It remains even smarter to not weigh your food but use common sense in
determining when you are overeating, I think.

Make no mistake -- I'm a diabeteic not by choice of diet.

On Mar 16, 10:56 am, "Andrew B. Chung, MD/PhD"
<heartdo...@emorycardiology.com> wrote:

Review on "Atkins Diabetes Revolution: The Groundbreaking Approach to
Preventing and Controlling Type 2 Diabetes" by Mary C. Vernon and
Jacqueline A. Eberstein

Surender Arora1,2 email and Samy I McFarlane1,2 email

1State University of New York Downstate Medical Center, 450 Clarkson
Avenue, Brooklyn, New York 11203, USA

2Kings County Hospital, Brooklyn, New York, USA

author email corresponding author email

Nutrition & Metabolism 2004, 1:14doi:10.1186/1743-7075-1-14

The electronic version of this article is the complete one and can be
found online at: http://www.nutritionandmetabolism.com/content/1/1/14
Received:     13 October 2004
Accepted:     9 November 2004
Published:     9 November 2004

(c) 2004 Arora and McFarlane; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/
licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly
cited.
Book details

Vernon MC, Eberstein JA: Atkins Diabetes Revolution. The
Groundbreaking Approach to Preventing and controlling Type 2 Diabetes.
William Morrow; 2004, 538. ISBN 0-06-054008-7

Before beginning the review of this book, we had no particular opinion
about the role of low carbohydrate diets in diabetes. In order to
write a fair and unbiased review, we have done a rather extensive
search on the subject. One of the most disturbing findings of our
search is the amount of hostility towards low carbohydrate diets that
is on the web and in the scientific literature. We found several sites
that present no scientific arguments but are, rather, full of ad
hominem attacks. This was particularly disturbing in that we are in
the midst of a growing epidemic of obesity and diabetes with very
alarming figures and projections from all over the world. Any
intervention that has the potential for helping curb this dangerous
epidemic which claims thousands of lives every day should be looked at
with a great deal of objectivity.

The low carbohydrate approach, in fact, is not new and was used in
England more than a century ago, made popular by William Harvey [1],
an ENT surgeon. He prescribed a low carbohydrate diet for William
Banting, an obese carpenter who had been having a great difficulty
losing weight. Banting was able to lose weight and as a service, he
published in 1863 a small booklet entitled Letter on Corpulence
Addressed to the Public [2], the first book to be published on obesity
and one which popularized low carbohydrate diets. He has been called
"Father of low carbohydrate diets" and was honored by his name being
included in the dictionary as the verb "to bant" meaning "to diet".
The low carbohydrate diet also been called a "Harvey-Banting diet"
after the names of these pioneer. Since then, it has been in and out
of fashion with different versions and names but with the same
underlying concept, most recently popularized by the late Dr. Robert
C. Atkins.

The Atkins Diabetes Revolution [3] plan is similar to the Atkins
weight loss strategy: four levels of carbohydrate restriction are
instituted. The induction phase restricts dieters to 20 g of
carbohydrate. On the weight loss plan, this is recommended for about 2
weeks. In diabetes this is maintained until glycemic control is
attained. In the latter stages, carbohydrates are added as long as
weight loss or stability is maintained. For diabetes, carbohydrates
are only reintroduced if glycemic control is acceptable. In the later
phases, the Atkins Diabetes plan adds a Glycemic Ranking (AGR),
derived from the glycemic index, glycemic load and net carbs.
Preference is given to whole fruits and berries and juices and dried
fruits are low on the list. As in weight loss, exercise is
"mandatory."

The Atkins Diabetes Revolution book is an attempt by the authors to
present the low carbohydrate diet as a preventive and treatment
strategy for patients with type 2 diabetes and those with the
metabolic syndrome, who are at high risk for developing diabetes and
cardiovascular disease. In doing so, the book, which is very well
written, and which clearly presents illustrative cases, explains very
complex metabolic concept in a very easy to read and understandable
format. The first nine chapters explain the different concepts
involved in glucose and lipid metabolism and the interplay of the
various cardiovascular risk factors that culminate in cardiovascular
disease the number one killer of Americans today. Definitions of
metabolic syndrome, pre-diabetes, body mass index, waist to hip ratio,
central obesity and their relationship to diabetes, heart attacks and
strokes, are eloquently presented with a great deal of accuracy yet in
a simple format. Most impressive were the case presentations,
especially that of reactive hypoglycemia and carbohydrate craving.
This response is associated with hyperinsulinemia in the pre-diabetic
phase and sometimes puzzles clinicians unless they know to look for
it.

