This article appeared in the Times newspaper here in the UK today, July 15, 2002, so hopefully the low carb message is getting some serious mainstream global attention.
More fat, please, I'm on a diet...
by Gary Taubes
Whisper it...fat may be good for you. For 25 years, nutritionists and health experts said it caused obesity and heart disease. Diet gurus who disagreed, such as Robert Atkins, were vilified. Now it seems he may have been right all along.
If the medical establishment were to have a collective nightmare, this might be it. They spend 30 years ridiculing Robert Atkins, author of the best-selling Dr Atkins’ Diet Revolution and Dr Atkins New Diet Revolution, only to discover that he was right all along. Or maybe it’s this: they find that their own dietary recommendations — eat less fat and more carbohydrates — are the cause of the rampaging epidemic of obesity in America. Or, just possibly this: they find out that both of the above are true.
When Atkins published his Diet Revolution in 1972, people were coming to terms with the proposition that fat — particularly the saturated fat of meat and dairy products — was the primary nutritional evil. Atkins managed to sell millions of copies of a book promising that we would lose weight eating steak, eggs and butter, because it was carbohydrates — pasta, rice, bread and sugar — that caused obesity and even heart disease.
Fat, he said, was harmless.
The perversity of this alternative hypothesis is that it identifies the causes of obesity as, firstly, precisely those refined carbohydrates that we are told should be the staple of our healthy low-fat diet, and, secondly, the sugar in the soft drinks, fruit juices and sports drinks that we have taken to in quantity because they are fat-free and so appear healthy.
Over the past five years, however, there has been a subtle shift in the scientific consensus. It used to be that even considering the possibility of the alternative hypothesis, let alone researching it, was tantamount to quackery by association. Now a small but growing minority of establishment researchers have come to take seriously what the low-carb-diet doctors have been saying all along. Walter Willett, chairman of the department of nutrition at the Harvard School of Public Health, is the spokesman for the longest-running and most comprehensive diet and health studies ever performed, which include data on nearly 300,000 individuals. Those data, says Willett, clearly contradict the low-fat-is-good-health message “and the idea that all fat is bad for you; the exclusive focus on adverse effects of fat may have contributed to the obesity epidemic”.
These researchers point out that there are plenty of reasons to suggest that the low-fat-is-good-health hypothesis has now failed the test of time. In particular, that the US is in the midst of an obesity epidemic that started around the early 1980s, and that this was coincident with the rise of the low-fat dogma. Type 2 diabetes, the most common form of the disease, also rose significantly during this period. They say that low-fat weight-loss diets have proved in clinical trials and real life to be failures. Cholesterol levels have been declining and we have been smoking less, yet the incidence of heart disease has not declined.
“That is disconcerting,” Willett says. “It suggests that something else bad is happening.”
David Ludwig, a researcher at Harvard Medical School, runs the paediatric obesity clinic at Children’s Hospital Boston and prescribes his own version of a carbohydrate-restricted diet to his patients. He calls the science behind the alternative hypothesis Endocrinology 101, which requires an understanding of how carbohydrates affect insulin and blood sugar and, in turn, fat metabolism and appetite. This is basic endocrinology, Ludwig says, which is the study of hormones, but it is still considered radical because the low-fat dietary wisdom emerged in the 1960s from researchers almost exclusively concerned with the effect of fat on cholesterol and heart disease. At the time, Endocrinology 101 was underdeveloped, and so ignored.
If the alternative hypothesis is right, then it strongly suggests that the current epidemic of obesity is not due simply to a collective lack of willpower and a failure to exercise. Rather, it occurred (as Atkins has been saying) because the public health authorities told us — unwittingly, but with the best of intentions — to eat precisely those foods that would make us fat, and we did. We ate more fat-free carbohydrates, which, in turn, made us hungrier and then heavier.
Put simply, if the alternative hypothesis is right, then a low-fat diet is not by definition a healthy diet. In practice, such a diet cannot help being high in carbohydrates, and that can lead to obesity, and perhaps heart disease.
“For a large percentage of people, perhaps 30 to 40 per cent, low-fat diets are counterproductive,” says Eleftheria Maratos-Flier, director of obesity research at Harvard’s prestigious Joslin Diabetes Centre. “They have the paradoxical effect of making people gain weight.”
Scientists are still arguing about fat, despite a century of research, because the regulation of appetite and weight in the body is almost inconceivably complex and the experimental tools we have to study it are still inadequate. This combination leaves researchers in an awkward position. To study the entire physiological system involves feeding real food to real human subjects for months or years on end, which is prohibitively expensive, ethically questionable and impossible to do in a rigorously-controlled scientific manner.
