The Great Diet Debate -- Dean Ornish, MD, Stuart Trager, MD -- 04/03/03
WebMD Live Events Transcript
http://my.webmd.com/content/article/63/71972.htm
High-protein, low-carb weight-loss programs such as the Atkins Diet are gaining new acceptance in the medical community, but some experts, such as Dean Ornish, MD, are still skeptical. He squared off with Atkins lifestyle consultant Stuart Trager, MD, to debate the best ways to shed pounds and improve health.
The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
"What I have a hard time with is recommending that people consume meat, bacon, sausage, brie ... when thousands of studies have shown that these increase your risk of heart disease and the most common types of cancer."
Dean Ornish, MD
"Atkins is not about eating all the bacon and red meat that [Dr. Ornish] would lead you to believe. It is about controlling carbohydrates, which is a significant, fundamental difference."
Stuart Trager, MD
Moderator: Gentlemen, we in the media are great at creating polarizing views; everybody likes a good fight. But I'd like to start by pointing out that the programs you advocate and use both put an emphasis on cutting out "bad" carbohydrates. Is that a fair statement? And if so, please discuss the role of carbs in your respective programs. Dr. Trager, since you're making your first visit to WebMD, you may go first.
Trager: Thank you for allowing me to start this part of the discussion. Making intelligent food choices is integral to the Atkins nutritional approach. We start off an induction by significantly restricting carbohydrates and then finding a level people can tolerate without gaining weight. Simple carbohydrates need to be eliminated because these cause the greatest rise in the blood sugar levels. Americans are clearly eating too many simple carbohydrates, and making choices that emphasize nutrient-dense foods made up of complex carbohydrates is stressed in the Atkins for Life long-term phase of his diet.
Ornish: We both agree that Americans eat too many simple carbohydrates. The most healthful and scientifically proven approach is to go from simple carbohydrates to complex carbohydrates. These include whole-wheat flour, brown rice, and fruits, vegetables, grains, and beans in their natural forms. These foods are rich in fiber, which gives you a double benefit: First, fiber fills you up before you get too many calories. Also, fiber slows the absorption of food, so your blood sugar rises slowly, preventing an exaggerated insulin response. Thus, you get the benefits of an Atkins-type diet without the harmful effects, which we can discuss in a while.
Also, you get the added weight loss benefit of eating foods that are less dense in calories, i.e., less fat. Fat has nine calories per gram, whereas protein and carbohydrates have only four. Therefore, when you eat less fat, you consume fewer calories without having to eat less food and you get at least a thousand substances that are protective.
So, an optimal diet is low in simple carbohydrates, low in fat, and high in complex carbohydrates. It's not all or nothing -- you have a spectrum of choices. To the degree you move in this direction, you lose weight and gain health.
Member: Could you tell us what you mean by simple carbs? By simple do you mean white carbs? Are fruits' sugars considered simple carbs?
Ornish: Simple carbohydrates include sugar, high fructose corn syrup, and white flour, white rice, etc. These have had the fiber and bran removed, so they get absorbed quickly, causing your blood sugar to rise too high. Also, as mentioned earlier, you can consume large amounts of these without getting full, so you have a double-whammy: too many calories, and you are more likely to convert them into fat. The diet I recommend is high in complex carbohydrates, which are rich in fiber and in protective substances.
Fruit sugars are simple carbs, because you've removed the fiber and the bran. Fruit in its whole form is rich in fiber and is beneficial.
Trager: Dr. Ornish's comments about simple carbohydrates reflect our understanding of the difference between these groups. There is another component that is becoming increasingly important as we discuss individual foods' impact on weight loss and gain as well as other health risks besides obesity. This other component is referred to as glycemic index, which is a measure of how much a specific food elevates the glucose or sugar in the blood. Some foods significantly raise blood sugar as compared to others, even if they are in the same category of simple or complex carbohydrates. To this end, just providing carbohydrates into the simple and complex categories, may not give enough information. In addition to the glycemic index, it is helpful to talk about glycemic load, which takes into account the volume of food ingested.
Ornish: We both agree with the need to reduce simple carbohydrates. What I have a hard time with is recommending that people consume meat, bacon, sausage, brie, and other foods when thousands of studies have shown that these increase your risk of heart disease and the most common types of cancer. Dr. Atkins claims that the diet he recommends can reverse coronary heart disease but has never published any peer-reviewed data to support this assertion, nor has anyone else.