The second section of the book is devoted to an in-depth discussion of
the various macro and micronutrients and their role in diabetes and
obesity. Concepts such as the glycemic index and glycemic load are
very well illustrated. The last section consists of meal plans and
menus of low carbohydrate diet that the book is advocating.

The concept of low carbohydrate diet and glycemic control certainly
has a pathophysiological merit. First, dietary carbohydrates are the
principal source for the initial rise of glucose in the diabetic
populations, who generally have a defect in the first phase insulin
secretion that is responsible for handling the glucose load [4]. There
is mounting evidence that postprandial hyperglycemia is in itself a
risk factor for cardiovascular disease in the diabetic patients [5].
This evidence comes from large, well-conducted, randomized controlled
trials [5,6]. Furthermore, control of postprandial hyperglycemia has
been shown to provide cardiovascular benefits, and contribute to the
overall decrease of hemoglobin A1c, something that has been clearly
shown to reduce microvascular disease in both type 1 and type 2
diabetes [7,8]. Second, the initial blood glucose rise associated with
high carbohydrate load, in the presence of absolute/relative insulin
deficiency leads to significant rise in triglycerides and free fatty
acids which perpetuate the cycle of insulin resistance [9,10]. So,
from a metabolic stand point, low carbohydrate diet makes physiologic
sense. However, in the science and practice of medicine, not
everything that makes sense turns out to work the way it is supposed
to. In looking at the low carbohydrate diet, we must examine the
evidence from the studies that were conducted using such diets keeping
in mind that weight loss by itself, is beneficial in terms of
improving insulin sensitivity and correcting the abnormalities
associated with the metabolic syndrome and insulin resistance [9,10].
Also, weight loss has much greater effect on the prevention of type 2
diabetes in pre-diabetic patients than pharmacological interventions
[9]. This fact was well illustrated in the Diabetes Prevention
Program, a large multicenter trial sponsored by the National Institute
of Health, where pre-diabetic patients on diet and exercise program
had a 58% reduction in the development of diabetes, compared to only
34% reduction with the use of metformin [11]. This landmark study had
a population where women and minorities were very well represented
[11]. The fact that weight loss was associated with reduction of type
2 diabetes in high risk populations was illustrated in several other
studies including examples from Finland and from China, making it
evident that weight loss works for a variety of ethnic populations
[12-15].

In two recent randomized controlled trials published in the New
England Journal of Medicine [16,17], the effects of low carbohydrate
and low fat diets were compared in obese and diabetic patients. Both
of these studies showed a substantial decrease of triglycerides in
patients on low carbohydrate diet with simultaneous increase in high-
density lipoprotein (HDL) over 6 month to 1 year period. The studies
did not show a change in the low-density lipoprotein (LDL) values in
the low carbohydrate group compared to their baseline, while those on
traditional low fat diet had a reduction in LDL levels. Patients on
low carbohydrate diet, however, had substantially significant weight
loss, almost double that achieved with the traditional diet, in the
first 3-6 months. At one year, there was no significant difference in
weight loss between the two groups [16-18]. Although participants on
the low carbohydrate diet initially tended to have higher rate of side
effects such as nausea, muscle cramps and constipation, compliance
with diet was similar in both groups. In fact, more participants
adhered to the low carbohydrate diet. Although weight loss was similar
after one year between groups, the effects on atherogenic dyslipidemia
and glycemic control were still more favorable with a low-carbohydrate
diet after adjustment for differences in weight loss.

