Low-carb diet wins, losers cry foul

The paper that the London Times wrote about last week finally saw publication today in the Journal of the American Medical Association (JAMA). The study showed that a low-carb diet, followed for a year, produced vastly superior weight loss in premenopausal women as compared to a handful of low-fat diets. As might be expected, the promoters of the low-fat diets are crying foul.

The study is pretty straightforward. 311 overweight, premenopausal women were recruited by researchers at Stanford University and randomized into one of four dietary regimens: the Atkins diet, the Zone diet, the LEARN diet or the Ornish diet. After randomization into a specific diet the women received literature and weekly instruction for two months. Researchers obtained blood work, weight and measurements of the subjects at the start of the study and at 2 month, 6 month and 12 month intervals. At the end of the study, those subjects on the Atkins diet lost substantially more weight than subjects on the other three regimens and had either equal or better metabolic findings.

This study is pretty interesting for a couple of reasons. First, the participants were given the books and literature of the various regimes.

Participants were assigned 1 of 4 diet books: Dr Atkins’ New Diet Revolution, Enter the Zone, The LEARNManual for Weight Management, Eat More, Weigh Less by Ornish.

And the one month instruction involved weekly one hour meetings in which the various books were read and studied.

Each diet group attended 1-hour classes led by a registered dietitian once per week for 8 weeks and covered approximately one eighth of their respective books per class. The same dietitian taught all classes to all groups in all 4 cohorts and was rated by participants at the end of the 8-week sessions for enthusiasm and knowledge of the material (rating scale of 1-5, from “strongly disagree” to “strongly agree,” respectively). The LEARN program is intended to be a 16-week program and, therefore, the 8 weeks of guidance through this book reflected an accelerated time frame, which was necessary to match the time frame given for the other 3 diet groups. Efforts to maximize retention in the study included e-mail and telephone reminders for appointments, e-mail or telephone contact from staff between the 2- and 6-month and between the 6- and 12-month data collection points, and incentive payments of $25, $50, and $75 for completing the 2-, 6-, and 12-month data collection, respectively.

The two month instruction period ensured that participants at least read (or had read to them) the book that promoted the particular regimen they were following. Although the participants rated the instructor the same (4.7 out of 5), I can’t imagine that there wasn’t some variation in enthusiasm for a particular program. The same instructor gave instruction to all the groups. How can you get enthusiastic about recommending the Atkins diet then turn around and be just as fired up about hyping Ornish? Or vice versa? I couldn’t do it.

Let’s take a look at what the participants went through in their weekly instruction.

Each group received specific target goals according to the emphasis of the assigned diet. The Atkins group aimed for 20 g/d or less of carbohydrate for “induction” (usually 2-3 months) and 50 g/d or less of carbohydrate for the subsequent “ongoing weight loss” phase. The Zone group’s primary emphasis was a 40%-30%-30% distribution of carbohydrate, protein, and fat, respectively. The LEARN group was instructed to follow a prudent diet that included 55% to 60% energy from carbohydrate and less than 10% energy from saturated fat, caloric restriction, increased exercise, and behavior modification strategies. The primary emphasis for the Ornish group was no more than 10% of energy from fat. Additional recommendations given for physical activity, nutritional supplements, and behavioral strategies were consistent with those presented in each diet book.The guidelines for the Zone and LEARN diets incorporated specific goals for energy restriction, while for the Atkins and Ornish diets, there were no specific energy restriction goals.

So, the subjects were randomized into the various diets, which is important because were they allowed to self-select each would have gravitated to a diet most in sync with his (or her) nutritional beliefs. (Putting someone who would prefer Atkins into the Ornish group and vice versa gives a little more validity to the dropout figures, which, as we’ll see, are enlightening.) And the subjects were given pretty intensive instruction in the particular dietary promoter’s regimen. Not just a generic low-fat diet, for example, but the Ornish low-fat diet as presented by Ornish himself in his own book.

So what happened?

Well, this little graph pretty much says it all.

jama-figure-2-jpeg.JPG

As you can see, in terms of weight loss the Atkins diet won hands down. The other three contenders were clustered together at a distant second.

Let’s take a look the what the people following the various diets ate in terms of calories and carbs.

jama-table-2-en-carbs.JPG

If you do the calculations as I did you discover that at the two month mark the subjects on the Atkins diet are eating an average of 1381 kcal per day, 61 grams of which are carbohydrate. The calories and carbs climb throughout the year so that by the end of the study period the Atkins dieters are eating 1599 kcal per day, 140 grams of which are carbohydrate. These carbohydrate figures don’t really fit with the Atkins’ recommendation to restrict carbs to 20 grams per day (the induction phase) for 2-3 months. Were carbs restricted to Atkins levels they would have represented about 5-6 percent of intake instead of the 18-35 percent that it actually turned out.

MD and I are always asked (in fact, she got three emails today alone asking) what is the difference between our diet and the Atkins diet. One of the differences is that we have a different way of counting carbs that allows a more total carb than Atkins, but still provides the same weight loss and metabolic improvement benefits. We discovered by trial and error with ourselves and thousands of patients that insulin can be lowered just fine without the drastic carb restriction the Atkins diet as described in his book demands. In fact the people in this study – although schooled for two months from the Atkins book – were actually on a Protein Power diet, at least for the first two months. (Someday I’ll post on the relationship I had with Atkins and my annoyance that every incarnation of a low-carb diet is referred to as the Atkins diet.)
Here is the complete Table showing the intake of all the macronutrients.

jama-table-2-jpeg.JPG

I could drone on forever about all the interesting findings that can be plucked from just this one table, but let me leave you with just two. First, take a look at the fiber intake. I don’t really care about fiber because it’s been shown to be pretty much worthless as any kind of a healthful thing, but others haven’t read all the medical literature yet and so continue to think it’s wonderful. Look at the highest of the high carb diets, the Ornish diet, and notice that there just ain’t that much more fiber than on the Atkins diet. None of the diets has the recommended 25 grams per day. And look at the saturated fat intake. The Atkins diet followers ate a little over 15 percent of their calories as saturated fat (50% more than the recomended 10%), yet they had no increase in LDL. (See chart below). Once again proving that there is really no correlation between saturated fat intake and LDL levels. Finally, I found it interesting that twice as many subjects dropped out of the Zone, Ornish, LEARN diets than did from the Atkins.
The authors of this study drilled down pretty deeply into the lipid levels as a function of fat, especially saturated fat, in the diet.

