Vol. 3 No. 6
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THE SKINNY ON ATKINS
By Michael Greger, M.D.*
Reprinted from the June 2004 issue of Dr. Greger’s Nutrition Newsletter. To subscribe, send a blank e-mail to firstname.lastname@example.org
WHAT THE EXPERTS THINK OF ATKINS
Atkins "Nightmare" Diet
When the chief health officer for the State of Maryland,2 was asked "What’s wrong with the Atkins Diet?" He replied "What’s wrong with… taking an overdose of sleeping pills? You are placing your body in jeopardy.” He continued "Although you can lose weight on these nutritionally unsound diets, you do so at the risk of your health and even your life."3
The Chair of Harvard’s nutrition department went on record before a 1973 U.S. Senate Select Committee investigating fad diets: “The Atkins Diet is nonsense… Any book that recommends unlimited amounts of meat, butter, and eggs, as this one does, in my opinion is dangerous. The author who makes the suggestion is guilty of malpractice.”4
The Chair of the American Medical Association’s Council on Food and Nutrition testified before the Senate Subcommittee why the AMA felt they had to formally publish an official condemnation of the Atkins Diet: "A careful scientific appraisal was carried out by several council and staff members, aided by outside consultants. It became apparent that the [Atkins] diet as recommended poses a serious threat to health."5
The warnings from medical authorities continue to this day. "People need to wake up to the reality," former U.S. Surgeon General C. Everett Koop writes, that the Atkins Diet is "unhealthy and can be dangerous."6
The world’s largest organization of food and nutrition professionals,7 calls the Atkins Diet "a nightmare of a diet."8 The official spokesperson of the American Dietetic Association elaborated: "The Atkins Diet and its ilk—any eating regimen that encourages gorging on bacon, cream and butter while shunning apples, all in the name of weight loss—are a dietitian's nightmare."9 The ADA has been warning Americans about the potential hazards of the Atkins Diet for almost 30 years now.10 Atkins dismissed such criticism as "dietitian talk".11 "My English sheepdog," Atkins once said, "will figure out nutrition before the dieticians do."12
The problem for Atkins (and his sheepdog), though, is that the National Academy of Sciences, the most prestigious scientific body in the United States, agrees with the AMA and the ADA in opposing the Atkins Diet.13 So does the American Cancer Society;14 and the American Heart Association;15 and the Cleveland Clinic;16 and Johns Hopkins’17and the American Kidney Fund;18 and the American College of Sports Medicine;19 and the National Institutes of Health.20
In fact there does not seem to be a single major governmental or nonprofit medical, nutrition, or science-based organization in the world that supports the Atkins Diet.21 As a 2004 medical journal review concluded, the Atkins Diet "runs counter to all the current evidence-based dietary recommendations."22
A 2003 review of Atkins "theories" in the Journal of the American College of Nutrition concluded: "When properly evaluated, the theories and arguments of popular low carbohydrate diet books… rely on poorly controlled, non-peer-reviewed studies, anecdotes and non-science rhetoric. This review illustrates the complexity of nutrition misinformation perpetrated by some popular press diet books. A closer look at the science behind the claims made for [these books] reveals nothing more than a modern twist on an antique food fad."23
Dr. Atkins Had a Dream
After failing to produce the promised sustained weight loss, the high-fat fad melted away only to re-emerged in the 1920’s with a doctor advocating a minimum of three porterhouse steaks a day and stating that the only two perfect foods were probably "fresh fat meat and water."25 It then disappeared until the 1940’s with a book extolling the virtues of eating whale blubber. Then it was recycled again in the 1960’s with Dr. Herman Taller's bestseller "Calories Don't Count" that discouraged people from exercising. "By whatever name," one nutrition textbook reads, "the diet is to be avoided."26
Taller’s "Calories Don't Count" diet empire collapsed when he was found guilty of six counts of mail fraud for using the book to promote a particular brand of safflower capsules, which the court called a "worthless scheme foisted on a gullible public."27
That same year, Dr. Irwin Stillman wrote the "Doctor's Quick Weight Loss Diet," allowing his patients to eat only meat, eggs, and cheese. Stillman himself died of a heart attack, but not before misleading 20 million people onto his diet.28
One might wonder why, if this kind of diet was such a "foolproof"29 "ultimate"30 path to "permanent joyful weight loss” that “WORKS 100% OF THE TIME!” (emphasis in original),31 they seemed to always quickly fade into obscurity, only to be resurrected shortly after by publishers guaranteed a new bestseller by America’s short attention span. This brings us to 1972, and the publication of Dr. Atkins Diet Revolution.32
Atkins’ diet was centered on fried pork rinds, heavy cream, cheese, and meat. For Atkins, bacon and butter were health foods and bread and bananas were what he called "poison."33
Drawing on his experience as a salesman and resort entertainer, Atkins proved a natural at self-promotion. He was featured in Vogue magazine (and hence the Atkins Diet was actually first known as the "Vogue Diet") and soon after appeared on the Tonight Show34 and Merv Griffen.35 In 1973, the publisher boasted that it became the “fastest selling book in publishing history.”36
