Moonrise Jackson Hole (click to enlarge)
Moonrise, Jackson Hole (click to enlarge) photo by Daniel Eades

A study published in the current edition of the New England Journal of Medicine demonstrates once again that the low-carbohydrate diet is better than the low-fat diet in bringing about both weight loss and an improvement in lipid profiles. This study, as published, is not without its flaws, which we will get to in a due course. What I find amazing – or maybe I don’t – has been the press reaction.
First came the television reports (here, here and here), all of which reported the study as the Atkins diet triumphing over the low-fat diet and the beloved Mediterranean diet. TV was made for sound bites and sensationalism, so this report fits right in. Although numerous studies have shown the same superiority of the low-carb diet, the TV media seems to treat these studies in one of two ways: it ignores them or it treats them as a man-bites-dog kind of story. The print media has had a little time to reflect on the situation and is reporting the study in a different way.
Two of the primary press sources that many newspapers rely on for press releases are HealthDay and Reuters. Both of these reported this study incorrectly. The headline of the Reuters report is:

Similar weight loss on 3 different, popular diets

HealthDay weighs in with

Diet Plans Produce Similar Results

And follows up with the subtitle

Study finds Mediterranean and low-carb diets work just as well as low-fat ones

If you ever harbored illusions that the print media never lies, these two reports should cure you. And if these aren’t enough to persuade you, take a look at this dog’s breakfast of a coverage by Tara Parker Pope of the New York Times.

You can read the full-text of the actual study yourself and come to your own conclusions. And you can wonder why HealthDay and Reuters decided to run the story the way they did. Most newspapers that subscribe to these services will tend to report the study the same way. In fact, most will print the story verbatim from whichever agency they get it from. And many readers will simply glance at these headlines and figure they know the contents of the story. Or the headline will set their expectations for the story and will give them the take-home lesson.

As you can read, the study shows that the subjects in the group following the low-carb diet had a statistically significantly greater weight loss and improvement in lipid profiles as compared to those subjects following the low-fat diet and the Mediterranean diet. A number of other health parameters changed for the better with all the diets, but did not reach statistical significance between the diets.

I have a few comments to make on this study, but I want to let everyone know up front to take everything I say with a grain of salt. When it comes to reading medical studies I am severely handicapped if I have to read them online. I like to make notes, underline, and otherwise write all over the hard copies of studies that I review. I can’t do this online and so always don’t feel that I’ve really read the thing thoroughly if I read it online only. And I’m still here in Jackson Hole, where I have no access to a printer.

Having covered myself with the above caveat, I have found a couple of problems with this study. First, it would have been nice to have known the caloric intake of the subjects at the beginning of the study. Table 2 lists the caloric change from baseline from the beginning of the study, but not the actual baseline caloric intake, which makes it impossible with the data presented to tell what the actual caloric intake of the three groups were at the various points of the study. Consequently, it’s impossible to tell if the weight-loss changes came about simply because those on the low-carb arm consumed fewer calories or if something else is a foot.

Second, I would liked to have seen the data points for all the subjects, which is pretty easy to represent in a couple of different ways. This would allow is to see if the changes came about in pretty much the same way across the group of subjects or if it came about because there was a large weight loss in a few subjects that skewed the averages. It’s always nice to see all the data.

Third, I haven’t a clue why the researchers who ran this study decided to encourage those on the low-carb arm to

choose vegetarian sources of fat and protein and to avoid trans fat.

Say what? The avoiding trans fat I can understand, but if it’s the Atkins diet (or Protein Power, for that matter) that’s being tested, why on earth would the subjects be counseled to go vegetarian for their fat and protein? It beggars belief. One of the results of this bizarre recommendation is that the anti-low-carb-diet crowd can disavow the results of this study by claiming that the diet isn’t really an Atkins-style diet. You don’t think they would do that? Think again. Read all about it in today’s New York Times. Why didn’t the researchers just give the subjects the instruction to restrict carbs and be done with it? Your guess is as good as mine.

Finally, I can’t understand why the instructions to the low-carb group were to increase carbs to 120 grams per day after the initial two month induction. We don’t know how many carbs the subjects in this study were actually consuming because the data shows carbohydrate intake only as the percent of total energy intake, but without showing what total energy intake is. If we assume that the subjects were eating about 120 grams per day, we know that they were right on the cusp of having any advantage from the low-carbohydrate diet other than the spontaneous caloric restriction it brings about. Our bodies need about 200 grams of glucose per day for all the tissues requiring sugar for proper function. Under conditions of zero carb intake, the body replaces about 70 grams of this glucose with ketone bodies, leaving about 130 grams that the liver must produce, which it does via the process called gluconeogenesis. Consuming zero carbs puts the body into the metabolic status that drives gluconeogenesis. If we are consuming 120 grams per day of carb, as the subjects in this study apparently were, then we are riding on the edge in terms of driving gluconeogenesis. We probably are making a little sugar to bridge the gap, but probably aren’t in the metabolic status most of the day that gives the low-carb diet its real advantage. It’s interesting to note that the data from this study show that only about 8 percent of those in the low-carb diet arm were spilling ketones in their urine, which leads me to believe that most were probably not gaining the full metabolic advantage that a low-carb diet offers.

