The New England Journal Of Medicine is highly prestigious
While I was away on vacation in Florida seeing my brother recently, a well-publicized weight loss study comparing a low-carbohydrate, Mediterranean, and low-fat diet was released and published in the July 17, 2008 issue of The New England Journal Of Medicine. All the headlines were screaming how the Atkins diet is best and livin' la vida low-carb is champion of them all. It was in virtually every newspaper (including this Wall Street Journal story I was quoted in), local and national television news outlet, and all the health and weight loss blogs--A BIG STORY!
And because it put low-carb living in such a positive light as compared with the low-fat diet or the much-beloved Mediterranean diet, you would think I'd be a happy camper touting this study as the best thing to happen for low-carb in a long while. But as I stated after this other highly-publicized study out of Stanford published in Journal of the American Medical Association last March, I can't get too thrilled about yet another study that shows such insignificant weight loss on a low-carb diet after two years and doesn't really require the participants to adhere closely to anything resembling the Atkins weight loss diet. This puts me in the minority I'm sure, but I have to say this is one big reason why I was disappointed with the New England Journal study.
For those of you who missed this study, lead researcher Iris Shai, R.D., Ph.D. from the S. Daniel Abraham International Center for Health and Nutrition in Israel, put 322 "moderately obese subjects" on one of three specific diets for a two-year observation:
- LOW-CARB--Two months of 20g daily and slowly increase to 120g maximum for the duration of the study. Calorie-restriction was not required for this group.
- MEDITERRANEAN--Calorie restriction of 1500 daily for females, 1800 daily for males consuming a diet with 35 percent fat from olive oil and nuts while consuming fish and poultry in place of higher-fat cuts of meat like pork and beef.
- LOW-FAT--Calorie restriction of 1500 daily for females, 1800 daily for males consuming a diet with 30 percent of calories from fat as recommended by the American Heart Association (AHA)
Before I share the results, I have some comments. While 20g carbs is indeed the Induction phase of the Atkins diet, 120g is nowhere close to ANY phase of the Atkins diet. EVER! Why do they put people on a low-carb diet and then let 'em go to town eating carbs later? What's so freakin' hard about requiring them to stay at or under 50g a day? I just don't get that with these studies. I do like the fact there were no constraints on calories with the low-carb group and they just naturally kept their calories in check eating this way.
The Mediterranean diet group looked fine, but I was surprised to see the low-fat diet group to include so much fat. While the AHA may consider a 30 percent fat diet to be low (and it is relatively speaking), it doesn't come anywhere near the kind of low-fat diet that the infamous Dr. Dean Ornish said in my first interview with him suggesting obese and unhealthy people go on to lower their weight and improve their health. His plan is a 10 percent fat diet with upwards of 70-80 percent carbohydrates. That's not what they did with this study which is too bad since it supposedly shows the difference between low-fat and low-carb. We'll have more from Ornish is a moment.
First, let's take a look at the results of this less-than-spectacular study:
The LOW-CARB group lost the most amount of weight with 12.1 pounds followed by the MEDITERRANEAN group who lost 10.1 pounds and bringing up the tail was the LOW-FAT group who only shed 7.3 pounds (confirming the results of this long-term large study that found weight loss was insignificant on a reduced-fat diet). The researchers also observed what happened to HDL and triglycerides on these various nutritional approaches and the results were not at all shocking to those of us paying attention to our health--LOW-CARB saw a greater INCREASE in their HDL "good" cholesterol and a more significant DECREASE in their dangerous triglyceride levels making their ratio of HDL/total cholesterol much better than the other groups. Additionally, the A1C levels, an important marker in blood sugar health, as well as their C-reactive protein levels, a marker look at dangerous inflammation, both improved more with the LOW-CARB group.
Pretty good news, right? Well, it depends on who you ask. Let's see what Dr. Ornish thought about this study in this op-ed piece published in Newsweek magazine. It appears he had an issue with several things that may or may not have validity:
1. The study was funded by The Atkins Foundation, a non-profit organization led by Veronica Atkins that has donated millions of dollars to various researchers looking into low-carb diets and their effect on weight and health carrying on the legacy of the late great Dr. Robert C. Atkins.
This shouldn't disqualify the study altogether, but Ornish seems to think it does. So, are we to negate all the research conducted by you and your group on low-fat diets using the same logic, Dr. Ornish? You're better than this.
2. The LOW-FAT participants didn't eat a "low-fat" diet.
I agree, Dr. Ornish. But neither did the LOW-CARB group eat a genuinely "low-carb" diet beyond the first couple of months of the study. If we are ever gonna see a real comparison of low-fat and low-carb diets going head-to-head, then mandatory compliance is gonna have to be implemented. That's the only way to keep advocates on both sides from whining about the diet not being the actual diet every time one of these comparison studies is released.
3. The study is questionable because of calories difference.
Dr. Ornish claims the study lacks "quality" because the LOW-FAT group ate less calories but lost less weight. He says this calls into question the veracity of the data because it is "physiologically impossible" to eat less calories and lose less weight than the other groups. Ornish believes in the mistaken notion of calories in, calories out, so this is not surprising. How about that metabolic advantage at work? :D
4. The Atkins diet group ate "vegetarian sources of fat and protein" which isn't the Atkins diet with all the bacon and beef you can eat.
