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Many things in life require patience, and losing weight is one of them. A weight-loss journey also requires consistency, with a constant focus on the basics. What this means is eating less than you consume, performing lots of strength training, and getting in regular cardio workouts as well. That's why we've put together a super-effective cardio workout that's great for faster weight loss. Read on to jump on this regimenyou will not be disappointed. And next up, don't miss The 6 Best Exercises for Strong and Toned Arms in 2022, Trainer Says.

Your cardio sessions should be challenging and include fitness choices you can do routinely over the week. When it comes to choosing the right equipment for cardio, I recommend the exercise bike. The benefits of working out on a stationary bike or cycling are plenty. They make your heart, muscles, and lungs stronger, in addition to enhancing the stream of oxygen and blood through the body. This could result in improved sleep, lower blood pressure, greater energy, less stress, enhanced memory, and even a mood boost.

Plus, according to Healthline, the stationary bike can be a key player in your weight loss journey. Depending on how much you weigh and how intense your bike workout is, you could torch over 600 calories every hour with this kind of regimen.

Related: Get Rid of a Pot Belly in Your 50s With This 10-Minute Workout, Trainer Says

When toning down, a great plan is to blend in both steady-state and interval training, so that you benefit from the best of both worlds. When you're trying to lose fat at a fast pace, I recommend you place a strong emphasis on interval-style training for your conditioning work. My reasoning is simpleintervals burn more calories and fat than steady state. With interval training, make your workout challenging, but don't overdo it. It's important to not compromise your recovery. It's also crucial to make a plan you can maintain long-term, not just for a weight-loss period.

Related: The #1 Workout To Get Rid of a "Big Belly" for Good, Trainer Says

I have a cardio workout that will result in faster weight loss. Check out this interval-style routine you can do on a stationary bike that'll help you burn calories and body fat:6254a4d1642c605c54bf1cab17d50f1e

1. Work 30 seconds, rest 10 seconds2. Work 30 seconds, rest 10 seconds3. Work 15 seconds, rest 15 seconds4. Work 30 seconds, rest 30 seconds5. Work 20 seconds, rest 20 seconds6. Work 20 seconds, rest 10 seconds7. Work 10 seconds, rest 10 seconds8. Work 10 seconds, rest 40 seconds9. Work 15 seconds, rest 15 seconds10. Work 15 seconds, rest 45 seconds

For more mind and body news, be sure to check out Slim Down a Thick Waistline With This No-equipment Workout, Trainer Says and Lose Your Gut in Your 40s With 5 Easy Strength Exercises, Trainer Says.

Tim Liu, C.S.C.S.

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Try This Cardio Workout for Faster Weight Loss, Trainer Says Eat This Not That - Eat This, Not That

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WASHINGTON Yo-yo dieting increases the risk of heart disease and diabetes, warns new research.The study conducted in rats suggests that dramatic swings in calories consumed have long-term impacts on cardiovascular health and metabolism.

Scientists at Georgetown University say that their findings offer potential insights into the long-term impacts of weight-loss diets, as well as involuntary reductions in food intake caused by food insecurity.Most previous studies in humans and animals have focused on the short-term impacts of weight loss, but less is known about how cycles of weight loss and gain may affect long-term health.

For the new study, researchers divided 16 rats into two groups. One group received a normal amount of food throughout, while the other group experienced three cycles of a restricted diet: 60 percent of their normal daily food intake, followed by three weeks of a normal diet.At the end of the study period, the research team used ultrasound to assess the rats cardiac and renal functioning and blood tests to assess insulin sensitivity, a measure of how the body processes sugar.

We found that animals going through several cycles of weight loss and body weight recovery had reduced heart and kidney function at the end, says studyfirst author Dr. Aline de Souza, a postdoctoral fellow at the university, in a statement.They also had more insulin resistance, which can be a cause for diabetes.Even though the animals look to be healthy after recovery from the diet, their heart and metabolism are not healthy.

She says the findings also raise questions about public health in light of the COVID pandemic, such as whether people who had trouble accessing food as a result of lockdowns and economic impacts face increased risk of cardiovascular problems in the years ahead.

Our data supports the need for additional research in people to find out if individuals who do cycles of very restrictive diets to lose weight are at higher risk of developing heart problems later in life, says de Souza.We still need to do more studies in this field but the findings suggest the more restrictive the diet is, the worse the health outcomes may be.Weight loss diets need careful consideration of long-term health, especially if rapid weight loss is being contemplated as an option.

The researchers believe that changes in gene expression in response to caloric restriction could alter biological pathways that regulate blood pressure and insulin metabolism.

Dr de Souza presented the findings at the American Physiological Society annual meeting in Philadelphia.

South West News Service writer Stephen Beech contributed to this report.

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Yo-yo dieting can lead to long-term heart problems, raise risk of diabetes - Study Finds

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Overweight is defined as having a body mass index of 30 or greater; a BMI of 25 to 29.9 is considered overweight.Tibor Kolley/The Globe and Mail

Its estimated that adults gain, on average, one to two pounds a year. For some people, this gradual creep could lead to overweight or obesity.

Preventing weight gain is a fundamental objective of health authorities worldwide. Even modest annual weight gain in adults with overweight and obesity has been linked to an increased risk of chronic illness, including cardiovascular disease and cancer.

The good news: you dont have to make major changes to your diet to prevent incremental weight gain. Instead, studies have found that adopting a small change approach cutting 100 to 200 calories a day by eating less, exercising more or a combination of the two can do the trick.

The latest study to investigate the small change approach, published earlier this year in the Canadian Medical Association Journal, involved 320 sedentary adults, average age 52, living with overweight or obesity.

Obese is defined as having a body mass index (BMI) of 30 or greater; a BMI of 25 to 29.9 is considered overweight. BMI is calculated as your weight in kilograms divided by the square of your height in metres. (Use an online calculator to determine your BMI.)

For the trial, participants were assigned to a small change approach (SCA) or monitoring alone (MA) for two years. Those in the SCA group were counselled to cut 100 calories from their daily diet and increase daily steps by 2,000 (about 20 minutes).

People in the MA (control) group were asked to maintain their usual diet and physical activity.

Both groups had their weight monitored regularly over the two-year study. Participants had their weight measured once again one year after the trial ended.

I want to lose weight. Should I focus on diet or exercise?

Compared with monitoring only, the small change approach led to a weight loss of two pounds (versus one pound) over the first 15 months of the study. At the two-year mark and one year later, prevention of weight gain did not differ between the two groups; both groups did not gain weight.

The finding that the MA group did not gain weight over the study surprised the researchers. One reason may be that simply having weight monitored on a regular basis can lead to positive behavioural change. Its also possible that being in a study can cause people to do better.

When the researchers looked at overweight participants (versus participants with obesity), however, they found that weight gain was prevented in the SCA group while the MA group gained weight. These findings are consistent with those of a 2016 trial conducted in 599 young adults with overweight.

The latest study enrolled prominently white people and 77 per cent were female so the findings may not be transferable to other groups.

Making small tweaks to diet and exercise is easier to integrate into your everyday life and maintain long-term than bigger lifestyle changes required to lose weight.

A number of randomized controlled trials have found that large dietary changes are effective for short-term weight loss but, over time, weight regain is common.

A more reasonable and achievable goal, many experts contend, may be to focus on preventing weight gain.

According to Dr. Robert Ross, the lead study author and professor in the School of Kinesiology and Health Studies at Queens University, Kingston, Ont., preventing people moving from overweight to obesity is associated with health benefits regardless of your body weight.

For Canadians to adopt the small change approach, though, requires a change in expectations. If we can make subtle and sustainable changes eating a healthy diet, sitting less, moving more and appreciate that preventing weight gain is associated with health benefit, then weve made progress, says Dr. Ross.