But if researchers seek to study something less costly and more controllable, they end up studying experimental situations so oversimplified that their results may have nothing to do with reality. The result is a splintered community in which researchers seem easily convinced that their preconceived notions are correct and are thoroughly uninterested in testing any hypotheses but their own.One of the few reasonably reliable facts about the obesity epidemic in the US is that it started around the early 1980s. By the end of that decade, nearly one in four Americans was obese. Any theory that tries to explain obesity in America has to account for that.
Meanwhile, overweight children nearly tripled in number. And, for the first time, doctors began diagnosing Type 2 diabetes in adolescents. Type 2 diabetes often accompanies obesity. It used to be called adult-onset diabetes but now, for the obvious reason, is not.
So how did this happen? The ubiquitous explanation is that we live in a “toxic food environment” of cheap fatty food, large portions, pervasive food advertising and sedentary lives. And because some of us are predisposed to gain weight while others are not, this explanation also has a genetic component — the thrifty gene. It suggests that storing extra calories as fat was an evolutionary development by our Paleolithic ancestors, who had to survive frequent famine. We inherited these “thrifty” genes, despite their being a liability in today’s toxic environment.
This theory makes perfect sense and plays to our puritanical prejudice that fat, fast food and television are innately damaging to our humanity.
But there are two catches. First, to buy this logic is to accept that the copious negative effects of obesity — both social and physical — are easily overcome by the constant bombardment of food advertising and the lure of a supersize bargain meal. Second, little data exist to support any of this.Fast-food consumption, for example, continued to grow steadily through the 1970s and 1980s, but it did not take a sudden leap, as obesity did. As far as exercise and physical activity go, the 1990s data show obesity rates in the US continuing to climb, while exercise activity remained unchanged. This suggests the two have little in common.
As for the thrifty gene, it provides the kind of evolutionary rationale for human behaviour that scientists find comforting but that cannot be tested.
It is also undeniable, students of Endocrinology 101 argue, that mankind never evolved to eat a diet high in starches or sugars. “Grain products and concentrated sugars were essentially absent from human nutrition until the invention of agriculture,” Ludwig says, “which was only 10,000 years ago.”
This is discussed frequently in the anthropology texts but is mostly absent from the obesity literature, with the prominent exception of the low-carbohydrate-diet books.
What’s forgotten in the current controversy is that the low-fat dogma itself is only about 25 years old. Until the late 1970s, the accepted wisdom was that fat and protein protected against overeating by making you feel full, and that carbohydrates made you fat. In The Physiology of Taste, for instance, an 1826 discourse that is among the most famous books ever written about food, the French gastronome Jean Anthelme Brillat-Savarin says he could easily identify the causes of obesity after 30 years of listening to one “stout party” after another proclaiming the joys of bread, rice and (from a “particularly stout party”) potatoes. But by the 1980s all that had been forgotten, and the typical breakfast of bacon and eggs was being supplanted by a bowl of Special K with low-fat milk, a glass of orange juice and dry toast.
Few experts now deny that the low-fat message is radically oversimplified. If nothing else, it effectively ignores the fact that unsaturated fats, such as olive oil, are relatively good for you: they tend to elevate your good cholesterol, high-density lipoprotein (HDL), and lower your bad cholesterol, low-density lipoprotein (LDL), at least in comparison to the effect of carbohydrates. What this means is that even saturated fats are not nearly as harmful as you would think. True, they will elevate your bad cholesterol, but they will also elevate your good cholesterol. As Willett explained to me, you will obtain little or no health benefit by giving up milk, butter and cheese and eating bagels instead.
But it gets even weirder than that. Foods considered more or less deadly under the low-fat dogma turn out to be comparatively benign if you look at their fat content. More than two-thirds of the fat in a porterhouse steak, for instance, will improve your cholesterol profile (at least in comparison with the baked potato next to it); it’s true that the remainder will raise your LDL, the bad stuff, but it will also boost your HDL. The same is true for lard.
If you work out the numbers, you come to the surreal conclusion that you can eat lard straight from the pack and reduce your risk of heart disease.
The crucial example of how the low-fat recommendations were oversimplified is shown by the potentially lethal impact of low-fat diets on triglycerides, the component molecules of fat. By the late 1960s researchers had shown that high triglyceride levels were at least as common in heart-disease patients as high LDL cholesterol, and that eating a low-fat, high-carbohydrate diet would, for many people, raise their triglyceride levels, lower their HDL levels and accentuate what the American endocrinologist Gerry Reaven calls Syndrome X — a cluster of conditions that can lead to heart disease and Type 2 diabetes. It took Reaven a decade to convince his peers that Syndrome X was a legitimate health concern, in part because to accept its reality is to accept that low-fat diets will increase the risk of heart disease in a third of the population.
Of course, everyone involved in drafting dietary guidelines wants people simply to eat less junk food. But instead we eat more starches and refined carbohydrates, because, calorie for calorie, these are the cheapest nutrients for the food industry to produce and can be sold at the highest profit. It’s also what we like to eat. Rare is the person under 50 who doesn’t prefer a biscuit or sweetened yogurt to a head of broccoli.