I'll agree that vegetarian fats and proteins are not preferred over animal fats on the Atkins diet, it's ludicrous to continue stating that the Atkins diet by the book doesn't include veggies. Anyone who has read the book and doesn't have an agenda like Dr. Ornish knows that you get two cups of green leafy veggies as well as one cup of non-starchy vegetables per day on the most restrictive Induction phase of the Atkins diet. Hello?! You make yourself look idiotic when you keep repeating the same lie over and over again, Dr. Ornish.
As for the actual sources of fat and protein in the LOW-CARB group, low-carb researcher Dr. Eric Westman from Duke University asked Dr. Shai to clarify what kind of foods were eaten by members of the low carb group. The notion that the researchers pushed a "vegetarian low-carb diet" on the participants is NOT what was done.
Here was Dr. Shai's response to Dr. Westman's inquiry:
This is kind of funny that some could think of a "vegetarian low-carb" diet. Is it a new suggested strategy? Could be interesting idea but this wasn't the case here. Our low-carb diet was based on Atkins, the participants read the book and the recipes were more or less comparable to what you know in the states.
Beef is the main red meat. What could be different? People here (in Israel) would not mix in the same meal meat and butter, a salad is considered a very rich one and not a lettuce based, and the main dressing is olive oil. As for beverages, same industry that makes money everywhere.
For example, a plate could include: fish or fried/not bread coated chicken/or red meet, broccoli and mushrooms coated with eggs, roasted eggplants, vegetable salad (peppers, cucumber, green leaves, not lettuce) with olive oil dressing. I understand that some of the low-fat people find it hard to believe that such a low-carb diet was tremendously favorable within 2 years in a well designed study, but these are the facts and the science of tomorrow, with the next long-term studies in the pipeline, may confirm or not these findings.
So, as you can see, the LOW-CARB did indeed follow more of an Atkins diet approach in terms of the specific foods they ate, not the mocking of a "vegetarian low-carb diet" as Dr. Ornish made fun of in his op-ed column.
5. HDL is only a risk factor among many to be looked at.
Oh, how convenient for you, Dr. Ornish. Yes, we know all about your "garbage trucks" analogy for HDL stating that you need more of them when you have more "junk" (LDL) to be removed. But the fact is eating a high-carb diet as Ornish suggests leads to LOWER HDL and HIGHER triglycerides, neither of which is healthy by any stretch of the imagination. And the very latest researcher is showing us that LDL and total cholesterol are not nearly as important as the HDL/triglycerides ratio that is becoming the new standard bearer for heart health. Dr. Ornish may dismiss these improvements with HDL and triglycerides by the LOW-CARB group as insignificant, but we know better.
At the end of his op-ed trying to dismiss this study as irrelevant in the grand scheme of things, Dr. Ornish states that it's time to "call a truce in the diet wars." That's something I've tried to do before noting all the areas of agreement between low-fat and low-carb, but the fact does remain we don't all agree on what is healthy, Dr. Ornish. To state so bluntly that "an optimal diet is one that is low in fat" shows just how entrenched you remain in your ideology without looking at the latest data (and I'm sure you STILL haven't read Gary Taubes' Good Calories, Bad Calories because you're afraid to have your lifelong beliefs about health challenged with evidential facts!).
Okay, enough about what Ornish thinks of this study. Let's see what some other prominent and REAL health experts think about the New England Journal study:
DR. JONNY BOWDEN
"Call me crazy, but I can't help wondering if the low-carb group would had lost even more weight if they had eaten less than the 120 grams of carbs these folks ate, all the while keeping calories at a moderate, reduced amount and incorporating other lifestyle changes like exercise and stress reduction. Can you imagine? A more reasonable level of under 100 grams a day (or even less) might have made a lot of difference--that's a level that seems to work the best for people who have problems with sugar, insulin and carbohydrates in general."
DR. JOHN BRIFFA
"This study adds to the body of evidence that suggests that lower carb and carb-controlled eating has distinct merit and generally has the capacity to out-perform low-fat diets in the weight-loss stakes (and without any conscious restriction of food intake, either). The results of this study suggest that such a diet may be superior in terms of cardiovascular disease risk too."
DR. RICHARD FEINMAN
"The major significance of the NEJM paper is that it is confirmatory of much work that has gone before. It is really not, as portrayed in the media, revolutionary. Much prior work from the laboratories of Jeff Volek, Eric Westman, Steve Phinney, Jay Wortman, Mary Gannon and Frank Nuttal and others has shown that carbohydrates, beyond simple calories, have a role in controlling how fats are used or stored. Directly or indirectly through insulin, carbohydrates encourage the storage rather than burning of fat and lead to the organization of fat into the cholesterol-containing particles that have been associated with cardiovascular disease. At the same time, the NEJM paper also confirms the evolving picture of fat as playing a passive role and emphasizes that what was once thought to be an intuitive benefit for lowering fat has consistently not panned out. The new article is a key block in a scientific structure that has been put together by many previous investigators. If the NEJM paper finally catalyzes some recognition of the scientific principles of carbohydrate restriction it will be a very important contribution."
