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Very-low-fat diets are superior to low-carbohydrate diets (***sigh!***)



 
 
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Old March 21st, 2006, 06:20 PM posted to alt.support.diet.low-carb
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Default Very-low-fat diets are superior to low-carbohydrate diets (***sigh!***)

Very-low-fat diets are superior to low-carbohydrate diets: evidence shows
that very-low-fat diets (not low- or moderate-fat diets) may be easier, not
harder, to follow and make more sense physiologically. They should also
produce the best weight loss and health outcomes in the long
run.(VIEWPOINT). Daniel S. Kirschenbaum. Patient Care 39.11 (Nov 2005):
p47(7).
For more than half a century, millions of Americans have periodically
followed diets that were very low in carbohydrates (and high in protein and
fat) in search of the best and easiest way to lose weight. The late Robert
C. Atkins' 1998 revision of his 1972 Dr. Atkins' Diet Revolution was on the
New York Times best-seller list for more than 6 years, and many other
best-sellers have advocated similar low-carbohydrate diets. (1) Several
professional organizations, including the American Dietetic Association
(ADA) and the American Heart Association (AHA), have advised against the use
of low-carb diets because considerable scientific evidence suggests that
diets like these may promote cardiovascular, kidney, and liver diseases, as
well as cancer. (2)

Despite the ostensible health risks of low-carb diets, some people have
followed this approach and lost weight. This anecdotal evidence, coupled
with successful marketing campaigns, has led even neutral consumer advocates
to encourage weight controllers to "add a little fat" to their diets. (3)
Despite waning interest in this approach, acceptance of the supposed
benefits of low-carb dieting still appears routinely in the media and is
evident in restaurant menus and on supermarket shelves. Only a careful
review of the scientific literature can determine whether health
professionals should recommend or oppose low-carb dieting for their confused
overweight patients.

Bravata et al recently identified 2616 articles in professional journals
(including 94 empirical studies) pertaining to the efficacy of low-carb
dieting. (2) However, only 6 studies--5 of them published since the Bravata
review was completed--have compared low-carb/moderate- to high-fat diets
with diets described as "low-fat" using random assignment and evaluations
lasting at least 6 months. (4-10) The authors of 4 of these 6 studies
concluded that their low-carb diets helped their overweight participants
lose more weight than their low-fat diets. (4,6,7-9) A critical review of
these studies, however, reveals that none provides scientifically valid
evidence for this claim. This article presents the basis for this assertion
and provides an empirically grounded rationale for recommending very low-fat
diets.

Flaws in research designs

Three major flaws in research designs undermine the validity of these
studies. First, all 4 of the studies that found some ostensible benefits for
low-carb diets used elaborate intervention programs (for example, 18 months
of weekly sessions), not dietary instructions alone. (4,6,7-9) Including the
diets within extensive programs confounds the integrity of the independent
variable, decreasing internal validity ("diffusion of treatment") and
external validity ("multiple treatment interference"). (11)

Second, the administrators of these diet/behavioral programs had far more
opportunities for their beliefs or biases to have an impact on outcomes than
they would have had in a study, like that of Foster et al, that used a diet
intervention alone. (5) This raises possibilities of investigator and
experimenter bias that threaten both internal and external validity
("reactivity of experimental arrangements" and "combination of experimental
setting and treatment"). (11) Two of the 4 studies that supported the
supposed differential benefits of low-carbohydrate diets were funded by
companies (olive oil and peanut companies and The Dr. Robert C. Atkins
Foundation) that had--and still have--major financial allegiances to
low-carbohydrate diets. (6,8) This fact clearly increases the salience of
concerns about investigator/experimenter bias, although it by no means
impugns the integrity of the researchers.

The third design flaw is the most important: None of the 4 studies that
ostensibly found benefits for low-carb diets used a truly low-fat diet (for
example, 5%-10% of calories from fat), sometimes referred to as a
very-low-fat diet. Thus, these studies actually compared low-carb diets with
moderate-fat diets (goals were 20%, (6) 25%, (5) and 30% (4,7,8) of calories
from fat; obtained: 29%-33%), thereby creating a "construct validity"
problem. (11)

When is a diet a diet?

Only Foster et al tested the relative efficacy of a diet per se, as it is
usually attempted by the millions of people who buy diet books. (5) This
study also yielded no differences between low-carb and low-fat diets at a
1-year follow-up and produced about half the weight loss in their best
group, as compared with the best group of 2 of the other studies. (4,8) The
remaining studies tested dietary instructions within educational and
behavioral programs.

Professionally conducted weight-control programs are far more likely to help
people lose weight than self-help approaches. (12) In fact, a meta-analysis
showed that the single best predictor of weight loss is length of treatment.
(13) Longer treatments also produced much more weight loss in studies that
experimentally compared longer to shorter treatments. (14) These effects of
amount of contact with professionals emerge almost regardless of the content
that is focused on within the sessions. (15) Apparently, participation in
such programs helps weight-controllers set goals, monitor and evaluate their
behaviors, and generally stay motivated, optimistic, and focused on change.
These findings indicate that the 5 low-carb studies under consideration here
that embedded the diets within educational/behavioral programs must
attribute some of their effects to the programs themselves, not the diets.

Investigator and experimenter bias

Investigators' hypotheses can intentionally or unintentionally affect the
manner in which the experimental protocol is specified and delivered and the
accuracy of data gathering and analyses. Similarly, experimenters (in these
studies, dietitians) can affect recruitment and retention of participants.

[GRAPHIC OMITTED]

In the present set of studies, the researchers and dietitians probably knew
that publication, notoriety, and subsequent funding may have depended on
finding benefits for low-carb diets. The enthusiasm of the dietitians who
administered the programs could have varied according to condition, quite
possibly unintentionally, thereby affecting attrition and recruitment for
evaluations. In fact, the attrition in some of the low-fat groups was as
much as 400% higher than the usual attrition rate for related behavioral
programs that used low-fat or very-low-fat diets (80% versus 20%) and was
significantly higher in low-fat compared with low-carb groups in 3 of the 6
studies. (6,7,8,15) This suggests the possibility of differential enthusiasm
for the treatments.

Research on investigator and experiment bias has revealed some dramatic
effects, including studies showing that experimenters' computational errors
favor investigators' hypotheses 75% of the time. (16) The authors of the 2
studies under review here that received financial support from companies
with vested interests in low-carbohydrate diets based their conclusions
favoring low-carb/moderate-to-high fat diets on potentially flawed analyses.
(6,8)

First, the "primary analyses" of McManus et al were conducted using a
"low-fat" group in which 67% (20 of 30) subjects analyzed had dropped out of
the program. (6) Thus, they almost certainly were no longer following the
low-fat approach when they were counted as "low-fat" dieters. This group was
compared with a higher-fat group comprising 25 active participants and only
6 dropouts. Forty additional dropouts were not "available for measurements."
Based purely on research showing the powerful impact of active participation
in weight-loss programs, 67% of the low-fat group included in the primary
analyses would be expected to fare poorly, compared with 19% of the low-carb
group. (13) This differential subject attrition, one of the primary threats
to internal validity, was statistically very significant (P .001) but
ignored by the authors. When the researchers compared only current
participants (excluding dropouts), the groups did not differ in weight loss.

The quality and outcomes of the manipulation checks in the study by Yancy et
al raise questions about the nature of the independent variable (the
distinctiveness and characterizations of the diets). (8) The Atkins'
(low-carb) diet group was instructed to consume less than 20 g/d of
carbohydrates--a severely restricted level of carbohydrate consumption. The
authors noted that carbohydrate consumption under 40 g/d (twice the allowed
level) should have been readily detected by urinary dipstick tests. However,
only 19 of 59 (32%) participants included in analyses had observed trace
levels of ketones. Since the vast majority of those assigned to the
low-carbohydrate diet failed to restrict their carbohydrate consumption
enough to be detected at twice the allowed level, it seems problematic to
consider this group to be a "low-carbohydrate diet group."

Perhaps the researchers considered their dietary assignments to be
successful based on analyses of the diets reportedly consumed by
participants. Unfortunately, only 20 out of 119 (17%) of participants were
selected (not randomly assigned: 13 low-carb dieters, 7 low-fat dieters) for
analyses of their diets. No measure of the reliability of these dietary
assessments was reported.

Even if participants had followed Yancy et al's dietary manipulation exactly
as intended, these researchers, like McManus et al, largely ignored the
potential impact of differential subject attrition. (6,8) The Yancy study
did not acknowledge the McManus study or others showing that dropouts often
fail to lose weight, compared with those who stay in treatment. (13,15) The
McManus and Yancy low-fat participants prematurely discontinued treatment
almost twice as often (43%) as their low-carbohydrate groups (24%). Unlike
McManus et al, however, Yancy et al did not analyze the data separately for
completers only. Without taking into account the likely poorer performance
of the greater number of dropouts in the low-fat group, Yancy et al may have
inadvertently skewed the results in favor of their low-carbohydrate group.

Furthermore, the use of linear mixed-effects models to project expected
weight losses (instead of analyzing the data actually obtained) may have
capitalized on the well-known effect of low-carbohydrate diets to produce
initially greater weight losses. (9) Also, as Yancy et al noted, their use
of projected values depended on the assumption that including dropouts would
not affect the meaning of the results ("noninformative dropouts"). In
weight-control research, however, dropouts lose less weight than completers.
(13,15) Therefore, including these dropouts "informed" the outcomes, thereby
perhaps violating an assumption of the analyses.

This argument gains support by calculating the impact on the results of
including the dropouts. The low-carbohydrate dieters were projected to lose
85% more weight than those assigned to the low-fat group at the 24-week
point. When dropouts are deleted from these projections (counting them as
losing no weight in both diet conditions), the discrepancy between groups
decreases substantially. The projected difference decreases by 236% (from
85% to 36%), quite possibly rendering the actual differences between groups
nonsignificant.

When is a low-fat diet a low-fat diet?

