Sunday, May 06, 2007

Does A Study Prove A High-Protein, Low-Carb Diet Leads To Higher Mortality Rates?

Antonia Trichopoulou found that higher protein leads to increased death

Oh no! I guess all of us low-carbers need to make sure our will is written because it looks like we're all headed for a one-way ticket to the cemetary. Well, that's what some are claiming after reading this European Journal of Clinical Nutrition study about mortality rates of people on a high-protein, low-carb diet.

Lead researcher Antonia Trichopoulou from the Department of Hygiene and Epidemiology in the School of Medicine at the University of Athens in Athens, Greece wanted to see what the mortality rates of people who stay on a high-protein, low-carb diet over the long-term.

Using the Greek population to comprise her pool of study participants, Trichopoulou observed the diet of 22,944 healthy adults and assessed their diet by way of a questionnaire. The researchers paid especially close attention to the protein and carbohydrate levels of the people in the study and more specifically their relationship to the rate of death among specific categories of people.

What she found was that 455 deaths happened over the 10-year period which Trichopoulou contributed to "high values of the additive low carbohydrate-high protein" diet. She also added that the study participants who ate such a diet saw more cardiovascular and cancer deaths than those who ate a high-carb diet.

Trichopoulou's grim conclusion? She said, "Prolonged consumption of diets low in carbohydrates and high in protein is associated with an increase in total mortality."

Aw man! I was just getting used to eating this way and now this researcher has to come along and ruin my day like this! Actually, while it is certainly an interesting study to look at, I'm not buying it. Whenever you leave the study data in the hands of the participants as they did in this study, you are opening yourself up for suspicious results.

But, despite my doubts about the veracity of the study results, you and I were challenged by a board certified dietitian named Dr. Steven Acocella to refute it under the assumption that it is a legitimate study. Before I share with you his challenge, I think you need to know a little more about this gentleman first.

As you can see from this article featuring Dr. Acocella, he's no fan of the late great Dr. Robert C. Atkins and his low-carb, high-protein diet. As a fellow colleague of low-fat vegetarian diet advocate Dr. Joel Furhman, we can presume he too believes meat should not be a major part of a healthy diet. Thus, a study like this one from Greece seems to further his position.

So, here's his challenge to people who are livin' la vida low-carb:

Dear Jimmy and blog members -

I know that the low-carb approach focuses caloric intake on high-fat but we all agree by default this diet style is also low-carb and high in protein, as fatty foods are often derived from high-protein foods. I know I'm in the lion's den here but Jimmy often posts opposing view and allows hearty debate. My post will hopefully inspire such discourse.

I will not editorialize on the study, but simply listen to you and your reader’s comments. I will say that there's no reason that we need to dispute the efficacy of the study itself. Let's go from the position that the study is not flawed. Let's discuss the science and findings.

The conclusions of the authors are reproducible and consistent. What do you all think? If you do post this study I applaud your willingness to explore the science and not ignore nor dismiss it.

I am keen on hearing the comments.

Dr. Steven Acocella
Board Certified Dietitian
Doctor of Chiropractic Medicine
Master of Science Human Nutrition
Fellow - American College of Lifestyle Medicine
Diplomate - American Clinical Board of Nutrition

THANK YOU for the challenge, Dr. Acocella! I'm more than happy to let my intelligent audience of readers share with you their collective wisdom about carbohydrate restriction. Debate of ideas is what I'm all about and I appreciate your willingness to listen.

Okay, if you are on a high-protein, low-carb diet and STILL living, please let us know by leaving a comment. LOL! Just kidding, but I think it makes a point.

The idea that you are killing yourself eating this way is absolutely absurd, study or no study. I don't need a study to tell me this because I'm living it, Dr. Acocella. And so are millions more to the betterment of their health and weight.

Also, you can e-mail Antonia Trichopoulou about her study at

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Blogger Science4u1959 said...

Well, for starters, this was from the "Department of Hygiene and Epidemiology". Especially the latter word tells a lot, but also the study parameters itself. This researcher assessed the diet of the participants by way of a questionnaire. Can we see that questionnaire? Can we see the raw data and assessment methodology used? I am sorry, but I am not so convinced that this "study" (which it wasn't) wasn't flawed. Why should we assume it wasn't flawed? Because Dr. Acocella says so? I am sorry, but I'd like to assess it myself first.

Second, this was an epidemiological study, which are notorious for the many confounding factors. Many "experts" absolutely love epidemiological studies because it's possible to prove almost anything with epidemiological studies. Is there any documentation about these confounding factors? How was that accounted for in the assessment?

I bet it wasn't accounted for at all.