DR. MARY C. VERNON
"For years, carbohydrate restriction and the low-carb folks, those of us who really spent our lives telling patients they could regain metabolic control and kind of being ostracized for it, we’re finally validated."
DR. JEFF VOLEK
"The findings from the recent NEJM study that showed a diet lower in carbohydrate outperformed a low fat diet confirms our previous work and that of many others. It is unique in that the intervention was 2 years and yet there was a very low subject attrition rate over such a long period of time. The low carbohydrate diet was only moderately restricted in carbohydrates (about 40% of calories). Based on our research, had the level of carbohydrate restriction been in the 10-15% range, the results would have been even more impressive. The results add to a growing body of work supporting the value of restricting carbohydrate as opposed to fat for superior weight management and metabolic health."
"These latest trials just happen to be the best data we have on the long-term effects of saturated fat in the diet, and the best data we have says that more saturated fat is better than less. It may be true that if we lowered saturated fat further — say to 7 % of all calories as the American Heart Association is now recommending — or total fat down to 10 percent, as Dean Ornish argues, or raised saturated fat to 20 percent of calories, as Keys did, that we’d see a different result, but that’s just another hypothesis. The trials haven’t been done to test it. It’s also hard to imagine why a small decrease in saturated fat would be deleterious, but a larger decrease would be beneficial.
It’s also true that I don’t think that LDL is a particularly meaningful predictor of heart disease risk, and I think total cholesterol is meaningless (based on the evidence that I recount in the book). But the point is that the AHA and the National Cholesterol Education Program and the authorities at the National Heart, Lung and Blood Institute do think LDL is meaningful, and that’s the basis by which they have always recommended low-saturated-fat diets. They also think that total cholesterol/HDL is the single best predictor of heart disease risk, so by their assessment, more saturated fat is better than less. I think the best predictors of risk regarding cholesterol profiles are HDL and the size and density of the LDL particles themselves, and maybe measurements of a protein known as ApoB (the protein component of the LDL particle itself) — and the existing diet trials in those cases also suggest that saturated fats are at worst harmless and perhaps even beneficial.
Last point, the funding. It’s true that the study was financed by the Atkins Foundation, but to assume that the researchers went out and falsified their findings or twisted their observations to satisfy the source of funding is naive. Regrettably, the only institutions that will finance clinical trials, for the most part, are those that stand to gain from the results. That’s why the pharmaceutical industry finances drug trials. It would be nice if the government financed all these trials, but they don’t. So it’s up to the Atkins Foundation and any other organizations that might hold similar beliefs. In this case, the Atkins-funded diet trial observed the exact same results as similar NIH-funded diet trials."
Incidentally, Taubes says the National Institutes of Health (NIH) has spent $5 million for a large (300+ subjects, two-year-long) Atkins vs. AHA low-fat diet trial--the REAL THING! This is a larger and longer version of a pilot trial that observed results similar to the Israeli trial. This is the largest diet/weight loss trial the NIH has ever funded. The principal investigator is Gary Foster of Temple University, currently the president of the Obesity Society. In February 2007, Dr. Foster told Taubes the researchers had "completed the final 2 year assessments on most but not all" of their subjects. Currently the paper is "in the peer review process" and that's all we know at this point. Cross your fingers that this is the great elusive study that actually looks at low-carb vs. low-fat once and for all.
Coming as a shock to nobody, the AHA weighed in on this study expressing their concerns over the long-term weight and health impact of low-carb diets and saturated fat consumption and the lack of application to women since the majority of the study participants were men. Yadda yadda yadda...what do you expect from a group pushing two cartoon characters known as "The Bad Fat Brothers" named "Sat" and "Trans?" These people lost all dignity a long time ago.
I have long held the position that if low-carb is at least as effective as low-fat for weight loss and health, then both should be recommended alongside one another as healthy options for people to choose from. The American Diabetes Association recognized low-carb diets to diabetics for the first time beginning in January 2008 and the AHA, AMA, and other health groups should follow suit. The evidence is there if you'll simply open your eyes to it. We don't need another study, flawed or otherwise, to tell us that one way of eating that is working for so many people is livin' la vida low-carb. GIVE PEOPLE THE TRUTH and then let them choose. It's that easy.
Although I'm not particularly overjoyed by this latest study out of Israel, that doesn't mean I don't appreciate the way it helped carry on the conversation about low-carb living across mainstream America. My stepdad Frank, who only recently started on the Atkins diet to lose about 50 pounds along with my mother, was all excited when he saw the television news coverage about this study a couple of weeks back. If this excites people and gets them interested in learning more about the healthy low-carb lifestyle, then that's awesome! I can't wait to see that new NIH study Taubes was talking about, though. That one looks like the REAL DEAL.
You can e-mail Dr. Iris Shai about this study at firstname.lastname@example.org.