One of the major complications of diabetes involves injury to the small blood vessels traveling throughout your body. The excess glucose circulating in your blood stream is toxic to these blood vessels, resulting in damage to the organs or structures they supply. In the kidney, this results in damage to the glomeruli, the microscopic sieves that filter your blood. A new study in mice has shown that a ketogenic diet may reverse this damage: 

Read the whole article here.

"When you're a hammer, everything looks like a nail." No where is this statement more true than in medicine.  A perfect example is in the treatment of type 2 diabetes.

If a doctor suspects their patient may be diabetic, they can run an oral glucose tolerance test (OGTT), in which the patient is given a glucose load, and subsequent blood response is measured to see how effectively the glucose is cleared from the blood. In a non-diabetic, the blood sugar only rises a relatively small amount, as the intact and functional beta cells of the pancreas secrete just the right amount of insulin to reduce the blood sugar levels to normal levels. 

If a person is given an OGTT and their blood sugar spikes more than expected, then by definition they are glucose intolerant. They have failed their OGTT, and cannot tollerate carbohydrates the way a non-diabetic can.

In medical school, we are taught that the primary goal in treating diabetics is to keep blood sugar levels low, and that hemoglobin A1C levels are predictors of further disease progression. There are two major ways to control this blood glucose level, with what we put into our bodies as well as ways to control the blood glucose after it has already risen, such as insulin or other diabetes drugs, such as the alpha-glucosidase inhibitors.

Alpha-glucosidase inhibitors are a category of drug that work by decreasing the absorption of carbohydrates in your gut, resulting in a smaller rise in blood glucose. However, the unabsorbed carbohydrates need to go somewhere, causing the predicted unpleasant side effects of stomach discomfort and diarrhea.

Now instead of taking a drug that will reduce our absorption of carbohydrates, result in various side effects and and cost additional money, why not just eat less of the very foods spiking the blood sugar in the first place? In other words, why would the American Diabetes Association tell us that a diabetic diet should be 40-50% of the calories from carbohydrates, when by definition, these are the vey foods they cannot tolerate? Here is how they describe it on their meal planning page:

It seems equivalent to a person with a peanut allergy slightly lowering their peanut intake and just injecting him or herself with an epinephrine pen after each meal. Why not just stop eating peanuts and avoid the potential side effects of epi injections? Why don't they just not eat the carbohydrates in the first place? After all this was the treatment of diabetes in the pre-insulin era. Here is how Dr. Elliot Proctor Joslin described it in 1893:  

And here is how the Joslin Diabetes Center, named after Dr. Joslin above,  describes it 120 years later:

Diabetes is diagnosed by demonstrating a glucose intolerance and therefore, the first line of therapy should be a reduction in glucose. Why is this logic not the first, most obvious treatment? Of course if the patient refuses, or they reduce their carbohydrates and their blood glucose levels continue to remain elevated, then further therapy is in order.

I believe it is because food is not "a hammer" physicians are equipped with. Medical training in nutrition is essentially absent apart from outdated vitamin deficiencies,  yet doctors are expected to know it, so they default to the USDA's MyPlate for advice and information. This is seen as a constant, unchangeable  variable in treatment of any food related disease, regardless of the etiology, given the label of "diet" or "lifestyle." Just the fact that alpha-glucosidase inhibitors are used as a treatment before a low carbohydrate diet confirms this.

Furthermore, if the patient is given a low fat high carbohydrate diet (as is the standard of care today) to manage their high blood sugar and they do comply with it meticulously, they will very likely need the insulin, alpha-glucosidase inhibitors, and/or metformin to control their daily dose of 180 grams of the very nutrient they cannot tolerate.

Clinical Trials
When you look for clinical trials testing this logic, you see things like this:

The triangle lines are the diabetic patients. The dark triangles represent those on a low carb, ketogenic diet. Their blood glucose and Hemoglobin A1C is significantly lower than those eating a low fat, high carbohydrate diet. This graph also illustrates how in non-diabetics (the circle lines), there is no difference, further supporting the fact that diabetics are carbohydrate intolerant.

