'Shrinkdown' Nutritionist Discusses Her 'Concerns' With The Low-Carb Lifestyle

My blog post from last Friday about the nutritionist who wrote the educational materials for the South Carolina "Shrinkdown" event where literally thousands of people in my home state are seeking to lose weight and get healthy caused quite a stir, primarily among the family members of the author of the nutritional information being distributed to the participants.

A nutritionist from Furman University in Greenville, SC named Kelly Frazier unfortunately took my criticisms of her anti-low-carb viewpoints as exhibiting "hostility" towards her and she believed all I did was "bash" her personally. Of course, that's not true since my comments were directed at the substance of the "Healthy Living Guide" worksheets she authored as dietary truth about carbohydrates. None of my comments were about her as a person.

It also led her two sisters--Paula and Julie Anne--to post similar comments that I should not "bash" Kelly and explaining how everyone knows just how unhealthy livin' la vida low-carb is. Yadda yadda yadda! We've heard that so many times before while refuting it point-by-point here at my blog ad nauseam.

Even still, I'm willing to defend what I believe even when the tough questions are asked of me by people like Kelly who wonder how I can support such a paradoxical nutritional approach that is in the minority of support among the so-called health establishment these days. Just because we don't conform doesn't mean we're wrong!

Nevertheless, although Kelly originally expressed to me the "pain" she felt from my original post, she was very open and willing to share her genuine questions about the low-carb lifestyle and was interested in hearing my responses back to each of them. This post today will serve to offer those answers and provide Kelly with feedback to help her understand where we are coming from as low-carb advocates.

I applaud Kelly's willingness to exchange ideas about this subject and I am proud of her for having the courage to do it when so many other nutritionists and dietitians would simply ignore whatever a low-carb supporter would have to say. That says a lot about her character and I'm honored she would at least listen to what I have to say. THANK YOU, Kelly!

I'd like to give a special thanks to my low-carb blogging friend Regina Wilshire from the "Weight Of The Evidence" blog for assisting me with answering some of these questions from Kelly. I will add links to previous posts I have written that are relevant to each question as well to give context to my answers.

Here's what Kelly wrote to me in an e-mail and my responses:

Hi Jimmy,

I am going to try to explain some of my concerns about low-carbohydrate diets below (get ready for the longest email of your life). As I mentioned during my last email, I realize that some people can achieve long term weight loss on low-carb diets.

However, our sponsors (including major universities, hospital systems, and YMCAs statewide) have decided to stick with the guidelines of worldwide nutrition authorities. I welcome your reactions to the comments below. I am glad that we can have a peaceful discussion about our differences.

Yes, I'm glad we can discuss this openly so that everyone can benefit from the curiosity of your questions since these are some of the most oft-repeated "concerns" that continue to get spread about livin' la vida low-carb. I'm anxious to set the record straight for people who believe these are actually true.

1) Nutritional deficiencies

The perception of a low-carb diet varies from person to person and diet to diet. Let's make sure that we are talking about the same thing. The traditional Atkins style low-carb diet consists of large amounts of meat, bacon, pork rinds, butter, etc.

Just as I will acknowledge that an all vegetable diet is not balanced, I hope that we can agree that an all meat diet is also unbalanced. A nutritional analysis of the meal plans recommended during the early stages of Atkins suggests that there are many nutrient deficiencies with this style of eating. We have computer programs that will analyze foods and tell you the overall vitamin and mineral content of the diet. Researchers have also done this and published the findings on Medline.

Anyone who has taken the time to actually read Dr. Atkins New Diet Revolution or Atkins For Life books, they will very likely be shocked to learn that this diet, even during the misunderstood Induction phase, is very clearly NOT an all meat, bacon, pork rinds and butter nutritional approach. Some people do try to go on a zero-carb diet, but that's not the way recommended by Dr. Robert C. Atkins.

In fact, Dr. Atkins WARNED people about eating too much cured and processed meats since they are not as good for your body as whole meats are. The truth of the matter is that green leafy and other non-starchy vegetables are ENCOURAGED even during the most restrictive Induction phase of Atkins which only lasts for two weeks. The same goes for the widely accepted South Beach Diet, too.

