it contains in both the short and long-term, and where vagueness may lead to misinterpretation:

Rule 3:

• Eat no more than 20 grams a day of carbohydrate, most of which must come in the form of salad greens and other vegetables. You can eat approximately three loosely packed cups of salad, or two cups of salad plus one cup of other vegetables.

First, we know from the published books, that the Induction period is a minimum of two weeks; while one can, and many do, stay within the 20g of carbohydrate beyond two weeks, the above rule is in place for at least the first two weeks.

During this time, the person starting the low-carb diet is tasked with two things in this rule:

1. limiting carbohydrate to just 20g a day and
2. ensuring that most of those 20g carbs are from salad greens and other (allowed) vegetables.

As an example, the rule says this is "approximately" three loosely packed cups of "salad" (note not simply salad greens), or two cups of "salad" (again not simply salad greens) plus one cup of other (allowed) vegetables (without mention of raw or cooked state).

We also know that the plan includes a deduction of fiber, so the amount of non-starchy vegetables (and fruits which I'll get to in an upcoming post) - in cups - that one is expected to consume depends highly on which allowed vegetables are selected in a day. Regardless of which are included, a minimum 10g net (deducting fiber) must come from non-starchy vegetables!

We also plainly see that it is not *mandatory* to deduct fiber per the rule above; however, I strongly suggest folks do deduct fiber as it allows a greater intake of non-starchy vegetables, which are not only low in calories, but nutrient powerhouses. When you deduct the fiber, you're able to consume more essential nutrients than if you don't.

I've previously offered examples of how different selections of non-starchy vegetables may look in a day of eating on a plan allowing 20g net in a day. Once again, I am providing examples to emphasize, even at 20g net carbohydrate, where 10g net is the minimum, a low-carb plan - done properly - meets or exceeds intake recommendation of at least five servings per day in the Dietary Recommendations for Americans for fruits and vegetables.

Example 1

• 1-cup green beans (cooked measure)
• 2-cups Shredded Cos/Romaine Lettuce (raw)
• 4-pieces Crimini Mushrooms (raw)
• 1/4-cup Shredded Red Cabbage (raw)
• 4 Cherry Tomatoes (raw)
• 1-cup Spinach (raw)
• Total Carbohydrate = 18g
• Fiber = 8g
• Net Carbohydrate = 10g
• USDA Servings of fruits/vegetables = 5

Example 2

• 1/2 Avocado (raw)
• 3-cups Cos/Romaine Lettuce (raw)
• 4 Cherry Tomatoes (raw)
• 1/4 cup Shredded Red Cabbage (raw)
• 1-cup Spinach (cooked measure)
• 1/2-cup Broccoli Florets (raw)
• 1/2-cup Sliced Cucumber (raw)
• Total Carbohydrate = 24g
• Fiber = 14g
• Net Carbs = 10g
• USDA Servings of fruits/vegetables = 6

Example 3

• 2-cups Shredded Cos/Romaine Lettuce (raw)
• 1/2-cup Cherry Tomatoes (raw)
• 1-cup Spinach (cooked measure)
• 1/2-cup Asparagus (cooked measure)
• 1/2 cup Sweet Green Peppers (cooked measure)
• Total Carbohydrate = 21g
• Fiber = 9g
• Net Carbs = 12g
• USDA Servings of fruits/vegetables = 6

One can see from the examples above, depending on selections made from those fruits and vegetables allowed in the first two weeks, it is not difficult to meet the recommended intake of 5-or-more servings of fruits and vegatables.

The aim to include a minimum of 10g (of the 20g allowed) from non-starchy vegetables is a "must" in the rule above.

It is also clearly stated as a "minimum," and therefore understood that if you would like to include 12g, 15g or more from non-starchy vegetables in lieu of other foods that have carbohydrate, that is also allowed.

So, if one is cognizant of and desiring more than the minimum intake of fruits and vegetables, they are completely allowed to consume more - with the only restriction being not to exceed 20g net (deducting fiber) during the first two weeks.

Must you aim to consume half your allowed carbohydrate from fruits/vegetables? YES

Can you eat more fruits/vegetables (allowed ones), say 12g, 15g, 18g? YES

Can you deduct fiber? YES

Do you have to? NO (but doing so allows a greater intake of fruits/vegetables and associated essential nutrients)

With all that said, and focus on what all the rules mean for the long-term, I contend that one is expected to continue eating this level (as minimum each day) as they progress toward the long-term eating. I believe that this is one more "foundational" part of carbohydrate restricted diets in the long-term and something intended to be continued as one increases carbohydrate and includes a wider selection of foods, including more vegetables, fruits, nuts, seeds, legumes, and if desired, even whole grains.