Treating Type 2 diabetes with food
Once you have a basic understanding of how the three major macronutrients alter your blood glucose and insulin levels, devising a plan to reduce blood sugar levels becomes simple. 

• Carbohydrates of all kinds raise blood glucose AND insulin
  
• Protein spikes insulin AND DOES NOT seem to spike blood glucose, despite the theoretical ability of the amino acids to be converted into glucose via gluconeogenesis
• Dietary fat does not raise blood glucose OR insulin

Armed with these 3 simple facts, the intuitive treatment of high blood glucose would be: 

1. A decrease in carbohydrates, which spike blood glucose 
2. An increase in protein which acts to secrete insulin and thus reduce blood glucose (essentially acting as giving a patient insulin or sulfonylureas)
3. An increase in dietary fat, which is insulin and blood glucose neutral.
   

And when people eat this way, this is exactly what you see when it is tested:

Link to Video Here.

Dr. Dayspring reviews the methods of SpecialtyHealth's risk assessment and treatment of a 34-year old insulin resistant police officer. He went from incredibly high cardiovascular risk with insulin resistance to low risk in four months following SpecialtyHealth's model treatment program of a low carbohydrate diet, WWGF by Gary Taubes, and a statin. A must watch!

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I remember starting my first “diet” and attending my first Weight Watchers meeting at age 10, and for almost 40 years, I battled constantly with my weight. I was an expert at losing the weight, but could never keep it completely off for long, and like many, found myself caught in a vicious “yo-yo” weight loss cycle. I was always at odds with the scale. Always at war with food. And always hungry.

For almost 40 years, I tried every diet that came along in search of the magic bullet that would make me thin, keep me thin, and satisfy my constant hunger. I restricted food, weighed my food, and counted calories. I attended meetings, weighed in, and kept food diaries. I popped diet pills, drank weight loss formulas, and ate protein bars to curb hunger. Over the years, I’d go for weeks at a time eating nothing but cottage cheese, or grapefruit, or rice cakes, or low-fat yogurt, or Special K cereal with skim milk, or Diet Coke and gummie bears (they’re low-fat, right??). In a final act of desperation, I signed onto a very expensive, hospital-based, medically supervised weight loss program, which required that I drink nothing but protein shakes (taking in under 800 calories a day) for six months. I did that twice. It “worked” - both times. I spent a lot of money – both times. I lost a lot of weight – both times. But consuming only protein shakes for the rest of my life was not a sustainable solution for me.

The diet gimmicks worked for a while – especially during my high school years (while in marching band) and college years (as a performer in live shows and parades at Walt Disney World for four summers). In my twenties and thirties, I fluctuated between 124 lbs. and 150 lbs. But as I reached my forties, things started to change. I couldn’t keep the weight off. And by the time I reached my late forties, I had gained 200 lbs. I reached my highest weight…at 5 feet 4 inches, I weighed 324 lbs. And I was afraid.

I continued to struggle with food and went through periods of “all or nothing”…starving myself (“nothing”), and when that wasn’t working, I would eat whatever (“all”), because it just didn’t seem to matter. I couldn’t lose the weight when I was starving. I couldn’t lose it when I was eating a low-fat diet and exercising like my physicians prescribed. I was beyond discouraged. I was exhausted from extremely stressful situations in my work environment and at home. And I was struggling to balance the challenges of being the primary caregiver for my mother (who had been diagnosed with type 2 diabetes) for eight years prior to her death in 2010. 

As I cared for my Mom during those years, I witnessed how type 2 diabetes ravaged her health and destroyed her once full and vibrant life, until complications from the disease took her life at age 74. My wonderful Mom taught me how to live. But her greatest gift to me was showing me that type 2 diabetes and the litany of complications that accompany it were not the way to die.

I knew that I had to do something, but had no idea what that “something” was. Eating a low-fat diet and exercising more – as my doctors prescribed – were doing nothing more than making me hungrier, sicker, and fatter. I was exhausted all the time. I felt like a complete failure. 

