Anti-Atkins Researcher Requests 'Any Alternative Explanation'
After blogging against a widely reported new study released this week about a 40-year-old obese patient suffering from ketoacidosis allegedly from being on the Atkins diet, I heard back from the lead researcher with his comments on my criticism of his study.
Dr. Klaus D. Lessnau posted his comments at my blog today and claims that he stands by his study's conclusion that his patient got sick after "meticulously adhering to the Atkins' diet."
What does that mean, Dr. Lessnau? Did the patient read Dr. Atkins New Diet Revolution and follow it exactly as prescribed? Or did she merely cut back on her carbs and only eat steak, bacon and eggs all day as the media would have us believe represents the Atkins diet? I think it is extremely important to distinguish between the two.
Urging me to shell out big bucks to read his ridiculous case study report in its entirety at The Lancet, Dr. Lessnau said his patient was forced to be admitted into intensive care because of the Atkins diet.
"Generally speaking, you do not want to start a diet and end up in the intensive care unit," Dr. Lessnau exclaimed.
Ya think? But who's to say it was the Atkins diet that caused your patient to end up in ICU, Dr. Lessnau? That's about as preposterous as me claiming that all medical doctors are killers because Dr. Jack Kevorkian likes to murder his patients.
But that would be silly, wouldn't it? It's clear to everyone that there's no link between what Dr. Kevorkian did and what other doctors do and so why make the connection between those of us who enjoy the low-carb lifestyle and this ONE patient of yours? Hmmmm? Even those of us who aren't as smart as you doctors and researchers can use a little common sense that the good Lord gave us and figure that one out on our own.
Dr. Lessnau said he is now looking for "any alternative explanation of this severe metabolic acidosis" that his patient had to deal with.
"I would be happy to know if there is any other cause that could explain such a severe disease," Dr. Lessnau inquired. "We could not explain it by any other disease."
If you don't know what caused this disease, then how can you so easily attribute it to the Atkins diet? It seems rather convenient for you to point the finger at your patient's alleged eating habits (which are still highly suspect whether or not she actually ate a "low-carb" diet) rather than looking at other areas of her lifestyle that could have contributed.
Questioning just "how common this event is," Dr. Lessnau even admits he is clueless about "how often this happens."
That wouldn't be hard to decipher. Rather than relying on a singular example in your patient of what ALL Atkins dieters are like, how about asking those of us who have been doing this for a while to see what our health is like eating this way? I'd be happy to show you the difference it has made in my life with my weight, blood pressure, cholesterol, triglycerides, energy, self-esteem, shall I go on?
The example of ONE person does not negate the good that livin' la vida low-carb has been for millions of others. Putting doctors on "alert" over this "possible complication" is simply absurd, Dr. Lessnau. Don't you see that?
My wife has been to see the doctor recently because of a pain in her side (no, it's not me!). She had a CT scan to see if it was her appendix. Nope. Then she had a gall bladder test done to see if she had problems there. Negative. She is now scheduled to see a gastrointestinal physician next week to see if he can help her out. In other words, she has a mysterious condition that nobody can seem to figure out and yet she's still in pain. What could it be?
Oh, I know what it is! Since she sleeps every night, then THAT must be causing her the pain. Let's send out an immediate health warning to doctors everywhere to tell their patients to avoid sleeping at all costs. It's way too dangerous. The resulting health consequences are just too risky to even try to sleep at night. The public must know!
The headlines should scream, "Sleeping Too Dangerous To Health" or "Snoozing Too Much May Cause Pain In Your Side." Somebody get a press release out now!!!
Idiotic? Laughable? Crazy? Of course it is, but so is describing the Atkins diet as unhealthy and dangerous. Since I am not a medical doctor, I am obviously not legally allowed to give out medical advice nor do I even pretend to know what caused your patient's ketoacidosis. But what I do know is this is not such a common problem with the Atkins diet that it should be avoided as you claim along with all the obnoxious, sensationalist headlines from your buddies in the media over the past couple of days.
"Please let me know if you have a better idea how to explain this severe metabolic acidosis," Dr. Lessnau pleaded.
Okay, Dr. Lessnau, I'm happy to put out the call to all medical professionals asking them to weigh in on the condition of your study patient. Anyone who has an explanation for Dr. Lessnau can send your comments to him at KLessnau@pol.net.
We've already got one explanation for you from my friend Regina Wilshire. Expect many more to come, Dr. Lessnau.
But I also have an assignment for you, too, Dr. Lessnau. If this problem is so prevalent, then find me 100 more cases just like your case study who by following the Atkins diet were hospitalized for "severe metabolic acidosis."
Since you are making the assumption that this is such a widespread problem, how about proving it with hard evidence? If the prevalence of this condition is so normal then you shouldn't have any problem getting those examples to me within the next week.
