In The News Weight Loss with a Low-Carbohydrate, Mediterranean, or Low- Fat Diet: Diet Face-off in the New England Journal of Medicine  Yes, there is still more to say about the research study published in the NEJM on July 17, 2008. There are the facts of the study and the spin as reported in the media. I will touch on both.  A few important points regarding the design of this 2 year, randomly assigned study comparing the American Heart Association (AHA) diet with a Mediterranean and a low carb diet:   The AHA and Mediterranean diets were calorie-controlled: men 1800 per day, women-1500 per day. Although the low-carb arm did not limit calories, the participants naturally lowered their intake due to the satiating effects of higher protein and fat. The AHA diet recommended no more than 30% of calories from fat and less than 10% of that in saturated fat. The Mediterranean diet was moderate in fat (no more than 35% of calories), low in red meat, concentrating on fats from olive oil and nuts. The low carb arm was based on Atkins induction and did not limit the amount of fat including natural saturated fat. For 2 months the Atkins group limited carbs to 20 grams as outlined in Dr. Atkins book. For the next 4 months the participants followed the carb ladder, gradually increasing carb intake. After 6 months and for the remainder of the study this group was advanced to 120 grams of carbs daily. This was not a “vegetarian version” of Atkins as has been reported but based on Atkins induction. This information was obtained directly from one of the main researchers Dr. Iris Shai, R.D., Ph.D. This is the first trial comparing diets of different ratios of fat, protein and carbohydrate lasting 2 years. This study had a very high completion rate. Weight loss studies generally have high drop-out rates. It was done in a relatively controlled environment with all groups receiving dietitian support and follow-up.  The Results   All groups lost weight. By the end of 2 years those who completed the study on the AHA diet lost an average of 7.26 lbs, Mediterranean diet an average of 10.12 lbs., and low-carb an average of 12.1 lbs. There were no differences between groups in the amount of change in the LDL or so-called “bad cholesterol”. The greatest increase in the HDL or “good cholesterol” occurred in the low carb group. The greatest drop in triglycerides occurred in the low carb group. The cholesterol to HDL ratio improved in the low carb group by 20%, Mediterranean diet by 16% and the AHA diet by 12%. The best improvement in an important inflammation marker, CRP, occurred in the low carb group. The Mediterranean diet decreased the fasting blood sugar the most while it increased in the AHA group! The low carb group also improved blood sugar but to a lesser degree than the Mediterranean diet. However, after 24 months the best improvement in A1C (a measure of long-term glucose control) occurred in the low carb arm. Discussion This is not the first time results such as these have been demonstrated with an Atkins lifestyle. This long-term study can be added to mounting data that this program is both safe and effective. The “dangerous” side effects so often mentioned by critics have not been demonstrated in any of the research done over the years. It is worth noting that the AHA diet did not do better than either low carb or the Mediterranean diet in any respect!  After 6 months those on the low carb arm were advanced to 120 grams of carbs daily. This is more than most people who are at their goal weight would be able to eat on the maintenance phase of their plan. Yet despite the oft repeated criticism that people might be able to lose weight on Atkins but when they stop losing the diet will be bad for the heart, has not been borne out. Cardiovascular risk factors were still better with low carb even after weight loss stopped. This is an important finding.  There is one puzzling finding in this study that differs from others done with low carb and people with diabetes. The fasting blood sugar dropped more with the Mediterranean diet than on low carb. Other studies have demonstrated a significant and rapid improvement in blood sugar similar to results seen when using a low-carb lifestyle clinically. In fact, the blood sugar improvement can be so immediate that people are cautioned to work with their doctors to avoid a dangerous drop in blood sugar due to over-medication. There may be several reasons why the improvement in this study wasn’t as expected. It appears that the Atkins group had a larger number of people on meds for diabetes than the other arms which may imply that their diabetes was more long-term and severe. The amount of carbs allowed in the study protocol was higher than one would use in someone with diabetes. As explained in Atkins Diabetes Revolution  the amount of carbs is kept very low until there is significant improvement in blood sugar levels and a good amount of weight is lost. Clearly, Atkins is personalized when used in a clinical setting that may not fit into a research protocol.  As for the issue of the dreaded saturated fat, it is worth noting that the participants doing low carb ate more natural saturated fat but still had the best weight loss and better lipid improvements than the other groups. This finding will of course be ignored by the “saturated fat is bad group”. In fact, not surprisingly, the 10% fat Ornish group was quick to distance themselves from this study stating that 30% fat is way above their recommendation of not more than 10% fat intake as the only way to be healthy.  