Third of five parts
Clipboard in hand, Dr. Eric Westman strides into the office to see his patients. All of them are overweight. Many of them are diabetic and have high blood pressure or other weight-related ailments.
He scans a list of foods they eat and doesn't bat an eye at their consumption of eggs, sausage and bacon, coffee with heavy cream or pork rinds. He doesn't require them to exercise. He tells one: "Fat is your friend."
With those four words, Westman, an internist who directs Duke University's Lifestyle Medicine Clinic, declares his stance in the often vitriolic low-fat vs. low-carb debate. His research helped spark the 2004 Atkins diet boom, and he is a co-author of "The New Atkins for a New You," which devotes a chapter to the past decade's research on low-carb diets.
Westman seems out of place in Durham, which has been called "the diet capital of the world." Obese people come from afar and spend up to $7,000 a month to shed pounds at The Rice Diet Program Clinic, Structure House and the Duke Diet & Fitness Center. All three clinics prescribe a low-fat, calorie-restricted diet along with exercise.
Meanwhile, Westman runs a one-man clinic out of a Duke office building. Most of his patients live nearby, and the most they have to pay to see him is a health insurance co-pay.
For the past 10 years, Westman and other low-carb researchers have been fighting an uphill battle against the medical consensus that a low-fat, high-carb diet is best.
Low-fat dieters aim to get 65 percent of their calories from carbohydrates, such as whole-grain breads, pastas, fruits and starchy vegetables. A low-fat diet helps you lose weight because you eat bulky foods with fewer calories.
A low-carb, high-fat diet favored by Westman reduces carbohydrates to 30 percent or less. Most of the calories come from fats, protein and low-carb vegetables, such as leafy greens, broccoli and zucchini. The low-carb diet helps you slim because protein and fat leave you full longer so you consume fewer calories.
"Fat is very satiating," Westman said. "Diets that restrict fat, that's a problem. Hunger is the main reason people go off a low-fat diet."
Westman and his colleagues are not saying that low carb is better than low fat. Both diets work because they restrict calories. Research shows that the best diet for someone is the easiest one - based on personal food preferences - to follow. Westman's point is that a low-carb diet is a viable option that has been wrongly maligned by the mainstream medical community.
A long debate
Those mainstream diet doctors want to make Westman eat his words.
But he and his fellow researchers contend that their findings are solid - more solid than Ancel Keys' 1950s studies that first suggested that a diet high in saturated fat caused heart disease. Keys' theory would be cemented into the American consciousness by the U.S. Department of Agriculture's food pyramid, which critics contend is influenced more by the agriculture industry than by science.
When Westman and others proved that people could lose as much weight on a low-carb diet as on a low-fat one, their detractors asked, "But what happens to their cholesterol?"
When they proved that a low-carb diet decreases LDL, or bad cholesterol, while improving HDL, the good cholesterol, their detractors pointed out that the study followed patients for only six months.
When a two-year study found similar results, those in the low-fat camp still weren't convinced that eating so much animal fat wouldn't kill you in the end.
"There's no doubt that the Atkins diet will lower your cholesterol, weight and blood pressure and get rid of your diabetes, but then what?" asked Dr. Robert Rosati, the cardiologist who runs The Rice Diet Program Clinic, granddaddy of Durham's diet centers.
That's the main criticism of the low-carb research from Dr. Dean Ornish, likely the most outspoken critic of low-carb diets and often a debate opponent of Dr. Atkins. Ornish is president of the nonprofit Preventive Medicine Research Institute in Sausalito, Calif. This research, he says, studies only the diet's effect on the risk factors for heart disease and not its effect on heart disease.
"The Atkins people have never published a study that the diet they recommend actually improves heart disease," he says.
The 'irresponsible' label
This nutrition debate can get so heated that Westman and other low-carb researchers have to defend themselves from being labeled fringe advocates for a fad food plan.
In September, Westman said at a diabetes conference in Sweden that a low-carb diet is better than drugs at controlling type 2 diabetes, which is prevalent among the obese.
Dr. Robert Eckel, an endocrinologist and spokesman for the American Heart Association, then derided Westman on the association's website as a "tremendously biased investigator who is very much in favor of his own work."
When Westman suggested that one way to prove his assertion was to study diabetics on the two diets, Eckel denounced the idea as "irresponsible," concerned about the effect of a high-fat diet on the heart. Eckel later added in an interview: "To manage diabetes long term with an Atkins diet is not worthy of serious consideration."
Others applaud Westman's willingness to challenge conventional wisdom.
"Eric had a sufficiently open mind that he looked into it," said science writer Gary Taubes, author of "Good Calories, Bad Calories: Challenging the Conventional Wisdom on Diet, Weight Control and Disease," which touts the low-carb regimen. "He's really one of a handful of people making this attempt at revolution. Why can't all these doctors be as open-minded?"
Diet research can be complicated. For one thing, a researcher, unlike with a lab rat, can't always control what a human subject eats or how much he exercises. The few studies that have housed and fed people for diet research have been costly - too costly for most researchers. And if people in weight-loss studies don't lose weight, they tend to quit the project, potentially skewing the results.
Westman spends Wednesdays seeing patients who visit his clinic regularly to track their weight loss and other health goals. Patients describe him as a "cheerleader" who offers encouraging words and reading materials.