Should you fail to provide this information to me by Saturday, March 25, 2006, then it will prove your theory was mistaken and you will owe those of us who make low-carb living our metabolic choice, doctors, and the American people a sincere and public apology.
Your friends in the media should also be required to print a retraction and allow those of us who have been highly successful on this wonderful way of eating an open platform for educating people about the healthy benefits of the low-carb lifestyle.
It's the right thing to do, don't you think? I'll be waiting...
3-19-06 UPDATE: A dietician weighs in with her thoughts about low-carb allegedly causing ketoacidosis in an e-mail to me today.
If adhering to the low carb lifestyle leads to ketoacidosis, how come most people with type 2 diabetes aren't in a state of ketoacidosis more often than not? It is my understanding that this is more a problem with type 1 diabetics.
I have been a practitioner of low carbing since the mid 60s when I went to college and gained weight like all most all do. And at the time I was studying dietetics with plans to become dietician. I lost weight with "my" plan, and continued it through young motherhood, teen motherhood and now as a grandmother, continue to follow this diet plan, but a bit more stringently now.
Low carbing, exercise, etc. didn't prevent me from having type 2 diabetes, but probably slowed the progress of this disease down a bunch. I never got more than 25 pounds overweight, but all of it showed. Now if I don't want to take more insulin, I absolutely must follow Atkins, South Beach, whatever other low carb diet forms there be, very strictly.
No it isn't Atkins that causes ketoacidosis, it is probably lack of following it properly and lack of exercise! And one person does not a study make!
THANK YOU for sharing your comments with my readers. It would be interesting for someone to examine what this ONE patient actually ate and whether THAT had anything to do with the ketoacidosis than the fact that she was on the Atkins diet. I'm not saying she didn't have ketoacidosis or that others haven't developed this condition, but my concern is that this is not such a prevalent problem that it warrants such stern warnings against the low-carb lifestyle like we have seen in the media over the past few days.
Where have these cases of ketoacidosis been for the past three decades since Dr. Atkins first released his diet? Hmmmm? Surely there would be hundreds of thousands of cases like this one by now if this was such a widespread problem with the Atkins diet, right? Where are these people?
3-20-06 UPDATE: I received a response for Dr. Lessnau regarding "any alternative explanation" for his patient's ketoacidosis from a three-decades long physician today:
For starters, I applaud Dr. Lessnau for bringing this interesting case up for discussion. That said, however, Dr. Lessnau seems a bit too eager to blame carbohydrate restriction for his patient's metabolic acidosis. With apologies for my rather formal style, here's why I think he shot from the hip.
In the Lancet case report, Chen and Lessnau (see ref 1 below) suggest that a carbohydrate-restricted diet can induce ketoacidosis in a non-diabetic patient, but the data presented do not support this conclusion.
First: the reported anion gap of 26 represents a 12 mM anion excess above the upper limit of normal. The serum beta-hydroxybutyrate (the dominant circulating ketone moiety in humans), reported at 390 ug/mL, translates to a concentration of 3.7 mM. That is, the ketones in this case (both beta-hydroxybutyrate and acetoacetate) account for only about a third of the apparent anion excess. Thus the ketonemia in this case represents only a minor fraction of the anion excess, and thus is not the primary factor in the reported metabolic acidosis.
Second: the normal physiologic state of nutritional ketosis, also called starvation ketosis, is associated with serum ketones in the 1-5 mM range (as in this case), and this is not normally associated with metabolic acidosis (see refs 2,3,4). So given that nutritional ketosis does not cause acidosis despite up to 5 millimolar ketones, how is it credible to blame 4 millimoles of ketones for a 12 millimolar of excess anions in this case?
Third: in their case report, Dr. Lessnau states that they provided the patient with dextrose at the rate of only 38 g/d (5% dextrose at 30 ml/hr). This is not enough carbohydrate to reverse nutritional ketosis, and yet the patient improved. If the ketogenic state was the cause of her problem, why did it improve on a homeopathic dose of glucose?
Fourth: Yes, a barcarbonate of 8 and an anion gap of 26 are worrisome, and any ER doc would admit this patient for evaluation and rehydration. However most of us would save the term "severe acidosis" for anion gaps greater than 30 and blood pH values under 7.1. Calling an arterial blood pH of 7.19 "severe acidosis" is a bit of hyperbole.
Fifth: patients with pancreatitis can have an elevate lipase but normal serum amylase (see ref 5). Given her elevated lipase, white blood cell count of 13x10.ninth, and gastrointestinal symptoms, why was this not just a case of mild pancreatitis? We all know that CT scans of the abdomen in someone with a BMI of 41 are notoriously difficult to interpret for soft-tissue injury.