Many folks say a low/controlled-carb diet is a way of life, yet find it difficult to take what they start with - 20g net (deducting fiber), of which most must be provided by non-starchy vegetables, a 10g minimum each day - and maintain that aspect as one solid foundation to build upon as they continue to lose weight and then maintain their weight.

Old eating habits start to creep back with more carbs; habits such as preferrentially selecting sweeter foods or grains (even if whole grain) with consumption of non-starchy vegetables waning as one re-introduces more carbohydrate.

If one takes this rule, and continues to extend it --- fully --- until they reach 40g net carbohydrate each day (deducting fiber), they will be consuming incredibly healthful levels of fruits and vegetables, and will be able to eat a very wide variety of them too. That is, until 40g carbohydrate is achieved in the diet during weight loss, one must always include half those carbohydrates from fruits and vegetables with each incremental increase in carbohydrate. (Beyond that, it is increasingly difficult to continue adding more non-starchy vegetables and fruits due to their bulk; you can, of course - it's just not as easy to do).

Now that isn't exactly stated explicitly in the rule, but it is from my experience and those I've given assistance, one significant contributor to maintenance of weight in the long-term. That's because if you're aware of and including a lot of fruits and vegetables (specifically non-starchy vegetables and low-glycemic load fruits) it is difficult to consume excess calories each day over the long-term.

It becomes much easier to consume excess calories when you "play" the carb game (like many play the "points" game with Weight Watchers) and make choices to stay within a number, rather than focus on quality of choice.

But if you're committed to making sure that, no matter what intake of carbohydrate you reach (60g, 90, 120g or more), that you always are sure you include at least 10g net minimum at the start and then 20g minimum (net) from non-starchy vegetables/low glycemic-load fruits as you continue along, you'll have a favorable calorie intake that helps maintaining weight easier.

As you add back carbs, this rule must remain in your eating habits, even if you only stick with 10g net as minimum (which I don't suggest you do) as you're learning in the beginning - you cannot add back carbs and eliminate or reduce how many vegetables and salads you eat each day and expect to maintain your weight using grains, nuts, fruits, etc. as your primary source of carbohydrate later....you must always maintain a level of carbs from your vegetables and salad greens - even in maintenace.

This rule, like rule two, is taking you "back to basics" - helping you learn, step-by-step, how to nourish your body with high quality nutrients from real foods; over time you're encouraged to include a wider variety of non-starchy vegetables, low glycemic-load fruits, nuts, seeds, legumes and more, and the starting basics for the diet should be extended out for the long-term; that is, establish now, at the start, that as part of your long-term habitual diet, non-starchy vegetables and low-GL fruits will be a large part of your overall diet - your body will thank you!

Rule Two: Back to Basics

Over the last few decades, the population at large, has slowly been indoctrinated to fear dietary fat; to limit intake of dietary cholesterol; and to limit consumption of foods rich with saturated fat like meat, whole dairy, butter and eggs. This happened despite little evidence that such an approach to eating provided a long-term health benefit, or ability to maintain weight. But, with decades of reinforcement in the popular thinking, it's understandable how the second rule in the Rules of Induction is the most misunderstood and maligned of them all.

Let's take a look:

Rule 2:

• Eat liberally of combinations of fat and protein in the form of poultry, fish, shellfish, eggs and red meat, as well as pure, natural fat in the form of butter, mayonnaise, olive oil, safflower, sunflower and other vegetable oils (preferably expeller-pressed or cold-pressed).

Is it any wonder that, when a diet comes along and allows these foods, in complete contradiction to decades of fat phobia propoganda, it is vehemently opposed by the leading health organizations and government agencies? That we're innundated with dire warnings of consequence to health, heaped upon us in a concerted effort to discredit and dismiss anyone who says differently; despite scientific evidence and data supporting not only the inclusion of these foods in the human diet, but their inportant contributions to the human diet!

Ignore the man behind the curtain Dorothy....ignore that in the noble attempts to improve the health of our population, researchers and clinicians were lead astray by what we now know was half-truth data, published in the fifties and sixties.

They know it, we know it, but still it's difficult to come to grips with that fact and reverse direction after decades of building the foundation of a "truth" only to find it terribly flawed. It's often easier to continue on in the lie than face the fact you're wrong; moreso when the entire group and community you exist within endorses the continuation of the established dogma, despite the evidence to the contrary.

It's easier to "kill the messenger" than kill the flawed paradigm that hold these foods are to be limited, heck, even avoided at all cost.

To admit such is akin to killing thyself and the core set of beliefs one holds to be true.

Dramatic license here?

Sure, but it does speak of something critically important one must do for their long-term health when they begin to, perhaps for the first time in their life, establish good eating habits for the rest of their life.

