« February 2006 | Main | April 2006 »
March 23, 2006
Low-carb diet takes one below the belt
There's a hold up in the Bronx, Brooklyn's broken out in fights. There's a traffic jam in Harlem that's backed up to Jackson Heights. There's a scout troop short a child, Kruschev's due at Idlewild! Car 54 where are you?
Anyone who watched TV in the early sixties no doubt remembers the hilarious show Car 54 Where Are You? starring Fred Gwynne and Joe E. Ross as New York uniformed police officers Francis Muldoon and Gunther Toody. Muldoon and Toody were well meaning but hopelessly inept, always screwing things up in outrageous fashion, causing no end of grief and embarrassment to their precinct commander Captain Block, who had to sort out the idiocy and try to make things right.
Now comes the medical equivalent of Muldoon and Toody in the persons of in-training physicians Tsuh-Yin Chen, M.D. and William T. Smith, M.D. The role of precinct commander in this production is played by one Klaus-Dieter Lessnau, M.D., who, unlike Captain Block, only adds to the problem with another layer of ignorance and stupidity. And whereas Car 54 Where Are You? left its viewers with their sides hurting from laughter, the repercussions of our medical drama will be felt painfully in the world of nutrition for years to come. A well-respected medical journal will have a blot on its record in much the same way CBS did after rushing to air the discredited George Bush Air National Guard story before it was authenticated, and, lastly, the whole episode will serve as a cautionary tale to anyone considering going to the emergency room of a teaching hospital.
Our drama unfolds not on the TV screen but in the emergency room of Lenox Hill Hospital in New York. The script for this show is contained in an article in the current issue of The Lancet entitled "A life threatening complication of Atkins diet." Let's tune in.
First, a brief synopsis of what happened--a treatment as they say in Hollywood--then we'll review the case in more detail to see what really happened.
An obese woman who had been on the Atkins diet for the previous month came to the emergency room complaining of shortness of breath. The resident physicians who saw her found evidence of elevated ketone bodies in her blood, diagnosed her with ketoacidosis, admitted her to the intensive care unit, gave her IV fluids, tested and x-rayed everything, and discharged her four days later after a complete recovery. The resident physicians along with their attending physicians wrote this case up as an example of what could happen to someone following a low-carb diet and got it published in a prestigious British medical journal, accompanied with an editorial issuing a further warning as to the risks of low-carb dieting. The press was all over the story and one of the attending physicians issued statements to anyone who called.
Let's look a little deeper. This is the patient's history:
In February, 2004, we saw a 40-year-old obese white woman who complained of dyspnoea (shortness of breath). 5 days earlier, her appetite had decreased, and she had felt nauseous and had since vomited four to six times daily. She became increasingly short of breath, and presented to us as an emergency.
She had strictly followed the low-carbohydrate high-protein Atkins diet, eating meat, cheese, and salads for the previous month.
This lady was truly on the Atkins Diet:
She took vitamins recommended by the diet: chromium picolinate, Atkins Basic3 (multivitamins; Atkins Nutritionals, Inc, USA), Atkins Essential Oils (omega fatty acids), Atkins Dieters' Advantage (electrolytes and extracts), and Atkins Accel (a "thermogenic" formula). As instructed by the original Atkins diet book, she monitored her urine twice daily, with dipsticks strongly positive for ketones. She reported a weight loss of about 9 kg over this 1-month period.
Here is her presentation and the doctors' physical findings along with my commentary:
On presentation to the emergency department, our patient was in moderate distress, with a respiratory rate of 20-30 breaths per min.
'Moderate distress' breathing at a rate of 20-30 breaths per minute? I don't think so. A normal respiratory rate is between 12-20 breaths per minute, but obese people tend to breath a bit faster since they have a lot going on metabolically and need a little more oxygen. I wouldn't say that an obese person breathing 20-30 times per minute was in distress, especially in view of the rest of the physical exam, which we'll see in a moment. The resident physicians are trying to make a case for severe metabolic acidosis with this patient. If the patient truly was in severe metabolic acidosis (as type I diabetics can be if they go into ketoacidosis) she would have been demonstrating a type of breathing called Kussmaul breathing, which is characterized by rapid, deep, labored, sighing breaths familiar to anyone who has ever seen a bad case of ketoacidosis. We're this patient exhibiting Kussmaul breathing, I'm sure it would have been identified as such in the published case report.
On examination, her bowel sounds were hyperactive and she had mild epigastric tenderness. Otherwise, clinical examination was unremarkable with normal vital signs.