Sixth: I agree with Science4u1959 in questioning the frequency of events such as this case during low carbohydrate dieting. As an academic physician with 30 years of experience in adult weight management, I have not seen a similar case in over 3000 patients followed closely during a very low calorie ketogenic diet. Given this experience, I think that it is likely that the current case represents association without causality. Not having this experience, it is unfortunate that Dr. Lessnau chose to conclude causality rather than raising it as a hypothesis.
Stephen D. Phinney, MD, PhD
Professor emeritus, UC Davis
Elk Grove, CA, USA
References
1. Chen TY, Smith W, Rosenstock JL, Lessnau KD. A life-threatening complication of Atkins diet. The Lancet 2006;367:958.
2. Cahill GF. Starvation in man. N Engl J Med 1970; 282:668-675.
3. Phinney SD, Horton ES, Sims EAH, Hanson JS, Danforth E, LaGrange BM. Capacity of moderate exercise in obese subjects after adaptation to a hypocaloric, ketogenic diet. J Clin Invest. 1980;66:1152-1161.
4. Phinney SD, Bistrian BR, Wolfe RR, Blackburn GL. The human metabolic response to chronic ketosis without caloric restriction: physical and biochemical adaptation. Metabolism 1983; 32:757–768.
5. Sharma P, Lim S, James D, Orchard RT, Horne M, Seymour CA. Pancreatitis may occur with a normal amylase concentration in hypertriglyceridaemia
BMJ 1996;313:1265.
THANK YOU, Dr. Phinney, for adding to this discussion. Anyone else have something to add? This isn't looking well for Dr. Lessnau.
3-21-06 UPDATE: Another nutrition expert weighs in on Dr. Lessnau's conclusions about his patient with ketoacidosis:
Dr. Lessnau: I don't believe you are the real Dr. Lessnau. In fact I think you are an imposter, claiming to be Dr. Lessnau. If you are however Dr. Lessnau, you should go back to medical school. Because if you are a real medical doctor you should know that ketoacidosis is something totally different from ketosis and only can occur in diabetics with uncontrollable in-serum glucose swings.
However, if there is ONE diet that has been shown to offer absolutely superior glycemic control, dear doctor, it is a low-carb diet. Glycemic control, as you should know, STABILIZES glucose levels, so ketoacidosis can never occur in such patients. The editors of the Lancet, where you published your "research", should have realized that too.
So, this "dangerous condition" that you discovered has nothing to do with the Atkins diet, or any other low-carb diet for that matter. And even if by some miracle you could prove (any) causation your conclusions are far too premature. Did you document any cofounding intervention factors, doctor? I highly doubt it.
I also wonder, dear doctor, did you also write a simular article in the "Lancet" for the tens of millions of people that died as a result of the low-fat diet fallacy, the calorie theory / portion control lie, or perhaps the millions suffering from the sideeffects of unnecessary statin drugs, or maybe the incredible number of people that is currently suffering from the dietary delusions of the Government and "health experts"? I don't think so, huh?
To base your conclusions, "warnings" and outright scare mongering on the - higly unfortunate - death of ONE person, and then even have the nerve to call it a "scientific study" (a scientific study of one? ridiculous!) worthy of publication in a medical journal is a total travesty and completely unprofessional as well as unscientific. You should do your research by investigation rather than proclamation.
The very fact that a respected and prestigeous publication as the "Lancet" approved your unscientific scribbles for publication shows that even such publications are no longer reliable these days and open to manipulation.
It also proves, I am afraid, that even a (alleged) medical degree does not protect against severe mental and moral degeneration.
Your entire idea and intent was to discredit this diet, nothing more. You failed.
But please, Dr. Lessnau (or the imposter), don't forget to call the Post, the NY Times, CNN, and all those other wonderful "free and unbiased media" outlets regarding this great scientific discovery that you made!
I am sure they will be more than happy to oblige!
Now THERE'S somebody with some passion and makes good sense, too! Anyone else care to chime in?
3-25-06 UPDATE: If you haven't read the blog entry by Dr. Michael Eades on this from 3-23-06, then you'll want to check out "Low-carb diet takes one below the belt." I LOVE the passion Dr. Eades has for livin' la vida low-carb!
Yet ANOTHER researcher wanted to share his thoughts on this study today as well:
When the rate of mobilization of fatty acids from fat tissue is accelerated, as, for example, during a very-low-carbohydrate diet, the liver produces ketone bodies. The liver cannot utilize ketone bodies and thus, they flow from the
liver to extra-hepatic tissues (e.g., brain, muscle) for use as a fuel.