Despite the instruction to increase carbs to 120 grams per day, I believe these subjects had a long-term benefit from the two months of rigid low-carb dieting (20 grams per day) with which they started the study. Why do I believe that? There is a terrific study in Nutrition & Metabolism showing that subjects with diabetes who underwent a strictly supervised low-carb diet for six months, and who lost weight, improved blood sugar control and lipid parameters, were still showing the positive effects of this intervention 44 months later. These impressive findings seem to indicate that there is some sort of rejuvenation that takes place in people after they have spent a period of time on an honest-to-God low-carb diet that carries over for several years. Maybe this is the phenomenon we’re seeing in the subjects in this NEJM study. The two months of rigid low-carb carries over for the rest of the study despite the subjects cranking their carbs up to non-low-carb levels.

It’s really too bad that the researchers didn’t check all the lab parameters and measure weight loss after the two month induction period. And it’s too bad they made the silly recommendation to go vegetarian low-carb. And it’s too bad they encouraged the subjects in the low-carb arm to increase their carbs to 120 grams per day. But despite all these missteps, the low-carb dieters were still triumphant over the other diets. It just goes to show what a powerful metabolic strategy restricting carbs is.


  1. Thanks for your review Dr. Eades. I too read the study online and I was hoping to see a bit more information as well. I wanted to see the actual diet recommendations in the appendix to get details on what the particiants were consuming. Perhaps a sample menu? I could not find details in the appendix.
    I found it interesting that the females in the study seemed to do best on the Mediterranean style diet. Perhaps this was due to the small sample size but I am interested in your thoughts on this?
    It’s really difficult to completely parse this study without the data that isn’t there. I wish I could, but it would be a guess.

  2. I’ve been trying to figure out the recommendation to choose vegetarian fats and proteins, too. One possible reason I came up with is because the study was done at an Israeli nuclear research facility. Maybe the participants have certain dietary restrictions for religious reasons, but they wanted to test the diets using the same fat/protein/carb breakdowns.
    I thought of this, too. But I’m pretty familiar with the dietary restrictions that observant Jews follow, and I can’t see how going vegetarian would be in conflict. If there were many observant Jews in this study, one would think that a Kosher kitchen would be available to them. I can understand the admonition about avoiding trans fats because during meat meals many Jewish people use margarine and other trans fat-laden dairy substitutes in an effort to avoid dairy. But I don’t see why there would be a recommendation for other vegetarian fats and proteins.

  3. One of the things I noted was that protein intake declined, at every point measured, in the low-carb group, from their baseline intake. I don’t recall seeing that in any other study trying to advise (sometimes poorly) a low-carb diet – if it doesn’t increase slightly, it usually stays similar to baseline intake.
    Also, the fiber content of the low-carb diet declined over time, from the level of intake at baseline. To me that says a lot without saying it – if they subjects were increasing carbohydrate with quality carbohydrates, such as nuts, seeds or beans, they’d be increasing their fiber intake with their carb intake – it would not be declining over time! What were they eating to increase carbs, white bread…candy?
    Hey Regina–
    Interesting question. It would be nice if we could see more of the data.

  4. Perhaps the vegetarian bias might be due to a concern with regard to level of saturated fat intake. i can only guess that the level of saturated fat intake in foods such as eggs,milk, and some fish if eaten, would be less than in a diet heavily meat oriented. Would a vegetarian oriented low carb diet provide better results than a meat oriented diet?
    Based on my experience, a meat-based low-carb diet would perform much better than a vegetarian-oriented one.

  5. Dr. Mike,
    From what I’ve read, the NEJM is the “big daddy” of medical journals and it’s a pretty big deal that this study was published in it. Is this the type of thing that could snowball into more funding for low-carb research?
    It might be. I hope so. There have been several major articles published in the NEJM over the past few years showing the superiority of the low-carb diet, but it doesn’t seem to have mattered a whole lot.

  6. “the main sources of added fat were 30 to 45 g of olive oil and a handful of nuts (five to seven nuts, <20 g) per day.”
    Hmm, is this some new form of torture or is the paper simply averaging the weekly/monthly intake into a ridiculous daily figure? Who on earth is willing/able to eat only 5 nuts a day?!?