To prevent weight from creeping up, aim to cut 100 to 200 calories daily through diet, exercise or both.

For example, eat one medium orange instead of drinking 12 ounces of orange juice to save 117 calories. Skip the cheese slice on your sandwich to drop 115 calories. Reduce your portion size of brown rice by one-half-cup to lose 128 calories.

Add one less tablespoon of cooking oil when sauting and save 120 calories. Try 2% milk instead of 10% cream in your coffee to cut 80 calories per one-quarter-cup.

Twenty minutes of brisk walking, 12 minutes of hiking, 10 minutes of moderate cycling and 8 minutes of swimming (breaststroke) all burn roughly 100 calories for a 170-pound person.

Leslie Beck, a Toronto-based private practice dietitian, is director of food and nutrition at Medcan. Follow her on Twitter @LeslieBeckRD

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The obesity epidemic in the U.S. puts physicians in a tight spot. In their efforts to break through on this stubborn chronic health condition, they may get questions from patients about taking dietary supplements to lose weight or maintain weight loss. But they should be aware that over-the-counter weight loss products are neither reviewed nor approved by the Food and Drug Administration (FDA) for safety or efficacy, and medical ethics prohibit doctors from recommending them.

Following are highlights from an article published in the AMA Journal of Ethics (@JournalofEthics) by Melinda M. Manore, PhD, RDN, emeritus professor of nutrition in the School of Biological and Population Sciences at Oregon State University, and Megan Patton-Lopez, PhD, RDN, associate professor of public health at Western Oregon University.

Using the hypothetical case of a 42-year-old Latina with a high body mass index and a history of dieting for weight loss, the authors explored three crucial facts about over-the-counter products, as well as how physicians can support by promoting culturally and individually sensitive weight-management strategies backed by science.

Unknown safety and efficacy

The FDA does not review or approve nonprescription, over-the-counter dietary supplements for safety or efficacy and does not require certification of substance purity on labels, although it does require listing of all ingredients, the authors noted.

Supplement manufacturers sometimes add adulterantssuch as sibutramine, fenfluramine, laxatives and diureticsto spur weight loss, even though its illegal to do so.

Research on over-the-counter weight loss supplements shows that these products have little efficacy and pose potentially serious risk of harm, the authors wrote. Clinical studies for weight-loss supplements typically include only one or two ingredients in a trial, lack a control group, are not double-blinded and require lifestyle changes.

Learn more with a CME course on dietary supplements from the AMA and FDA.

Five drugs are now approved by the for long-term weight management in adults: orlistat, phentermine/topiramate, naltrexone/bupropion extended release, liraglutide and semaglutide. Find out more with JN Learning video, Pharmacotherapy for Obesity.

Questionable ingredients

Weight-loss supplements typically rely on one or more of four mechanisms, the authors noted: Blocking carbohydrate or fat absorption, increasing metabolism and fat burn, changing body composition, or suppressing appetite.

The problem is that their ingredients arent well studied and, at higher intakes, may be unsafe. For example, consuming more than 400 mg per day of caffeine can cause insomnia, irritability, heart palpitations and anxiety.

Other substances similarly appear to be safe at low levels, but over-the-counter products are not required to list their total contents, so consumers can never be sure how much they are getting in a dose or a serving.

The May 2022 issue of AMA Journal of Ethics further explores underregulated supplements.

What to recommend instead

Weight loss and management are challenging in our current environment of readily available energy-dense foods and a sedentary lifestyle, the authors wrote. Telling the patient to eat less and exercise more does not work.

More to the point, there is no magic formula for weight loss, they noted, and research has shown extreme weight loss approaches do not work for most patients and can even slow metabolism. Measured approaches are more effective.

Almost any diet that reduces energy intake will produce weight loss if followed. Explaining dynamic energy balance and the many factors that contribute to ones body weight will help reduce patients guilt about past weight loss failures, the authors wrote. Clinicians should emphasize moderate, achievable weight loss and health goals and the importance of lifelong healthy lifestyle changes over quick, dramatic weight loss.

Find out what doctors wish patients knew about healthy eating.

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2 reasons to steer patients away from supplements for weight loss - American Medical Association

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Photo (c) Mukhina1 - Getty ImagesA new study conducted by researchers from Rutgers University explored how consumers eating habits while dieting may affect their food choices long-term. According to their findings, eating more protein while on a diet may prompt consumers to choose healthier options overall.

The impact of self-selected dietary protein on diet quality has not been examined before, to our knowledge, like this, said researcher Anna Ogilvie. Exploring the connection between protein intake and diet quality is important because diet quality is often suboptimal in the U.S., and higher-protein weight loss diets are popular.

For the study, the researchers analyzed data from over 200 overweight or obese men and women between the ages of 24 and 75 involved in a six-month clinical trial. The participants followed a calorie-deficit diet for the duration of the study, and they recorded everything they ate. The team then assessed the quality of their diets to understand how healthy the participants were eating.

While the researchers recommended that the participants allot 18% of their daily calories to protein, the participants fell into two groups: 18% of calories coming from protein or 20% of calories coming from protein. Though the team found that both groups lost the same amount of weight, eating more protein improved the participants diets overall.

Those who ate more protein were more likely to adopt other healthier eating habits. The study showed that higher-protein eaters reached for sugary foods less often and for green vegetables more often. Additionally, eating more protein helped the participants retain more of their lean muscle mass, as opposed to eating less protein on a regular basis.

The researchers hope that these findings highlight the benefits associated with eating diets higher in protein, as they can help consumers adopt healthier habits long-term.

Its somewhat remarkable that a self-selected, slightly higher protein intake during dieting is accompanied by higher intake of green vegetables, and reduced intake of refined grains and added sugar, said researcher Sue Shapses. But thats precisely what we found.

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Eating more protein while dieting may lead to healthier food choices overall, study finds - ConsumerAffairs

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There are so many different diets out there that it can often be bewildering for anyone looking to get in shape or at least shed a few pounds. It seems everyone is looking for the secret to losing weight without having to go without their favourite foods and cherished treats.

That's one reason why the much-vaunted Keto diet has won over so many fans - among ordinary dieters as much as TV celebrities. The popular diet, you see, is fat-heavy, with advocates claiming you can still indulge in the odd hamburger or bacon roll.

Many people swear by the Keto diet, crediting it with helping them to slim down where other diets failed them. Its main principle is reducing the amount of sugars and carbohydrates you consume.

READ MORE: 10 foods that can help you burn fat including broccoli, green tea and eggs

Nutrition expert and author Lauryn Lax at BreakingMuscle.com, the fitness website, warns that the Keto diet is not for everyone. She goes onto explains that, in some cases, it can actually do more harm than good.

Revealing why some diets may not be working for their adherents, Dr Lax said: "Having a better diet is often at the forefront of many peoples minds, however, with so many different types of diets, it can be overwhelming to know the right way to achieve your nutrition goals."

Lauryn suggested that some groups of people may find that the keto diet may not work as well for some women. In some instances, 'women who have issues with their blood sugar or insulin resistance have found ketogenic diets beneficial as a short-term dietary approach'.

'However, women who have their blood sugar under control, but have some adrenal fatigue or hormone imbalances, have found a ketogenic diet more harmful in the long run.'

In these instances, she suggests that certain bodies may react better to other diets, with some doing better with more carbs, while others do better with more fat.

She also outlined key aspects that may be the reason behind why your diet isn't working, including not eating enough berries or citrus, or not paying enough attention towards your food when it comes to chewing or assessing your level of hunger. Being stressed about you diet could also have an effect.

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Keto diet warning as nutritionist says it can be 'more harmful' in long run for some groups of people - Daily Record

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This potential new pill could be worth the weight.

Researchers at Stanford University found an anti-hunger molecule, called Lac-Phe, which is normally only produced after an intense workout.

