Vegan Lifestyle Coach

THE SKINNY ON ATKINS

By Michael Greger, M.D.*

(Part II)

Reprinted from the June 2004 issue of Dr. Greger’s Nutrition Newsletter. To subscribe, send a blank e-mail to drgregersnewsletter-subscribe@lists.riseup.net

WHAT THE EXPERTS THINK OF ATKINS

Bringing Home the Bacon

Atkins conceded that the "WORST [emphasis his]" feature about his diet is the "rapidity with which you gain [weight] if you abandon it." "But the BEST feature," he claims, "is that you don’t HAVE to go off this diet…"246

The reason people fall of the wagon, Atkins claimed, is because of "carbohydrate addiction." What he calls "addiction," though, others might call our natural urge to eat the fuel our bodies evolved to live on—carbohydrates. Patients inevitably cheat and then tragically blame themselves instead of the diet for this failure.

Low carb diets, like all fad diets, tend to fail.247 Even Atkins admitted that there is "no formal documentation" of long-term weight loss on his diet. He’d been supposedly seeing patients for decades on his diet; why didn’t he do a study?

When challenged on just that point Atkins replied, "Why should I support a study? It's all in my book." When it was pointed out that the book was "all anecdotal," Atkins said mainstream medicine's demand for proof simply functioned to "maintain it at its current level of ineptitude."248

In February 2000, the USDA brought Atkins in to discuss his diet. When asked why he doesn’t conduct his own study, he pleaded poverty: "But I haven't been able to fund a study." To which the Director of Nutrition Sciences at Albert Einstein College of Medicine, replied, "Ten million books in print and you can't fund a study?"

The Director continued: "You market the vitamins. You sell the vitamins. You market this. This is not for the public good. This is a money-making proposition."249 The Chair of the Board of Atkins’ own New York County Medical Society made a similar charge when Atkins’ book was first published, alleging it was "clearly… unethical” and “self-aggrandizing."250 The New York Board of Health later tried, unsuccessfully, to revoke his medical license.251

Why has the U.S. government been lax in testing the Atkins Diet at any point in the last 30 years? One reason may have been that it might be difficult to get approval from an ethical review committee to put people on the diet long term, given what is known about the dangers of a meat-laden diet. As one medical review concluded, "There is no evidence that low carbohydrate diets are effective for long-term weight management, and their long-term safety is questionable and unproven."252

The current Director of Nutrition at Harvard advises that all physicians should produce a handout warning about all of the adverse effects of the Atkins Diet. Not only should the handout explain explicitly that the diet may increase one’s risk of heart disease, cancer, and stroke, but also that "Other health risks include… dizziness, headaches, confusion, nausea, fatigue, sleep problems, irritability, bad breath, and worsening of gout and kidney problems; osteoporosis, since a high ratio of animal to vegetable protein intake may increase bone loss and the risk of hip fracture in elderly women; a rise in blood pressure with age…and rapid falling blood pressure upon standing up (orthostatic hypotension), which can… put older patients at higher risk for falls."253 After running through the adverse effects associated with ketosis, the American institute for Cancer Research wrote, "Those are the short-term effects. The long-term effects are even more dire."254

LONG-TERM SIDE EFFECTS

"Massive Health Risk"

The Atkins’ Diet downfall is also its one saving grace—people may not be able to tolerate it for long enough to suffer the long-term consequences. The American Heart Association states: "Individuals who follow these diets are therefore at risk for compromised vitamin and mineral intake, as well as potential cardiac, renal [kidney], bone, and liver abnormalities overall."255

In Europe, hospitals have already started banning the Atkins Diet256,257 after the British government’s Medical Research Council, backed up by the British Nutrition Foundation and the British Dietetic Association,258 condemned the Atkins Diet as "negligent"259 "nonsense and pseudo-science"260 posing a "massive health risk."261

An article out of the Cleveland Clinic Journal of Medicine entitled "Physician’s Guide to Popular Low Carbohydrate Weight-Loss Diets" noted that the Atkins Diet "can jeopardize health in a variety of ways."262 Let us count the ways.

Malnutrition

Atkins followers risk a number of serious nutrient deficiencies.263 In fact some people have become so deficient on low carb ketogenic diets that they almost went blind because their optic nerves started to degenerate.264,265

When cutting calories, it’s especially important to eat nutrient-dense diets, but the Atkins Diet presents a double whammy; it restricts the healthiest foods, like fruit, and unrestricts some of the unhealthiest, like meat. Shortly after Atkins’ original book was published, the highly prestigious Medical Letter on Drugs and Therapeutics concluded that the Atkins Diet was "unbalanced, unsound and unsafe."266 As noted in a Medical Times review, Atkins has created a "ridiculously unbalanced and unsound" "hazardous" diet.267 Twenty-seven years later the Medical Letter offered an update noting that the safety of the Atkins Diet had still “not been established.”268

A diet like Atkins maximizes the consumption of disease-promoting substances like the cholesterol, saturated fat, and industrial pollutants in meat, yet restricts one’s intake of fiber and the literal thousands of antioxidants and phytochemicals found exclusively in the plant kingdom (like the carotenoids, lycopenes, bioflavenoids, phytic acid, indoles, isothiocyanates, etc.) that have "anti-aging, anti-cancer and anti-heart disease properties."269 As a 2004 medical review concluded, the Atkins Diet is so "seriously deficient" in nutrition that "there is real danger of malnutrition in the long term."270

Where might then one get one’s vitamins on the Atkins Diet? From the Atkins website, of course, on sale now for just over $640 a year.271 Add some antioxidants and the tab is up to $1000.272 That is of course in addition to the estimated $400273-$1400274 the pricey Atkins food—meat and cheese—costs every month (unless one chooses to live off hot dogs).

Realizing his diet is so deficient in nutrients, Atkins prescribed no less than 65 nutritional supplements in part to help fill the nutritional gaps created by his diet.275 A "proper Atkins Dieter" Atkins wrote, "follows the entire program, including the supplements."276 In his last edition Atkins even had a chapter entitled "Nutritional Supplements: Don’t Even Think of Getting Along Without Them."277 Perhaps this is because his corporation sells them.

