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Response to Dean Ornish's New York Times Op Ed

9/22/2012

28 Comments

 
Dean Ornish just published an Op-Ed in the New York Times, touting the benefits of an ultra low-fat, high carbohydrate diet, criticizing the Atkins diet, and highlighting the dangers in eating this way.

"In 35 years of medical research, conducted at the nonprofit Preventive Medicine Research Institute, which I founded, we have seen that patients who ate mostly plant-based meals, with dishes like black bean vegetarian chili and whole wheat penne pasta with roasted vegetables, achieved reversal of even severe coronary artery disease."

This claim - which is ubiquitous in the medical literature - is based on one study on 35 people, deemed the "landmark heart disease-reversal trial" by US News and World Report. 20 of the 35 people were randomized to receive the intervention which included consuming a low-fat vegetarian diet for at least a year. The diet consisted of fruits, vegetables, grains, legumes, and soybean products without caloric restriction. No animal products were allowed except egg whites and one cup per day of non-fat milk or yoghurt; 10% of calories as fat, 15-20% protein, and 70-75% carbs. Cholesterol intake was limited to 5 mg/day. Subjects were also asked to practice stress management techniques at least 1 hour per day, exercise for at least 3 hours per week, and quit smoking if they were smokers. They also attended group meetings two times per week. The control group was given no guidance besides to continue following their own physician's advice. 

After one and five years, the experimental group had less cardiac events, and a decrease in the size of the plaques in their coronary arteries. 

This is perhaps one the most referenced studies in support of the protective effects of a low-fat diet, cited over 930 times (previous publication cited over 1500) according to Google Scholar, which is unfortunate due to the tremendous amount of confounding interventions. Along with an extremely low fat diet, the experimental group ate more fruits and vegetables, lost 23.9 pounds (control lost no weight), performed relaxation techniques 1 hour each day, exercised at least 3 hours a week, and had group counseling. The control group had none of this. The experimental group contained only 20 subjects (all male), and the control group had 15 (12 men and 3 women). 

The small sample size resulted in an uneven distribution of risk factors between groups. At baseline, the mean age of the control group participants was 4 years higher, mean total cholesterol 8% higher and mean LDL 10% higher than those in the experimental group. Mean BMI was three points higher in the experimental group. 

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Dr. Ornish goes on to say that "in a randomized controlled trial, patients on this lifestyle program lost an average of 24 pounds after one year and maintained a 12-pound weight loss after five years. The more closely the patients followed this program, the more improvement we measured in each category — at any age."

This is a true statement, and a misleading use of the exact same clinical trial cited above twice, to likely add credibility to the argument. While they are two separate links, the linked "reversal of even severe disease" from above and this controlled trial cite the identical article on 35 people: Here and Here.

"Calories do count — fat is much denser in calories, so when you eat less fat, you consume fewer calories, without consuming less food. Also, it’s easy to eat too many calories from sugar and other refined carbs because they are so low in fiber that you can consume large amounts without getting full." 

This argument is made over and over, reducing the complexities of the hormonal control and appetite regulation of the human body to simple arithmetic. The satiating nature of eating high fat, high protein diets cannot be over stated, and will have a much greater effect on subsequent eating behaviors than consciously ignoring our most basic physiological drive to eat when we are hungry, simply because we have reached our daily limit of fat calories mandated by the Ornish diet. 

The satisfying, filling nature which lay the foundations for a P
aleo or Atkins diet has been shown in clinical trials, and supported by literally thousands of people who have registered on the Ancestral Weight Loss Registry, from over 35 countries around the world. Based on the first 1,100 people to register, 95% report rarely or never feeling hungry between meals and 88% reported feeling less hungry than on a low-calorie diet (if they had tried it in the past). If you do not believe these stats, then you can read the hundreds of stories from the people themselves:

"After a lifetime of being overweight... through childhood, the teen years, my twenties, thirties, and forties,... finally, at the age of 55, I experienced a "normal" appetite on a low carb diet. For all of those decades I "overate" because I was hungry...It certainly is NOT a problem of weak willpower."

"I was amazed how quickly my body adjusted to the new way of eating. In previous attempts to lose weight I had gone on low-fat, calorie-restricted diets that are based on 'mainstream' advice for weight loss. I would always be hungry and feel fatigued, and could never resist 'cheating' on my diets. On the low-carb diet, I rarely get hungry between meals and never feel fatigued. I weigh myself once a week. By the end of the first full month on the diet, I had lost twenty pounds."