Okay, when the resident physicians listened to this patient's abdomen they heard more active, louder bowel sounds than normal and when they pushed on her abdomen she told them it was mildly tender. And her clinical examination was 'unremarkable' and her vital signs (blood pressure, heart rate, etc.) were normal. It doesn't sound like someone in distress to me. When patients are in distress, their heart rates and/or blood pressure readings are usually elevated.
Her body-mass index was 41.6 kg/m2.
Interestingly, the case report doesn't tell us this patient's height or weight, only her body mass index (BMI). I assumed a height of 5' 5", which, when run through the BMI calculator, gives a weight of 250 pounds.
So, let's see what we've got so far. An obese, 40 year old lady who has been nauseated and vomiting (4-6 times per day) for the past five days shows up in the emergency room. She is breathing a little faster than normal, but, given her weight, probably not by much. She doesn't appear to be in any distress and all her vital signs are normal. Her abdomen is a little tender (whose wouldn't be after vomiting for five days?) and her bowel sounds are hyperactive (think of the last time you got some kind of abdominal flu; I would be willing to bet that you could hear your own bowels gurgling without the aid of a stethoscope). Every doctor who has taken care of patients for any length of time has seen this same picture countless times. It's a diagnosis that can be practically made from across the room.
The patient has gastroenteritis, an infection (probably viral) of the gastrointestinal tract. She may be a little dehydrated if she hasn't been able to keep any fluids down, but she has probably been able to hold some fluids on her stomach or her blood pressure would be low and her heart rate rapid from the dehydration. If you're the physician taking care of this patient you might want to run a couple of other tests just to make sure, which you do and find out that her blood sugar is normal (so you know she isn't a diabetic in ketoacidosis) and her amylase is okay (so she doesn't have acute pancreatitis) and her liver enzymes are normal (so she probably isn't afflicted with hepatitis) and her white blood cell count is elevated, which goes along with an infection. You then might drip a liter of fluid into her intravenously to rehydrate her and make her feel better, give her a shot to reduce the nausea and vomiting or maybe a prescription for a suppository for the same thing, tell her to drink only clear fluids, and come back if she doesn't get any better. In virtually all cases the patient will get well.
Then as you're discussing all this with the patient, you find out that OH MY GOD, SHE'S BEEN ON THE ATKINS DIET! Now, if you're an experienced physician, you tell her to not worry about her diet for a while until she gets over her nausea and vomiting, but that once she's recovered she can return to her low-carbohydrate weight-loss efforts..
If you're Muldoon and Toody, however, you panic. Low-carb diets cause ketosis, you think. Maybe she's in ketoacidosis, which can be fatal. Since you're an idiot, you ignore her normal blood sugar level, which should tell you that she's making plenty of her own insulin. As the level of ketone bodies rises in the blood, it stimulates the release of insulin from the pancreas. The spurt of insulin then shuts down the process that makes ketones. Ketones only rise to dangerous levels in people who have type I diabetes and can't make their own insulin. If the system didn't work this way, people who starved would die from ketoacidosis relatively quickly, but they don't; they live for weeks without food before they succumb to protein malnutrition, not ketoacidosis. The idea that this patient, who had a normal (or probably an elevated) insulin level was in dangerous ketoacidosis is absurd, but Muldoon and Toody don't realize this because the patient HAS BEEN ON THE ATKINS DIET, FOR GOD'S SAKE.
In their frenzy of misdiagnosis, the panic-stricken Muldoon and Toody check the patient's blood levels of beta-hydroxybutyrate, a specific ketone body, and find it to be high. They, of course, don't bother to realize that, the Atkins diet notwithstanding, elevated levels of ketones would be expected since the patient hadn't been able to hold anything on her stomach for five days, and when people don't consume food they break down body fat for energy and produce ketones in the process. Nope, that would be way too rational. These doctors-in-training have the diagnosis of ketoadidocis burned into their brains thanks to the red herring of the Atkins diet, and they're looking for anything to confirm it. They check a bunch of other labs that don't really show anything all that earth shattering (and, in fact, don't even really compute--but that's a technical issue beyond the scope of this post) and admit the patient to the intensive care unit. Car 54 Where Are You?