"Who needs orange juice," Atkins wrote, "when a Vitamin C tablet is so handy?"278 Oranges, of course, contain much more than vitamin C. As Sue Radd, a world leader on phytonutrient research, put it "There's not one vitamin pill in the world that can give you everything you need."279 A review in the Cleveland Clinic Journal of Medicine agreed that the Atkins Diet is "deficient in nutrients that cannot be replaced by supplements and are excessive in nutrients that may increase the risk of mortality and chronic disease."280

Responding to the criticism that the Atkins Diet was deficient in fruits and vegetables, Atkins-funded researchers responded that people in Atkins could include a limited quantity of some vegetables "and even small amounts of fruit." Even during later, more liberal phases of the diet, though, Atkins warned readers that eating fruit will "always be somewhat risky." The Atkins researchers continued, "It would be prudent to take a multivitamin/mineral supplement."281 A low carb diet is a low nutrition diet.

Cancer

Atkins followers also risk cancer. Studies at Harvard and elsewhere involving tens of thousands of women and men have shown that, for example, regular meat consumption increases colon cancer risk as much as 300 percent.282,283 As one Harvard School of Public health researcher noted, because of the meat content, two years on the Atkins Diet "could initiate a cancer. It could show up as a polyp in 7 years and as colon cancer in ten."284

It’s tragically ironic that after McDonald’s CEO apparently dropped dead of a heart attack in 2004, their new CEO was in the operating room with colo-rectal cancer only 16 days later.285

Women with the highest intake of animal fat seem to have over a 75% greater risk of developing breast cancer.286 The American Cancer Society has officially condemned diets high in animal grease, concluding "a low carb diet can be a high-risk option when it comes to health."287

Kidney "Scarring"

Atkins followers also risk kidney damage.288 Like his advice for pregnant women, Atkins once wrote "The diet is safe for people even if there is a mild kidney malfunction."289 We now know this to be false.

In a press release entitled "American Kidney Fund Warns About Impact of High-Protein Diets on Kidney Health," Chair of Medical Affairs, Paul W. Crawford, M.D., wrote, "We have long suspected that high-protein weight loss diets could have a negative impact on the kidneys, and now we have research to support our suspicions." Dr. Crawford is worried that the strain put on the kidneys could result in irreversible "scarring in the kidneys."290

Three months later, the newest edition of the New Diet Revolution was released in which Dr. Atkins stated: "Too many people believe this untruth [that too much protein is bad for your kidneys] simply because it is repeated so often that even intelligent health professionals assume it must have been reported somewhere. But the fact is that it has never been reported anywhere. I have yet to see someone produce a study for me to review…"291

Although evidence that such diets could be risky for one’s kidneys existed years before he made that statement,292 the definitive study showing just how dangerous his diet could be to a dieter’s kidneys was published a month before Atkins died. The Harvard Nurse’s Study proved that high meat protein intake was associated with an accelerated decline in kidney function in women with mild kidney insufficiency.293 The problem is that millions of Americans—as many as one in four adults in the United States—seem to already have reduced kidney function, but may not know it, and would potentially be harmed by high meat diets like Atkins.294 And the "excessive" amount of protein which furthered kidney damage in the women in the Nurses Study is only about half of what one might expect to get on the Atkins Diet.295

The American Academy of Family Physicians notes that high animal protein intake is also largely responsible for the high prevalence of kidney stones in the United States. Kidney stones can cause severe pain, urinary obstruction, and kidney damage. Plant protein did not seem to have a harmful effect.296

American Kidney Fund’s Dr. Crawford concluded, "Chronic kidney disease is not to be taken lightly, and there is no cure for kidney failure. The only treatments are kidney dialysis and kidney transplantation. This research shows that even in healthy athletes, kidney function was impacted and that ought to send a message to anyone who is on a high-protein weight loss diet."297

Peeing Your Bones Down the Toilet

A 2003 review of the safety of low carbohydrate diets reeled off an alarming list of potential problems: "Complications such as heart arrhythmias, cardiac contractile function impairment, sudden death, osteoporosis, kidney damage, increased cancer risk, impairment of physical activity and lipid [cholesterol] abnormalities can all be linked to long-term restriction of carbohydrates in the diet."298

There is a particular concern that children who go on the Atkins Diet might suffer permanent physical and mental damage as a result of starving their bodies of critical nutrients. As one U.S. child nutrition specialist explained, "The effect can be to dull the mind, stunt growth, and soften bones…I wouldn't want to risk it by putting my child on a low carbohydrate diet."299

The concern with bone health arises from the fact that muscle protein has a high sulphur content. When people eat too much of this meat protein, the sulphur forms acid within our bodies which must somehow be neutralized to maintain proper internal pH balance. One way our bodies can buffer the sulphuric acid load caused by meat is with calcium borrowed from our bones. People on high meat diets can lose so much calcium in the urine that it can actually solidify into kidney stones.300 Over time, high animal protein intakes may leach enough calcium from the bones to increase one’s risk of osteoporosis. People may be peeing their bones into the toilet along with the ketones.

The Harvard Nurse’s study, which followed over 85,000 nurses for a dozen years, found that those who ate more animal protein had a significantly increased risk of forearm fracture. While plant-based proteins did not show a deleterious effect, women eating just a serving of red meat a day seemed to have significantly increased fracture risk.301 Other studies have linked meat consumption to hip fracture risk as well.302

Although Atkins conceded, "kidney stones are a conceivable complication,"303 Atkins dismissed any assertion that his diet might endanger bone health. Researchers decided to test his claim directly.