"I ate an extremely low calorie diet for perhaps two years. I didn't follow any particular plan, I just avoided empty calories and counted calories carefully, limiting myself to about 1000 calories per day. I didn't eat an obsessively low-fat diet and I ate a lot of carbs I thought were healthy - rice, whole grain bread, potatoes. I was hungry all the time; I obsessed about food to the point that I planned every meal for several days in advance. I felt cold much of the time, especially at night. In addition, I fasted many weekends. Doing this, I was able to get down to a 34 inch waist."

"I've literally been on a diet all my life.  Lost weight through calorie deprivation and also following the ill-advised low fat/high carb recommended by conventional wisdom and the U.S. government.  I was always hungry with low energy.  Eating that way was completely unsustainable for me."

"I was always hungry and thinking about food.  Now on a low carb diet I eat without worrying about counting calories. It makes life easier."

Read literally hundreds more such quotes here, all of which are variations on a similar theme: Sudden lack of hunger on a diet high in meats, fats, and vegetables.

Dr. Ornish goes on to say:

"But never underestimate the power of telling people what they want to hear — like cheeseburgers and bacon are good for you. People are drawn to Atkins-type diets in part because, as the study showed, they produce a higher metabolic rate. But a low-carb diet increases metabolic rate because it’s stressful to your body. Just because something increases your metabolic rate doesn’t mean it’s good for you."

The cited study is the recent clinical trial done in a metabolic ward, in which the researchers explain: "Among overweight and obese young adults compared with pre-weight-loss energy expenditure, isocaloric feeding following 10% to 15% weight loss resulted in decreases in Resting Energy Expenditure (REE) and Total Energy Expenditure (TEE) that were greatest with the low-fat diet, intermediate with the low-glycemic index diet, and least with the very low-carbohydrate diet." In other words, the fewer carbohydrates in the diet, the higher the resting and overall expenditure, which was exciting news for the proponents of the Alternative hypothesis. 


Dr. Ornish criticizes these results, explaining that "patients on an Atkins diet in this study showed more than double the level of CRP (C-reactive protein), which is a measure of chronic inflammation and also significantly higher levels of cortisol, a key stress hormone. Both of these increase the risk of heart disease and other chronic diseases."

As Dr. Peter Attia explains so eloquently on his blog, this is simply untrue. "Each group experienced a significant decline in both PAI-1 and CRP, and there was no significant difference between the groups for either marker. However, the trend was (barely) significant, favoring the low carbohydrate group for PAI-1 and favoring the low GI group for CRP. Sorry low fat, you didn't win either." As you can see in the graphs below, each group showed a reduction in CRP levels, just the Atkins group had a slightly smaller decrease than the other groups.
Picture
From Eatingacademy.com
Inconspicuously Absent Evidence

And what about these 14 clinical trials? How can the calorie unlimited, high fat diets keep producing more weight loss as compared to a low fat, calorie-restricted diet (at least in the short term), if they are characterized by high amounts of dietary fat, the vilified cause of obesity according to Dr. Ornish?

Even more striking is the fact that to our knowledge, a low-fat diet has NEVER in dietary clinical trial history produced more weight loss than a calorie unlimited, high fat diet. Many studies have shown no difference, but if it is true that a fat makes you fat, where are the clinical trials supporting this? 

If you can find a randomized control trial in which a calorie restricted low fat diet produces more weight loss than a calorie unlimited high fat diet, please e-mail it to us and we will post it: info@awlr.org.


Saturated Fat is Bad for you

Dr. Ornish says that "It’s not low carb or low fat," and then a few words later explains that an optimal diet is  "low in fat (especially saturated fats and trans fats) as well as in red meat and processed foods."

While we can definitely agree that trans fats and highly processed foods should be limited, the saturated fat argument is an archaic one that is not supported in the literature and has become an academic argument perpetuated by selective citation of supportive trials and variations in inclusion criteria. 

If we were to focus on the largest (i.e. > 100 subjects), randomized, most famous trials ever done lasting longer than 1 year, we are left with very few to assess that meet the following 2 criteria:

1) The only significant intervention involved a reduction in fat and saturated fat and an increase in polyunsaturated fats
2) They ask the question: does this diet reduce heart disease? (defined as heart attacks or death from heart disease)

Listed in reverse chronological order:
Women’s Health initiative (2006) – 48,835 women, 8 years, no significant difference between intervention and control.