After giving obese mice this molecule, they were discovered to have not only eaten 30% less but also weighed less in the long term. They also had a lower percentage of body fat and improved blood sugar regulation, according to a study published in the journal Nature.

Dr. Yong Xu, from the Baylor College of Medicine, claims that the research could lead to the creation of a fat-fighting pill.

This could lead to the development of a pill that can directly be used to suppress appetite for certain individuals who cannot easily exercise because of other conditions, aging or bone issues, he told New Scientist.

We just filed a patent for hopefully using this knowledge to treat human diseases such as obesity.

This is the latest attempt to get a weight loss pill to consumers. What has mostly been on the market are pills and injections meant to trim body fat or drugs, such as a diabetes medication that is being prescribed off-label, to curb hunger.

Scientists are still conducting research to determine what Lac-Phe can do to the brain besides suppressing hunger. Lac-Phe was said to be responsible for almost 25% of the anti-obesity effects of exercise. It was seen to have no effect when given to lean mice.

Despite only being tested on animals, the researchers are suggesting their results would be the same for humans.

As of 2020, the obesity prevalence for adults was 41.9% in the United States, according to the Centers for Disease Control and Prevention.

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Pill to help you lose weight in the works - New York Post

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What Is the Intuitive Fasting Diet? Intermittent fasting is a dietary pattern that cycles between normal eating and fasting. If

What Is the Intuitive Fasting Diet?

Intermittent fasting is a dietary pattern that cycles between normal eating and fasting. If youre seeking more health benefits, or pound-shedding potential, from an eating plan and you also want to develop inner serenity and a sense of being grounded you might be attracted to intuitive fasting.

Intermittent fasting is known for its medical and weight-loss purposes but can offer still more, says Will Cole, author of Intuitive Fasting: The Flexible Four-Week Intermittent Fasting Plan to Recharge Your Metabolism and Renew Your Health.

The four-week plan uses a variety of intermittent fasting protocols designed to recharge your metabolism, renew your cells and rebalance your hormones, says Cole, who is a functional medicine practitioner. His plan combines elements of intermittent fasting with metaphysical meals that fit mindfulness practices into fasting periods so you make fasting a meditation.

As this is a relatively new plan, with the book published in 2021, research that specifically supports intuitive fasting is lacking. However, its two major components are individually backed by evidence, Cole says. Theres a lot of research looking at intermittent fasting, he says. And theres a lot of research looking at mindfulness practices. So, I wanted people to really lean into both.

No foods are strictly forbidden. Instead, I just want to educate people on whats going to make their fast easier, Cole says. So focus on nutrient-dense foods first.

Nutrient-dense foods are high in nutrients such as vitamins, minerals, lean protein, complex carbohydrates and healthy fat. Theyre also relatively low in calories, which can be a plus for weight loss. Nutrient-dense foods are also key in several U.S. News Best Diets including Volumetrics, Nutritarian and Noom.

When somebody gets their blood sugar stabilized and theyre eating nutrient-dense food and theyre satiated, then the fast is a lot more effortless because they are fueled during their eating window, Cole says.

As it relates to eating, intuitive means being able to look inward and respect your bodys hunger and fullness signals to guide your choices in terms of when and what to eat. With intuitive fasting, Cole says, followers become more intuitive in their eating and fasting choices.

Metabolic flexibility is the bodys ability to adapt whatever fuel is available the ability to use both sugars in your blood and stored fat for food, Cole says. Introducing the body to various types of fasting helps people regain that flexibility, he says. Intuitive fasting involves a four-week plan in which you explore different fasting windows. By doing so, he says, youll strengthen your metabolism, feel good all day, reduce cravings and blood sugar crashes, and gain resilience and intuition in your body.

[Read: Calorie Reduction vs Fasting.]

How Does Intuitive Fasting Work?

Heres a glimpse at the four-week plan thats further fleshed out in the Intuitive Fasting book:

Week 1 (12/12 Body Reset Fast). With a long 12-hour feeding window, this fast is least disruptive to a usual daily routine of breakfast, lunch and dinner. You have your last meal in the early evening, for instance at 6 p.m., and then you dont eat again until 6 a.m. the next day. (You choose your exact window times.)

Week 2 (14- to 18-Hour Metabolic Recharge Fast). Your fasting window is extended to 14 to 18 hours. Your body will go deeper into ketosis (fat-burning). The aim is to improve metabolic markers such as better blood sugar balance, lower levels of leptin a hormone linked to hunger and appetite and reduced inflammation.

Week 3 (20- to 22-Hour Cellular Renewal Fast). You complete these longest fasts, which basically allow one meal a day, every other day. Potential benefits include supporting cellular repair among other longevity pathways.

Week 4 (12/12 Rebalance Fast). Returning to the 12-hour fasting window from Week 1, you now increase nutritious carbohydrates such as fruit, sweet potatoes and rice.

During standard mealtimes, you can fill the gap with metaphysical meals while fasting. These are simply mindful practices such as:

A 10-minute meditation or prayer.

A neighborhood walk.

Forest bathing or other nature immersion.

Journaling.

Overall, the cyclical approach of the four-week plan is meant to provide gentle, flexible fasting windows, along with a high-fat, low-carb nutrition plan, to help center yourself and make peace with food and your body. According to Cole, people who might do particularly well with intuitive fasting include those who are:

Struggling with fatigue.

Struggling with weight-loss resistance.

Struggling with an autoimmune problem.

Struggling with brain fog (which can tie into fatigue).

Those are the people who are going to benefit the most, because theyre struggling with some sort of inflammatory problem or metabolic issues, and those people do really well with the book, Cole says.

[See: 15 Best Weight-Loss Diets at a Glance.]

Intuitive Fasting Overview

Intuitive fasting is:

Budget-friendly.

Planet-friendly.

Can be adapted for vegans or vegetarians.

Can be adapted for a gluten-free diet.

Can be adapted for halal or kosher diets.

Low-carb.

High-fat.

What Are the Benefits of Intuitive Fasting?

Intuitive fasting pros

Nutritionally sound.

Diverse foods and flavors.

No counting carb, points or calories.

Filling (during feeding windows) its rich in high-fiber foods.

No off-limit foods or food groups.

A clearly defined plan with recipes.

Intuitive fasting cons

Youll likely get hungry when fasting.

Unsafe for some people.

Little research to back it up specifically.

Could fall short nutritionally when fasting.

[See: Ways to Shift Your Mindset for Better Weight Loss.]

Can I Lose Weight on Intuitive Fasting?

Youll probably lose weight on intuitive fasting. During fasting periods youll consume significantly fewer calories than you normally would. In addition, you may have better weight maintenance if intuitive fasting helps improve metabolism and reduce weight-loss resistance as intended.

Short-term weight loss

Youre likely to lose weight in the first week of the plan, primarily due to loss of water weight. During any fasting period, youll probably consume significantly fewer calories than otherwise.

A meta-analysis found that alternate-day fasting is an effective dietary method and may be superior to very-low-calorie dieting for people with obesity.

A systematic review of intermittent fasting studies, with most studies lasting 12 to 13 weeks, found that participants lost 7 to 11 pounds over a 10-week period, with a maximum weight loss of 35 pounds over a 20-week period.

Long-term weight loss

You could maintain weight loss by sticking to intuitive fasting over time. In another systematic review of various intermittent fasting regimens for people with overweight or obesity, some studies lasting up to one year, participants lost about 15 pounds on average.

Health Benefits of Intuitive Fasting

To date, research focused on intuitive fasting specifically is lacking. However, research supports some health benefits from both intermittent fasting and from mindfulness, two of the plans key components:

Heart disease

People with obesity who alternated days of fasting with either high- or low-fat diets reduced heart disease risk factors in a study that also showed weight loss.