In 2002, researchers from the Universities of Chicago and Texas published a study that put people on the Atkins Diet and measured 1) how acidic their urine got and 2) just how much calcium they were losing in their urine. They reported that the Atkins Diet resulted in a "striking increase in net acid excretion." After just two weeks on the Atkins Diet, the subjects were already losing 258mg of calcium in their urine every day. They concluded that the Atkins Diet "provides an exaggerated acid load, increasing risks for renal calculi [kidney stone] formation and bone loss."304 In addition, the Atkins Diet is actually deficient in calcium in the first place—even if one includes his 65 supplements.305 Luckily there’s a 66th, available on his website.306

"Eaters of Raw Flesh"

We don’t have any long-term published data on the bone health of Atkins followers (or any other health parameter for that matter). One might look to the Inuit peoples—the so-called "Eskimos"—for hints, though. (The word Eskimo comes from the word Eskimaux—"eaters of raw flesh.")307 They seem to be the only population on Earth approximating the Atkins Diet, living largely off Atkins dream foods like blubber.

Despite having some of the highest calcium intakes in the world, the Inuit also have some of the worst rates of osteoporosis.308 Although calcium intakes vary widely, people in some villages get over 2500mg a day, almost 5 times what most Americans get, due to their eating many of their fish whole, bones and all.309 So for example, in one of their recipes for “Ice Cream," although the "2 cups moose grease" the recipe calls for is not high in calcium, the "1 dressed pike" added to the recipe gives the Atkins-friendly dessert a respectable 130mg of calcium per serving.310 The "unusually rapid bone loss" found in every study ever published on Inuit bone health is blamed on the "acidic effect of a meat diet."311,312,313,314,315

While the near-Akins level of animal protein intake seems to be dissolving their bones, due to the near-Atkins level of animal fat intake, the Inuit women have some of the highest levels in the world of PCBs in their breast milk. Their blood is swimming with mercury and other toxic heavy metals. "They're at the top of the food chain," says Dr. Russel Shearer, an environmental physical scientist with the Canadian Department of Indian Affairs and Northern Development, and therefore "accumulate the highest levels of these contaminants."316 In the last edition of his book, Atkins did finally acknowledge the threat posed by the industrial pollutants in animal foods and urged his followers to choose organic free-range meat.317

Atkins Distorted His Record on Cholesterol

Although ketogenic diets have caused a number of "serious potentially-life-threatening complications,"318 perhaps the greatest danger of the Atkins Diet, according to the American Medical Association, lies in the heart.

Atkins claimed a worsening of cholesterol levels typically only occurs "when carbohydrates are a large part of the diet."319 We’ve known this to be false since 1929 when the Institute of American Meatpackers paid to see what would happen if people lived on an all-meat diet. The blood plasma of the unfortunate subjects was so filled with fat it "showed a milkiness" and one of the subject’s cholesterol shot up to 800!320

Atkins revelations like "Reverse heart disease with filet mignon!"321 notwithstanding, in the head-to-head comparisons of the four popular weight-loss diets, Ornish’s vegetarian diet was the only one that showed a significant decrease in LDL levels—the so-called "bad" cholesterol. Even researchers paid by Atkins concede that high saturated fat diets like Atkins tend to increase LDL cholesterol.322 They have to concede the truth, though, since they publish their work in peer-reviewed scientific journals. Dr. Atkins, though, died without ever publishing a single paper in any scientific journal about anything, and thus had more freedom to bend the truth.

"The truth," Atkins wrote, "is that every one of a score of studies on [very low carb diets] showed a significant improvement in cholesterol." He accused those who say otherwise of simply not doing their homework. Any claim that cholesterol doesn’t significantly improve in "every one of scores of studies" is, he wrote in the last edition, "one of the many examples of untruths being perpetrated because the accusers don’t bother to read the scientific literature."323 Of course he then goes on to recommend no less than 17 supplements for the "prevention of cholesterol elevations" on his diet.324

But what about his claim that "every one of a score of studies showed a significant improvement in cholesterol." When the AMA and the American Heart Association question this "fact," is it just because they "don’t bother to read the scientific literature?" That statement of his, in the latest edition of his book, presents a clear opportunity to test the veracity of his claims. And the actual truth is almost the exact opposite.

Unfortunately, Dr. Atkins didn’t include citations to back up his "score of studies" statement. In fact, when pressed for a list of citations in general, Dr. Atkins told an interviewer that “It and the papers I quoted were in a briefcase I lost some time ago.”325 Researchers have located about a dozen studies, though, that measured the effects of low carb diets on cholesterol levels. Did they all "show a significant improvement in cholesterol?" No. In fact, seemingly with only one exception, every single controlled study showed just the opposite—LDL cholesterol either stagnated or was elevated by a low carb diet, even in those that showed weight loss.326,327,328,329,330,331,332,333,334,335,336,337,338,339

During active weight loss—any kind of weight loss (whether from chemotherapy, cocaine use, tuberculosis or the Atkins Diet) cholesterol synthesis temporarily decreases340 and LDL cholesterol levels should go down.341 Yet, with all the saturated animal fat in the Atkins Diet tending to instead push levels up, in most studies the bad cholesterol doesn’t fall like it should have. The saturated fat in effect cancelled the benefit one would expect while losing weight. And what happens when people on the Atkins Diet stop losing weight? People can’t lose weight forever (Stephen King novels aside). The fear is that their LDL cholesterol level might then shoot through the roof.342,343

Sometimes even during the active weight loss, however, LDL cholesterol levels became elevated on the Atkins Diet. One study on women, for example, showed that just two weeks on the Atkins Diet significantly elevated average LDL levels over 15%.344 In a trial of men on the Atkins Diet, even though they lost an average of 17 pounds after 3 months, their LDL cholesterol jumped almost 20%.