Diet and Reinfarction trial (1989) – 2,033 men, 2 years, no significant difference between the groups given and not given fat and fiber advice. No significant differences in ischaemic heart disease between intervention and control (intervention was only advice in this trial)

Minnesota Coronary Survey* (1989) – 4,393 men and 4,664 women, double-blind, 4 years, no significant reduction in cardiovascular events or total deaths from the treatment diet

Finnish Mental Hospital (1972) – 12 years, physicians not blinded, significant decrease in coronary heart disease (CHD) death in men ( 5.7 deaths /1000 person-years vs 13 deaths /1000 person-years in the control. Non-significant decrease in CHD in women. (Not randomized, although included here because this is main experiment cited in support of diet-heart hypothesis)

Los Angeles Veteran’s Trial* (1969) –  846 subjects, up to 8 years, non significant difference in primary endpoints –  sudden cardiac death or myocardial infarction. More non-cardiac deaths in experimental group, resulting in near identical rates of total mortality

Oslo Heart Study (1968) – 412 men, 5 year, slight decrease in CHD with intervention. Many dietary interventions accompanied the low saturated fat diet. When stratified by age, the results were significant only in subjects younger than 60.

* Double blind

A full list of all the trials done supporting and refuting the saturated fat-heart-disease relationship, and a more in depth description of each, can be found here. 

Meta-analyses
If we instead focus on the recent meta-analyses of clinical trials testing this relationship, the majority have failed to elucidate a benefit associated with a low saturated fat diet:
  • In 2010, Ramsden et al. published a meta-analysis of randomized clinical trials, including trials where polyunsaturated fats (PUFAs) were increased in place of saturated fats (SFAs) and/or trans fatty acids (TFA), and non-fatal heart attacks, coronary heart disease related deaths, and/or total deaths were reported.  In the nine studies included, there was a non-significant increased pooled risk of 13% for n-6 PUFA intake (RR=1.13, CI: 0.84, 1.53) and a decreased risk of 22% (RR=0.78, CI: 0.65, 0.93) for mixed n-3/n-6 PUFA diets. In other words, increasing polyunsaturated fats in the diet provides no benefit, and may be harmful according to this study.        
  • Also in 2010, Mozaffarian et al published a systematic review and meta-analysis of randomized clinical trials investigating the effects of increasing PUFAs in place of other nutrients.  Among the seven studies included, an overall pooled risk reduction of 19% (RR= 0.81, CI=0.83-0.97) was observed for each 5% of energy of increased PUFA in the diet.      
  • In 2009, Mente et al. published a systematic review of the randomized clinical trial (RCT) evidence that supports a causal link between various dietary factors and coronary heart disease.  The pooled analysis from 43 RCTs showed that increased consumption of marine omega-3 fatty acids (RR=0.77; 95% CI: 0.62-0.91) and a Mediterranean diet pattern (RR=0.32, 95% CI: 0.15-0.48) were each associated with a significantly lower risk of CHD. Higher intake of polyunsaturated fatty acids or total fats were not significantly associated with CHD, and the link between saturated fats and CHD received a Bradford Hill score of only 2 (out of a maximum score of 4), signifying weak evidence of a causal relationship.
  • Also in 2009, the Cochrane Collaboration, an international not-for-profit organization, published a meta-analysis of clinical trials that either reduced or modified dietary fat for preventing cardiovascular disease. Twenty-seven studies met the inclusion criteria, and no significant effect on total mortality (RR = 0.98, 95% CI: 0.86-1.12) or cardiovascular mortality (RR = 0.91, 95% CI: 0.77-1.07) was found between the intervention and control groups 

The only study above showing a benefit to replacing saturated fats with polyunsaturated fats was the Mozaffarian meta-analysis. The authors of the study claim to have only included randomized clinical trials in their meta-analysis. Surprisingly, the Finnish Mental Hospital Study was included twice – split into separate analytical pools of male and female subjects. It is unclear why this study was even included to begin with, since it was not randomized and contained a disproportionate number of control subjects who were taking cardio-toxic medications and consuming higher levels of trans fats than the experimental group. 