Intermittent fasting diets reduced total cholesterol and bad LDL cholesterol, according to a March 2022 study.

Meditation may support heart health by changing how your heart responds to stress and by lowering high blood pressure, according to a scientific statement from the American Heart Association.

Diabetes

Intermittent fasting diets can significantly improve insulin sensitivity, the March 22 study also found. Doing so may reduce the risk of Type 2 diabetes.

Meditation had a remarkable improvement on blood sugar control for patients with Type 2 diabetes in a study that also found improved emotional well-being.

Brain health

A September 2021 review found no clear evidence of a positive short-term effect of intermittent fasting on cognition in healthy people. However, it has benefits for people with epilepsy, Alzheimers disease and multiple sclerosis in terms of symptoms and disease progression, the review noted.

Inflammation

Intermittent fasting reduces inflammation by decreasing blood levels of monocytes, cells that cause inflammation in the body, according to an August 2019 study.

Health Risks of Intuitive Fasting

Lightheadedness, constipation, dizziness, muscle cramps and headaches can result from fasting, particularly in the beginning before your body has become accustomed to it.

Who should not try this diet?

Intuitive/intermittent fasting is not for everyone. People who should not do fasting protocols include:

Women who are pregnant.

People with a history of eating disorders.

Those who are underweight.

Children, as they are still growing and developing.

People with Type 1 diabetes.

Anyone with other medical conditions, such as gout, liver, kidney or heart disease, should talk to their doctors in advance, as should anyone taking prescription medicines.

Food List for Intuitive Fasting

Foods to Eat

These are filling, nutritious foods for feeding windows:

Vegetables like leafy greens.

Fruits like berries and pineapple.

Wild-caught fish, organic beef and grass-fed chicken.

Shrimp and scallops.

Sweet potatoes and other starchy tubers.

Avocados, olives and extra-virgin olive oil for healthy fat.

Foods to Avoid or Limit

No foods are strictly forbidden, but these may affect fasting results:

Sugar or artificial sweeteners.

Pasta.

Alcohol.

Dairy products.

Gluten-containing grains like wheat, rye and barley.

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What Is Intuitive Fasting? - WTOP

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In Part 3 of the esteemed Professor Tim Noakes series on insulin resistance, Noakes tells a genuinely compelling story about the heavyweights that assisted in establishing the foundation and credibility of the low carbohydrate, high fat (LCHF) diet. One of these is Dr Robert Atkins, whose deep depression after President John F Kennedy was assassinated in 1963 was the catalyst for an overweight Atkins to decide that it was time to save his own life and immediately find a way to begin his recovery. Noakes also relays the journey undergone by Dr Eric Westman, a physician practising at Duke University Medical Centre. Westman, initially sceptical of the Atkins diet, was transformed by his observation of its success in his patients and, after a visit from Atkins, he was convinced of the safety of the Atkins diet and its ability to successfully treat obesity and Type 2 diabetes. BizNews had a hugely informative interview with Dr Westman earlier this month. Nadya Swart