In a typical teaching setting, the next morning the resident physicians would present their patient who is now resting comfortably in the intensive care unit at about $5,000 per day, and whom, in their own minds at least, they had just snatched from the jaws of impending death from ketoacidosis, to their attending physician. In a typical teaching hospital, the attending physician, who would have had a number of years of patient experience, would gently (or maybe not so gently) tell the residents that they had overreacted a little and would walk them back through the situation with a Socratic-type dialogue that would probably go something like this:
'You checked this patient's blood sugar and it was normal, right? Okay, now, what does that blood sugar tell you about the condition of the patient's pancreas? Uh huh, that's right, it's making plenty of insulin. Okay, now, if the patient is making plenty of insulin, is it really possible that she could be in life-threatening ketoacidosis? Okay, guys, let's review how ketones are made...' You get the picture. I know how these little dialogues go because I was a resident at one time and I was on the other end of a number of them. In fact, I had an attending physician in surgery, famous for his sarcasm, who, had I done something like these two had done here, would have led me through the whole Socratic-dialogue process so that I could see every misstep I made along the way, then would have shaken his head and said, "Well, Doc, which is it? Are you stupid or do you just not care?"
But that wasn't how this one must have gone there at the Lenox Hill Hospital. Instead of Captain Block gently reading Muldoon and Toody the riot act, our leader, Dr. Klaus-Dieter Lessnau, must have fallen into the OH MY GOD SHE'S BEEN ON THE ATKINS DIET trap. Instead of showing his underlings the folly of their ways, he jumped right in there with them, wallowed in their stupidity, kept this poor patient in the intensive care unit for four days, and may have even said, 'let's write a paper on it.' After the paper was published and made the news, our attending was ever so eager to bask in his 15 minutes of fame and talk to any reporter that called and further memorialized his own boneheadedness. See here, here, and here. Had members of the press possessed even a smidgen of medical knowledge or had they checked with anyone other than Dr. Lessnau himself, the many pieces appearing about this fiasco might have been entitled something along the lines of:
Buffoons misdiagnose mild gastroenteritis, costs patient thousands.
Unfortunately, however, the press, afflicted with its own pro-low-fat bias, has been more than happy to take this opportunity to lambaste low-carb diets. Car 54 Where Are You?
In a perfect world, after this idiocy had consumed both the residents and their attending physician, and was then written up and sent out to journals for publication, someone, somewhere, with good sense, doing peer review would see it, realize it for what it was, and reject it. I have no way of knowing, but I suspect from the dates involved that that is exactly what happened. These events took place over two years ago in February of 2004, and were, I'm sure, written up shortly thereafter, and shipped off to some medical journal. I seriously doubt that The Lancet was the first choice. I would imagine that these authors received a number of rejections, but kept sending the paper out. It finally fell on fertile soil with The Lancet where not only did the editors fall for this ignorance hook, line, and sinker, they saw fit to publish a supporting editorial written by a dietitian turned PhD at the University of Minnesota. Car 54 Where Are You?
The editorial goes through the following argument. Although a number of studies have shown the low-carbohydrate to be superior to the low-fat diet in oh so many ways, we've got to be concerned about dieter safety. The report by Muldoon and Toody shows what can happen to a dieter on a low-carbohydrate diet. This patient could have died. The Atkins diet (and by extension all low-carbohydrate diets) are unbalanced. If you don't believe it, compare the Atkins diet to the 2005 US Dietary Guidelines (and we all know how perfect those are). We'll even provide the table. There, you see:
Clearly, the Atkins diet is not nutritionally balanced.
And they finish off with:
Special care needs to be taken when formulating the best prescription for weight loss, because people choosing to lose weight range from being marginally to significantly overweight, and might have a wide range of disease risk factors with varying levels of severity. As researchers and clinicians, our most important criterion should be indisputable safety, and low-carbohydrate diets currently fall short of this benchmark.
So, with this paper and accompanying editorial all the low-fat zealots have gotten what they've been waiting for. For years when MD and I and Robert Atkins and Ron Rosedale and Robert Crayhon and Jonny Bowden and a host of others have extolled the virtues of the low-carbohydrate diet, all the naysayers said: Where are the studies? All your clinical experience is simply anecdotal; we want to see the science. Show us the studies.
Well, over the last three or four years these pinheads have been deluged with studies showing the superiority of the low-carb diet over the low-fat diet for not just weight-loss, but for lipid lowering, blood sugar control, and blood pressure reduction as well. In any head to head challenge, the low-fat diet hasn't been able to lay a glove on the low-carb diet.
Now that the low-fatters have been bloodied with all these studies they have been demanding for years, they haven't given up, they've only changed their strategy. Since they can't successfully argue on the merits, they're resorting to scare tactics. Sure, they'll say, you'll lose weight alright, solve your lipid problems, and all the rest, but look at that poor lady who almost died. It was written up. That could happen to you, you know.