The biggest problem in the studies that supposedly favored low-carb diets
was the failure to use truly low-fat diets. Samaha et al used a moderate-fat
goal, 30% calories from fat, in their "low-fat" group. (7) They reported a
baseline level of fat consumption by that group of 33% of calories from fat
(68 g/d) and even after "six months of dietary counseling," this group
averaged the same percentage of calories from fat (33%; 57.8 g fat). Data in
McManus et al also showed minimal changes and moderate levels of fat
consumption at baseline (31%) and follow-up (30%) in the low-fat group. (6)
Brehm et al and Yancy et al used low-fat goals of about 30%, and they both
reported 29% fat consumption during the program. (4,8)

In their extensive review of the efficacy of popular diets, Freedman et al
categorized the level of fat consumption obtained in these 4 studies as
"moderate-fat." (16) Current evidence suggests that the moderately high
levels of fat consumption achieved in these studies should not have helped
weight-controllers succeed. (17,18) In a review of dietary interventions,
Barnard et al reported that "only very stringent dietary manipulations led
to effective change." (19) They found that the 3 studies that clearly
produced the greatest changes in diets limited "dietary fat to no more than
10% of energy," not the 25% to 30% of calories from fat used by almost all
of the other 27 studies in their review and obtained (29%-33%) by the
studies under discussion here. Freedman et al also asserted that "data
support the contention that those consuming low-fat, low-calorie diets are
most successful in maintaining weight loss." (16)

Stice's survey of 396 adolescents also illustrates the differential benefits
of very-low-fat compared with low/moderate-fat diets. (20) He found that
only those who followed a very stringent approach lost weight; those who
reported following more moderate diets actually gained weight.
Weight-controllers in Jeffery et al also found a low-fat approach easier to
use and more palatable than a calorically restricted diet without limits on
fat. (21) (It's easier to eat no potato chips at all than just one.) The
data from both these studies and the Barnard et al review support Barnard's
conclusion: "Higher limits on fat intake, which may be selected in hopes of
maximizing the acceptability of prescribed diets, may actually discourage a
greater degree of dietary change." (19)

Lowering levels of fat consumption is crucial

[GRAPHIC OMITTED]

Other analyses of the impact of macronutrients on weight change support the
view that moderate (and certainly high) fat consumption can inhibit weight
loss and maintenance of reduced weight. The extensive review of the efficacy
of low-carb diets in Bravata et al showed that "among obese patients, weight
loss was associated with longer diet duration, restriction of caloric
intake, but not with reduced carbohydrate content". (2) The Freedman et al
review also found no support for the benefits of reducing carbohydrate
content, without restricting calories, on weight loss. (16)

For example, Harris et al studied 157 weight-controllers over 18 months and
found that reducing the percentage of calories from carbohydrates (and
protein) did not affect weight loss. (22) In contrast, eating very little
fat, and specifically minimizing consumption of beef, hot dogs, and sweets,
did predict weight loss (as it did in Holden et al). (23) Reducing calories
from fat actually predicted weight loss even better than change in total
calories (as it did in Jeffery et al). (21)

In a remarkably similar vein, but with children as the focus, Gazzaniga and
Burns found that a group of obese children ate much more fat and many fewer
carbohydrates than their lean peers. (24) Even after statistically adjusting
for total energy intake, physical activity, and metabolic rates, obese
children still ate more fat and fewer carbohydrates.

As would be expected from these results, highly successful adult
weight-controllers consume much less fat than average Americans and about 10
times the level of carbohydrates recommended by Atkins. (25) Weight-loss
programs that counsel people to eat like this have produced among the most
promising outcomes in long-term evaluations. (26)

Animal and physiologic research also supports the benefits of truly low-fat
diets compared with moderate-fat diets. Several studies showed that animals
fed high-fat diets gained weight much more readily than those fed diets much
lower in fat. (27) Boozer et al also found that high-fat diets not only
promote weight gain but also inhibit weight loss. (28) They compared several
groups of rats whose food was restricted to 75% of the calories in their
baseline diets. The rats that were fed high-fat, restricted-calorie diets
(45% fat) failed to lose weight, compared with rats that consumed diets of
the same restricted calorie level that were moderately high in fat (28%) and
low in fat (12%). Three human studies also found that much-lower-fat diets
resulted in weight loss even when total calories were not reduced, an effect
never obtained with low-carb diets. (16)

Bessesen et al demonstrated a method through which high-fat diets inhibit
weight loss. (29) They found that when obese rats consumed dietary fat, it
was transported to storage in fat cells and away from muscle cells much more
so than was the case in lean rats. This pattern was accentuated for formerly
obese rats. Formerly overweight people also show a differential sensitivity
to fat at the cellular level. (30) They may also have greater physiologic
sensitivity (insulin secretion, salivation) to the presence and even the
thought of highly palatable high-fat food. (31) Consuming high-fat foods may
also encourage overeating by increasing appetite and decreasing satiety to a
greater extent than low-fat foods. (32) This may occur because eating such
foods may stimulate the endogenous opioid peptide system.

Consuming a high-fat diet also induces heightened sensitivity to leptin,
leads to increases in ghrelin, and inhibits the transportation of insulin
into the brain, all of which probably increase eating and weight gain. (16)
In fact, a recent study showed that a very low-fat/high-carbohydrate diet
(15% calories from fat, 65% carbohydrate, 20% protein) failed to trigger the
type of increase in ghrelin (a potent orexigenic signal) that is typically
seen when people lose weight by restricting calories in higher-fat diets.
(33)

Why were truly low-fat diets not used in these studies?

This evidence raises questions about why these researchers chose "low-fat"
dietary levels (actually "moderate-fat" diets, according to Freedman et al)
that were 50% to 100% higher than genuinely "low-fat" or "very-low-fat"
levels. (16) Part of the answer is that the current evidence, while
compelling, remains somewhat controversial and circumstantial. Definitive
treatment outcome studies that clearly favor very-low-fat diets have not yet
emerged, although the evidence certainly points in that direction.

The reliance on tradition (actually, myths) provides another explanation.
For decades, major professional groups that focus on diet and health (such
as the AHA and ADA) have advocated moderation as the key to success in
weight control. Extreme approaches, or so the myth goes, will not work
because they induce feelings of deprivation and binge eating. Yet, the
scientific evidence shows that more stringent goals for fat consumption seem
easier (not harder) to implement consistently, make more sense
physiologically, and produce the most promising results.

Implications

Perhaps the greatest irony in the current low-carb craze pertains to the
overwhelming scientific evidence showing that self-help and other minimal
interventions (for example, diet books and instructions alone) rarely help
people lose much weight. Yet, publications in prestigious journals with
favorable editorial commentaries, public relations campaigns, anecdotal
claims, sales of millions of books, and countless stories in the media have
prompted literally thousands of papers addressing this issue. (2,16)

It is time for diet to be put in its place. A diet is just one element that
can facilitate weight loss only when weight-controllers sustain major
efforts to transform their lifestyles (activity level, stress management,
focusing, and commitment). Furthermore, even when extracting the
contribution of diet on weight loss, the possible long-term risks of
low-carbohydrate/high-fat diets and some noteworthy short-term adverse
effects (such as significantly increased GI distress, headaches, and muscle
weakness) should discourage the use of such diets. (8) Unless valid
scientific research shows reliable and differential weight loss and other
benefits for low-carb diets, which seems unlikely at this juncture, the
recommended pathway to successful weight control should include a
very-low-fat diet, not a low-carb/high-fat diet.

This article was contributed by Dr Kirschenbaum and edited by Peter D'Epiro,
PhD.

Dr Kirschenbaum discloses that he is Clinical Director and Chief Program
Officer, Healthy Living Academies Division of Aspen Education Group,
Cerritos, Calif.

www.patientcareonline.com

Visit our Web site for

* Quick access to the reports and Internet resources discussed in these
pages

REFERENCES

1. Atkins RC. Dr. Atkins' New Diet Revolution (Revised and Updated). New
York, NY: Avon Books; 1998.

2. Bravata DM, Sanders L, Huang J, et al. Efficacy and safety of
low-carbohydrate diets: a systematic review. JAMA. 2003;289:1837-1850.

3. The truth about dieting. Consumer Reports. 2002;67:26-31.

4. Brehm BJ, Seeley RJ, Daniels SR, et al. A randomized trial comparing a
very low carbohydrate diet and a calorie-restricted low fat diet on body
weight and cardiovascular risk factors in healthy women. J Clin Endocrin
Metab. 2003;88:1617-1623.

5. Foster GD, Wyatt HR, Hill JO, et al. A randomized trial of a
low-carbohydrate diet for obesity. New Engl J Med. 2003;348:2082-2090.

6. McManus K, Antinoro L, Sacks F. A randomized controlled trial of a
moderate-fat, low-energy diet compared with a low fat, low-energy diet for
weight loss in overweight adults. Int J Obesity. 2001;25:1503-1511.

7. Samaha FF, Iqbal N, Seshadri P, et al. A low-carbohydrate as compared
with a low-fat diet in severe obesity. N Engl J Med. 2003;348:2074-2081.

8. Yancy WS, Olsen MK, Guyton JR, et al. A low-carbohydrate ketogenic diet
versus a low-fat diet to treat obesity and hyperlipidemia. Ann Intern Med.
2004;140:769-777.

9. Stern L, Iqbal N, Seshadri P, et al. The effects of low-carbohydrate
versus conventional weight loss diets in severely obese adults: one-year
follow-up of a randomized trial. Ann Intern Med. 2004;140:778-785.

10. Dansinger ML, Gleason JA, Griffith JL, et al. Comparison of the Atkins,
Ornish, Weight Watchers, and Zone diets for weight loss and heart disease
risk reduction: a randomized trial. JAMA. 2005;293:43-53.

11. Cook TD, Campbell DT. Quasi-Experimentation: Design and Analysis Issues
for Field Settings. Chicago, III: Rand McNally College Publishing Company;
1979.

12. Heshka S, Greenway F, Anderson JW, et al. Self-help weight loss versus a
structured commercial program after twenty-six weeks: a randomized
controlled study. Am J Med. 2000;109:282-287.

13. Bennett GA. Behavior therapy for obesity: a quantitative review of
selected treatment characteristics on outcome. Behav Ther. 1986;17:554-562.

14. Baum JG, Clark HB, Sandler J. Preventing relapse in obesity through post
treatment maintenance systems: comparing the relative efficacy of two levels
of therapist support. J Behav Med. 1991;14:287-302.

15. Kaplan RM, Atkins CJ. Selective attrition causes over estimates of
treatment effects in studies of weight loss. Add Behav. 1987;12:297-302.

16. Freedman MR, King J, Kennedy E. Popular diets: a scientific review. Obes
Res. 2001(suppl 1):1S-40S.

17. Perri MG, Nezu AM, Viegener BJ. Improving the Long-Term Management of
Obesity: Theory, Research, and Clinical Guidelines. New York, NY: John Wiley
& Sons; 1992.

18. Barber TX. Pitfalls in Human Research: Ten Pivotal Points. New York, NY:
Pergamon Press; 1976.

19. Barnard ND, Akhtar A, Nicholson A. Factors that facilitate compliance to
lower fat intake. Arch Fam Med. 1995;4:153-158.

20. Stice E. Prospective relation of dieting behaviors to weight change in a
community sample of adolescents. Behav Ther. 1998;29:277-297.

21. Jeffery RW, Hellerstedt WL, French SA, et al. A randomized trial of
counseling for fat restriction versus calorie restriction in the treatment
of obesity. Int J Obesity. 1995;19:132-137.

22. Harris JK, French SA, Jeffery RW, et al. Dietary and physical activity
correlates of long-term weight loss. Obes Res. 1994;2:307-313.

23. Holden JH, Darga LL, Olson SM, et al. Long-term follow-up of patients
attending a combination very-low calorie diet and behaviour therapy weight
loss programme. Int J Obes. 1991;16:605-613.

24. Gazzaniga JM, Burns TL. Relationship between diet composition and body
fatness, with adjustment for resting energy expenditure and physical
activity, in preadolescent children. Am J Clin Nutr. 1993;58:21-28.

25. Shick SM, Wing RR, Klem ML, et al. Persons successful at long-term
weight loss and maintenance continue to consume a low-energy, low-fat diet.
J Amer Diet Assoc. 1998;98:408-413.

26. Wadden TA, Foster GD, Letizia KA, et al. A multicenter evaluation of a
proprietary weight reduction program for the treatment of marked obesity.
Arch Intern Med. 1992;152:961-966.

27. Salmon DMW, Flatt JP. Effect of dietary fat content on the incidence of
obesity among ad libitum fed mice. Int J Obes. 1985;9:443-9.

28. Boozer CN, Brasseur A, Atkinson RL. Dietary fat affects weight loss and
adiposity during energy restriction in rats. Am J Clin Nutr.
1993;58:846-852.

29. Bessesen DH, Rupp CL, Eckel RH. Dietary fat is shunted away from
oxidation, toward storage in obese Zucker rats, Obes Res. 1995;3:179-189.

