A Physicians' Guide To The Atkins Diet
A Physicians’Guideto the Atkins DietEric C. Westman, M.D. M.H.S.Duke University Medical CenterDurham, NCewestman@duke.edu
Eric C. Westman, M.D., M.H.S.Associate Professor, Department of MedicineDuke University Medical CenterDirector, Lifestyle Medicine ClinicFellow, Society of General Internal MedicineFellow, The Obesity SocietyVice President, American Society of Bariatric MedicineCourse Director, Medical Management of Obesity, FourthYear Elective, Duke Medical School
Atkins Puts Patients in the Fat-Burning Zone
Results After Three Months on Subjects withMetabolic Syndrome
Low-Glycemic CarbsHigh-GlycemicCarbs
What Do You Eat on the Atkins Diet?
Eat from All Macronutrient Groups Low-glycemic, nutrient-dense, fiber-rich carbohydrates A variety of protein sources All natural fatsALL HAVE LOW GLYCEMIC IMPACT
Four Phases of Atkins Phase 1, Induction 20 grams of Net Carbs (total carbs minus fiber) per dayPhase 2, Ongoing Weight Loss (OWL) Each week or several weeks, add 5 daily grams of Net Carbs,as long as weight loss continuesPhase 3, Pre-Maintenance Every week or several weeks, add 10 daily grams of NetCarbs, as long as weight loss continuesPhase 4, Lifetime Maintenance Continue to consume the number of grams of Net Carbs thatenables weight maintenance and appetite control
Primarily Low-Glycemic CarbohydratesSalad Greens: Any leafyvegetable, such as lettuce,spinach, parsley, watercress,seaweed (if it is a leaf—you caneat it), and other saladvegetables, including beansprouts, bell peppers, celery,celery root, cucumber, jicama,mushrooms, onions, scallions andradishes. Also fruits generallythought of as veggies: avocados,tomatoes and olivesVegetables that are usuallycooked: artichoke, asparagus,bamboo shoots, string beans, beetgreens, bok choy, broccoli,Brussels sprouts, cabbage,cardoon, cauliflower, chard,collard or dandelion or mustardgreens, eggplant, escarole, fennel,hearts of palm, kale, kohlrabi,leeks, mushrooms, okra, onion, bellpeppers, pumpkin, rhubarb,sauerkraut, shallots, sorrel, snowpeas, zucchini and other summersquash, spaghetti squash,tomatillo, white turnips, waterchestnuts12–15 daily grams of NetCarbs must come fromfoundation vegetables.Vegetables not on this listshould not be consumedin Phase 1 Induction.Vegetables such as celeryroot, kohlrabi, leeks,mushrooms, onions, andpumpkin, are higher incarbs than most, so keepportions small.
Other Acceptable Phase 1 Carbohydrate FoodsDairy foods high in fat and low incarbs: cream or half-and-half or sourcream (up to 1.5 ounces a day),aged cheeses (up to 4 ounces a day)such as Swiss, Cheddar andmozzarella and soft cheeses such ascream cheese, brie and CamembertLemon or lime juice: up to 3 ouncesa dayHerbs, spices and seasonings (aslong as they have no added sugar),plus any condiments without addedsugar or flour, cornstarch or othercarb-filled thickeners. They includeancho chili pepper, anchovy paste,,capers, chipotle en adobe, clam juice,enchilada sauce, fish sauce, garlic,ginger, horseradish sauce, jalapeñoand other chiles, miso paste, Dijonmustard, yellow mustard, olives,pesto, dill or kosher pickles, roastedred pepper (pimentoes), salsa withno added sugar, soy sauce, tabascoor other hot sauces, taco sauce, tahini,tamari, wasabi paste.
Carbohydrate Foods Off Limits in Phase 1In later phases, add the following carbohydrate foods* in this order:1.Nuts and seeds and their butters and meals (not chestnuts)2.3.Berries, cherries and melon (not watermelon)Plain whole-milk yogurt, cottage cheese, ricotta and other freshcheeses4.Legumes, including chickpeas, lentils, edamame and the like5.Tomato and vegetable juice “cocktail” and more lemon and lime juice6.Other fruits (not fruit juices or dried fruits)7.Starchy vegetables such as winter squash, carrots, peas in pods8.Whole grains (not refined grain products)*Not everyone can tolerate these foods at any point or can handle only small amounts.