And to think that The Lancet has been a party to this travesty is almost beyond belief until it is recalled that it was The Lancet that published the Dean Ornish I've-proved-that-my-diet-has-reversed-heart-disease paper back in 1990. Like the current paper, the 1990 Ornish paper, in my opinion, was not worthy of publication without some serious rewriting. But, it is obvious that the powers that be at The Lancet have a bias in favor of low-fat dieting. And, based on the publication of these two papers, not just a mild bias, but a totally slanted perspective. In fact, I think that the name of the journal should be changed the The Slantcet.
Car 54 Where Are You?
Posted by mreades at 11:24 PM | Comments (16)
March 22, 2006
Palm oil scare tactics
Yesterday's New York Times carried a full page ad showing a baby orangutan posed amidst a bunch of orangutan skulls. I say 'posed' because a couple of the skulls are different colored and they have etched designs on them. The title of the ad printed in giant bold letters was:
Dying for a Cookie?
The subtitle was:
Palm Oil Production is Killing Orangutans and other Endangered Wildlife
The body of the ad tells how palm oil used in products made by:
Keebler, Oreo, Mrs. Fields, Pepperidge Farm and other companies.
According to the ad, palm oil is found in:
Crackers, pastries, cereals, and microwave popcorn.
The ad goes on to describe palm oil as follows:
Though not as unhealthy as partially hydrogenated oil, palm oil still promoted heart disease.
Note that the ad doesn't say that 'palm oil may promote heart disease;' it claims that it does promote heart disease. I defy the folks responsible for this ad to show me any scientific evidence to support their claim. They make the claim because palm oil contains saturated fat, and they suppose that there is significant evidence showing that saturated fat causes heart disease. Show me.
Who paid the money for this ad? Who else but the Center for Science and the Public Interest and its leader Michael Jacobson, the Hugo Chavez of the nutritional world.
I agree that no one should be eating cookies, pastries, crackers, etc., but not for the reasons the CSPI gives. The sugars and other refined carbohydrates do much more damage than the saturated fats with which these products are made.
Remember, it was folks like the CSPI that brought the whole trans fat disaster down on our heads. These people attacked saturated fat to such an extent that food manufacturers felt they had to get rid of it in their products, so there went butter, lard, ghee, and beef tallow, which had long been used as shortening. These good, natural products were replaced with trans fats, which were polyunsaturated fats artificially hydrogenated to make them behave like saturated fats in cooking. Then comes all the scientific evidence that trans fats are truly bad, much worse, in fact, than the saturated fats they replaced were thought to be. In steps the CSPI to decry them. So, the manufacturers go to a plant product that doesn't have trans fats but contains plant-based saturated fats, and here comes the CSPI after them again.
Irrespective of whether they do or don't cause heart disease (and I'm firmly in the camp that believes they don't) saturated fats have certain cooking qualities (especially for baked goods) that can't be reproduced by anything other than trans fats. If the CSPI went on the rampage against baked goods in general, I might just join them. But count me out if all they're going after is palm oil.
And don't let the orangutan pictures fool you. The CSPI is after the saturated fat, they know the evidence isn't there to back their disease claims, so they're resorting to the worst kind of emotional blackmail to cudgel the unenlightened into submission.
Posted by mreades at 10:28 AM | Comments (8)
March 15, 2006
Protein Power Forums
The new and improved Protein Power bulletin board/ forum is up and operational. To get to it click here.
This bulletin board has been moderated and nurtured along by a group of truly dedicated and knowledgeable people who have been wonderful to work with. MD and I have been almost totally hands off, although we cruise through and post occasionally. If you're looking for a community of people who have lived low-carb and can give you support and intelligent information, head for the forum. Ditto if your looking for recipes and answers to your low-carb questions. I can't sing the praises too highly of the folks who work hard to make this forum as good as it is.
Posted by mreades at 9:23 PM | Comments (1)
March 14, 2006
Vampire Myths
A few days ago I received the following letter from a reader of the Protein Power LifePlan that I would like to share.
Dear Drs. Eades:
My wife and I are committed practitioners and advocates of your Protein Power LifePlan and have been since your initial publication in 1995. [Actually Protein Power was published in 1996, the Protein Power LifePlan in 2000] We believe that our health and appearance have been significantly improved since reversing our emphasis on carbohydrates and introducing a higher, appropriate amount of protein, good fat, while substantially lowering our overall carbohydrate intake. My overall muscle profile has radically improved, and although my wife has gained a fair amount of weight back, we believe this is simply the result of inadequate vigorous exercise at present.
We stumbled onto the attached article [a Xeroxed copy of the article was enclosed] that caused us a considerable amount of dismay and discussion. It seems, in a rough sense, diametrically to contradict the basic principles and biological/physiological rational outlined in your protein-based protocol.