Simply put, the second rule of induction grants us permission to dismiss everything we've been told and taught to hold as truth about eating, macronutrients (carbohydrate, protein, fat) and a "balanced, healthy" diet; allows us to re-learn what it means to be human and eat food; and encourages us to enjoy the experience of truly eating a healthy diet while losing weight and then continue to do so along the way to finally, once and for all, maintain that weight well into the future.

I'm quite the optimist aren't I?

Seriously, don't studies tell us again and again that dieting to lose weight fails, that all we really ever do is get good at losing weight, but we're never quite able to master maintaining our weight in the long-term?

Let's start by examining the very base reason most folks even begin a diet to lose weight - they're overweight or obese and have decided it's time to do something about it.

So they begin, they are off to a good start, they're motivated and continue to be motivated with each incremental decline they see on the scale.

Problem?

Absolutely - the focus is on the scale; the number on the scale matters most and damn the torpedos, no matter how inconvenient, stressful or annoying it is to weigh, measure and count every calorie, the individual is in a battle against their bathroom scale to reach a desired number in the shortest period of time possible.

Millions have mastered this task, only to have to repeat it again and again throughout their life. I apolgize now if this sounds crass, but anyone can lose weight with even just a small level of effort; it doesn't take an Einstein to eat less for weeks or months to reach a number on the scale; most will put up with high levels of discomfort to reach that goal - hunger, moodiness, irritability, stress and counting, measuring and weighing anything they consider putting in their mouth.

In the short-term, such measures do work; in the long-term they fail because the person has been mistakenly led to believe "if only..." they do this, measure that, control this and avoid that over the short-term, somehow that alone will enable them to maintain their new lower weight without much more than keeping on keeping on; except the keeping on part is next to impossible!

That's because the very dogmatic recommendations we're repeatedly told are balanced and healthy to lose weight are scaring people away from the very foods that we need to eat to thrive as humans; this forces an unnatural eating patten across the population due to a deeply flawed fear of dietary fat and cholesterol and leads to failure in the long-term because it is not only unsustainable, it's incompatible with true health in the longer term.

The heart and soul of our metabolism is the endocrine system - when it dysfunctions, a cascade of health problems follow - insulin resistance, high blood pressure, dyslipidemia, diabetes, and other chronic and debhilitating diseases.

Why then are we specifically told to avoid the very foods that fuel the proper function of this system?

The current recommendations not only scare us from healthy food, they make simply eating way too stressful for an average person - measure this, weigh that, watch this, avoid that, don't eat this, that's better, blah, blah, blah - who wants to deal with that much stress each day? Sure, a motivated person, desiring weight loss will submit to such stress to reach a goal - but then what happens? They do what is natural and human - they do what they need to do to relieve the stress and relax, are then an easy target to point to as someone lacking willpower, someone just not commited to sticking with it; someone who simply doesn't care and is lazy!

Anyone who has attempted to lose weight only to regain it can relate - no matter how hard you try to stick with a diet that is, for lack of a better phrase, "high maintenance" to follow each day for the rest of your life - sooner or later you find the "benefit" (weight on scale) isn't worth the time and "stress" (weighing, measuring, going hungry, chastising yourself for wanting to eat, etc.).

As I said in my last post, what if the problem isn't you or your "willpower," but a deep flaw within the recommendations that lead not to success, but failure in the long-term?

Here's the rule again:

Rule 2:

• Eat liberally of combinations of fat and protein in the form of poultry, fish, shellfish, eggs and red meat, as well as pure, natural fat in the form of butter, mayonnaise, olive oil, safflower, sunflower and other vegetable oils (preferably expeller-pressed or cold-pressed).

The short and long-term secrets within this rule include:

1. Eating "liberally" is not the same as eating until you are stuffed and goes hand-in-hand with rule 6, which we'll look at later this week. This rule is also a natural extention to rule 1 to eat regular sized portions.

2. You're allowed to eat animal foods such as meats, poultry, fish and eggs provides you with combinations of both fats and protein - necessary for health, losing and maintaining weight on a carbohydrate restricted diet.

Note that in the rule, no one is told they must eat "fatty meats" or must consume "bacon, brie and oodles of t-bone steaks." No, instead they're to eat foods that provide both fat and protein; they can choose whatever cuts they like, whatever combinations suit their tastes; whatever they prefer.

Want boneless skinless chicken breast? Allowed.

Want a filet mignon? Allowed.

Want some eggs? Allowed.

Want some dark turkey meat? Allowed

Want some salmon? Allowed.

This "allowance" of all things that provide a good fat-protein combination reinforces our mindfullness not to fear food, food is not the enemy!

Adding to this is that using fats and/or oils as part of your meals is allowed - from sources of natural, good fats and oils; with those natual oils being preferentially from expeller-pressed or cold-pressed sources.