A Variety of Protein SourcesHave 4–6 ounces of protein at every meal. Tall men can have up to 8 ounces ifthey wish. Pick from the following:Meat: beef, lamb,veal, pork, ham,bacon or any gamemeat, but noprocessed meatsmade with fillers suchas some salami,pepperoni, hot dogs,meatballs ormeatloaf. Also noham or bacon curedwith sugarPoultry: chicken,turkey, duck andgame birds, but nobreaded orprocessed productsFish or shellfish:fresh, canned,smoked or dried,including salmon,halibut, cod, crab,shrimp, clams, oysters,mussels, squid,octopus or roe, but noproducts cured withsugar, pickled herringwith added sugar,artificial crab orother processed orbreaded products.No more than 4ounces of oysters ormussels a dayEggs: whole eggscooked in any styleVegetarian: Quornproducts(unbreaded), seitan,shirataki soy noodles,soy or rice “cheese,”tempeh, tofu and tofumeat analogs, vegan“cheese,” veggieburgers, crumblesand meatballs
A Variety of Natural FatsYou can consume the following fats and oils:Butter and the following oils:canola, coconut, flaxseed, grapeseed, olive, high-oleic safflower,sesame and walnut, preferablycold pressed or expeller pressedSalad Dressings: Any dressingwith no more than 2 grams of NetCarbs per 2-tablespoon serving,but no dressings with sugar, honey,maple syrup or other caloricsweetenersAvoid corn, soy, sunflowerseed and other vegetable oils,which tend to be high inomega-6 fatty acids.Also avoid “lite” or “low-fat”products and all margarinesand shortening products,which may contain smallamounts of trans fats.
How Much Fat to Consume in a DayIt’s essential to consume enough natural fats to provide satiety,encourage lipolysis and make foods tasty. But there’s no need tooverdo it. A typical day’s intake might include the following: 2 tablespoons oil for dressing salads and cooking 1 tablespoon butter 1 ounce cream 2–3 eggs 2–3 servings of meat, poultry, fish or shellfish 10 olives and/or half a Haas avocado 2 ounces nuts or seeds (after first 2 weeks on Phase 1)
Example of an Atkins Phase 1, Induction, Meal Plan(20 grams of Net Carbs Per Day) Breakfast: Asparagus-cheese omelet, coffee with cream Snack: String cheese and half a cucumber Lunch: Chicken Caesar salad with Caesar dressing Snack: Half a Haas avocado Dinner: Grilled salmon, steamed broccoli, sliced tomatoeswith blue cheese dressing and olives
Acceptable Beverages in Phase 1 You can drink the following beverages: Club soda, plain or flavored seltzer (must say “no calories”) Caffeinated or decaffeinated coffee and tea Diet soda sweetened with non-caloric sweeteners Herb tea (without added barley or fruit sugars) Unsweetened, unflavored soy or almond milk or unsweetened, unflavoredcoconut dairy beverage Broth/bouillon (not low sodium and without added sugars, hydrogenated oils orMSG)
Acceptable SweetenersThe following are acceptable in moderation: Splenda (sucralose) Truvia or SweetLeaf (stevia) Sweet ’N Low (saccharin) XylitolHave no more than 3 packets a day and count each as1 gram of Net Carbs
Foods to Avoid in Phase 1, InductionIn addition to any foods cited above, avoid the following: Fruits other than those considered vegetables in the vegetable list Fruit and vegetable juice other than lemon and lime juice Regular sodas (with sugar or corn syrup) and alcohol of any sort Any food made with flour or other grain products Any food with added sugar such as evaporated cane juice, glucose, dextrose, honeyand corn syrup Nuts and seeds, nut and seed butters (acceptable after two weeks) Grains, including whole grains, and legumes Dairy products other than hard cheese, cream, sour cream and butter, including cow orgoat milk of any kind, yogurt, cottage cheese, or ricotta “Low-fat” products “Diet” products, unless they have no more than 3 grams of Net Carbs per serving
The Evidence Obesity, metabolic syndrome Type 2 diabetes mellitus
The Goal of a Low-Carb Diet Is to ReduceSerum Insulin Levels Low-carb diets reduce the dietary contribution toserum glucose, which then lowers insulin levels.Because insulin is a potent stimulator of lipogenesisand inhibitor of lipolysis, lowering insulin levels allowsan individual to use his stored body fat for energy.Taubes, G.T., Good Calories, Bad Calories, Knopf, 2007.