At 6 feet 1 inch and 190 pounds, Westman, 50, shares tips - how to make low-carb pizza, a cheese plate for dessert and vodka and Fresca drinks as a low-calorie cocktail - culled from following the low-carb diet since 1999.
Westman, who grew up in Madison, Wis., earned his undergraduate degree at Stanford University and then went to medical school at the University of Wisconsin. He married his high school sweetheart, Gretchen, a school librarian in Chapel Hill. They have three children.
He often favors khakis and sports-related T-shirts to encourage exercise chitchat with his patients. On this Wednesday, he's wearing a "Fear the Tree" T-shirt, a reference to the Stanford marching band's mascot.
Among the patients Westman is seeing is Larry Boone of Durham. Boone, 63, carries about 300 pounds on his 6-foot frame and has diabetes. Boone had been steadily gaining weight while on a diabetic diet so his primary care doctor sent him to Westman.
Westman scans a list of foods that Boone has been eating the first week on his new diet.
For breakfast, eggs with bacon or sausage, diet cola or coffee with heavy cream. Lunch and dinner have been tuna salad, garden salad, hamburger, grilled chicken, beef stew, turnips, collards and diet cola. For snacks, he's had sugar-free Jell-O, boiled shrimp, deviled eggs and pork skins. Boone's wife, Molly, reports that their refrigerator is the fullest it has ever been and that she made whipped cream from scratch for the first time ever.
When Boone questions his new diet - "I've always been told in the past about butter clogging the arteries," he says - Westman reassures him. "That's the old way of thinking."
Since late August, Boone has lost 41 pounds and been taken off his diabetes medication.
Westman hasn't always been a low-carb advocate. He accepted the little he was taught in medical school about nutrition, basically that a low-fat diet is the healthiest.
He began questioning that belief in the late 1990s while treating patients at Durham's VA hospital. He found a fertile topic for research when a patient ignored his advice, went on the Atkins diet and lost weight.
Westman was sure the man's bad cholesterol would increase. Instead, it improved. After a second patient achieved the same results, Westman, already doing research on smoking cessation, was intrigued.
Reading Dr. Robert Atkins' book, "Dr. Atkins' Diet Revolution," which popularized low-carb diets, Westman found only anecdotal evidence to support the approach.
He wrote to Atkins asking to see what research had been done. Because it wasn't scientific, Westman approached Atkins about testing the diet using randomized controlled trials - the gold standard of medical research. (In such a trial, patients are randomly assigned to one diet or the other to compare the results.)
Atkins and his foundation would go on to pay for Westman's low-carb studies, an association that led Westman to co-author the new Atkins book. Any book royalties are to go into a Duke research account for Westman's work.
"This is new science, and it's going against the mainstream belief," Westman said.
Proof after proof
Westman's team published its first study in 2002. Researchers followed 51 volunteers on a low-carb diet for six months. Forty-one completed the study; all lost weight, and the effect on their cholesterol was favorable.
Two years later, Westman was the co-author of a clinical study that tracked 120 patients for six months. Half were on a low-fat diet; half on low-carb. More of the low-carb patients stayed with the diet; they also lost more weight while improving their cholesterol.
Then Westman studied how people with type 2 diabetes did on a low-carb diet. A 2005 study followed 21 such patients for four months and showed they lowered their blood glucose, allowing some to discontinue or reduce their diabetes medication.
Next, Westman and his colleagues examined whether a low-carb diet or a low-glycemic index diet was better for diabetics. (The glycemic index assigns numerical ratings to carb-rich foods based on how much they increase blood glucose levels.)
The clinical trial followed 84 volunteers for six months and found that a low-carb diet was the winner.
In 2009, Westman's team reported on a study comparing a low-carb diet with a low-fat diet combined with Orlistat, an over-the-counter drug known as Alli or Xenical that blocks fat absorption.
After a year, all 122 patients in the trial experienced similar weight loss, but the low-carb patients had a larger decrease in their blood pressure.
On the horizon is a look at the success rates of people who get to choose a diet to follow. On this project, Westman is helping Dr. William Yancy of Durham's VA hospital, his collaborator on many of the previous low-carb studies.
For his years of work, Westman was chosen "Bariatrician of the Year" in November by the American Society of Bariatric Physicians, a group of medical professionals who use nonsurgical means to treat obese patients.
Here and gone
Although research continues, the low-carb diet craze came and went.
At the diet's peak in 2004, an estimated 100 million Americans were watching their intake of carbohydrates, fueling a $40-billion-a-year industry. Then Atkins died in a fall, and a confidential medical report about his death was made public. It showed he weighed close to 250 pounds, classifying him as obese.
The incident illustrates how vitriolic the two sides can be. The report was leaked to The Wall Street Journal by the Physicians Committee for Responsible Medicine, which promotes a vegan diet. In response, Atkins' widow, Veronica, painted the group as the "vegetarian Taliban." She and others say Atkins gained 60 pounds from the glucose and fluids pumped into his body while he was in a coma.
Westman is convinced the controversy surrounding Atkins' death brought the diet's popularity to an end.
"All I know is science did not stop the craze," Westman said. "There was no new science that low-carb diet was bad. It took new science to get it out there. It took no science to take it away."
Coming tomorrow: Breakthroughs in diabetes research
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