Why are the animal products with combinations of fat and protein and the use of natural fats & oils so important?

By integrating both into your meals you are also beginning the process of balancing your essential fatty acid ratios in your eating from the fats found in these sources, and perhaps for the first time, consuming adequate protein, thus adequate essential amino acids.

Important too is to choose quality, eat well and enjoy your food and meals. Don't worry each day about how much fat is in a particular food or meal at this stage, over time you'll be able to "tweak" as you go and learn better how to nourish your body and eat what really is a well-balanced, healthy diet.

With fat and protein providing the vast majority of "essential" nutrients, this liberal approach at the start of your weight loss diet takes you "back to basics" and with time, provides you the opportunity to not only learn how to eat well for the long-term, but to actually enjoy your meals again - without fear that you're killing yourself with every bite!

Establishing Good Eating Habits: Rule One

Odds are, overweight or not, by the time a girl reaches adulthood, she's tried one or more diets to lose weight or not gain weight; with boys, the incidence of dieting in the teenage years is less prevalent. In early adulthood this often continues, with many women and men developing what is termed "disordered" eating habits; skipping breakfast or other meals, relying on meal replacement products, like ready-to-drink shakes, rather than eat food for all meals, eating lots of small things on the run, or going long hours without eating anything, then taking one large meal at the end of the day, in the belief that will keep thier calorie intake lower over the day.

These types of habits aren't necessarily "eating disorders," though they may be part of one; more often than not, they are habits that one develops over time that are counter-productive to developing and maintaining a healthy relationship with food, and can stand in the way of long-term success when one loses weight and tries to maintain that loss over the long-term.

Food, while an easy target of blame in the weight loss game, is not an enemy to be avoided or held in disdain; it is essential to our health and well-being and, in the long-term, it's not simply learning what to eat that helps one maintain weight, but how to eat that sets the stage for long-term success.

With this understanding, it is easier to see why I believe the first rule in the Rules of Induction (for the Atkins diet) is the most important:

Rule 1:

• Eat either three regular-size meals a day or four or five smaller meals. Do not skip meals or go more than six waking hours without eating.

The first rule is straight forward and critically important not only in the first two weeks, but throughout the entire weight loss period, and then for maintaining weight in the long-term.

The reason is simple - it establishes that one doesn't need to eat in a typical three-meal-a-day pattern, but highlights the importance that eating regularly - even simple smaller meals multiple times each day - is a habit to continue with if you're already doing so, or establish now as you begin and continue to learn how to eat properly for the rest of your life.

Without establishing this as habit, you'll leave yourself open to disordered eating habits and continue to view food and eating as something bad or to be avoided. Now is the time to set aside all that disdain for food, eating, portions, and all that and dismiss that thinking so you can begin to learn to love food again!

This is the first step to "get back to basics" - a means to develop a healthy relationship with food and avoid continuing in a disordered eating pattern that is counter-productive in the long-term. In anything you do in life, be it your job, your hobbies, or anything else that requires skill, one thing that clearly sets apart those who succeed from those that fail is the feeling of confidence in ones ability. Few are "born naturals" in a given situation - most take the time and put in an effort to learn and do along the way, to build their confidence and master whatever it is they enjoy.

This is no different; by taking the time to work on this as you start a diet to lose weight, you will develop not only a sense of confidence that food is really not an enemy (since you will be losing weight while you establish good eating habits), you will also learn to listen to your body and take cues based on hunger to learn when to eat in a pattern that is in synch with your body. This is because eating regularly keeps your metabolism functioning and enables your metabolism to hum along nicely.

If you read the rule, you'll notice it says " three regular-size meals a day or four or five smaller meals" which hints at learning how much is enough; stated another way, portion size is important. If you're inclined to eat three meals a day, these meals will be larger than if you are inclined to eat four or five smaller meals.

We know from the various publications written by Dr. Atkins, that Induction is not a license to overeat or stuff ourselves. In my view, this Induction period is an opportunity to learn what a "portion size" means to you as an individual.

So many weight loss diets prescribe specfic weights and measures, claiming such portions are more than adequate for anyone attempting to lose weight.

But let's be honest - how many are truly satisfied after eating a tiny 2-to-3 ounce portion of bonless, skinless chicken breast? If you're one of the few who find this intake adequate for you and you're satisfied and not hungry, great!

If not, maybe the problem isn't you, or as you are often told, your lack of willpower, but instead that you have not eaten enough to adequately provide for your needs.

Listen to that - have some more - and as you begin to feel that sense of "satisfied," not stuffed, but satisfied and confident you've eaten well, without worry that you're going to be hungry again way too soon, then stop eating.