The final chapter of Dr. Atkins Diet Revolution was entitled "Why We Need a Revolution…." It detailed his proposal to have some carbs literally banned. "Our laws must be changed to provide a proper way of eating for everyone." He urged everyone to start lobbying their legislators. "Political action and protest on your part," he wrote, "can help revolutionize the food industry, by forcing it to decarbohydratize many foods … with a federal law to back this change!"37
"Martin Luther King had a dream," Dr. Atkins wrote, "I, too, have one."38
"The Diet Fad of the 21st Century"
What may have truly made it "The Diet Fad of the 21st Century" (as an editor of the Journal of the American Dietetics Association coined it)41 came a decade later with the publication of the infamous pro-Atkins New York Times Magazine article "What If It's All Been a Big Fat Lie."42 Atkins quickly wrote an editorial for his Web site claiming the article "validated" his work. Gushingly favorable follow-up stories appeared on NBC's Dateline, CBS' 48 Hours, and ABC'S 20/20. The Atkins corporation claimed literally billions of media hits.43 By the time the article’s many flaws were exposed weeks later, the book had already catapulted to #1 on a New York Times bestseller list and Atkins’ net worth zoomed to $100 million.44
The piece was written by freelance writer and Atkins advocate45 Gary Taubes (who reportedly scored a book deal from it—and a $700,000 advance).46 The Washington Post investigated his pro-Atkins article and found that Taubes simply ignored all the research that didn't agree with his conclusions.
Taubes evidently interviewed a number of prominent obesity researchers and then twisted their words. "What frightens me," said one, "is that he picks and chooses his facts…. If the facts don't fit in with his yarn, he ignores them."47
The article seemed to claim that experts recommended the diet. "I was greatly offended at how Gary Taubes tricked us all into coming across as supporters of the Atkins Diet," said John Farquhar, a Professor Emeritus of Medicine at Stanford,. The Director of the Center for Human Nutrition at the Washington University School of Medicine was asked to comment of one of Taubes’ claims. He replied, "It’s preposterous."48
"He took this weird little idea and blew it up," said Farquhar, "What a disaster."49
"The article was written in bad faith," said another quoted expert. "It was irresponsible."50 "I think he's a dangerous man. I'm sorry I ever talked to him." Referring to the book deal, "Taubes sold out."51
What the researchers stressed was how dangerous saturated fat and meat consumption could be, but Taubes seemed to have conveniently left it all out. "The article was incredibly misleading," said the pioneering Stanford University endocrinologist Gerald Reaven who actually coined the term Syndrome X. "I tried to be helpful and a good citizen," Reaven said, agreeing to do the interview, "and I ended up being embarrassed as hell. He sort of set me up… I was horrified."52
The South Beach Diet
The Tufts University Health and Nutrition Letter weighed in on the South Beach Diet in their May 2004 issue: "Disappointingly, the South Beach Diet is simply yet another version of a fad wrapped within a gimmick." They concluded that it was "based on fallacies… replete with faulty science, glaring nutritional inaccuracies, contradictions, and claims of scientific evidence minus the actual evidence."56
The article notes, "The faulty and confusing science is compounded by The South Beach Diet’s own internal inconsistencies."57 Up front, for example, the author says that his diet doesn’t depend on exercise, but then goes on to tell people to get 20 minutes a day.58 He tells readers to avoid bananas in "phase 2"; then goes on to recommend: bananas dipped in chocolate sauce. He says up front that the diet is "distinguished by the absence of calorie counting or even rules about portion size" and that one shouldn’t "even think about limiting the amount you eat." He then, of course, proceeds to count calories and measure out servings every step of the way, even to the point of specifying "I recommend counting out 15 almonds or cashews."59 That sounded like a rule about portion size to the reviewers.
Tufts lists a few of the "out-and-out food and nutrition inaccuracies" in The South Beach Diet.60 Agatston says that whole-wheat bread is not whole grain, but cous cous is (actually the reverse is true). He claims watermelon is full of sugar but cantaloupe is not (they have the same amount). For a cardiologist who claims, "I feel nearly as comfortable in the world of nutrition as I do among cardiologists,"61 Dr. Agatston "sprinkled an awful lot of nutrition gaffes throughout his book."62 He claims eggs have minimal saturated fat—wrong. Each egg can have as much as 2 grams,63 giving some of his recipes over third of one’s daily limit.64
To be fair, though, he does frown on lard, although the
Atkins corporation is quick to point out that the South Beach menus do
not have significantly less saturated fat than Atkins.65 Just as Atkins
himself claimed he followed his diet for decades yet, according to his
own cardiologist, was overweight,66 Agatston revealed that he needs to
take medication to lower his cholesterol.67 Agatston, at least, doesn’t
call fruit "poison."68
Of course, pigs—in Arkansas and elsewhere—have presumably little use for astronomy. It doesn’t seem like too much to ask, however, that cardiologists like Dr. Atkins know something about nutrition.
