Low-carbohydrate diets: mythical phoenix or Grail quest?

The mythical phoenix is not unique to low-carbohydrate diets; it is a characteristic of nearly every diet program, which implies excess caloric intake can be treated with anything other than calorie restriction, or that suggests caloric restriction can be achieved in a manner that does not require eating less. A search of the online bookstore Amazon.com with the subject “weight reduction” yielded 2436 titles. A similar search of Barnes and Noble with “weight loss” as keywords yields 3224 books with publication dates as far back as 1982. These titles include keywords such as carbohydrate counting, fat gram counting, God’s way, the caveman’s way, and even the duct tape diet. This barrage of titles has overwhelmed many of our patients and much of the medical community as well. Each diet is held up as the “Holy Grail” of diets, the answer for which we have all been searching. There is no “Holy Grail” in obesity treatment. We need to stop the search for the one diet that will be all things to all people. Human beings lose weight only when energy intake is less than overall energy expenditure. To imply there is another truth is misleading. There may be many ways in which energy deficits are achieved. There are some bad weight-loss strategies. We know starvation is bad, and major restriction with provision of poor-quality protein results in cardiac deaths. The obese patients are looking for help, and occasionally they actually turn to nutrition and healthcare providers. We need to be informed and ready to help. As nutrition professionals, we have 3 roles: 1. Do no harm. 2. Guide the client to select a weight-loss program that will maximize the probability of success for that individual. 3. Help balance efficacy of diet against the resource demands, time and financial, of the program. Low-carbohydrate diets probably are not dangerous. Safety has been pretty well demonstrated in studies with a duration of 6–12 months. Patients who do not like the side effects quit the program. For longer-term studies, I would suggest a review of the many studies of patients who have undergone gastric bypass surgery. These patients are generally instructed to focus on reaching a certain protein goal and the remainder of calories is divided between carbohydrates and fats, not exceeding 30% of total calorie intake as fat. In my practice, the protein goal for a patient who has undergone bariatric surgery is 1.2 g/kg of ideal body weight for the first 2 postoperative years. So the proverbial 70-kg woman who ingests about 1200 kcal per day for 9 –12 months postoperatively is eating approximately 38% of calories as carbohydrate, 30% as fat, and 28% as protein. This places the gastric bypass “bar” between South Beach and Atkins diets on Dr Kushner’s graph (as modified by Choban; Fig. 1). A growing cohort of these postoperative individuals exists, both in number and in years since undergoing bariatric surgery and eating this dietary regimen. Calcium supplementation, a daily multivitamin, and iron supplements in reproductive-age women are customary recommendations for these patients. With this plan, long-term metabolic complications have not appeared. Even with surgically induced satiety and side effects such as dumping, these patients have been able to comply long enough to gain some level of comfort with eating. Restriction is restriction; no rearrangement of nutrients gives an individual a “calorie exemption.” When we feed the hospitalized patient, we do not identify any of the particular nutrients as a silver bullet or as being empowered with any mythical powers, nor are any specific nutrients excluded from the mix because of their inherently evil nature. Why do nutrients take on these properties when we begin to therapeutically restrict intake? Highprotein diets have been popular over the past 20 years. Protein is a good satiety agent. Americans tend to be big meat eaters. Most patients are more successful when they monitor something. Whether they are counting carbohydrate grams, fat grams, or steps probably does not matter. It is Correspondence: Patricia S. Choban, MD, FACS, 3964 Hamilton Square Blvd, Groveport, OH 43125. Electronic mail may be sent to choban.1@osu.edu.