In this period, you are allowed to portion your meals as "regular-size" meals, keeping in mind that you won't eat larger portions just because you can. If three "regular-size" meals isn't your style, you simply adjust to more "smaller sized" meals in a regular pattern throughout the day.

The key here is to develop good eating habits and then maintain them as you move along.

Long-term this rule is the "golden rule" of maintenance. It is the most important rule of all the rules if you ask me!

By the time you reach maintenance, if you have been following this rule all the time - not just in induction - you're not only eating an adequate level of calories, no longer in ketosis and at your goal weight - you're also in the habit of eating portions that are "normal" for you and eating regularly to keep your metabolism working at a steady pace.

You've also learned that skipping meals may lead to eating more when you do eat and that it is best to keep your appetite sated by eating regularly for your particular needs - whether it is three regular meals each day or four or five smaller meals each day; and you may also have learned you're less likely to snack as often because your appetite is sated with regular meals!

This rule firmly establishes that you are tasked with setting the frequency of your eating pattern, sticking with an eating pattern that is regular, and develop a sense of what your needs are, learn what your "portion size" is in meals, and learn how to eat regularly instead of fearing food or your appetite!

Over the long-term you'll set the stage for success with this rule because you're allowing yourself to establish a healthy relationship with food and come to know that food is not your enemy, eating well is not a bad thing, and that enjoying your meals is truly a wonderful thing!

Handing you the Keys to Success

All weight loss diets come with some sort of rules; how much to eat, what to eat, when to eat, how to control portions, etc. The weight loss diet that enabled me to finally lose the excess weight was Dr. Atkins' New Diet Revolution (1992/1999), and like all other diets had its rules to follow - the Rules of Induction.

While Induction is heavily criticized by many, it is the period I call "back to basics" for the individual just starting out. While one is to carefully count carbohydrate, eating no more than 20g each day, they are also encouraged to view foods once subject to elimination or strict limitation differently; foods like whole eggs, red meat, full fat salad dressings, cream and real cheese are allowed, while "low-fat" products are strongly discouraged.

Within the books published by Dr. Atkins, the list of foods allowed during the first two weeks includes almost any red meat, poultry, fish, shellfish, fowl or game; with caution to limit or avoid nitrates and processed meats. Real whole milk cheese, cream and half & half are allowed within the dairy group, with limits on intake each day if one is consuming them; a long list of non-starchy vegetables and fruits (that is fruits that are fruits that we often don't recognize as "fruit" but are fruits - olives, macadamia nuts, summer squash, cucumber, tomatoes, etc.); all herbs and spices, and finally what to drink and what types and quantity of artificial sweetener is allowed.

One reason I call this the "back to basics" period in the diet is because it is focused on whole foods and provides for the most important essential nutrients our metabolism needs each day - quality protein (essential amino acids), quality fats (essential fatty acids) and nutrient-dense carbohydrates (essential vitamins, minerals and trace elements). The plan also encourages one to supplement with a high quality multi-vitamin (with minerals including potassium, calcium and magnesium; without iron) and provides additional information about other supplements if necessary.

In addition to the basic foods allowed during the period of Induction, the diet focuses the individual to follow what are called the Rules of Induction as a way to help them follow the diet correctly.

The Rules of Induction, from the 1999 publication of Dr. Atkins' New Diet Revolution are as follows: (they differ slightly from those published online by the company since his death in 2003; to read the updated version, published by Atkins Nutritionals, click here)

1. Eat three regular-size meals a day or four or five smaller meals. Do not skip meals or go more than six waking hours without eating.
2. Eat liberally of combinations of fat and protein in the form of poultry, fish, shellfish, eggs and red meat, as well as pure, natural fat in the form of butter, mayonnaise, olive oil, safflower, sunflower and other vegetable oils (preferably expeller-pressed or cold-pressed).
3. Eat no more than 20 grams a day of carbohydrate, most of which must come from in the form of salad greens and other vegetables. You can eat approximately three cups - loosely packed - of salad, or two cups of salad plus one cup of other vegetables.
4. Eat absolutely no fruit, bread, pasta, grains, starchy vegetables or dairy products other than cheese, cream or butter. Do not eat nuts or seeds in the first two weeks. Foods that combine protein and carbohydrates, such as chickpeas, kidney beans and other legumes, are not permitted at this time.
5. Eat nothing that isn't on the Acceptable Foods list. And that means absolutely nothing! Your "just this one taste won't hurt" rationalization is the kiss of failure during this phase of Atkins.
6. Adjust the quantity you eat to suit your appetite, especially as it decreases. When you're hungry, eat the amount that makes you feel satisfied, but not stuffed. When you're not hungry, eat a small controlled carbohydrate snack to accompany your nutritional supplements.
7. Don't assume any food is low in carbohydrate—instead, read labels! Check the carb count (it's on every package) or use a carbohydrate gram counter.
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.
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.
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.
11. Drink at least eight 8-ounce glasses of water each day in addition to anything else you may drink, to hydrate your body, avoid constipation and flush out the by-products of burning fat.
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.