  7. How could a low-card diet be ever vegetarian?. Protein in vegetarian stuff is always mixed up with carbs in ratio 1:1 in nuts to 1:8 in wheat and 1:24 in rice.
    So if you limit yourself to 20 g carb and eat only nuts, you get just 20 g of protein.
    Does vegetarian include egg, fish, chicken?

  8. From
    “Go lean with protein. Choose low-fat or lean meats and poultry. Vary your protein routine–choose more fish, beans,peas, nuts, and seeds.”
    Perhaps study designers thought that to “choose vegetarian sources of fat and protein” was even a step better.

  9. Dean Ornish about the study:
    What do you think about his following statement?
    “There is often a simplistic view that HDL is good, so that anything that raises HDL is good for you, and anything that lowers it is bad for you. Nothing could be farther from the truth.
    Your body makes HDL to remove excessive cholesterol from your blood and tissues, a process known as “reverse cholesterol transport.” Think of HDL as the garbage trucks of your body. HDL transports cholesterol back to your liver where it is metabolized and removed from your body.”
    He regards the view as simplistic because his own diet lowers HDL. Take a look at this post I did on the subject a while back.

  10. Noticed a report on MSN stating that Brazil is developing a low fat low sodium beef. Excuse me, but the best thing about the low carb way of life is the delicious beef fat. And sodium is not the culprit, it is the carbs. Whatever! Obviously they haven’t been paying attention to your and Gary Taubes and others who make it abundently clear that saturated fat is not the issue. Keep up the good work and Jackson Hole looks really beautiful in the moonlight.

  11. Hi Dr.,
    Thanks for including pix of the view — a nice treat.
    In my local paper, they had a throwaway quote from a ‘former president’ of the Heart Association, or something like that, who, despite the science, recommended against low carb because consuming fat ‘must be bad for you.’ Pretty amazing, not only the quote, but why the reporter wouldn’t ask the obvious: since the study proves the exact opposite, maybe your reasoning is defective? The second thing I found, on the way to reading the actual study, was Dean Ornish’s indictment of the study in Newsweek. What a halfwit! He sets up a strawman, then knocks it down. His ‘beef’ is that the ‘low fat’ diet is not really a low fat diet. It is the American Heart Association recommended diet, not his recommended diet and, therefore, he finds the whole study flawed. What an ego! The study was very clear that it used the AHA diet as the low fat version. He also insults the N.E. Journal and the authors by suggesting bias because the study was funded, in part, by the Atkins Foundation. I don’t suppose his own obvious conflict of interest could impeach his own conclusions?
    I was very grateful to read this study, because it deals in a pretty comprehensive fashion weight loss, cholesterol issues and insulin/glucose in the three diets, and even covers liver issues in a manner which is completely beyond my understanding. Hopefully, in time, someone will translate this a little better for the masses.
    Finally, I read, today, that a vaccine which was used to try to halt/reverse Alzheimers found that it did not improve the disease despite the fact that it did, in fact, remove the plaques or whatever gooey mess was in the brain — the point being that part of the conventional wisdom of what ’causes’ Alzheimers is proven to be wrong. If, in the world of dieting, more of the conventional wisdom can be discarded, we may actually make some progress, and the new study is one more, or less (depending on your point of view) brick in the wall.
    Thanks again for all you do!
    You can read an old post of mine here about Ornish’s idiotic ramblings when a study doesn’t go to suit him.

  12. Hey Doc,
    why don’t they do the diet right 20 to 30 grams starting out to get that insulin down than they will really see results or is that what there afraid of? they would freak on DR Jan Kwasniewski’s diet the optimal diet 80 % saturated fat have you ever heard of him or his work?
    thanks bill
    I have heard of him and have read a lot of his writings, which I enjoyed a lot.

  13. The good news about people’s resistance to accepting the truth, and even to the flaws in the study, is that it will ultimately lead to even more studies, longer studies, better studies, that keep right on proving what we’ve known for so long. And we get the free entertainment of watching them all be baffled, LOL!

  14. Dean Ornish comments on the study here:
    Of course the low-fat diet in the study wasn’t truly low-fat by his standards. He also trots out the worn out phrase “physiologically impossible”, which seems to be used quite often by the anti-low-carb types.
    More on Ornish’s excuses here.

  15. Dear Dr Eades,
    The UK press seems to have reported this study differently from the US press:
    The UK Daily Telegraph headline was “Low fat diets ‘not as effective for weight loss’:”
    and the Daily Mail: “The controversial Atkins diet is ‘safe and far more effective than a low-fat one’, study shows”:
    Thought you might be interested in the difference !

    I am interested. Thanks. Maybe the print press in the UK doesn’t have the same anti-low-carb bias that it does over here.