In contrast, we reported in a randomized controlled trial that 99% of patients with coronary heart disease were able to stop or reverse the progression of their illness as measured by cardiac PET scans by making comprehensive lifestyle changes. It concerns me that people may be discouraged from making changes that we have proven to be so beneficial.
Trager: When Dr. Ornish suggested thousands of studies are critical of consuming meat, bacon, sausage, and brie he does a great disservice to the many people who have taken the time to understand that the controlled carbohydrate nutritional approach is not about eating the foods he describes, but instead is about empowering individuals with the necessary tools to impact a serious health risk: the risk of obesity that claims 300,000 lives a year.
His approach in this argument ignores the more than 100 recipes suggested in the new Atkins for Life book that don't include red meat at all. In discussing the thousands of studies he refers to, he neglects to mention these studies do not look specifically at an Atkins-like diet in which increased protein and fat are ingested in the absence of significant carbohydrates. Atkins is not about eating all the bacon and red meat that he would lead you to believe. It is about controlling carbohydrates, which is a significant, fundamental difference.
Ornish: Give me a break, Stuart. Every photo I've seen of Dr. Atkins, including the covers of his books, have him sitting before a buffet of steak, hamburgers, brie, and butter. If you're representing Dr. Atkins, at least take responsibility for what he advocates. I'm glad there are some new recipes that don't include meat, but many of them do.
In our study, published in The Journal of the American Medical Association in 1998, patients in the experimental group lost 24 pounds during the first year and kept off approximately one-half of that weight five years later. LDL cholesterol decreased by an average of 40% after one year, without lipid-lowering drugs, much more than has ever been reported from a high-protein diet. Less than 1% of people in the National Weight Loss Registry maintain their lower weight using an Atkins diet. Most people use a low-fat diet to lose weight and maintain lost weight.
Trager: One of the most interesting and exciting developments in this debate is the emergence of new research from prestigious universities like Duke, University of Pennsylvania, Cincinnati, and Connecticut, that show the efficacy and safety of the Atkins Nutritional Approach in studies lasting six months, with 12-month follow-up data soon to be available.
This research has resulted in the NIH currently funding a long-term multi-center study because of the significantly positive results and responses identified in this body of research. As renewed interest in this approach is leading to funding from groups like the NIH and the American Heart Association more long-term studies are becoming available.
Ornish: There are several problems with these studies. The most important is that they are not comparing to a very low-fat, low simple-carbohydrate diet. In every case, they are comparing to an American Heart Association diet, which is much higher in fat and also in simple carbohydrates. I've been critical of the AHA diet for many years because it doesn't do much. For example, LDL cholesterol does not come down much on either the AHA diet or the Atkins diet, whereas we found a 40% reduction in LDL cholesterol.
The second problem is that none of these studies measure real disease, just cholesterol and weight. In our studies, we found that heart disease actually reversed after one month, more improvement after one year, and even more after five years. One study that actually measured blood flow to the heart, published in a peer-reviewed journal (and available on my web site at WebMD, a shortcut is
www.Ornish.com) showed that blood flow improved on a diet like I recommend but actually worsened on an Atkins-type diet.
So the goal is not just to lose weight but also to do so in a way that enhances your health rather than one that may harm it. Another example is that a recent study from Harvard showed that high total protein intake, particularly high intake of nondairy animal protein, may accelerate renal function decline in women with mild renal insufficiency. In a randomized controlled trial, ketogenic diets impaired cognitive performance in higher order mental processing after only one week.
Trager: In the study Dr. Ornish describes regarding kidney function, he neglects to mention that more than 1,000 of the women with normal function who were followed for, I believe, eight years showed no abnormalities or negative impacts of a high-protein diet.
Member: Aren't most people overweight because of emotional eating, i.e., eating when they are not really hungry, rather than just making the wrong food choices?
Trager: There are many reasons why people overeat. Stress and emotion are clearly responsible for some of our attraction to comfort foods. Nonetheless, we live in a toxic environment with more highly processed foods available and less time to exercise and the time to prepare nutrient-dense or healthful meals. With these time constraints, following a nutritional approach that requires the intensive lifestyle changes advocated by Dr. Ornish is very challenging; specifically, in his programs individuals are asked to exercise and perform stress reduction techniques on an average of approximately five hours. In his published report with significant reduction of heart disease, individuals were spending 12 hours a week with professionals for exercise, nutrition, and stress counseling.