Outpatient LCKD Randomized Controlled nVisitsSondike 2003RCTClinicHealthyteens3mq2WkBrehm 2003RCTClinicHealthyadults6mq2Wk x 6, then @ 6moSamaha 2003 Stern2004RCTClinicOutptadults6m 12mqWk x 4, then monthlyFoster 2003RCTClinicHealthyadults12mq2Wk x 2, q4Wk x 4,then Wk 26, 34, 42, 52Yancy 2004RCTClinicHealthyadults6mq2Wks x 6, then monthlyBrinkworth 2009RCTClinicHealthyadults12 mq2Wks x 4, then monthlyNordmann et al., Arch Intern Med 2006;166:285-293.
Outpatient LCKD RCTs: Weight Loss and Serum LipidsLow FatRefLow DLSondiken 303 mo-4.1kg-17%*-6% 2%-9.9kg* 4%-48%* 4%Brehmn 426 mo-3.9kg†-5% 2% 8%-8.5kg*†0%-23%* 13%Samaha/Sternn 1326 mo12 mo-1.9kg†-3.1kg 3%-3%-4% 2%-2%-12%-5.8kg*†-5.1kg 4% 6%-20%*-29%0%-2%Foster6 mo-5.3kg†-3%-13% 4%-9.7kg*† 4%-21% 20%*n 6312 mo-4.5kg†-6% 1% 3%-7.3kg† 1%-28%* 18%*Yancyn 1196 mo-6.5kg-3%-15%-1%-12.0kg* 2%-42%* 13%*12 mos-11.5kg 3%-12%0%-14.5kg 3%-35%BrinkworthN 40* p 0.05 for between-groups comparison 21%
Popular Diet Effects on Weight CardiacRisk Among Women“Each diet group attended 1-hour classes led by a registered dietician once per week for 8 weeks andcovered approximately one eighth of their respective books per class.Efforts to maximize retentionincluded email and telephone reminders and incentive payments.”2 months (“efficacy”)Groupnkcal/d 1 62g1455 1521476 1801408 2209787736084574933-4.3 kg 2.3-2.0 kg -5.3-2.8 kg -7.3-2.8 kg 3-2.9-2.1-1.4-0.412 months (“effectiveness”)Groupnkcal/d CHOPROAtkinsZoneLEARNOrnish777979761599 140g 841594 179 801654 194 791505 195 68Gardner CD et al., JAMA, 5 kg 0.8 -29.3 4.9-1.5 kg0-4.2 2.2-2.5 kg 0.6 -14.6 -2.8-2.4 kg -3.8 -14.9 0-4.4-2.1-2.2-0.7
Popular Diet Effects on Weight Loss andCardiac Risk Factors“To approximate the realistic long-term sustainability of each diet, we asked participants to followtheir dietary assignment to the best of their ability to their 2 month assessment, after which time weencouraged them to follow their assigned diet according to their own self-determined interest level.”2 months (“efficacy”)Groupnkcal/d CHOPROFATAtkinsZoneW 70.089.554.554.527.5137g157191230WeightLDLTrig-3.6 kg 1.3 -32.3-3.8 kg -9.7 -54.1-3.5 kg -12.1 -9.2-3.6 kg -16.5 -0.4HDLL/H 3.2 1.8-0.2-3.6-0.18-0.33-0.42-0.2112 months (“effectiveness”)Groupnkcal/d CHOPROFATWeightAtkinsZoneW 76.580.571.564.064.0-2.1 kg-3.2 kg-3.0 kg-3.3 kg190g173208218Dansinger ML et al., JAMA, 2005;293:43-53.LDLTrigHDL-7.1 -1.2 3.4-11.8 -2.5 3.3-9.3 -12.7 -3.4-12.6 5.6 -0.5L/H-0.39-0.52-0.55-0.31
Effect of Diet Programs on Metabolic SyndromeParameters from Baseline to 12 MonthsAtkinsZoneLEARNOrnishP(n 77)(n 79)(n 79)(n 76)valueBMI, kg/m2-1.65-0.53-0.92-0.77.01Waist-hip ratio-0.019-0.013-0.009-0.012.10HDL-C, mg/dL 4.9 2.2 2.80.00.002Triglycerides, mg/dL-29.3-4.2-14.6-14.90.01Non-HDL-C, mg/dL-5.1-0.5-4.0-6.80.36Insulin, mU/mL-1.8-1.5-1.8-0.20.17Glucose, mg/dL-1.8-1.6 0.5-0.80.54Diastolic b.p., mmHg-4.4-2.1-2.2-0.70.009Systolic b.p., mmHg-7.6-3.3-3.1-1.9 0.001Gardner CD et al., JAMA, 2007;297:969-977.