30. Tremblay A, Despres JP, Bouchard C. Adipose tissue characteristics of
ex-obese long-distance runners. Int J Obes. 1984;8:641-648.

31. Johnson WG, Wildman HE. Influence of external and covert food stimuli on
insulin secretion in obese and normal persons. Behav Neurol.
1983;97:1025-1028.

32. Blundell JE, Cotton JR, Delargy H, et al. The fat paradox: fat-induced
satiety signals versus high fat overconsumption. Int J Obes.
1995;19:832-835.

33. Weigle DS, Cummings DE, Newby PD, et al. Roles of leptin and ghrelin in
the loss of body weight caused by a low fat, high carbohydrate diet. J Clin
Endocrinol Metab. 2003;88:1577-1586.

DANIEL S. KIRSCHENBAUM, PhD

Clinical Director and Chief Program Officer, Healthy Living Academies
Division of Aspen Education Group, Cerritos, Calif; Director, Center for
Behavioral Medicine & Sport Psychology; and Professor of Psychiatry and
Behavioral Sciences, Northwestern University Medical School, Chicago, Ill.
His most recent book is The Healthy Obsession Program: Smart Weight Loss
Instead of Low-Carb Lunacy (http://www.benbellabooks.com).

RELATED ARTICLE: Article at a glance

** Five studies published in the past 3 years compared low-carbohydrate to
low-fat diets using random assignment and evaluations lasting about 6 months
or longer.

** The authors of most of these studies concluded that their low-carb diets
helped their overweight participants lose more weight than their low-fat
diets.

** A critical review, however, reveals that none of these studies provides
valid evidence of the differential effectiveness for weight control favoring
low-carb diets.

** This analysis provides an empirically grounded rationale for recommending
truly low-fat diets for weight loss, unless and until valid evidence
suggests otherwise.

Low-carb Sample Menu

Breakfast
Cheese-baked eggs
Sausage patties
Tea or decaf coffee with cream and sugar substitute

Lunch
Chicken croquettes on a bed of lettuce
Sugar-free orange gelatin parfait

Dinner
Sour cream clam dip with fried pork rinds
Fennel red snapper
Tossed green salad with creamy dijon vinaigrette dressing
Tea or decaf coffee with cream and sugar substitute

Snack
Vanilla ice cream

Low-fat Sample Menu

Breakfast
Egg white omelet with red potatoes, fat-free cheese, diced onion, and
garlic
Nonfat blended berry yogurt
Berries
Herbal tea or coffee with skim milk and sugar substitute

Lunch
Pepperoni pita pocket pizza (fat-free pita bread, pizza sauce, soy
pepperoni, fat-free shredded jack and cheddar cheese)
Low-fat split pea or vegetable soup
Iced tea or diet soda

Dinner
Broiled lobster with lemon
Roasted new potatoes
Asparagus
Salad with fat-free dressing
Fruit salad and frozen sorbet or yogurt
Hot herbal tea or diet soda

Snack
Pretzels, low-fat popcorn, or whole fruit


  #2  
Old March 22nd, 2006, 01:26 AM posted to alt.support.diet.low-carb
external usenet poster
 
Posts: n/a
Default Very-low-fat diets are superior to low-carbohydrate diets (***sigh!***)

Roger Zoul wrote:

Snip article...

There is nothing surprising here. It just goes to support that the core
of all successful diets is calorie deficit. An extremely low fat diet
would lower calories quite successfully, fat containing more calories
than carbs.

The point isn't what type of diet, it is the ability to sustain whatever
diet is chosen, along with the supply of sufficient nutrients to ensure
good health. I lost a lot of weight while eating large and satisfying
meals simply by choosing my foods carefully (lowering unecessary carbs
in my case, but not to ketonic levels) and increasing both the frequency
and degree of exercise in my life. Not just gym, but including
pleasurable pastimes that require exertion.

I see the real problem as being a very definite reluctance on the part
of the majority of overweight people to incorporate sufficient exercise.
They all want an *easy* weight loss program. Diets don't need to focus
on any particular calorie source, they just need to avoid excesses of
any particular calorie source, provide nutrients and incorporate regular
exercise.

It isn't difficult to determine how to lose weight, the difficulty is in
applying a particular choice.

Regards

David


--

To email me, please include the letters DNF anywhere in the subject line.

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  #3  
Old March 22nd, 2006, 04:30 AM posted to alt.support.diet.low-carb
external usenet poster
 
Posts: n/a
Default Very-low-fat diets are superior to low-carbohydrate diets (***sigh!***)

Man... is this pulling out the swords and declaring war. And, the
declaration that we need a new army of professional diet therapists or
their equivalent.

And that what is needed is not LOW FAT but VERY LOW FAT diets, possibly
administered by therapists.....

This rings of Dr. Dean Ornish again springing into action to fill the
void left by the negative $400 million study on the lack of benefit of
LOW FAT.

The alleged hidden secret of the first trials of the Ornish ultra-low
fat diet in fact had intensive personal therapy for the participants in
making this enormous change in eating style. The same study allegedly
had intensive physical exercise programs which were also administered by
the diet therapists.


A few items extracted from the long paper below.....

These diet people are as despicable as politicians ....


Jim

-------------------------------------------------------------

Should.....

Suggest ..... may cause

Professionally conducted weight-control programs are far more likely to
help people lose weight than self-help approaches. (12)

Perhaps the greatest irony in the current low-carb craze pertains to the
overwhelming scientific evidence showing that self-help andother minimal
interventions(for example, diet books and instructions alone)rarely help
people lose much weight. Yet, publications in prestigious journals with
favorable editorial commentaries, public relations campaigns, anecdotal
claims, salesof millions ofbooks, and countless stories inthe media have
prompted literally thousands of papers addressing this issue. (2,16)


As would be expected from these results, highly successful adult
weight-controllers consume much less fat than average Americans and
about 10
times the level of carbohydrates recommended by Atkins. (25) Weight-loss
programs that counsel people to eat like this have produced among the most
promising outcomes in long-term evaluations. (26)


Yet, the scientific evidence shows that more stringent goals for fat
consumption seem easier (not harder) to implement consistently, make
more sense physiologically, and produce the most promising results.


Unless valid scientific research shows reliable and differential weight
loss and other benefits for low-carb diets, which seems unlikely at this
juncture, the recommended pathway to successful weight control should
include a very-low-fat diet, not a low-carb/high-fat diet.




Roger Zoul wrote:
Very-low-fat diets are superior to low-carbohydrate diets: evidence shows
that very-low-fat diets (not low- or moderate-fat diets) may be easier, not
harder, to follow and make more sense physiologically.


They should also
produce the best weight loss and health outcomes

They should also
produce the best weight loss and health outcomes in the long
run.(VIEWPOINT). Daniel S. Kirschenbaum. Patient Care 39.11 (Nov 2005):
p47(7).
For more than half a century, millions of Americans have periodically
followed diets that were very low in carbohydrates (and high in protein and
fat) in search of the best and easiest way to lose weight. The late Robert
C. Atkins' 1998 revision of his 1972 Dr. Atkins' Diet Revolution was on the
New York Times best-seller list for more than 6 years, and many other
best-sellers have advocated similar low-carbohydrate diets. (1) Several
professional organizations, including the American Dietetic Association
(ADA) and the American Heart Association (AHA), have advised against the use
of low-carb diets because considerable scientific evidence suggests that
diets like these may promote cardiovascular, kidney, and liver diseases, as
well as cancer. (2)


evidence suggests that diets like these may promote cardiovascular,


Despite the ostensible health risks of low-carb diets, some people have
followed this approach and lost weight.



Despite the ostensible health risks of low-carb diets, some people have
followed this approach and lost weight. This anecdotal evidence, coupled
with successful marketing campaigns, has led even neutral consumer advocates
to encourage weight controllers to "add a little fat" to their diets. (3)
Despite waning interest in this approach, acceptance of the supposed
benefits of low-carb dieting still appears routinely in the media and is
evident in restaurant menus and on supermarket shelves. Only a careful
review of the scientific literature can determine whether health
professionals should recommend or oppose low-carb dieting for their confused
overweight patients.

Bravata et al recently identified 2616 articles in professional journals
(including 94 empirical studies) pertaining to the efficacy of low-carb
dieting. (2) However, only 6 studies--5 of them published since the Bravata
review was completed--have compared low-carb/moderate- to high-fat diets
with diets described as "low-fat" using random assignment and evaluations
lasting at least 6 months. (4-10) The authors of 4 of these 6 studies
concluded that their low-carb diets helped their overweight participants
lose more weight than their low-fat diets. (4,6,7-9) A critical review of
these studies, however, reveals that none provides scientifically valid
evidence for this claim. This article presents the basis for this assertion
and provides an empirically grounded rationale for recommending very low-fat
diets.

Flaws in research designs

Three major flaws in research designs undermine the validity of these
studies. First, all 4 of the studies that found some ostensible benefits for
low-carb diets used elaborate intervention programs (for example, 18 months
of weekly sessions), not dietary instructions alone. (4,6,7-9) Including the
diets within extensive programs confounds the integrity of the independent
variable, decreasing internal validity ("diffusion of treatment") and
external validity ("multiple treatment interference"). (11)

Second, the administrators of these diet/behavioral programs had far more
opportunities for their beliefs or biases to have an impact on outcomes than
they would have had in a study, like that of Foster et al, that used a diet
intervention alone. (5) This raises possibilities of investigator and
experimenter bias that threaten both internal and external validity
("reactivity of experimental arrangements" and "combination of experimental
setting and treatment"). (11) Two of the 4 studies that supported the
supposed differential benefits of low-carbohydrate diets were funded by
companies (olive oil and peanut companies and The Dr. Robert C. Atkins
Foundation) that had--and still have--major financial allegiances to
low-carbohydrate diets. (6,8) This fact clearly increases the salience of
concerns about investigator/experimenter bias, although it by no means
impugns the integrity of the researchers.

The third design flaw is the most important: None of the 4 studies that
ostensibly found benefits for low-carb diets used a truly low-fat diet (for
example, 5%-10% of calories from fat), sometimes referred to as a
very-low-fat diet. Thus, these studies actually compared low-carb diets with
moderate-fat diets (goals were 20%, (6) 25%, (5) and 30% (4,7,8) of calories
from fat; obtained: 29%-33%), thereby creating a "construct validity"
problem. (11)

When is a diet a diet?

Only Foster et al tested the relative efficacy of a diet per se, as it is
usually attempted by the millions of people who buy diet books. (5) This
study also yielded no differences between low-carb and low-fat diets at a
1-year follow-up and produced about half the weight loss in their best
group, as compared with the best group of 2 of the other studies. (4,8) The
remaining studies tested dietary instructions within educational and
behavioral programs.

Professionally conducted weight-control programs are far more likely to help
people lose weight than self-help approaches. (12) In fact, a meta-analysis
showed that the single best predictor of weight loss is length of treatment.
(13) Longer treatments also produced much more weight loss in studies that
experimentally compared longer to shorter treatments. (14) These effects of
amount of contact with professionals emerge almost regardless of the content
that is focused on within the sessions. (15) Apparently, participation in
such programs helps weight-controllers set goals, monitor and evaluate their
behaviors, and generally stay motivated, optimistic, and focused on change.
These findings indicate that the 5 low-carb studies under consideration here
that embedded the diets within educational/behavioral programs must
attribute some of their effects to the programs themselves, not the diets.

