The first time I showed up at a patient’s house with a tureen of fatty bone broth, I was scared it might cause her to have a stroke. As a lifelong dieter, I firmly believed that saturated fat was the enemy. As a physician, I was trapped by dietary guidelines into recommending low-fat foods. But my patient wasn’t doing well and I had to do something radical. So I made her a big fatty meal and I hoped for the best.
What happened next won’t surprise anyone who’s ever been on the Atkin’s diet: My patient lost weight and her sugars got better. Even her asthma went away. Completely. That low-carb-high-fat (LCHF) diet saved her life.
So when the new obesity guidelines were released last month, I expected they might contain, well, some guidelines on when it’s appropriate to use a LCHF diet. But they say nothing of the sort. The new guidelines, brought to us by the same folks who delivered the now infamous cholesterol guidelines, primarily recommend calorie restriction and dietary counseling for anyone even slightly overweight—anyone with a body mass index (BMI) of 25 or more.
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Yet it’s well established that calorie restriction causes rebound weight gain.
So, this recommendation could very well serve to make a nation of fat people even fatter. This is, after all, exactly what obese people tell us—the more they diet, the fatter they get. What’s more, many people now believe that along with the dangers of calorie restriction, low-fat diets themselves—the type the American Heart Association (AHA) recommends—might also be contributing to our obesity epidemic.
“While low-fat eating has increased, so have body weight and waistlines,” says Kerry Stewart, Professor of Medicine and Director of Clinical and Research Exercise Physiology at Johns Hopkins. “Based on what we know now about high carbohydrate eating, the obesity epidemic was predictable.”
And it is an epidemic (PDF): some 155 million Americans are overweight or obese (PDF).
This is a public health crisis that you might think would give us an all-hands-on-deck attitude. After all, if this were an infectious disease — a big collection of fat worms or something — it’s doubtful we’d keep recommending the same feeble treatment for decades and then blame the victims for not complying. No. We’d be scared. Scared for ourselves and our kids and our country.
We might even be frightened enough to reconsider our entire dietary approach. But the new obesity guidelines don’t address the low-fat/low-carb debate. Instead, they say there’s no good evidence to recommend any particular diet. (They say they reviewed 17 diets.) Yet, last month the Swedish obesity guidelines also came out, and after a review of 16,000 studies the Swedish committee endorsed LCHF diets as the most effective way to combat weight gain.
Our committee must have access to the same research the Swedes reviewed—so why there’s such a discrepancy is anybody’s guess. But some believe that our committee is under pressure to not reverse 30 years of AHA low-fat doctrine—even if it’s causing an epidemic. Instead, the committee took the almost comical stance of implicating practicing physicians in the obesity crisis. As the co-chair of the committee Donna Ryan, MD, explained, “primary care physicians have not been trained in obesity etiology or pathogenesis much less in its diagnosis and treatment”.
Not only is this statement somewhat laughable—last I checked, most doctors knew how to use scales — but it’s also off mark. Previous guidelines have urged doctors not to spend time on diet and lifestyle recommendations as they’re not terribly fruitful. Nevertheless, ignoring the guidelines, some doctors have found very effective ways to achieve long lasting weight loss using Atkins-type LCHF diets. And at this point good evidence is building up in their corner: LCHF diets lower blood sugar, insulin and triglycerides and raise good (HDL) cholesterol.
The improvements in cardiac risk factors notwithstanding, many physicians will remain cautious about recommending fatty diets because of the role fats may play in heart disease. After all, the only diets proven to open blocked arteries are no-added-fat vegetarian (Ornish-style) diets. Doctors are simply afraid that all that blubber is going to clog up our patients’ arteries, as I was when I threw caution to the wind and brought my patient a lamb chop and a mugful of saturated fat.
But a raft of studies now shows that saturated fat does not increase your likelihood of vascular or heart disease. And after many years, the results from the Women’s Health Initiative showed that women who ate higher levels of saturated fat actually had no increased risk of obesity or heart disease. What’s more, some doctors advocating high fat diets have shown individual reports of reversal of atherosclerosis.
This is not to say that LCHF diets will suit everyone.
Obviously, many people thrive on low fat diets. But while it’s pretty much universally acknowledged that we’re “supposed” to eat low fat diets, most Americans are overweight or obese. So it seems like low-fat diets are a prescription that most people can’t follow or won’t follow or follow and find that it just doesn’t work.
Why this is the case is a matter of both science and speculation. Some say that while giving lip-service to low-fat diets, we’ve actually increased our fat intake as our cheese and olive oil consumption have skyrocketed. But others say that overeating carbohydrates causes insulin to surge and essentially drives fat storage. This can explain why people who starve themselves can only lose minimal amounts of weight. Anyone who works with dieters—who doesn’t accuse them of lying about their food intake—will tell you that this is exactly what frustrated dieters report.
The fact that some people respond to low-fat diets and others to low carb is under active research. The current thinking is that it may be because most of us are over-producing insulin and that high levels of insulin may be causing the fat accumulation. In this case, a low-fat calorie restricted diet will be exactly the wrong prescription. On the other hand, insulin-sensitive people would account for those who respond well to low-fat diets.
At this late date, no one could possibly think this is the full story or be naïve enough to think that high-fat diets will be a panacea—and a one-size-fits-all approach might just get us into the kinds of trouble that high-carb diets have. We now know that obesity is complex — involving gut bacteria and cold viruses, hormones and sleep, culture and habit, good calories and bad calories. But it’s vital that physicians have up-to-date information to support patients as they strive to regain their health.
This is where a thoughtful set of obesity guidelines would have been helpful. Given the enormity of this problem, if there really is something that will work for even a significant portion of our people, the committee should be recommending it. The guideline committee has the ability to get the word out: for some patients, diets high in fats may be just what the doctor should order.