Nutrition researchers also played a role by trying to feed science into the idea that carbohydrates are the ideal nutrient. It had been known for almost a century, but considered mostly irrelevant to the aetiology of obesity, that fat has nine calories per gram compared with four for carbohydrates and protein. Now it became the fail-safe position of the low-fat recommendations: reduce the densest source of calories in the diet and you will lose weight.
Then, in 1982, the American biochemist JP Flatt published his research demonstrating that it is rare for the human body to convert carbohydrates into body fat. This was misinterpreted by the media and quite a few scientists to mean that eating carbohydrates, even to excess, could not make you fat — which is not the case, Flatt says.
As a result, the major trends in American diets since the late 1970s have been a decrease in fat calories and a greatly increased consumption of carbo hydrates. At the same time, they suddenly began consuming more calories: now up to 400 more each day since the US Government started recommending low-fat diets.
If these trends are correct, the obesity epidemic there can be explained by the consumption of more calories than ever and, specifically, more carbohydrates. The question is why? The answer provided by Endocrinology 101 is that people are hungrier than they were in the 1970s, and the reason is physiological more than psychological. In this case, the salient factor is how carbohydrates affect blood sugar and insulin. In fact, these were obvious culprits all along, which is why Atkins and the low-carb-diet doctors pounced on them.
The primary role of insulin is to regulate blood-sugar levels. After you eat carbohydrates they are broken down into their component sugar molecules and transported into the bloodstream. Your pancreas then secretes insulin, which shunts the blood sugar into muscles and the liver as fuel for the next few hours. This is why carbohydrates have a significant impact on insulin and fat does not. And because juvenile diabetes is caused by a lack of insulin, doctors had believed since the 1920s that the only evil with insulin was not having enough.
But insulin also regulates fat metabolism. We cannot store body fat without it. Think of it as a switch. When it’s on, in the few hours after eating you burn carbohydrates for energy and store excess calories as fat. When it’s off, after the insulin has been depleted you burn fat as fuel. So when insulin levels are low, you burn your own fat.
The fatter you are, the more insulin your pancreas will pump out per meal and the more likely you are to develop what’s called “insulin resistance,” which is the underlying cause of Syndrome X. In effect, your cells become insensitive to the action of insulin and you need ever greater amounts to keep your blood sugar in check. So, as you gain weight, insulin makes it easier to store fat and harder to lose it. But the insulin resistance in turn may make it harder to store fat — your weight is being kept in check, as it should be. But now the insulin resistance might prompt your pancreas to produce even more insulin, potentially starting a vicious cycle.
Which comes first — the obesity, the elevated insulin, known as hyperinsulinemia, or the insulin resistance — is a chicken-and-egg problem that hasn’t been resolved. Insulin also profoundly affects hunger, although to what end is another point of controversy. On the one hand, insulin can indirectly cause hunger by lowering your blood sugar, but how low does blood sugar have to drop before hunger kicks in? That’s unresolved. Meanwhile, insulin works in the brain to suppress hunger. The theory, as explained to me by Michael Schwartz, an endocrinologist at the University of Washington, is that insulin’s ability to inhibit appetite would normally counteract its propensity to generate body fat. In other words, as you gained weight, your body would generate more insulin after every meal, and that in turn would suppress your appetite; you’d eat less and lose weight.
Schwartz, however, can imagine a simple mechanism that would throw this “homeostatic” system off balance: if your brain were to lose its sensitivity to insulin, just as your fat and muscles do when they are flooded with it. Now the higher insulin production that comes with getting fatter would no longer compensate by suppressing your appetite, because your brain would no longer register the rise in insulin. The result would be a physiological state in which obesity is almost pre-ordained, and in which the carbohydrate-insulin connection could play a major role. Schwartz says he believes this could indeed be happening, but research hasn’t progressed far enough to prove it.
David Ludwig says that it’s the direct effect of insulin on blood sugar that does the trick. He says that when diabetics get too much insulin, their blood sugar drops and they become ravenously hungry. They gain weight because they eat more, and the insulin promotes fat deposition. The same happens with lab animals. This, he says, is effectively what happens when we eat carbohydrates — in particular, sugar and starches such as potatoes and rice, or anything made from flour, such as bread.
These are known as high-glycaemic-index carbohydrates, which means that they are absorbed quickly into the blood. As a result, they cause a spike of blood sugar and a surge of insulin within minutes. The resulting rush of insulin stores the blood sugar away and, a few hours later, your blood sugar is lower than it was before you ate. Your body effectively thinks it has run out of fuel, but the insulin is still high enough to prevent you from burning your own fat. The result is hunger and a craving for more carbohydrates. It’s another vicious circle, and another situation ripe for obesity.