You may be wondering why I'm posting this here, today, on my blog?

The reason is simple - over the years of following a diet that is controlled-carb, and maintaining my weight loss, I've realized that the above Rules of Induction contain the keys to long-term maintenance. The critical points needed to succeed in the long-term are right there if we look closely and examine why they are in place for the first two weeks, and why they are necessary throughout weight loss and maintenance.

Years ago I wrote an article for a publication that has since gone out of business, and my original copy is long gone. So, without that in hand to simply re-post here, I'm going to re-write it from my longer-term perspective today, some years later, continuing to follow a controlled-carb approach.

In the coming days and next week, I'll take one or two (if they are related) rules and explain why they are critical in the first two weeks, and the lesson I believe they are teaching us for the long-term. I'll begin tomorrow with the first rule, "Eat three regular-size meals a day or four or five smaller meals. Do not skip meals or go more than six waking hours without eating;" and provide data as to why it is important not only in the short-term, but also for long-term success.

As you'll learn in the upcoming posts, each of the rules looks to foster one or more things, including:

1. Your responsibility in what you eat
2. Breaking habits that contribute to weight gain
3. Establishing a solid foundation for healthy eating in the future
4. Providing the tools & strategies you'll need to maintain your weight loss
5. Creating good habits that lead to better health
6. Your health and well-being is in your hands and is your responsibility in the long-term

UPDATE: Thank you to a reader who sent me an archived copy of the original article, which i will link to at the end of the upcoming series, for my readers to compare my changes to with my additional years perspective to add to!

Is There a Secret to Success?

Lou Shuler, over at Male Pattern Fitness wrote about the article in Slate yesterday and asked What if Nothing Works?

Weight loss advice almost never helps anyone lose weight.

And yet, something must work. We all know people who've lost weight and kept it off. We've all known non-exercisers who became exercisers. We all know people who've turned their lives around by eating better and exercising more, or at least more effectively.

[...]

Instead, researchers tend to discover, over and over again, that whatever we're doing now just isn't working for most of the people who try it. And sometimes the results are worse than they would've been if the dieters hadn't tried at all.

His observation is dead on if you ask me.

True, I know some people who have lost weight and maintained their lower weight for years (myself included), but I know many, many more who were able to lose weight effectively in the short term, but then as time passed, the weight was regained, sometimes leaving the person heavier than before they dieted to lose weight.

If we look at data from the National Weight Control Registry (NWCR) a self-reported database of "successful losers," we're told they have four similar behaviors post-weight loss:

1. They eat a low-fat diet (23-24% fat) with just 1300-1500 calories a day
2. They eat breakfast everyday
3. They monitor weight frequently with 75% weighing themself once a week
4. They engage in a high level of physical activity - 60 to 90 minutes a day

Me?

None of the above - daily I eat almost twice as many calories each day with a lot more fat; I skip breakfast more often than not; if I remember I might weigh myself once a month and my activity is daily routine stuff, not a formal exercise program specifically to meet certain targets each day.

For me, it's been eating adequate calories to meet, yet not exceed, my active metabolic requirements each day with primary focus on consuming sufficient quality protein - whatever fat that includes, so be it; eating breakfast if I'm hungry, but not forcing myself to do so if I'm not; I weigh myself occasionally and if my clothes feel a bit snug, weigh to see what's up - if I'm a few pounds up, I review what I'm eating daily and make adjustments if necessary; and I maintain a level of activity that really isn't much more than day-to-day things, but I do have to say includes keeping up with an extremely active almost three child!

Which leaves me wondering - how do you maintain weight once you've lost weight?

If you've lost weight and are able to maintain that loss, share here how you've done it...if you've lost to only re-gain the weight, what do you think is the problem?

Low-Carb Increases CRP?

Last month the Journal of the American College of Nutrition published a study, Low Carbohydrate, High Fat Diet Increases C-Reactive Protein during Weight Loss, that I'd set aside to write about when time permits.

I'm also a strong believer in not re-inventing the wheel, so when someone else writes a good analysis, I'm inclined to point you in that direction rather than repeat what's been already said.

Cassandra Forsythe is a PhD Fellow at the University of Connecticut, Storrs, and works with Dr. Jeff Volek; her studies include exercise and nutrition.

Her blog is Female Fitness and Nutrition Scientist, and yesterday she posted her analysis of the study and its findings.