Many concerns have been expressed that low-carbohydrate weight-loss diets, high in total and saturated fat, will adversely affect blood lipid levels and cardiovascular risk. These concerns have not been substantiated in recent weight-loss diet trials. The recent trials, like the current study, have consistently reported that triglycerides, HDL-C, blood pressure, and measures of insulin resistance either were not significantly different or were more favorable for the very-low-carbohydrate groups. [My italics]

The exception to this pattern has been LDL-C concentrations. Two of the most consistent findings in recent trials of low-carbohydrate vs low-fat diets have been higher LDL-C concentrations and lower triglyceride concentrations in the low-carbohydrate diets. Although a higher LDL-C concentration would appear to be an adverse effect, this may not be the case under these study conditions. The triglyceride-lowering effect of a low-carbohydrate diet leads to an increase in LDL particle size, which is known to decrease LDL atherogenicity. In the current study, at 2 months, mean LDL-C concentrations increased by 2% and mean triglyceride concentrations decreased by 30% in the Atkins group. These findings are consistent with a beneficial increase in LDL particle size, although LDL particle size was not assessed in our study. In addition, we examined non–HDL-C concentrations as an alternate indicator of atherogenic lipoproteins—a variable not substantially influenced by changes in triglyceride concentrations—and observed no significant differences among groups at any time point.

Therefore, we interpret these findings to suggest that there were no adverse effects on the lipid variables for women following the Atkins diet compared with the other diets and, furthermore, no adverse effects were observed on any weight-related variable measured in this study at any time point for the Atkins group. Further examination of the dietary effects on lipid variables would benefit from analyses of lipoprotein particle subfractions and follow-up of longer than 12 months.

Here is the chart of the blood and anthropomorphic findings with all the diets. (I cropped the notes so that the table would fit the page better.)

jama-table-3-jpeg.JPG

You can pretty much cruise through these charts and tables yourself and get the gist of the study. The low-carb diet preformed magnificently, as it typically does. Subjects following the low-carb diet lost more weight and had improvement, or at the very least, no change, in all other parameters measured. It was pretty much a grand slam no matter how you count it.

What I have found wonderfully amusing are the anguished cries from those promoters whose diets were savaged in this comparison study. Remember, as you read their comments, that the subjects followed the promoters diets as laid out by the promoters. The subjects on the Dean Ornish diet learned from Dr. Ornish’s book. If they didn’t follow it correctly, who’s fault it that?

From David Katz, who is involved with the LEARN program:

“You lose weight if you have cholera, too,” said Dr. David Katz, director and co-founder of the Yale Prevention Research Center and a longtime critic of the Atkins diet. “You can’t measure overall health by a few cardiac risk factors.” [Is this the same David Katz who says we all need to take statins to lower our cholesterol levels?]

“It’s flawed,” Katz said. [Oh, really? Mind telling me how?]

“Nothing in this study will change nutritional recommendations I make to my patients,” Katz said. [Nothing like an open minded scientist.]

Katz argues that given everything researchers know about food, the debate over the best types of nutrition should be over. People need fresh fruits and vegetables and should stay away from saturated fats and junk food, he said.

He also noted the relatively small amount of weight loss among the women in the study as proof that people need to be exposed to healthy foods at an early age before they gain weight.

“It is sad,” Katz said. “It points out the importance of our overall food environment,” he said.

From Barry Sears:

Barry Sears, creator of the Zone diet, defended his approach to weight loss despite Zone’s fourth place showing in the JAMA study.

He blamed the result on the fact that subjects on his diet in the study group actually ate more carbohydrates and less protein than he recommends in his plan.

The percentage of carbohydrates, proteins and fats subjects consumed in the Atkins group more closely resemble his own recommendation that dieters consume about 40 percent of the calories they take in as carbohydrates, 30 percent in fat and 30 percent in protein. [Go back and look at the charts, Barry]

“I like the term moderation,” Sears said.

The study ”had a good concept and incredibly pathetic execution

And from Dean Ornish:

A new comparison of four diets—including mine—is misleading and riddled with problems.

…many people may go on a diet that harms them based on inaccurate information.

Most study participants weren’t following an Ornish diet, which is 10 percent fat. They reduced their fat intake from an average of 35 percent to only 30 percent after one year. If they’re not following the dietary recommendations, it’s not surprising that they didn’t show as much improvement. By analogy, two thirds of people prescribed Lipitor aren’t taking it only four months later. Lipitor is a very effective way to lower cholesterol levels, but only if you take it. It would have been helpful if the authors had reported findings on the subset of people who actually followed the different diets to see what happened to them.

Dr. Ornish then prattles on about how those who really stick to his diet really do well. Really, they do. It’s tougher to stick to the Ornish diet than it is to discover the father of Anna Nicole Smith’s baby.

As you might imagine, this study won’t put an end to the great diet debate. But those of us who are old hands at the low-carb diet know the answer. It’ll just take the rest of the world a little longer to figure it out.

Please note: I reserve the right to delete comments that are offensive or off-topic.

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34 thoughts on “Low-carb diet wins, losers cry foul

  1. ok, great, sooooo… let’s hear about you and Dr. Atkins!

    In due course, mrfreddy, in due course.

    Cheers 

  2. “As you might imagine, this study won’t put an end to the great diet debate.”

    This is huge. This is the beginning of the end of the incorrect paradigm about the relationship between metabolism and nutrition. that has been pushed on us for decades.

