Recently I have been re-studying low carbohydrate diets spurred on by an extensive email dialogue with Dr. Richard Feinman, Prof. of Cell Biology at Downstate Medical School in Brooklyn (my alma mater), and by multiple inquiries about the Paleo diet from friends and acquaintances. Dr. Feinman is a highly-regarded scientist who has done research on metabolism in low carb diets and I have learned a lot from him. He studies and advocates a VLCKD (very low carb diet-20% of total calories from carbs with no fat restriction.) This is the diet that most lab research has been done on. It produces ketosis and ketone bodies supply much of nutritional needs of the cells rather than glucose. Dietary ketosis, as opposed to diabetic ketosis, is not harmful to the body. The source of the limited amount of carbs is optional but most advocates including Dr. Feinman eat leafy green and other non-starchy vegetables for their nutrient value and fiber.

Most low-fat and other low-carb diets recommend consumption of non-starchy vegetables and most fruits while avoiding sugars, refined grains and limiting salt. Some low carb programs suggest avoiding saturated fat as much as possible.

Vegetables and fruits can rarely supply enough calories for long-term existence in humans. Remaining calories have to come from either starches or animal products or refined vegetable oils.

Low-carb advocates suggest meat (some including Paleo want this to be low fat), fish, vegetable oils, and dairy products (Paleo excludes dairy and others say low fat dairy.)

Most low-fat advocates suggest starches.

Inside each camp there is variation with some low-carb people favoring organ meats and full fat dairy while others suggest no dairy at all. Many in the low-fat group aim at total fat consumption of 10% of calories and total protein consumption about the same. This is not the “low” fat diet of the AHA, ADA, Framingham Study, or Nurses Health Initiative Study which suggest 30% of calories from fat. But again there is variation, particularly in regard to the amount of seeds and nuts consumed. This group also advocates little or no vegetable oils except as found naturally in whole foods.

Books and articles on the subject have mainly been quite well written and sometimes very thoroughly researched. Low-carb supporters emphasize the need for insulin control as a basis for good health while low-fat advocates want to avoid almost all dietary fat especially saturated fat and cholesterol. There is excellent laboratory and clinical support for both these positions. Each of the writers from both groups tend to ignore the strong positions of the others while showing the rationale and clinical evidence for their position. I’ve not found a book or article which looks at it well from both sides. Some have termed this the war of the diets and I don’t think that term is far off based on the approaches many scientists and authors have staked.

Another group of diets looks more towards portion control while supporting high vegetable and fruit intake with avoidance of sugar, refined grains and saturated fat. Variations on this theme were the most popular with professional nutritionists as seen in the 2013 “US News and World Report” evaluation of 29 diet programs by a panel of 21 nutrition experts selected by the magazine. In this survey, most of the low-fat diet programs were in the middle of the ratings and most of the low carbohydrate programs were at the bottom with the Paleo diet tied for last. Objections to both the low-fat and low-carb diets often centered around palatability and ease of adherence to the diet with the low-carb diets also criticized as not having long-term performance experience and a danger for development of vascular disease. My observation on these rating criteria is that many, if not most, people have a serious problem with portion control and keeping track of what quantity of food is eaten while they can more readily adapt to relatively unlimited quantities of certain foods while avoiding other foods entirely. Both the low-fat and low-carb diets typically offer this approach which many people I have talked to find easier. Also, results of these moderation diets are poor in the treatment of chronic disease. They may help somewhat in prevention but effects are small compared to a true plant based whole food diet.
Two popular versions of a lower fat, higher nutrient diets do not stress portion control. The Mediterranean Diet advocates lots of fruits, vegetables and fish plus oils with less meat, dairy, refined carbs. Compared to the standard American diet (SAD) people who eat this way live longer and have better health but do not have nearly the longevity or lack of chronic disease which those who eat a whole food plant based diet enjoy. This diet is not very effective in the treatment of chronic disease. Another version of a low-fat diet is flexitarian, in which the low-fat plant based whole food diet is modified to include small amounts of fish, low fat dairy and/or meat. Several knowledgeable physicians I’ve met follow this diet as preventative but say they would eliminate all animal products for themselves or patients to treat many chronic diseases. The issue for advocates of the low-fat diet is what qualifies as a “small” amount and how reliable patients will be if allowed this flexibility. Esselstyn says that he knows he can successfully treat all his patients with coronary disease so why take a chance on a modification.