The Devil in the Details - Low-Carb High Protein Diet Kills

A study - Low-carbohydrate–high-protein diet and long-term survival in a general population cohort - published in the May edition of the European Journal of Clinical Nutrition (originally available ahead of print, November 2006), concluded that "Prolonged consumption of diets low in carbohydrates and high in protein is associated with an increase in total mortality."

When I read the first publication of the study, back in November, I decided not to write about it since I was focused on penning articles about diabetes throughout National Diabetes Month and this study wasn't about diabetes. It remained on my pile of studies to consider, but as time passed, it seemed less and less important to write about. Now, with it hitting the print edition, and a renewed interest in the findings, it's time to take a look at what the researchers found and how they reached their conclusions.

Jake Young, who writes at Pure Pedantry, thought it worthwhile to take a look too. In summing up the design of the study, he wrote "[j]ust to cross the t's and dot the i's, they also control sex, age, years of schooling, smoking, BMI, physical activity, ethanol intake, and (in the data I am going to talk about) energy intake;" thinking, I believe, that adjusting for these confounding variables leads to higher quality conclusions.

Except in this case, adjusting for some of these variables led to a leap-of-faith extrapolation from the data because without making adjustments there was no significant finding to speak of, "[i]n model 2, the LC/HP score (absolute values) was positively associated with mortality, although the association did not reach statistical significance (P=0.14)." [emphasis mine]

In other words the association was statistically due to chance and therefore a null finding.

But, let's not let that get in the way of a good chance to find statistic significance!

Rather than take the data at face value for absolute intake (what people were eating), the researchers decided to adjust energy intake and considered this adjustment "as they should be, isocaloric..." to show how, after adjusting for energy intake variables things change.

And change they did.

With this one adjustment, statistical significance magically appears and now "mortality was significantly associated with reduction of energy-adjusted carbohydrate intake and nonsignificantly with increasing protein intake."

But still, how exactly to find protein problematic?

Ah, one more adjustment just might do it.

The researchers noted that their "model 3" "does not specify the complementary changes that have to be introduced for the preservation of total energy intake, when carbohydrates and proteins change." So, they created "model 4" and said it was "the most appropriate" since it was both isocaloric (adjusted for energy intake) and now adjusted to reflect changes from less carbohydrate and more protein.

Viola!

"In this model, increasing LC/HP score was significantly associated with mortality (P=0.001)."

Except, no one in the cohort ate like the adjusted diet, the statistically significant findings are not from real people eating real food (absolute intake), but are only found upon adjustment of energy and intake from protein and carbohydrate. The researchers justified this adjustment as necessary with "[i]ndeed, many of contemporary public health policies rely on extrapolations, so that if something is detrimental at a certain exposure level, its effect is likely to be more detrimental at a more extreme level."

Perhaps this is part of the problem with our public health policy? We're basing recommendations on extremes, extrapolated from adjusted models, rather than real world eating habits.

This is how the American Heart Association comes up with recommending less than 7% saturated fat to all Americans, even those at low risk for heart disease; they take data from studies that found no benefit from reducing saturated fat to 10% or less of calories and do the mental gymnastics to leap to an idea that benefit will be seen when saturated fat is less than 7% of calories. No data, just pure extrapolation and wishful thinking.

But, I digress...

There'd be nothing to talk about with this study if the researchers only went with their cohort and their habitual diet. Remember, when the absolute intake data was crunched, there was no statistically significant finding.

It's only after the researchers play with the data and make adjustments - adjustments outside the "norm" of their population cohort - into the extreme models, that they find significance.

In the real world you'll be hard pressed to find someone eating a diet within the extreme models they created. That's because the fundamental flaw in their model adjustment was the belief that decreasing carbohydrate means increasing protein. As the researchers noted in their paper, their adjustment model "relies on opposite changes of two nutrients with equivalent energy values and tends to be unrelated to total energy intake."

Simply put, the assumption was that reduction of carbohydrate translates to an isocaloric increase in protein.

The problem with this is that in the real world, increasing protein beyond what the body needs is extremely difficult due to satiety hormones that effectively shut down hunger when protein intake is adequate and carbohydrate is restricted. So the idea that one is effectively replacing carbohydrate with protein has a limit. A limit that seems beyond the grasp of this research group, who didn't seem to ask the important question - why did those with higher LC/HP (low-carb/high-protein) scores consume less calories than those eating a higher carbohydrate diet?

Rather than delve into this, they adjusted protein as if this group could and would consume more calories and more protein in a linear progression, adjusted their habitual intake to reach an isocaloric level comparable with their higher carboydrate counter-parts. But, because protein is such a sating macronutrient, this adjustment is not based on reality, but is purely hypothetical; and a hypothetical situation that one is likely to find impossible in a real world eating situation.