Investigator and experimenter bias

Investigators' hypotheses can intentionally or unintentionally affect the
manner in which the experimental protocol is specified and delivered and the
accuracy of data gathering and analyses. Similarly, experimenters (in these
studies, dietitians) can affect recruitment and retention of participants.

[GRAPHIC OMITTED]

In the present set of studies, the researchers and dietitians probably knew
that publication, notoriety, and subsequent funding may have depended on
finding benefits for low-carb diets. The enthusiasm of the dietitians who
administered the programs could have varied according to condition, quite
possibly unintentionally, thereby affecting attrition and recruitment for
evaluations. In fact, the attrition in some of the low-fat groups was as
much as 400% higher than the usual attrition rate for related behavioral
programs that used low-fat or very-low-fat diets (80% versus 20%) and was
significantly higher in low-fat compared with low-carb groups in 3 of the 6
studies. (6,7,8,15) This suggests the possibility of differential enthusiasm
for the treatments.

Research on investigator and experiment bias has revealed some dramatic
effects, including studies showing that experimenters' computational errors
favor investigators' hypotheses 75% of the time. (16) The authors of the 2
studies under review here that received financial support from companies
with vested interests in low-carbohydrate diets based their conclusions
favoring low-carb/moderate-to-high fat diets on potentially flawed analyses.
(6,8)

First, the "primary analyses" of McManus et al were conducted using a
"low-fat" group in which 67% (20 of 30) subjects analyzed had dropped out of
the program. (6) Thus, they almost certainly were no longer following the
low-fat approach when they were counted as "low-fat" dieters. This group was
compared with a higher-fat group comprising 25 active participants and only
6 dropouts. Forty additional dropouts were not "available for measurements."
Based purely on research showing the powerful impact of active participation
in weight-loss programs, 67% of the low-fat group included in the primary
analyses would be expected to fare poorly, compared with 19% of the low-carb
group. (13) This differential subject attrition, one of the primary threats
to internal validity, was statistically very significant (P .001) but
ignored by the authors. When the researchers compared only current
participants (excluding dropouts), the groups did not differ in weight loss.

The quality and outcomes of the manipulation checks in the study by Yancy et
al raise questions about the nature of the independent variable (the
distinctiveness and characterizations of the diets). (8) The Atkins'
(low-carb) diet group was instructed to consume less than 20 g/d of
carbohydrates--a severely restricted level of carbohydrate consumption. The
authors noted that carbohydrate consumption under 40 g/d (twice the allowed
level) should have been readily detected by urinary dipstick tests. However,
only 19 of 59 (32%) participants included in analyses had observed trace
levels of ketones. Since the vast majority of those assigned to the
low-carbohydrate diet failed to restrict their carbohydrate consumption
enough to be detected at twice the allowed level, it seems problematic to
consider this group to be a "low-carbohydrate diet group."

Perhaps the researchers considered their dietary assignments to be
successful based on analyses of the diets reportedly consumed by
participants. Unfortunately, only 20 out of 119 (17%) of participants were
selected (not randomly assigned: 13 low-carb dieters, 7 low-fat dieters) for
analyses of their diets. No measure of the reliability of these dietary
assessments was reported.

Even if participants had followed Yancy et al's dietary manipulation exactly
as intended, these researchers, like McManus et al, largely ignored the
potential impact of differential subject attrition. (6,8) The Yancy study
did not acknowledge the McManus study or others showing that dropouts often
fail to lose weight, compared with those who stay in treatment. (13,15) The
McManus and Yancy low-fat participants prematurely discontinued treatment
almost twice as often (43%) as their low-carbohydrate groups (24%). Unlike
McManus et al, however, Yancy et al did not analyze the data separately for
completers only. Without taking into account the likely poorer performance
of the greater number of dropouts in the low-fat group, Yancy et al may have
inadvertently skewed the results in favor of their low-carbohydrate group.

Furthermore, the use of linear mixed-effects models to project expected
weight losses (instead of analyzing the data actually obtained) may have
capitalized on the well-known effect of low-carbohydrate diets to produce
initially greater weight losses. (9) Also, as Yancy et al noted, their use
of projected values depended on the assumption that including dropouts would
not affect the meaning of the results ("noninformative dropouts"). In
weight-control research, however, dropouts lose less weight than completers.
(13,15) Therefore, including these dropouts "informed" the outcomes, thereby
perhaps violating an assumption of the analyses.

This argument gains support by calculating the impact on the results of
including the dropouts. The low-carbohydrate dieters were projected to lose
85% more weight than those assigned to the low-fat group at the 24-week
point. When dropouts are deleted from these projections (counting them as
losing no weight in both diet conditions), the discrepancy between groups
decreases substantially. The projected difference decreases by 236% (from
85% to 36%), quite possibly rendering the actual differences between groups
nonsignificant.

When is a low-fat diet a low-fat diet?

The biggest problem in the studies that supposedly favored low-carb diets
was the failure to use truly low-fat diets. Samaha et al used a moderate-fat
goal, 30% calories from fat, in their "low-fat" group. (7) They reported a
baseline level of fat consumption by that group of 33% of calories from fat
(68 g/d) and even after "six months of dietary counseling," this group
averaged the same percentage of calories from fat (33%; 57.8 g fat). Data in
McManus et al also showed minimal changes and moderate levels of fat
consumption at baseline (31%) and follow-up (30%) in the low-fat group. (6)
Brehm et al and Yancy et al used low-fat goals of about 30%, and they both
reported 29% fat consumption during the program. (4,8)

In their extensive review of the efficacy of popular diets, Freedman et al
categorized the level of fat consumption obtained in these 4 studies as
"moderate-fat." (16) Current evidence suggests that the moderately high
levels of fat consumption achieved in these studies should not have helped
weight-controllers succeed. (17,18) In a review of dietary interventions,
Barnard et al reported that "only very stringent dietary manipulations led
to effective change." (19) They found that the 3 studies that clearly
produced the greatest changes in diets limited "dietary fat to no more than
10% of energy," not the 25% to 30% of calories from fat used by almost all
of the other 27 studies in their review and obtained (29%-33%) by the
studies under discussion here. Freedman et al also asserted that "data
support the contention that those consuming low-fat, low-calorie diets are
most successful in maintaining weight loss." (16)

Stice's survey of 396 adolescents also illustrates the differential benefits
of very-low-fat compared with low/moderate-fat diets. (20) He found that
only those who followed a very stringent approach lost weight; those who
reported following more moderate diets actually gained weight.
Weight-controllers in Jeffery et al also found a low-fat approach easier to
use and more palatable than a calorically restricted diet without limits on
fat. (21) (It's easier to eat no potato chips at all than just one.) The
data from both these studies and the Barnard et al review support Barnard's
conclusion: "Higher limits on fat intake, which may be selected in hopes of
maximizing the acceptability of prescribed diets, may actually discourage a
greater degree of dietary change." (19)

Lowering levels of fat consumption is crucial

[GRAPHIC OMITTED]

Other analyses of the impact of macronutrients on weight change support the
view that moderate (and certainly high) fat consumption can inhibit weight
loss and maintenance of reduced weight. The extensive review of the efficacy
of low-carb diets in Bravata et al showed that "among obese patients, weight
loss was associated with longer diet duration, restriction of caloric
intake, but not with reduced carbohydrate content". (2) The Freedman et al
review also found no support for the benefits of reducing carbohydrate
content, without restricting calories, on weight loss. (16)

For example, Harris et al studied 157 weight-controllers over 18 months and
found that reducing the percentage of calories from carbohydrates (and
protein) did not affect weight loss. (22) In contrast, eating very little
fat, and specifically minimizing consumption of beef, hot dogs, and sweets,
did predict weight loss (as it did in Holden et al). (23) Reducing calories
from fat actually predicted weight loss even better than change in total
calories (as it did in Jeffery et al). (21)

In a remarkably similar vein, but with children as the focus, Gazzaniga and
Burns found that a group of obese children ate much more fat and many fewer
carbohydrates than their lean peers. (24) Even after statistically adjusting
for total energy intake, physical activity, and metabolic rates, obese
children still ate more fat and fewer carbohydrates.



Animal and physiologic research also supports the benefits of truly low-fat
diets compared with moderate-fat diets. Several studies showed that animals
fed high-fat diets gained weight much more readily than those fed diets much
lower in fat. (27) Boozer et al also found that high-fat diets not only
promote weight gain but also inhibit weight loss. (28) They compared several
groups of rats whose food was restricted to 75% of the calories in their
baseline diets. The rats that were fed high-fat, restricted-calorie diets
(45% fat) failed to lose weight, compared with rats that consumed diets of
the same restricted calorie level that were moderately high in fat (28%) and
low in fat (12%). Three human studies also found that much-lower-fat diets
resulted in weight loss even when total calories were not reduced, an effect
never obtained with low-carb diets. (16)

Bessesen et al demonstrated a method through which high-fat diets inhibit
weight loss. (29) They found that when obese rats consumed dietary fat, it
was transported to storage in fat cells and away from muscle cells much more
so than was the case in lean rats. This pattern was accentuated for formerly
obese rats. Formerly overweight people also show a differential sensitivity
to fat at the cellular level. (30) They may also have greater physiologic
sensitivity (insulin secretion, salivation) to the presence and even the
thought of highly palatable high-fat food. (31) Consuming high-fat foods may
also encourage overeating by increasing appetite and decreasing satiety to a
greater extent than low-fat foods. (32) This may occur because eating such
foods may stimulate the endogenous opioid peptide system.

Consuming a high-fat diet also induces heightened sensitivity to leptin,
leads to increases in ghrelin, and inhibits the transportation of insulin
into the brain, all of which probably increase eating and weight gain. (16)
In fact, a recent study showed that a very low-fat/high-carbohydrate diet
(15% calories from fat, 65% carbohydrate, 20% protein) failed to trigger the
type of increase in ghrelin (a potent orexigenic signal) that is typically
seen when people lose weight by restricting calories in higher-fat diets.
(33)

Why were truly low-fat diets not used in these studies?

This evidence raises questions about why these researchers chose "low-fat"
dietary levels (actually "moderate-fat" diets, according to Freedman et al)
that were 50% to 100% higher than genuinely "low-fat" or "very-low-fat"
levels. (16) Part of the answer is that the current evidence, while
compelling, remains somewhat controversial and circumstantial. Definitive
treatment outcome studies that clearly favor very-low-fat diets have not yet
emerged, although the evidence certainly points in that direction.

The reliance on tradition (actually, myths) provides another explanation.
For decades, major professional groups that focus on diet and health (such
as the AHA and ADA) have advocated moderation as the key to success in
weight control. Extreme approaches, or so the myth goes, will not work
because they induce feelings of deprivation and binge eating. Yet, the
scientific evidence shows that more stringent goals for fat consumption seem
easier (not harder) to implement consistently, make more sense
physiologically, and produce the most promising results.

Implications

Perhaps the greatest irony in the current low-carb craze pertains to the
overwhelming scientific evidence showing that self-help and other minimal
interventions (for example, diet books and instructions alone) rarely help
people lose much weight. Yet, publications in prestigious journals with
favorable editorial commentaries, public relations campaigns, anecdotal
claims, sales of millions of books, and countless stories in the media have
prompted literally thousands of papers addressing this issue. (2,16)

It is time for diet to be put in its place. A diet is just one element that
can facilitate weight loss only when weight-controllers sustain major
efforts to transform their lifestyles (activity level, stress management,
focusing, and commitment). Furthermore, even when extracting the
contribution of diet on weight loss, the possible long-term risks of
low-carbohydrate/high-fat diets and some noteworthy short-term adverse
effects (such as significantly increased GI distress, headaches, and muscle
weakness) should discourage the use of such diets. (8) Unless valid
scientific research shows reliable and differential weight loss and other
benefits for low-carb diets, which seems unlikely at this juncture, the
recommended pathway to successful weight control should include a
very-low-fat diet, not a low-carb/high-fat diet.