    Hi Gary–

    It is huge, but don’t hold your breath.  See today’s post to see what I mean.

    Cheers–

    MRE 

  3. “These carbohydrate figures don’t really fit with the Atkins’ recommendation to restrict carbs to 20 grams per day (the induction phase) for 2-3 months. Were carbs restricted to Atkins levels they would have represented about 5-6 percent of intake instead of the 18-35 percent that it actually turned out.”

    Am I mistaken or is the Atkins Induction level of 20 grams to be for only 2 weeks and not 2-3 months? That’s how I read it anyways. Also I remember in an Atkins interview the reason he started at this level would be so “everyone” including the metabolically resistant would achieve ketosis. After Induction the diet becomes more individual in terms of the amount of carbohydrates.

    Hi Mandy–

    My Atkins book is in a box somewhere, still unpacked since my latest move, so I can’t look it up.  But, as I recall, the induction phase is several months.

    Best–

    MRE 

  4. You know, I tell people that I am on Atkins. Why? Because of what he went through to promote this lifestyle. It seemed like this man was always on trial and criticized for showing us that it was okay to eat meat.Truthfully, I eat everything that is low carb be it meat or a vegetable, fruit or my homemade low carb ice cream. I don’t count carbs but I can give you an educated guess that I don’t eat more than 40-60 grams of carbs per day. I will always be a low carber…period. I call it Atkins but I take the Eades advice seriously. I probably am more of a Protein Power dieter then Atkins but one thing for sure, low carbing is mucho healthy.

    Mucho, mucho healthy.

    Cheers–

  5. Love the article and the way you’ve laid it out. I noticed that all the groups were closest to the various programs at 2 months, possibly from the training and reading. Atkins is lowest carb and the others lowest in fat in the three low fat diets.

    A great read. Thanks.

  6. Mame,
    in all due respect I think Barry Sears has a point. Like yours his nutritional plan offers a significant degree of precision. Precision that quite frankly isn’t that hard to grasp. I’m not going to argue for his nutritional plan but his statement is accurate:

    He recommends a 40Carb:30Protein:30Fat ratio and the average intake as claimed associated to his prescription was:

    46% Carbohydrate
    20% Protein
    35% Fat

    Doesn’t look like 40:30:30 to me, though one may argue that it’s close. Is it that to a scientist or a Doctor 5% here or 10% there is really insignificant? Seems pretty out of whack to me! Frankly I feel it is quite significant an error and in that case I think a reevaluation may be in order even if my own feelings toward the study are favorable and here’s why:

    Let me crudely examine the Atkins (Protein Power) numbers here:

    Carbohydrate – 32%
    Protein – 22%
    Fat – 47%

    while Barry Sears’ initial prescription is 40:30:30 his athletes zone with 5x fat would look something like this:

    Carbohydrate – 29%
    Protein – 22%
    Fat – 48%

    Interesting, lets put those side by side:
    Atkins: Zone(5x)
    Carb – 32% 29%
    Prot – 22% 22%
    Fat – 46% 48%

    WOW things are looking familar. These two prescriptions are nearly identical!

    Now a 3% percentage variation I think is much more acceptable. Barry Sears’ point is spot on! The application of his program was flawed, most probably due to a teacher who simply didn’t understand the curriculum. Lack of enthusiasm?

    The ratios of Protein to Carbohydrate intake are the same whether they are 40:30:30 or 29:22:48 all he suggests doing is increasing (in your own words) “metabolically inactive” fat in order to account for caloric deficit.

    It seems that I’m following an extremely similar diet but going about it a different way because I count Zone Blocks. We’re accomplishing the same thing, and so is Barry Sears.

    Maybe you would get along!!!

    Hi Pierre–

    First, Barry Sears and I are great friends.  We’ve known each other for years and have spent a lot of time together.  In fact, I’ll probably be seeing him tomorrow at the big natural foods expo in Anaheim.  He and I argue – in a freindly way, of course – over all these things constantly.

    You wrote:

    Barry Sears’ point is spot on! The application of his program was flawed, most probably due to a teacher who simply didn’t understand the curriculum. Lack of enthusiasm?

    I disagree.  His program is difficult to follow what with all the counting of this and that.  It is custom made for the truly anal among us, and those truly anal individuals love it because it provides an outlet for their anality.  For the rest of humanity (which, one assumes, includes many in this study) it’s just too damned hard to follow.  I’m sure the folks randomized to the Zone gave it their best, but you read the consequences.

    Speaking of anality, I can’t tell you how many Zone groupies I’ve had to endure telling me how to make this or that ‘Zone favorable.’  Somehow I think they’ve missed the point.  I’ve had people tell me that if they add a few almonds, a couple of macadamia nuts, and a strip of bacon along with their giant muffin, it makes the whole thing ‘Zone favorable.’  I’m pretty sure that isn’t what Barry had in mind.

    Cheers–

    MRE 

  7. Sorry about calling you Mame Doc my RSS reader had me thinking I was reading MD’s blog when I wrote my post! No insults intended.

    No problem.  No insult taken.  In fact, I didn’t even notice.

    Cheers–

  8. Two-and-a-half cheers!

    What are the chances that Protein Power can/will be included in any pending studies? I’d be anxious to see you/MD quoted as advocates of lo-carb (especially now that Atkins himself cannot do so) along side Sears. Ornish, etc.

    Maybe it’s time for a new book (in your copious free time!)

    Hi Rick–

    I don’t know about pending studies, but the Protein Power LifePlan was the program used in the biggest, baddest, best grandaddy low-carb study of them all, the one with the best results ever. It didn’t matter. When the papers reported it, it was reported as the Atkins diet.

    Cheers–

    MRE

  9. Let me just say that although the findings reported by the JAMA substantiates almost everything that low carb lifers like me have always believed thanks to people like you and Dr Atkins, I didn’t need a ringing endorsement of my low carb lifestyle to know I made the right food choices.

