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SANTA ANA, Calif. - In his lifetime, Dr. Robert Atkins believed people could lose weight and keep it off by eating a diet low in carbohydrates and high in protein. Despite the torrent of criticism against his diet, Atkins continued to extol the diet's benefits for 30 years until his death in April.
Last month, possible validation of Atkins' beliefs was delivered like an eloquent eulogy: Two separate studies published in the New England Journal of Medicine, or NEJM, showed that people lost weight after practicing the Atkins diet for at least six months and up to a year. Some risk factors for heart disease decreased, contrary to the concern of skeptical cardiologists and dieticians.
Was Atkins right all along?
There's still no consensus from the medical and dietary community.
But the studies at the Philadelphia VA Medical Center and the University of Pennsylvania add momentum to a perceptible evolution of attitudes toward the diet. Where doctors once dismissed the diet because of lack of studies, some physicians today say the diet may have some value.
Exactly what that is isn't clear yet.
Dr. Dena Bravata, a social science research scholar at Stanford University, knows that the low-carb phenomenon continues to sit in a hazy limbo between good-for-you and bad-for-you camps. After conducting an extensive analysis of more than 100 studies on low-carb diets, Bravata and her colleagues, including sister Dr. Dawn Bravata, concluded that there isn't enough evidence to make a recommendation for or against the diet. Their findings, which were published in the Journal of the American Medical Association on April 9, did not include the two studies in the NEJM.
Yet, in dealing with patients who ask her whether they should try the diet, Bravata has found that the answers in real life are not sliced as straight as study conclusions. When counseling patients who are obese or overweight and possibly with other conditions such as diabetes or high blood pressure, she has had to weigh available information about low-carb diets with a patient's immediate medical need to lose weight.
"Because there is no significant evidence for or against the diet and because weight loss is a key component of improving these patients' health, I'll tell them to go ahead and try this," Bravata said. "But I'll monitor closely their blood pressure, cholesterol and other factors."
Dr. Frederick Samaha, lead author of one of the studies in NEJM, agrees that certain circumstances may make the low-carb diet worth trying.
"I would advise this diet only to people who are very overweight and have diabetes or metabolic syndrome - and only if they have failed to lose weight on a low-fat diet," said Samaha, chief of cardiology at the Philadelphia VA Medical Center.
Longtime Atkins-diet advocates and followers say the studies confirm what they've known all along: The diet works.
Rich Liem of Placentia, Calif., has been a believer in the Atkins diet since 2000. "My doctor said, 'I want you to lose weight,''' Liem said. " 'Try to do (the Atkins diet)' not because of its nutritional value but because others on it have been successful in keeping the weight off. He said, 'You're a big guy and it's difficult to micromanage your calorie intake.'"
The 6-foot-6 schoolteacher with a sweet tooth gave up candies, as well as pasta, bread and rice.
Liem lost 50 pounds toward his goal of 70 pounds after one year on the Atkins diet. But in the past two years, he's gained half of what he lost. "I've flirted with the diet back and forth," he said. He attributes the weight gain to recidivism - eating carbohydrate-rich foods when he thought he was on the fast track to more weight loss.
Now, he's back on the Atkins plan with a new resolve to stick to it. "The diet is unique once you get into it, you don't crave carbohydrates," he said.
If Atkins were still alive, he would not be surprised at the results, said Colette Heimowitz, director of education and research at Atkins Health and Medical Information Services in New York. "He knew that there was an alternative to the common wisdom of the health profession that low fat was the only way to a healthy lifestyle and permanent weight loss," she said. "His is a safe and effective approach for people who had failed at low-fat diet attempts."
Still, some critics say that while the recent studies may get a lot of media attention, we still don't know enough about whether the diet is safe and effective over a longer period than one year.
While subjects did lose weight in the VA and the University of Pennsylvania studies, there also were other compelling findings and limitations that raise questions.
It's possible that it's calorie restriction, not the amount of protein and carbs, that results in weight loss, said Gail Frank, Los Alamitos, Calif.-based spokeswoman for the American Dietetic Association.
In the studies, people on the low-carb diet were not told to restrict their calories, but to limit their carbohydrate intake. In the six-month VA study, the low-carb group lost an average of 13 pounds, while the low-fat group lost an average of 4 pounds.
One of the popular theories to explain why those on the low-carb diet lost more weight is that they ate less because proteins and fats may make them feel satisfied or full for longer periods than if they ate carbohydrate-rich food.
Another finding that bears more examination: In the University of Pennsylvania study, the weight-loss difference between the low-carb and low-fat groups was not significant after one year. Researchers do not know why.
Among the surprising findings: Low-carb dieters reduced triglyceride levels in both studies much more than low-fat dieters did. Triglycerides are blood fats that may contribute to clogged arteries. Low-carb dieters in the Penn study increased their high-density lipoprotein cholesterol (HDL, the good cholesterol) more than the low-fat group did. It's not known why low-carb dieters fared better in these areas.
The dropout rate from the studies was high, underscoring how difficult it is for people to stick to these diets. Yes, you will lose weight, ADA's Frank said. But whether you'll be able to keep it off for years remains to be seen, she said.
With many unanswered questions, it may be better to focus on the quality of the foods and to encourage eating more vegetables and fruits, rather than to emphasize proportions of carbs, protein and fats or eliminate fats or carbs from one's meals, Frank said. Choosing better quality, she said, means getting one's carbohydrates from high-fiber unsweetened grains and veggies rather than from low-fat cookies. Or cooking with a small amount of olive oil rather than lard or butter.
As for the Atkins diet, long-term studies on safety and effectiveness are under way.
Not that people who want to lose weight are waiting. Books about low-carb diets are frequently found The New York Times bestseller list for hardcover advice.
In the No. 7 spot for the week ending Friday: the late doctor's "Atkins for Life."
(c) 2003, The Orange County Register (Santa Ana, Calif.). Distributed by Knight Ridder/Tribune News Service.