  16. Once you get the article in print in front of you, Table 2 will be very, very interesting to descramble. It has curiously incorporated two sets of data in a way that I love and hate in Harvard studies (The love part comes from listing the actual raw data and the hate part comes in screwing it up into almost inedible form). Namely, percentages point to food eaten while calories and grammes point to changes to the baseline.
    However, combining the two parts of the Table 2 with two otherfacts (one: that all groups ate similar amounts oc calories and two: that the aim was 1800 calories for most of the people included into the study) you get this weird “Atkins”:
    – Carbohydrates consumed: about 40% of calories or 180g (at 6, 12 and 24 months)
    – Protein: about 20% of calories pr 90g (at 6, 12 and 24 months)
    – Fat: about 40% of calories (at 6, 12 and 24 months)
    * I would neve call a diet with 40 E% from carbohydrates as Atkins – or even low-carb.
    But even this small change appear to have made quite a difference here 🙂
    Meat and animal fat:
    – Tn “Atkins” group there was an increase in both saturated fat and in cholesterol, although both protein and fat consumption themselves decreased from the base line.
    * So, it does not appear to be very veggie based diet after all 🙂
    With regards
    Thanks for the effort. I can’t wait to get back and get a print copy of this thing in my hands. I sort of figured it out the way you did, but I took them at their word that the Atkins group consumed 120 gram of carb per day. If the Atkins group actually ate 180 grams per day, then the change truly was small.

  17. Does anyone have any idea why the Mediterranean diet in this study was more effective in stabilizing blood sugar?

  18. NBC also had a couple of minutes of coverage with their resident MD (Dr. Snyderman I think). Similar to Ornish, she mentioned that the main flaw of the study was that it wasn’t ‘low-fat’ enough and the the funding came from the Atkins Center. Well, yes the Atkins Center contributed partly but there are two other big contributors as well, none of them associated to the Atkins Center. Then the low-fat part, yet the researchers are using what the American Heart Association recommends as a low-fat diet. She failed to see the actual flaws in the low-carb arm. At first I thought that when she said ‘Atkins-like’ diet, she actually realized the flaw on the low-carb arm of the study. Maybe she did but in the end decided to talk about how not so low-fat the study was and where the funding came from, completely missing the point.
    What I really like of this study, even though is flawed, is that even doing a poorly structure low-carb diet, these individuals stood to gain a lot more than following a low-fat diet. That alone should entice people to at least try to do it.

    I agree, Gabe. Even a poorly structured low-carb diet beats a well-structured low-fat diet.

  19. What bothers me about this study (as a diabetes educator), is the reporting that the LC diet did not fair best for morning blood sugars. Question: is it possible that because the LC group happened to have the most diabetics in it [see table 1, 19% in the LC group, vs 12% in the low fat group], so it skewed the results?
    They also fail to mention, for which group they had to intervene with diabetes medication, they write that a few people has to get medication to control blood sugars, but they don’t list for which group it was needed.
    I think the reason they asked them to reduce saturated fat, is because they wanted to show improvement in the LDL/HDL ratio. Would they used the “Eades” Trigs/HDL ratio they wouldn’t have bothered. Since they do not know this, if Saturated fat would have been unlimited, they wouldn’t have reported on the improvement of the LDL/HDL ratio.
    Rabbi Hirsch Meisels
    Jewish Friends With Diabetes International
    I agree. This study leaves a lot of questions unanswered.

  20. Over here in the Philippines, here is what the Philippine Daily Inquirer printed…
    Low-carb diet proven best for weight control
    Philippine Daily Inquirer
    First Posted 06:50:00 07/18/2008
    ATLANTA—The Atkins diet may have proven itself after all: A low-carb diet and a Mediterranean-style regimen helped people lose more weight than a traditional low-fat diet in one of the longest and largest studies to compare the dueling weight-loss techniques.
    A bigger surprise: The low-carb diet improved cholesterol more than the other two approaches. Some critics had predicted the opposite.
    The study is remarkable not only because it lasted two years, much longer than most, but also because of the huge proportion of people who stuck with the diets—85 percent. More than 82 percent of the dieters were men, with an average starting weight of just over 90 kilograms (200 pounds).
    Hmmm. Maybe I should start getting my nutritional news from the Philippines press.

  21. I liked one part: “Diabetes Free”.
    Two subjects out of 10 got their A1C to below 5 and a fasting sugar of 94, if my conversion is right. Not bad considering they started with A1C of 8.