Would you be kind enough to comment on the article and its claims in light of your current scientific and nutritional knowledge and understanding of the function and role of carbohydrates in the human diet? I am particularly struck by the article's assertions in light of your comment on p. 9 of The Protein Power LifePlan: ("Carbohydrates, the third macronutrient, are totally unessential to human health.")
Thank you kindly,
[Name withheld by me]
I've got to tell you, letters like this one drive me nuts. Why? Because it took MD and me about six solid months of writing (not to mention the 20 years apiece of medical practice and research so that we would know what to write) to complete the Protein Power LifePlan
Before I get into the article (which I have reproduced below or you can read online by clicking here) I want to discuss exactly how the vast majority of magazine articles and other pieces of this nature come about. Editors decide what articles they want to go in which issue of whatever magazine, including online magazines. These editors then approach free lance writers and ask them to write the articles. The editors don't call the free lancers and say, "I want a full-blown investigative piece on the pros and cons of the low-carb diet," because unless the free lancer is an investigative scientific journalist he or she won't have the background to do the job. And those kinds of jobs cost the magazine a fair amount of money, well into the thousands. Typically, editors know exactly what they want and assign it. For example, the theme of a particular issue of a magazine may be about entertaining with comfort foods, so the editor calls a free lancer and says, "We need a 2000 word article attacking low-carb diets." The free lancer, who probably gets paid a few hundred dollars for such a piece calls a couple of "experts" and gets the needed info. Since the assignment was to attack low-carb diets any positive information is ignored and the negative information is written up.
This particular article was written by Abby Christopher, a free lance writer based in Portland, Oregon. If you google Ms. Christopher you will find that she writes frequently for Wired magazine, the trade journal more or less for computer and gaming geeks, which, of course, qualifies her to write knowledgeably about nutrition. She, being in Portland, picks up the phone and calls Diane Stadler, a "research assistant professor" at the University of Oregon. Ms. Stadler is so obscure that searching the university's websites garners very little information about her. But Ms. Stadler, whom I suspect is a Registered Dietitian, is more than happy to provide Ms. Christopher with all sorts of negative information on low-carb diets.
To give her article a little bit more panache Ms. Christopher quotes none other than my good buddy Dean Ornish. And she does it in a carefully crafted way that would lead one to believe that Dr. Ornish was actually interviewed for this article, which I'm sure he wasn't. She writes:
Diet guru [I love it] Dr. Dean Ornish also worries about the effect of such diets on the kidneys. "High total protein intake, particularly animal protein," says Ornish, "may accelerate renal-function decline."
He's only said this about 50,000 times, so I'm sure she picked up the direct quote and dropped it in her piece.
This short article reminds me of a joke I once heard about a redneck that went to see Hamlet for the first time. When he came out of the theater someone asked him what he thought of the play. He replied" "Not much. It wasn't nothing but a bunch of quotes all strung together."
This article is nothing but a bunch of misleading myths about low-carb dieting all strung together. These myths have been refuted so many times in the medical literature that it defies belief that they're still hanging on. But they are. It's as if they're impossible to kill. As a consequence I've named them the Vampire Myths.
Here is a listing of the Vampire Myths as I see them. (feel free to add to the tally)
Low-carb diets cause heart disease
Low-carb diets will destroy your kidneys
Low-carb diets cause osteoporosis
Low-carb diets decrease endurance
Low-carb diets make your thinking fuzzy
Low-carb diets cause cancer
Low-carb diets cause dangerous ketoacidosis
There are probably more, but these are the ones almost everyone is familiar with. These are all untrue. They are myths. In due course I will address all of these, but for now, let's just hit a couple.
First, the idea that is made much of in this idiotic article concerns low-carb diets causing fuzzy thinking, so let's take a little deeper look. Ms. Christoper writes:
...to achieve and maintain normal brain function, adults and children need 130 grams of carbohydrates a day. On the Atkins Diet or similar regimens, you're allowed to eat about 20 grams of carbs daily at first; you can later nudge up the intake, but never to the minimum amount nutritionists recommend.
"Restricting carbs like that is going to have an effect on the brain," Stadler warns.
She is absolutely correct. The brain does need about 130 grams of glucose per day. It actually needs more like 200 grams of glucose per day, but during fasting or a low-carbohydrate diet the body begins producing ketones, which replace about 70 grams of the required glucose in the brain, dropping the overall requirement to about 130 grams per day. If a person only eats 20 grams of carbohydrate per day, the liver makes the other 110 grams. The liver is perfectly capable of churning out about 200 grams, or a cup, of sugar per day--even if you don't eat anything--so the brain isn't going to be deprived.