The entire theoretical framework of low carb diets, like Atkins and The Zone, hang upon the notion that insulin is the root of all evil and so to limit insulin release one needs to limit carbohydrate intake. Dr. Atkins, for example, has a chapter entitled "Insulin—the Hormone That Makes You Fat,"71 Protein Power calls it the “monster hormone,”72 and the author of the Zone Diet calls insulin "the single most significant determinant of your weight."73
What they overlook is that "protein- and fat-rich foods may induce substantial insulin secretion" as well.74 For example, a quarter pound of beef raises insulin levels in diabetics as much as a quarter pound of straight sugar.75
Atkins featured foods like cheese and beef elevated insulin levels higher than "dreaded” high-carbohydrate foods like pasta. A single burger’s worth of beef, or three slices of cheddar, boosts insulin levels more than almost 2 cups of cooked pasta.76 In fact a study in the American Journal of Clinical Nutrition found that meat, compared to the amount of blood sugar it releases, seems to cause the most insulin secretion of any food tested.77
Low carb advocates like Atkins seem to completely ignore these facts. Recent medical reviews have called Atkins’ feel-good theories "factually flawed"78 and "at best half-truths."79 "In the scientific world, books like the Zone Diet are generally regarded as fiction,” one reviewer wrote in the Journal of the American College of Nutrition. “The scientific literature is in opposition…"80 In a medical journal article entitled "Food Fads and Fallacies," the Atkins Diet is referred to as a "’New wives’ tale" with a "sprinkling of fallacies."81
According to a 2003 article in the Journal of the American Medical Association, "Dr. Atkins and his colleagues selectively recite the literature" to support their claims.82 When researchers take the time to actually measure insulin levels, for instance, instead of just talking about them like Atkins does, they often find the opposite of what Atkins asserted.
A study done at Tufts, for example, presented at the 2003 American Heart Association convention, compared four popular diets for a year. They compared Weight Watchers, The Zone Diet, the Atkins Diet (almost no carbs), and the Ornish Diet (almost all carbs) for a year. The insulin levels of those instructed to go on the Ornish diet dropped 27%. Out of the four diets that were compared that year, Ornish’s vegetarian diet was the only one to significantly lower the “Monster” “Hormone That Makes You Fat," even though that’s supposedly what Atkins and The Zone diets were designed to do.83
In another study researchers took over a hundred pairs of identical twins and found that the more fat they ate, the higher their resting insulin levels were. Even with the same genes, the study "showed a consistent pattern of higher fasting insulin levels with intake of high-fat, low carbohydrate diets."84
Other studies show that a high (70-85%) carbohydrate diet (combined with walking an average of 15-30 minutes a day) not only can result in significant reductions in body weight, blood pressure, cholesterol and triglycerides, but significant drops in baseline insulin levels as well, exactly opposite of what low carb pushers would predict. In just three weeks on a high (unrefined) carb vegetarian diet and a few minutes of daily walking, diabetics reduced the amount of insulin they needed and most of the pre-diabetics seemed cured of their insulin resistance.85 In general vegetarians may have half the insulin levels of nonvegetarians even at the same weight.86
In an article entitled "Americans Love Hogwash," Edward H. Rynearson, Emeritus Professor of Medicine at the Mayo Clinic, singled out Dr. Atkins for dispensing hogwash he defines as "worthless, false or ridiculous speech or writings" and praised the AMA for "condemning this diet for its dangers."87 The "evidence" cited by Atkins has been called "nearly all anecdotal and misleading."88 "Carbophobia is a form of nutritional misinformation," a 2003 review in the Journal of the American College of Medicine noted, "infused into the American psyche through… advertising… infomercials… and best-selling diet books."89
We know that the Atkins Diet is successful—at making money. What about for weight loss? We know that cutting down on carbs will help people lose variety and nutrition in their diet,90 and if they buy his supplements, their wallet may get slimmer, but what about their waistline?
Who cares if the American Medical Association calls Atkins’s theory "naive," "biochemically incorrect," "inaccurate," and "without scientific merit?" Who cares if it "doesn't make physiological sense?"91 The question is, does it work?
Losing (Water) Weight
In biochemistry class, doctors learn that fat "burns in the flame of carbohydrate." When one is eating enough carbohydrates, fat can be completely broken down as well. But when one’s body runs out of carb fuel to burn, its only choice is to burn fat inefficiently using a pathway that produces toxic byproducts like acetone and other so-called “ketones.” The acetone escapes through the lungs—giving Atkins followers what one weight-loss expert calls "rotten-apple breath"92—and the other ketones have to be excreted by the kidneys. We burn fat all the time; it’s only when we are carbohydrate deficient and have to burn fat ineffectively that we go into what’s called a state of ketosis, defined as having so much acetone in our blood it noticeably spills out into our lungs or so many other ketones they spill out into our urine.