Low-Carbohydrate Ketogenic Diet Mechanism When dietary carbohydrate is restricted, appetite is suppressed .1Appetite suppression leads to a Calorie deficit state. 1In a Calorie-deficit state, the body draws on stored fat for fuel (lipolysis). 1Possible but as yet unproven mechanisms: Inefficiency of protein- and fat- processing leads to extra energy loss. 2Lipolysis is maintained despite calorie excess state because glycerol fromfat is needed as a gluconeogenic precursor. 31. Boden, G. et al.,” Effect of a low-carbohydrate diet on appetite, blood glucose levels, and insulin resistance in obese patients withtype 2 diabetes,” Ann Intern Med, 2005;142:403-411.2. Feinman, R.D., Fine, E.J., “Thermodynamics and metabolic advantage of weight loss diets,” Metabolic Syndrome and Related Disorders,2003;1:209-219.3. Klein, S., Wolfe, R.R., “Carbohydrate restriction regulates the adaptive response to fasting,” Am J Physiol, 1992;262:E631-E636.
Workplace Diet Trial322 workers at Israeli research center, BMI 27 kg/m2Low-Fat Diet 30% fat Calorie-restricted Grains, veggies,fruits, legumesMediterranean Diet 35% fat Calorie-restricted Grains, veggies,fruits, legumes, fish,nuts, olive oilLow-Carb Diet 20 g/day carbsinitially Increase to max of120 g/day No calorie restriction
Weight Changes Over 2 Years by Diet Group
Weight Changes Over 2 Years by Diet Group (cont.)
Recent Meta-Analysis of RCTs Comparing Low-Carbto Low-Fat Diets “Low-carbohydrate/high-protein diets are moreeffective at 6 months and are as effective, if not more,as low-fat diets in reducing weight and cardiovasculardisease risk up to 1 year.”Hession, M., Rolland, C., Kulkami, U., Wise, A., Broom, J., “Systematic review of randomized controlled trialsof low-carbohydrate vs. low-fat/low-calorie diets in the management of obesity and its comorbidities,”Obes Rev, 2008
The Evidence Obesity, metabolic syndrome Type 2 diabetes mellitus
5 grams of glucosein human bloodstream
Very Low-Carbohydrate Diet DecreasesPostprandial Glycemic/Insulin Response8am8am8am8amBoden, G. et al., Ann Intern Med, 2005;142:403-11.
Low-Carbohydrate Diets for Type 2 DiabetesPilot StudiesReferencenWeightkgCHOFollow-up HA1cPrePostHAIc Wt Diff%%Vernon200314123.2 10%8 months 10.05.9-9.7O’Neill20032082 10%10 months 8.45.8-6.7Nielsen200516100 20%12 months 8.06.6-11.9Yancy200528131.4 7%16 weeks 7.56.3-6.6Vernon, M.C. et al., Metabolic Syndrome and Related Disorders, 2003;1:233-238.O’Neill, D.F. et al., Metabolic Syndrome and Related Disorders, 2003;1:291-298.Nielsen, J.V. et al., Upsala J Med Sci, 2005;109:179-184.Yancy, W.S., Jr. et al., Nutrition & Metabolism, 2005;2:34.%
Short-Term Effects of Severe Dietary Carbohydrate-Restriction Advice inType 2 Diabetes: a Randomized Controlled Trial102 patientsvolunteers Type 2DM(A1c 8-12%)BMI 30Standard Diet instruction“reducing fat intake and portionsize” 3 monthly group sessionsRRLow-Carbohydrate Dietinstruction“ 70g carbohydrate/day” 3 monthly group sessionsDaly et al., Diabetes Medicine, 2006;23:15-20.
ResultsDaly et al., Diabetes Medicine, 2006;23:15-20.
Study DesignOverweight orobese volunteerswith type 2diabetesRRLow-Glycemic Index Diet (LGI)instruction group meetings exercise recommendation nutritional supplementsLow-Carbohydrate KetogenicDiet (LCKD) instruction group meetings exercise recommendation nutritional supplementsWestman et al., Nutrition & Metabolism, 2009;5:36.
Primary Outcome: Hemoglobin A1cLCKDLGILGI (n 29)HgbA1c, %Baseline12 Weeks24 WeeksBase 24mean (sd)mean (sd)mean (sd)change, %8.3 (1.9)7.5 (1.7)7.8 (2.1)-0.5 (-6.0%)*8.8 (1.8)7.2 (1.2)7.3 (1.5)-1.5 (-17.0%)*LCKD (n 21)HgbA1c, %*p 0.05 between groupsWestman et al., Nutrition & Metabolism, 2009;5:36.