    Just by feeling so good emotionally and physically since I started living the low carb way back in 1999 when I first discovered Protein Power, I wouldn’t give a toss if the JAMA said “Atkins” diet was a sure fire way to early death.

    But it is vindication I suppose for those who need that endorsement of their lifestyle.

    By the way, you did intrique me concerning your sentence regarding your relationship with Dr Atkins and your annoyance of his name when it’s in reference to any and all low carb diets.That would make another interesting read. It should make you feel wonderful however to know that both you and Dr Atkins have made so many life changing positive differences in so many different lives . Kudos!

    Hi Ron–

    Thanks for the kind words.

    Best–

    MRE 

  10. Thanks Dr. Eades for a wonderful article. I agree that it gets to be a bit much to see every low-carb diet referred to as “Atkins,” but catch phrases are tough to shake, and those of us like my wife and I, who are following a protein power diet are quick to inform anyone who asks us. Is there any reason why the news reports of the study are quick to emphasize that the Atkins dieters seem to gain the weight back more quickly? I can’t comment on the Ornish diet as to the difficulty of staying on it, but it looks mighty tough. However,unlike many of my co-workers who seem to think that it’s tough to keep eating “bacon, eggs and cheese,” (pure ignorance of what low carb is all about), the diet personified by the Low-Carb Cookworx shows is VERY EASY to stick with, and provides us with the ability to eat the breads and other comfort foods not really lost to us (with much of the success due to ingredients like almond meal and whey protein powder). Thanks again!!!

    David and Susan Futoma

    Hi David and Susan–

    Yes, there is a reason that all the news reports are quick to emphasize that those on the Atkins diet regain weight so much more quickly.  There is a bias against the low-carb diet and everyone is quick to diss it.

    Aside from that, however, I think people probably do regain weight quicker after stopping a low-carb diet than after going off a low-fat diet.  And the phenomenon once again proves that carbohydrates cause weight gain.  When one goes on a low-carb diet, what foods does one restrict?  Carbs, right?  And when one quits a low-carb diet and goes back to ‘regular’ eating, what does one add?  Carbs, right?  If one is following a low-fat diet, what does one restrict?  Fat, right?  And when one goes off a low-fat diet, what does one start eating more of?  Fat, right?  So, if it’s true that carbs cause the body to store more fat than does dietary fat, it stands to reason that going from fewer carbs to more carbs would cause more weight gain sooner than would going from less fat to more fat. Which seems to be the case.  So from now on when some idiot says that you regain faster after a quiting a low-carb diet, simply say:  That proves the superiority of a low-carb diet, you moron.

    Cheers–

    MRE 

  11. Nice post Mike. I see you jumped right on top of this one as I did. Interestingly enough what this study DOES indicate is that calories DO count. As calories went down, weight went down as they rose, weight rose. So it wasn’t just the carbs or fat or…

    Since these women only lost 10 pounds at best (Atkins dieters – well really PP dieters) over 12 months (my clients achieve this in 2 months), they needed to stay at the 1300 calorie level to achieve significant loss. I mean losing 4 pounds in 12 months is pretty pitiful. (I’ll bet on the ornish diet most of this was lean tissue another parameter that should have been accounted for.)

    Which leads me to the next point – the Atkins women in this study regained the weight they lost at 6 months in 6 months by eating only ~70 calories more (in the end) and NOT increasing their % of cals by carbs. I find this curious. 70 calories! That’s the cream in your 2 cups of coffee!

    This study seems to be screaming out that calories matter – a lot. Atkins did the best at the 2 month mark BUT while they ate the least amount of carb, they were eating the least amount of calories.

    The study is somewhat flawed in the sense that they did not account for total calories. Each of the women would have needed to eat the same amount of calories and to do this researchers would need to use women who’s BMR’s were fairly identical for this study to really compare the 4 diets. I hate to say it but…

    Anyhow, nice post! Keep ’em coming!

    Hi Fred–

    As I’ve said before, it’s a pretty good real world study of how people respond to diets as presented by the authors of four different diet books.  It’s hard to know how the calories actually came out without looking at the raw data–there could have been some real outliers that skewed the results.  I imagine, though, that people underreported early on while they were supposed to be being so good.

    If the researchers had controlled for calories, then we wouldn’t have had a real look at how people respond to the diets as presented by the authors.

    Cheers–

    MRE 

  12. Thank you for posting this detailed info on the study Dr. Mike. It was all over Canadian TV and radio yesterday as well and it was so incredibly frustrating to hear the comments of the so- called “experts” at the end of the segment. A couple of “prominent” Cdn. dieticians and nutritionists commented on the study and basically told us not to jump too fast and that a diet like Atkins was probably not harmful in the short term but that for the long term, a healthier diet, such as one promoted by the Canada Food Guide (hilarious!) was a much better way to eat. Then when the camera panned away from the person eating steak or bacon or whatever it was, the news announcers both said something to the effect of – Oh I could never do that…I could never give up my carbs and eat all that greasy, fatty food. I love my English muffins and bagels too much! Ha ha. Dr. Mike, you know that those of us who live low carb know all the wonderful health benefits that come with it but I think your statement about the rest of the world taking a little longer to figure it out is very optimistic. Sorry for the long comment and thank you again.

    Hi Cathy–

    See today’s post.  The evil forces from the other side aren’t taking this lying down.

    Cheers–

    MRE 

  13. Drs Eades,

    It’s a shame that this study was a combination of adherence to a diet and performance of a diet. It leaves a lot of wiggle room for the other guys. Unfortunately even the “Atkins” (Eades!!) diet was not really tested.

    Ornish will never shut up because it is impossible to test his diet as this and other studies (including his own) have shown. You would need to lock the testers up and feed them from a laboratory – not a kitchen! It makes me sick when I open up a magazine and he is either on staff or being interviewed as the diet guru.