What sometimes does occur is what we call Ketone Brain. Let me explain. If you are on a high carbohydrate diet containing 200-400 grams of sugar (or sugar equivalents) per day, your brain has all the glucose it needs. (It actually has more than it needs; excess brain glucose is thought by many to be one of the driving forces behind Alzheimer's and other dementias of aging. But that's another story for another day.) If your brain is steaming along, fueled with all the glucose it needs, then you go on a low-carb diet and the glucose is cut off, the brain converts to using ketone bodies. But this conversion doesn't happen in a split second. It takes a little bit for the conversion to take place. During this brief period you may feel a little fuzzy headed, but as soon as the conversion is complete, you actually think more clearly.
So, Ms. Christopher, along with a little help from Ms, Stadler, has taken a couple of strands of truth and spun them into a web of deceit and misinformation.
Let's look at one more.
Diet guru Dr.Dean Ornish also worries about the effect of such diets on the kidneys. "High total protein intake, particularly animal protein," says Ornish, "may accelerate renal-function decline."
Does so-called diet guru Dean Ornish have anything to worry about with high-protein diets and the kidney? Hardly.
If you want to read about protein and the kidney, click here for a full-text article from the journal Nutrition & Metabolism.
My favorite article showing the absurdity of this claim comes from research performed in Israel almost 20 years ago by Dr. Marion Blum. There have been numerous studies since showing the same thing, but I like this one because of its simplicity and elegance.
Dr. Blum and her group recruited a number of vegetarian subjects (I don't remember how many right now because I don't have the paper in front of me and it's too old to pull down) of varying ages and sexes. These subjects had been vegetarians for over 13 years (so there were no recent coverts in the bunch) and had consumed low amounts of plant-based protein for a significant portion of their lives. Dr. Blum then found a group of meat-eating subjects who were the same ages and sexes as the vegetarians, but who consumed large amounts of mainly animal protein. Dr. Blum then tested the kidney function of both groups.
It is an unfortunate fact of life that as we age the function of our kidneys (and all our organs, for that matter) deteriorates. This deterioration can be measured and plotted on a graph showing decreased function as we get older.
Dr. Blum plotted the course of the age-related decline of kidney function in the vegetarians. She them plotted the same thing in the meat eaters and found that the two graphs were exactly the same. There was no difference in the age related kidney function of a long term vegetarian and a meat eater of the same age and sex.
I guess Dr. Ornish missed that study.
Here is the article that inspired this post. I have to give Ms. Christopher stylistic credit. She was able to fit a large number of Vampire Myths into a fairly small article. I hope they paid her well.
Oh, and by the way, the quote from page 9 of the Protein Power LifePlan that inspired the writer of the letter that kicked this post off is absolutely true:
Carbohydrates, the third macronutrient, are totally unessential to human health.
The article as published at www.edutopia.org.
Caveat Eater
Learning to love (again) the much-maligned carbohydrate.
By Abby Christopher
The craze for high-protein, low-carbohydrate diets is on the wane. One sure sign is that Atkins Nutritionals, the company that produces Atkins Diet-related products, declared bankruptcy this summer. Another is that the number of low-carb foods introduced this year was down compared to the past two years. But not everyone has given up the extreme approach to shedding pounds. So, if you're on a high-protein, low-carb diet, watch out: You may be courting a nasty case of "Um ... er ... ah, what was I saying?" in front of an unforgiving classroom of students. According to nutritionists, diets too low in carbs can affect brain power, not to mention energy, bone mass, and kidney function.
On a low-carb diet, "you'll have problems with word recall, and you'll feel less sharp," says Diane Stadler, research assistant professor in the Oregon Health and Science University's Health Promotion and Sports Medicine Division.
Dietary reference tables published this year by the Institute of Medicine indicate that to achieve and maintain normal brain function, adults and children need 130 grams of carbohydrates a day. On the Atkins Diet or similar regimens, you're allowed to eat about 20 grams of carbs daily at first; you can later nudge up the intake, but never to the minimum amount nutritionists recommend.
"Restricting carbs like that is going to have an effect on the brain," Stadler warns. She adds that a high-protein/low-carb diet can also whittle away at your bone mass, regardless of your age or relative health. Diets high in meat raise the acid level of blood, increasing excretion of calcium and phosphorus from the bone, which leads to early loss of bone density and accelerating osteoporosis. High-protein diets that rely on meat also decrease levels of urinary citrate, which can cause kidney stones.