My take - the researchers would have been better off publishing their findings from the absolute intake data and letting the data stand as it is rather than make various adjustments to convoluted extremes and try to make headlines. Nice try though.

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!

Weight Loss, Cholesterol and Blood Sugar Improvements - What's the Wonder Drug Now?

While the media is hot and heavy to lead their headlines with junk science complete with amateurish conclusions, a study was quietly published Friday in the journal, Molecular and Cellular Biochemistry - Beneficial effects of ketogenic diet in obese diabetic subjects (abstract) - that's remains ignored.

No fanfare, no ballyhoo, in fact, not one headline to call attention to the significant findings, over the course of a year, of a dietary trial in obese subjects with and without type II diabetes.

Findings that included:

For both groups, diabetic and normal glucose:

• Weight loss of 24.55kg in 56-weeks (that's 54-pounds)
• Total Cholesterol down 19.3%
• LDL down 28.2%
• HDL up 52.3%
• Triglycerides down 59%
• Fasting Blood Glucose down 31%

For those with type II diabetes:

• Weigth loss of 24.4kg in 56-weeks (that's 53.7-pounds)
• Total Cholesterol down 28.5%
• LDL down 33%
• HDL up 63.4%
• Triglycerides down 40.8%
• Fasting Blood Glucose down 50.9% (yes, glucose fell more than 50%)

So, what exactly did the researchers have these subjects do that led to such impressive improvements over the course of 56-weeks?

Sixty-four subjects were divided into two groups - thirty one had abnormal glucose levels (type II diabetes) and the remaining thirty-three had normal glucose levels. Both groups were instructed to modify their diet to include only 20g of carbohydrate a day from a list of foods allowed along with 5-tablespoons of olive oil on salads, and allowed 80g-100g of protein from meat, eggs, fish, poultry and full-fat cheese each day. No alcohol was consumed by participants. At week 12, participants were allowed to increase carbohydrate to 40g per day. Throughout the 56-weeks some foods were forbidden - flour, bread, rice, macaroni, noodles, honey, sugar, sweets, cakes, potatoes, all fruit juices and all soft drinks.

Yes, shocker - the study was designed to measure the effects of a ketogenic diet in subjects with and without type II diabetes.

So, with the above findings, it's no wonder this one is being quietly ignored.

While the media, government policy makers and leading health organizations keep wishing for negative findings from studies of low carbohydrate diets, the opposite keeps happening - the pile of studies finding significant improvement keeps growing higher and higher.

How profound were the changes in real numbers?

Those with diabetes had baseline fasting blood glucose levels of 188.64mg/dl; by the end of the trial, at week 56, their fasting blood glucose averaged 87.66mg/dl. Even those with normal blood glucose, who started with a baseline fasting blood glucose of 92mg/dl, saw improvement; at the end of the trial they had a fasting blood glucose of 85mg/dl.

There is not one drug on the market today, recommended for those with diabetes, that shows such significant improvement in fasting blood sugar, sustained over a period of more than a year!

Oh, but it gets better. Cholesterol improvements in this trial were unmatched by any drug trial.

Those with diabetes:

Baseline Week-56

Total Cholesterol 265 190
LDL 203 131
HDL 39 62
Triglycerides 418 89

Those with normal glucose:

Baseline Week-56

Total Cholesterol 214 181
LDL 156 109
HDL 47 63
Triglycerides 160 77

No cholesterol medication reduces LDL by 33% while also increasing HDL by 63.4%; and reducing triglycerides by 59%.

If the above finding were for a new drug, not only would the headlines be screaming for everyone with dyslipidemia to be prescribed it immediately, but every last expert in the country would be making the rounds in the media to be heard about this new wonder drug!

Sadly this isn't a new wonder drug rich with potential for profits. Instead it's simple dietary therapy, with no bottomline enhancement for anyone, save for a few farmers and ranchers.

So no headlines, no urgent call to take a look at the data which validates previous studies, no demands for reviewing the evidence; nope, the powers that be will continue along, fingers in ears, singing "La La La" as they hope no one notices the mountain of evidence growing.

If you have diabetes, or are at risk for developing diabetes, get to know what a carbohydrate restricted diet is and how to integrate it into your health management, it may save your life.

UPDATE 4/24/2007

A reader brought to my attention a pretty glaring error in reporting of reduction of triglycerides. I posted the numbers from the full-text above as published - a reduction in triglycerides in those with high blood glucose = -40.8%

A review of the actual numbers shows a reduction over the 56-week period from 4.681mmol/l to 1.006mmol/l - a 78.72% reduction in those with high blood glucose; and from 1.827mmol/l to 0.861mmol/l in those with normal blood glucose - a 54.01% reduction.