Low carbohydrate diet is vindicated
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7400.1166-h (Published 29 May 2003) Cite this as: BMJ 2003;326:1166All rapid responses
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As a practicing dietitian, I hear time and again about the the
current "bad food" of the moment. These days it's carbs, as we all know.
In my mind, we cannot blame an entire food group soley for our obesity and
diabetes epidemic. It's never that simple.
Although this was an interesting take on the debate, I could hardly
agree that the low-carb diet is vindicated. Instead, I would say that
these more recent studies do indeeed show some interesting results, but I
will still not flatly recommend a low-carb, high-protein meal plan for any
Joe Consumer who walks in the door.
In my mind, vindication will come when...
*Someone can show the LONG TERM impact (more than 1 year, at least)
of this meal plan
*Someone looks at cancer risk in people following this type of diet
*Someone can show in a large population, over time, with control
groups (perhaps an identical twin study is in order?) that it's the LOW
CARBS and not the LOW CALORIES that are causing the benefits we have seen
in the current literature
Clearly, fiber and phytochemicals play a role in our overall health
that we are only just beginning to understand. Low carb diets are very
low in these nutrients, which is a concern for me. Constipation is a very
common complaint of people following theses diets, which also concerns me.
From my limited understanding of anthropology, tubers, roots, nuts and
seeds made up the bulk of our diets and we ate meat only on occassion
since it was no easy task to kill a large animal with an arrow, spear or
rock. This goes against the low-carb philosophy of the "cave-man type"
diets.
I think we are far from being able to make sweeping conclusive
recommendations for the general population about these diets. Until we
have some more research, I think we need to continue to individualize
eating recommendations for macronutrients and calories, heavily encourage
activity, discourage highly processed foods and sitting on your bum
watching television or playing computer games. I know I will continue to
emphasize the importance of high fiber, low saturated fat diets rich in
whole grains, fresh fruits and vegetables.
Competing interests:
None declared
Competing interests: No competing interests
While the focus of "low carb" seems to be sugar, I think it is
significant that the diet nature originally intended for us did not
include any sort of grain. Our preferred food was probably meat, though
this meat was quite different in composition from the meat we consume
today, which is also(unnaturally) grain fed. Aside from the scientific
evidence, the low carbohydrate diet makes perfect sense from this point of
view.
In fact, I recently encountered a book which espouses the "Paleo"
diet. The author is a paleontologist. The book went far beyond the low
carb diet in exploring what we were intended to eat and how we have caused
ourselves problems by deviating form these foods. Particularly interesting
was the fact that Paleolithic man did not consume any additional salt.
Ketosis has been a widely debated issue with the low carb diet, but
as hunter/gatherers who often led a binge and starvation existence, it is
likely that ketosis was a frequent condition.
Competing interests:
None declared
Competing interests: No competing interests
We were astonished to hear that authors of the two diet studies
reported in the recent News extra(1) were surprised by the metabolic
effects of Dr Atkin´s diet. Due to such misleading presentation of the
results, the readers are left with impression that there is a new
breakthrough discovery.
We would like to stress that hypertriglyceridemic effects of low fat
diets has been recognized for several decades. (2) A meta-analysis of 27
trials published between 1970 and 1991 revealed that decreases in dietary
total fat, saturated fatty acids, monounsaturated (MUFA) and even
polyunsaturated (PUFA) fatty acids can lower plasma HDL-cholesterol.(3)
Although these effects may be lessened with dietary fiber and moderate
physical activity, they appear to be worse among individuals with insulin
resistance.
As reviewed by Kris-Etherton(4) adverse metabolic effects of low fat
diet do not occur with substitution of MUFA or PUFA for saturated and
trans-fatty acids. This is also the case for individuals with diabetes,
with the added benefit of better glycaemic control.
As predicted by metabolic studies, replacement of saturated fat, and
even more so trans fatty acids with either PUFA or MUFA was associated
with a larger reduction in risk of cardiovascular diseses than simple
reduction of total fat consumption.(6) With respect to weight control, a
moderate-fat diet can be as, or even more, effective that lower-fat diet.