    The forces against the low carb movement – the medical establishment and their upside down pyramid, the manufactured food industry, the drug industry and the puppets of these factions in the media and government – will fight hard against a movement that will leave them marginalized. Short of revolution, those people are not going away. Sadly, truth alone will not win the day.

    Thank you for championing the low carb movement. It would be nice to see the “right side up” pyramid someday – the “Eades Pyramid”!!!

    Phil Thackray

    Hi Phil–

    Among other things, this study shows how difficult it is for people to stick to any regimen for a year.  The lure of carby foods is too great for those on low-carb; the lure of fatty foods is too great for those following low-fat.  As I’ve always said, sticking on a diet is tough, tough, tough.  Anyone who does it for the long term deserves to be congratulated.

    Best–

    MRE 

  14. I couldn’t find any info on the drop out rate in the post. I think it is odd that the averages show no one stuck to their diet. I will admit sticking to my low carb diet is difficult with weddings, anniversaries, holiays, etc coming around but the averages show these peoples weren’t even close.

    Hi David–

    The four groups each started with about 80 subjects.  Nine dropped out of the Atkins group over the 12 months, 18 dropped out of each of the other three.

    It’s tough to stick with any diet for the long haul, but it has to be done to continue getting the benefits.

    Cheers–

    MRE 

  15. Great post, Dr. Eades.

    Care to speculate on how a no-carb, high Sat.fat diet would fare in such a study? No matter how clearly the signs point in that direction, it will be many years, if ever, before such a diet is studied by Stanford.

    Hi Robert–

    I think a no-carb, high saturated fat diet would kick this studies butt from here to Cleveland.  If, that is, the subjects stayed on the regimen.  Or I could be whining like the rest of these guys that no one actually followed the program.

    Cheers–

    MRE 

  16. Hi Mike–thanks for the interesting info. I do question whether these reports of food consumption are accurate. Shouldn’t overweight people who are eating such few calories lose more than a whopping 3-10 lbs. in one year? I agree that low carb, when done properly, is healthy and effective, but let’s be fair. No diet in this study yielded what I would consider significant weight loss, and let’s face it, the Zone and Ornish diets weren’t given a fair shot here (e.g. Zoners didn’t eat 30% protein, Ornishers got nowhere near 10% fat). Those of us who watch our carbs get upset when our diets are mischaracterized, or not implemented properly. I think we need to avoid doing that to the other camps.

    Hi Paul–

    I agree that the caloric intake is probably off.  Eating as few calories as reported should have resulted in more weight loss than reported in this study.

    I disagree, however, about whether or not Ornish and the Zone had a “fair shot.”  I think all the diets tested had a fair shot in a real world situation.  In fact, better than a fair shot since they had 8 weeks of instruction on the specific books.  If the people following the diets didn’t stick to them as presented in the various books, then maybe the books need rewriting or perhaps the specific plan promoted is not followable in a practical sense.

    To me what the study showed was that if you took a group of people and gave them four different diet books, those following the Atkins diet to the best of their abilities would lose more weight and end up with better looking bloodwork than those following the other diets.  Which would predict that if someone gave Atkins book to everyone in America more people would lose more weight than if the same humanitarian gave Ornish’s book or the Zone to everyone.

    Cheers–

    MRE 

  17. Dr. Eades, there was one part of the Ornish’s article that I thought was interesting: he dismissed rises in HDL as something that happens as a result of increased cholesterol levels in the blood. In other words, he seems to view an increase in HDL as a fighting mechanism by the body to control high cholesterol levels rather than an indicator of heart health. Of course, his argument assumes that high cholesterol levels are something to be concerned about, in and of themselves.

    What are your thoughts on this?

    Hi Keenan–

    I posted on this idiocy a while back.  You can read it here.

    Cheers–

    MRE 

  18. Thanks for the quick response, Dr Eades. I assumed Ornish was only doing a first-order analysis of the HDL situation, but I don’t have the medical background to figure out where the problem was. The article you linked me to is excellent – thanks for the explanation.

    I’ve been following a paleo/protein-power/evolutionary fitness diet for a little over a year now, and I posted before-and-after blood tests here if you’re curious: Lipids.

    I don’t expect these results to surprise you at all though – you know that this is the way we were meant to eat and that low carb is the way to =D

    Hi Keenan–

    Thanks for the report on your lipid values.  Good work.

    Keep it up.

    Best–

    MRE 

  19. Thanks for the brief comments on fiber. I feel like complete garbage when I eat even 5 grams of fiber a day, much less 25. This should put my wife at ease about my eating habits.

    Hi hap–

    Glad I could bring some marital harmony.

    Cheers–

    MRE 

  20. humanitarian gave Ornish’s book…

    No humanitarian would do such a thing!

    I had good friends who tried the Ornish plan for the husband’s angina. They were bright, committed folks and she was willing to put in the hours (and I do means hours) necessary to make the meals to Ornish’s specs. As friends, we would go over and have dinner with them.

    I’d come home ready to gnaw off my own arm. All those carbs with so little fat had an effect on my metabolism like a lit match and gasoline.

    They lasted three months. They didn’t get the results they were hoping for, but of course they blamed themselves… they weren’t doing it long enough, they didn’t get enough exercise in, he didn’t meditate every day…

    Personally, I think Ornish’s brain has been affected by his eating not enough fat… of all the plans outlined in this study, Ornish’s is the one I would have dropped out of the fastest.

    Hi WereBear-

    I would bet you’re right about more people taking a powder on the Ornish diet quicker than any other.  That’s why his full program involves so much hands on help from a staff.  It requires it to get people to remain on the tasteless dreck he calls food.  

    Cheers–

    MRE 

  21. Yes, the idiocy is astounding. Even a little bit of critical thinking reveals why Ornish, LEARN, etc. are tough to stick with compared with Protein Power/Atkins/Paleo etc. The bozo “experts” are stuck in the mindset that somehow modern science can cook up a better recipe for health than millions of years of evolution. Remember the whole infant formula vs. breast milk debacle?