Effect of Diet Programs on MetabolicSyndrome ParametersLGI (n 29)LCKD (n 21)Week 0Week 24ChangeWeek 0Week 24ChangemeanmeanmeanmeanmeanmeanFasting glucose, mg/dL166.8150.8-16.0*178.1158.2-19.9*Waist circumference, in.47.042.4-4.6 *47.141.8-5.3 *Triglycerides, mg/dL167.1147.8-19.3210.4142.9-67.5 *HDL cholesterol, mg/dL48.748.7-0 †44.049.6 5.6 * †Systolic blood pressure,mmHg140.8130.1-10.7 *144.4127.8-16.6 *Diastolic blood pressure,mmHg84.178.5-5.6 *83.975.8-8.1 *Body mass index, kg/m237.935.2-2.7 * †37.833.9-3.9 * †* p 0.05 for within-group change from Week 0 to Week 24.† p 0.05, for between groups change from Week 0 to Week 24.
Case StudyHgb A1c7.4%Insulin120 units/dayGlipizide XL 20 mgMetformin1000 mg qdLisinopril60 mg qd6.0%offGlipizideMetformin20 mg qd
Case StudyHgb A1cLantusByettaGlipizide8.2%46 units hs5 mcg BID20 mg BID5.7%offoffoff
Case StudyHgb A1c6.5%Insulin dose 50uMetformin1000mg25135.2%001000
Diabetic Diet in the Pre-InsulinEra 1914-1921Meats, poultry, game, fishSoupsEggsButterOlive OilCoffee, TeaOsler, W., McCrae, T., The Principles and Practice of Medicine, NY: Appleton and Co., 1923.Allen, F.M., ”Protein diets and undernutrition in treatment of diabetes,” JAMA, 1920; 74:571-577
American Diabetes Association, 2008 In overweight and obese insulin-resistant individuals, modest weight losshas been shown to improve insulin resistance. Thus, weight loss isrecommended for all such individuals who have or are at risk fordiabetes.For weight loss, either low-carbohydrate or low-fat calorie-restricteddiets may be effective in the short term (up to 1 year).For patients on low-carbohydrate diets, monitor lipid profiles, renalfunction, and protein intake (in those with nephropathy), and adjusthypoglycemic therapy as needed.“Nutrition Recommendations and Interventions for Diabetes: A Position Statement of the AmericanDiabetes Association,” Diabetes Care, 2008;31:S61-S78.
Summary Atkins is effective for resolving obesity, metabolic syndromeand type 2 diabetesDespite previous concerns, low-carbohydrate diets have beenfound to be safe in randomized, controlled trials of up to twoyears durationRelatively easy to use: Individuals consume “real” whole foodsAppetite is under controlNo need to count caloriesSimple to teach
Further Resources Atkins.com: The patient site Atkins-hcp.com: The healthcare professional site The New Atkins for a New You By Eric C. Westman, Stephen D. Phinney and Jeff S. Volek Obesity: Evaluation and Treatment Essentials Edited by G. Michael Steelman and Eric C. WestmanDr. Atkins’ Diabetes Revolution By Mary C. Vernon and Jacqueline A. Eberstein Innovative Metabolic Solutions Lecture Series, CME Provided, myimsonline.com
Four Phases of Atkins Phase 1, Induction 20 grams of Net Carbs (total carbs minus fiber) per day Phase 2, Ongoing Weight Loss (OWL) Each week or several weeks, add 5 daily grams of Net Carbs, as long as weight loss continues Phase 3, Pre-Maintenance Every week or several weeks, add 10 daily grams of Net .
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Le genou de Lucy. Odile Jacob. 1999. Coppens Y. Pré-textes. L’homme préhistorique en morceaux. Eds Odile Jacob. 2011. Costentin J., Delaveau P. Café, thé, chocolat, les bons effets sur le cerveau et pour le corps. Editions Odile Jacob. 2010. Crawford M., Marsh D. The driving force : food in human evolution and the future.
Le genou de Lucy. Odile Jacob. 1999. Coppens Y. Pré-textes. L’homme préhistorique en morceaux. Eds Odile Jacob. 2011. Costentin J., Delaveau P. Café, thé, chocolat, les bons effets sur le cerveau et pour le corps. Editions Odile Jacob. 2010. 3 Crawford M., Marsh D. The driving force : food in human evolution and the future.