  22. the ornish and esselstyn crowd base their diet on the fact that they say that in the Framingham heart study no one with a cholesterol under 150 had a heart attack and therefore HDL does not matter.
    Is that true? Similarly can you say that no one regardless of LDL levels has been known to have a heart attack if the HDL is above a certain level ? Is it possible both are right?
    If one or the other is easier to achieve then it would seem that would be the way you would want to structure your diet.
    The Japanese have the lowest incident of heart disease: would you characterize the diet as low fat, or low carb, or possibly both?
    There is a book out called the Blue Zone that analyzes the diets of people from various parts of the globe. There is an absence of disease which the author attributes to a vegetarian diet. All confusing i must say.
    Many people with low LDLs (even under 150) have had heart attacks. People with elevated HDL levels have had heart attacks. There is no absolute correlation between lipids and heart disease – that’s why it’s called the lipid hypothesis and not the lipid fact.
    The Japanese are becoming a more diverse society. There are rural Japanese and urban Japanese. As far as I can tell, there is no defined Japanese diet, so it’s impossible to know if it’s low-carb, low-fat, etc.

  23. @Anne,
    UK (and US) reporting far better than Aussie reporting: NONE AT ALL. Looks like His Holiness the Pope has pushed all this stuff off the front, middle and back pages.
    Must go, as the Mrs and I have to get to the Opera House for a Don Giovanni matinee. A nude shower scene is promised (unfortunately it’s a guy, but Angela will enjoy it). Also, the Harbour Bridge is closed for the whole day as Pilgrims are crossing it on foot and we’ll have to get there in a ferry. What a life!
    Michael Richards
    Enjoy the Commendatore scene for me. It’s one of my favorites.

  24. As a former newspaper-man, I can tell you more people saw the AP article than any other and AP seems to have reported it clearly by giving low-carb its due. It was featured in the top left corner all day on MSNBC the day it was released.
    “Low-carb beats low-fat in diet duel”
    “Those eating fewer carbs also had lower cholesterol, surprising study finds”
    Sure, some reporters butchered the truth and the study seemed flawed in odd ways with the “vegetarian” suggestion, but I see it as a positive development, especially since it appeared in the New England Journal of Medicine and got top billing on the front page of probably the most visited news website in the US.
    The fact it irritated Dean Ornish is further proof of the study’s success.
    Thanks for the info. I hope you’re right. Love to see Ornish annoyed.

  25. The whole “vegetarian sources of protein and fat” thing just pisses me off, as does the recommendation to ramp up carbs to 120 grams a day — if they’re going to do those sorts of things, could they please, please not call it the Atkins Diet? I’ve read Atkins’s stuff, and nowhere did he recommend choosing vegetable protein and fat over animal, and his recommendations for increasing carbohydrate intake were very clear and geared to individualization — adding back carb in 5-gram–per-day increments till you were just barely in ketosis for Ongoing Weight Loss, then adding just enough more to get out of ketosis for maintenance.
    It just bothers the hell out of me that every research jerk wants to call his or her stupid version of “low carb” “the Atkins diet” when it patently is not. Bob Atkins is a hero of mine, and it angers me to see his work abused this way.

  26. Oh, and forgot to say: I saw it reported that the reason given for recommending vegetable proteins and fats was to minimize trans fats. Huh? Steak is not a source of trans fats. Cutting out commercial baked goods and deep fried stuff — you know, carby garbage — automatically eliminates most trans fats. Just nonsensical.

  27. Hmmm I totally missed that carbs were increased to 120 g after 2 months! I read the part where it said carbs were “gradually increased to maintain weight loss”… but I took that to mean when the study terminated (after all, the participants were still losing weight throughout the study right?)
    Now that I know they were eating 120 g carb/day, I’m even MORE amazed at the awesomeness of low carb.
    If diets were a children’s soccer team, low carb would be that goalie who had a growth spurt before everyone else, towering over the other children as they desperately try to compete, LOL.
    Even when handicapped, low carb still wins.

  28. I like how Ornish uses an old picture of himself, probably from his college yearbook, which has little resemblance to his unhealthy appearance in recent photos. Take his debate with Taubes on the Charlie Rose show (guest hosted by Dr. Oz). I’d say Taubes won the debate hands down just because he looked healthier than Ornish and the clueless woman from the AHA. Gary tore apart their flimsy arguments like tissue paper. If more people saw what Ornish really looks like, they’d be even less likely to follow his deficient and stifling diet.

  29. Re the reason for the plant fat bias, my guess would be the IRB made them do it. No way in hell that a U.S. IRB having been indoctrinated by the media re animal fat=deadly would permit an intervention that OVERTLY said “please go ahead and eat animal fat”. Presumably Israeli conducted clinical trials research would be governed by an IRB like we have in the West…
    I would assume that Israel has the same IRB requirements that we do.