Following those 14 days of Induction, even more healthy carbohydrates from such healthy foods as spinach, green beans, cauliflower, blueberries, strawberries, and melons are introduced to the menu of the typical low-carb dieter. This recent survey of active low-carbers found that vegetable consumption actually DOUBLES for people who begin the low-carb lifestyle while their meat and egg consumption remained the same as before or even decreased!

By all accounts, the low-carb plan is the most nutrient-dense way to eat on the planet. Compare low-carb eating with other so-called "balanced" diets and there's no comparison.

In this poster presentation at the NMS scientific sessions that took place in Brooklyn, New York in January 2006, four popular government "endorsed" dietary plans (AHA No-Fad, ADA, DASH and Food Pyramid) were found to be deficient in a number of essential nutrients at 2,000 calories as published for the public to follow. Men's Health magazine featured the ADA diet deficiency in its November 2006 issue and the ADA response was basically that 2,000 calories isn't enough calories to meet RDA's for all essential nutrients.

It is incumbent upon anyone promoting any diet to publish at least seven days of menus that are nutritionally complete for essential nutrients (vitamins, minerals, trace elements), essential fatty acids and essential amino acids at the normal calorie level being promoted. Can we see such a menu from you, Kelly, because it would certainly allow us the opportunity to see what you believe is healthy?

If the "Shrinkdown" recommendations are sound and nutritionally complete, then such a request should be simple to fulfill and will benefit everyone participating in this weight loss program since such materials provide a real-world example of what is expected for consumption in the real world. Are you open to providing a seven-day menu to verifiably prove that the guidelines you've helped develop are nutritionally complete and not setting up nutritional deficiencies? We'll be waiting to see such a menu.

2) Cancer

I am also concerned about the link between excessive meat consumption and increased risk of cancer. High red meat consumption has been associated with higher rates of breast, prostate, colon, pancreatic, and kidney cancer.

Population and lab studies suggest this link. For example, higher intakes of meat generally correlate with higher incidences of these cancers. Researchers have suggested several possible mechanisms for this link.

One is that certain carcinogens may be formed during the cooking process. Chargrilling, frying, and smoking animal fat and protein can create substances such as heterocyclic amines and polycyclic aromatic hydrocarbons. Some of these substances are known carcinogens. This means that they may cause and accelerate the cancer process.

A high-fat diet has also been associated with cancer. This may be due to excess calories and obesity, but that doesn't seem to explain the whole picture. For example, when fat reaches the small intestine, the gallbladder squirts a little bile into the small intestine to help emulsify the fat (sort of like how Dawn detergent emulsifies grease when you do the dishes). Bile can be converted into secondary bile acids which are also carcinogens that seem to irritate the linings of the intestines and may accelerate the cancer process. Some evidence suggests that a high saturated fat intake increases the conversion of bile to secondary bile acids which compounds this effect.

Researchers have also suggested that excess heme iron in the diet may act as a pro-oxidant and be involved in the cancer process. Since red meat is a high source of bioavailable heme iron, this is another mechanism that may be at work.

Of course, there is an abundance of data suggesting that phytonutrients in plant foods (whole grains, fruits, vegetables, beans, olives, nuts, etc.) reduce the incidence of cancer. Diets that restrict these foods may not provide optimal nutrient intake.

What are your definitions for "high" and "excessive" within the context of this discussion, Kelly? These are merely arbitrary without real numbers attached. We cannot adequately discuss this until these parameters are understood.

The fact that you cite one or two studies to declare proof that the low-carb diet is harmful is a bit ridiculous, especially when you are talking about cancer. I have studies showing that a low-fat, high-carb diet as promoted by you has actually been found to lead to cancer in the pancreas as well as in the esophagus. Can we conclude that these high-carb diets that you promote are highly carcinogenic based on these studies? It certainly appears to be that way according to the latest research!