To wash these toxic waste products out of our system our body uses a lot of water. The diuretic effect of low carb diets can result in people losing a gallon of water in pounds the first week.93 This precipitous early weight loss encourages dieters to continue the diet even though they have lost mostly water weight94 and the state of ketosis may be making them nauseous or worse.95 If one wanted to try to lose water weight, sweating it away in a sauna may be a more healthful way.
The Director of Yale University's Center for Eating and Weight Disorders explains the miracle formula used by diet books to become bestsellers for over a century now: "easy, rapid weight loss; the opportunity to eat your favorite foods and some scientific 'breakthrough' that usually doesn't exist."96 The rapid loss of initial water weight seen particularly on low carb diets has an additional sales benefit. By the time people gain back the weight, they may have already told all their friends to buy the book, and the cycle continues. This has been used to explain why low carb diets have been such "cash cows" for publishers over the last 140 years.97 As one weight loss expert notes, "Rapid water loss is the $33-billion diet gimmick."98
In 2001, the medical journal Obesity Research published "Popular Diets: A Scientific Review." Claiming to have reviewed every study ever done on low carb diets, they concluded, "In all cases, individuals on high-fat, low carbohydrate diets lose weight because they consume fewer calories."100 Calories count—every time, all the time. "No magic ingredients, strange food combinations or pseudoscientific formulas will alter this metabolic fact."101
Dr. Atkins disagreed. In fact, he accused his critics of having "subnormal intellects" for even holding such a view.102 For three decades he peddled his claim that people could eat more calories and still lose weight. Decrying what he called the "calorie hoax," Atkins had a chapter entitled "How to Stay Fat—Keep Counting Calories." Atkins even subtitled his book "The High Calorie Way to Stay Thin Forever." The Zone Diet made a similar claim on its back cover: "You can burn more fat by watching TV than by exercising."103 (As one commentator exclaimed, "Goodness, what channel does he watch!")104
Atkins claimed people could lose 85 pounds, without exercising, eating an incredible 5,500 calories a day.105 The only problem, critics claimed, was that this ran counter to the First Law of Thermodynamics, considered to be the most fundamental law in the universe. No wonder the AMA scolded Atkins publishers for promoting "bizarre concepts of nutrition and dieting."106
"Metabolic Advantage" Advantageous Only In Selling Books
The "Atkins Physician Council" also claims that one’s body expends more energy burning fat and thus "You wouldn't have to increase your exercise at all because your body would be working harder, so that you could literally sit in your armchair and lose weight."108 As the Secretary of the AMA’s Council on Food and Nutrition tried to make clear, “The whole [Atkins] diet is so replete with errors woven together that it makes the regimen sound mysterious and magical.”109
These claims sounded so far fetched that as part of an investigative documentary, the BBC paid obesity researchers to design an experiment to test it. So researchers took two identical twins and put one on the Atkins Diet for a while, the other on a high carbohydrate diet and locked them both in sealed chambers to measure exactly where the calories were going. Did the twin on the Atkins Diet have any sort of metabolic "advantage" by burning fat and protein as his source of fuel? Was he literally flushing more calories down the toilet? Of course not. "We found no difference whatsoever," the researcher said.110
As the evidently "subnormal intellects" at the AMA concluded, "No scientific evidence exists to suggest that the low carbohydrate ketogenic diet has a metabolic advantage over more conventional diets for weight reduction."111 The only comprehensive systematic review ever done of low carb diets found that the carbohydrate content of the diet seemed in no way correlated with weight loss.112 The truth seems to be that nothing matters more than calories when it comes to weight loss.113
But what about all the scientific studies Dr. Atkins cited in his book to back up his claims? Although his first book had essentially no citations, by the final edition he listed over 300.114 Reviewing all of the studies on low carb diets, researchers concluded, "The studies by Atkins to support his contentions were of limited duration, conducted on a small number of people, lacked adequate controls and used ill-defined diets."115 Most importantly, though, some of the very studies he cites actually refute exactly what he’s claiming. And he accused the AMA of being “intellectually dishonest.”116
Of the few studies that did back up his claims, some had seriously questionable validity117 and researchers could not replicate the findings of the rest.118,119,120,121,122,123,124,125,126,127,128,129,130,131,132,133,134,135 One review of studies that have defended Atkins claims concluded, "It turns out that when these data are critically analyzed they are often found to be in error, and it’s therefore impossible to accept the validity of the conclusions derived by the authors from such erroneous data."136
People lost weight on low carb diets the way everybody loses weight on any diet—by eating fewer calories.137
Low Calorie Diet in Disguise
Americans get half of their energy from carbohydrates,138 so if people cut out half the food they eat, what they are left with is calorie restriction. Yes, one can eat unlimited amounts of fat on the Atkins Diet, but people typically can’t stomach an extra two sticks of butter’s worth a day to make up for the calorie deficit. Since so many foods are taboo, people end up eating less out of sheer boredom and lack of variety. As one obesity researcher put it, "If you're only allowed to shop in two aisles of the grocery store, does it matter which two they are?"139
Yes, all the butter one can eat but no bread to put it on. All the cream cheese, but no bagels. Sour cream, but no baked potato. Sandwich lunchmeat, but, of course, no sandwiches. All the pepperoni one can eat, but no pizza crust. Cheese, but no mac.