Low-carb programs have convincingly shown excellent control of weight and metabolic syndrome (MetS) including diabetes and high blood pressure. Low-fat programs have had similar results with a comparison study between the two-favoring low-carb. However, in this study in the low-fat group 24% of calories came from fat which does not come close to the guidelines suggested by the low-fat diet promoters. Low-carb diets may also induce good serum lipid profiles which suggests to some researchers that atherosclerosis would be well treated and controlled by this diet. This diet also generates low blood insulin levels together with a ketotic state both favoring less cancer development and growth. Another hormone, IGF-1, a strong promotor of cancer growth, is increased with animal, not vegetable, protein consumption. I don’t know how these changes balance out for tumor growth. I have not seen a study which treats patients with advanced coronary artery disease with a low-carb diet nor am I aware of any long-term studies in groups of patients following this program except those of contemporary indigenous groups in whom heart attacks are rare until western food choices are introduced. The few autopsy studies pre-western food in these people usually show atherosclerosis but they often die young for other reasons so that clinically relevant vascular disease and cancer rates are uncertain.

Low-fat diet programs are well documented to prevent and reverse advanced coronary artery disease and population studies of large groups following this diet show low rates of cancer and other chronic diseases especially vascular disease. This diet typically is associated with longevity and low end-of-life morbidity where there is not famine or infectious disease.
Many people have asked me about body building and diet. Most body builders and professional athletes eat large amounts of animal protein and many take protein supplements, usually but not always from animal products. I am convinced that any protein supplement, animal or vegetable is a bad idea. Isolated protein concentrates promote cancer growth according to many studies. Some world class athletes eat plant based diets and feel they perform better because of it (Venus and Serena Williams, Martina Navratilova, Arian Foster, Tony Gonzalez among others) and a few champion body builders also eat a plant based diet. However, I’m sure it is easier to build muscle bulk with animal products. A plant based diet may be as good or better for performance.
It is certain that you are very unlikely to have good health with lots of processed food, sugars, salt, and refined carbs in your diet and that if you combine a high carb with a high fat diet that you will have a poor diet likely to lead to chronic diseases. The question is; are some people better off with low carb and others with low fat. Certainly, some people strongly prefer one over the other. Is this genetic or due to degree of fat addiction or due to an individual’s body doing better on one of them? Is it cultural? Does it matter which you choose? I am confident that you will thrive on a plant based whole food diet which avoids processed oils. A few people have reported doing poorly on this diet, then feeling better switching to a low carb diet or some modification of a fully plant based diet. When physicians have evaluated the few, who don’t thrive typically they find a deficiency in vitamin B-12, an essential fatty acid, or a mineral (often zinc or iodine.) These deficiencies are easily treated. Constipation and headaches are usually a problem with low-carb diets but this is not the case with low fat (8-12%) diets. Incidence of vascular disease and cancer are certainly much lower on a low-fat diet. I don’t know what they would be on a long term low carb diet.

When Evidence Says No, but Doctors Say Yes

By Axel Pfaender

Long after research contradicts common medical practices, patients continue to demand them and physicians continue to deliver. The result is an epidemic of unnecessary and unhelpful treatments.

https://www.theatlantic.com/health/archive/2017/02/when-evidence-says-no-but-doctors-say-yes/517368/

• DAVID EPSTEIN AND PROPUBLICA 

• FEB 22, 2017

John McDougall spoke about current practices in diabetes treatment, a topic I have recently studied and given presentations about. Diabetes drugs and monitoring devices are a huge business, one of the major profit sources for the medical industry. In recent years many of these products have increased dramatically in price as pharmaceutical companies try to increase profits. The strength of big pharma’s relationship to government has prevented control of unjustifiable prices in the United States.