As distance runners know, carbs are fuel, so if your lifestyle includes intense cardio workouts or you plan to start an exercise program at the same time you begin a high-protein diet, you may lack the stamina for even thirty minutes on an elliptical machine.
"Even going up a flight of stairs, not just working out, you're going to have some fatigue," says Stadler. And though you may be okay during short workouts with weights, Stadler adds that the potassium concentration of a high-protein diet is more likely to cause muscle cramps.
Diet guru Dr.Dean Ornish also worries about the effect of such diets on the kidneys. "High total protein intake, particularly animal protein," says Ornish, "may accelerate renal-function decline."
More dangerous possible consequences exist, such as raised levels of bad cholesterol, as does a less dire but socially embarrassing side effect: bad breath. But losing focus while trying to hold students' attention is a professional downside that even a rapid drop in weight can't justify. Working to get yourself in better shape is a worthy goal, but when shape trumps sharpness, something's got to give. So cook yourself a veggie stir fry on rice, whip up a plate of pasta primavera, or have a slice of whole-grain bread with your soup. Carbs are back. Your brain is hungry for them.
Posted by mreades at 7:38 PM | Comments (15)
March 10, 2006
Three steps forward
I’ve had a hectic past few days what with switching the website, blog and bulletin board to a new server and a new tech person along with all the other trials and tribulations of simply maintaining life on a somewhat even keel. I didn’t even get to play golf once.
In catching up on my reading I came across an article in last Tuesday’s Wall Street Journal that set my teeth on edge. The piece was entitled: Meditating for Heart Health. It was a balanced take on the idea that Transcendental Meditation (TM) improves heart health. Followers of TM have claimed that its practice can help reduce blood pressure, reduce arterial plaque, reduce the incidence of heart attack, and even reduce mortality. And they have the studies to prove it. One of the studies mentioned in the article is found in an issue of last year’s American Journal of Cardiology and presents data showing that subjects with high blood pressure who took up TM and other behavioral stress reducing interventions had reduced rates of all-cause mortality and cardiovascular mortality after a follow up of 7.6 years. The references at the end of this paper list a number of other studies purporting to show the same thing. I pulled down a few of these and thumbed through them and they all pretty much indicated the same thing. I didn’t go over the statistics with a fine-toothed comb like I usually do simply because I didn’t have the time, and the studies all told me what I wanted to know, which is that there is evidence that TM and other sorts of meditation and stress reduction decrease mortality, or at the very least, don’t appear to increase it.
Why does all this stick in my craw? Because it reminds me of the paper that put Dean Ornish on the map, the one that he has been running around crowing about since.
Dr. Ornish published a paper in The Lancet, the prestigious British medical journal, in 1990 that purported to show that his program of lifestyle modification reversed the progression of coronary artery disease. He has lived off that paper since. And he continues to trumpet the idea that his program is the only one that has been shown to actually reverse coronary artery disease.
And guess what? I believe him, sort of.
Ornish and his group divided subjects with mild, radiographically-proven coronary artery disease into two groups, the experimental group, which got intensive interventional attention, and the control group who got "usual care." The subjects in the treatment group started and followed a low-fat vegetarian diet, stopped smoking, started meditating and undergoing stress management, and began a regimen of moderate exercise. After one year, 82% of the subjects in the treatment group (23 of 28) showed a regression (a very slight regression) of their coronary artery narrowing while those in the usual-care group showed a very slight increase in arterial narrowing. And subjects in the treatment group had fewer episodes of chest pain and other cardiac symptoms than their compatriots in the other group.
Ignoring the fact that it is virtually impossible to determine the slight differences in arterial narrowing shown in this study and ignoring the fact that there were a number of patients "lost" to follow up in the treatment group (losing the right subjects can make data look a lot better statistically) and ignoring the fact that the randomization process wasn’t exactly according to Hoyle and ignoring the fact that the only death in the study was in the treatment group I still believe the subjects in the intervention group got better and probably did improve their coronary artery disease (I say this with one caveat that I’ll address in a moment.) I just don’t believe they improved for the same reasons that Dr. Ornish does.
If we look at how the study was structured, we see that the subjects were put on a lifestyle modification program. In fact, the study was called "The Lifestyle Heart Trial." The subjects modified their lifestyles in four basic ways.
The went on a low-fat vegetarian diet
They stopped smoking
They began meditation and stress management
They started to exercise
We know that smoking is disastrous for people with coronary artery disease and that stopping smoking helps immeasurably. We know that exercise improves coronary blood flow and all around fitness and decreases mortality. And we suspect from the studies above mentioned in the Wall Street Journal article that meditation and stress reduction improves cardiac function and decreases cardiac mortality. If you have heart disease and you do these three things, odds are you’re going to get better.