  30. I absolutely detest news report summaries of studies.
    The participants were “moderately obese”, 82% of them were men, and yet the average weight was 200 pounds ? I can’t imagine that all of the participants were actually moderately obese. Overweight, OK, mildly obese, fine, but moderately obese ? I don’t think it’s mathematically possible. 🙂
    Also, the low-fat and Mediterranean the diets were calorie restricted … 1500 calories per day for a woman and 1800 for men. Those limits would result in FAR greater weight loss than just 12 pounds in two years ! Remember, the participants are allegedly “moderately obese”. The caloric requirements to maintain their heavy weights are surely quite high, so 1500 or 1800 cals would create quite the deficits. Clearly the people on these diets cheated, and they must have cheated quite a bit. If they hadn’t cheated they would have lost far more weight than that low carb group. Yes, I realize that part of dieting is learning to maintain, but the study should have allowed all three groups unlimited calories. I’ll bet the calorie-restricted groups suffered cravings and binged because of the low caloric intake. Had they been allowed to eat more and yet stick to the diet principles, I’ll bet they would have lost more weight. Poor design study.
    Btw, the Reuters article doesn’t say that the low-carb diet was actually an Atkins diet, it says that it was based on Atkins in the sense that it “does not limit calories but reduces intake of processed carbohydrates.”

  31. Hello all: I agree that high-protein diets are the way to go for total health. Capitalist doctors tell us that we should consume a low fat high carb diet (What a nonsense), low fat and high-starchy carbohydrate diets lead to weight-gain. Most US supermarkets are full of starchy-carbohydrates foods like cakes, breads, bakery foods, this is like a terrorism of food, terrorizing our life. An excess of carbohydrates is killing America. This country needs a low-carb-revolution. A radical, extreme change in supermarkets, i know that a lot of corporations will lose, like cake, bread and cookie makers, etc. But changes are not easy, but we must change the way we eat.
    It’s strange that the more capitalist a society is, the more meat that society eats. As societies drift toward socialism it appears that they drift towards a low-fat diet as well. Just my observation.

  32. Dr. Mike,
    Do you think leptin has any substantive role in keeping the hunger down or signaling satiety in either a low-fat or low-carb diet?
    Not really in the short run. Leptin is more of a long-run modulator of energy intake. I’ve seen a few studies showing that leptin drops a little more quickly on a low-carb diet, but then seems to rise more quickly, which would mean that it would suppress hunger a little more over the long run. But these studies are far from definitive.

  33. I mostly avoid solid fats (animal fat, butter), but refuse hydrogenated fats (margarine, crisco). I’m still confused about coconut oil.
    So as long as my proteins don’t have huge amounts of solid fats, I’ll eat them as is, or trim off the enormous globs. Um, well I’m weak with bacon LOL
    But I’ve been watching my starches (high-glycemic carbs) even more. Basically I try to eat lean’ish meats or beans (pinto because they have low insoluble and high soluble fibers for IBS sufferer, and supposedly red meats trigger IBS more, so mostly poultry and eggs for meat proteins). Olive and sesame oils are used a lot here. And lots of low-glycemic carb veggies — my reasoning is because IBS sufferers need to take in soluble fibers on an empty stomach to buffer insoluble fibers (and red meat?), so many of the foods containing mostly solubles have high glycemic indexes, so veggies that are low-glycemic AND low insolubles are what I’m still looking for.
    The IBS site I found recommends finely-diced or pureed insolubles (mixed with solubles), so it seems to me that nut butters would also be ok, but I’m going to have to search it on the site to be certain (mmmm tahini).
    PS: the sunset photo at the beginning of the post is 1.7mb, wow!

  34. Hi Dr Mike,
    Unfortunately the Commendatore didn’t make a reappearance. Instead he becomes this disembodied voice that moves around the auditorium. The Don gets kind of sucked into this giant digital watch display and disappears. (Or in the immortal words of my wife: “The Tardis* got him!”) Also, this was the Prague version, so no “Il mio tesoro” or final sextet. The Leporello was magnificent and his Catelogue Aria was a treat. A nice touch: Don Giovanni defaces the Comendatore’s Hi Tech monument with a spray can!
    Michae Richards
    * Dr Who’s space craft.
    Hey Michael–
    It sounds like a little too high-tech for my Don Giovanni taste. And sounds kind of weird to boot. Although it’s kind of hard to imagine a bad Don Giovanni.
    Glad you enjoyed it.

  35. I have an off topic question, but the post that inspired it is closed. I read your entire blog including the comments (OK I skipped some of the travel posts) so I pretty sure you haven’t posted on this somewhere (I imaging it gets old having people repeatedly ask questions you’ve already answered when a little research would show them you have already posted on that subject – I know I get tired of seeing it and its not my blog!). Anyway your post on inflammation putting a load on the body got me wondering. I have a foot fungus in my toe nails that I can’t get rid of through topical treatments. I’m not too worried about it because I assume its just a cosmetic issue – looks terrible nails are thick. Is there any chance that this is more of a problem than that? That its putting some kind of load on my body? Do the internal drugs that would treat it destroy the friendly flora in the intestines? I’ve heard that you need to have your liver tested while you are on those drugs – does this mean they can damage the liver? I don’t want medical advice (I understand that you can’t give that over the internet) just a general discussion if you don’t mind.
    First, I’m not an expert on subungual fungal infections although I have treated my share of them. I suspect they do put a little inflammatory load on the body, but not as much as a bacterial infection lurking away somewhere, i.e., periodontal disease. It’s been my experience that these fungal infections respond pretty well to oral anti-fungals. It takes a little while, but the fungus dies, and the nails ultimately return to normal. Some of the oral anti-fungals can have some liver toxicity, but I’ve never seen it occur in any patients of mine. The liver tests are just to be on the safe side. If the tests show a problem, stopping the drug usually solves it.