This article was contributed by Dr Kirschenbaum and edited by Peter D'Epiro,
PhD.

Dr Kirschenbaum discloses that he is Clinical Director and Chief Program
Officer, Healthy Living Academies Division of Aspen Education Group,
Cerritos, Calif.

www.patientcareonline.com

Visit our Web site for

* Quick access to the reports and Internet resources discussed in these
pages

REFERENCES

1. Atkins RC. Dr. Atkins' New Diet Revolution (Revised and Updated). New
York, NY: Avon Books; 1998.

2. Bravata DM, Sanders L, Huang J, et al. Efficacy and safety of
low-carbohydrate diets: a systematic review. JAMA. 2003;289:1837-1850.

3. The truth about dieting. Consumer Reports. 2002;67:26-31.

4. Brehm BJ, Seeley RJ, Daniels SR, et al. A randomized trial comparing a
very low carbohydrate diet and a calorie-restricted low fat diet on body
weight and cardiovascular risk factors in healthy women. J Clin Endocrin
Metab. 2003;88:1617-1623.

5. Foster GD, Wyatt HR, Hill JO, et al. A randomized trial of a
low-carbohydrate diet for obesity. New Engl J Med. 2003;348:2082-2090.

6. McManus K, Antinoro L, Sacks F. A randomized controlled trial of a
moderate-fat, low-energy diet compared with a low fat, low-energy diet for
weight loss in overweight adults. Int J Obesity. 2001;25:1503-1511.

7. Samaha FF, Iqbal N, Seshadri P, et al. A low-carbohydrate as compared
with a low-fat diet in severe obesity. N Engl J Med. 2003;348:2074-2081.

8. Yancy WS, Olsen MK, Guyton JR, et al. A low-carbohydrate ketogenic diet
versus a low-fat diet to treat obesity and hyperlipidemia. Ann Intern Med.
2004;140:769-777.

9. Stern L, Iqbal N, Seshadri P, et al. The effects of low-carbohydrate
versus conventional weight loss diets in severely obese adults: one-year
follow-up of a randomized trial. Ann Intern Med. 2004;140:778-785.

10. Dansinger ML, Gleason JA, Griffith JL, et al. Comparison of the Atkins,
Ornish, Weight Watchers, and Zone diets for weight loss and heart disease
risk reduction: a randomized trial. JAMA. 2005;293:43-53.

11. Cook TD, Campbell DT. Quasi-Experimentation: Design and Analysis Issues
for Field Settings. Chicago, III: Rand McNally College Publishing Company;
1979.

12. Heshka S, Greenway F, Anderson JW, et al. Self-help weight loss versus a
structured commercial program after twenty-six weeks: a randomized
controlled study. Am J Med. 2000;109:282-287.

13. Bennett GA. Behavior therapy for obesity: a quantitative review of
selected treatment characteristics on outcome. Behav Ther. 1986;17:554-562.

14. Baum JG, Clark HB, Sandler J. Preventing relapse in obesity through post
treatment maintenance systems: comparing the relative efficacy of two levels
of therapist support. J Behav Med. 1991;14:287-302.

15. Kaplan RM, Atkins CJ. Selective attrition causes over estimates of
treatment effects in studies of weight loss. Add Behav. 1987;12:297-302.

16. Freedman MR, King J, Kennedy E. Popular diets: a scientific review. Obes
Res. 2001(suppl 1):1S-40S.

17. Perri MG, Nezu AM, Viegener BJ. Improving the Long-Term Management of
Obesity: Theory, Research, and Clinical Guidelines. New York, NY: John Wiley
& Sons; 1992.

18. Barber TX. Pitfalls in Human Research: Ten Pivotal Points. New York, NY:
Pergamon Press; 1976.

19. Barnard ND, Akhtar A, Nicholson A. Factors that facilitate compliance to
lower fat intake. Arch Fam Med. 1995;4:153-158.

20. Stice E. Prospective relation of dieting behaviors to weight change in a
community sample of adolescents. Behav Ther. 1998;29:277-297.

21. Jeffery RW, Hellerstedt WL, French SA, et al. A randomized trial of
counseling for fat restriction versus calorie restriction in the treatment
of obesity. Int J Obesity. 1995;19:132-137.

22. Harris JK, French SA, Jeffery RW, et al. Dietary and physical activity
correlates of long-term weight loss. Obes Res. 1994;2:307-313.

23. Holden JH, Darga LL, Olson SM, et al. Long-term follow-up of patients
attending a combination very-low calorie diet and behaviour therapy weight
loss programme. Int J Obes. 1991;16:605-613.

24. Gazzaniga JM, Burns TL. Relationship between diet composition and body
fatness, with adjustment for resting energy expenditure and physical
activity, in preadolescent children. Am J Clin Nutr. 1993;58:21-28.

25. Shick SM, Wing RR, Klem ML, et al. Persons successful at long-term
weight loss and maintenance continue to consume a low-energy, low-fat diet.
J Amer Diet Assoc. 1998;98:408-413.

26. Wadden TA, Foster GD, Letizia KA, et al. A multicenter evaluation of a
proprietary weight reduction program for the treatment of marked obesity.
Arch Intern Med. 1992;152:961-966.

27. Salmon DMW, Flatt JP. Effect of dietary fat content on the incidence of
obesity among ad libitum fed mice. Int J Obes. 1985;9:443-9.

28. Boozer CN, Brasseur A, Atkinson RL. Dietary fat affects weight loss and
adiposity during energy restriction in rats. Am J Clin Nutr.
1993;58:846-852.

29. Bessesen DH, Rupp CL, Eckel RH. Dietary fat is shunted away from
oxidation, toward storage in obese Zucker rats, Obes Res. 1995;3:179-189.

30. Tremblay A, Despres JP, Bouchard C. Adipose tissue characteristics of
ex-obese long-distance runners. Int J Obes. 1984;8:641-648.

31. Johnson WG, Wildman HE. Influence of external and covert food stimuli on
insulin secretion in obese and normal persons. Behav Neurol.
1983;97:1025-1028.

32. Blundell JE, Cotton JR, Delargy H, et al. The fat paradox: fat-induced
satiety signals versus high fat overconsumption. Int J Obes.
1995;19:832-835.

33. Weigle DS, Cummings DE, Newby PD, et al. Roles of leptin and ghrelin in
the loss of body weight caused by a low fat, high carbohydrate diet. J Clin
Endocrinol Metab. 2003;88:1577-1586.

DANIEL S. KIRSCHENBAUM, PhD

Clinical Director and Chief Program Officer, Healthy Living Academies
Division of Aspen Education Group, Cerritos, Calif; Director, Center for
Behavioral Medicine & Sport Psychology; and Professor of Psychiatry and
Behavioral Sciences, Northwestern University Medical School, Chicago, Ill.
His most recent book is The Healthy Obsession Program: Smart Weight Loss
Instead of Low-Carb Lunacy (http://www.benbellabooks.com).

RELATED ARTICLE: Article at a glance

** Five studies published in the past 3 years compared low-carbohydrate to
low-fat diets using random assignment and evaluations lasting about 6 months
or longer.

** The authors of most of these studies concluded that their low-carb diets
helped their overweight participants lose more weight than their low-fat
diets.

** A critical review, however, reveals that none of these studies provides
valid evidence of the differential effectiveness for weight control favoring
low-carb diets.

** This analysis provides an empirically grounded rationale for recommending
truly low-fat diets for weight loss, unless and until valid evidence
suggests otherwise.

Low-carb Sample Menu

Breakfast
Cheese-baked eggs
Sausage patties
Tea or decaf coffee with cream and sugar substitute

Lunch
Chicken croquettes on a bed of lettuce
Sugar-free orange gelatin parfait

Dinner
Sour cream clam dip with fried pork rinds
Fennel red snapper
Tossed green salad with creamy dijon vinaigrette dressing
Tea or decaf coffee with cream and sugar substitute

Snack
Vanilla ice cream

Low-fat Sample Menu

Breakfast
Egg white omelet with red potatoes, fat-free cheese, diced onion, and
garlic
Nonfat blended berry yogurt
Berries
Herbal tea or coffee with skim milk and sugar substitute

Lunch
Pepperoni pita pocket pizza (fat-free pita bread, pizza sauce, soy
pepperoni, fat-free shredded jack and cheddar cheese)
Low-fat split pea or vegetable soup
Iced tea or diet soda

Dinner
Broiled lobster with lemon
Roasted new potatoes
Asparagus
Salad with fat-free dressing
Fruit salad and frozen sorbet or yogurt
Hot herbal tea or diet soda

Snack
Pretzels, low-fat popcorn, or whole fruit




--
1) Eat Till SATISFIED, Not STUFFED... Atkins repeated 9 times in the book
2) Exercise: It's Non-Negotiable..... Chapter 22 title, Atkins book
3) Don't Diet Without Supplemental Nutrients... Chapter 23 title, Atkins
book
4) A sensible eating plan, and follow it. (Atkins, Self Made or Other)
  #4  
Old March 22nd, 2006, 01:18 PM posted to alt.support.diet.low-carb
external usenet poster
 
Posts: n/a
Default Very-low-fat diets are superior to low-carbohydrate diets (***sigh!***)


Jbuch wrote:
Man... is this pulling out the swords and declaring war. And, the
declaration that we need a new army of professional diet therapists or
their equivalent.

And that what is needed is not LOW FAT but VERY LOW FAT diets, possibly
administered by therapists.....

This rings of Dr. Dean Ornish again springing into action to fill the
void left by the negative $400 million study on the lack of benefit of
LOW FAT.



That's what I thought too. The inescapable conclusion from the recent
NUH study results are that in the real world trying to do low fat
doesn't work. The women doing low fat did achieve a significant
reduction in fat intake for 8 years, with no statistical reduction in
CHD or cancer. They met with nutritionists at least 4 times a year and
many times more than that in the first couple years. They volunteered
for the study and were motivated at least as much as the average person
trying to follow low fat, and likely much more.

So, rather than accept that what these alleged experts have been
telling us for years is wrong, and it's time for a re-evaluation and a
long term study of something else like low carb, the spin misters are
out with this sorry sack of crap, It's not that they are all wrong.
It's that the women who tried their best to do low fat simply failed
and the reason no benefit was found was that they had to go to very low
fat. How exactly are they proposing for 48000 women to do that for 8
years? Lock them up in a lab? And how the hell is the general
population going to do this? Do these idiots even have a clue?







The alleged hidden secret of the first trials of the Ornish ultra-low
fat diet in fact had intensive personal therapy for the participants in
making this enormous change in eating style. The same study allegedly
had intensive physical exercise programs which were also administered by
the diet therapists.


A few items extracted from the long paper below.....

These diet people are as despicable as politicians ....


Jim

-------------------------------------------------------------

Should.....