Until November 5, 2009, when I had the great fortune of finding and coming under the medical care of Eric C. Westman, MD – Founder and Director of the Duke Lifestyle Medicine Clinic at Duke University Medical Center, Durham, NC, and internationally known researcher and expert in the clinical use of very low sugar/very low starch nutrition to manage obesity and to prevent and reverse diseases – including type 2 diabetes. 

Before meeting Dr. Westman, I had no idea that everything that I’d learned about diet, food, and nutrition was wrong. I had no idea that the “low-fat diet” that the “experts” had been telling me to eat was precisely what was making permanent weight loss virtually impossible for me. Most importantly, I had no idea that low-fat dieting was silently setting me up for the very same things (type 2 diabetes, heart disease, obesity) that ultimately caused my Mom’s death.

Thankfully, my Mom’s story won’t be mine, because in the three years since implementing Dr. Westman’s very low sugar/very low starch approach (from November 2009 to current, September 2012), I have lost 185 lbs. and kept it off. Thanks to Dr. Westman, I have learned to eat a well-formulated very low sugar/very low starch diet. I enjoy beautiful, fresh foods every day – eating right at or under 20 g Total Carbs a day, comprised of optimal protein (chicken, beef, poultry, pork, seafood), good fats (olive oil, coconut oil), full-fat dairy (butter, heavy whipping cream, cheeses), eggs (yolks and whites), very low sugar fruits (blueberries, blackberries, strawberries, raspberries), and non-starchy vegetables (lettuce, kale, spinach, onion, tomatoes, green beans, squash, zucchini, broccoli, bell peppers). 

I am 51 years old, weigh 139 lbs., and have more energy than I did thirty years ago. My arteries are clear and my blood pressure, cholesterol, glucose, and A1C levels are all beautifully normal…all of which are hard to believe for those who don’t understand the science behind very low sugar/very low starch eating. But it is true. 

I have the best health of my life and my healthiest years ahead…because of Eric Westman, MD, and others who know the science and understand that very low sugar/very low starch foods are the most powerful medicine we have. We can heal broken metabolisms and prevent and reverse a myriad of health conditions by simply eating beautiful, fresh very low sugar/very low starch foods that truly nourish us on all levels. 

We can’t exercise our way out of a bad diet. But we really can heal ourselves with the right one. I am thankful for Dr. Westman and for his work with very low sugar/very low starch nutrition. To say that it changed my life is an understatement. It saved my life. And I’m thankful for finally finding a wonderful way of eating that is sustainable, healthy and right for me. I am no longer at war with food. No longer at war with the scales. No longer at war with myself.

What was the biggest challenge to adopting a carbohydrate-restricted or paleo diet?
I'll never forget the day I went to particular appointment to see my doctor (Eric C Westman, MD, MHS, (founder-director of the Duke Lifestyle Medicine Clinic, Durham, NC, and President-Elect of the American Society of Bariatric Physians (not surgeons :-). At that appointment, Dr Westman told me, "Lynne, you have to eat fat to lose fat"...I couldn't believe it! Had a hard time wrapping my head around that one...but it's true. From that point on, I made a conscious effort to include more of the good fats in my diet. And the pounds melted away. 

What advice (if any) would you give to someone interested in trying a carbohydrate-restricted or paleo diet? Were there any obstacles that you overcame that could help future dieters?
My advice would be to immerse yourself in the real science out there that supports low-carb living. Read books by authors like Eric C Westman, MD (The New Atkins for a New You), Drs Steve Phinney and Jeff Volek (The Art & Science of Low-Carb Living, and The Art & Science of Low-Carb Performance), and of course, Gary Taubes (Good Calories, Bad Calories, and Why We Get Fat & What To Do About It). 

Search the web and enjoy the myriad of low-carb websites and low-carb recipes...there is no reason in the world to be hungry or bored with food when you low-carb...check out some wonderful recipe sites and bloggers, like Linda's Low-Carb recipes, Jamie Van Eaton's Your Lighter Side blog, Chef George Stella's site and amazing success story at Stella Style. Real food is delicious!! And it's made a 185 lb weight loss sustainable and permanent for me. 