  36. Hi Dr. Mike,
    Not really a comment on this particular blog entry, but I don’t know how to email you.
    My uncle is a doctor and we were talking about the study and l.c. dieting in general, and he explained insulin resistance in terms of muscle cells, not fat cells. He also talked about excess fat (in the blood) being stored in fat tissue, which I understood to be incorrect — it is glucose that gets stored. However, what I am interested in is this idea of insulin resistance as it pertains to muscle cells, vs. fat cells. Following is a text grab from a site, cited below:
    In conclusion, it is clear that an increase in fatty acids
    within the muscle cells often leads to insulin resistance.
    Thus overexpression of lipoprotein lipase, either in liver
    or in muscle, led to tissue-specific insulin resistance [34].
    It should however be observed that a high level of
    triglyceride (triacylglycerol) inmuscle is not always linked to
    insulin resistance. Indeed, exercise training increases muscle
    triglyceride content but ameliorates insulin sensitivity as well
    as the capacity for fatty acid oxidation. These observations
    point to the importance of relating muscle triglyceride
    content with the capacity of the muscle for fatty acid
    metabolism. Thus a high level of muscle triglyceride may not
    affect insulin sensitivity if the muscles have the capacity for
    efficient lipid utilization. Along this line, mice lacking acetyl-
    CoA carboxylase 2, which show increased oxidation of fatty
    acids inmuscles, have a reduced fat accumulation and storage,
    despite an increase in their food intake [35]. In contrast,
    the inability or failure to periodically deplete triglyceride
    in muscle, as is likely to occur in sedentary individuals,
    is associated with insulin resistance. Studies with different
    models of knockout mice suggest that a correct partitioning
    of fuel substrates is required for the maintenance of insulin
    sensitivity [36].
    It comes from:
    I guess what I question is whether you have some thoughts on this and whether, if there is this insulin resistance issue with muscle cells, if it is an either/or or if these both apply. The key point he made, which I don’t think is inconsistent with anything in low carb theory, is that exercise will use up the fat/fatty acids or whatever, in the muscle cells, thus decreasing the muscle cell resistance, which will be a good thing. He seems to think that that lets the muscles take the fat (glucose?), which keeps it out of the fat cells.
    All a bit confusing to me, but I would appreciate it if you could clarify, or keep in mind for future post.
    All kinds of cells can be insulin resistant. Liver cells can be insulin resistant; fat cells can be insulin resistant; and muscle cells can be insulin resistant. Since muscle is the largest organ (it’s not really an organ, but let’s pretend) in the body, it can consume the most glucose. If muscle cells are insulin resistant, then that resistance can be pretty large in terms of the overall degree of insulin resistance simply because there is so much muscle. And it is true that fat within the muscle is associated with insulin resistance in those cells. Exercise will use up the fat within the muscle, but so will a low-carb diet. As insulin falls – as it does on a low-carb diet – the malonyl CoA (made from the acetyl CoA carboxylase (the enzyme mentioned in the text you pasted)) level drops allowing the fat to move into the mitochondria for oxidation. As the fat gets burned there is less in the muscle to cause insulin resistance. It’s a little more complex than this, but you get the picture. Maybe worth a longer post sometime. I’ll keep it in mind.

  37. The MSNBC article had this little bit thrown in…
    “CAVEATS: Experts say the low-fat diet in the experiment allowed more fat than the American Heart Association recommends.”
    So I guess the low-fat dieters would have fared even worse if they had followed the AHA guidelines.

  38. I found this most un-remarkable…
    “among the 272 participants who completed the intervention, the mean weight losses were 3.3 kg[LF], 4.6 kg [Med], and 5.5 kg [LC}, respectively.”
    Over 2 years! Come on…this is hardly news worthy or even worth the trouble of dieting in this way. There is some small advantage to LC for improving blood profiles and there may be some if they focused on the blood sugar levels, etc. of diabetics. Over the long term it looks like the three performed about the same.
    It seems unremarkable, but it’s a statistically significant difference. When you get a large number of subjects in a study such as this one, many of them don’t lose much and bring down the average for the group. The results in these types of studies are not as high as you would like to see, but given the numbers of subjects involved, the differences are meaningful.