Simply stated, ketone body metabolism by the brain displaces glucose utilization and thus spares muscle mass (muscle protein). Dietary ketosis is a harmless physiological state; however, many health care professionals and even some
scientists have confused dietary ketosis with diabetic ketoacidosis (an abnormal condition of increased acidity).
All diabetic patients know that the detection in their urine of the ketone bodies is a danger signal that their diabetes is poorly controlled. In severely uncontrolled diabetes, if the ketone bodies are produced in massive supranormal quantities, they are associated with ketoacidosis. In this life-threatening complication of diabetes mellitus, ketone bodies are produced rapidly, which overwhelm the body’s acid-base buffering system.
However, a very-low-carbohydrate diet cannot lead to dangerous ketoacidosis in HEALTHY subjects (without alcohol
or drug abuse), because ketone bodies have effects on insulin and glucagon secretions that contribute to the control of the rate of their own formation.
Nevertheless, a case report, published in The Lancet, described a 40-year-old female patient who was vomiting as often as six times daily and had difficulty breathing after strictly following the Atkins diet for a month. According to the report, ”Our patient denied alcohol use; her serum osmolar gap was 0, which excludes the presence of unmeasured osmotic agents such as methanol or ethylene glycol; L-lactate concentration was normal; and salicylate was undetectable…Serum [blood] was positive for acetone, and ß-hydroxybutyrate [a major ketone body] was high at 390 µg/mL (normal 0–44 µg/mL), consistent with ketoacidosis."
However, it is my view that the level of ketones in her urine (390 µg/mL) are not alarming. Just to be sure, I contacted Dr. Richard Feinman, a Professor of Biochemistry at SUNY Downstate Medical Center and a well-known researcher in the
area of carbohydrate-restriction, to ask his opinion about The Lancet case report.
According to Dr. Feinman, ”Clinicians here agree that it was kind of a rash conclusion. The ketones are, in fact, not sufficient to have caused the acidosis and while high for most people on the Atkins diet, they are in the ball-park of people who are in starvation for 10 days (who can live for at least another 20-60 days) and less than half of the ketoacidosis seen in untreated
type 1 diabetes. We are actually using the case with students to show how to do the calculations correctly. I think the physicians were just not familiar with the whole problem of ketosis and got carried away.
The Atkins diet still has so much baggage in medical circles that they didn't realize you can't attribute things to diet just on what people tell you. In any case, she apparently hadn't retained much food at all for three days and was probably in starvation rather than on any diet. The treatment was actually minimal (mostly re-hydration) and the whole thing was blown way out of proportion.
Also, even if the problems were due to the diet, millions of Americans are on some kind of carbohydrate restricted diet and nutritionists have been trying unsuccessfully to find a problem for thirty years. Do you know any drug, or even any weight loss diet, that has this kind of record?'"
In a commentary also published in The Lancet, Drs. Lyn Steffen and Jennifer Nettleton of the University of Minnesota's School of Public Health blasted low-carbohydrate/high-protein diets like there's no tomorrow. These sadly misinformed ladies supposedly hold some sort of doctoral degrees yet cannot even perform a appropriate PubMed search. They stated, "These
[low-carb/high-protein] diets also increase the protein load to the kidneys and alter the acid balance of the body, which result in loss of minerals from bone stores, thus compromising bone integrity."
This statement is misleading, at best. The best available scientific evidence indicates that protein-induced changes in kidney function are a NORMAL adaptative mechanism well within the functional limits of a healthy kidney. However, protein restriction may benefit patients with chronic kidney disease.
Also, there is no scientific evidence supporting the notion that low-carbohydrate/high-protein diet leads to loss of minerals from bone stores. Quite to the contrary. Many experimental and clinical studies indicate that low-protein diet negatively affects bone health. Furthermore, it has been demonstrated that proteins enhance IGF-1, a growth factor that exerts positive
activity on bone formation. Consequently, high-protein intake is, if anything, protective against the loss of bone minerals.
Don’t get me wrong. I'm not advocate for the Atkins diet. I feel a diet containing moderate amounts of low-glycemic carbohydrates is generally the healthiest way to achieve and maintain ideal body weight. However, I realize one diet approach
doesn’t fit all. Identifying specific needs, goals and the activity level of each individual is the key for success.
Thus, I advocate for applying science to ALL diets, including the Atkins diet. Certainly, diet-related public warnings should
be based on thorough analysis of the scientific literature, not unsubstantiated fears and misrepresentations.
Anssi Manninen, M.H.S.
Senior Science Editor
Advanced Research Press, Inc.
Do you get the feeling Dr. Lessnau wishes he'd never said a word about his little "study" as foolish as he is looking right about now? :) Dr. Lessnau, we're still waiting?
Dr. Klaus D. Lessnau posted his comments at my blog today and claims that he stands by his study's conclusion that his patient got sick after "meticulously adhering to the Atkins' diet."
