Carbohydrates and the Tragic Low-Carb Legacy of Dr. Atkins

Carbohydrates - what are they?

Last week we both talked a little bit about carbohydrates and their role in the body. Today I am going to expand a bit on that.

Carbohydrates are molecules that consist of carbon, hydrogen and oxygen in different proportions. They are classified based on their structure, and the main classifications are monosaccharides, disaccharides, oligosaccharides, and polysaccharides. These are also divided into more commonly known categories - which are simple and complex carbohydrates. The difference between these two categories is based on their structure, how quickly they are digested and how quickly they are absorbed into the system.

Simple carbohydrates are often called simple sugars and are made up of mono- and di-saccharides. Monosaccharides include glucose, fructose and galactose; and these are the most basic simple sugars. Then we have disaccharides, which are essentially made up of two monosaccharides. They include sucrose (aka table sugar), maltose and lactose.

Complex carbohydrates, on the other hand, are polysaccharides, meaning they consist of even more saccharides and take even longer to digest. They are also known as “starch” or “dietary fibre”. Some examples are whole grains, fibre-rich fruit and veggies.

With the exception of insoluble fibre, some sugar alcohols and the monosaccharides (which includes glucose), most of the other carbohydrates are broken down to get the glucose and turned into energy through a process called glycolysis. One gram of carbohydrates equates to 4 kilocalories of energy. One kilocalorie is the amount of energy in the form of heat that is needed to raise the temperature of a kilogram of water by 1 degree C. (Diabetes Co UK, 2020).

One fun fact about carbohydrates is that they start to breakdown in the mouth. There is an enzyme called amylase that is excreted by your salivary glands that starts to break up the starch as soon as the food is in your mouth.

You have likely also heard about refined carbohydrates, which are simply carbs that have been stripped of one or more of their components and are no longer considered “whole grains”. A whole grain consists of the bran, germ, and endosperm of the plant, so a refined grain is stripped of one or more of these things. With that, they are often stripped of their fibre and some nutrients as well. The starch, however, is left behind, which gets absorbed much more quickly in the body without the slowing digestive effect of fibre. Refined carbohydrates can sometimes be referred to as processed carbohydrates. HOWEVER, it is good to keep in mind that almost all of the foods that we eat are processed to some degree - whether it be through cooking, baking, freezing, even cutting is technically considered a processing method. The term “processed” has received a bad rep, when in reality people are usually referring to “ultra-processed” foods when they refer to refined or processed products.

Ultra-processed foods have undergone multiple processing methods to manipulate the food product. For example, the process to make chips is as follows: potatoes are picked, stored in temperature controlled environments, washed, peeled, sliced, washed again, fried, salted or flavoured and packaged (Ontario Potato Board, 2020).

So, unless you are eating fruit and veggies directly from their source, your carbohydrates, and food for that matter, have been processed at some capacity.

Overall, carbohydrates are fundamental to human life; we wouldn’t be able to live without them. If you cut carbs from your diet, your body may experience hypoglycemia, which is low blood sugar. Mild symptoms include the shakes, hunger, headaches, confusion, and dizziness; more severe symptoms include seizures or unconsciousness (U.S. Department of Health and Human Services, 2016). Despite how important carbs are, diet culture has been demonizing them for centuries.

Low-carb diets and the science behind them

One of the first instances of implementing a low-carb diet was in the late 1700’s, when a Scottish military surgeon placed individuals with what is now known as type II diabetes on a “meat diet” only to find that it helped improve their condition. A low carb diet was a common treatment for diabetes in the 1800’s (Morgan, 1877). Make note, with type II diabetes, you want to manage your blood sugar levels rather than eliminate carbohydrates entirely. Today, the nutrition therapy for diabetes is a bit more complex than simply cutting carbs, but its WAY more effective.