Dr Westman says that low-carb living isn't a weight-loss diet...weight loss is a nice side benefit (true!!), but that the real magic is happening on the inside...with prevention and reversal of diseases and major improvements in a number of health markers, like cholesterol,triglycerides, and blood glucose levels,to name a few. I see insulin dependent/med dependent diabetics coming completely off of meds and insulin every day when they are under the care of Dr Westman...in essence, he is curing diabetes...totally reversing it...every single day. Miracles. I just wish more in the medical community knew and understood the real science behind low-carbing. (Ironically, Dr Westman teaches the only course in an American medical school (here at Duke University School of Medicine) that addresses the use of ketogenic diet to address obesity and to prevent and reverse disease. It is an elective for our medical students. one of these days...I hope Dr Westman and other physicians like him will get the respect deserved and that courses like this will be mainstream). 

I help Dr Westman lead the Low-Carb Support Group here at Duke...as a patient, group member, and group coordinator...I know how important it has been to me to surround myself with others who "get" low-carb. We have a wonderful group here in Durham, NC, that meets with Dr Westman monthly...we'd love to have anyone coming to the area join us! Click here for more information.

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I started out a few months before my 39th birthday at about 320 pounds with the goal of meeting 40 at a reasonable weight, which for me is around 200 pounds (not the 175 recommended according to BMI recommendations, due to my larger frame). I had previously attempted weight loss before, and had been at healthy weights a couple of times over the intervening 30 or so years. I kept reading that after 40 it becomes somewhat difficult to lose weight, so I wanted to attempt it one more time before resigning myself to all the metabolic problems that come with excess fat storage. I had previously been successful following the Dr. Atkins plan, but as so many others, I started the Induction phase and had such good success that I never progressed on to OWL. That is to say, I severely restricted my carb intake to about 60g of carbs a day, period. I was able to maintain this for a few months, but when it got close to a year, I found that I couldn't continue to eat this way. 

I read Gary Taubes' "Good Calories, Bad Calories", and realized that nutrition was not simply carbs vs proteins, vs fats, but rather nutrients and metabolic processes that would compliment and feed back on each other. I changed my eating habits as follows; first, I did severely restrict carbohydrates for the first few weeks for a couple of reasons. First off to break the carbohydrate/insulin feedback loop and get my body burning fats instead of sugars. The second reason was to de-sensitize my palate to sweet. Our diets contain so much added sugar that we can no longer taste the natural sugars and sweet flavors in real food. After a couple of weeks of severely restricting carbohydrates in general (but specifically any kind of sugar; sucrose, HFCS, fructose, lactose, etc) of course the weight started to come off. 

Over time I re-introduced some carbohydrates into my diet, but for the most part fruits and vegetables. I did avoid grains in general, especially corn and wheat. The only exceptions to the ban on grains was Quinoa, which I found as a great compliment to any dish, and brown rice, as my ethnic background made it very difficult to eschew rice completely. Those were infrequent additions to my menu which consisted of mostly proteins and fats. The main focus of my eating plan was to avoid processed foods completely. I did a lot of cooking at home and starting with raw ingredients. I rarely if ever ate anything that would come out of a box, a bag, or a can. I became a label-reader and would avoid any product that had more than 5 ingredients (to me that was a sure indicator that it had been moderately processed). I also consciously watched my portions, as I knew that I was overeating in any case. My golden rule was "all things in moderation". The trick is determining what the appropriate amount of any given food was. 

After eating in this style for almost two years now, I know it is a sustainable approach to eating. What I did not realize at the time is that this closely follows the "Paleo" or "Primal" nutritional approaches. What I realize now is that as omnivores, we are equipped to nourish ourselves with a lot of different sources. It is when we take one nutritional source and consume it almost to the exclusion of other foods that we get into metabolic trouble. Too much science has been devoted to isolating carbs, or fats, or refined sugars, or this micronutrient, or that micronutrient, and then making these huge sweeping claims about their benefit or dangers. What had not been approached is how we need all of these nutrients in the correct amounts based on our own metabolic chemistry to keep us at healthy weights and at optimal health. This balance will vary by individual and ethinc background, but by and large we can all agree that none of us are equipped to consume the huge amounts of refined sugars we find in our foods nowadays. By cutting down to the bone and starting with reasonable quantities of proteins, HEALTHY and NATURAL carbohydrates, natural (not processed and industrially extracted) fats, any one of us can start to repair the metabolic damage that our modern refined and processed diets have done to us.