ATKINS DISCOVERS THE WORK OF DRS. BLAKE DONALDSON AND ALFRED PENNINGTON

Atkins subsequent academic search introduces him to the work of two other New York physicians, Drs. Blake F. Donaldson and Alfred Pennington, both of whom had been promoting low-carbohydrate diets, Donaldson from as early as the 1920s.As Gary Taubes, who carefully researched the topic, explains, Donaldson had been working with a group of fat cardiacs in New York (7). Frustrated at their inability to lose weight when trying to eat less and exercise more, Donaldson seeks another explanation (1). By chance, he befriends a Canadian engineer who is himself a friend of the Arctic explorer Vilhjalmur Stefansson, author of a series of books describing his life among the Arctic Inuit (8-12). After they meet in New York City and Stefansson describes how the Inuit live on a purely carnivorous diet, Donaldson recalls wondering, What was I worrying about? If Stefansson could get his people (North American Europeans) to live that way, I certainly should have enough executive ability to get my patients to stick to a beautifully broiled sirloin and a demitasse of black coffee (1, p. 41).Based on the meat-only diet Stefansson had eaten for a full year during the iconic laboratory study that included himself and fellow explorer Karsten Anderson (13), Donaldson designs an identical diet of three meals a day, each of a half-pound of fatty meat, three parts fat to one part lean protein by calories. After cooking, this would provide 18 ounces of lean meat with six ounces of attached fat per day (1). The Stefansson/Donaldson diet prohibits all sugar, flour, alcohol, and starches, with the exception of a small portion of raw fruit or potato once a day.According to Taubes (7), Donaldson claims to have treated about 17,000 patients over four decades, most of whom lost two to three pounds per week on the diet without experiencing hunger. The only patients who failed to lose weight were those with a bread addiction, for which his advice was, No breadstuff means any kind of bread . They must go out of your life, now and forever. To diabetics, he admonished: You are out of your mind when you take insulin in order to eat Danish pastry.Donaldson does not publish any personal scientific research, preferring to speak only to audiences at the New York Hospital, where Pennington, a local internist, hears him speak. Impressed, Pennington tests the diet on himself and soon begins prescribing it to his patients.At the time, Pennington is employed as a company physician in the medical care division of E.I. du Pont de Nemours and Company. By 1948, the company is becoming concerned about the rising incidence of heart attack among its employees; the target of the diet prescription is the prevention and reversal of obesity in the hope that this will reduce heart-disease risk.The original dietary intervention followed the standard for the day, which called for a reduction in portion size, calorie counting, limiting the amount of fat and carbohydrate consumed in meals, and exercising more (7). The results of the original diet were predictable: None of those things worked, so instead Pennington and his team decided to test Donaldsons diet on their overweight executives.In his first publications (14, 15), Pennington reports the outcomes in 20 Du Pont executives who have lost between nine and 54 pounds at an average rate of nearly two pounds per week. Subjects ate a minimum of 2,400 calories.Notable was a lack of hunger between meals, increased physical activity and sense of well-being, Pennington writes. Although carbohydrate intake was restricted to no more than 80 calories (20 grams) at each meal, he notes that in a few cases even this much carbohydrate prevented weight loss, though an ad-libitum (unrestricted) intake of protein and fat, more exclusively, was successful (14, p. 260).Pennington subsequently writes extensively on what he learns from his clinical experience working with these patients (16-23). The model of obesity he develops includes the following:Appetite is homeostatically regulated to ensure energy intake exactly matches energy expenditure. The mechanism can be affected by (i) altered hormonal influences, as in hyperinsulinemia or through the action of the stress hormones; (ii) structural damage to the center (in the hypothalamus); (iii) conscious overeating (careless or perverted eating habits).Alterations in lipophilia, which is the theory that obesity is the result of increased fat storage in the body (and which is) presumed an active regulation of the size of the adipose deposits, rather than the mere passive response to the balance between calorie intake and output (18, p. 102, my emphasis). (This concept is first described in the English scientific literature by Julius Bauer (24): The adipose tissue is not merely a passive storing place for reserve fat, but a living and active part of the body, with its own physiologic and pathologic processes (p. 993). Lipophilia explains, for example, why hunger is stimulated by weight loss and is only restrained when the adipose fat stores are again refilled.)Fat is stored in adipose tissue, not just from ingested fat but also from carbohydrate (22), and this later process is stimulated in the presence of insulin.The oxidation of fat is impaired in the obese, a consequence of a reduced capacity to fully oxidize carbohydrates. Instead, partial (glycolytic; fermentation) carbohydrate metabolism causes blood pyruvic (and lactic) acid levels to rise. Higher pyruvic acid levels then inhibit fat oxidation in all tissues, particularly in the muscles. Thus, pyruvic acid is a metabolic regulator, stimulating fat formation and inhibiting fat oxidation (18, p. 104).Since the obese have an impaired capacity to generate energy from both carbohydrate and fat, they will be continually hungry. As a result, excessive fat storage, or obesity, would be the cause of an increased appetite, rather than the result of it (22, p. 71).Pennington states his hypothesis in the following terms: Obesity, in most cases, is a compensatory hypertrophy of the adipose tissues, providing for a greater utilization of fat by an organism that suffers a defect in its ability to oxidize carbohydrate (21, p. 68).He concludes that if obesity is due to excessive fat storage (lipophilia) directed by the fat cells themselves, then caloric restriction is a non-specific therapy that acts solely at the level of the appetite, reducing calorie consumption without addressing the disordered drive of the fat cells to store excessive amounts of fat. His solution is to promote treatment directed primarily toward mobilization of the adipose deposits, which would allow the appetite to regulate the intake of food needed to supplement the mobilized fat in fulfilling the energy needs of the body.Since incomplete metabolism of carbohydrate is the key factor preventing fat utilization, Limitation of dietary carbohydrate, specifically, as the chief source of pyruvic acid makes possible a treatment of obesity without restriction of the total caloric intake (22, p. 73). His experience with the Du Pont executives teaches him, The use of a diet allowing an ad libitum intake of protein and fat and restricting only carbohydrate appears to meet the qualifications of such a treatment (18, p. 104).The advantages of this approach include the following:Restriction of carbohydrate, alone, appears to make possible the treatment of obesity on a calorically unrestricted diet composed chiefly of protein and fat. The limiting factor on appetite, necessary to any treatment of obesity, appears to be provided by increased mobilization and utilization of fat, in conjunction with the homeostatic forces which normally regulate the appetite. Ketogenesis appears to be a key factor in the increased utilization of fat. Treatment of obesity by this method appears to avoid the decline in the metabolism encountered in treatment of caloric restriction. (19, p. 347).Pennington also notes that some patients become hungry on the low-carbohydrate diet and need to increase their fat intake (23, p. 36). He writes: Provided carbohydrate is restricted sufficiently, there does not seem to be any need to restrict fat at all . Although the emphasis has often been put on protein in constructing diets for the obese, it seems that the emphasis should be put on fat as the major source of energy, with carbohydrate restricted to the degree necessitated by the obesity defect, and ample protein allowed for its well-recognized benefits to health (23, p.36).Penningtons ideas strengthen Atkins understanding that a low-carbohydrate diet that induces ketosis and reduces hunger without requiring significant caloric restriction is the solution for his own weight problem and perhaps for many others who have a similar problem.Atkins is further encouraged by a recent publication showing that the Pennington diet reduces hunger and produces weight loss in the majority: Our results do show that satisfactory weight loss may be accomplished by a full caloric, low carbohydrate diet. The patients ingested protein and fat as desired. Careful attention was paid to keeping carbohydrate intake to a minimum (25, p. 1413).The authors continue: All the other methods of weight reduction mentioned earlier have been utilized by the author in the past. The diet discussed was found to be the most satisfactory of all these methods in our hands. Weight reduction occurred dramatically with a rapid fall early and proceeding slowly but surely (25, p.1414).Perhaps Atkins also reads the chairmans address, presented by George L.Thorpe, MD, of Wichita, Kansas, at the 106th Annual Meeting of the American Medical Association in New York on June 4, 1957 (26). There, Thorpe repeats the Pennington interpretation of how a low-carbohydrate diet induces weight loss in the obese: That the usual low-calorie diet is rarely successful is readily understood in the light of our present knowledge of carbohydrate and fat metabolism (as) the presence of carbohydrate suppresses the fat-mobilizing ability of the pituitary gland and increases the fat-depositing activity of insulin (p.1364).Thorpe says, It is possible to lose weight without counting the calorie intake, without being weak, hungry, lethargic, irritable, and constipated. There is no magic or mystery, no fancy rules to follow, and the entire program may be successfully conducted without radical change to ones normal routine but the key to long-term success is the simple return to normal eating habits. Normal eating habits might be described in technical language as adhering to a high-protein, high-fat, low-carbohydrate diet (p. 1364).Thorpe then describes how his own consumption of high-carbohydrate foods had caused him to develop a personal problem of excess weight and how, in trying to solve this personal issue, he had discovered the low-carbohydrate diet promoted by Stefansson, Donaldson, and Pennington.This information likely confirms to Atkins that the solution to his personal weight problem is the same as it was for Thorpe: a low-carbohydrate diet.THE STUDIES OF KERWICK AND PAWANAtkins finds one final piece of evidence to further support his growing conviction that he has discovered a cure for obesity. Dr. A. Kerwick and Mr. G. L. S. Pawan from Middlesex Hospital Medical School had also become disillusioned with the calories-in, calories-out model of human weight control (27-29). As they wrote, If deficiency of calories accounts for loss of weight, low calorie diets should induce the same rate of weight loss in the same patient, no matter what the composition of the diet. Manifestly they do not do so (29, p. 449).A series of their studies shows that whereas subjects eating a low-calorie (1,000 cal), high-protein or high-fat diet for seven days lost substantial amounts of weight, eating a high-carbohydrate diet resulted in little if any weight loss (28). They conclude, An alteration in metabolism takes place (in those eating low-carbohydrate diets) (28, p. 161). This alteration in metabolism apparently explains the greater rates of weight loss in those eating low-carbohydrate diets.We now know that Kerwick and