Kelly is most certainly correct when she notes there is a study that shows what she says it does, but there are other studies that suggest it is the processes involved in oxidative damage that are the culprit. The following was recently published in Medical Hypothesis:

"Oxidative biochemical damage is widespread in diseases. It is apparent that decreasing the amount of dietary red meat will limit the level of oxidative catalysts in the tissues of the body. Increasing consumption of vegetables and fruits elevates the levels of antioxidative components, for example, selenium, vitamin E, vitamin C, lycopene, cysteine-glutathione and various phytochemicals. These detrimental processes of heme catalysis of oxidative damage hypothesized here are not well recognized."

Oxidative damage is harmful to our cells, but it again comes down to what constitutes a nutritionally complete diet. For example, the sulphur amino acids require B6 to be metabolized to antioxidants rather than oxidants (free radicals); deficiencies within the trans-sulfuration pathway induces the generation of reactive species of oxygen and halogens, homocysteine accumulation, and the synthesis of proinflammatory molecules by macrophages, thus contributing to pathologies like atherosclerosis and tumor development.

For example, methionine is a powerful antioxidant to clear free radicals, but can cause oxidative stress if you're not consuming adequate vitamin B-6. Inadequate supply of B6 would produce an oxidative environment in the body. Other cofactors are that are critical in the process too are B12, B-complex, choline, folic acid, and magnesium. So while it's easy to point to the potential of heme iron from meat, there are other equally important factors to consider before jumping the gun and suggesting individuals eliminate meat from an otherwise healthy and nutritionally complete diet!

3) Saturated fats

You mentioned that they were very healthy. I am interested to hear the logic behind that statement. I understand that during active weight loss, all bets are off. Saturated fats do not appear to increase LDL in some people while they are losing weight.

Since weight loss also tends to decrease LDL, the effect of saturated fats on LDL seems to be diminished in some people while they are losing weight. However, if you do a quick search of literature on Medline (what researchers use to evaluate published literature, www.pubmed.org), you will find thousands of articles describing the negative effects of saturated fats on raising LDL, risk for certain cancers, and other ailments.

It appears that the liver has a hard time clearing cholesterol when excess saturated fats are consumed. It may start to package more cholesterol as low-density lipoproteins. LDL, as you probably know, is involved in the process of atherosclerosis. It appears that when oxidized, LDL damages the delicate endothelial cells that line the arteries and starts the process of plaque build-up. LDL may also contribute to atherosclerosis by joining the plaque build-up itself (LDL acts kind of like spackle on walls).

Studies conducted before 2000 categorize trans fatty acids as saturated fats which merely serves to confuse the data. We must keep the proper context when discussing issues like this because it plays an important role in understanding what it all means.

We know from reviewing the literature that insulin is atherogenic and a high intake of carbohydrates stimulates both higher blood sugars and, thus, higher levels of insulin in the blood. This is why a low-carb diet was found in this study to actually LOWER the existence of saturated fat in the body compared with those on a low-fat diet. Hmmm, ironic, isn't it?

We also know, from decades of research that LDL cholesterol is most certainly NOT the whole story--HDL, triglycerides and the levels of the harmful vLDL are critically important to overall health and well-being. A low-carb diet not only has the potential to increase LDL (specifically the large "fluffy" benign type), but it raises HDL levels while significantly lowering triglycerides to below 100--considered VERY healthy! In fact, my HDL is around 72 and my triglycerides are at 43. Will anyone argue with me that this is unhealthy?

It is all too easy to adopt a viewpoint based on findings that are in agreement with your personal views. But a closer look at the actual literature that has been coming out in recent years and continues to pour out in 2007 very clear does not support the lipid hypothesis that so many health "experts" believe and often point to a different direction to consider when it comes to healthy cholesterol levels. Especially for people who are livin' la vida low-carb, the cholesterol concerns are a moot point.

Kelly, if you want to read more scientific data on this subject of cholesterol, then you may want to pick up a copy of the book The Great Cholesterol Con by independent researcher Anthony Colpo from Australia for more information. It's available on Amazon.com.

4) Bone health is my next concern. Meat contains high amounts of protein, especially sulfur containing amino acids. High protein intakes, especially of sulfur containing amino acids, appear to accelerate calcium excretion in the urine. This may contribute to a higher risk of osteoporosis. High protein diets have been associated with a higher rate of bone fracture (e.g., Harvard's Nurses Health study).