The May 2004 Annals of Internal Medicine study showed that a third of Atkins Dieters suffered a significant increase in LDL cholesterol. The goal is to have a double digit LDL—an LDL under 100 (mg/dl).345 In the study one person’s LDL shot from an unhealthy 184 to a positively frightening 283 (which means their total cholesterol was probably somewhere over 350).346 With so many people on these diets, that could mean Atkins is endangering the health of millions of Americans.347 LDL cholesterol is, after all, one of the most important risk factors for heart disease, the number one killer in the United States for both men and women.348

In another clinical trial, despite statistically significant weight loss reported in the Atkins group, every single cardiac risk factor measured worsened after a year on the Atkins Diet (measures included LDL, triglycerides, total cholesterol, HDL, total-to-HDL cholesterol ratio, homocysteine, Lp(a), and fibrinogen). While the LDL in the Atkins group increased 6%, the LDL cholesterol levels in the whole-foods vegetarian group was cut in half—dropping 52%. When the pro-Atkins journalist who wrote the misleading New York Times Magazine piece was confronted as to why he didn’t include the results of this landmark study, which directly contradicted what he wrote in the article, all he could do was to accuse the researchers of just making the data up.349

It’s interesting to note that the one exception of a published study of the Atkins Diet showing a significant LDL lowering had no control group, put subjects on cholesterol-lowering supplements and was funded by the Atkins corporation itself. Even in that study though, the drop was modest—only a 7% drop (compared, for example, to the 52% drop on the vegetarian diet)—and didn’t include two subjects who quit because their cholesterol levels went out of control.350

Yet studies like this have been heralded as a vindication of the Atkins Diet by the mainstream media.351 As journalist Michael Fumento, co-author of Fat of the Land, pointed out, "How peculiar when the most you can say for the best-selling fad-diet book of all time is that it probably doesn't kill people."352 To which I might add, "in the short-term." Based on an analysis of the Atkins Diet, long-term use of the Atkins Diet is expected to raise coronary heart disease risk by over 50%.353 "The late Dr. A," Fumento quips, "still gets an F."354

Less often reported in the media is the fact that one of the research subjects placed on the Atkins Diet in the 2003 "vindication" study was hospitalized with chest pain and another died.355 Similarly, in the widely publicized May 2004 study, less widely publicized was the fact that two people in the low carb-diet arm of the study couldn’t complete the study because they died. One slipped into a coma; the other dropped dead from heart disease.356 As the Director of Nutrition at the Harvard School of Medicine has written, "there is still much danger in the widespread fad enthusiasm for these diets."357

The Atkins corporation boasts of the supposed ability of the Atkins Diet to significantly raise the level of HDL, or "good" cholesterol in a consistent manner.358 HDL transports cholesterol out of one’s arteries to the liver for disposal or recycling. Only a minority of controlled studies on Atkins-like diets, however, have shown such an effect,359,360,361,362,363,364,365,366,367,368,369,370,371,372 but more importantly, the type of HDL increase seen sometimes on the Atkins Diet isn’t necessarily healthful.373 When one eats more garbage (saturated fat and cholesterol) one may need more metabolic garbage trucks (like HDL) to get rid of it. Eating a stick of butter may raise one’s HDL, but that doesn’t mean chewing one down is good for one’s heart. In any case, significantly lowering one’s LDL seems more important than significantly raising one’s HDL,374 though the studies done on low carb diets typically show neither.

Because of these “well-known hazards,” the Chair of the Nutrition Department at Harvard when Atkins’ book was originally published warned physicians that recommending the Atkins diet “borders on malpractice.”375

The Proof is in the SPECT Scan

Until the year 2000, all anyone had to evaluate the impact of the Atkins Diet on the heart was changes in cardiac risk factors like cholesterol. But then a landmark study was published which, for the first and only time, actually measured what was happening to peoples’ arteries on this kind of diet. The results were shocking.

Richard Fleming, MD, an accomplished nuclear cardiologist, enrolled 26 people into a comprehensive study of the effects of diet on cardiac function. Using echocardiograms, he could visualize the pumping motion of the heart, and with the latest in nuclear imaging technology—so-called SPECT scans—he was able to actually directly measure the blood flow within the coronary arteries, the blood vessels that bring blood to the heart muscle and allow it to pump. It is when one of these coronary arteries gets blocked that people have a heart attack.

Fleming then put them all on a low saturated fat, high carbohydrate diet—the kind that has been proven to not just stop heart disease, but to in some cases actually reverse it, to open up the arteries.376 A year later the echocardiograms and SPECT scans were repeated. By that time, though, 10 of his patients had, unbeknownst to him, jumped on the low carb bandwagon. All of a sudden, Dr. Fleming had an unparalleled research opportunity dropped in his lap. Here he had extensive imaging of 10 people following a low carb diet and 16 following a high carb diet. What would their hearts look like at the end of the year? We can talk about risk factors all we want, but compared to the high carb group, did the coronary heart disease of the patients following the Atkins Diet improve, worsen, or stay the same?

Those sticking to the whole-foods vegetarian diet showed a reversal of their heart disease as expected. Their partially clogged arteries literally got cleaned out, and blood flow to their hearts through their coronary arteries increased 40%. What happened to those who abandoned the high carb diet, though, and switched over to the Atkins Diet and started chowing down on bunless cheeseburgers? Their condition significantly worsened. All that saturated fat and cholesterol in their diet clogged their arteries further—the blood flow to their hearts was cut 40%. The only study on the Atkins Diet to actually measure arterial blood flow showed widespread acceptance of a high saturated fat diet like Atkins could be heralding a future epidemic of fatal heart attacks. Validation that "If you were trying to damage your heart," wrote the Center for Science in the Public Interest, "you couldn’t do much better than to eat a cheeseburger."377 Maybe filet mignon doesn’t work after all.

The blood flow scans have been posted online so people can see the evidence for themselves: http://my.webmd.com/content/pages/1/3075_903

"We worry about this," explains Dr. James W. Anderson, Professor of Medicine and Clinical Nutrition at the University of Kentucky School of Medicine, "because many of the people who love these diets are men aged 40 to 50, who like their meat. They may be 5 years from their first heart attack. This couldn't be worse for them. Did you know that for 50% of men who die from heart attacks, the fatal attack is their first symptom? They will never know what this diet is doing to them."378

Emerging evidence also suggests that ketogenic diets may "create metabolic derangement conducive to cardiac conduction abnormalities and/or myocardial dysfunction"—in other words cause other potentially life-threatening heart problems as well. Ketogenic diets may cause a pathological enlargement of the heart called cardiomyopathy, which is reversible, if the diet is stopped in time.379 The Atkins corporation denies that Dr. Atkins’ own cardiomyopathy induced-heart attack, hypertension, and blocked arteries had anything to do with his diet.380