    When viewed in the light of evolution, it’s such a no-brainer, I wonder if even Ornish could find a way around the obvious conclusions (probably, given his idiocy about HDL, and so forth). In nature, foods taste good to organisms because they contain nutrients required for good health. Similarly, cravings are the body’s way of telling you that you’re running short on something it needs. Fat is an essential nutrient, so it’s no surprise it’s so difficult to stick to 10% of calories. Ornish and the rest of his Puritanical ilk would have us believe that the desire for tasty and satisfying food is akin to a mortal sin.

    The real issue here (no surprise to followers of Protein Power) is one of manipulating natural impulses through food processing. Take away any significant processing, beyond harvest, kill, clean, and cook, and what’s left? Sugar, grains, and vegetable oils go bye-bye, taking with them almost every boxed food in the grocery store. Stick with locally available food, and you’ve got meat, leafy and root veggies, and fruit when in season.

    It’s no surprise it’s easiest to stick with this diet, because it gives you the nutrients your body evolved to require. Instead of having to fight against several million years of evolutionarily ingrained biochemistry, you need only resist the psychological temptations of industrially manipulated foods. Not that that is easy either, but definitely easier than battling deep survival instincts.

    I love watching people’s faces when I lay this argument on them. After all, who ultimately has more credibility: Dean Ornish or Mother Nature? The usual expression is one of complete cognitive dissonance, much like that of Nigel Tufnel in “Spinal Tap” when asked why he didn’t just make 10 the loudest setting on his amplifier. After a long glassy-eyed pause, the best he could muster was “This one goes to 11.”

    That’s about all Dean Ornish seems to be able to come up with as well.

    Hi Dave–

    Thanks for the great comment!

    Best–

    MRE 

  22. I will agree with you that the zone requires a different kind of character. I suppose I forget that in my environment (athletics) that precision (obsessive compulsiveness) is somewhat of a necessity for success.

    You’re also right that people tend to sway toward the path of least resistance “hence the bagel” or Zone friendly cake! This is one of the reasons I read this blog, you and your wife are always harping about food quality, nutrient density etc, etc…

    You have to admit though that while the means may have been different the best results were as prescribed. Perhaps thats the issue its not a problem with the prescription perse, but an issue with the delivery system which is what leads me to argue that the results are still somewhat flawed.

    If you prescribed a drug to a patient and they didn’t understand the instructions, they ate the whole bottle and died, is the precription at fault or the patient? I’d say the patient, so what if its complicated but the results of a study on prescriptions must show the results of the prescriptions not the results of what people did with the prescription.

    Do this study, 3 groups, 250 people per group:

    Group 1 – is Rx’d 0.5mg of Morphine/Day, but given a 1000mg bottle.

    Group 2 – is Rx’d 10mg of T3/day, given a 1000mg bottle.

    Group 3 – is Rd’d 25mg of Ibuprofen/day, given 25mg dose/day.

    Here’s my bet:

    Group 1
    – 85 are addicted to Morphine within 1 month and suffering from hallucinations.
    – 82 are selling large portions of their presciptions
    – 83 are taking their presciptions as Rx’d (might be overeaching here;)

    Group 2
    – 175 are selling their prescriptions
    – 25 have died from mixing with alcohol
    – 50 are taking as Rx’d

    Group 3
    – 248 are taking it as is forced upon them!
    – 2 have allergies

    HEADLINES:
    Morphine and T3 proven to be addictive, deadly and lead to unlawful behavior in 75% of prescriptions.

    Ibuprofen proven to be safe 99% of the time.

    Its not that the prescriptions were faulty its that the delivery system was faulty. The people taking the prescriptions were flawed. Tis the problem when dealing with people. They are people and they are going to screw it up unless it is forced upon them. So saying that one diet is better than another in terms of fat loss is only part of the question. The other question is how many people actually followed the diet?

    Find those who did then crunch the numbers again… The zone being for anal people not withstanding of course which I agree with!

    These studies should be done on inmates who have no choice but to eat what is provided.

    Does that make sense at all? I’m sure you understand what I’m saying better than I do 😉

    Hi Pierre–

    Re: your analogy.  If I gave someone a bottle of prescription medicine with the instructions clearly printed on the bottle, then spent 8 weeks going over exactly what the instructions said, I would figure that the patients would be able to follow the instructions to the letter.  But if they didn’t and instead took the medications incorrectly, I would have to conclude that there is something wrong with the instructions.  Or the patients are complete morons.

    My point is that this study was done using diet books that are available to anyone.  It shows what kind of results people can get following those diet books to the best of their ability.  In the case of this study, the Atkins diet won hands down.  Several conclusions can be drawn from this fact.  Maybe the Atkins book is written much more clearly than the others.  Maybe people reading the Atkins book are more inspired to follow the instructions because of the way the book is written.  Or (and I think this is the case) when people follow a low-carb diet in a half-assed fashion they get a lot better results than they do if they follow the Zone, Ornish or the LEARN program in a half-assed fashion.  And since the truth of the matter is that most people who buy diet books probably follow the diet contained therein in a half-assed fashion, then it would seem that  the best odds for success would be with a low-carb diet book.

    Cheers–

    MRE 

  23. Dr. Mike,

    I think your response to Paul B. really nailed it. A low carb diet is pretty easy to stay on if you believe it will work. My father tried for a few weeks and was skeptical of it but he lost some weight and felt better. His lack of faith however moved him right back into the welcoming arms of Weight Watchers.
    In the end, it appears all the diets were tough to stick to and that should speak volumes to the state of our food supply. It is killing us. Mix in a little marketing and bad science/reporting and it is a miracle we live past our 20’s.

    Hi Dave–

    Too bad about your dad and Weight Watchers.

    Keep working on him.