Again, I must ask, what is the definition of the word "high" in this context, Kelly? That's such an arbitray term--do you have any hard numbers you can assign to it?

But to directly address your point, I can point you to this study released in December 2006 that found low-CALORIE diets put bones at risk for degeneration, NOT low-carb ones. This was published in the Archives of Internal Medicine, a highly respected medical journal. What is your response to that?

The sad thing is you hear critics blame low-carb diets on osteoporosis while the research continues to suggest strong bone health results from this way of eating and that low-carb bone loss is a myth.

There are many more studies that specifically say protein intake is NOT correlated with bone health, calcium loss leading to fractures, and that nutritional density of the diet is important to properly understand bone health.

5) Kidney and liver health are my next concerns.

Protein differs from fat and carbohydrate in several ways. While carb and fat are made of carbon, hydrogen, and oxygen, protein also has nitrogen. This means that for protein to be metabolized (including for gluconeogenesis), your body must excrete the extra nitrogen. To do this, it kicks of the protein's amine group and excretes it as urea.

High amounts of urea may cause or worsen kidney complications. According to the American Liver Foundation "Certain proteins are converted into ammonia, a toxic metabolic product, by bacteria in the intestine or during the breakdown of body protein. The ammonia must be broken down by the liver and made into urea which is then excreted by the kidneys." They also add "good nutrition - a balanced diet with adequate calories, proteins, fats, and carbohydrates - can actually help the damaged liver to regenerate new liver cells."

In individuals with mild kidney disease, high protein diets can be life threatening (Please see proteinuria) The National Kidney and Urologic Diseases Information Clearinghouse adds "In people with diabetes, excessive consumption of protein may be harmful. Experts recommend that people with kidney disease of diabetes consume the recommended dietary allowance for protein, but avoid high-protein diets. For people with greatly reduced kidney function, a diet containing reduced amounts of protein may help delay the onset of kidney failure. Anyone following a reduced-protein diet should work with a dietitian to ensure adequate nutrition."

To sum all of that up, carbohydrates are clean burning fuel. They do not create excess metabolic waste products like urea that can damage the kidneys. When fats are metabolized without the presence of glucose, ketone bodies are formed. Since fats cannot be used by the brain and nervous system directly, ketones are formed to help the body survive during periods of starvation. Ketones can cause the blood pH to drop to deadly levels (also known as a diabetic coma).

The science behind this is very clear here. Anyone who has normal kidney function is NOT at any higher risk for kidney disease eating a low-carb diet. The issue of protein is a red herring and does not address the critical importance of nutrient-density as I have noted previously about this nutritional approach.

It is advised, across the board, by every medical professional who uses a low-carb nutritional approach on patients that those with advanced kidney disease should NOT follow this diet unless they are under strict medical supervision. Anyone with kidney disease should consult their physician before beginning a low-carb program. Those with normal kidney function are not going to get kidney disease just because they restrict their carbohydrates and eat foods like meat or eggs.

One final observation: Studies in real people with diabetes have found improvement in kidney function in those who follow a low-carb diet as well as a stabilization of their blood sugar levels. How about that?

6) Other interesting info according to Sizer and Whitney's Concepts and
Controversies

From my nutrition course that I teach at Furman:

"Scientists have only recently uncovered other roles for sugars in living tissues. For example, sugar molecules dangle from many of the body's fat and protein molecules. Once thought to be mere hitchhikers, these sugars can often have dramatic effects. They can change the shape of a protein, for instance, by altering its function. The protein of mucus, which protects body membranes and the digestive tract with a slippery coating, depends on a sugar molecule for its functional properties. Sugars also bind to cell membranes, affecting cellular interactions that may play roles in disease processes."

Of course, the authors are using the word "sugar" to describe the fragments of carbohydrate containing foods (mono- and disaccharides) and are not suggesting that we eat large amounts of table sugar (sucrose).