The following is a combination of my findings and McDougall’s:

Diabetes prevention and treatment are among the greatest tragedies of modern medicine. As we have developed brilliant diagnostic tools and surgical techniques we have failed in the management of chronic diseases, especially diabetes. Diabetes is typically divided into type 1, a disease of insufficient insulin production and type 2, a disease of insulin resistance where cells cannot effectively use insulin. Recently, more people have developed a combination of the two types in which there is less than optimal insulin production plus insulin resistance, a condition sometimes referred to as type 1.5 diabetes. All types have increased blood sugar plus very high rates of premature death, many vascular diseases, cancer and dementia. This is a terrible disease.

When insulin was discovered in the early 1920’s people with type 1 diabetes were no longer doomed to early death due to high blood sugar. In that era type 2 diabetes was much less common (the western diet was not as bad as it is now) and not understood as a separate disease. A few years after insulin became available doctors were shocked that their diabetic patients were still dying prematurely just as before insulin was available- only a few years later in life. Even with glucose (blood sugar) lowering, diabetes of both types predisposes to aggressive vascular disease in large vessels (heart attacks, strokes, amputations) and small vessels (kidney failure, blindness, neuropathy.) Elliot Joslin, a famous diabetologist of the early 20th century, said that diabetic patients formerly died of too much blood sugar but now died of too much fat in the blood which caused fatal forms of vascular disease. We’ve known this for 90 years but little has been done to effectively fix the problem, and diabetics are still dying prematurely and suffering from heart attacks, strokes, amputations, kidney failure, blindness and neuropathy. The assumption that control of blood sugar with insulin and oral drugs would prevent these diabetes complications has turned out to be false. In fact, all of the drug treatments for diabetes have major side effects which often over-shadow the advantage of their blood sugar lowering. Multiple reviews have concluded that there is little advantage to intensive blood sugar monitoring and treatment. Intensive monitoring fills the patient’s life, preventing joy in day to day activities. Intensive treatment often leads to episodes of hypoglycemia (too low blood sugar) which are dangerous, even fatal.

A major multi-university study in 1970 concluded that diabetic patients would be just as well off if they had no treatment at all! Little has changed since then. Oral drugs are more sophisticated and much, much more expensive but offer little benefit.
http://www.diapedia.org/introduction-to-diabetes-mellitus/1104938831/the-university-group-diabetes-program
Since this area is such a huge, profitable business the medical industry does not acknowledge this proven fact, and most doctors are trained to give these drugs in large quantities. Type 1 diabetes will always require insulin; type 2 diabetes is curable by diet alone. Some patients with type 1.5 diabetes will require small doses of insulin even on a healthy whole food plant based diet. McDougall emphasizes that he gives no one oral diabetes drugs since, with a healthy diet, their glucose lowering effect is not necessary and they may lead to dangerous hypoglycemia and other serious side effects.

First line oral therapy is usually metformin, chosen because it has the least side effects. But multiple reviews of this drug have failed to show increased longevity and there is only questionable minimal improvement in some complication rates. Other common drugs, sulfonylureas and Avandia, have increased rates of cardiovascular disease and other serious side effects.
Avandia is still heavily marketed and prescribed in spite of a $3 billion fine for poor reporting of results, and there are over 50,000 lawsuits pending due to serious complications from this drug. https://www.drugwatch.com/avandia/lawsuit.php
You can imagine the profits made by these drugs if they are still selling one with this track record. A few new drugs are reported to offer a very small decrease in cardiovascular disease but with serious drug side effects and at great expense. Drugs are approved by the FDA and heavily prescribed if they lower blood sugar, but the problem with diabetes is premature death, terrible vascular complications, increased cancer and dementia rates which drugs do not help. Only a whole food plant based diet allows diabetics good health and longevity!