Inclusion of male and female Finnish data separately further raises concern since it clearly exaggerates the apparent cardio-protective effect of PUFAs demonstrated in this meta-analysis. Excluding the Finnish data from their pooled analysis would diminish the observed results and elicit a null finding, since all other included studies apart from the Oslo heart study (RR=0.75, CI 0.57-0.99) were null:    
Picture
From Mozaffarian et al. 2010

Closing Thoughts

In medical school we are taught how to take an HPI (History of present illness) whenever we see a new patient. The importance of this history is stressed in every class, because of how important the patient's story is, and how helpful it can be in coming up with the diagnosis. 

Yet when it comes to figuring out why people are gaining weight, we don't listen. We are absolutely sure that the patient is at fault and we are correct: Just Eat less. 

We don't listen to the fact that people are universally hungry on a calorie-restricted diet. Eat 500 less calories a day than you normally would, then run for an hour each day, then ignore your most basic physiological drive to eat when you get hungry. And repeat this for the rest of your life and our obesity problems will be solved.

What if instead there was a way of eating in which people ate when they were hungry, and stopped when they were satisfied. A way of eating which didn't force you to count calories. A way of eating that, based on our most rigourous scientific data available, produces the most weight loss, reduces triglycerides and increases HDL. 

This way of eating exists, vilified by the medical community as "The Atkins diet", and relegated to a fringe movement and diet fad by the media as the "Caveman diet."

Yet when it comes down to which diet we should eat, the media, physicians and dietitians can make their case, but the final vote should be given to the patient. To the person actually eating the diet. If these patients from all over the world say they are no longer hungry, then maybe we should listen. 


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28 Comments
Jeffry Gerber, MD link
9/22/2012 09:07:51 am

Thanks for the comments. Gary Taubes will have a filed day with this one. NY Times is his turf!

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Ketopia link
9/22/2012 10:38:12 am

It's striking that he would spend his time bloviating and trying to promote his personal agenda without once mentioning the NuSi initiative or the fact that we have the potential to unequivocally settle these questions.

Thank you for this response. It is much needed. Sadly, it likely won't reach the same audience as the original NYT article, but perhaps our good friend Gary will respond as only he can.

-Michael

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Linda Armistead link
9/22/2012 12:19:47 pm

I could cry reading this! I lived most of my life being fat, ill, and constantly hungry trying to follow the purported Ornish-way of losing weight. It wasn't until going low carb, eatin optimal protein, and not being afraid of fat did I finally free myself of 110 lbs and have maintained that weight loss for the past 4 years. I have my health and self esteem back!

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Larry link
9/22/2012 10:54:18 pm

Linda - That is great to hear! Thank you for the comments. We'd love for you to submit your story to the registry, if you have not already done so.

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Linda Armistead link
9/22/2012 10:58:33 pm

Thank you, I hadn't submitted my story, but I will! I just now responded to one of Dr Katz's tweets endorsing Dr Ornish's original article with a link to this one. Keep up the good work!

Kris
9/23/2012 01:19:42 am

I too am going to join the registry. I found this through a posting on an Atkins forum. I had begun gaining an alarming amount of weight after developing hypothyroid. I followed the mainstream advice and ate clear soups, toast and cereal (all whole grain/high fiber varieties), snacked on carrots, and kept my calories under 1,000 per day. I continued to gain weight until I discovered low carb. I must have done a lot of damage to my body by eating the SAD recommended diet combined with severe calorie deprivation to try to lose weight, as it took me close to two years to lose 50 pounds. However, I did lose those pounds and have maintained that loss.

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Larry link
9/23/2012 01:37:50 am

Thanks for the comment. I am so happy for you that low carb has helped. 1,000 calories per day is just not a way to live!

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Jonathan
10/6/2012 02:49:30 am

I really like Jack Kruse's website. I highly recommend it for great health. His blog index is full of good information that fits well with low carbohydrate diets.

http://jackkruse.com/brain-gut-6-epi-paleo-rx/

Body by Science is the best book I've read on fitness so far and only 12 dollars on Amazon.

Good to hear all the success stories on this post and others I've also done much in 4 months lowering cholesterol and improving all around.

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jake3_14
9/23/2012 10:05:08 am

It's becoming less relevant where critiques of op-ed pieces reside than how quickly they can be found. Even though the ALWR is not as prominent as the NYT, it's just as easily findable, given the right SEO strategy in the body text and META tags and linking strategies from other sites.