What does that mean, Dr. Lessnau? Did the patient read Dr. Atkins New Diet Revolution and follow it exactly as prescribed? Or did she merely cut back on her carbs and only eat steak, bacon and eggs all day as the media would have us believe represents the Atkins diet? I think it is extremely important to distinguish between the two.
Urging me to shell out big bucks to read his ridiculous case study report in its entirety at The Lancet, Dr. Lessnau said his patient was forced to be admitted into intensive care because of the Atkins diet.
"Generally speaking, you do not want to start a diet and end up in the intensive care unit," Dr. Lessnau exclaimed.
Ya think? But who's to say it was the Atkins diet that caused your patient to end up in ICU, Dr. Lessnau? That's about as preposterous as me claiming that all medical doctors are killers because Dr. Jack Kevorkian likes to murder his patients.
But that would be silly, wouldn't it? It's clear to everyone that there's no link between what Dr. Kevorkian did and what other doctors do and so why make the connection between those of us who enjoy the low-carb lifestyle and this ONE patient of yours? Hmmmm? Even those of us who aren't as smart as you doctors and researchers can use a little common sense that the good Lord gave us and figure that one out on our own.
Dr. Lessnau said he is now looking for "any alternative explanation of this severe metabolic acidosis" that his patient had to deal with.
"I would be happy to know if there is any other cause that could explain such a severe disease," Dr. Lessnau inquired. "We could not explain it by any other disease."
If you don't know what caused this disease, then how can you so easily attribute it to the Atkins diet? It seems rather convenient for you to point the finger at your patient's alleged eating habits (which are still highly suspect whether or not she actually ate a "low-carb" diet) rather than looking at other areas of her lifestyle that could have contributed.
Questioning just "how common this event is," Dr. Lessnau even admits he is clueless about "how often this happens."
That wouldn't be hard to decipher. Rather than relying on a singular example in your patient of what ALL Atkins dieters are like, how about asking those of us who have been doing this for a while to see what our health is like eating this way? I'd be happy to show you the difference it has made in my life with my weight, blood pressure, cholesterol, triglycerides, energy, self-esteem, shall I go on?
The example of ONE person does not negate the good that livin' la vida low-carb has been for millions of others. Putting doctors on "alert" over this "possible complication" is simply absurd, Dr. Lessnau. Don't you see that?
My wife has been to see the doctor recently because of a pain in her side (no, it's not me!). She had a CT scan to see if it was her appendix. Nope. Then she had a gall bladder test done to see if she had problems there. Negative. She is now scheduled to see a gastrointestinal physician next week to see if he can help her out. In other words, she has a mysterious condition that nobody can seem to figure out and yet she's still in pain. What could it be?
Oh, I know what it is! Since she sleeps every night, then THAT must be causing her the pain. Let's send out an immediate health warning to doctors everywhere to tell their patients to avoid sleeping at all costs. It's way too dangerous. The resulting health consequences are just too risky to even try to sleep at night. The public must know!
The headlines should scream, "Sleeping Too Dangerous To Health" or "Snoozing Too Much May Cause Pain In Your Side." Somebody get a press release out now!!!
Idiotic? Laughable? Crazy? Of course it is, but so is describing the Atkins diet as unhealthy and dangerous. Since I am not a medical doctor, I am obviously not legally allowed to give out medical advice nor do I even pretend to know what caused your patient's ketoacidosis. But what I do know is this is not such a common problem with the Atkins diet that it should be avoided as you claim along with all the obnoxious, sensationalist headlines from your buddies in the media over the past couple of days.
"Please let me know if you have a better idea how to explain this severe metabolic acidosis," Dr. Lessnau pleaded.
Okay, Dr. Lessnau, I'm happy to put out the call to all medical professionals asking them to weigh in on the condition of your study patient. Anyone who has an explanation for Dr. Lessnau can send your comments to him at KLessnau@pol.net.
We've already got one explanation for you from my friend Regina Wilshire. Expect many more to come, Dr. Lessnau.
But I also have an assignment for you, too, Dr. Lessnau. If this problem is so prevalent, then find me 100 more cases just like your case study who by following the Atkins diet were hospitalized for "severe metabolic acidosis."
Since you are making the assumption that this is such a widespread problem, how about proving it with hard evidence? If the prevalence of this condition is so normal then you shouldn't have any problem getting those examples to me within the next week.
Should you fail to provide this information to me by Saturday, March 25, 2006, then it will prove your theory was mistaken and you will owe those of us who make low-carb living our metabolic choice, doctors, and the American people a sincere and public apology.
