Low-carb and Mediterranean diets beat low-fat for weight-loss, lipid changes at two years
http://www.theheart.org/article/882281.do

Beer-Sheva, Israel - Both a low-carbohydrate diet or a Mediterranean-style diet may be "effective alternatives" to a low-fat diet, with more favorable effects on lipids and/or glycemic control, new research suggests [1]. The two-year study, which managed to keep almost 85% of the 322 study participants on one of the three diets for the entire period, offers the hope that weight-loss diets can be tailored to personal preferences, without sacrificing efficacy, researchers say.

"Several recent one-year dietary studies have led the American Diabetes Association to state in January 2008 that low-carb diets should be considered for a maximum of one year," lead author on the study, Dr Iris Shai (Ben Gurion University of the Negev, Beer-Sheva, Israel), told heartwire. "The current two-year study suggests that one low-fat diet doesn't fit all, meaning that the old paradigm should be reconsidered."

Shai and colleagues publish the results of the Dietary Intervention Randomized Controlled Trial (DIRECT) in the July 17, 2008 issue of the New England Journal of Medicine.



Diet options


At the start of the study, DIRECT subjects were middle-aged (mean age 52 years) and mildly obese (body-mass index=31). All participants were randomized to one of three diets: low-fat/restricted-calorie diet; Mediterranean/restricted-calorie diet; or low-carbohydrate diet, with no restriction on calories. After two years, adherence to their respective diets ranged from more than 90% in the low-fat group, to 85% in the Mediterranean diet group, to 78.0% in the low-carb group.

Weight loss occurred in all three groups over the 24 months but was greater in the Mediterranean and low-carb groups. In men—who made up the bulk of the study cohort—weight loss was greatest in the low-carb group, whereas women—just 45 in the study cohort—appeared to lose more weight on the Mediterranean diet. When the analysis was performed just in the 272 "completers" who adhered to the diet for the entire study period, the pattern of weight loss associated with each diet was similar.


Changes in lipid parameters were also most striking in the low-carb and Mediterranean-diet groups. HDL increases and triglyceride decreases were most pronounced in the low-carb group, while reductions in LDL cholesterol were greatest in the Mediterranean-diet group. Reductions in total cholesterol/HDL ratio were greatest in the low-carb group, closely followed by the Mediterranean-diet group.

Lipid changes

Parameter
Low-fat (mg/dL)
Low-carb (mg/dL)
Mediterranean (mg/dL)

HDL
+6.4
+8.4
+6.3

LDL
-0.05
-3.0
-5.6

Triglycerides
-2.8
-23.7
-21.8

Total cholesterol/HDL ratio
-0.6
-1.1
-0.9


In the subset of patients with diabetes—just 36 out of 322 subjects—the Mediterranean diet appeared to improve fasting plasma glucose levels. According to Shai, the results suggest that "one size doesn't fit all."

"The current results suggest that Mediterranean and low-carbohydrate diets are effective alternatives to low-fat diets," she said. "The more favorable effects on lipids with the low-carbohydrate diet and on glycemic control with the Mediterranean diet suggest that personal preferences and metabolic considerations might inform individualized tailoring of dietary interventions."



An "optimal" study environment


One of the unique features of the study was its location: the DIRECT study was conducted at a nuclear research center in Israel with an on-site cafeteria and medical clinic. Participants in the trial ate their main meal of the day—lunch—in the workplace cafeteria, where food choices were carefully controlled and labeled. On-site dieticians worked regularly with participants to help them adhere to their diets. Indeed, the Nuclear Research Center Negev itself, along with the Robert C and Veronica Atkins Foundation—the low-carb diet in DIRECT was based on the Atkins diet—helped fund the study.

In the paper, Shai et al acknowledge that the setting was perfectly suited to a study of this kind, but that this doesn't mean these diets would not have worked elsewhere. "We took advantage of the isolated place, which is highly monitored by an excellent internal medical department, and a set of cafeterias [whose menus] we could modify," she told heartwire. And in fact, she said, "we do believe that this optimal model could be applied in other workplaces, once the manager prioritizes this kind of long-term health-promotion project."




Why do they work?
Asked what she thinks is behind the success of the low-carb and Mediterranean diets, Shai said that, at least in the case of the Mediterranean diet, reducing calories may be slightly easier when moderate fat consumption is permitted.

In the case of the low-carb diet, there are a number of possible explanations, she says.