But what about the low-fat vegetarian diet? The low-fat diet by itself, unlike the other three activities, hasn’t really been shown conclusively to improve cardiac function. In fact, based on the recent accumulation of studies comparing low-fat diets to low-carbohydrate, higher fat diets, the low-fat diet has faired poorly. It is my opinion that the subjects in the Ornish study took three steps forward and one step back. The three steps forward, i.e., the smoking cessation, exercise, and meditation improved their cardiac function more than the low-fat diet they followed damaged it, leading to an overall improvement in their condition.
What evidence do I have to make that assertion? If you take a look at the lipid values of the subjects following the low-fat vegetarian diet you notice a fairly sinister finding (the caveat mentioned above): triglycerides went up markedly while HDL-cholesterol went down. Exactly the opposite of what you would like to see in patients with heart disease.
In 1990 when this study was published the lipid focus was on total cholesterol and LDL-cholesterol, both of which fell in this study. Evidence has accumulated over the intervening years that pretty conclusively shows that if your going to believe in the lipid hypothesis of heart disease—and Dr. Ornish certainly does—then a rise in triglycerides and a fall in HDL are ominous signs that your therapy isn’t working. If this study were published today, one wonders if the lipid values that looked so good to 1990 eyes would even be listed. (Happily, we who prescribe low-carbohydrate diets don’t have to worry because triglycerides always fall and HDL usually goes up.)
Now getting to what agitates me about all this...I’m annoyed because Ornish, who never fails to mention that he has "proven" that he can reverse heart disease, always attributes the improvement of the subjects in the treatment group to the low-fat diet they followed. Whenever anyone brings up the fact that it was a comprehensive program of lifestyle modification that did the trick (if the trick was really done), he always minimizes the role of the three activities known by everyone to improve vascular disease and emphasizes the role his diet played.
I believe that if this same study had been carried out using the same interventional modalities except that a low-carb diet had been substituted for the low-fat diet, the results would have been significantly better. The subjects in the treatment group would have taken four steps forward.
Posted by mreades at 9:16 PM | Comments (14)
March 8, 2006
Blog moved successfully (for the most part)
My blog (and MD's) appear to have made the transition to the new server in pretty good shape. During the transfer process a bunch of apostrophes and other punctuation were replaced by bizarre-looking symbols. My new tech guy is going through and finding and replacing with the appropriate marks. As soon as he's finished, I will rebuild the site, and it should be back to normal.
I've noticed that a number of recent comments that I hadn't yet approved (and some that I had) didn't make the transfer. Now that the DNS is directed to the new site, I can't get back into the old site and copy them. If anyone posted a comment and hasn't seen it up, please repost.
I hope all the server snafus and blog technical problems are behind us. Thanks for your patience.
Posted by mreades at 9:16 AM | Comments (3)
March 6, 2006
Server change
I am in the process of migrating this blog to a new, more reliable server. The old server, despite protestations to the contrary by its owner, was down from time to time (without warning) and, in one case, lost a bunch of data. The new server has multiple backups with generators in place to insure continuous service even in the face of power loss.
The only problem is that it takes a few days to do this and make sure all the bugs are worked out. Bear with me and I'll be back to blogging regularly in just a day or two. There is a lot going on right now in the nutritional world and I'm eager to write about it.
Posted by mreades at 1:59 PM | Comments (0)
March 4, 2006
FDA diet supplement warning
In catching up on my mountains of mail I came across a warning issued by the Food and Drug Administration that I thought I would pass along. A couple of dietary weight loss supplements manufactured in Brazil have been shown to contain a number of controlled substances and should be avoided.
According to the FDA the two supplements Emagrece Thin and Herbathin, both of which are being sold over the Internet at a cost of between $140 and $230 for a month's supply, have been found to contain chlordiazepoxide (the active ingredient in Librium), fluoxetane (Prozac), and fenproporex, an unapproved stimulant that the body converts to amphetamine.
According to the FDA press release, chlordiazepoxide may be habit forming and can cause dizziness and drowsiness, and fluoxetine has been linked to several serious drug interactions and to even the possibility of promoting suicide in its takers. Amphetamines can be disastrous.
These two products are made by the Brazilian firms Fitoterapicos and Phytoterm Slim. The FDA is making an effort to prevent the importation of both products, but warns that there may be knock-offs with the same or similar names made by other manufacturers.
It should go without saying that it pays to be careful when ordering ingestible products made available from unknown sources.
Posted by mreades at 6:51 PM | Comments (0)