Saturated Fat and Cholesterol Are Bad for You

The Atkins Diet restricts foods that prevent disease and promotes foods that promote disease.381 No matter what Atkins or other diet books tell people, the balance of evidence clearly shows that the intake of saturated animal fat is associated with increased risk of cancer,382,383 diabetes, and heart disease.384 For over 40 years medical reviews have also shown the detrimental impact of dietary cholesterol consumption.385 Even independent of the effects on obesity, meat consumption itself has been related to an increased risk of coronary heart disease386

The best dietary strategy to reduce one’s risk of dying from the number 1 killer in the U.S. is to reduce one’s consumption of saturated fat and cholesterol. The evidence backing this, according to the American Heart Association, is "overwhelming."387

Decreasing America’s intake of saturated animal fat is the primary reason why Johns Hopkins, supported by 28 other public health schools, launched the Meatless Mondays campaign trying to get Americans to cut meat out of their diet at least one day out of the week.388 Dr. Jean Mayer, one of the most noted nutrition figures in history— author of over 750 scientific articles, President of Tufts University, recipient of 16 honorary degrees—warned those going on “this faddish high-saturated-fat high-cholesterol [Atkins] diet” that they may be “playing Russian roulette with your heart and with your blood vessels.”389 "The Council," wrote the American Medical Association in their official critique of the Atkins Diet, "is deeply concerned about any diet that advocates an ‘unlimited’ intake of saturated fats and cholesterol-rich foods."390

In return, Atkins accused the American Medical Association of being in the pockets of carbohydrate manufacturers. “If you look at the financial records of the AMA and the Harvard School of Nutrition,” said Atkins in an interview, “and see the list of their benefactors, advertisers, and endowers you'll see why they insist on our eating carbohydrates." 391

Interestingly, the Atkins corporation seems like it’s already backpedaling. A front page article in the New York Times revealed that the Atkins corporation was quietly telling people to restrict their bacon and butter intake, urging people to keep saturated fat intake under 20% of calories,392 Of course it seems every major health organization on the planet recommends less than half that, but it does show at least that Atkins Inc. may be recognizing the dangers of their diet.393

The Atkins corporation claimed that their saturated fat guideline was nothing new and that Atkins never said people could eat as much meat as they wanted. They blamed the media for just misconstruing the Atkins Diet as an eat-as-much-meat-as-you-want diet.394 Really? Atkins wrote, "There is no limit to the amount of… [any kind of meat in any quantity] you can eat… You eat as much as you want, as often as you want” (emphasis in original.)395 In fact he specifically boasts that his diet "Sets no limit on the amount of food you can eat."396 Maybe the media got it right.

The Director of Research and Education at Atkins Nutritionals claims that "Saturated fat isn't as much of an issue when carbohydrates are controlled; it's only dangerous in excess when carbs are high." Dr. Frank M. Sacks, a professor of cardiovascular disease prevention at the Harvard School of Public Health, scoffed at such a claim. "What they are saying is ridiculous," he said. The revision to 20% saturated fat, he added, "has nothing to do with science; it has to do with public relations and politics."397

Closing Off His Heart to the Atkins Diet

One can still go to the Atkins website, though, and read how innocuous saturated fat is. One reader asks, "Is it OK for me to consume more than 20% of my calories in the form of saturated fat?" The answer given is "Absolutely."398

With this kind of advice, 53-year-old businessman Jody Gorran stayed on the Atkins Diet, and continued to recommend it to his friends even though his cholesterol had shot up 50%. Before starting the Atkins Diet, his cholesterol was excellent, he had no history of heart disease, and an unrelated CT scan showed that his coronary arteries were clean.399

For Jody Gorran it took two years on the Atkins Diet before the crushing chest pain started. By then one of his coronary arteries was 99% blocked and his heart function was suffering for it. An immediate cardiac catheterization and stent placement may well have saved his life. In the opinion of his cardiologist, Gorran might well have otherwise had a massive heart attack and died within a short period of time. Mr. Gorran is now suing the Atkins corporation, alleging that they "knew, or should have known," that what they were saying about their diet and heart disease risk were false. He is trying to get the corporation to include warning labels on its books, website, and products that a low carbohydrate diet “may be hazardous to your health—check with your physician.”400

This is not the first time Atkins was sued. When the book first came out, a million dollar class action suit was brought against Atkins and his publisher to recover medical expenses incurred by the diet’s side effects.401 A Brooklyn Assemblyman on Atkins who nearly died after a heart attack sued Atkins and the publisher for publishing the book “without regard to the safety, truth or accuracy if the statements contained in the book.”402 As revealed in the book Nutrition Cultism, on three separate occasions Atkins was sued and the cases were settled out of court in favor of the plaintiffs.403

"The point is," Gorran said in an NBC News interview, "Dr. Atkins lied to the public. He didn't care. For his ego or for corporate greed, that's what this thing's about."404 "A successful diet has to be more than simply losing weight" Gorran said on Good Morning America, "A successful diet should not kill you."405

Rachel

Most people aren’t able to remain on the Atkins Diet long enough to develop osteoporosis, kidney damage or hardening of the arteries. Sixteen year-old high school student Rachel Elizabeth Huskey only lasted seven weeks.

Rachel had a crush on a boy in her church. So she started the Atkins Diet to lose weight. In part because she was so nauseated on the diet, she lost 16 pounds. She was hoping being thinner would make her more popular at school. After a brief carbohydrate relapse, she restarted it again "very strictly"406 but could only stick with it this time for 9 days

In history class, amidst cheering fellow students for acing a tough question, she collapsed without warning. And then she died. Frenzied attempts to resuscitate her failed.407 Her doctors blame the Atkins Diet.

The kidney uses minerals like potassium and calcium to help rid one’s body of toxins like ketones. People on the Atkins Diet are urinating these minerals away. And critically low levels in the blood of these electrolytes can lead to fatal cardiac arrhythmias—lethal heart rhythms. Rachel was on the Atkins Diet and was found on autopsy to have critically low blood levels of both potassium and calcium and she died of a cardiac arrhythmia. Rachel was previously in good health and had no history of any medical problems.