Pawans conclusions are in error. Marjorie Yang and Theodore Van Itallie subsequently show that, in the short term, any differences in absolute weight losses on isocaloric diets differing in their fat, protein, and carbohydrate contents can be explained entirely by much greater water losses on the higher fat and protein diets (30). However, this applies only to short-duration studies of less than perhaps 14 days or so. The one fact established by these studies is that high-carbohydrate diets promote fluid retention, most likely as a result of an insulin effect increasing water retention by the kidneys (31).Fortunately, at the time, Atkins is unaware of this error.THE ERIC WESTMAN, MD, CONNECTIONBy the late 1960s, Atkins has converted his private medical practice to focus purely on weight loss using the low-carbohydrate diet. Although he treats tens of thousands of patients during this period, he has little interest in documenting the results of his diet prescription on their health. He is happy to be surrounded by so much clear evidence of success.In 1997, Dr. Eric Westman, a physician practising at the Duke University Medical Center in Durham, North Carolina, is becoming concerned that some of his patients have chosen to follow what had by then become known as the Atkins Diet. In particular, he is worried that the high fat content of the diet will increase his patients blood cholesterol concentrations, placing them at risk of artery clogging and heart attacks. He is initially so sceptical of Atkins dietary advice that he didnt believe Atkins actually had gone to medical school and earned his M.D. (2, p. 167).Yet Westmans patients continue to show impressive weight loss. At their suggestion, he agrees to read Atkins first book (32). He remains puzzled about how Atkins can claim success from a diet that conflicts with everything Westman has been taught in his medical training. He cant understand how, first, his patients are losing weight eating so much fat, and second, why their blood cholesterol concentrations dont seem to be reaching dangerous levels.When faced with such a paradox, the majority of physicians simply ignore it as if what they are seeing hasnt really happened. But Westman is different. He writes to Atkins, who invites him to come to New York to sit in on some patient consultations. Later, Westman recalls, I was both surprised and impressed that he actually had an office and was seeing patients. I had to see through the veneer of the book before I could actually start to believe the concept behind the diet (2, p. 169).By the end of his visit, Westman has convinced Atkins that he needs to fund rigorous scientific studies to prove to a growing body of medical sceptics that his diet is safe and can successfully treat obesity and Type 2 diabetes mellitus (T2DM).WESTMAN FINDS A LOW-CARBOHYDRATE DIET CAN PUT T2DM INTO REMISSIONWestman uses Atkins funding to undertake a six-month pilot study of the effects of a low-carbohydrate (<25 g/day) diet with no limit on caloric intake on body weight and blood lipid parameters in 51 overweight/obese healthy volunteers (33). The 41 subjects who adhere to the program lose an average of 9.0 kg (19.8 lb.) and improve all their blood parameters, including lowering their total cholesterol and LDL-cholesterol concentrations. The authors conclude rather modestly, A very low carbohydrate diet program led to sustained weight loss during a 6-month period (without any adverse effects in the 41 subjects who completed the programme).The study leads to a larger study, this time with 120 subjects, 60 of whom follow a hypocaloric low-fat diet and the other 60 a low-carbohydrate diet for 24 weeks (34). The study finds that compared with a low-fat diet, a low-carbohydrate diet program had better participant retention and greater weight loss. The authors observe, During active weight loss, serum triglyceride levels decreased more and high-density lipoprotein cholesterol levels increased more with the low-carbohydrate than with the low-fat diet (p. 769).Predictably, when the same study is presented at the American Heart Association (AHA) meeting in November 2002, the Association feels compelled to issue a media advisory that conveys its concerns with the study in the following terms:The study is very small, with only 120 total participants and just 60 on the high-fat, low-carbohydrate diet.This is a short-term study, following participants for just 6 months. There is no evidence provided by this study that the weight loss produced could be maintained long term.There is no evidence provided by the study that the diet is effective long term in improving health.A high intake of saturated fats over time raises great concern about increased cardiovascular risk the study did not follow participants long enough to evaluate this.This study did not actually compare the Atkins diet with the current AHA dietary recommendations. (35)The advisory concludes with a statement from Robert O. Bonow, MD, President of the AHA: Bottom line, the American Heart Association says that people who want to lose weight and keep it off need to make lifestyle changes for the long term this means regular exercise and a balanced diet.Bonow adds, People should not change their eating patterns based on one very small, short-term study. Instead, we hope that the public will continue to rely on the guidance of organisations such as the American Heart Association which look at all the very best evidence before formulating recommendations.This advisory echoes some of the sentiments published in the Journal of the American Medical Association 29 years earlier in a highly critical review of Atkins first book (36). The article is attributed to Philip L. White, D.Sc., Secretary of the American Medical Association Council on Food and Nutrition. White is not a trained medical practitioner.Whites relevant points include the following:The low-carbohydrate diet approach to weight reduction is neither new nor innovative (p. 1415).If such diets are truly successful, why then, do they fade into obscurity within a relatively short period only to be resurrected some years later in slightly different guise and under new sponsorship? (p. 1415).Moreover, despite the claims of universal and painless success for such diets, no nationwide decrease in obesity has been reported (p. 1415).Dietary carbohydrate, particularly sugar, is considered by some advocates to be a nutritional poison that promotes hypoglycemia, diabetes, atherosclerosis and, of course, obesity (p. 1415). the weight reduction that occurs in obese subjects who are shifted to a low-carbohydrate diet seems to reflect their inability to adapt rapidly to the marked change in dietary composition (p. 1416).There appears to be no inherent reason why body weight cannot be maintained on a diet devoid of carbohydrate if the other essential nutrients are provided (p. 1416). (Dr. White appears to have forgotten this is a discussion on diets for weight loss, not weight maintenance.)Many human populations remain lean on diets extremely high in carbohydrate (by American standards) and correspondingly low in fat. Thus, there is equally no inherent reason to associate a diet rich in carbohydrate with obesity (p. 1416).Potential hazards of low-carbohydrate diets include hypercholesterolemia and hypertriglyceridemia (p.1416-1417). (White does not realize hypertriglyceridemia is caused by high-carbohydrate diets in those with carbohydrate-sensitive hypertriglyceridemia, but he is right to note hypertriglyceridemia is a risk factor for coronary heart disease).Other potential hazards include hyperuricemia, fatigue, and postural hypotension. (Note: Postural hypotension is a benign condition and indicates that the diet is producing an overall reduction in blood pressure. This surely is good since high blood pressure is common and in most is described as essential hypertension. In other words, medicine has no understanding of what is causing the hypertension, but if a low-carbohydrate diet causes hypotension, could this not possibly be an indication of a possible mechanism for hypertension high-carbohydrate diets in persons with insulin resistance?)The assertion that carbohydrates are the principal elements in foods that fatten is, at best, a half-truth (p. 1417). White argues instead that higher rates of dietary fat intake explain the high rates of obesity in North Americans: Obesity is relatively rare in large areas of the world where the hidden sugar of rice starch comprises a very high proportion of the total daily food intake (p. 1417).White concludes: The diet revolution is neither new nor revolutionary (p. 1418). He argues the low-carb diet is simply a variant of a diet that has been promoted for many years. The rationale used to promote the diet is for the most part without scientific merit (p. 1418). The unlimited intake of saturated fat and cholesterol-rich foods may well increase coronary artery disease and other clinical manifestations of atherosclerosis particularly if the diet is maintained over a prolonged period (p. 1418). Any grossly unbalanced diet, particularly one which interdicts the 45% of calories that is usually consumed as carbohydrate, is likely to induce some anorexia if the subject is willing to persevere in following such a bizarre regimen (p. 1419). Bizarre concepts of nutrition and dieting should not be promoted to the public as if they were established scientific principles (p. 1419). Patients should counsel their patients as to the potentially harmful results that might occur because of the adherence to the ketogenic diet (p. 1419). And finally: Observations on patients who suffer adverse effects from this regimen should be reported in the medical literature or elsewhere, just as in the case of an adverse drug reaction (p. 1419).Important points missing from Whites critique include the following:He ignores evidence from North America that establishes a high-fat diet can manage T2DM (see subsequent discussion). He also ignores Penningtons work, which shows obesity can be effectively treated with this dietary intervention.He ignores opinions from Britain, especially the published work of John Yudkin, a former Professor of Nutrition and Dietetics at the University of London. Unlike White, but like Pennington (and Atkins), Yudkin had actually studied the low-carbohydrate diet in real patients and become convinced of the value of this diet for the management of obesity (37-41). Thus, Yudkin wrote in 1972: I have no doubt that in practice the low-carbohydrate diet will be found to be the most effective and, nutritionally, the most desirable for the management of obese patients (41, p. 154). In the same article, he warned of the danger of drawing conclusions from theoretical considerations rather than practical experience.White ignores the editorial by Thorpe, advocating the value of this diet in the same journal two decades earlier (26).He ignores Atkins extensive discussions of the role of carbohydrate intolerance (insulin resistance) in obesity and T2DM, as well as Atkins explanation of why the high-fat diet works in persons with this condition. White, who is not a medical practitioner and has no personal experience in the treatment of persons with obesity/T2DM, fails to appreciate that Atkins advocacy was for a diet that worked best for persons with carbohydrate intolerance/insulin resistance.Whites errors are further underscored by the absence of reports in the medical literature of adverse effects from the regimen in the 46 years since he made the plea that all such negative outcomes should be reported.None of Whites misgivings deter Westman, who negotiates with Atkins to fund another trial, this time in persons with T2DM. The resulting study finds that 21 patients with T2DM who followed the diet for 16 weeks lost an average of 9 kg (19.8lbs), reduced their blood HbA1c values by 1.2% (Figure 1), and improved all their blood markers, including reducing blood triglyceride concentrations by an average of 1.1 mmol/L (42). Seventeen of the 21 patients reduced or stopped using anti-diabetic medications, indicating disease remission or perhaps even reversal in some.