In later phases of the diet, with less carb restriction, Atkins throws in a thin wedge of cantaloupe—wrapped in ham, of course.140 Having all the mayonnaise one can eat only goes so far.
On the Atkins Diet one can eat steak, but no potatoes—and watch the gravy (it may have corn starch in it). All the shortening one can eat, just no making cookies with it. Eat all the burgers one wants; you just can’t put them on buns, no fries—and "beware of ketchup."141
Atkins described how to make cheeseburgers without the bun: "I put all the meat on the outside… put the cheese on the inside… The cheese melts on the inside and never gets out."142
Although his recipe for "hamburger fondue,"143 combining burger meat, blue cheese, and butter, might top the cheeseburger recipe for heart disease risk, the prize would probably go his recipe for "Swiss Snack,"144 which consists of wrapping bacon strips around cubes of Swiss cheese and deep frying them in hot oil. The recipe, which supposedly serves one, calls for four strips of bacon and a quarter-pound of cheese.
Atkins rivals the creativity of the raw-food chefs of today in his uses for pork rinds. Pork rinds are chunks of pigs’ skin that are deep-fried, salted and artificially flavored. He recommends people use them to dip caviar. Or, perhaps if for those who can’t afford caviar, one can use fried pork rinds as a "substitute for toast, dinner rolls…You can use them as a pie crust… or even matzo ball soup (see our recipe on p. 190)."145 Matzo balls made out of pork rinds?—now that is a diet revolution!
The Real Big Fat Lie
Of course a quick trot across the globe shows that some of the thinnest populations in the world, like those in rural Asia, center their entire diets on carbs. They eat 50% more carbs than we do, yet have a fraction of our obesity rates.149 Taubes also left out that the amount of added fat and total fat Americans eat has also been increasing—we’re eating more of everything now, fat and carbohydrates. Grease and protein peddlers blame our obesity epidemic on a low-fat diet that our nation never ate.
Thirty years ago, the average woman ate about 1500 calories per day, now it’s closer to 2000.150 Men also significantly bumped up their calorie consumption. With that many extra calories, we’d have to walk about two extra hours a day to keep from gaining weight. As analyzed in the May 2004 USDA report on obesity, with more calories, yet the same sedentary lifestyle, of course we gained weight.151
The reason we’re fat is not because of bread and fruit. Much of the obesity crisis has been blamed on eating out more (Americans spend almost twice as much time per week eating out as exercising),152 soft drinks, snacking, bigger portion sizes and "the enormous amount of very clever and very effective advertising of junk food/fast food."153 Our children, for example, are subjected to 10,000 ads for processed food every year.154 There’s no way parents can compete. As one medical journal pointed out, our children "will never see a slick high-budget (or even low-budget) ad for apples or broccoli."
Twenty years ago, a typical US bagel was 3 inches; now it’s twice that and contains a whopping 350 calories.155 Outback Steakhouse now has an appetizer of cheese fries, which breaks the scale at over 3000 calories, an appetizer containing more calories than most people eat all day. One would have to walk about 35 miles to burn that kind of thing off.156
The standard coke bottle used to be around 6 ounces. Then came the 12 ounce can. Now we have the 20 ounce bottles, or, of course, the 64-ounce "Double Gulp," containing about 50 spoonfuls of sugar. In fact, the Double Gulp is selling so well that 7-Eleven considered an even larger size, which a company spokesperson described only as a "wading-pool-sized drink."157
The National Soft Drink Association boasts on their website that "Soft drinks have emerged as America's favorite refreshment. Indeed, one of every four beverages consumed in America today is a carbonated soft drink, averaging out to about 53 gallons of soft drinks per year for every man, woman and child."158 Interestingly, the introduction of high fructose corn syrup around 1970 seems to exactly parallel the sudden rapid rise in obesity in this country.159 Thanks in part to the American food corporations, becoming overweight, as one prominent obesity researcher pointed out, "is now the normal response to the American environment."160
There is no mystery why we are the fattest country on Earth. "We're overfed, over-advertised, and under-exercised," says Stanford obesity expert John Farquhar. "It's the enormous portion sizes and sitting in front of the TV and computer all day" that are to blame. "It's so gol'darn obvious—how can anyone ignore it?"161
SHORT-TERM SIDE EFFECTS
So fine, maybe calories, not carbohydrates, are to blame for our obesity epidemic, and maybe Atkins’ claims, as described by one of the world’s leading obesity researchers, are "the most unutterable nonsense I ever saw in my life.”162 So what if it’s just a low calorie diet in disguise? It’s still a low calorie diet where one can eat all the (albeit bunless) bacon cheeseburgers you want. So what’s the problem?