Researchers’ comments on their study  In the discussion section of their study a number of important take-home points were made:  Both the low-carb and Mediterranean diets are effective alternatives to low-fat and appear to be just as safe. Both low-carb and Mediterranean diets have beneficial metabolic effects suggesting that in clinical practice diets be individualized to metabolic needs and personal taste. Since all three groups reached similar calorie intakes (the low carb group without a mandated calorie restriction) low-carb may work best in those who are unable to follow a calorie-restricted plan. Increasing improvements in health markers seen during the 2 years of the study, even though the maximum weight was lost by 6 months, implies that a healthy diet, including low-carb, has benefits beyond just the weight loss attained. The behavioral approaches that assisted in weight loss were similar to results obtained with drug therapy. Results in a number of biomarkers measured appear to be a result of the differing diet compositions. The results imply that dietary composition modifies metabolic biomarkers in addition to leading to weight loss. How it’s been reported  The results of this study have been spun any number of ways.  Dr. Ornish, as already mentioned, thinks the only diet for everyone is a diet with virtually no saturated fat and not more than 10% total fat.  The AHA spokesperson responded that the most recent AHA guidelines have changed. They have moved away from limiting fat to 30% of total calories to between 25 to 35% of “healthy fats” while cutting the saturated fat recommendation from 10% to 7% of total calories. He neglected to mention on what evidence the stricter saturated fat restriction was made and how the public can use this info. Since saturated fat is supposed to increase LDL cholesterol this study found no differences in LDL changes between the three diets. How does he explain that? He did acknowledge the low carb group lost more weight but still claims that a diet high in saturated fat might do harm to blood vessels and the heart over time. Nor did the spokesperson comment on the fact that lipid parameters were better with low carb than with low fat and that the low fat arm increased fasting blood sugars in those with diabetes: a problematic finding since heart disease is a major complication of diabetes.  Others pointed out the Atkins group didn’t eat the usual cheese and bacon buffet that they think is Atkins but had better results because it was a vegetarian version. Sorry people, it was Atkins from the book and the results were still better with higher saturated fat.  Many focused only on the weight loss with no mention of the other important benefits. I was particularly unhappy with the report by Dr. Tim Johnson on Good Morning America. He ridiculed the two pound difference between the Mediterranean diet and low carb while ignoring the AHA result coming in at a distant third. He did not mention that the low carb arm didn’t mandate a calorie restriction and had an increased carb intake after 6 months which would stop or slow weight loss. I found his comments a particular disservice to people struggling with weight. We know that losing 5 to 10% of excess weight can decrease risk factors and should be encouraged as an important goal. In my opinion, Dr. Johnson lost an important opportunity to educate the public but rather chose to minimize the results of this research.  Several other articles including medical education pages on the Internet headlined that low-carb and Mediterranean diets may equal watching fat intake except that they didn’t--- they did better all around.  A few called the study highly flawed because it was partially funded by the Dr. Robert C. and Veronica Atkins Foundation. As if that automatically implied tampering with the design or the results of the study. Sorry, none of that happened. It is doubtful that the researchers and institutions involved would be willing to damage their careers or integrity for a relatively small amount of money.  One obesity researcher did called the study highly credible.  My comments  What we see is that anything positive about an Atkins type program is a lightening rod. When there was no research on Atkins it was criticized because there was no research. We were told any number of bad things would happen based purely on supposition. None of this has been shown to be true. Rather, as has been seen for decades in both clinical practice and consumer use, it is a safe and effective lifestyle. After the first studies were published with positive results the criticism was that studies were too short. Critics were sure there would be damaging long-term effects or positive results would disappear once weight loss stopped. Now we have a two year study and it still comes out on top.  It’s time to include the Atkins lifestyle as a proven, doable, healthy and effective choice to combat obesity. It’s time to stop thinking one-size-fits-all and encourage the diet that a person can turn into a permanent lifestyle change. Instead of focusing on rapid scale loss, focus on inch loss and health benefits. Keep the bigger picture in mind. It’s time we all began to take responsibility for the only body we will ever have and make the change that works for you while supporting others who choose the one that works for them.  In my opinion and experience, people with a family history of diabetes, addiction to carbs, increasing belly fat or those at risk for metabolic syndrome,  can address these issues best with a low-carb approach. Educate yourself about the approach you choose and get as much support as you can. There are many low-carb sites and forums to make the process easier. Take advantage of them and remember you’re in it for the long haul.      Previous News Stories The information presented on this site is in no way intended as medical advice or as a substitute for medical treatment. This information should be used in conjunction with the guidance and care of your physician. Consult your physician before beginning this program as you would any weight-loss or weight-maintenance program.  Those of you on diuretics or diabetes medication should proceed only under a doctor’s supervision as changing your diet usually requires a change in medication dosages. As with any plan, the weight-loss phases of this program should not be used by patients on dialysis or by pregnant or nursing women. As with any weight-loss plan, we recommend anyone under the age of 18 follow the program under the guidance of their physician.