Figure 1: Changes in glycated hemoglobin (HbA1c) concentrations in 21 patients with T2DM who ate a low-carbohydrate diet for 16 weeks. HbA1c concentrations are a measure of the average 24-hour blood glucose concentrations over the previous three months. Values greater than 6.5% are considered diagnostic of T2DM. According to this measurement, 14 of 21 (67%) patients put their T2DM into remission on this eating plan. Reproduced from reference 42.

Since an HbA1c below 6.5% is considered to be the upper end of the normal range, perhaps this is the first study in the modern literature showing remission or reversal of T2DM while using nothing more than a dietary intervention. Importantly, there is no single report in the medical literature documenting T2DM remission or reversal while following usual medical care including the prescription of insulin or other medications.

For historical completeness, its appropriate to mention that Leslie Newburg and colleagues at the University of Michigan began to use a high-fat, low-carbohydrate diet to treat T2DM in the 1920s (43-49). It seems probable that among the 73 patients they reported in their first paper (43), some may have gone into remission on the high-fat diet. Indeed, their second paper (44) shows a number of patients whose random blood glucose concentrations fall below 5.5 mmol/L (0.10%), as does their third paper (45). The authors also argued that mortality in the group treated with this diet was no worse and might even have been slightly better than that for similar patients treated with the low-fat, low-calorie diet then promoted at the Joslin clinic.

In 1973, J.R. Wall and colleagues also reported the use of a carbohydrate-restricted diet produced good diabetic control on diet alone, in two-thirds of cases by the time of the second visit that is, within 2 to 3 weeks (51, p. 578). The authors main focus was not on reversal of T2DM. Rather, they wished to determine whether weight loss or carbohydrate restriction was the key to successful management of T2DM. They concluded that control of diabetes in obese patients who respond to diet alone is due to carbohydrate restriction rather than to weight loss (p. 578).

These studies show that already in the 1920s, there were those who argued that a carbohydrate-restricted diet is beneficial for the management of T2DM.

Westman and his colleagues establish this as fact, and their study shows that on a carbohydrate-restricted diet, some T2DM patients do not require medications to maintain good glucose control (42).

It takes another 13 years for a larger study to confirm these findings and bring the value of the low-carbohydrate diet for the management of T2DM to a much wider audience.

Drs. Jeff Volek, Ph.D., and Stephen Phinney, MD, are two other scientists whose research was funded by the Atkins Foundation. They undertake a number of studies of low-carbohydrate diets in different populations, ultimately focusing on changes in blood lipid profiles in those with metabolic syndrome (52-58).

The key difference between their work and Dr. Gerald Reavens is, for the reasons I will suggest in due course, that Reaven balks at studying truly low-carbohydrate diets. Instead, Volek and Phinney choose to study properly low-carbohydrate diets (<50 g/day), and in the end, that makes all the difference.

Some of the most important findings from these studies are shown in Figure 2.

Figure 2: Changes in metabolic and other health markers in person with metabolic syndrome, randomized to either a high-carbohydrate (56%), low-fat (24%) diet or a high-fat (59%), low-carbohydrate (12%) diet. Both diets were hypocaloric (~1,500 cal/day). Note that all variables show greater improvement on the low-carbohydrate diet than the low-fat diet. Data from reference 54.

The evidence clearly shows that all variables improve to a greater extent on the low-carbohydrate diet. The greatest reductions are in blood triglyceride, insulin, and saturated fatty acid concentrations, with a marked increase in blood HDL-cholesterol concentrations as well.

The authors conclude:

Restriction in dietary carbohydrate, even in the presence of high saturated fatty acids, decreases the availability of ligands (glucose, fructose, and insulin) that activate lipogenic and inhibit fatty oxidation pathways. The relative importance of each transcriptional pathway is unclear, but the end result increased fat oxidation, decreased lipogenesis, and decreased secretion of very low-density lipoprotein is a highly reliable outcome of a low-carbohydrate diet. (55, p. 309)

In their most recent study, Phinney and Volek find that these benefits can occur rapidly and are not dependent on weight loss (58). There, they conclude: Overall, this work highlights the importance of the dietary carbohydrate-to-fat ratio as a control element in Metabolic Syndrome expression and points to low carbohydrate diets as being uniquely therapeutic independent of traditional concerns about dietary total and saturated fat intakes . Based on these results, any long-term trials in participants with Metabolic Syndrome should include low carbohydrate diets (p. 11).

Phinney and Voleks studies confirm and extend Reavens findings from between 1987 and 1994 (59), and address the impact of low-carbohydrate diets on the metabolic profile and other health markers of persons with the metabolic syndrome.

Logically, Reavens group should have completed and published studies identical to these already by the turn of the last century. Why they did not is a mystery I will explain subsequently.

Certain that the low-carbohydrate diet could correct the metabolic syndrome (55) and might even reverse T2DM in some individuals (41), some time around 2014, Phinney has the opportunity to speak to recently retired Sami Inkinen, who was planning to row across the Pacific from San Francisco to Honolulu on a carbohydrate-free diet (60, 61). Phinney, together with Jeff Volek, wishes to repeat the Westman study (41) in a larger group. But Phinney and Volek need help, so they ask Inkinen if he would be interested.

Inkinen agrees on one condition: that the study becomes part of a startup tech company, the ultimate goal of which is to reverse diabetes in 100 million persons by the year 2025. And thus, the Virta Health company is founded.

By 2016, the new company has recruited 262 persons with T2DM for a five-year study using a novel model of remote care that focuses on the prescription of a ketogenic, low-carbohydrate diet with regular feedback using relevant biometric measurements of food intake, and blood glucose and insulin concentrations.

In early 2017, the results of the first 10 weeks of the intervention are published (62). They show that the ketogenic diet reduces blood HbA1c by 1% (compare with Figure 1), even though 57% of subjects have either reduced or terminated their use of diabetic medications; 56% of subjects have reduced HbA1c values to below 6.5%, the value traditionally used for a diagnosis of T2DM.

In February 2018, the results for the first year of the study are published (63)*. Average HbA1c levels were now 6.3%, down from 7.6%; average weight loss was 13.8 kg; medication use other than metformin had decreased from 57% to 30%; and 94% of subjects had reduced or eliminated insulin therapy (Figure 3).

*Editors Note: As noted on CrossFit.com on May 14, 2019, the trial to which Prof. Noakes refers was funded and run by Virta Health, a private company that sells the app used in the trial to privately insured employers; as such, the trial involves a conflict of interest similar to a pharma-funded drug trial. Additionally, the 262 subjects all chose to opt into the Virta program and were neither randomized nor blinded. Despite these issues, the significance of this trial can hardly be overstated. This trial represents the first clear, long-term evidence in a large population that a ketogenic diet, when followed properly, can lead to significant improvements in health among Type 2 diabetics, and in many cases (in this trial, the majority) even resolves diabetes completely.

Figure 3: Top Panel: Percent changes in HbA1c, fasting blood glucose and insulin concentrations, Homeostatic Model Assessment Insulin Resistance (HOMA-IR), and diabetic medication use in persons with T2DM on the Virta Health intervention (blue) compared to patients receiving standard care (gray). Bottom left panel: Absolute changes in average HbA1c levels over the first 12 months of the Virta Health intervention. Bottom right panel: Percent weight loss in T2DM patients receiving the Virta Health intervention. Reproduced from the Virta Health website.

A separate paper compared changes in cardiovascular disease risk factors in the same populations (64). With one exception (circled in Figure 4), all changes in the Virta Health group were greater and considered to be more healthy than those in the usual care group.

Figure 4: Percent changes in multiple cardiovascular risk factors measured in persons with T2DM receiving either the Virta Health intervention or usual care. All changes favor the Virta Health group, with perhaps one exception (circled) persons in the usual care group show a reduction in blood LDL-cholesterol concentrations, whereas these concentrations rose in persons on the Virta Health intervention. However, as in the studies from the Volek research group (49, 53), this change was due to an increase in the size of the LDL-cholesterol particles. This is not considered an adverse health consequence. Redrawn from reference 64.