(6)
Michal R Pijak
Consultant Rheumatologist
Department of Clinical Immunology
Institute of Preventive and Clinical Medicine
Bratislava, Slovakia, pijak@upkm.sk
Frantisek Gazdik
Senior Research Fellow
Department of Clinical Immunology
Institute of Preventive and Clinical Medicine
Bratislava, Slovakia
References
1. Hopkins Tanne J. Low carbohydrate diet is vindicated. BMJ
2003;326:1166.
2. Ahrens EH, Hirsch J, Insull W, Tsaltas TT, Blomstrand R, Peterson
ML. The influence of dietary fats on serum lipids in man. Lancet
1957;87:943-53.
3. Mensink RP, Katan MB. Effect of dietary fatty acids on serum
lipids and lipoproteins. A meta-analysis of 27 trials. Arterioscler
Thromb. 1992;12:911-9.
4. Kris-Etherton PM, Kris-Etherton PM, Binkoski AE, Zhao G, Coval SM,
Clemmer KF, et al. Dietary fat: assessing the evidence in support of a
moderate-fat diet; the benchmark based on lipoprotein metabolism. Proc
Nutr Soc 2002;61:287-98.
5. Krauss RM, Eckel RH, Howard B, Appel LJ, Daniels SR, Deckelbaum RJ
et al. AHA Dietary Guidelines: revision 2000: A statement for healthcare
professionals from the Nutrition Committee of the American Heart
Association. Circulation. 2000;102:2284-99.
Competing interests:
None declared
Competing interests: No competing interests
It rarely seems to occur to people that no animal in its natural
habitat, eating its natural food, gets overweight? It doesn't matter how
plentiful its food supply. Primitive human cultures also are remarkably
free from obesity -- and all the other diseases that are the major killers
in our society.
The only animals on this planet that suffer these diseases are
"civilised Man" and his pets.
This is highly significant.
The reason why domestic dogs, for example get obese, diabetes, heart
disease and cancers, while their wild relatives do not, is that we feed
them the wrong foods. The dog is a carnivore, but we feed it wheat in the
form of biscuits. We also feed it rice and vegetable-laden commercial dog
food, the leavings from our plates and sweets. In other words we have
turned the dog into a vegetarian. That's why the domestic dog is so
unhealthy.
We get these diseases for exactly the same reason. Any study of the
human gut shows that it is remarkably similar to that of any carnivorous
animal, and totally different from any herbivore.
Tip the food pyramid on its head and you will much closer to what
really is a healthy diet. Our bodies run on fat as a fuel much, much
better than they do on glucose.
And, by the way, the low-carb diet is not American, it was first
written about by William Banting, a Londoner, in 1863. Over a century of
epidemiology and clinical study has consistently found it to be effective
and safe. I and my family have lived on a low carbohydrate, high animal
fat diet for 41 years.
Barry Groves, PhD (Nutritional Science)
Lecturer in diabetes and obesity
Author: The Calorie Fallacy, and Eat Fat, Get Thin!
No conflict of interest
Competing interests:
None declared
Competing interests: No competing interests
The primary arguments I perceive to the low carbohydrate lifestyle
are:
1. NO long term studies and unknown possible health affects
2. Possible harm from deleting all vegetables from the diet.
The first point I would like to make is that according to the
American Government the American population is eating less fat and more
carbohydrates than they ever\r have and yet obesity and diabetes are at an
all time high. This becomes especially true in the economically
challenged where education and finances virtually dictate high
carbohydrate diet. Therefore looking at the American population of the
only long-term study available on a high carbohydrate low fat diet I could
locate, we can see that it is a dismal failure. Further, I have not been
able to locate any clinical long term studies that prove the effectiveness
of a high carbohydrate low fat diet providing long term relief from
obesity as well as favorable lipid and insulin control.
In researching these types of diets I have found several books on
metabolic typing that suggest that weight management can best be achieved
by customizing the protein/fat /carbohydrate intake to the individual
metabolism. My personal experience leads me to believe it is in this way
we can best help the obese overcome their problem.