The immediate concern centers on the state of ketosis. Pregnant women are the most at risk. Based on detailed data from 55,000 pregnancies,163 acetone and other ketones may cause brain damage in the fetus, which may result in the baby being born mentally retarded.164 The fact that ketones seemed to cause "significant neurological impairment" and an average loss of about 10 IQ points was well known and aroused "considerable concern" years before Atkins published his first book.165 Atkins nonetheless wrote. "I recommend this diet to all my pregnant patients."166
After enough pressure from the AMA, Atkins finally relented. "There’s one other point I’m very sorry about," Atkins finally admitted, "I now understand that ketosis during pregnancy could result in fetal damage. My pregnant patients have never had this problem, but I realize I didn’t study enough cases to validate my recommendation. If anyone wants a retraction, I’ll be glad to give one."167
Subsequently at the congressional hearing on fad diets, however, when asked by Senator George McGovern if he had made a public retraction of his reckless recommendation, Atkins replied, "No; I will stand by the statement I made in the book… I have recommended it for use by the pregnant woman with the observation of the managing obstetrician or physician…"168 After the Senate Select Committee hearings, the publisher added a small print disclaimer on the copyright page in the front of the book.169
Highlighting Atkins’ recommendation of his diet even during pregnancy, one nutrition textbook reads "Proponents of the low carbohydrate diet have been extraordinarily irresponsible in ignoring these hazards."170 “The woman who goes on a ketogenic diet [like Atkins] for six months of pregnancy,” noted one fetal specialist, “is playing Russian roulette.”171
More to Lose Than Weight
The symptoms of ketosis include general tiredness, abrupt or gradually increasing weakness, dizziness, headaches, confusion, abdominal pain, irritability, nausea and vomiting, sleep problems and bad breath.175 One study found that all those subjected to carb-free diets complained of fatigue after just two days. "[T]his complaint was characterized by a feeling of physical lack of energy… The subjects all felt that they did not have sufficient energy to continue normal activity after the third day. This fatigue promptly disappeared after the addition of carbohydrates to the diet."176 From a review published in a German medical journal, "[lightheadedness], fatigue, and nausea are frequent, despite what Dr. Atkins claims."177
In World War II, the Canadian Army had an illuminating experience with ketogenic diets. For emergency rations, infantry troops had pemmican, which is basically a carbohydrate-free mixture of beef jerky and suet (animal fat). The performance of the infantrymen forced to live off pemmican deteriorated so rapidly that they were incapacitated in a matter of days. As reported in the journal War Medicine in 1945, "On the morning of the fourth day of the diet, physical examination revealed a group of listless, dehydrated men with drawn faces and sunken eyeballs, whose breath smelled strongly of acetone."178 A ketogenic diet, concluded one medical review, "can be associated with significant toxicity."179
In a study funded by Atkins himself, most of the people who could stick with the diet reported headaches and halitosis (bad breath). Ten percent suffered hair loss. While most people lost weight—at least in the short-term—70% of the patients in the study also lost the ability to have a normal bowel movement.
Atkins can’t help but concede the health benefits associated with fiber found in, as he describes, "vegetables, nuts and seeds, fruits, beans and whole unrefined grains;" but then asks "How can you get the benefits of fiber without the carbs contained in these foods? The answer is supplementation." He then goes on to basically recommend that all his followers start taking sugar-free Metamucil. What must Mother Nature have been thinking, putting all the fiber into such "poison" foods?
The May 2004 Annals of Internal Medicine study which was misleadingly183 much lauded in the press with headlines like "Scientists Give Thumbs Up to Atkins Diet," showed once again that most of the Atkins Dieters suffered from headaches and constipation. They also had significantly more diarrhea, general weakness, rashes and muscle cramps—despite taking the 65 supplements prescribed by Atkins. One subject was so constipated he had to seek medical attention. Another developed chest pain on the diet and was subsequently diagnosed with coronary heart disease.184 No wonder Consumer Guide gave the Atkins Diet zero out of four stars for being “outright dangerous”185 and the editor of the Healthy Weight Journal gave Atkins the dubious Slim Chance Award for "Worst Diet."186
"Disease of Kings"
There is also concern that uric acid levels on a meat-centered diet might be forced so high that it could start crystallizing in one’s joints, triggering gout, an excruciating arthritic condition. A March 2004 article published in the New England Journal of Medicine documented the effect of meat intake on gout risk.