"First, the advantage of this strategy is that the 'enemy'—carbohydrates—is well defined and once learning it, the [dieter] knows what to stay away from, without counting calories," Shai told heartwire. "And after the initiation phase, the dieter has less craving. Second, we assume that a relatively high-protein diet does contribute to higher satiety. Third, the immediate response of the body to weight loss may encourage the dieter."
-SW





Commenting on the study for heartwire, Dr Eric Westman (Duke Clinical Research Institute, Durham, NC), a long-time skeptic of low-fat diets, acknowledged that the low-carb diet craze of the early 21st century has died down, something he can't explain. "There is this study, and there are two additional National Institutes of Health studies in the US that are progressing well, so I don't know what the push-back was. Some have speculated that Dr [Robert C] Atkins dying or the company going bankrupt made the wind change, even though the science has just marched along. It's a mystery to me."

Like Shai, Westman thinks it might be time to "get beyond that old low-fat diet" and that, slowly but surely, this is actually starting to happen.

I'm reading my daughter's high school health textbook, and it's like a religion: 'Everyone should follow a low-fat diet' and 'Saturated fats kill you,' and that's just wrong, plain wrong. "I'm reading my daughter's high school health textbook and it's like a religion: 'Everyone should follow a low-fat diet' and 'Saturated fats kill you,' and that's just wrong, plain wrong," he told heartwire. "There are more people coming out of the closet saying they weren't part of this low-fat diet thing all along, but I guess they felt they couldn't speak up. I think that what we're soon going to find is that nobody's going to be defending the 30% fat, low-fat diet anymore."

Indeed, AHA past-president Dr Robert Eckel (University of Colorado Health Sciences Center, Denver), points out that Shai et al's study used the outdated 2000 AHA guidelines as the template for its low-fat diet.

"The AHA updated its dietary guidelines in 2005, which are quite different from the diet that's quoted here," he told heartwire. "The dietary fat restriction at 30% of calories is no longer part of the AHA guidelines, and the saturated-fat content has been reduced from 10% to 7% and the cholesterol content from 300 to 200 mg/day. I think it's a little bit unfair to kind of generalize that the AHA, number one, stands for a low-fat diet; that's no longer the case. And number two, there is some kind of mysterious benefit of being on the Mediterranean and low-carb diets over time that doesn't necessarily at this point have any explanation."

But Eckel rejects the idea that saturated fats could be embraced by any legitimate weight-loss approach. "Anything that would endorse the Atkins-type of food-intake pattern would not be something that the AHA would back," he said firmly. "Saturated fats raise LDL cholesterol—I don't think many people would disagree with that. . . . At this point limiting saturated fats is still a position the AHA would claim, and I think that's consistent with the National Cholesterol Education Program guidelines, the American Diabetes Association, the US Department of Agriculture. I don't think there is any major professional organization at this point that's willing to throw in the towel on saturated fats and say they are unimportant."

Both Westman and Eckel had some niggling questions about Shai et al's study. Westman pointed out that there were only 10 people in each diet group with diabetes and as such the effects of the Mediterranean diet in this group may have been "overstated." It's likely that both the Mediterranean and low-carb diets are beneficial in diabetics, he says, since both were higher in fat and lower in carbohydrates.

Eckel, for his part, points out that a study cohort that is 86% male is unusual in a diet study, which typically enrolls more women. "How generalizable this study is to women with obesity is not clear to me," he said.

He also pointed to the lack of emphasis on physical activity in the study—something he believes is key to keeping weight off long term.



More tools in the trunk

I don't think there is any major professional organization at this point that's willing to throw in the towel on saturated fats and say they are unimportant. What the authors, as well as Westman and Eckel, agree is on the notion of different options for different people, with different medical concerns. Eckel points to the AHA's "No Fad Diet," which offers three strategies for people to choose from, including a low-carb option. Westman stresses the need for physicians treating overweight and obese patients to stop quibbling over diets. "In the end, all of these lifestyles work," he said. "Low-fat diets work, but the low-carb and Mediterranean diets are stronger, and that's good because we need more tools. All this 'my diet is better than your diet'—we need to get beyond that. What we really want are the metabolic outcomes, and there are many ways to go about it."

Westman also points out that a decades-old bias against the possibility of higher-fat diets having any benefits to them has hampered research. "It's time to study low-fat and high-fat diets with cardiac end points and genetic markers to tailor diets for cardiac risk reduction," he says.