Your friends in the media should also be required to print a retraction and allow those of us who have been highly successful on this wonderful way of eating an open platform for educating people about the healthy benefits of the low-carb lifestyle.
It's the right thing to do, don't you think? I'll be waiting...
3-19-06 UPDATE: A dietician weighs in with her thoughts about low-carb allegedly causing ketoacidosis in an e-mail to me today.
If adhering to the low carb lifestyle leads to ketoacidosis, how come most people with type 2 diabetes aren't in a state of ketoacidosis more often than not? It is my understanding that this is more a problem with type 1 diabetics.
I have been a practitioner of low carbing since the mid 60s when I went to college and gained weight like all most all do. And at the time I was studying dietetics with plans to become dietician. I lost weight with "my" plan, and continued it through young motherhood, teen motherhood and now as a grandmother, continue to follow this diet plan, but a bit more stringently now.
Low carbing, exercise, etc. didn't prevent me from having type 2 diabetes, but probably slowed the progress of this disease down a bunch. I never got more than 25 pounds overweight, but all of it showed. Now if I don't want to take more insulin, I absolutely must follow Atkins, South Beach, whatever other low carb diet forms there be, very strictly.
No it isn't Atkins that causes ketoacidosis, it is probably lack of following it properly and lack of exercise! And one person does not a study make!
THANK YOU for sharing your comments with my readers. It would be interesting for someone to examine what this ONE patient actually ate and whether THAT had anything to do with the ketoacidosis than the fact that she was on the Atkins diet. I'm not saying she didn't have ketoacidosis or that others haven't developed this condition, but my concern is that this is not such a prevalent problem that it warrants such stern warnings against the low-carb lifestyle like we have seen in the media over the past few days.
Where have these cases of ketoacidosis been for the past three decades since Dr. Atkins first released his diet? Hmmmm? Surely there would be hundreds of thousands of cases like this one by now if this was such a widespread problem with the Atkins diet, right? Where are these people?
3-20-06 UPDATE: I received a response for Dr. Lessnau regarding "any alternative explanation" for his patient's ketoacidosis from a three-decades long physician today:
For starters, I applaud Dr. Lessnau for bringing this interesting case up for discussion. That said, however, Dr. Lessnau seems a bit too eager to blame carbohydrate restriction for his patient's metabolic acidosis. With apologies for my rather formal style, here's why I think he shot from the hip.
In the Lancet case report, Chen and Lessnau (see ref 1 below) suggest that a carbohydrate-restricted diet can induce ketoacidosis in a non-diabetic patient, but the data presented do not support this conclusion.
First: the reported anion gap of 26 represents a 12 mM anion excess above the upper limit of normal. The serum beta-hydroxybutyrate (the dominant circulating ketone moiety in humans), reported at 390 ug/mL, translates to a concentration of 3.7 mM. That is, the ketones in this case (both beta-hydroxybutyrate and acetoacetate) account for only about a third of the apparent anion excess. Thus the ketonemia in this case represents only a minor fraction of the anion excess, and thus is not the primary factor in the reported metabolic acidosis.
Second: the normal physiologic state of nutritional ketosis, also called starvation ketosis, is associated with serum ketones in the 1-5 mM range (as in this case), and this is not normally associated with metabolic acidosis (see refs 2,3,4). So given that nutritional ketosis does not cause acidosis despite up to 5 millimolar ketones, how is it credible to blame 4 millimoles of ketones for a 12 millimolar of excess anions in this case?
Third: in their case report, Dr. Lessnau states that they provided the patient with dextrose at the rate of only 38 g/d (5% dextrose at 30 ml/hr). This is not enough carbohydrate to reverse nutritional ketosis, and yet the patient improved. If the ketogenic state was the cause of her problem, why did it improve on a homeopathic dose of glucose?
Fourth: Yes, a barcarbonate of 8 and an anion gap of 26 are worrisome, and any ER doc would admit this patient for evaluation and rehydration. However most of us would save the term "severe acidosis" for anion gaps greater than 30 and blood pH values under 7.1. Calling an arterial blood pH of 7.19 "severe acidosis" is a bit of hyperbole.
Fifth: patients with pancreatitis can have an elevate lipase but normal serum amylase (see ref 5). Given her elevated lipase, white blood cell count of 13x10.ninth, and gastrointestinal symptoms, why was this not just a case of mild pancreatitis? We all know that CT scans of the abdomen in someone with a BMI of 41 are notoriously difficult to interpret for soft-tissue injury.
Sixth: I agree with Science4u1959 in questioning the frequency of events such as this case during low carbohydrate dieting. As an academic physician with 30 years of experience in adult weight management, I have not seen a similar case in over 3000 patients followed closely during a very low calorie ketogenic diet. Given this experience, I think that it is likely that the current case represents association without causality. Not having this experience, it is unfortunate that Dr. Lessnau chose to conclude causality rather than raising it as a hypothesis.