In the mean time, it seems rather obvious that it has been proven
that the short term benefits of a low carbohydrate diet far out weigh the
definite negative health effects of obesity. As far as the perceived
dangers (perceived because so far every study has shown them to be false)
of a low carb diet can be quieted by suggesting the dieter takes a good
multi-vitamin multi-mineral supplement daily. They should also eat at
least a cup of good dark green type vegetable, cabbage or cauliflower, it
is important that they the meal includes at least a 50/50 portion of
protein. Also, suggest lean meats and fewer fats. I found you could
still lose about 1 pound a week following this simple diet plan.
Since clinical proof does not exist that a high carb low fat diet is
anymore effective than a diet where the dieter ingests proportionately
more protein and fat than carbohydrates and at the same time completely
removes all simple sugars and starches from their diet, it is my hope that
healthcare practitioners will stop the chicken little “the sky is falling
approach” when ever a patient suggests they would like to try this
approach to weight management, but simply suggest that should the patient
decide to go ahead that they present themselves quarterly for a check up
and blood work to insure they are not risking their long term health.
Competing interests:
None declared
Competing interests: No competing interests
I OFTEN REFER MY PATIENTS TO LOOKING AT THE GLYCAEMIC INDEX OF THEIR
CARBOHYDRATES.SHOULD WE NOT ADVISE ON TYPE OF CARBOHYDRATE IE LOW GI
.RATHER THAN GENERAL ADVICE TO LOWER ALL CARBOHYDRATE.
Competing interests:
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Not only do we have essential fatty acids and essential amino acids,
but we also do have essential glyconutrients. In the current Harpers
biochemistry edition we can readily find this information. The results of
abiding by an adequate intake of these three essential groups, combined
with a low carbohydrate approach has not only resulted in my improved
health, but also within my clinical practice has made standard drug
approaches obsolete.
Competing interests:
I use glyconutrients
Competing interests: No competing interests
We seem to forget basic things in the ongoing debate about the best
nutrition: there are essential amino acids and there are essential fatty
acids.But there is no such thing as an essential carbohydrate.
We also forget that the so called food pyramid is far from relying on
scientific evidence, it is but the result of fierce lobbying (read M.
Nestles wonderful book: Food Politics).
Human genome seems not to be designed for this food pyramid. We most
probably started as habitual binge eaters who suffered starvation between
the meals. Those who were able to store a lot of fat after the meals might
have been the fittest for survival. The diet was protein/fat and
fruit/vegetables. There is one more striking difference between the hunter
-gatherers and the post industrial digital generation: the first hunted,
they moved. Agricultural revolution brought us carbohydrates, the
industrial revolution brought us processed carbohydrates and
immobilisation.
Thinking this way it sounds reasonable to eat less carbohydrates but more
protein with its concomitant fat and more vegetables/fruits. And to move
much more (first by just starting to remove all these obstacles which keep
us from moving ourselves).
Competing interests:
None declared
Competing interests: No competing interests
POSITIVE EXPERIENCE WITH THE LOW CARBORATE REGIME AND THE RATIONALE
FOR IT.
RON RAAB B.Ec.
President, Insulin For Life Inc
vice-President, International Diabetes Federation
(Copyright – Ron Raab)
I was diagnosed with Type 1 diabetes in 1957 at the age of 6.
I I have had some mild background retinopathy, and do have some mild
neuropathy, including some delayed stomach emptying.
In 1998, through the many contacts I had made, I became aware of a
new approach - the low carbohydrate, low glycemic index food plan together
with much lower insulin dose and a choice of protein intake. I also
visited a diabetes center in New York that specialises in this. Its
Director (Dr. Richard Bernstein ) has had Type 1 diabetes for over 50
years. He adopted this food plan many years ago after a lot of
experimentation and he reported that his diabetes control very
significantly improved. I was also interested in this approach, as I had
observed over many years that when my carbohydrate intake was less, my
bloodsugars were improved. This further encouraged me to try this very
different food plan. I was intrigued by reports of normal HbA1c's in Dr.
Bernstein's book, news reports and internet site and the many other
similar reports.