The frequency of diabetic vascular complications is much lower in those on a whole food plant based diet. Isidore Snapper, a famous physician-researcher of the mid 20th century, was chief of medicine at the Rockefeller Institute hospital in Beijing (then called Peiping.) He wrote that, none of the patients in his large diabetes clinic had any complication of the disease and concluded that their diet of rice and vegetables with little animal products or vegetable oils (they were too poor to afford these foods) protected them from the ravages of diabetes which most western civilization patients suffer. Ironically, the mainstay of their diet was white rice, a relatively low nutrient food which is frequently vilified as a cause of health issues. Vascular disease and all its sequelae are the result of too much animal product food and refined vegetable oils, not carbohydrates. Refined grains (wheat, rice) and sugars including honey and agave are unhealthy foods but do not cause diabetes or diabetic complications. If combined with animal products and refined oils they will add to the problem. Experimental animals and people fed sugar don’t become diabetic; those fed a high fat diet do.

John McDougall also spoke on “Does Sugar Feed Cancer:”

Proponents of low carb diets claim that sugar is the major culprit in the development and progression of cancer. The scientific literature contradicts this.
A review by a national study group concluded that high fat diets are the problem in cancer and that there is not good evidence that carbohydrates promote cancer. A possible mechanism is the slowing of blood flow caused by a high fat meal. (Vegetable oils like olive oil cause even more slowing than than animal product fat.) A typical American high fat meal leads to a 20% decrease in the amount of oxygen delivered to body tissues for several hours, often up until the next high fat meal. The theory that low oxygen levels promote the development and progression of cancer was proposed by the Nobel winning biologist, Otto Warburg, and later confirmed in cell cultures and experimental animals. Clinical studies have confirmed that a whole food plant based diet (which will be low fat) significantly increases longevity in people with known cancer and the American Cancer Society now states this in its patient information literature.

Kevin Hall, the lead researcher on obesity at the NIH, discussed his findings:

Drastic diets change the perception of what you need to eat and so participants in THE BIGGEST LOSER TV series all are long term failures. They revert quickly to normal eating habits and back towards previous weight. Most think they are still dieting since the effort not to eat even more is very high. Very severe calorie restriction plus heavy exercise always fails because of this reprogramming of appetite levels.

A modest number of those on true low fat or true low carb diets do succeed at long term weight control but it’s currently not possible to predict who will succeed on either. Hall mentions other issues like longevity, cardiovascular disease and cancer due to diet but doesn’t discuss them. As he points out, weight is a marker for health and is not the bottom line. Of course, this is where a whole food plant based diet shines, with overwhelming evidence that it is good at avoiding/treating many diseases regardless of the relative value of different diets for weight loss.

Ironically one of his studies was partially funded by the Taubes group to help prove the carb-insulin model of insulin secretion. Proponents of low carb diets have claimed that carbohydrates cause insulin secretion (true) and therefore lead to promotion of obesity and poor health (totally false.) In metabolic ward studies (research subjects live in the research lab where all their food intake and activity are monitored) Hall’s studies showed that a low fat diet resulted in more body fat loss than a low carb diet which led to loss of more muscle tissue, not fat- exactly the opposite of what Taubes and other low carb advocates have been claiming. It’s a devastating study for this movement since it destroys the major scientific basis of their diet. In addition to being bad for health (CV, auto-immune, cancer, overall longevity) the low carb diet is also bad for fat loss versus muscle loss. In spite of this research, none of them have retracted their dangerous advocacy of high fat and protein diets. Even worse, the popular press parrots their advice like gospel.

https://www.nih.gov/news-events/news-releases/nih-study-finds-cutting-dietary-fat-reduces-body-fat-more-cutting-carbs