And until that time, Eckel remains unconvinced. "Until we have studies . . . that show me that heart attacks, cancer, or other comorbidities of obesity are reduced in terms of hard end points, I'm not going to be convinced that any diet is better, even though you may be down a few more kilograms on that one diet," Eckel told heartwire. "I'm not denying the success of [Shai et al's] study, I'm just saying that this is more hand-waving with soft outcomes, which really don't get at the question: can people lose weight for five, 10, 15, and 20 years, and what does that do to risk for heart disease, stroke, and mortality?"

Ornish has changed his tune about refined carbs over the years. He used to dismiss it, and I think I read a Time article once where he begrudgingly credited Dr. Atkins for that realization. He is still using science to get the conclusion he wants rather than the other way around, but it's a bit of progress.

People have often said "Atkins works but it's hard to maintain." Ornish wants you to eat less than 10% fat. How hard is THAT to maintain in comparison? Especially if he now preaches reducing simple carbs.

Maybe Jane Brody can have Dr Robert Eckel for some statins and a glass of Zima so they can whine together.

Study Fuels Low-Fat vs. Low-Carb Debate

Overweight people on low-carbohydrate and Mediterranean diets lost more weight and got greater cardiovascular benefits than people on a conventional low-fat diet, according to a study that endorses alternative diets published in a major medical journal.

The study, which tracked 322 Israelis for two years, surprisingly found that a low-carb diet, often associated in the U.S. with high levels of meat consumption -- was better than a low-fat diet in boosting blood levels of "good" cholesterol, or high-density lipoproteins associated with cardiovascular health benefits. It also determined that the Mediterranean diet, which includes wine, olive oil, whole grains and fruits, was better than the low-fat diet in controlling glucose levels.

The researchers suggested that doctors and nutritionists could use the findings to tailor diets individually to patients with heart disease or diabetes, stressing that these were alternatives to low-fat diets that many people find hard to follow. The results also indicated that worries that low-carb diets, in particular, might cause health problems, are unfounded.

"A lot of people believe a low-fat diet is the only sanctioned weight-loss diet," said Meir J. Stampfer, an epidemiology and nutrition professor at the Harvard School of Public Health who was senior author of the report, published in Thursday's edition of the New England Journal of Medicine. The study found that "there are alternatives that work better."

The study's leader, Iris Shai of Ben-Gurion University of the Negev, said, "We believe that this study will open clinical medicine to considering low-carb and Mediterranean diets as safe, effective alternatives for patients."

The study was funded with a $497,000 grant from the Jenkintown, Pa., nutritional-research foundation established by Robert Atkins, the late diet guru whose Atkins diet is controversial because it allows dieters to consume large amounts of meat and cheese, while eliminating bread and pasta. The foundation said it didn't influence the findings, and the study's authors said they didn't have any financial conflicts under the New England Journal guidelines.

Dean Ornish, a doctor and University of California at San Francisco professor who advocates extremely low-fat diets, said the Israel study shouldn't be seen as endorsement of the Atkins diet because the low-carb participants in the study were encouraged to consume vegetable fats, as opposed to the meat fats that Atkins dieters typically ingest. "A vegetarian Atkins diet is almost an oxymoron," he said. He also said the low-fat diet in the study, which was based on recommendations by the American Heart Association, doesn't cut out enough fat.

Low-carb diet advocates said they weren't surprised by the results, which they said confirm shorter, smaller, studies done over the past 20 years. Last March, Stanford University researchers reported in the Journal of the American Medical Association that over the course of a year, overweight women assigned to follow the Atkins diet lost an average of 10 pounds, exceeding losses recorded by women on other diets in the study. However, the study was criticized because many of the women didn't stick with diet guidelines and because they were paid to participate.

Stephen Phinney, professor emeritus of nutrition at University of California at Davis who has researched high-protein, low-carb diets for more than 25 years, said that with publication in the New England Journal -- which he called "the keeper of the consensus in medicine" -- he expects that "what was considered unacceptable, becomes mainstream thought."

Jimmy Moore, a 36-year-old from Spartanburg, S.C., who operates a dieter's Web site, says he lost 180 lbs. after going on the Atkins diet four years ago. He said he did it even though his doctor "thought I was nuts." He says his doctor was impressed with his diet success, and publication of the study may convince him to recommend the diet to other overweight patients.