If this would have been a tightly controlled, randomized clinical study, we would have something real to talk about and study. But since this is merely an epidemiological number crunching game, it is near worthless, especially since no account is given for the confounding factors. Perhaps dr. Acocella can give us that information - until then, no meaningful discussion is possible.

I am not impressed (nor amused) :)

5/07/2007 12:17 AM  
Blogger Science4u1959 said...

Oh, by the way: it has been well over a decade now since I started to, at least partially, use the gray matter between my ears and study the scientific literature with regard to proper nutrition - and subsequently (or, more exact, consequently) adhered closely to the Atkins dietary regimen. And, in the process, lost (and kept off) well over 220 pounds. A bit off-topic perhaps, but I just now received my annual full lab checkup results, and my specialists assured me that all my biomarkers are excellent. Like last year, the cardiologist told me that I have the heart of a young man (I used to have heart problems as well as arthritis and a very slow thyroid). Also, no signs of plaque whatsoever although I consume more (saturated!) fat than ever. My lungs are completely clear although I am a smoker. My doctor hypothesizes (and I agree with him) that the fat in my diet protects my lungs.

"Odd", huh? My 94-year old mother, who started low-carbing after my father died at the age of 60 from his ultra-low-fat diet, 30 years ago, says it's not that odd. Maybe it's because she's a (nutritionally educated) doctor :)

5/07/2007 1:13 AM  
Blogger Ladyred56 said...

Before making a judgment about the veracity of this study, I would love to know more about the background of the people who died. Many of us who come to the low carb way of life have a history of health problems from being overweight before beginning the diet. Some things just don't go away!In my opinion in order to provide stats from a study like this, all of this has to be taken into account. Some of us are in such bad shape from earlier weight gain that if we would not have undertaken the Atkins diet we would most certainly have died long before from conditions already present. It is my opinion that losing the weight with a diet we can follow gives many of us a chance to live a longer life than if we had kept attempting the diets we could not follow.
Personally I lost 50 pounds on low fat, was hungry all of the time and gained it and even more back.
You can manipulate almost any study to say whatever you want it to, but if you are going to look at mortality rates you need to do a full background check on the person's health conditions before the study begins.

5/07/2007 7:05 AM  
Blogger TESS said...

Well said Lady Red!I would like to know, if high protein low carb kills you quick, then how did our ancestors live long enough to procreate? This study and challenge sure started my day with a smile. I am quite happy living low carb and feel I have a better chance of getting struck by lightning than dying from my diet. I have lost 140 lbs and would surely have died from the weight or resulting complications. No study that depends on the participants word is a valid study, how many people put their honest weight on their drivers license?

5/07/2007 8:00 AM  
Blogger CB said...


Utter absurdity, on at least two points:

1) Challenging us to refute the study, while holding above dispute the efficacy of the study itself? (Hey, I'll be a study of one: seven and a half years and still counting, extremely low carb, and I'm still alive - with blood chemistry to rival anyone's. I am a perfect correlation, and epidemiological proof of the efficacy of long-term low-carb diet. Refute THAT, Dr. Acocella!)

2) The results themselves are statistically insignificant, in the context in which they are presented. (The statistical difference between incidence rates of 0.94 and 1.22 is NOT significant.)

There's plenty more to refute; I'll do a proper work-up, and link back to this post.

5/07/2007 8:53 AM  
Blogger PLC said...

What Dr Acocella wants us to do is nonsense. If we accept the validity of the study, then mustn't we accept the validity of their conclusion?

In reading the full text of the study, I found the following disclaimer:

"In our study population, consumption of carbohydrates, even at the low extreme of the distribution, was higher than that advocated by the prescribed low-carbohydrate diets and few individuals consumed more than 20% of their energy from proteins."

It appears they weren't actually studying "low carb/high protein" vs its inverse. No wonder they had statistically insignificant results. There is no validity in extrapolating their data into the statement that low carb/high protein diets increase morbity or anything else. They did this, apparently on the assumption that all their factors will continue to vary linearly as they approach the extremes. The study states, "it is unlikely that at the extremes of the low-carbohydrate–high-protein intake distribution there would be a reversal of the trend evident in our study population. Indeed, many of contemporary public health policies rely on extrapolations, so that if something is detrimental at a certain exposure level, its effect is likely to be more detrimental at a more extreme level." (An excellent example of simplistic public-health thinking.)

This incorrect assumption is the biggest fault in the study. The trend changes enormously when carbohydrates are truly restricted. That is the whole basis of the low carb way of eating, and why this study cannot be taken serioulsy by the low-carb community.

5/07/2007 11:22 AM  
Blogger Carol Bardelli said...