Another historical instance of a low-carb diet was famously uncovered in 1862, when William Banting, a notable English undertaker, was “so overweight he couldn’t tie up his own shoes” and went to his doctor, Dr. William Harvey, because he was having trouble hearing. The doctor said “your problem isn’t deafness, your fat is pressing on your inner ear” - and so Dr. Harvey put him on a low carb diet that included “no beer, no sugar in your tea or coffee, daily meat, no potatoes, and ‘the fruit of any pudding ‘so long as he didn’t touch the pastry’; and at dinner, he was to have 2-3 glasses of good quality sherry, claret, or madeira and a night cap if required of whisky, gin [or] brandy”. This diet was so successful that Banting wrote “A Letter on Corpulence: addressed to the public” where he describes his diet in detail, his 100 pound weight loss, and - if you can believe it - how his hearing improved. SOURCE

The low-carb diet made another notable appearance in the 1920’s when it was found that consuming fewer carbs could help patients with epilepsy by reducing the frequency and severity of their seizures. There is even a reference in the New Testament where Jesus cures a child with epilepsy through prayer and fasting (New Testament, Matthew 17:14–21). This diet is what we know as the ketogenic diet today. The objective of this diet, whether used as treatment for epilepsy or used by individuals hoping to lose weight, is to enter the metabolic state of ketosis. Ketosis occurs when carb intake is very low and the body (which is lacking it’s preferred form of energy, aka glucose) is forced to burn fat for fuel instead, which creates ketone bodies that are used for energy. SOURCE

The logic behind this diet as a treatment for epilepsy is still somewhat unknown, but many hypotheses have tried to explain why this works. My favourite hypothesis is that an increase in ketone bodies reduces neural excitability and therefore reduces the frequency and severity of seizures. This diet is still used as treatment for epilepsy to this day, however, it is usually only used in children when medication is not effective (Paoli, Rubini, Volek & Grimaldi, 2013). 

So why might this type of diet be effective for weight loss? Other than the fact that it forces the body to burn fat as fuel, studies show that those on a low carb diet are typically ingesting the same amount of calories as calorie restricted diets, but that the dietary protein helps the dieter feel satisfied and full. Also, protein has a greater thermogenic effect than carbohydrates simply because high protein foods are less efficient - so they are harder to break down than carbohydrates.

While there is very little consistency on what defines a “low-carb” or ketogenic diet, it typically includes limiting carbohydrates to 5-15% of all energy consumed; versus the recommended 45-65% by the Dietary Guidelines for Americans. Having less than 50 grams per day will cause glycogen depletion (glycogen is the stored form of glucose) and ketone production from the breakdown of fat.

A big part of the rapid weight loss that occurs at the beginning of carbohydrate restriction is attributable to the loss of glycogen and water, since every gram of stored glycogen has approx 3-4g of water associated to it. SOURCE

The ketogenic dieter will want to be careful though, because if the fat content in your body is not high enough, your body may begin metabolizing proteins. And what does protein make up? Muscles, bones, skin, etc. You want to make sure you have enough of that.

There are some studies that suggest that the ketogenic diet “may affect skeletal muscle hypertrophy” (Paoli, Cancellara, Pompei & Moro, 2019). Other research has expressed concerns regarding kidney function when it comes to a low-carb, high-protein diet (Oh, Gilani & Uppaluri, 2020).

Thank you for that perfect intro to today’s story! Becca, as a child of the 90s’, I’m sure you’ve heard of the Atkins diet? Did you ever know anyone who did the Atkins diet?

I had a boss who would do the Atkins diet semi-regularly and her weight would drop pretty quickly and she would eat hot dogs everyday for lunch. 😐

Okay, so what exactly is the Atkins diet? 

The Atkins diet is, quite simply, a low-carb fad diet. Now, unless you live under a nutritional rock, you’ve probably heard about another low-carb diet that is everywhere these days - the ketogenic diet. Atkins is to the 70s/80s/90s what keto is to fad dieters today - a fad diet that emphasizes animal-based products and can result in rapid weight loss, with a cult following and a fair amount of controversy.  Today I’m going to focus solely on the Atkins diet, starting with a little bit of background information. There are different phases of the Atkins diet based on how much weight you intend to lose, your lifestage, and how restrictive you want the diet to be. All forms of the Atkins diet are focused on restricting carbohydrates by tracking your net carb consumption (total g of carbohydrates - total g of fibre - total g of sugar alcohols, so it’s really a measure of the carbs that we’re absorbing in the body because we don’t absorb fibre or most sugar alcohols) and the focus is on eating protein fat and some vegetables. The Atkins diet skyrocketed to popularity through the 70s/80s/90s as a diet that promised weight-loss without hunger, as you could freely enjoy foods high in protein and fat as much as you wanted, as long as you limited those carbs. 