In the Israel study, after two years, those in the group assigned to the low-carb diet lost an average of 10.3 lbs. -- 58% more than the 6.5 lbs. lost by dieters who followed the low-fat diet based on the Heart Association recommendations. Those on the Mediterranean diet, which includes lots of carbohydrates like pasta and more calories from fat in the form of olive oil than the Heart Association recommends, lost 10 lbs., nearly as much as the low-carb diet.

Excluding drop-outs, the average weight loss was 12.3 lbs. for the low-carb dieters, 10.2 lbs. for the Mediterranean dieters and 7.3 lbs. for the low-fat dieters. The subjects started out with an average body-mass index of 31, well above the top level of 24.9 considered normal weight. About 85% of those in the study were men.

The study was conducted among a group of workers at Israel's Nuclear Research Center in Dimona. Aided by support from the center, including color-coded menu information in the company cafeteria, 95% of the employees stuck with their diets for a full year and 85% were still involved at the end of the two-year study. Dr. Shai, the lead researcher, said that the "support in the workplace," helped people stay on the diets, even after weight loss plateaued at the six-month mark. She said the success suggests that workplace support for diet programs could help employers improve employee health.

The low-carb diet was also found to reduce harmful triglycerides, a precursor of heart disease, more than the low-fat diet. Levels of "bad" cholesterol, or low-density lipoprotein, which is associated with the formation of arterial blockages, didn't significantly differ among the three diets.

Low-carb diets permit people to freely eat cheese, meats and animal fats that are discouraged in traditional diets, although in the Israel study, employees were counseled to emphasize vegetable fats. The low-carb dieters weren't given any restrictions on the number of calories they could consume, although they ended up eating about the same number of calories as the other two groups, indicating that they were satiated by their fat consumption. After an initial two-month period with just 20 grams a day of carbohydrates, they were allowed to consume up to 120 grams a day, well above the Atkins-recommended levels.

The low-fat and Mediterranean dieters were restricted to 1,800 calories a day for men and 1,500 for women. The Mediterranean dieters were urged to eat poultry and fish instead of beef and lamb, and they ate a handful of tree nuts and about five tablespoons of olive oil a day, so they got 35% of calories from fat. The low-fat dieters got just 30% of calories from fat.

Dr. Shai, the study leader, said she conceived the study when she was at Harvard School of Public Health in Boston on a Fulbright scholarship. "Before I came, I had the understanding that a low-fat diet was the best. But after I came, I started to think maybe we are wrong." Dr. Shai, 39 years old, said she thought the Israel nuclear research center would be a good place to run a study because it is isolated and people seldom leave. In addition, people were all on a private computer network, making it easy to monitor employee compliance by administering electronic questionnaires. But she says, "The main effects could be achieved in any workplace."

Barbara Howard, former chairwoman of the American Heart Association's Council on Nutrition, said that the group hasn't advocated a low-fat diet in recent years. She said reducing total calories and exercise are the key to weight loss. The group also urges people to avoid saturated fats and limit "calorie dense foods" such as fats and "highly processed carbs like pastries."

http://online.wsj.com/article/SB121...=googlenews_wsj

I agree that the sheep are not going to throw in the towel on saturated fat. But if this idiot thinks everyone agrees with his statements then he should pull his head out of his ass, get a whiff of fresh air, and read some of the excellent research done by people other than his friends.

And another view....which I have been also wondering if I should go buy some beef that is grass fed and stock my freezer.

[I]* A Radical New Vision of Nutrition *

Dr. Robert Atkins died this spring from an accidental fall, but not before he changed the world of nutrition. His radical low-carb diet dared to confront conventional nutrition. His ensuing persecution exposed the medical profession's close-minded intolerance of new ideas. Now after his death, independent and accredited research has finally proved what Atkins knew for nearly his entire life.

What did Dr. Atkins say that was so different? Since the 1960's, he has been making two very contrarian claims.

? One, Americans are fat not because they eat too much fat and calories but because they eat too much carbohydrate.

? Two, the best way to lose weight was not a low fat diet but a low carb diet.

Nutritionists have always presumed that weight equaled calories consumed minus calories burned and the type of calories didn't really matter. Nutritionists still have trouble accepting Atkins' theory but new research has prompted even the staunchest critics to take notice. Here are some examples of evidence supporting Atkins' theory.