What exactly is their definition of "high protein" and "low carb"?
I've seen scientists and nutritionists who define a diet with up to 50 percent of calories coming from carbs as "low carb". Same with protein. When the US government recommends as little as 10 to 15 percent of calories from protein and up to 60 percent from carbs, this study may also define a relatively low protein diet as "high protein" and a high carb diet as "low". Its all relative to their definitions.

5/07/2007 11:23 AM  
Blogger Jimmy Moore said...

You guys are doing FANTASTIC! I've heard just about every rebuttal to this "study" that I was thinking of and I appreciate your feedback. Are you getting all of this Dr. Acocella?

Anyone else have something to share?

5/07/2007 11:42 AM  
Blogger CB said...


Here's a preview of my analysis of this study:

According to the study:

"With respect to the choice LC/HP score that relies on energy-adjusted components, at the high extreme of the distribution around 20% of energy intake was derived from proteins, whereas around 25% was derived from carbohydrates. At the low extreme of the distribution, around 10% of energy intake was derived from protein, whereas more than 50% was derived from carbohydrates."

The most extreme decile group in this study consumed 20% protein, 25% carbohydrate. This group does not constitute "low carb" as defined by conventional low-carb diets.

Further on in the study:

"In this population, the mean intake of protein was 76 g/day with standard error of the mean (s.e.m.) 0.16 g/day, the mean intake of carbohydrates was 208 g/day with s.e.m. 0.44 g/day, and the mean intake of lipids was 109 g/day (28% saturated, 15% polyunsaturated, 48% monounsaturated fatty acids and 9% other components of the lipid group) with s.e.m. 0.25 g/day."

Let me do some quick math:

Population carbohydrate consumption:
mean: 208 g/day, SEM: 0.16

Population size: 22,944 (according to Table 2)

Some quick calculations (SEM, Standard Deviation - will be explained more thoroughly on my blog post):

SEM for carbohydrate is 0.16.
Total population = 22,944;
sqrt 22,944 = 151.5;
SEM = 0.16 = SD/151.5;
thus SD = 24.2 g/day

Thus, 67% of the population were between 184 and 232 g per day of carbohydrate, and 90% of the population were between 164 and 256 g per day.

In order to reach even 90 g per day of carbohydrate, which would be the approximate UPPER end of the carbohydrate intake for most low-carb diets (Atkins, PP, etc.), we must extend 5 standard deviations from the mean.

[b]In other words, only 0.00003% of this population follow anything even closely resembling a low-carb diet.[/b]

5/07/2007 2:59 PM  
Blogger Ahavah bat Sarah said...

Tell the good doctor to get a degree in anthropology and then come back and debate. We all know early man ate almost no carbohydrates except fresh fruits and veggies in season (and not many of those, as many we now enjoy were not considered "food" back then). They were taller, lived longer, had healthy teeth, low infant mortality, and ate meat constantly.

As soon as any community adopted agriculture and a carb-based diet, their height and health went downhill immediately, they lost their teeth, their children died at alarming rates, and their economy made bread their chief staple. You can tell what kind of society you are dealing with when you dig them up just by looking at their teeth and height - if they had rotten teeth and stunted growth you know they are agriculturists. If they have healthy teeth and good height they are hunter-gatherers.

The evidence is well-documented. There is not any debate at all about these findings in any antropology college. Ask any field antropologist or archaeologist.

People who push vegan and vegetarian diets do so for ideological reasons that have nothing whatsoever to do with the biological requirements that evolution has produced in the human body.

Their idea of "proper nutrition" is based on false premises and the strange idea that the sickness of the agricultural communities in the last 10,000 years is "normal" for humans. It isn't. But when they see we have made "progress" in health and mortality, you've got to remember they're cherry-picking their starting point to make their stats look good. In truth, human health has gone way downhill since the hunter-gatherer days. If they had had antibiotics, they would have rivaled us today or passed us in health measures.

5/07/2007 9:13 PM  
Blogger Cindy said...

This is a doozy!! Not only are we supposed to believe that the "study" isn't flawed, but we're supposed to respond not even knowing what the levels of carbs/protein/fat were, let alone what KIND of carbs/protein/fat???

If the people that ate the higher carb intake were only getting their carbs from fruits, veggies and dairy....and the people with the higher protein intake were eating poor quality highly processed foods, I have no doubt that the higher carb dieters would live longer.

But if these people are ALL eating whole, natural foods high in protein and fat and low in carbs, then you will never convince me that this study is valid.

I've been following a low carb diet for over 2 yrs. I've seen my cholesterol levels improve dramatically, triglycerides, LDL and total cholesterol dropping and HDL increasing almost 3 fold. I've also found I have less arthritis symptoms, less reflux symptoms, better sleep and better glucose levels.