Stephen D. Phinney, MD, PhD
Professor emeritus, UC Davis
Elk Grove, CA, USA
References
1. Chen TY, Smith W, Rosenstock JL, Lessnau KD. A life-threatening complication of Atkins diet. The Lancet 2006;367:958.
2. Cahill GF. Starvation in man. N Engl J Med 1970; 282:668-675.
3. Phinney SD, Horton ES, Sims EAH, Hanson JS, Danforth E, LaGrange BM. Capacity of moderate exercise in obese subjects after adaptation to a hypocaloric, ketogenic diet. J Clin Invest. 1980;66:1152-1161.
4. Phinney SD, Bistrian BR, Wolfe RR, Blackburn GL. The human metabolic response to chronic ketosis without caloric restriction: physical and biochemical adaptation. Metabolism 1983; 32:757–768.
5. Sharma P, Lim S, James D, Orchard RT, Horne M, Seymour CA. Pancreatitis may occur with a normal amylase concentration in hypertriglyceridaemia
BMJ 1996;313:1265.
THANK YOU, Dr. Phinney, for adding to this discussion. Anyone else have something to add? This isn't looking well for Dr. Lessnau.
3-21-06 UPDATE: Another nutrition expert weighs in on Dr. Lessnau's conclusions about his patient with ketoacidosis:
Dr. Lessnau: I don't believe you are the real Dr. Lessnau. In fact I think you are an imposter, claiming to be Dr. Lessnau. If you are however Dr. Lessnau, you should go back to medical school. Because if you are a real medical doctor you should know that ketoacidosis is something totally different from ketosis and only can occur in diabetics with uncontrollable in-serum glucose swings.
However, if there is ONE diet that has been shown to offer absolutely superior glycemic control, dear doctor, it is a low-carb diet. Glycemic control, as you should know, STABILIZES glucose levels, so ketoacidosis can never occur in such patients. The editors of the Lancet, where you published your "research", should have realized that too.
So, this "dangerous condition" that you discovered has nothing to do with the Atkins diet, or any other low-carb diet for that matter. And even if by some miracle you could prove (any) causation your conclusions are far too premature. Did you document any cofounding intervention factors, doctor? I highly doubt it.
I also wonder, dear doctor, did you also write a simular article in the "Lancet" for the tens of millions of people that died as a result of the low-fat diet fallacy, the calorie theory / portion control lie, or perhaps the millions suffering from the sideeffects of unnecessary statin drugs, or maybe the incredible number of people that is currently suffering from the dietary delusions of the Government and "health experts"? I don't think so, huh?
To base your conclusions, "warnings" and outright scare mongering on the - higly unfortunate - death of ONE person, and then even have the nerve to call it a "scientific study" (a scientific study of one? ridiculous!) worthy of publication in a medical journal is a total travesty and completely unprofessional as well as unscientific. You should do your research by investigation rather than proclamation.
The very fact that a respected and prestigeous publication as the "Lancet" approved your unscientific scribbles for publication shows that even such publications are no longer reliable these days and open to manipulation.
It also proves, I am afraid, that even a (alleged) medical degree does not protect against severe mental and moral degeneration.
Your entire idea and intent was to discredit this diet, nothing more. You failed.
But please, Dr. Lessnau (or the imposter), don't forget to call the Post, the NY Times, CNN, and all those other wonderful "free and unbiased media" outlets regarding this great scientific discovery that you made!
I am sure they will be more than happy to oblige!
Now THERE'S somebody with some passion and makes good sense, too! Anyone else care to chime in?
3-25-06 UPDATE: If you haven't read the blog entry by Dr. Michael Eades on this from 3-23-06, then you'll want to check out "Low-carb diet takes one below the belt." I LOVE the passion Dr. Eades has for livin' la vida low-carb!
Yet ANOTHER researcher wanted to share his thoughts on this study today as well:
When the rate of mobilization of fatty acids from fat tissue is accelerated, as, for example, during a very-low-carbohydrate diet, the liver produces ketone bodies. The liver cannot utilize ketone bodies and thus, they flow from the
liver to extra-hepatic tissues (e.g., brain, muscle) for use as a fuel.
Simply stated, ketone body metabolism by the brain displaces glucose utilization and thus spares muscle mass (muscle protein). Dietary ketosis is a harmless physiological state; however, many health care professionals and even some
scientists have confused dietary ketosis with diabetic ketoacidosis (an abnormal condition of increased acidity).