OTOH, the AWLR testimonies suffer from selection bias, and the ALWR itself, like the National Weight Control Registry suffer from poor data quality, both being ultimately based on food recall questionnaires, which many researchers dismiss out of hand due to inherent the inherent fallibility of memory, under-reporting of undesirable behavior and over-reporting of desired behavior. How can the ALWR bolster its reliability, so that researchers give its data more consideration?

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Personal Trainer Gold Coast link
9/23/2012 06:21:32 pm

I agree with each and every conclusions made on this topic. It is really very informative. Thanks for sharing.

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Alexandra M
9/24/2012 03:20:06 am

Great response, and so quick! I was fuming over this. It really is too bad that this sort of thing in the NY Times will influence so many people. How come Ornish gets to run an ad for free? Because that's all it is. I hope you or Gary will write a letter. I've already directed people here for your response.

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Jacquie L.
9/24/2012 05:07:38 am

So glad you posted a response! Ornish's op-ed left me a tad fuming.

I have lost a great deal of weight and kept it off through an Atkins-type low-carb lifestyle, and it's such a relief to know that I can eat a satisfying diet that is guaranteed to prevent weight gain. I spent years yo-yo dieting, constantly worried that I was losing the battle with my weight. That constant anxiety, the constant change of diet--THAT's what's stressful on the body. Consistently adhering to a low-carb lifestyle that will maintain a healthy weight helps me take my mind off the dieting demons. So when Ornish claims that a high-fat, low-carb diet is stressful on the body, I want to give him the mental finger. What's way more stressful on the body is hunger, and his recommended diet is pretty much guaranteed to cause hunger. So good luck with that, Ornish!

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Deborah Gordon link
9/24/2012 05:14:28 am

My first response to Ornish's op-ed was dismay and fury, but after calming down I realize that his piece is actually the dying gasp of the low fat faddists. He is inspired to write because even he is convinced that weight loss occurs most effectively with a low carb program, so he grasps at this one ancient (and thanks to this post, well critiqed) refrain which he has been chanting over and over to a smaller crowd -- unfortunately with Medicare sanctions. NUSI will make all the difference, and, hey given another decade or two, maybe even Medicare and Ornish will come to their senses.

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Ty Mac
3/8/2015 12:21:45 am

Horse manure. I had a heart attack two years ago. Had two stents put in, which did away with chest pains until I went back to work a month later. Then chest pains began again. Very discouraging, to put it mildly. A friend gave me Dean Ornish's book, and I immediately began eating a low fat vegan diet and exercising every day. The chest pains went away, and over time my cholesterol level dropped to 77 (with a very low LDL count of 29), blood pressure dropped dramatically, weight dropped by 30 pounds, and now, two years down the road, I feel the best I've felt in years.

The Ornish diet was VERY easy for me to adopt, in part because the alternative would have meant ongoing discomfort with chest pains. Once I got used to eating a veggie diet, it became very easy to sustain - I enjoy eating now more than ever ... I eat AS MUCH AS I WANT OF WHATEVER I WANT, within the parameters of it being veggie. Easy as pie! It is NOT hard once one commits to it. I only wish I'd done it sooner. The criticisms here of the Ornish diet are not well directed, focusing on "weight loss" rather than health. Ornish's diet is not, primarily, a weight loss diet, though one will drop some pounds with it. It is a diet for cardiovascular health, and as such it just plain works. I don't know why people would feel anger about this. Eat a plant based diet - you'll feel better, and the cows will thank you! ^_^

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K. Brooks
3/23/2015 02:00:33 pm

I am so happy to see a supportive comment for Dr. Ornish. I am High carb vegan and I have never been fitter. Yeah high fat might help you lose weight... but unless you are smashing in those carbs you aren't going to have the vibrancy that high carbers have.

I bike 100 to 200 km a week. And hit the weights heavy 3-4 times a week. I would like to see a low carber keep up with that!

One person even wrote "I was doing everything right...keeping my calories under 1000" THAT IS NOT DOING IT RIGHT! That is starvation. I am 5'3'', female in my late 20s and eat 2000 to 3000+ calories a day and maintain a healthy weight (a few extra kilos are even starting to drop off) I don't restrict at all. My only thought is am I eating enough?