The sole exception was the increase in blood LDL-cholesterol concentrations in the Virta Health group. However, the long-term health consequences of this change are uncertain. For example, the Framingham study, which was designed specifically to determine which biological markers might predict future health risk, established that a falling blood cholesterol concentration with age is an indicator of failing, not improving health. In that study (65), falling blood cholesterol concentrations over the studys first 14 years were found to predict an increased mortality rate over the next 18 years. The study found a direct association between falling cholesterol levels over the first 14 years and mortality over the following 18 years (p. 2176). Thus, there was an 11% overall and 14% CVD death rate increase for each 1 mg/dL per year drop in blood cholesterol concentrations. In contrast, there was a lack of an association of total serum cholesterol measured after age 50 years with overall mortality (p. 2179).

Additionally, the increase in LDL-cholesterol concentrations in persons eating a low-carbohydrate diet was due to an increase in the number of large LDL-cholesterol particles (54, 55) and was not considered harmful.

In June 2019, the two-year results of the Virta Health study were reported (66). All the benefits already apparent at one year were sustained, and 54% of participants receiving the Virta Health intervention had reversed their T2DM; another 18% were in remission. No patient in usual care showed this response. Overall medication use fell from 55% to 25% in the Virta Health group so that daily insulin use fell from an average of 89 to 19 units/day.

Another recent study found evidence of significant improvements in non-invasive markers of liver fat and fibrosis (non-alcoholic fatty liver disease) in persons receiving the Virta Health intervention and no change in the usual care group (67).

Atkins is the single strongest thread binding all those on the North American continent who have promoted the low-carbohydrate diet over the past century.

He is the link from Icelandic Arctic explorer Vilhjalmur Stefansson to the work of the Virta Health company, guided by Finnish entrepreneur and ultradistance athletic explorer Sami Inkinen.

Most importantly, the definitive studies of Westman, Phinney, and Volek, together with those performed by the Virta Health company, prove that Atkins was correct.

So when the 100-millionth patient with T2DM is reversed by the Virta Health intervention sometime before 2025, Atkinss legacy will become one of the most significant in the history of modern medicine.

But what of Reaven? What will be his monumental contribution? How will he be remembered?

We take up that story next.

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No one wants to see their child sick, even if its just temporary. For example, the occasional upset stomach or diarrhea is expected if your child is home with stomach flu or eats something that doesnt agree with them. And often, the solution is simple eliminate troublesome foods or recover from the stomach flu.

But sometimes, you might suspect that theres something more going on. So, how do you determine that theres a more serious bowel or digestive problem with your child, and how do you work toward a long-term solution?

Lets look at some of the most common bowel problems that are found in children and their symptoms. Well also discuss treatment options and when you should contact a doctor or healthcare provider.

Digestive and bowel discomfort is quite a large health category, with many temporary or underlying causes that might be contributing to your childs tummy woes. But ultimately, you know your child better than anyone. So, if you see the following persistent symptoms, it might mean your child has a more serious digestive or bowel issue.

To receive a diagnosis of constipation, your child must be 4 years old or older and exhibit at least two or more of the below symptoms and experience them once a week for at least 2 months. Common symptoms include:

While uncomfortable, irritable bowel syndrome (IBS) isnt life threatening for your child, nor does it cause them additional health problems or digestive tract damage.

Symptoms of IBS include:

Inflammatory bowel disease (IBD) is another type of intestinal disorder that can cause inflammation in your childs digestive tract. Common forms of IBD include Crohns disease and ulcerative colitis.

Common symptoms include:

Unlike IBS, if left untreated IBD can create further complications such as bowel obstruction, malnutrition, and fistulas, and in more severe cases, it can contribute to colorectal cancer.

Hirschsprungs disease is a condition that impacts the large intestines. While its always present at birth, it can sometimes take a while for symptoms to appear. Children with Hirschsprungs disease may have trouble emptying their bowels. Symptoms can vary depending on your childs age.

Symptoms in newborns:

Symptoms in toddlers and older children:

While some formal diagnoses, such as constipation, wont be applied until certain timelines have been met, that doesnt mean that you cant see a pediatrician, or a doctor for infants and children, before then. For example, with constipation, if your childs symptoms and inability to pass stool have persisted for more than 2 weeks, youre encouraged to see a doctor.

And especially if your childs symptoms begin to get worse such as developing a fever, losing weight, or refusing to eat dont delay scheduling your child an appointment with a physician to start the diagnostic process and work toward a treatment plan.

The diagnostic process used to determine if your child has a bowel problem is going to depend on what disease or condition is suspected.

For example, childhood IBS and IBD both rely on a physical exam and a review of medical history (including family history). Depending on the results of initial reviews, a pediatrician may order a blood test, stool test, ultrasound, or even an endoscopy or colonoscopy.

Meanwhile, a suspicion of constipation will include a medical history and physical exam. It may sometimes also require other tests, such as a barium enema X-ray, abdominal X-ray, and even a motility test, if other conditions need to be ruled out, but often a doctor will be able to diagnose constipation without further tests.

A barium enema is also a primary tool for diagnosing Hirschsprungs disease, but a biopsy may also be necessary for this condition.

If youre concerned that the diagnostic process may be stressful for your child, make sure to talk with a doctor or pediatric team so you can know exactly what their testing process will be like.

Similar to diagnosing bowel problems, treatment methods can vary depending on your childs condition and the severity of it.

While constipation in children is very common, its also often undiagnosed and untreated. For many children, constipation can be treated at home by boosting fiber in their diet, increasing water intake, and encouraging more physical activity. With a doctors supervision, stool softeners or laxatives may be occasionally used.

IBD requires a comprehensive approach to treatment that incorporates both medication and dietary changes. The overall goal is to relieve symptoms and prevent future flare-ups to heal the intestines.

If an infection is suspected, your child might be prescribed antibiotics. But other treatments can include:

To treat IBS, nutritional changes are frequently encouraged, along with possibly being prescribed probiotics to help balance your childs gut. A doctor may also prescribe a range of different medications depending on their symptoms.

Depending on the type of IBS, your child may be prescribed medications to treat associated conditions such as constipation or even antidepressants depending on how severely the condition is impacting your childs quality of life.

Due to the seriousness of Hirschsprungs disease, surgery is the most effective method for treating the condition. Depending on the severity of their condition, children may either undergo one or two surgeries to remove the unhealthy part of their colon and treat the disease.

Although some bowel conditions arent life threatening, they can impact your childs quality of life. For example, conditions such as IBS which usually dont cause more concerning medical conditions can cause children to miss out on social events, or to even find it difficult to be present in school. This can negatively impact your childs mental health.

Meanwhile, if left untreated, other conditions can act as precursors to more serious health complications. Even constipation, which is incredibly common in children, can manifest into bladder control issues, fecal impaction, hemorrhoids, rectal prolapse, and even anal fissures.

Untreated IBD can lead to painful ulcers and damaging bowel inflammation. Additionally, it has been known to also cause rashes, arthritis, eye and liver problems, and slow growth and delayed puberty.

Because Hirschsprungs disease already prevents children from properly passing stools, leaving it untreated can be life threatening and lead to toxic enterocolitis.

Regardless of the source of your childs gastrointestinal distress, its important to get a treatment plan established with a doctor as soon as you can.

Sometimes an upset stomach or a case of diarrhea is temporary, and at other times it might be more serious. These bowel problems in children can be caused by a variety of conditions, some of which can lead to more health problems if not dealt with.

If you suspect that your childs tummy issues might be something more, be proactive and reach out to a pediatrician. When caught early, treatment can prevent further long-term problems that would impact your childs quality of life.

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Bowel Problems in Children: When It's More Than an Upset Tummy - Healthline

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