Harvard researchers followed almost 50,000 men for 12 years and found that "each additional daily serving of meat was associated with a 21 percent increase in the risk of gout."189 In fact, the Atkins Diet has been blamed directly for the rising incidence of this so-called "disease of kings."190 Well, Atkins did claim his diet is "fit for a prince or princess."191
Prescription for Muscle Cramps
Atkins realized this potential danger and recommended his followers take potassium supplements In fact, some people lose so much potassium they may need professional help. According to Atkins himself, sales of potassium supplements "of anywhere near the proper amount of potassium you may need are illegal over the counter; therefore you may need a doctor to write you the proper prescription."193 Even Barry Sears, the author of the flawed194 Zone Diet, recognizes the danger the Atkins Diet might present: "Any meal that you have to take potassium supplements, there's something wrong with that."195
After one week in ketosis, higher order mental processing and mental flexibility significantly worsened into what the researcher called a "modest neuropsychological impairment."197
The Director of MIT’s distinguished Clinical Research Center measured the serotonin levels in the brains of 100 volunteers eating different diets.199 Serotonin is a chemical messenger in the human brain that regulates mood. In fact, the way antidepressants like Prozac are purported to work is by increasing brain levels of this neurotransmitter.
The MIT researchers found that the brain only made serotonin after a person ate carbohydrates. Carbohydrates seemed to naturally stimulate serotonin.200 By starving the brain of this essential mood elevator, the researchers fear that the Atkins Diet may make people restless, irritable or depressed. They noted that women, people under stress, and those taking anti-depressants might be most at risk.201
When one follower of low carb guru Herman Tarnower’s 1978 "Scarsdale Diet," wrote to him, "When I diet, I get cranky, and my husband says, ‘I like you better fat than cranky’; have you any suggestions?" Dr. Tarnower responded, "You should be able to diet without getting cranky. Your husband, I am sure, would like to have you attractive, lean, and pleasant." His paternalistic prescription may make one sympathize, as one journalist wrote, "with his lover Jean Harris, the former school headmistress who later did prison time for his murder."202
Based on the MIT serotonin research, Judith Wurtman, Director of the Women's Health Program at the MIT Research Center, warns that filling up on fatty foods like bacon or cheese may make people tired, lethargic and apathetic. Eating a lot of fat, she stated, may "make you an emotional zombie."203
"Sunshine and Sex"
Leg cramps? They are "probably due to a calcium deficiency," Atkins explained, "I treat it with calcium supplements and Vitamins E and C. Sometimes magnesium and potassium have to be added."205
What if uric acid goes up? Not an obstacle for Atkins, who wrote: "this rarely poses a problem because I routinely prescribe a drug to prevent uric acid formation… if it goes above the normal range after being on the diet."206 He fails to mention, however, that this drug can cause irreversible liver damage, life-threatening anemia, and, in rare cases, even death.207
Bad breath? Great—that means it’s "working at full efficiency."208 Just "carry around… one of those purse-sized aerosol mouth fresheners, and you can have sweet breath…"209
Despite the side effects of ketosis, Atkins’ books encourage people to repeatedly test their urine for ketones to ensure they remain in this unhealthy state. Atkins almost fetishized ketosis, describing it being "as delightful as sunshine and sex."210 Atkins did, after all, start his career off as a stand-up comic.211 One dieter replied, "I don’t think Dr Atkins had much sex if he thinks that ketosis is better than sex. It’s certainly not."212
In fact, thanks to its side effects, those who go on the
Atkins Diet in an attempt to attract others may find it
counterproductive when a potential mate gets too close and finds a
constipated, cognitively impaired "zombie" with bad breath.
Atkins Comes In Last For Long-Term Weight Maintenance
There have been 3 such yearlong studies and not a single one showed significantly more weight lost at the end of the year on the Atkins Diet than on the control diets.214,215,216 In the yearlong comparison of the Atkins Diet to Ornish’s diet, Weight Watchers, and The Zone Diet, the Atkins Diet came in dead last in terms of weight lost at the end of the year. Ornish’s vegetarian diet seemed to show the most weight loss.217 The Atkins website has no comment.218
Noting that by the end of the year, half of the Atkins group had dropped out, and those who remained ended up an unimpressive 4% lighter, Fat of The Land author Michael Fumento commented, "do you really think any of them could sell a single book copy, much less as many as 15 million (for Atkins), by admitting to a 50 percent drop-out rate in one year with a mere five percent of weight loss among those left?"219
Ornish’s vegetarian (near-vegan) diet has been formally tested for years.220 Even though the diet was not even designed for weight loss, after five years most of the Ornish adherents were able to maintain much of the 24 pounds they lost during the first year "even though they were eating more food, more frequently, than before without hunger or deprivation."221 This is consistent with what research we have on vegans themselves. Vegans are vegetarians that also exclude dairy and eggs from their diet.