Another aspect of my weight loss success is definitely getting exercise whenever possible. During my weight loss efforts, I was diligently going to the gym three times a week for an hour each time to do resistance training and some cardio. I would change up my routine almost every time I was in the gym. I had a big list of different exercises and the goals of that particular exercise, and would mix and match from there. I would always do some kind of cardio-ish work; sprints some days, stationary bikes some day, a run outdoors some days. Same with the strength. Some days I would do body weight exercises like pull-ups, push-ups lunge squats. Some days I would do static resistance like planks, other days I would just use resistance machines. The goal was always to work the muscles both in reaction-type exercises (to build fast-twitch muscle fibers) and more sustained resistance (to build up the slow-twitch muscle fibers). I continue this workout routine to this day, and it is easily sustainable and is still enjoyable. 

Another big contributor was to move as often as possible. I never take an elevator any more, always the stairs. I don't look for the closest parking spot at the office or the shopping center. I turn common household chores into an opportunity to do exercises by concentrating on balancing and squatting when I am putting away dishes, or reaching and stretching when I need to get things off of the top shelf. I avoid plopping down on the couch or on the bed after dinner and staring at the TV or the computer. Its not to say I won't watch TV, but I am doing something while I watch. I also took up some additional hobbies that keep me occupied at night. It doesn't necessarily have to be something physically active, but at the very least I am standing while I do it (motor repair, or wood work, that kind of thing) At lunch time I don't just go to the break room and sit, but rather take my lunch outside and take a walk while eating lunch. I make an effort to get enough sleep (7-8 hours every night), and make an effort to rise with the sun even on weekends and days off. When I have down time, it is spent taking my kids on a hike, or a bike ride, or a swim if its the right time of year. I basically keep trying to move as often as possible to keep the muscles moving, contracting, and out of "idle" mode.

In conclusion, I do want to say that I have been at my healthy weight of 195 pounds for a year and a half now. My goal is to maintain this weight for at least the next 5 years without having to plunge back into "restricted" mode i.e. just maintaining my eating and exercise regimen as it is now. I have relaxed a little bit in that I will occasionally indulge in something sweet (birthday cake, or a spectacular dessert to cap off a night out) or possibly have something that is served with bread. My body can now tolerate it without showing obvious ill effects. I have reached a sustainable balance of restricting certain foods, eliminating other foods, and exercising. I can foresee me maintaining this lifestyle and my healthy weight and build into my 50s, 60s, and beyond.

What was the biggest challenge to adopting a carbohydrate-restricted or paleo diet?
The biggest challenge was managing my portions. Even though I had eliminated a lot of the processed foods, fact is that our bodies will still take excess calories and store them as fat. Its the way we are made, its the mechanisms that helped us survive as a species for hundreds of thousands of years. You still can't have a half pound of bacon, a dozen eggs, and a 16 ounce (thats a pound of meat, boys and girls) steak every day and expect to lose weight. Your body will want to hold on to those excess calories in case the local market closes down and your next meal is a week down the road. If your metabolic mechanisms that regulate hunger and satiety are broken, you need to rely on visual queues to insure you are not consuming excess nutrients. Learn to measure portion sizes and recognize them, and learn to limit yourself based on these visual queues rather than the biochemical indicators which at this point may be damaged and in need of repair. 

What advice (if any) would you give to someone interested in trying a carbohydrate-restricted or paleo diet? Were there any obstacles that you overcame that could help future dieters?
My biggest advice I can offer other carb-restricted dieters is to remember that it is a process. You didn't become obese or overweight from one day to the next. Your metabolism is probably damaged, and needs to be repaired. Like healing any broken body part it takes time, and sometimes feels unpleasant. Stick with it as best as you can, and if you fall off the wagon, don't give up. Don't even say "today is shot, I'll try it again tomorrow". Recognize that you may have eaten something that is not proper for optimal health, and immediately dismiss it and go on. Even small changes in your eating habits where you eliminate some of the refined and processed foods will have a benefit.