Humans have five ways to create increases of glucose in their bodies, but only one to lower it. This suggests that in the evolution of the human body, high blood sugar was not a threat to our ancestors who did not have the instant access to carbohydrates that we have today. Instead, what they dealt with was low blood sugar, so their body was able to create all the glucose it needed for survival.

As we stand today in 2007, there remains NO actual requirement for carbohydrates in the human body to survive, but we do NEED both fatty acids and amino acids from the fats and proteins we consume or we will die. Yes, you heard me correctly--we can all live just fine without consuming another carbohydrate for the rest of our lives (because of that amazing little process known as gluconeogenesis!).

7) Participant adherence is my final concern

The low-carbohydrate lifestyle is very challenging to adhere to. By offering participants a moderate approach to weight management (e.g., enjoy a variety of foods in moderate amounts, include moderate physical activity regularly), we hope that participants will learn a lifestyle that they can maintain long-term. If we suggested a more drastic approach such as low-carb, low-fat, or vegan diet, they may give up when it becomes difficult to adhere to it.

With regards to blood glucose control and insulin fluctuations, the American Diabetes Association actually encourages individuals with diagnosed diabetes to follow a balanced diet of fruits and vegetables (even starchy ones), whole grains, lean meats, and healthy fats. (Please see this article)

I am not sure that I understand the theory that eating more than 100 grams of carbohydrate per day would cause "spikes in blood sugar." By eating moderate amounts of complex carbs, fat, and protein over the course of the day (3-6 evenly spaced meals), the blood sugar should remain steady and little energy will be converted and stored as fat. Complex carbohydrates must be broken down before they are absorbed so they generally do not induce a large glycemic response (with the exception being fast acting starches like those in white potatoes). If you include small portions of healthy fats and lean protein with the meal, they delay the emptying of the stomach contents and also slow the glucose response.

I recall you mentioning that the meat focus is a myth about low-carb diets. This leads me to believe that you don't recommend this style of diet. Perhaps a healthier lower-carb approach would consist of an abundance of vegetables and fruits and moderate amounts of whole grains, lean proteins, and healthy fats. This follows the Mayo Clinic Healthy Weight Pyramid that we recommend during Shrinkdown.

Since we cannot medically supervise our participants and do not know if they have existing health complications (e.g., kidney, bone, liver disease or susceptibility to certain cancers), we feel that it would not be prudent for us to recommend a low-carbohydrate diet when we are aware of the potential risks.

Kelly, the fact is that ALL weight loss endeavors are a challenging venture regardless of the nutritional approach implored. Any effective weight loss plan is going to restrict SOMETHING--low-carb cuts back on the carbs, low-fat lowers the fat, low-calorie reduces caloric intake, and portion control decreases the amount of food consumed.

This deprivation that exists with all weight loss diets is crucial to seeing success. There's no way I could have ever lost over 190 pounds if I didn't cut back on carbs, calories, fat, or portions. But to remain healthy while losing the weight, it is important to choose a plan that will make that happen and provide adequate nutrients for your body. Livin' la vida low-carb was that plan for me and it could very well be the plan that works for many others, too!

My problem with the "Shrinkdown" recommendation is that it is a one-size-fits-all low-fat, low-calorie dietary approach with the exact same risks you expressed about low-carb diets. The participants really have no business blindly following these nutritional guidelines provided by you and the other "Shrinkdown" literature authors without consulting their doctors first to see if it is healthy for them.

The bottom line is the dietary recommendations made in the "Shrinkdown" program seem to be nutritionally deficient and may be leaving you and the organizers of this event open to liability for endorsing a blatantly unbalanced dietary approach that is in fact nutritionally deficient and incomplete when followed.

Of course, you can prove me wrong, Kelly, by providing a week's worth of menus that either meet or exceed the recommended daily nutrient requirements. If you cannot do this, then can you live with promoting a diet that may very well lead to chronic disease and quite possibly even death for the people following such a plan?!

Do you REALLY believe in your own diet enough that you are unashamed to provide just seven days of what a healthy low-fat, low-calorie diet should actually look like? I'm willing to continue the conversation if you are willing to submit what should be an extremely easy request. Are you up to the challenge, Kelly? I'll be waiting...