Despite the evidence from these randomized controlled trials,
published in the prestigious New England Journal of Medicine, there is
a significant amount of reluctance in the scientific community to
acknowledge the beneficial effects of low carbohydrate diets. These
studies, in fact, provide a striking example of this resistance. A
commentary in the same issue of the New England Journal of Medicine
[20] states that "In both studies, the reduction in serum triglyceride
levels in subjects randomly assigned to the low-carbohydrate diet
might have been anticipated as a result of their greater weight loss,
although it is true that reduced carbohydrate intake is generally
associated with reduced triglyceride levels" [20]. In this statement,
despite the fact that low carbohydrate diet is known to reduce serum
triglyceride, the authors suggest otherwise. In another statement, the
authors of the commentary state that "the rise in HDL cholesterol in
the subjects following the low-carbohydrate diet (a change observed
only by Foster et al.) may reflect a change in HDL subfractions that
occurs with increased intake of saturated fats, and this change has
not been shown to be beneficial. Thus, caution is urged about over-
interpretation of this observation as a beneficial result of a low-
carbohydrate, high-fat diet" [20]. Again this statement illustrates
the difficulty in acknowledging what a randomized controlled trial has
shown. The authors suggest, without any evidence that the rise in HDL
cholesterol might have been in the non-beneficial HDL subfraction. In
other words, when low carbohydrate diet is shown to decrease
triglycerides, a suggestion is made that it might be just secondary to
weight loss and when this diet increases HDL, it is also suggested
that it could be the non-beneficial HDL. Now, let us examine the
evidence provided by the one year follow-up study on the same group of
patients where the investigators conclude that "Although weight loss
was similar between groups, the effects on atherogenic dyslipidemia
and glycemic control were still more favorable with a low-carbohydrate
diet after adjustment for differences in weight loss" [18]. This
indicates that the statements made in the commentary [20], in an
attempt to dismiss or downplay the beneficial effects of low
carbohydrate diet were simply wrong. Furthermore, the statement made
in the commentary regarding the HDL cholesterol, not only lacks
objective evidence, but also contradicts the current findings that
lowering insulin level by controlled carbohydrates shift HDL
production to a much more desirable, lighter HDL2subfractions [21,22].

On the other hand, the American Diabetes Association, despite
recommending the traditional low fat diet, has recently reduced the
recommended carbohydrate contents in the diet, perhaps reflecting a
trend towards a reduced carbohydrate diet to follow [19].

Returning to the Atkins book, despite the fact that the book is very
well referenced, certain statements such as "high carbohydrate diet
leads to diabetes" are not well substantiated, unless of course such a
diet leads to weight gain, which it may. Furthermore, the book does
not devote a sufficient amount of space discussing the side effects
associated with dieting in general and low carbohydrate diet in
particular. This is of concern, since it leaves the reader with the
impression that the low carbohydrate diet or dieting, in general, has
no negative consequences. Nonetheless, the amount of information the
book provides in a simple, yet accurate format will benefit patients
with diabetes and their families as well as those who are at risk for
developing diabetes and the metabolic syndrome. If, after reading this
book, the reader is able to identify that he or she is at risk for
diabetes and the metabolic syndrome and takes action that could
potentially save his or her life the book will be a valuable
contribution. Atkins Diabetes Revolution has a list price of $25.95
and is available at Amazon.com and presumably other sites for half
that price. Possibly, a shorter and still more affordable version of
the book would be helpful for diabetic patients, their families and
for the general reader, to help identify their risk for the disease.

As clinicians, we would not be comfortable recommending any diet
without first hand experience. The Atkins Diabetes Revolution,
however, is sufficiently convincing to make us believe that some form
of low carbohydrate intervention is worth investigating and should be
considered by practitioners. The highly negative un-scientific
response of critics, if anything, encourages us in this direction.
References

  1.

     Harvey W: On Corpulence in Relation to Disease. London, Henry
Renshaw; 1872. OpenURL

     Return to text
  2.

     Banting W: Letter on Corpulence, Addressed to the Public.
London, Harrison; 1863. OpenURL

     Return to text
  3.

     Vernon MC, Eberstein JA: Atkins Diabetes Revolution. The
Groundbreaking Approach to Preventing and Controlling Type 2 Diabetes.
New York, William Morrow; 2004. OpenURL

     Return to text
  4.

     Polonsky KS, Given BD, Hirsch LJ, Tillil H, Shapiro ET, Beebe C,
Frank BH, Galloway JA, Van Cauter E: Abnormal patterns of insulin
secretion in non-insulin-dependent diabetes mellitus.

     N Engl J Med 1988, 318:1231-1239. PubMed Abstract | Publisher
Full Text OpenURL

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     Hanefield M, Fischer S, Julius U, Schulze J, Schwanebeck U,
Schmechel H, Ziegelasch HJ, Lindner J, the DIS Group: Risk factors for
myocardial infarction and death in newly detected NIDDM: the Diabetes
Intervention Study, 11-year follow-up.

     Diabetologica 1996, 39:1577-1583. Publisher Full Text OpenURL

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     DECODE Study Group: European Diabetes Epidemiology Group:
Glucose tolerance and mortality: comparison of WHO and American
Diabetes Association diagnostic criteria.

     Lancet 1999, 354:617-621. PubMed Abstract | Publisher Full Text
OpenURL

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     The Diabetes Control and Complications Trial Research Group: The
effect of intensive treatment of diabetes on the development and
progression of long-term complications in insulin-dependent diabetes
mellitus.

     N Engl J Med 1993, 329:977-986. PubMed Abstract | Publisher Full
Text OpenURL

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