All diabetic patients know that the detection in their urine of the ketone bodies is a danger signal that their diabetes is poorly controlled. In severely uncontrolled diabetes, if the ketone bodies are produced in massive supranormal quantities, they are associated with ketoacidosis. In this life-threatening complication of diabetes mellitus, ketone bodies are produced rapidly, which overwhelm the body’s acid-base buffering system.
However, a very-low-carbohydrate diet cannot lead to dangerous ketoacidosis in HEALTHY subjects (without alcohol
or drug abuse), because ketone bodies have effects on insulin and glucagon secretions that contribute to the control of the rate of their own formation.
Nevertheless, a case report, published in The Lancet, described a 40-year-old female patient who was vomiting as often as six times daily and had difficulty breathing after strictly following the Atkins diet for a month. According to the report, ”Our patient denied alcohol use; her serum osmolar gap was 0, which excludes the presence of unmeasured osmotic agents such as methanol or ethylene glycol; L-lactate concentration was normal; and salicylate was undetectable…Serum [blood] was positive for acetone, and ß-hydroxybutyrate [a major ketone body] was high at 390 µg/mL (normal 0–44 µg/mL), consistent with ketoacidosis."
However, it is my view that the level of ketones in her urine (390 µg/mL) are not alarming. Just to be sure, I contacted Dr. Richard Feinman, a Professor of Biochemistry at SUNY Downstate Medical Center and a well-known researcher in the
area of carbohydrate-restriction, to ask his opinion about The Lancet case report.
According to Dr. Feinman, ”Clinicians here agree that it was kind of a rash conclusion. The ketones are, in fact, not sufficient to have caused the acidosis and while high for most people on the Atkins diet, they are in the ball-park of people who are in starvation for 10 days (who can live for at least another 20-60 days) and less than half of the ketoacidosis seen in untreated
type 1 diabetes. We are actually using the case with students to show how to do the calculations correctly. I think the physicians were just not familiar with the whole problem of ketosis and got carried away.
The Atkins diet still has so much baggage in medical circles that they didn't realize you can't attribute things to diet just on what people tell you. In any case, she apparently hadn't retained much food at all for three days and was probably in starvation rather than on any diet. The treatment was actually minimal (mostly re-hydration) and the whole thing was blown way out of proportion.
Also, even if the problems were due to the diet, millions of Americans are on some kind of carbohydrate restricted diet and nutritionists have been trying unsuccessfully to find a problem for thirty years. Do you know any drug, or even any weight loss diet, that has this kind of record?'"
In a commentary also published in The Lancet, Drs. Lyn Steffen and Jennifer Nettleton of the University of Minnesota's School of Public Health blasted low-carbohydrate/high-protein diets like there's no tomorrow. These sadly misinformed ladies supposedly hold some sort of doctoral degrees yet cannot even perform a appropriate PubMed search. They stated, "These
[low-carb/high-protein] diets also increase the protein load to the kidneys and alter the acid balance of the body, which result in loss of minerals from bone stores, thus compromising bone integrity."
This statement is misleading, at best. The best available scientific evidence indicates that protein-induced changes in kidney function are a NORMAL adaptative mechanism well within the functional limits of a healthy kidney. However, protein restriction may benefit patients with chronic kidney disease.
Also, there is no scientific evidence supporting the notion that low-carbohydrate/high-protein diet leads to loss of minerals from bone stores. Quite to the contrary. Many experimental and clinical studies indicate that low-protein diet negatively affects bone health. Furthermore, it has been demonstrated that proteins enhance IGF-1, a growth factor that exerts positive
activity on bone formation. Consequently, high-protein intake is, if anything, protective against the loss of bone minerals.
Don’t get me wrong. I'm not advocate for the Atkins diet. I feel a diet containing moderate amounts of low-glycemic carbohydrates is generally the healthiest way to achieve and maintain ideal body weight. However, I realize one diet approach
doesn’t fit all. Identifying specific needs, goals and the activity level of each individual is the key for success.
Thus, I advocate for applying science to ALL diets, including the Atkins diet. Certainly, diet-related public warnings should
be based on thorough analysis of the scientific literature, not unsubstantiated fears and misrepresentations.
Anssi Manninen, M.H.S.
Senior Science Editor
Advanced Research Press, Inc.
Do you get the feeling Dr. Lessnau wishes he'd never said a word about his little "study" as foolish as he is looking right about now? :) Dr. Lessnau, we're still waiting?
posted by Jimmy Moore at
3/18/2006 05:30:00 PM
2 Comments:
Regina points out that the woman was following the 1972 version of the diet, and that her BMI was 41.6. Her BMI alone could cause health problems!
Regina's article is very good. I blogged about it. It's a good bit of critical thinking, something all too rare today!
I response to the 3/21 letter, the woman didn't die. She was admitted to the hospital, improved, and was last known to be doing fine. Still morbidly obese, but alive.
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