After ruling out other potential causes, the medical team of child health specialists that investigated her death couldn’t help but conclude in their published report, "Sudden Cardiac Death of an Adolescent During Dieting," that the Atkins Diet was the most likely cause of her death.

The chief executive of the Atkins corporation denied there was a link between the diet and Rachel's death, but implied she should have consulted her doctor before starting the diet.408 In fact, concern over just such an event led the Director of the Nutrition Department at the esteemed Cleveland Clinic to declare that for people on the Atkins Diet, "Careful monitoring of electrolytes is absolutely essential…" Those who aren’t professionally monitored on this kind of diet "are at the greatest risk for dangerous complications."409

Dr. Paul Robinson, the Director of Adolescent Medicine at the University of Missouri involved in the investigation of Rachel’s death, is afraid that "we're having lots of near misses that we don't know about."410 "You wonder," he said, "whether there are other people dying and we don't know about it."411

One would think a teenager collapsing and dying after just 9 days on the diet might have ruined people’s appetite for Atkins, but her death was hardly reported in the American press. When her parents held a press conference to tell their story for the first time and warn others that Atkins "killed our little girl,"412 it was reported in London, Scotland, New Zealand, Australia and South Africa. But out of the 34 reports that made it into the papers around the world about this Missouri teen, only 3 appeared in the U.S.413 Despite repeated warnings from the American Heart Association, enthusiasm for the Atkins Diet did not seem to wane.

While tending her daughter's immaculately-kept grave, Rachel’s mom told a reporter her thoughts on the diet: "I want people to know you can actually die doing something as stupid as this."414

Down on Atkins Down Under

Australia seems to be the only nation in which action is actually being taken at a State level. The Victorian Health Minister, supported by the Australian Heart Foundation and the Australian Medical Association, issued a warning to alert people to the dangers of the Atkins Diet and other high-fat fad diets.415 The government is warning the public about the potential short-term effects—constipation, dehydration, bad breath, low energy and poor concentration—and potential long-term effects such as the increased likelihood of cancer, heart disease, depression, and osteoporosis. "When we know something is bad for people, like smoking," the health minister explained, "then we let people know what the health risks are."416

Initially, the government will distribute educational materials in doctors’ waiting rooms, gyms and universities, probably followed by advertising in bus shelters and in the media.417 Australia’s chief physician urged all governments to follow suit.418

The Atkins empire said that this was the first government to launch a public health campaign against them. The British government did issue a warning against low carbohydrate diets, saying they were "bad for your health" though it didn’t specifically name Atkins.419 The "US Federal Government officials," Atkins corporate representatives said, "had a much more positive response…"420 Perhaps "low carb" foods aren’t a $30 billion dollar business down under.

Only Under Monthly Clinical Supervision

In a medical journal article entitled "Bizarre and Unusual Diets" the authors warn that the Atkins Diet had such questionable safety that it should "only be followed under medical supervision."421 But what do doctors know about nutrition? Even though the United States Congress mandated that nutrition become an integrated component of medical education,422 as of 2004, less than half of all U.S. medical schools have a single mandatory course in nutrition.423 That explains the results of a study published in the American Journal of Clinical Nutrition that pitted doctors against patients head-to-head in a test of basic nutrition knowledge. The patients won.424 People off the street seem to know more about nutrition than their doctors.

Doctors can monitor for adverse effects, though. "The Atkins program falls short in insufficiently warning dieters," another review of popular weight loss diets warns, so that they "need to be monitored by a physician to ensure his or her safety."425 According to the Chair of the Nutrition Department at Harvard Medical School, people on Atkins "should be monitored for orthostatic hypotension… dizziness, headaches, fatigue, irritability, gout and kidney failure." And laboratory work should include "blood tests (glucose, blood urea nitrogen, sodium, potassium, chloride, and bicarbonate), urinalysis (specific gravity, pH, protein, and acetone) and a lipid profile. Vital signs… should be monitored at least monthly during a low carbohydrate weight-loss program."426

I suppose the expense of monthly visits would be in addition to the $10,000-$20,000 the food and supplements are estimated to cost every year.427,428,429,430

THE SAFER ALTERNATIVE

Where Atkins Deserved Credit

Once, when Dr. Ornish was being interviewed on Dateline NBC, his interviewer swore that he had lost 50 pounds on an Atkins Diet, ate a steak every day and felt great. He asked Ornish "How bad could it be?" When Ornish turned the tables and questioned the host, it came out that, before going on Atkins, the guy seemed to be living off french fries, fried onion rings, cheesecake, and at least five soft drinks per day, everyday. He had since cut all those out and started exercising religiously. Ornish pointed out that the reason he’s now feeling better was probably in spite of the steak, not because of it.431

While Atkins used to tell people to eat unlimited quantities of hydrogenated shortening like Crisco,432 thankfully he flip-flopped and now warns about the "dangers of trans fats." Just cutting out deep fried foods (most often fried in 100% vegetable—and 100% hydrogenated—oil) from one’s diet should alone improve one’s cholesterol profile. Atkins also encouraged everyone to cut out caffeine, eat more heart-healthy nuts and omega-3 fatty acids and does consider daily exercise a critical "non-negotiable" component to his plan.433

Anyone completely cutting out sugary soda, pastries, ice cream, cookies, cake, candy, kids’ cereals, and Snackwells is probably going to feel better. But does one need a 300-page diet book to tell us that? Anything that can give Krispy Kreme’s corporate profits that glazed look434 is a good thing for America’s health.