Prior to this I did not adopt this approach because the generally
accepted and recommended regime was a high carbohydrate food plan and
there was not support or encouragement to adopt this major change.
By 1998, the low carbohydrate diet was being discussed a lot in the
USA and there was increasing discussion in the diabetes journals and at
conferences.
I experimented a lot and have reduced since July 1998 the total
amount of daily carbohydrate from about 200 gm to recently 30-50 grams,
which is all of a slowly absorbed type.
Here are some of the results:
My insulin dose has fallen by over 45%. My HbA1c has improved by 24%
to 6.3% and continues to decline. I expect this to be even more so with my
further recent reduction to 30 grams daily carbohydrate. There is much
less variation in daily blood glucose. Hypoglycemia is much less severe.
Weight has dropped from 84 kg to 74 kg; retinopathy has stabilised (my
ophthalmologist made particular note of this new trend in its
progression); blood pressure and lipids remain normal.
Hunger has decreased (insulin is an appetite stimulant and this
regime has resulted in much less insulin). There is much more motivation,
less frustration and my subjective quality of life has improved
significantly.
I do not regard this food plan as "radical" or a "fad". It should not
be confused with the extreme food plans, which are periodically
publicised. It does not need to be a “ high protein diet “.
The significantly reduced insulin dose has been a major contributor
to the reduction in hunger, and I do not feel hungry during the day;
however there is some hunger in the evening.
Lowering daily carbohydrate intake makes sense on many levels. Why eat so
much of a food type that is at the root of blood glucose instability and
which needs (much) more insulin to (try to) take care of, which in turn
creates further problems. There is no evidence supporting high
carbohydrate intake over lower intake in terms of blood glucose control,
yet this is what is being generally advocated and promoted!! Also kidney
disease seems to be subsequent to high blood glucose rather than higher
protein intake.
The greater the intake of carbohydrate, the more unpredictable is its
absorption. This means that the timing and size of the increase in blood
glucose varies as the amount of carbohydrate in the meal increases. We
also know that insulin absorption (i.e. the size and timing of the effect
of insulin in lowering blood glucose) is variable, both between different
injection sites and at different times. This variability also increases as
the quantity of insulin injected increases. It therefore follows that a
high carbohydrate (even if of a slowly absorbed type) and a high insulin
regime is a formula for more erratic and unpredictable blood glucose
profiles, compared to a low carbohydrate and appropriately matched low
insulin regime.
Delayed and variable stomach emptying (gastroparesis), due to
impaired vagus nerve function (another form of diabetic nerve disease),
further adds to variable and unpredictable blood glucoses.
The greater the carbohydrate, the greater the size of the additional
unpredictable glucose variability due to this cause as well. Delayed
stomach emptying is common in most people with “longstanding” diabetes.
Just one example of a satisfying meal that I might eat when I go out
is
-glass of nice red wine (dry of course)
-garden salad
-medium size steak or grilled or baked fish
-cooked green vegetables (no potatoes)
-coffee with small amount of milk
Totals: 12 grams carbohydrate and 120 grams protein gross.
There is a whole world of satisfying, and indeed, delicious low
carbohydrate foods and meals which are readily available or can be easily
prepared.
For me, and many others who now have close to normal blood sugars 24
hours per day, there is no other way to achieve this than with a low
carbohydrate regime.
In summary, smaller amounts of carbohydrate require smaller amounts
of insulin and this results in more predictability and less variation in
blood glucose levels.
Competing interests:
None declared
Competing interests: No competing interests
Re: What happened to moderation?
I fully agree that the answer is moderation......in all things.
However some of those things, even in moderation are potentially
problematic!! Think of a diet moderate in sunny delight, white bread,
crisps, white rice, chips, tomato sauce, burgers, fizzy pop, salted nuts,
chocolate, etc etcetc. It might be moderate in all these things but the
combination of processed 'food' and the sheer lack of essential nutrients
IS a major problem.
I have been thinking long and hard about this.. yes moderatio BUT
moderation of healthy components. And anyway what is moderation - one
girls moderation is anothers binge!
Competing interests:
None declared
Competing interests: No competing interests