Suggest ..... may cause

Professionally conducted weight-control programs are far more likely to
help people lose weight than self-help approaches. (12)

Perhaps the greatest irony in the current low-carb craze pertains to the
overwhelming scientific evidence showing that self-help andother minimal
interventions(for example, diet books and instructions alone)rarely help
people lose much weight. Yet, publications in prestigious journals with
favorable editorial commentaries, public relations campaigns, anecdotal
claims, salesof millions ofbooks, and countless stories inthe media have
prompted literally thousands of papers addressing this issue. (2,16)


As would be expected from these results, highly successful adult
weight-controllers consume much less fat than average Americans and
about 10
times the level of carbohydrates recommended by Atkins. (25) Weight-loss
programs that counsel people to eat like this have produced among the most
promising outcomes in long-term evaluations. (26)


Yet, the scientific evidence shows that more stringent goals for fat
consumption seem easier (not harder) to implement consistently, make
more sense physiologically, and produce the most promising results.


Unless valid scientific research shows reliable and differential weight
loss and other benefits for low-carb diets, which seems unlikely at this
juncture, the recommended pathway to successful weight control should
include a very-low-fat diet, not a low-carb/high-fat diet.




Roger Zoul wrote:
Very-low-fat diets are superior to low-carbohydrate diets: evidence shows
that very-low-fat diets (not low- or moderate-fat diets) may be easier, not
harder, to follow and make more sense physiologically.


They should also
produce the best weight loss and health outcomes

They should also
produce the best weight loss and health outcomes in the long
run.(VIEWPOINT). Daniel S. Kirschenbaum. Patient Care 39.11 (Nov 2005):
p47(7).
For more than half a century, millions of Americans have periodically
followed diets that were very low in carbohydrates (and high in protein and
fat) in search of the best and easiest way to lose weight. The late Robert
C. Atkins' 1998 revision of his 1972 Dr. Atkins' Diet Revolution was on the
New York Times best-seller list for more than 6 years, and many other
best-sellers have advocated similar low-carbohydrate diets. (1) Several
professional organizations, including the American Dietetic Association
(ADA) and the American Heart Association (AHA), have advised against the use
of low-carb diets because considerable scientific evidence suggests that
diets like these may promote cardiovascular, kidney, and liver diseases, as
well as cancer. (2)


evidence suggests that diets like these may promote cardiovascular,


Despite the ostensible health risks of low-carb diets, some people have
followed this approach and lost weight.



Despite the ostensible health risks of low-carb diets, some people have
followed this approach and lost weight. This anecdotal evidence, coupled
with successful marketing campaigns, has led even neutral consumer advocates
to encourage weight controllers to "add a little fat" to their diets. (3)
Despite waning interest in this approach, acceptance of the supposed
benefits of low-carb dieting still appears routinely in the media and is
evident in restaurant menus and on supermarket shelves. Only a careful
review of the scientific literature can determine whether health
professionals should recommend or oppose low-carb dieting for their confused
overweight patients.

Bravata et al recently identified 2616 articles in professional journals
(including 94 empirical studies) pertaining to the efficacy of low-carb
dieting. (2) However, only 6 studies--5 of them published since the Bravata
review was completed--have compared low-carb/moderate- to high-fat diets
with diets described as "low-fat" using random assignment and evaluations
lasting at least 6 months. (4-10) The authors of 4 of these 6 studies
concluded that their low-carb diets helped their overweight participants
lose more weight than their low-fat diets. (4,6,7-9) A critical review of
these studies, however, reveals that none provides scientifically valid
evidence for this claim. This article presents the basis for this assertion
and provides an empirically grounded rationale for recommending very low-fat
diets.

Flaws in research designs

Three major flaws in research designs undermine the validity of these
studies. First, all 4 of the studies that found some ostensible benefits for
low-carb diets used elaborate intervention programs (for example, 18 months
of weekly sessions), not dietary instructions alone. (4,6,7-9) Including the
diets within extensive programs confounds the integrity of the independent
variable, decreasing internal validity ("diffusion of treatment") and
external validity ("multiple treatment interference"). (11)

Second, the administrators of these diet/behavioral programs had far more
opportunities for their beliefs or biases to have an impact on outcomes than
they would have had in a study, like that of Foster et al, that used a diet
intervention alone. (5) This raises possibilities of investigator and
experimenter bias that threaten both internal and external validity
("reactivity of experimental arrangements" and "combination of experimental
setting and treatment"). (11) Two of the 4 studies that supported the
supposed differential benefits of low-carbohydrate diets were funded by
companies (olive oil and peanut companies and The Dr. Robert C. Atkins
Foundation) that had--and still have--major financial allegiances to
low-carbohydrate diets. (6,8) This fact clearly increases the salience of
concerns about investigator/experimenter bias, although it by no means
impugns the integrity of the researchers.

The third design flaw is the most important: None of the 4 studies that
ostensibly found benefits for low-carb diets used a truly low-fat diet (for
example, 5%-10% of calories from fat), sometimes referred to as a
very-low-fat diet. Thus, these studies actually compared low-carb diets with
moderate-fat diets (goals were 20%, (6) 25%, (5) and 30% (4,7,8) of calories
from fat; obtained: 29%-33%), thereby creating a "construct validity"
problem. (11)

When is a diet a diet?

Only Foster et al tested the relative efficacy of a diet per se, as it is
usually attempted by the millions of people who buy diet books. (5) This
study also yielded no differences between low-carb and low-fat diets at a
1-year follow-up and produced about half the weight loss in their best
group, as compared with the best group of 2 of the other studies. (4,8) The
remaining studies tested dietary instructions within educational and
behavioral programs.

Professionally conducted weight-control programs are far more likely to help
people lose weight than self-help approaches. (12) In fact, a meta-analysis
showed that the single best predictor of weight loss is length of treatment.
(13) Longer treatments also produced much more weight loss in studies that
experimentally compared longer to shorter treatments. (14) These effects of
amount of contact with professionals emerge almost regardless of the content
that is focused on within the sessions. (15) Apparently, participation in
such programs helps weight-controllers set goals, monitor and evaluate their
behaviors, and generally stay motivated, optimistic, and focused on change.
These findings indicate that the 5 low-carb studies under consideration here
that embedded the diets within educational/behavioral programs must
attribute some of their effects to the programs themselves, not the diets.

Investigator and experimenter bias

Investigators' hypotheses can intentionally or unintentionally affect the
manner in which the experimental protocol is specified and delivered and the
accuracy of data gathering and analyses. Similarly, experimenters (in these
studies, dietitians) can affect recruitment and retention of participants.

[GRAPHIC OMITTED]

In the present set of studies, the researchers and dietitians probably knew
that publication, notoriety, and subsequent funding may have depended on
finding benefits for low-carb diets. The enthusiasm of the dietitians who
administered the programs could have varied according to condition, quite
possibly unintentionally, thereby affecting attrition and recruitment for
evaluations. In fact, the attrition in some of the low-fat groups was as
much as 400% higher than the usual attrition rate for related behavioral
programs that used low-fat or very-low-fat diets (80% versus 20%) and was
significantly higher in low-fat compared with low-carb groups in 3 of the 6
studies. (6,7,8,15) This suggests the possibility of differential enthusiasm
for the treatments.

Research on investigator and experiment bias has revealed some dramatic
effects, including studies showing that experimenters' computational errors
favor investigators' hypotheses 75% of the time. (16) The authors of the 2
studies under review here that received financial support from companies
with vested interests in low-carbohydrate diets based their conclusions
favoring low-carb/moderate-to-high fat diets on potentially flawed analyses.
(6,8)

First, the "primary analyses" of McManus et al were conducted using a
"low-fat" group in which 67% (20 of 30) subjects analyzed had dropped out of
the program. (6) Thus, they almost certainly were no longer following the
low-fat approach when they were counted as "low-fat" dieters. This group was
compared with a higher-fat group comprising 25 active participants and only
6 dropouts. Forty additional dropouts were not "available for measurements."
Based purely on research showing the powerful impact of active participation
in weight-loss programs, 67% of the low-fat group included in the primary
analyses would be expected to fare poorly, compared with 19% of the low-carb
group. (13) This differential subject attrition, one of the primary threats
to internal validity, was statistically very significant (P .001) but
ignored by the authors. When the researchers compared only current
participants (excluding dropouts), the groups did not differ in weight loss.

The quality and outcomes of the manipulation checks in the study by Yancy et
al raise questions about the nature of the independent variable (the
distinctiveness and characterizations of the diets). (8) The Atkins'
(low-carb) diet group was instructed to consume less than 20 g/d of
carbohydrates--a severely restricted level of carbohydrate consumption. The
authors noted that carbohydrate consumption under 40 g/d (twice the allowed
level) should have been readily detected by urinary dipstick tests. However,
only 19 of 59 (32%) participants included in analyses had observed trace
levels of ketones. Since the vast majority of those assigned to the
low-carbohydrate diet failed to restrict their carbohydrate consumption
enough to be detected at twice the allowed level, it seems problematic to
consider this group to be a "low-carbohydrate diet group."

Perhaps the researchers considered their dietary assignments to be
successful based on analyses of the diets reportedly consumed by
participants. Unfortunately, only 20 out of 119 (17%) of participants were
selected (not randomly assigned: 13 low-carb dieters, 7 low-fat dieters) for
analyses of their diets. No measure of the reliability of these dietary
assessments was reported.

Even if participants had followed Yancy et al's dietary manipulation exactly
as intended, these researchers, like McManus et al, largely ignored the
potential impact of differential subject attrition. (6,8) The Yancy study
did not acknowledge the McManus study or others showing that dropouts often
fail to lose weight, compared with those who stay in treatment. (13,15) The
McManus and Yancy low-fat participants prematurely discontinued treatment
almost twice as often (43%) as their low-carbohydrate groups (24%). Unlike
McManus et al, however, Yancy et al did not analyze the data separately for
completers only. Without taking into account the likely poorer performance
of the greater number of dropouts in the low-fat group, Yancy et al may have
inadvertently skewed the results in favor of their low-carbohydrate group.

Furthermore, the use of linear mixed-effects models to project expected
weight losses (instead of analyzing the data actually obtained) may have
capitalized on the well-known effect of low-carbohydrate diets to produce
initially greater weight losses. (9) Also, as Yancy et al noted, their use
of projected values depended on the assumption that including dropouts would
not affect the meaning of the results ("noninformative dropouts"). In
weight-control research, however, dropouts lose less weight than completers.
(13,15) Therefore, including these dropouts "informed" the outcomes, thereby
perhaps violating an assumption of the analyses.

This argument gains support by calculating the impact on the results of
including the dropouts. The low-carbohydrate dieters were projected to lose
85% more weight than those assigned to the low-fat group at the 24-week
point. When dropouts are deleted from these projections (counting them as
losing no weight in both diet conditions), the discrepancy between groups
decreases substantially. The projected difference decreases by 236% (from
85% to 36%), quite possibly rendering the actual differences between groups
nonsignificant.

When is a low-fat diet a low-fat diet?