For those who don’t remember, Snackwells were Nabisco's line of low-fat and fat-free junk food that went from zero to a billion dollars in revenues in four short years, in effect becoming America's most popular cookie. When Snackwells’ fat-free Devil's Food Cookie Cakes first appeared, demand was so high that Nabisco had to ration them out to stores and fights broke out, forcing store managers to keep boxes of the cookie under lock and key.435

People were mistaking low-fat for low-calorie. The intention of the government’s recommendation to cut down on fat was to get people to cut down on items like meat and switch to foods that are naturally low in fat—like beans, whole grains, fruits and vegetables. These don’t have much of a profit margin, though, so the food industry took advantage of the new guidelines to market low-fat junk food like Snackwells cookies, swapping fat for sugar. Each cookie was basically just white flour, no fiber and two spoonfuls of sugar. Even bags of jellybeans started boasting "fat-free." A similar phenomenon is now happening with low carb junk food. A new Atkins-friendly ice cream, for example, has almost twice the calories of regular ice cream (and of course twice the fat).436 “It's Snackwells all over again,” noted one WebMD Medical News article.437 Junk food—low fat or low carb—is still junk food

People also may feel better on the Atkins Diet because he tells people to stop drinking cow’s milk. Even the National Dairy Council admits438 that literally most people on the planet are lactose intolerant (and may not even know it).439 That change alone should make a segment of the people trying Atkins feel better. Other easy born-again Atkins converts might be those with an actual dairy allergy or the one out of every few hundred Americans who is allergic to wheat.440

Even at his strictest, Atkins "allowed" two small salads a day. Although they can only be a cup of "loosely" packed greens each, that’s sadly more salad than many non-Atkins Americans may get. Then again, of course, Atkins’ "spinach salad" recipe calls for an entire pound of bacon and 5 eggs. No croutons, of course—"use crumbled fried pork rinds instead."441

Atkins even recommended eating one’s greens organic, dark, and leafy,442 although the word "kale" does not seem to frequent the book sleeve. Unfortunately people may ignore the few reasonable suggestions that Atkins made, and just use his low carb phenomenon as an excuse to eat whatever they want.

The Answers are No and No

There seem to be two Atkins Diets: one that he describes in his books (particularly in later editions), and the one the public thinks he describes in his books. How many Atkins Dieters, for example, only eat free-range organic bacon? This may be one of the reasons why we haven’t seen even higher rates of serious side effects—so few people may be actually following the diet.

A recent study of 11,000 people found that only one in four of those claiming to be on a low carb diet were actually significantly cutting carbs at all.443 Another survey, commissioned by former Surgeon General C. Everett Koop’s organization Shape Up America!, found that most people claiming to be on Atkins, or another of the low carb fad diets, didn’t seem to even know where carbs were found.444 Most didn’t know, for example, that tomatoes were high in carbs. Thankfully, about half of them didn’t know apples had a lot of carbs, and 1 in 6 even thought steak was a carbohydrate.445 Thankfully most people on Atkins are actually not on Atkins.

Despite the softening of his stance on whole grains and many vegetables, Atkins still made saturated fat-laden meat and dairy the centerpiece of his diet. The Atkins Diet therefore remains dangerous even when "used as directed."

Isn’t it possible to do the Atkins Diet healthfully, though? Isn’t there some way to modify it to make if safer? Those exact questions were asked of the editors at the Tufts University Health and Nutrition Letter by one of the University’s Vice Presidents.

After trying their best, the editorial staff at the Tufts Letter couldn’t help but conclude, "So, as to whether it’s possible to follow the Atkins Diet healthfully or tweak it to make it safe and healthful, the answers are no and no"(emphasis in original).446

Too Good to Be True

What kind of diet can cause birth defects? Or blindness? Or requires 65 supplements? Or monthly medical checkups, where the monitoring of electrolytes is considered "absolutely essential?" Is it too much to ask that one’s diet facilitate instead of debilitate physical activity? (Here in Boston there has yet to be a night of pork-rind loading before the Marathon.) What kind of diet may require prescriptions to deal with the side effects? What kind of diet has side effects at all?

Rational people go on irrational diets because "they're desperate," says Kelly Brownell, Director of Yale University's Center for Eating and Weight Disorders. "If you're a person with an overweight body living in a thin-obsessed world… something that offers a miracle is highly attractive."447

The Director of Nutrition at the Center for Science in the Public Interest is dumbfounded that the high-fat regimes have caught on. "With all the evidence that saturated fat promotes heart disease, it's almost unbelievable to me that people could successfully tell people to eat bacon, eggs, ground beef, cheese and cream," she says. "It really shows that people care more about how they look than how healthy they are."448

Obesity shouldn’t be a cosmetic or moral issue, but it does remain a health issue. Obesity, as defined by the Institute of Medicine, is "an important chronic degenerative disease that debilitates individuals and kills prematurely."449 Obesity continues to contribute to hundreds of thousands of deaths in the U.S. every year.450,451,452,453 Losing weight is important, but the goal should be to lose weight in a way that enhances health rather than in ways that may harm it. People also use cocaine, amphetamines and tobacco to control their weight—not health promoting solutions to the problem.

The Consumer Guide concluded that the Atkins Diet “owes its appeal, like pornography, to the naughtiness of the approach, to the titillation we all feel in doing something which we think is not right.”454 Diet gurus like Atkins—the "bad boy of diets"455—gave "his readers what they wanted to hear," says James Hill, Director of the University of Colorado Center for Human Nutrition. Asks one Atkins disciple: "Who wouldn't like a diet that allows fried eggs and bacon and all the steak you can eat?"456 "But what people want to hear," Dr. Hill adds, "is killing them."457

Atkins is Based on a Half-Truth

Despite U.S. attempts to stall458 and sabotage459 the World Health Organization’s report on diet (as they tried to do with tobacco),460 in May 2004 the WHO Global Strategy on Diet, Physical Activity and Health was unanimously endorsed by all 192 Member States of the United Nations. The report blames the growing pandemic of global chronic disease in part on "greater saturated fat intake (mostly from animal sources), reduced intakes of complex carbohydrates and dietary fiber, and reduced fruit and vegetable intakes," in other words, they blame the global epidemic of obesity, cancer, heart disease and diabetes on exactly the kind of diet Atkins’ books recommend. As the Harvard Health Letter put simply, the Atkins Diet "is not a healthy way to eat."461 The World Health Organization is calling for limiting the consumption of saturated animal fats462 and "increasing the consumption of fruits, vegetables, legumes [beans, peas and lentils], whole grains and nuts."463

The evidence to support their position is "overwhelming."464 After 11 years following 11,000 people, for example, researchers found that eating whole grains may help people live longer. That did not seem to be the case for refined grains, though.465 And the Atkins Diet is based on that half-truth.