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Finding a medical doctor that understands low carb & paleo nutrition can be a daunting task. Even mentioning the words 'low carb' to your doctor will likely be followed by an eye-roll and a lecture on how damaging it will be to your health. Yet if what if you tell your physician instead that:

"I started a new program. After years of struggling with my hunger pangs and food-day-dreams, I am suddenly freed from the hunger-handcuffs that consumed my every thought for the past 10 years of my life. No longer do I have to attempt to count the calories I eat. I just eat when I'm hungry. And it's not just me. It seems that when people adopt this lifestyle, 95% report no longer feeling hungry between meals. When they test this new program in randomized clinical trials, it seems to produce the most weight loss, in at least 14 studies. On top of all those exciting benefits, my blood triglycerides have plummeted and my HDL is slowly rising."

Of course framed in this way, doctors would be more excited about it. These potential benefits reside behind the stigmatized "low carb" curtain  that has tainted our view of primal nutrition in the eyes of our health professionals. 

Yet shining a light through this dark curtain are people like Dr. Gerber, Denver's Diet Doctor. With years of experience treating patients with low carb high fat nutrition, Dr. Gerber has seen the results with his own two eyes and is not looking back. Above is his interview with Dr. Eenfeldt, discussing his success in treating his overweight, diabetic, or metabolically deranged patients with carbohydrate restriction. 
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The days in which finding such medical doctors to help you lose weight and get healthy are numbered. At the registry, we are making a centralized location where paleo and low carb health experts can connect with people around the world who need their help.

Teaming up with Dr. Gerber and other paleo and low carb health professionals, we now offer a marketplace where people can go to "shop" for services they need, or experts they want to work with. 

You can skype, talk on the phone, get some advice on your cholesterol levels and diet, or e-mail Dr. Gerber and our other experts as they guide you on your primal journey towards better health. 

See the services we offer, or view our experts here.

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The randomized clinical trial offers our best tool for determining the efficacy of an intervention as compared to another. Whether it is a drug trial or diet trial, the devil is in the details. Reading the abstract does not give you the whole story, and it can be profoundly misleading. 

For example, let us assess a popular randomized clinical trial testing the efficacy of different diets, performed by some of the biggest names in diet and obesity research, such as Dr. Frank Sacks and Dr. George Bray.

The conclusion of their study is simple. All diets are created equal. 

This is the headline that makes it into the newspapers and becomes accepted as fact. Why question the results? Dr. Bray and Dr. Sacks and very well respected world-wide for their work; The New England Journal of Medicine is a prestigious journal. No sub-par work would get through the cracks. 


When reading a dietary clinical trial, and assessing its internal validity, there are three major points to keep in mind:

1. How large was the difference between assigned exposures?
2. Is there any evidence that the study subjects followed the diet or intervention they were randomized to?
   
3. When assessing a study testing varying carbohydrate content, is there any difference in triglyceride levels between the groups?

Difference between assigned exposures
The nutrient goals for the four diet groups were:

Low fat, average protein - 20% fat , 15% protein, and 65% carbohydrates 

Low fat, high protein - 20% fat, 25% protein, and 55% carbohydrates 

High fat, average protein - 40% fat , 15% protein, and 45% carbohydrates

High fat, high protein -  40% fat, 25% protein, and 35% carbohydrates

This was how they described it in the paper. Of course, the low fat, average protein group could also be called high carbohydrate group, and the high fat, high protein group could be called low(er) carbohydrate group.

Right away, this study design is somewhat worrisome, since the carbohydrate content of the diets are relatively similar. Determining a 10% difference in macronutrient content is likely unrealistic, since study subjects tend to cheat on their diets and the dietary assessments are subpar. This concern is further compounded by this seemingly innocuous sentence buried in the methods:

"Blinding was maintained by the use of similar foods for each diet."