The biggest problem in the studies that supposedly favored low-carb diets
was the failure to use truly low-fat diets. Samaha et al used a moderate-fat
goal, 30% calories from fat, in their "low-fat" group. (7) They reported a
baseline level of fat consumption by that group of 33% of calories from fat
(68 g/d) and even after "six months of dietary counseling," this group
averaged the same percentage of calories from fat (33%; 57.8 g fat). Data in
McManus et al also showed minimal changes and moderate levels of fat
consumption at baseline (31%) and follow-up (30%) in the low-fat group. (6)
Brehm et al and Yancy et al used low-fat goals of about 30%, and they both
reported 29% fat consumption during the program. (4,8)

In their extensive review of the efficacy of popular diets, Freedman et al
categorized the level of fat consumption obtained in these 4 studies as
"moderate-fat." (16) Current evidence suggests that the moderately high
levels of fat consumption achieved in these studies should not have helped
weight-controllers succeed. (17,18) In a review of dietary interventions,
Barnard et al reported that "only very stringent dietary manipulations led
to effective change." (19) They found that the 3 studies that clearly
produced the greatest changes in diets limited "dietary fat to no more than
10% of energy," not the 25% to 30% of calories from fat used by almost all
of the other 27 studies in their review and obtained (29%-33%) by the
studies under discussion here. Freedman et al also asserted that "data
support the contention that those consuming low-fat, low-calorie diets are
most successful in maintaining weight loss." (16)

Stice's survey of 396 adolescents also illustrates the differential benefits
of very-low-fat compared with low/moderate-fat diets. (20) He found that
only those who followed a very stringent approach lost weight; those who
reported following more moderate diets actually gained weight.
Weight-controllers in Jeffery et al also found a low-fat approach easier to
use and more palatable than a calorically restricted diet without limits on
fat. (21) (It's easier to eat no potato chips at all than just one.) The
data from both these studies and the Barnard et al review support Barnard's
conclusion: "Higher limits on fat intake, which may be selected in hopes of
maximizing the acceptability of prescribed diets, may actually discourage a
greater degree of dietary change." (19)

Lowering levels of fat consumption is crucial

[GRAPHIC OMITTED]

Other analyses of the impact of macronutrients on weight change support the
view that moderate (and certainly high) fat consumption can inhibit weight
loss and maintenance of reduced weight. The extensive review of the efficacy
of low-carb diets in Bravata et al showed that "among obese patients, weight
loss was associated with longer diet duration, restriction of caloric
intake, but not with reduced carbohydrate content". (2) The Freedman et al
review also found no support for the benefits of reducing carbohydrate
content, without restricting calories, on weight loss. (16)

For example, Harris et al studied 157 weight-controllers over 18 months and
found that reducing the percentage of calories from carbohydrates (and
protein) did not affect weight loss. (22) In contrast, eating very little
fat, and specifically minimizing consumption of beef, hot dogs, and sweets,
did predict weight loss (as it did in Holden et al). (23) Reducing calories
from fat actually predicted weight loss even better than change in total
calories (as it did in Jeffery et al). (21)

In a remarkably similar vein, but with children as the focus, Gazzaniga and
Burns found that a group of obese children ate much more fat and many fewer
carbohydrates than their lean peers. (24) Even after statistically adjusting
for total energy intake, physical activity, and metabolic rates, obese
children still ate more fat and fewer carbohydrates.



Animal and physiologic research also supports the benefits of truly low-fat
diets compared with moderate-fat diets. Several studies showed that animals
fed high-fat diets gained weight much more readily than those fed diets much
lower in fat. (27) Boozer et al also found that high-fat diets not only
promote weight gain but also inhibit weight loss. (28) They compared several
groups of rats whose food was restricted to 75% of the calories in their
baseline diets. The rats that were fed high-fat, restricted-calorie diets
(45% fat) failed to lose weight, compared with rats that consumed diets of
the same restricted calorie level that were moderately high in fat (28%) and
low in fat (12%). Three human studies also found that much-lower-fat diets
resulted in weight loss even when total calories were not reduced, an effect
never obtained with low-carb diets. (16)

Bessesen et al demonstrated a method through which high-fat diets inhibit
weight loss. (29) They found that when obese rats consumed dietary fat, it
was transported to storage in fat cells and away from muscle cells much more
so than was the case in lean rats. This pattern was accentuated for formerly
obese rats. Formerly overweight people also show a differential sensitivity
to fat at the cellular level. (30) They may also have greater physiologic
sensitivity (insulin secretion, salivation) to the presence and even the
thought of highly palatable high-fat food. (31) Consuming high-fat foods may
also encourage overeating by increasing appetite and decreasing satiety to a
greater extent than low-fat foods. (32) This may occur because eating such
foods may stimulate the endogenous opioid peptide system.

Consuming a high-fat diet also induces heightened sensitivity to leptin,
leads to increases in ghrelin, and inhibits the transportation of insulin
into the brain, all of which probably increase eating and weight gain. (16)
In fact, a recent study showed that a very low-fat/high-carbohydrate diet
(15% calories from fat, 65% carbohydrate, 20% protein) failed to trigger the
type of increase in ghrelin (a potent orexigenic signal) that is typically
seen when people lose weight by restricting calories in higher-fat diets.
(33)

Why were truly low-fat diets not used in these studies?

This evidence raises questions about why these researchers chose "low-fat"
dietary levels (actually "moderate-fat" diets, according to Freedman et al)
that were 50% to 100% higher than genuinely "low-fat" or "very-low-fat"
levels. (16) Part of the answer is that the current evidence, while
compelling, remains somewhat controversial and circumstantial. Definitive
treatment outcome studies that clearly favor very-low-fat diets have not yet
emerged, although the evidence certainly points in that direction.

The reliance on tradition (actually, myths) provides another explanation.
For decades, major professional groups that focus on diet and health (such
as the AHA and ADA) have advocated moderation as the key to success in
weight control. Extreme approaches, or so the myth goes, will not work
because they induce feelings of deprivation and binge eating. Yet, the
scientific evidence shows that more stringent goals for fat consumption seem
easier (not harder) to implement consistently, make more sense
physiologically, and produce the most promising results.

Implications

Perhaps the greatest irony in the current low-carb craze pertains to the
overwhelming scientific evidence showing that self-help and other minimal
interventions (for example, diet books and instructions alone) rarely help
people lose much weight. Yet, publications in prestigious journals with
favorable editorial commentaries, public relations campaigns, anecdotal
claims, sales of millions of books, and countless stories in the media have
prompted literally thousands of papers addressing this issue. (2,16)

It is time for diet to be put in its place. A diet is just one element that
can facilitate weight loss only when weight-controllers sustain major
efforts to transform their lifestyles (activity level, stress management,
focusing, and commitment). Furthermore, even when extracting the
contribution of diet on weight loss, the possible long-term risks of
low-carbohydrate/high-fat diets and some noteworthy short-term adverse
effects (such as significantly increased GI distress, headaches, and muscle
weakness) should discourage the use of such diets. (8) Unless valid
scientific research shows reliable and differential weight loss and other
benefits for low-carb diets, which seems unlikely at this juncture, the
recommended pathway to successful weight control should include a
very-low-fat diet, not a low-carb/high-fat diet.

This article was contributed by Dr Kirschenbaum and edited by Peter D'Epiro,
PhD.

Dr Kirschenbaum discloses that he is Clinical Director and Chief Program
Officer, Healthy Living Academies Division of Aspen Education Group,
Cerritos, Calif.

www.patientcareonline.com

Visit our Web site for

* Quick access to the reports and Internet resources discussed in these
pages

REFERENCES

1. Atkins RC. Dr. Atkins' New Diet Revolution (Revised and Updated). New
York, NY: Avon Books; 1998.

2. Bravata DM, Sanders L, Huang J, et al. Efficacy and safety of
low-carbohydrate diets: a systematic review. JAMA. 2003;289:1837-1850.

3. The truth about dieting. Consumer Reports. 2002;67:26-31.

4. Brehm BJ, Seeley RJ, Daniels SR, et al. A randomized trial comparing a
very low carbohydrate diet and a calorie-restricted low fat diet on body
weight and cardiovascular risk factors in healthy women. J Clin Endocrin
Metab. 2003;88:1617-1623.

5. Foster GD, Wyatt HR, Hill JO, et al. A randomized trial of a
low-carbohydrate diet for obesity. New Engl J Med. 2003;348:2082-2090.

6. McManus K, Antinoro L, Sacks F. A randomized controlled trial of a
moderate-fat, low-energy diet compared with a low fat, low-energy diet for
weight loss in overweight adults. Int J Obesity. 2001;25:1503-1511.

7. Samaha FF, Iqbal N, Seshadri P, et al. A low-carbohydrate as compared
with a low-fat diet in severe obesity. N Engl J Med. 2003;348:2074-2081.

8. Yancy WS, Olsen MK, Guyton JR, et al. A low-carbohydrate ketogenic diet
versus a low-fat diet to treat obesity and hyperlipidemia. Ann Intern Med.
2004;140:769-777.

9. Stern L, Iqbal N, Seshadri P, et al. The effects of low-carbohydrate
versus conventional weight loss diets in severely obese adults: one-year
follow-up of a randomized trial. Ann Intern Med. 2004;140:778-785.

10. Dansinger ML, Gleason JA, Griffith JL, et al. Comparison of the Atkins,
Ornish, Weight Watchers, and Zone diets for weight loss and heart disease
risk reduction: a randomized trial. JAMA. 2005;293:43-53.

11. Cook TD, Campbell DT. Quasi-Experimentation: Design and Analysis Issues
for Field Settings. Chicago, III: Rand McNally College Publishing Company;
1979.

12. Heshka S, Greenway F, Anderson JW, et al. Self-help weight loss versus a
structured commercial program after twenty-six weeks: a randomized
controlled study. Am J Med. 2000;109:282-287.

13. Bennett GA. Behavior therapy for obesity: a quantitative review of
selected treatment characteristics on outcome. Behav Ther. 1986;17:554-562.

14. Baum JG, Clark HB, Sandler J. Preventing relapse in obesity through post
treatment maintenance systems: comparing the relative efficacy of two levels
of therapist support. J Behav Med. 1991;14:287-302.

15. Kaplan RM, Atkins CJ. Selective attrition causes over estimates of
treatment effects in studies of weight loss. Add Behav. 1987;12:297-302.

16. Freedman MR, King J, Kennedy E. Popular diets: a scientific review. Obes
Res. 2001(suppl 1):1S-40S.

17. Perri MG, Nezu AM, Viegener BJ. Improving the Long-Term Management of
Obesity: Theory, Research, and Clinical Guidelines. New York, NY: John Wiley
& Sons; 1992.

18. Barber TX. Pitfalls in Human Research: Ten Pivotal Points. New York, NY:
Pergamon Press; 1976.

19. Barnard ND, Akhtar A, Nicholson A. Factors that facilitate compliance to
lower fat intake. Arch Fam Med. 1995;4:153-158.

20. Stice E. Prospective relation of dieting behaviors to weight change in a
community sample of adolescents. Behav Ther. 1998;29:277-297.

21. Jeffery RW, Hellerstedt WL, French SA, et al. A randomized trial of
counseling for fat restriction versus calorie restriction in the treatment
of obesity. Int J Obesity. 1995;19:132-137.

22. Harris JK, French SA, Jeffery RW, et al. Dietary and physical activity
correlates of long-term weight loss. Obes Res. 1994;2:307-313.

23. Holden JH, Darga LL, Olson SM, et al. Long-term follow-up of patients
attending a combination very-low calorie diet and behaviour therapy weight
loss programme. Int J Obes. 1991;16:605-613.

24. Gazzaniga JM, Burns TL. Relationship between diet composition and body
fatness, with adjustment for resting energy expenditure and physical
activity, in preadolescent children. Am J Clin Nutr. 1993;58:21-28.

25. Shick SM, Wing RR, Klem ML, et al. Persons successful at long-term
weight loss and maintenance continue to consume a low-energy, low-fat diet.
J Amer Diet Assoc. 1998;98:408-413.

26. Wadden TA, Foster GD, Letizia KA, et al. A multicenter evaluation of a
proprietary weight reduction program for the treatment of marked obesity.
Arch Intern Med. 1992;152:961-966.