The gist of the glycaemic-index idea is that the longer it takes the carbohydrates to be digested, the less the impact on blood sugar and insulin and the healthier the food. Green vegetables, beans and whole grains cause a much slower rise in blood sugar because they have fibre, a non-digestible carbohydrate, which slows digestion and lowers the glycaemic index.
Protein and fat serve the same purpose, which implies that eating fat can be beneficial. And the glycaemic-index concept implies that a primary cause of Syndrome X, heart disease, Type 2 diabetes and obesity is the long-term damage caused by the repeated surges of insulin that come from eating starches and refined carbohydrates. At Ludwig’s paediatric obesity clinic, he has been prescribing low-glycaemic-index diets to children and adolescents for five years. His clinic has a nine-month waiting list and in April he received $1.2 million from the National Institutes of Health to test his low-glycaemic-index diet against a traditional low-fat-low-calorie regime. That might help resolve some of the controversy over the role of insulin in obesity, although the redoubtable Robert Atkins might get there first.
The 71-year-old Atkins says he first tried a very low carbohydrate diet in 1963 after reading about one in the Journal of the American Medical Association. He lost weight effortlessly, and turned a fledgling Manhattan cardiology practice into a thriving obesity clinic. He then alienated the entire medical community by telling his readers to eat as much fat and protein as they wanted, as long as they ate little to no carbohydrates. They would lose weight, he said, because they would keep their insulin down; they wouldn’t be hungry; and they would have less resistance to burning their own fat. Atkins also argued that starches and sugar were harmful because they raised triglyceride levels and that this was a greater risk factor for heart disease than cholesterol. When the American Medical Association released its scathing critique of Atkins’s diet in March 1973, it acknowledged that the diet probably worked, but expressed little interest in why. During the 1960s this had been the subject of considerable research, with the conclusion that Atkins-like diets were low-calorie diets in disguise; that when you cut out pasta, bread and potatoes, you have a hard time eating enough meat, vegetables and cheese to replace the calories.
That, however, raised the question of why such a low-calorie regimen would also suppress hunger, which Atkins insisted was the signature characteristic of the diet. One possibility was Endocrinology 101: that fat and protein make you sated and, lacking carbohydrates and the ensuing swings of blood sugar and insulin, you stay sated.
The other possibility arose from the fact that Atkins’s diet is “ketogenic”. This means that insulin falls so low that you enter a state of ketosis, which is what happens during fasting and starvation. Your muscles and tissues burn fat for energy, as does your brain in the form of fat molecules produced by the liver called ketones. Atkins saw ketosis as the obvious way to kickstart weight loss. He also liked to say that ketosis was so energising that it was better than sex, which set him up for some ridicule. An inevitable criticism of Atkins’s diet has been that ketosis is dangerous.
When I interviewed ketosis experts, however, they sided with Atkins, and suggested that maybe the medical community and the media confuse ketosis with ketoacidosis, a variant that occurs in untreated diabetics and can be fatal. “Doctors are scared of ketosis,” says Richard Veech, an NIH researcher. “They’re always worried about diabetic ketoacidosis, but I would argue that ketosis is the normal state of man. It’s not normal to have McDonald’s on every corner. It’s normal to starve.”
Simply put, ketosis is evolution’s answer to the thrifty gene. We may have evolved to store fat efficiently for times of famine, Veech says, but we also evolved ketosis to live efficiently off that fat when necessary.
Rather than being poison, ketones make the body run more efficiently and provide a backup fuel source for the brain. Veech has shown that both the heart and brain run 25 per cent more efficiently on ketones than on blood sugar.
The bottom line is that for the better part of 30 years Atkins insisted his diet worked and was safe, people tried it by the tens of millions while nutritionists, doctors, public health authorities and anyone concerned with heart disease insisted it could kill them, and expressed little or no desire to find out who was right. Now researchers have finally decided that Atkins’s diet and other low-carb diets have to be tested, and are doing so against traditional low-calorie-low-fat diets.
None of these studies has yet been published. But the results have been reported at conferences and they are consistent. Subjects on some form of the Atkins diet — whether overweight adolescents on the diet for 12 weeks or obese adults averaging more than 21st on the diet for six months — lost twice the weight as the subjects on the low-fat, low-calorie diets.
In all five studies, cholesterol levels improved similarly with both diets, but triglyceride levels were considerably lower with the Atkins diet. Though researchers are hesitant, it does suggest that heart-disease risk could actually be reduced when fat is restored to the diet and starches and refined carbohydrates are removed.
All of this could be settled sooner rather than later, and with it, perhaps, we might have some long-awaited answers as to why we grow fat and whether it is pre-ordained by societal forces or caused simply by our choice of food.
Contribute to Debate via comment~thetimes.co.uk
|