Atkins was right in going "against the grain" in the case of refined carbohydrates like white flour and sugar. But he was wrong to restrict good carbs—the carbs found in whole unrefined foods—like the WHO’s "fruits, vegetables, legumes, whole grains and nuts." A bunless burger is not the answer to a fat-free doughnut.

Just because jellybeans and Wonder Bread are not health-promoting foods does not mean one has to switch to pork rinds and bacon. Let’s not throw the wheat germ out with the wheat.

You Can Have Your Carbs and Eat Them Too

What evidence do we have that "good" carbs are good? Every single long-term prospective cohort study ever performed on the foods that the Atkins Diet restricts—fruits, vegetables, nuts and whole grains—show that they protect people from the nations’ biggest killer: heart disease.466 Harvard studied 75,000 women for a decade and the results suggest that the more whole grains people eat—like brown rice and whole wheat bread—the lower their risk of having a heart attack.467 Harvard studied 40,000 men for a decade and suggested that eating whole grains may cut one’s risk of developing diabetes by more than half.468 The only thing wrong with whole grains, perhaps, is that they may not sell as many books.

Atkins seemed to think that fruit was the worst thing since sliced bread. Fruit consumption alone, however, has been linked to lower rates of numerous cancers469 and may reduce heart disease mortality, cancer and even total mortality.470 The World Health Organization blames low fruit and vegetable consumption on literally millions of deaths worldwide.471 Everyone should eat more fruits and vegetables as if their lives depended on it.

The National Cancer Institute’s recommendation is now up to nine servings of fruits and vegetables every day. While Atkins preached to restrict fruit and vegetable intake, what Americans really need is more fruits and veggies, not less.472

Lose Weight without Losing Your Health—or Your Life

Life-long weight control is a marathon; fad diets are sold on the 100-yard dash. The UC Berkeley School of Public Health’s #1 rated473 newsletter’s "Bottom Line" on Atkins: "Bottom Line: If you follow the Atkins Diet, you will lose weight—but it could be dangerous beyond a few weeks. All fad diets get you to cut down on calories, usually by limiting the kinds of food you can eat, so of course you lose weight. Most, like the Atkins Diet, deny that ‘calories count,’ but nonetheless trick you into cutting way down on calories by distracting you with strange rules and psychological/biochemical babble. As with all crash diets, keeping the weight off is the hard part. Virtually all crash dieters eventually gain the weight back, unless they learn the basics of healthy eating, which crash diets do not teach."474 Diets are not something to be followed for days, weeks, or months. They should form the basis of everyday food choices for the rest of one’s life.

So what are the "basics of healthy eating?" According to the American Dietetics Association, "The overwhelming majority of studies reported to date including both epidemiological and laboratory approaches, suggest that eating carbohydrate-rich foods such as vegetables, fruits, legumes and whole grains, and limiting saturated fat intake, over a lifetime, is associated with substantially reduced risk for vascular disease and some cancers."475 It may be no coincidence that the longest-living people in the world, even by some accounts outlasting the Okinawa Japanese,476 are the California Seventh Day Adventist vegetarians.477

Every study over six months in duration of the Atkins Diet found that the Atkins Diet failed to significantly outperform the exact diet Atkins blamed our entire obesity epidemic on.478 Why not, then, choose a healthier diet?

Fewer than 20% of Americans trying to lose weight follow what’s considered the optimal diet plan for weight control, the one most proven to be safe and effective for losing weight, keeping the weight off and promoting health—a diet low in saturated animal fats, and high in fruits, vegetables and high-fiber-containing carbohydrates like beans and whole grains.479 How convenient that the most healthful diet also seems to be the one most successful in controlling one’s weight.480

To lose weight, one can cut down on calorie intake by restricting the amount of food one eats, or one can transition away from eating junk food—foodstuffs long on calories but short on nutrition—toward eating food that is nutrient-dense, but relatively calorie-dilute: foods like fruits, vegetables, beans and whole grains. One can add nuts to the list as well, since despite their caloric density, a 2003 review concluded eating nuts every day might actually help one maintain or even lose weight.481 People placed on nutrient-dense, calorie-dilute plant-based diets tend not to complain of hunger, but of having "too much food."482,483,484

The healthy alternative to the Atkins Diet is not a fat-free diet, but a fad-free diet. The optimal diet is one centered around good carbohydrates (unrefined), good fats (like nuts) and the best sources of protein, which, according to the Harvard School of Medicine, are "beans, nuts, grains and other vegetable sources of protein…"485 in other words, by eating a whole-food plant-based diet one can control one’s weight without risking one’s health—or one’s life. We don’t have to mortgage our health in order to lose weight.

Conclusion

"Nobody wants to hear this," groaned Dr. James W. Anderson in an interview. Anderson is a Professor of Medicine and Clinical Nutrition at the University of Kentucky School of Medicine. "People lose weight, at least in the short term. I am not arguing with that. But this is absolutely the worst diet you could imagine for long-term obesity, heart disease, and some forms of cancer. If you wanted to find one diet to ruin your health, you couldn't find one worse than Atkins'."486

Thankfully, the low carb mania may have peaked. According to the June 14, 2004 issue of Fortune magazine, data show that the number of Americans on a low carb diet has fallen 25% since January. As one Wall Street analyst explained, "Have you ever tried low carb bread?"487

* Michael Greger, MD, is a graduate of the Cornell University School of Agriculture and the Tufts University School of Medicine. Dr. Greger has been publicly speaking about mad cow disease since 1993. In 1997 he was invited as an expert witness to defend Oprah Winfrey in the infamous meat defamation trial. He has contributed to many books and articles on the subject and continues to lecture extensively. Dr. Greger can be contacted at 857-928-2778, or mhg1@cornell.edu .

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