27. Salmon DMW, Flatt JP. Effect of dietary fat content on the incidence of
obesity among ad libitum fed mice. Int J Obes. 1985;9:443-9.

28. Boozer CN, Brasseur A, Atkinson RL. Dietary fat affects weight loss and
adiposity during energy restriction in rats. Am J Clin Nutr.
1993;58:846-852.

29. Bessesen DH, Rupp CL, Eckel RH. Dietary fat is shunted away from
oxidation, toward storage in obese Zucker rats, Obes Res. 1995;3:179-189.

30. Tremblay A, Despres JP, Bouchard C. Adipose tissue characteristics of
ex-obese long-distance runners. Int J Obes. 1984;8:641-648.

31. Johnson WG, Wildman HE. Influence of external and covert food stimuli on
insulin secretion in obese and normal persons. Behav Neurol.
1983;97:1025-1028.

32. Blundell JE, Cotton JR, Delargy H, et al. The fat paradox: fat-induced
satiety signals versus high fat overconsumption. Int J Obes.
1995;19:832-835.

33. Weigle DS, Cummings DE, Newby PD, et al. Roles of leptin and ghrelin in
the loss of body weight caused by a low fat, high carbohydrate diet. J Clin
Endocrinol Metab. 2003;88:1577-1586.

DANIEL S. KIRSCHENBAUM, PhD

Clinical Director and Chief Program Officer, Healthy Living Academies
Division of Aspen Education Group, Cerritos, Calif; Director, Center for
Behavioral Medicine & Sport Psychology; and Professor of Psychiatry and
Behavioral Sciences, Northwestern University Medical School, Chicago, Ill.
His most recent book is The Healthy Obsession Program: Smart Weight Loss
Instead of Low-Carb Lunacy (http://www.benbellabooks.com).

RELATED ARTICLE: Article at a glance

** Five studies published in the past 3 years compared low-carbohydrate to
low-fat diets using random assignment and evaluations lasting about 6 months
or longer.

** The authors of most of these studies concluded that their low-carb diets
helped their overweight participants lose more weight than their low-fat
diets.

** A critical review, however, reveals that none of these studies provides
valid evidence of the differential effectiveness for weight control favoring
low-carb diets.

** This analysis provides an empirically grounded rationale for recommending
truly low-fat diets for weight loss, unless and until valid evidence
suggests otherwise.

Low-carb Sample Menu

Breakfast
Cheese-baked eggs
Sausage patties
Tea or decaf coffee with cream and sugar substitute

Lunch
Chicken croquettes on a bed of lettuce
Sugar-free orange gelatin parfait

Dinner
Sour cream clam dip with fried pork rinds
Fennel red snapper
Tossed green salad with creamy dijon vinaigrette dressing
Tea or decaf coffee with cream and sugar substitute

Snack
Vanilla ice cream

Low-fat Sample Menu

Breakfast
Egg white omelet with red potatoes, fat-free cheese, diced onion, and
garlic
Nonfat blended berry yogurt
Berries
Herbal tea or coffee with skim milk and sugar substitute

Lunch
Pepperoni pita pocket pizza (fat-free pita bread, pizza sauce, soy
pepperoni, fat-free shredded jack and cheddar cheese)
Low-fat split pea or vegetable soup
Iced tea or diet soda

Dinner
Broiled lobster with lemon
Roasted new potatoes
Asparagus
Salad with fat-free dressing
Fruit salad and frozen sorbet or yogurt
Hot herbal tea or diet soda

Snack
Pretzels, low-fat popcorn, or whole fruit




--
1) Eat Till SATISFIED, Not STUFFED... Atkins repeated 9 times in the book
2) Exercise: It's Non-Negotiable..... Chapter 22 title, Atkins book
3) Don't Diet Without Supplemental Nutrients... Chapter 23 title, Atkins
book
4) A sensible eating plan, and follow it. (Atkins, Self Made or Other)


  #5  
Old March 22nd, 2006, 04:21 PM posted to alt.support.diet.low-carb
external usenet poster
 
Posts: n/a
Default Very-low-fat diets are superior to low-carbohydrate diets (***sigh!***)


Roger Zoul wrote:

First, the "primary analyses" of McManus et al were conducted using a
"low-fat" group in which 67% (20 of 30) subjects analyzed had dropped out of
the program. (6) Thus, they almost certainly were no longer following the
low-fat approach when they were counted as "low-fat" dieters. This group was
compared with a higher-fat group comprising 25 active participants and only
6 dropouts. Forty additional dropouts were not "available for measurements."
Based purely on research showing the powerful impact of active participation
in weight-loss programs, 67% of the low-fat group included in the primary
analyses would be expected to fare poorly, compared with 19% of the low-carb
group. (13) This differential subject attrition, one of the primary threats
to internal validity, was statistically very significant (P .001) but
ignored by the authors. When the researchers compared only current
participants (excluding dropouts), the groups did not differ in weight loss.


...

The
McManus and Yancy low-fat participants prematurely discontinued treatment
almost twice as often (43%) as their low-carbohydrate groups (24%). Unlike
McManus et al, however, Yancy et al did not analyze the data separately for
completers only. Without taking into account the likely poorer performance
of the greater number of dropouts in the low-fat group, Yancy et al may have
inadvertently skewed the results in favor of their low-carbohydrate group.


I agree that the low-carb study authors shouldn't have ignored
differential attrition, but on the other hand, if twice as many
subjects can't even stick to a 'moderate-fat' program, how do the
authors of this paper think they're all going to stick to a very low
fat program? Isn't the ability of people to maintain a way of eating
somewhat relevant? I totally believe that if you locked me in a room
and fed me nothing but white rice, I'd lose weight on a high-carb diet.
The thing is, I'm not locked in a room with nothing but rice, I'm out
in the real world, and whatever dietary manipulations I use to maintain
a healthy weight have to be something I can actually do in that
environment.

That's really my peeve with low-fat low-calorie dieting - I can
definitely lose weight on it, I'm just miserable the entire time. I
lost weight that way at one point, quite a bit, through iron willpower
and the constant support of a friend. God, I remember the stuff I ate
- all those salads with weird-tasting low-fat dressing, baked corn
chips with low-fat cheese, Snackwells cookies.... oh yick. And I was
*always* hungry.

Beth

  #6  
Old March 22nd, 2006, 05:31 PM posted to alt.support.diet.low-carb
external usenet poster
 
Posts: n/a
Default Very-low-fat diets are superior to low-carbohydrate diets (***sigh!***)

wrote:
Roger Zoul wrote:


First, the "primary analyses" of McManus et al were conducted using a
"low-fat" group in which 67% (20 of 30) subjects analyzed had dropped out of
the program. (6) Thus, they almost certainly were no longer following the
low-fat approach when they were counted as "low-fat" dieters. This group was
compared with a higher-fat group comprising 25 active participants and only
6 dropouts. Forty additional dropouts were not "available for measurements."
Based purely on research showing the powerful impact of active participation
in weight-loss programs, 67% of the low-fat group included in the primary
analyses would be expected to fare poorly, compared with 19% of the low-carb
group. (13) This differential subject attrition, one of the primary threats
to internal validity, was statistically very significant (P .001) but
ignored by the authors. When the researchers compared only current
participants (excluding dropouts), the groups did not differ in weight loss.



...

The
McManus and Yancy low-fat participants prematurely discontinued treatment
almost twice as often (43%) as their low-carbohydrate groups (24%). Unlike
McManus et al, however, Yancy et al did not analyze the data separately for
completers only. Without taking into account the likely poorer performance
of the greater number of dropouts in the low-fat group, Yancy et al may have
inadvertently skewed the results in favor of their low-carbohydrate group.



I agree that the low-carb study authors shouldn't have ignored
differential attrition, but on the other hand, if twice as many
subjects can't even stick to a 'moderate-fat' program, how do the
authors of this paper think they're all going to stick to a very low
fat program? Isn't the ability of people to maintain a way of eating
somewhat relevant? I totally believe that if you locked me in a room
and fed me nothing but white rice, I'd lose weight on a high-carb diet.
The thing is, I'm not locked in a room with nothing but rice, I'm out
in the real world, and whatever dietary manipulations I use to maintain
a healthy weight have to be something I can actually do in that
environment.

That's really my peeve with low-fat low-calorie dieting - I can
definitely lose weight on it, I'm just miserable the entire time. I
lost weight that way at one point, quite a bit, through iron willpower
and the constant support of a friend. God, I remember the stuff I ate
- all those salads with weird-tasting low-fat dressing, baked corn
chips with low-fat cheese, Snackwells cookies.... oh yick. And I was
*always* hungry.

Beth



The original Dr. Dean Ornish ultralow fat diet trial was successful
because, in part, it didn't just change the diet of the 22 subjects, it
"Transformed their Lives". According to :

"Low Fat Lies: High Fat Frauds and the Healtiest Doet in the World" by
Kevin Vigalante, MD & Mary Flynn, PhD (1999)

They ( the 22 research subjects) had:
- "Aggressive coaching and Psychological Help"
- "Exercise, Lots of it"
- "Meditation, Lots of it"
- "Group Therapy, lots"
- "LOW FAT DIET"

Ornish just popularly reported only the LOW FAT part of it. He failed to
isolate the variables and claimed that only LOW FAT was important -- at
the time. It is said he denied the importance of the other parts of the
experiment.

With all of this control and attentin given to the research subjects, it
would not be unusual to have about zero dropouts.

So, with careful editing, once can claim that there is a low dropout
rate from the Ultra Low Fat diet. And therefore, any other diet
approach which does not account for the drop out rate is FLAWED.


A good system of support and encouragement and involvement will boost
the following of most systems of change of life patterns.

Maybe, on reflection, there is a need for adjuncts to diet plans to
include coaching and support. Something like "Personal Trainers for
Food" rather than personal trainers for exercise.

Maybe, ultimately, each person has to tailor any dietary program to
become something that works for them. When it becomes "Their" diet plan,
they own it and respect it and maybe stick to it.

This whole diet industry is starting to sound repulsive as ways for the
diet plan proponents to put their agenda before that of the client.

Classical Business -

Jim





--
1) Eat Till SATISFIED, Not STUFFED... Atkins repeated 9 times in the book
2) Exercise: It's Non-Negotiable..... Chapter 22 title, Atkins book
3) Don't Diet Without Supplemental Nutrients... Chapter 23 title, Atkins
book
4) A sensible eating plan, and follow it. (Atkins, Self Made or Other)
  #7  
Old March 22nd, 2006, 06:26 PM posted to alt.support.diet.low-carb
external usenet poster
 
Posts: n/a
Default Very-low-fat diets are superior to low-carbohydrate diets (***sigh!***)

Jbuch wrote:
::
:: This whole diet industry is starting to sound repulsive as ways for
:: the diet plan proponents to put their agenda before that of the
:: client.
::

Sounds just like religion & politics.


  #8  
Old March 23rd, 2006, 01:00 PM posted to alt.support.diet.low-carb
external usenet poster
 
Posts: n/a
Default Very-low-fat diets are superior to low-carbohydrate diets (***sigh!***)

Roger Zoul wrote:
Jbuch wrote:
::
:: This whole diet industry is starting to sound repulsive as ways for
:: the diet plan proponents to put their agenda before that of the
:: client.
::

Sounds just like religion & politics.


Exactly. If there's money to be made, that will always trump what is
really best for people. Hence, people need to learn for themselves and
not rely on "official" pronouncements.

 




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