    MRE 

  24. Don’t mind me Dr. Eades…the post was great, but I want to comment to Fred!

    Which leads me to the next point – the Atkins women in this study regained the weight they lost at 6 months in 6 months by eating only ~70 calories more (in the end) and NOT increasing their % of cals by carbs. I find this curious. 70 calories! That’s the cream in your 2 cups of coffee!

    This study seems to be screaming out that calories matter – a lot.

    Or protein matters a lot more than anyone is looking at. I’m still dredging data from other studies to write about it, but it’s curious that as protein intake peaked (96g – up from habitual baseline of 78g) their weight loss was stong. With each tick downward for protein (6mo down to 86g; 12mo down to 82g) they lost their ability to continue weight loss (with little calories added as you noted)….interesting too is that with each tick down of protein, fat followed back to pretty much their baseline level of consumption (76g baseline; 2mo 84g; 6mo 80g; 12mo 79g).

    Then go look at the other plans – their protein and fat we’re going in the exact opposite direction (Zone initially increased) – but with the exception of Ornish, they were also increasing carbs and calories.

    Then, if you have a chance, go take a gander at Simpson et al “Protein Leverage Hypothesis” published in 2005 (and ignored)…really interesting read.

    There’s something I think we’re all missing….and I have a hunch it’s the protein intake is what is really going to matter most…now I just have to find the time to flesh out the data from enough studies to see if it’s true!

    Hi Regina–

    Jump on in.  I, too, have read the “Protein Leverage Hypothesis” by Simpson and actually have several slides on his work (from this paper and one other of his) that I use in my talks.  I think protein has a major role to play, but I haven’t climbed on board with his total hypothesis that the slight decrease in protein over the past few years is the cause of the obesity epidemic.

    It’s interesting that Simpson and his co-authors are all insect biologists and came up with this idea from their study of bugs. 

    Cheers–

    MRE 

  25. I say lets put T.Colin Campbell (10% protein advocate) and Dean Ornish (10% fat) in a room for a year and feed them a diet thats 80% carbs and see what happens. I’ll bet that their brains will turn into oatmeal from the lack of fat. Never mind I think were too late.

  26. In response to Fred and Regina,

    I also think it has a lot to do with the amount of carb intake. The percentage of carbohydrate consumption in the Atkins group is a lot higher than my understanding of what Atkins should be. Granted I haven’t read the newest book. But with the amount of weight these women needed to lose, they should have been consuming a lot less carbohydrates for a lot longer.

    I am used to seeing closer to 5% carbohydrate during the initial induction phase (2 weeks is the minimum time, with up to a few months if the person has a lot to lose, or is highly resistant), and maybe 20% in the ongoing weight loss or maintenance phases.

    At 6 months the average is almost 30% carbs and at 12 months 35% carbs. I’m not surprised that they gained weight back, I know I certainly would.

    I’m not saying that protein doesn’t have anything to do with it, but I think the amount of carbs is a dead give away as to the results.

    Just my opinion.

    Hi Cathy–

    I’m with you.

    Cheers–

    MRE 

  27. Or (and I think this is the case) when people follow a low-carb diet in a half-assed fashion they get a lot better results than they do if they follow the Zone, Ornish or the LEARN program in a half-assed fashion.

    I just had to jump in to agree with this sentiment; somehow, lowcarbing seems to be more forgiving.

    Maybe it’s because we eat so MANY carbs that even cutting down from 300 to 150 does a world of good.

    My husband has a chronic illness and finds it difficult to stay on track when it flares up. Even doing low carb this half-assed way (I tease him that he’s doing “half-assedKins”) he’s lost almost 60 pounds.

    The last three months, being housebound, he still lost seven pounds.

    And his lipids look great. Low carbing has definitely been a great thing for him to do. Even if it is half measures.

    Half-AssedKins! I love it.

  28. You don’t even need to dig out your Atkins book to find out how long the Induction phase is. Just go to the official website.

    http://www.atkins.com/articles/atkins-phases/phase-one/phase-1-induction/

    Just thought this little tidbit of information was important for you to know.

    Hi Mandy–

    This is what the recommendation is of the people running the Atkins site right now.  The researchers used whatever was in the original book, which, as I recall, was a lot longer than 14 days.  Feel free to check and let me know.

    Cheers–

    MRE 

  29. Hey, quick question:

    Does anybody else’s copy of PP or PPLP have a cover quote from none other than Barry Sears, Ph.D.? Mine says:

    I strongly recommend this book.”

    and

    The Nutritional Primer of the Nineties.”

    Also, while I’m going over my bookshelf, everyone is right on Dr. Atkins Induction. It lasts 2 weeks for everyone. It can last 6 months if you want it to. But really: the difference between 7g/meal (atkins Induction) and 10g/meal (pp Induction for heavy folks) is pretty small change, right? The difference is the allowed food list and mandatory veggies on Atkins that makes it a little harder in Induction. But with the ketosis focus, well, you get what you pay for, right?

    At any rate, who are these people eating 30% carb calories on an LC diet? I’m closer to 10%.

    As to Dr. Atkins, poor soul/dead guy. Shameless self-promoter, so I guess he deserves to be the Name for the LC diet in studies. If you and MD get out and bust hump in the marketing field the way Dr. Atkins did, maybe you can change the paradigm. Course, it’s easier to become the first model than replace the first model. And I know there were other LC diets before Robert Atkins ever saw his first obese person. But, the world is what it is. Should we go back to calling it the Banting Diet?

    Hi Max–

    Yep, Barry Sears gave us a cover blurb as we did him.

    As to your last paragraph, I don’t even know where to begin, so I won’t.

    Cheers–

    MRE 

  30. Whoops, since there were more comments debating how long Dr. Atkins did and didn’t say to Induce for, let’s let the man himself tell it.

    From Dr. Atkins New Diet Revolution, copyright 92, 99, 2002, 10th printing in paperback, page 122. Chapter: And Away You Go: The Induction Phase.

    “The Induction Phase is not going to be your lifelong way of eating. It will last at least fourteen days, after which you should see a significant result.”