People need an approach that works. For me, controlling carbohydrates is just such an option. It allows people to make smart food choices and in doing so reduce their risk for lifestyle health diseases, while leaving time for everything else in their life.
Ornish: I agree, which is why my program includes more than just diet. My most recent book, Love & Survival, is all about these issues. Providing people with health information is important but not usually sufficient for people to make lasting changes in diet and lifestyle unless we also address these deeper issues. I'm proud of the fact that we ask people to exercise and perform stress management techniques. We ask people to walk for 30 minutes per day and to practice stress management techniques one hour per day. That's for reversing heart disease. For losing weight or general health, it's not all or nothing. Even a minute of day of meditation has benefits.
We have trained hospitals around the country in our program, and we have found that most people are able to make and maintain these changes in diet and lifestyle. Almost 80% of people who were eligible for bypass surgery or angioplasty were able to safely avoid it. The reason people are able to make these changes is because they feel so much better, so quickly that these are choices worth making. Not just to live longer but also to feel better. How do you feel after a big Thanksgiving meal that's high in fat and meat? Sleepy, because your brain gets less blood and oxygen. Dr. Trager exercises a lot more than 30 minutes a day, as he runs marathons, because he enjoys how he feels.
Trager: I do personally advocate exercise and have come to see firsthand the benefits that exercise can have throughout all aspects of life. I believe everyone should exercise for good health. Improving cardiovascular fitness is effective in preventing premature death. The difference is that to exercise for weight loss is very challenging. With 3,500 calories needed to burn one pound of fat, it would require running 35 miles per week to lose weight by this method alone. By separating the two, nutrition for weight management and exercise for good health, the positive effects of each can be fully realized.
Member: I read and tried both for 60 days. Dr. Atkins' is easy to stick to, but you smell bad and feel awful, whereas Dr. Ornish's leaves you healthier but exhausted, and it's just too hard to stick to with a family, with school foods, etc.
Trager: I believe that diet is a personal matter. No one diet is right for everyone. Atkins is about making choices. For those who find this approach effective and have struggled with a low-fat, low-calorie approach, the emerging science reinforces what they have seen on a personal basis. Those content with the food choices in Dr. Ornish's diet and with the time to devote to lifestyle changes he suggests should be applauded.
There is no one right answer, other than to realize the significance of obesity and its impact on health and the changes that need to be made to combat this epidemic.
Ornish: You're right about how you smell -- in the one study funded and published by Dr. Atkins, they reported that during six months on a high-protein/low-carbohydrate diet:
70% of patients were constipated.
65% had halitosis.
54% reported headaches.
10% had hair loss.
In our studies, people find that they have much more energy. People who can't walk across the street are able to climb 130 floors on a Stairmaster in only a few months.
Let me emphasize again that you have a spectrum of choices on my diet. The reversal diet is strict because that's what it takes to reverse heart disease. But if you're just trying to lose weight or feel better, then you have a spectrum of choices. To the degree you eat less fat, fewer simple carbohydrates, and more fruits, vegetables, grains, beans, and (if you desire) fish, then you lose weight and gain health, and feel so much better. It's not all or nothing, as Dr. Trager keeps misrepresenting.
Trager: Having personally followed the controlled carbohydrate approach for several years, I occasionally take offense to Dr. Ornish's comments about the way I smell and about my breath. In the study he refers, it's important to realize that:
85% of patients reported more energy.
27% had decreased heartburn.
51% had improvement in their mood.
26% of the women reported fewer premenstrual symptoms.
When we talk about a health risk that is claiming 300,000 lives a year, we need to focus on significant issues and avoid inflammatory statements that could be construed as referring to my personal breath.
Ornish: These are not inflammatory statements. These are in a peer-reviewed journal in a study funded by Dr. Atkins. I've never commented about you personally. A person's body excretes toxic substances through your breath, bowels, and perspiration, which is why this is such a common side effect of eating a high-protein diet, because it is toxic. A person may lose weight and start to attract people, but then when they get too close....