Personally I don't care what this study "proves", whether it is reproducable or not. After all, you can tweak the data to say almost anything you want it to say. But there have been studies that repeatedly show that low carb/high protein diets are better for glucose control and "heart risk markers". There are also studies that show a lower incidence of at least 2 types of cancer (pancreas and brain) that are more prevalent with high carb, and possibly even treated with low carb. And then there are the children that live their lives on ketogenic diets for seizure control.

5/07/2007 11:09 PM  
Blogger lovinglife said...


I applaud your sense of fairness when you allow your blog to post articles of disenting points of view. This one really, really got to me, big time.

I would like Dr. Accocella to have met my husband 5 years ago. 270 pounds, on 43 units of insulin a day, not able to walk over 100 feet at a time because of the neuropathy in both his feet, tired, irritable, had a Hemoglobin A1c of 11, hell to live with, total lack of energy, depressed and ready to give up.

He followed his doctors orders, took his meds faithfully, saw the doctor regularly every 3 to 6 months. He did not see a quack. He worked at a prestigious hospital here in Cleveland; University Hospital. His doctor was also at this hospital - one of the leading hospitals in the country.

At every doctor's visit, the doctor would check his blood pressure, check his blood sugar and his HA1c (Hemoglobin A1c). He would then tell my husband to lose weight and exercise. He NEVER, EVER told him how to do that little task of losing weight! DUH!

I read Dr. Richard Bernsteins book, "Diabetes Solutions" (first edition - now updated and recently published the third edition). I knew what to do to help my husband. When he was ready to take responsibility for this disease and for his weight, I put him on our program - one that is very similar to Dr. B.

He lost 75 pounds in 9 months, he came off of insulin totally within 3 months and has never gone back on it for the past 4 years, he exercises every day now (before he could barely move let alone exercise), he has been in 2 5K races (walking and finishing). His energy level is back to being what it was prior to the diabetes; in other words he just doesn't sit down anymore. He is happy and full of energy. Recently he lost another 10 pounds and is now looking at a goal weight of 180 pounds. He currently weights 194 - down from 275 pounds! Oh yes, and one other small detail - his HA1c recently was 6.5!

Yes, Dr. Acocella, I am sure you are a much more intelligent person than I am. You are degreed up the ying/yang. But you haven't got a clue when it comes to low carb living. First of all, if my husband were to die tomorrow because of low carb living - it would still have ALL been worth it. I wouldn't trade these last 4 years for another 50 more years of living the way we were living.

You may have all the experience and book smarts, Doctor, and I truly respect respect that education but living a life of energy, fun and enjoying each other because of a low carb lifestyle beats all your learning hands down.

If you haven't lived with diabetes, you have no clue as to the devastating effects of this epidemic disease. Low carb eating improves if not cures diabetes - period.

And lets look at what low carb living is really all about. Low carb living is eating healthy. Eliminating all of the foods that are unhealthy for anyone. Items like potato chips, breads, cookies, candies, bake goods, rice, potatoes, corn, cereals. Tell me what is so "unhealthy that it'll kill you" about eliminating these foods from your diet. On second thought, don't tell me because I don't want or need to hear your opinions (learned as they may be) because I have found the answer to living a good life for myself and my husband. That answer, Dr. Acoccella is LOW CARB LIFESTYLE!

5/08/2007 12:17 AM  
Blogger mrfritznyc said...

loving life, that was a great story. I can't speak for Dr. Acocella or the other ETL diseaseproofers, but I think I know what they might tell you. They claim that their diet is the diabetes solution, and they aren't actually that far off the mark in that regard. Their diet excludes sugar and starch, to the degree possible if you insist on avoiding animal protein, so in that respect, it's better for diabetes than most other diets. Just not nearly as good, good for you, and satisfying as a diet based on animal fats and proteins.

their big mistake is insisting animal protein is harmful to health. they cite the "thousands of studies", none of which involve meat consumption in a low carb context, of course.

I challenge Dr. Acoccella to this: show me one study linking a true low carb diet to anything harmful. Just one study. Just make sure it's really a low carb diet, that it involves animal protein based diet with a minimal amount of carbs, no additives, etc. etc.

Just one! Bring it on!

5/08/2007 1:59 PM  
Blogger Fat Victoria said...

I don't eat high fat because unlike many of you, fat doesn't do a thing to fill me up - it just adds a lot of calories. So when I was on Atkins I ate more high protein, moderate fat, low carb. Currently I'm on a low-fat program, but I am still trying to keep the carb down and the protein up as much as possible.

5/10/2007 12:46 AM  
Blogger CB said...

Jimmy, I have posted the first two parts of my critique of the study.

Part 1: Is It Really Low-Carb?

5/10/2007 8:02 PM  

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