    From page 159:
    “A lot of people think of Induction as
    only two weeks, but it can be followed for a longer time. If you have a lot of weight to lose or have difficulty losing weight, you might want to do Induction for quite a while.”

    He goes on to discuss when to go into OWL, which is too complicated to copy out of the book, but if you’re bored, don’t have a lot of weight to lose, are not very metabolically resistant and are willing to slow down your loss to get more food choices, move on. If not, you can do Induction “safely for six months or more.”

    Conclusion: 2 weeks is right. 2-3 months may be right too. Like PP/LP it’s highly customizable.

    Hi Max–

    Thanks for the clarification.

    Cheers–

    MRE 

  31. Once again, Dr Mike, thanks for the great post.

    The graphics are quite interesting too! Since I don’t have access to the article, I’ve wondered about several things that you’ve answered in your post.

    Curious tho….did anyone determine WHY people dropped out? or didn’t follow the assigned plan? I think that might be equally interesting!

    Now, I know random assignment of plans is the “best” way to conduct studies….but in the case of diets, don’t you think there would be different results if people actually chose the plan they were going to be on? I know for myself, the minute I was told I would be doing the Ornish plan I would have dropped out immediately! Even before discovering low carb, I knew I couldn’t follow a severely low fat diet. (for for me is much more effective than fiber, if you know what I mean)

    I may highjack a few of your graphics (if you don’t mind) if I ever get to posting my own opinion of the study and reports about it.

    Hi Cindy–

    Most of the people dropped out of the study for scheduling reasons.  A few got pregnant and several had ‘family’ reasons, whatever those might have been.  Another large category was listed simply as ‘Other.’

    The point about whether the dieters should have been randomized or selected the diet they wanted on their own can be argued either way.  It would have been interesting to have given a bunch of people all four books, let them read all of them, then select the diet they would feel most comfortable with.  I would love to see in a situation such as that which diet most would choose.

    Feel free to use the graphics.  They all came from the study.

    Cheers–

    MRE 

  32. Thought this might interest you. I love equating low-carb to cholera.

    Dr. David L. Katz
    Atkins diet still seems a bad idea
    Dr. David Katz
    03/12/2007
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    Despite the big splash made by a recent Stanford University study suggesting that the Atkins diet produces more weight loss at one year than several alternatives, I persist in my long-held view that the diet is just plain silly, and a bad idea.

    The study, conducted at Stanford’s Prevention Research Center, and published in the prestigious Journal of the American Medical Association, compared the “low-carb” Atkins diet to the Zone diet, the Ornish diet, and a behavior change program called LEARN, designed to help people achieve the balanced diet recommended by most authorities and the U.S. government, in a group of roughly 300 overweight and obese women.

    At the end of one year, the women assigned to the Atkins diet had lost the most weight, about 10 pounds. The several heart disease risk factors that were measured, including blood pressure, LDL cholesterol, HDL cholesterol, insulin, and blood glucose were fairly comparable across all four treatment groups overall, suggesting that the Atkins’ diet facilitated weight loss while lowering cardiovascular risk.

    But beyond these basic facts, the hype over this study and its real implications part company. A truly vast amount of scientific study suggests that a diet rich in fruits (mostly banned by Atkins), vegetables, whole grains (banned by Atkins), lean protein sources, nuts, seeds, healthful oils from such sources as olives, and restricted in saturated fat (essentially encouraged by Atkins) is optimal for lifelong health. All such diets already suggest limiting intake of sugar, white flour and starches; Atkins did not invent this concept.

    A healthful, balanced diet offers two other distinct advantages: It is pleasurable (imagine never eating bread or pasta again!), and it’s suitable for everyone in the family. In an age of epidemic obesity and diabetes in children, a diet for adults that leaves children behind is not just silly, it’s irresponsible.

    But what about the fact that the Atkins diet did lower weight the most, while also improving cholesterol and blood pressure? Doesn’t that mean it’s healthy? If so, then cholera, cancer and chemotherapy are healthy, because they lower weight, blood cholesterol and blood pressure, too. Cocaine use causes weight loss; that scarcely makes it a good idea.

    Another noteworthy aspect of this study is the poor performance of all four diets. The Atkins group “won” by losing 10 pounds in a year on average. If their weight loss had occurred at a steady pace, that would mean a loss of about 3 ounces a week! In fact, they lost weight faster at first, and were rapidly gaining it back by year’s end. So this study reaffirms that in a modern world that makes weight gain so easy and weight loss so difficult, most of us can’t seem to make any diet work.

    Both pinto beans and jelly beans are carbohydrate, and the difference is important! Atkins was wrong to suggest that better health, or lasting weight control, could be best achieved by discarding a large and diverse nutrient category, home to some of the most nutritious of all foods. And those studying the Atkins diet are wrong if they suggest that the hallmark of a healthful diet is how fast it produces weight loss in the short term.

    This latest trial, which asked and answered the wrong question, does not change my views about how best to feed myself and my family. It should not change yours, either.

    Dr. David L. Katz is director of the Yale Prevention Research Center at the Yale University School of Medicine.

    Visit his Web site at http://www.davidkatzmd.com.

    ©New Haven Register 2007

    Hi Marjorie–

    Sounds like a major case of sour grapes to me.

    Cheers–

    MRE

  33. Wow,

    I’m such a newbie! I just recently started the Atkins/Protein Power regimen, about 4 weeks ago.

    I am over in the slightly anal camp, and I record all of my meal plans with calories, protein, and carb totals for the day. I’m wondering if anyone would like to read what a low-carber/protein life planner eats on a typical day and how the numbers play out over time.

    I’d have to learn how to set up my own blog, but does this sound like it would be useful information to anyone? I could include recipes, as well.

    Hi Rachel–

    Go for it!  Get your feet wet.  You might want to take a look at the Discussion Forum (click at the top of this page) on this website.  It has a lot of people who would be interested.

    Cheers–

    MRE