We both agree that there is an epidemic of obesity. There have been many misstatements that Americans have been told to eat less fat, they're eating a smaller percentage of calories from fat, but they're fatter than ever, so fat isn't the problem. Actually, Americans are eating MORE fat than ever. The only reason that the percentage of calories from fat is lower is because they're eating even more simple carbohydrates. So the goal is to reduce both, then you get even more weight loss and you enhance your health rather than harm it.
Trager: People are eating more calories and more fat because they can't follow a low-fat, low-calorie approach. Controlled carbohydrate nutrition, as advocated by Dr. Atkins is a useful tool that can play a significant role in helping people lose weight that have been unable to achieve results despite the efforts of those like Dr. Ornish, who have for 20 years tried to convey the fact that they need to eat less fat to improve their health.
Member: Everything anecdotal I have read seems to favor Ornish, but I am concerned Harvard is saying it is not nearly as black and white as he suggests.
Ornish: The difference between Dr. Atkins and me is that his reports are all anecdotal, whereas ours are in randomized controlled trials. It's not black and white; you have a spectrum of choices. We all agree that it's beneficial to eat fewer simple carbs. It's also beneficial to eat less fat and more fruits and vegetables.
Trager: Dr. Ornish reports, again, that thousands of patients have been able to follow his diet. He doesn't mention that these were people who were diagnosed with severe heart disease, many of whom were following this lifestyle modification approach to prevent the need for coronary artery bypass surgery.
Whether we talk about the American College of Cardiology or the American Heart Association, what's important to remember is primordial prevention, which means avoiding the development of heart disease in the first place. Nearly 65% of the population is overweight or obese. I suggest that the percentage of people who can follow Dr. Ornish's program is only a fraction of this, and that we need, as physicians, to present more options to help stem this epidemic.
Again, recent science on a controlled-carbohydrate, Atkins approach has been published from institutions that began quite skeptically about this approach. Be it the work at Cincinnati, funded by the American Heart Association or the University of Pennsylvania as part of a pilot study, people are losing more weight following a low-carbohydrate diet than on a standard American diet. It has even been shown that when calories are greater people lose more weight on a low-carbohydrate diet than a higher-calorie, low-fat diet.
Ornish: All of the studies that are being conducted are comparing an Atkins diet to a standard American diet or to an American Heart Association diet (which is not very low in fat and is high in simple carbohydrates), not to the diet I recommend.
Moderator: We are almost out of time. Before we wrap up for today, do you have any final comments for us, Doctors?
Ornish: I get approximately 10,000 letters a year from people who have lost weight and improved their health simply from reading my books or going to my web site at WebMD. Again, you don't have to follow such a strict diet to prevent disease or to lose weight as you do to reverse heart disease. Clearly, if you can reverse heart disease, then you can prevent it even easier. The old saying about an ounce of prevention and pound of cure is true -- you don't have to make such big changes to prevent disease as to reverse it.
Thank you for this opportunity to be of service. For more information, please go to my site at WebMD; a shortcut is
www.Ornish.com.
Trager: I enjoyed the opportunity to participate in this discussion. Unlike Dr. Ornish, who seems determined to condemn the Atkins Nutritional Approach, I believe there are benefits to be realized from each of our points of view. Obesity is our enemy, not the philosophical differences. We need as physicians to help people fight obesity. Science is emerging and as we move forward in this debate, our opinions and recommendations need to remain grounded in evidenced-based science, not personal crusades and opinions.
Ornish: I have tried to avoid personal attacks, so I'm saddened that Dr. Trager felt the need to disparage me as a crusader. On the contrary, I have spent the past 26 years directing research published in the leading peer-reviewed journals, unlike Dr. Atkins, who has never published a single study anywhere. If we want to talk about evidenced-based medicine, let's do some good studies first. Having seen what a powerful difference changes in diet and lifestyle can make, it saddens me that people are confused by people like Dr. Atkins and his representatives.
Moderator: We could go back and forth for hours on this vital topic, but unfortunately we are out of time. Thanks to Dean Ornish, MD, and Stuart Trager, MD, for being our guests. To start a diet debate of your own, or just get great advice and support visit WebMD's weight management message boards, including Dieting 101, with Martha McKittrick, RD, CDE.
"World's Leading Diet Gurus Go Head-To-Head At 'The Great Health Debate'"
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