At first glance this would be great. Blinding adds to the rigor of the study design, by keeping the study subjects in the dark as to which intervention they are receiving. However, in a diet study, this is very difficult. The only way this can be done properly is when foods are chemically modified to contain different nutrients, while still maintaining the same look, smell, and taste of the original food. This has been done beautifully in the Minnesota Coronary Survey, testing the potential benefits of a low saturated fat diet. Although rarely mentioned in the scientific literature, it was a very large, double blinded study that chemically altered the fat composition of various popular foods served to the institutionalized study subjects. (On a side note, this study found absolutely no benefit to eating a low saturated fat diet.)

However, blinding a study comparing different percentages of carbohydrates, protein and fat is essentially impossible without making each intervention very similar.

Is there any evidence that the study subjects followed the diet or intervention they were randomized to?

This is the giant elephant in the room of every dietary clinical trial. It is an enormous problem that nobody really talks about, and it is the major inspiration for developing PhotoCalorie. The "gold-standard" in dietary research in the year 2012 is pen and paper. We have machines that can literally look through your skin and see your organs and bones in vivid detail. We can tell who your parents are, simply by a drop of your spit. Yet when we study obesity, arguably the most important disease that plagues the world today, we use technology from 1812. 

In this particular study, the gold standard was not used. They instead used a 24-hour recall twice throughout the 2 year study in 50% of the patients. In other words, out of the 730 days and 811 study subjects, the primary intervention was only measured on 6 days in 405 people. 

6 DAYS! 0.8% of the days. Assuming they ate 3 meals a day, this means out of 2,190 meals they ate, only 18 of them were reported!

Compounding this unfortunate number is the fact that a 24-hour recall is far from perfect, and people tend to forget what they ate, and report foods deemed healthier more often.

Given all these limitations, here is what the study subjects reported eating. The left three columns correspond to the low fat, average protein group and the right three are for the low fat high protein groups, at 6 months and two years follow up:

As you can see, the macronutrient composition is virtually identical. At 2 years the low fat, average protein group was eating 1531 calories, 53% from carbs, 19.6% from protein, and 26.5% from fat. The low fat high protein group was eating 1560 calories, 51.3% from carbs, 20.8% from protein, and 28% from fat.

When assessing a study testing varying carbohydrate content, is there any difference in triglyceride levels between the groups?

There are other, more objective ways, to assess dietary adherence in such studies. When comparing groups with varying levels of carbohydrates, one excellent tool is the triglyceride levels in the study subjects. Simply stated, when people eat lots of carbs, their triglycerides go up (and their HDL usually goes down). Here is the data from the Sacks study:

The triglyceride levels at 6 months and 2 years are virtually identical. Same with the HDL levels. 

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The authors conclude in the discussion that the  "principal finding is that the diets were equally successful in promoting clinically meaningful weight loss and the maintenance of weight loss over the course of 2 years."

When you combine all these clues together -  the blinded study design, the similar reported macronutrient intake, the identical triglycerides and HDL levels - you come to a dramatic conclusion that explains why all the groups were equally successful: They were all eating the exact same diet!


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It is very exciting to see a new documentary in the works about paleo and low carb nutrition. Here is how the film makers describe it:

"In Defense of Fat" clarifies the complex relationship between human evolutionary history and the science - and politics - of nutrition and health.The film is firmly rooted in current scientific research on Ancestral Health, a theory which proposes that the human body is not adapted to an agricultural diet, and especially not to the many processed foods in our daily lives.   As a result, 'healthy' low fat diets and "essential" carbohydrates may actually increase rates of diabetes and obesity, and dietary fat may not be to blame for our expanding waistlines. Through in-depth interviews, animation, and examination of our cultural attitudes, “In Defense of Fat” will explain the complex issues at play in our national discussion of diet and health.

They already have big name interviews lined up, like Mark Sisson and Robb Wolf. In order to get this off the ground, they need to raise $50,000. They are doing this through kickstarter. Please consider donating and contribute to the movement!

http://www.kickstarter.com/projects/kennonhulett/in-defense-of-fat-a-new-documentary-about-obesity