Keep living the good life Ty Mac. And living it compassionately, too! Ⓥ

ElDorado
3/23/2015 07:11:12 pm

5 years ago I had a heart attack and stent built in my vessel. Checking the net I found dr McDougall and his book. I followed the low-fat whole food diet and in 4 month I've lost 20 kg and was feeling great. My doctor after just 6 month could not beleive my numbers he said he didn't see so fast fall of cholesterol numbers in his career. His comment was interesting and significant - "Well you achieved it now you can eat a little meat". So stupid. At the same time my very good friend went to Atkins diet. Indeed he lost in few months about 16 kg. But he went to some routine check up and his numbers were terrible. His liver was very fatty, cholesterol numbers high etc. He is now very happy vegan as I am, we walk and trek alot, his liver is perfect now. But he needed 6 month to corrrect his numbers. And yes this diet is bout health NOT loosing weight!!!

TrueBrit
6/16/2015 09:58:28 pm

I have adopted the whole food plant based diet. Dropped 60 pound at a rate of 1-2 pound a week. Cholesterol dropped 40% without statins. Feel good. Capable of exercise now. Previously on the Atkins, didn't feel good, didn't work and later diagnosed with coronary artery disease and suspected familial hyperlipdemia.

As a layperson I have to gamble on which argument carries the most credibility because ultimately I don't know for certain.

I'd love to be able to eat all those foods that I've given up. I'd also like to win the lottery and have Angelina Jolie as my stalker. There is an element of low carbers that tells people what they want to hear. Who says that life must be easy and because eating meat is enjoyable then it must be good? Who says we mustn't be hungry sometimes? Low carbers perpetuate the myth that humans must not experience any discomfort. Suffer now or suffer later. I choose now.

mezzo
9/24/2012 07:46:47 am

They will NOT come to their senses. They are TRUE BELIEVERS: Arguments do not count with them-

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Jim Larsen
9/24/2012 07:52:25 am

http://www.nejm.org/doi/full/10.1056/NEJMoa1007137

http://jama.ama-assn.org/content/297/9/969.abstract

http://nutrition.stanford.edu/documents/AZ_press.pdf

http://www.youtube.com/watch?v=eREuZEdMAVo

http://www.youtube.com/watch?v=XR3FVvEJ-Nk

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Aaron Robertson
1/28/2013 02:49:08 am

Somebody should double check this, but I believe the c-reactive protien study Peter Attia is critiquing is different than the study Dean Ornish cites in his article. The one that Ornish links to does indeed appear to show that c-reactive protein increases with LC diets.

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Bob
8/30/2013 09:33:29 pm

Good

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JR
9/1/2013 07:04:51 pm

Every time I tried the Atkins diet, I felt deprived and always frustrated with the limitations of what I could eat. When I tried to go into maintenance mode, I started binge eating. And I always ended up regaining the weight plus more. The Atkins diet did not work for me... three times.

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joan
11/5/2013 10:55:27 pm

Then I'd continue eating those grains, breads and pastas. See how that works for you...

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Raheja link
4/6/2014 09:22:16 pm

I have to say I agree on this :)

Daniel
7/12/2014 12:45:29 pm

or one could subsist on sweet potato, like the Okinawans did... but of course they did not live very long.
Oh, actually... silly me, low meat consumption is the norm for all long-lived populations. Okinawans lived well.. on almost no animal protein. A very low meat intake is associated with greater longevity.

Denis MacDougall
3/24/2015 01:04:37 am

No one has argued that you don't lose weight on high protein diets. The argument really revolves around what the appropriate balance of foods that provide optimum nutrition for overall human health. I for one am tired of the plethora of books advocating competing diets one kind or another serving only to increase the wealth of their authors. Perhaps Michael Pollan in his book In Defense of Food said it best: Eat real food not processed, mostly vegetables and not a lot.

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jamie link
3/24/2015 02:05:07 am

More vegetables for sure. And understand that even our veggies have undergone massive hybridization(al) changes. Selecting for sweet over bitter has reduced phytonutrients.

I think we are evolutionarily supposed to eat massive quantities of leafy greens and grab meat whenever we could. We should fast more, (ugh) and have a better ratio of Omega-3's to '6's. How vegans can do this I don't know. Additionally, move, move all the time, not just a big run in the morning and rest the rest of the day.
I also wish we could hear from the high-carb people when they're in their 50's and the pancreas poops out. Especially females.

Health to all, Jamie

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