  39. Am I missing something here? The participants in this study were all obese (mean starting weight just over 200lbs), were mostly men and were all able to follow the dietary guidelines they were given (which included, in the cases of the “low fat” and “Mediterranean” diets, restricting their calorie intake to 1800 per day – or 1500 for the women who took part) for TWO WHOLE YEARS. And we are supposed to get excited about this study’s results: namely, that the MEAN decrease in BMI for these people was 1 point on the “low fat” diet compared to a massive 1.5 points for the Mediterranean and “low carb” diets? There may be statistical significance here but I can’t help thinking that for the researchers and the participants it was all rather a waste of two years.

  40. In Germany’s Tagesspiegel, they reported Atkins and Med as being equal to, “maybe even better than!” low-fat, with the reporter giving the edge to the Med diet.;art7761,2575164
    He states that low-fat and Med women were limited to 1500 calories, whereas the men got 1800. The Atkins people (and I say ‘Atkins’ because a different article said they were limited to 20g carbs/day) were not restricted in calories.
    Did everyone read the same study?

  41. Here’s a link to Fox News reporting on this. They interview a spokesperson from who says the study was a “suprise” since the low carb diet won. Then she offers the all too predictable warning against “evil saturated fats,” and says you should eat “good fats” if you go low carb. Still though…all-in-all I’m pleased to see this kind of exposure for the low carb lifestyle.

  42. To LeenaS et al with regards to “vegetarian atkins”:
    Regina Wilshire pretty much has it:
    I received an email today from a friend who asked one of the researchers about the reference to plant-based (vegetable) fats and proteins. Dr. Shai assured him that the low carbohydrate group was not advised to consume a vegetarian low-carb diet, nor were they specifically restricted from eggs, cheese, red meat, poultry or fish. Due to dietary restriction (religious) the group would not, for instance have a cheeseburger or butter on top of their steak. Olive oil featured prominently. The participants did read the Atkins diet book. And the examples provided of the types of meals was “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, notlettuce) with olive oil dressing.”
    I read somewhere else that the emailer in question is Dr Eric Westman, but I cannot relocate the exchange right now. Suffice it to say that the Israeli low-carbers got lots of animal fat and protein. Only the question remains: Why does the study claim to have urges the low-carb group to eat vegetarian stuff?

  43. Here is a more detailed account of the Westman/Shai correspondance:
    Eric Westman:
    In reponse to the queries about what was eaten on the “low-carb” arm of
    the study published this week in NEJM, I asked Dr. Shai to clarify what
    kind of foods were eaten, because the sentence in the methods section
    (page 231), “participants were counseled to choose vegetarian sources of
    fat and protein,” has been interpreted to mean that this was a
    “vegetarian low-carb diet.”
    “Hello Eric,
    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 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.
    Best regards, Iris [Shai]”
    This from
    Maybe someone with Westman access could verify this, so a lid could be put on the discussion?
    I have Westman access and the response is verified.

  44. Dear Dr. Eades;
    Sorry for sending this through here, as I’m just not sure you received my previous email. I truly understand if you can’t respond to all messages, but I’m just trying to make sure you received it at all.
    The question in reference was about translating your book.
    Rabbi Hirsch Meisels
    Jewish Friends With Diabetes International
    I didn’t see it, but I asked my wife, who goes through all the emails we get, and she said she remembered seeing it. She (and we) are woefully behind in all our correspondence.
    But it probably won’t be possible for you to do a translation because the book publisher owns all the rights to all languages. Protein Power is already translated into Hebrew and is sold in Israel. The others haven’t been. When an entity – typically a foreign publisher – wants to translate one of our books, that entity contacts our publisher and arranges to pay an advance to the publisher for the rights to translate and sell in that language. We don’t have the ability or the legal right to make those decisions; only our publisher does.

  45. what’s the name of the book in Hebrew? do you have a link where I can buy it?
    I can’t read the name of the book because it is in Hebrew, and I can’t read Hebrew. I assume it’s the Hebrew for Protein Power, but it’s in three words.
    The book is published by:
    Triwaks Enterprises / Matar Publishing House
    P.O. Box 17467
    Tel-Aviv 61774
    Maybe you could contact these people to get more information.

  46. I went on the Atkins diet 6 years ago and lost 200 pounds. I have remained on a low carb diet regimen and exercise program and have maintained my weight ever since. I feel so much better when I stay low carb. I have known that this diet worked. I find it funny that the “experts” are just realizing that it works. If you will recall, the Stillman Water diet of the early 70’s was also a low carb diet and many people lost a lot of weight on it. The biggest complaint that I have heard is that people will gain their weight back after going off the diet. Well, duh.
    Duh, indeed!

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