The biggest study on vegans to date compared over a thousand vegans in Europe to tens of thousands of meateaters and vegetarians. The meateaters, on average, were significantly heavier than the vegetarians, who were significantly heavier than the vegans. Even after controlling for exercise and smoking and other nondietary factors, vegans came out slimmest in every age group. Less than 2% of vegans were obese.222
In a snapshot of the diets of 10,000 Americans, those eating vegetarian had the slimmest BMI's whereas those eating the fewest carbs in the sample weighed the most. Those eating less carbs were on average overweight; those eating vegetarian were not.223
Vegetarians may have a higher resting metabolic rate, which researchers chalk up to them eating more carbs than meateaters (or possibly due to enhanced adrenal function).224 At the same weight, one study showed that vegetarians seem to burn more calories per minute just by sitting around or sleeping than meateaters—almost 200 extra calories a day. Although earlier studies didn’t find such an effect,225 if confirmed, that amounts to the equivalent to an extra pound of fat a month burned off by choosing to eat vegetarian.226
The only other two formal yearlong studies found that although the initial drop in weight on Atkins was more rapid, weight loss on the Atkins diet reversed or stalled after 6 months. The longer people stay on the Atkins Diet, the worse they seemed to do.227,228 None of the three longest studies on the Atkins Diet showed a significant advantage over just the type of high carbohydrate diets Atkins blamed for making American fat.
Anyone can lose weight on a diet; the critical question is whether the weight loss can be maintained and at what cost. If low carb diets really did cure obesity, the original in 1864 would have eliminated the problem and no more diet revolutions would be necessary. Short-term weight loss is not the same thing as lifelong weight maintenance.
Long-Term Weight Loss Secrets
"[B]asically, they're eating the opposite of a high-protein, low carbohydrate diet," Fletcher reported. When she asked them to describe their eating habits, the top responses were "low-fat" followed by "eating less meat."
These dieters with long-term success also told her they ate "more fruits and vegetables." Research seems to support this notion. One research study showed, for example, that significant weight loss could be triggered in people just feeding them extra fruit—3 added apples or pears a day.230 Harvard studied 75,000 women for a decade and the results suggest that the more fruits and vegetables women eat the less likely they will become obese.231 A 2004 review of the available research suggests that in general "increasing fruit and vegetable intake may be an important strategy for weight loss."232
Researchers at the National Cancer Institute followed over 75,000 people for ten years to find out which behaviors were most associated with weight loss and which with weight gain. They wrapped tape measures around people’s waists for a decade and found that the one dietary behavior most associated with an expanding waistline was high meat consumption and the dietary behavior most strongly associated with a loss of abdominal fat was high vegetable consumption.233
Even after controlling for other factors, men and women who ate over a serving of meat a day seemed to be 50% more likely to suffer an increase in abdominal obesity than those who ate meat just a few times a week. The researchers conclude: "Our analysis has identified several easily described behaviors [such as reducing meat intake to less than three servings per week and jogging a few hours every week] that, if widely adopted, might help reverse recent increases in adult overweight… Increases in vegetable consumption might reduce abdominal obesity even further."234
The sad thing, according to the Director of Nutrition for the Center for Science in the Public Interest, is that "people keep believing that the magic bullet is just around the corner . . . if they only eliminate food 'x' or combine foods 'a' and 'b,' or twirl around three times before each meal."235 The reality is that most ordinary people lose weight without the gimmicks Americans spend $30 billion236 a year on.237
In the largest survey ever undertaken on the long-term maintenance of weight loss, Consumer Reports found that the vast majority of the most successful dieters said they lost weight entirely on their own, without enrolling in some expensive program, or buying special foods or supplements or following the regimen of some diet guru.238 The most popular fad diet right now may be Atkins, but it’s not the most popular diet, and not the one that seems to work the best.
Atkins Missing in Action
These researchers, led by a team at Brown and the University of Colorado, found that the people most successful in losing and maintaining their weight were eating high carbohydrate diets—five times as many carbs as Atkins proscribed in the "weight loss" phase of his diet.241 Out of the thousands of people in the National Weight Control Registry, less than 1 percent follow a diet similar to the Atkins program. "We can't find more than a handful of people who follow the Atkins program in the registry," said one chief investigator, "and, believe me, we've tried."242
Fifteen million Atkins books sold; and investigators can only find a "handful" of followers who could qualify for the Registry? To qualify, all dieters have to do is prove they lost just 30 pounds and kept it off for at least one year. Twenty-six million Americans243 supposedly on "hard-core" low carb diets and "almost nobody" on Atkins has even qualified?
Maybe for some reason only dieters eating lots of carbohydrates hear about the Registry? No, the National Weight Control Registry has been plugged in Dr. Atkins’ own book for years and is promoted on the official Atkins website.244 The reason why anecdotes of Atkins Dieters maintaining their weight loss crop up in Atkins books and websites but seemingly nowhere else, may be because there isn’t much oversight when posting information to the web, whereas the Registry demands proof.245
* Michael Greger, MD, is a graduate of the Cornell University School of Agriculture and the Tufts University School of Medicine. Dr. Greger has been publicly speaking about mad cow disease since 1993. In 1997 he was invited as an expert witness to defend Oprah Winfrey in the infamous meat defamation trial. He has contributed to many books and articles on the subject and continues to lecture extensively. Dr. Greger can be contacted at 857-928-2778, or email@example.com.
Part II will continue in next month's, July 2004, McDougall Newsletter.
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