• February 2003: A landmark study that compared the American Heart Association's low fat diet to the Atkins' diet. The Atkins' diet caused greater weight loss and lowered cholesterol and triglycerides much more effectively than a low fat diet of equal calories.

• In May 2003: The prestigious New England Journal of Medicine published a study that found the Atkins approach beat out the American Heart Association's low fat approach for both weight loss and blood fats improvement.

• Nutrition Week 2003: National meetings recently reported preliminary results of a study performed by Heritage Medical Center on patients with Metabolic Syndrome. Participants ate a low-carb diet for 18 months. Their LDL (“bad” cholesterol) reduced by an average of 82%. HDL (“good” cholesterol) scores increased by an average of 30%.

Atkins was right about the problem. Excess starches like potatoes and breads made Americans fat – not too much dietary fat. But, here's where we part: I do not agree with his dietary solution.

It is true that fat is relatively inert at affecting the hormonal control of your metabolism. But I do not recommend you eat sausage, hot dogs, and spareribs for weight loss. Here's why:

The unnatural living conditions of animals in the modern food industry. This produces diseased animal fat. Modern farming techniques prevent the animals from getting normal exercise and feed a diet of grains instead of grasses. This makes for an obese animal. Not only do these products of the modern slaughterhouse have inordinate quantities of fat but it is the wrong kind of fat. It has an unnatural and unhealthy concentration of omega-6 fatty acids that cause heart disease. Additionally, all of the herbicides, pesticides, toxins and hormones that the animal has been exposed to collect in the fat.

Beyond Atkins

Manipulating macronutrients (protein, fat and carbohydrates) did not make Dr. Atkins a quack as conventional medicine insisted for decades. In fact, it is a sophisticated approach. The right balance of increased protein, decreased carbohydrate with the right healthy fats can effectively control aspects of your metabolism and weight. You can improve your energy and strength at the same time you lose body fat. It is also much easier to follow than the AHA's low-fat approach. Here are the easy rules for your new approach:

1. Eat excess protein. Quality protein is the key to good nutrition. Protein promotes muscle growth and over all health. Eating more protein than you need for daily metabolism signals to your body that “the hunting is good” and liberalizes the burning of carbs and fat for energy. Fish, lean meats, eggs, dairy, beans and nuts are all good sources of protein. Eat as much of them as you like.

2. Limit processed carbs. Processed carbs make you fat and diseased. Starches in particular are the main cause of the American obesity epidemic. Limit consumption of anything made from grains or potatoes. Get your carbs from unprocessed vegetables that grow above ground.

3. Eat natural fats. Fat is neutral as a macronutrient but most modern fat is a health nightmare. Eat unprocessed vegetable fats like avocados, nuts and virgin olive oil. Avoid corn oil, all hydrogenated oils and margarine. Get your animal fat from wild fish, free range or grass fed animals. Read Health Alert 49 for some more tips on finding quality natural meat.

Al Sears MD

The data tables are in the free full-text of the paper....

http://content.nejm.org/cgi/content...3/229?query=TOC

In this table: http://content.nejm.org/cgi/content...ll/359/3/229/T2

Low-carb Groups Carb intake at:

6-months = 41.4% of calories
12-months = 41.6% of calories
24-months = 40.4% of calories

Let's see if me trying to drop the graphic works:

Not many...just the smart ones! LOL

ABC has put some spin on this already saying the Mediterranean is the winner and hardly mentioning Atkins at all except to mention its impossible to stick to.http://abcnews.go.com/Health/Diet/s...=5389423&page=1

I wish the study had not muddled the waters with the "Mediterranean Diet" and at lest should have done the respective diets correctly by the book.

When your head is up your butt, it is hard to see the long term low carbers because of the obstructed view.

And the watering eyes from the smell...

Thanks Regina. Obviously you can drop a graphic. I doubt that I can. Can you drop the one that shows the weight loss curves for the diets? Something strange happened at about 6 months in the Mediterranean diet group. They went from tracking the LF diet group to tracking the LC diet group. I wonder what changed?

Also funny. People on the LC diet not only ate fewer grams of carbs as they were told, but also fewer grams of protein and fat, which they weren't encouraged to do.

Which absolutely makes sense to me since they didn't have carbohydrate driven hunger.

I don't understand all this worshiping of the Mediterranean diet. Have they been to Italy? Have they seen old Italian women? They are all very fat after the lifetime of eating "healthy" pasta and "good" fats.