Despite its popularity and success, there is actually no strong evidence that the Atkins diet can help dieters achieve sustainable weight loss and there are studies that suggest it may increase the risk of heart disease and possibly of atrial fibrillation (irregular heart beat), however, there are also plenty of studies that suggest the exact opposite that they are effective for weight loss and improve cardiovascular factors. At present, there is not enough evidence to suggest low-carb diets have a significant advantage over other types of diets. Also, it’s important to note that restrictive fad diets can also impact the way dieters view food and give them a warped sense of what is a “good” food or a “bad” food. And I believe that the Atkins diet made people scared of carbs - people think carbs are unhealthy, to the point where bread or pizza or pasta become stressful foods and people might feel guilty about eating them, and that’s not okay because carbohydrates are not bad - there are just many different forms and balance is key. 

So, the Atkins diet was a very popular diet with the public from the start, but it also always had its opponents, and it became even more controversial after the tragic demise of it’s creator - Dr. Robert Atkins. 

Dr. Robert Atkins was born in 1930 in Ohio, and as a young person he actually thought about being a comedian and he worked on a local radio show and as a server and entertainer at various resorts. He eventually settled on medicine and specialized in cardiology and opened up a private practice in New York. Apparently, the practice struggled at first and Atkins began to put on some weight himself and this led him to research nutrition and he decided to pursue a low-carbohydrate diet based on the research of some of his predecessors, like William Banting. 

Now, decades after William Banting’s Letter of Corpulence, we find ourselves just after WWII, at an American chemical firm called DuPont where there are concerns that the  executives are gaining weight and becoming obese. They hired Dr. Alfred Pennington to help them out because the calorie restriction they were trying just wasn’t working. (Should have hired a dietitian). Dr. Pennington comes to the conclusion that William Banting was right, carbs are the problem here, and they end up going on a low-carb diet and they all lose weight ~22lbs each. I’d love to see a 2-year follow up. 

This research inspired Dr. Atkins to create and share his own low-carb diet - the Atkins Diet. In 1972, he published his first book, Dr. Atkins' Diet Revolution, and over the next 3 decades the Atkins diet became immensely popular. Fast forward to 2003, that’s 31 years later - Dr. Atkins has had great financial success, multiple other books and different iterations of the Atkins diet with over 30 million readers, and great popularity with the general public, Dr. Robert Atkins fell on the sidewalk in front of his Atkins Center for Complementary Medicine and he hit his head. He was admitted to the hospital and remained in a coma for 9 days, before passing away on April 17, 2003. The cause of death was determined by the NY Medical Examiner to be “blunt injury of the head with epidural hematoma”. And from what I read, this is not an uncommon occurrence when there is a head trauma. 

Now, Atkins had been a controversial figure throughout his life, and he followed his own diet advice, so he was not stranger to having his personal health being scrutinized by critics. But what happened after his death could be characterized as a smear campaign and many of his advocates, including other doctors and his beloved wife Veronica Atkins, rushed to his defence. According to the New York Times, the mayor of New York at the time, Michael Bloomberg, was overheard expressing his skepticism about the circumstances of Dr. Atkins's death - saying basically that it wasn’t it the fall that killed him - and went on to describe him as fat, and then allegedly, Mayor Bloomberg described a fund-raiser he had attended at the Atkin's home, and he said he found the food so inedible that took one appetizer and had to spit it into his napkin. So why would the mayor of New York be talking shit about a recently deceased man?

Well, more information came to light when nearly a year after Dr. Atkins passed away, the Wall Street Journal published information from his personal medical report. 

The report bad sent to the Wall Street Journal by the Physicians Committee for Responsible Medicine, which is a group that advocates for a plant-based diet and has long been critical of the Atkins approach, and they should NEVER have had access to Atkins personal medical report. Only the treating physician or next of kin should have access to this report, and it looks like the city medical examiner's office simply made a mistake when they gave out this report. The office received a request for Dr. Atkins's medical report from Dr. Richard Fleming of the Fleming Heart and Health Institute and a member of the records staff mistakenly mailed it out. Dr. Fleming then provided the report to the Physicians Committee for Responsible Medicine, who released it to the Wall Street Journal. 

The report indicated that Dr. Atkins had a history of heart attack, congestive heart failure and hypertension, and also says that at his death Dr. Atkins weighed 258 pounds. Given that Dr. Atkins was 6 feet tall, this would have placed him in the “obese” BMI category. 

Dr. Stuart Trager, chairman of the Atkins Physicians Council in New York, stated that Dr. Atkins's heart problems were actually related to a condition called cardiomyopathy, which resulted from a virus - which is a thing, viral infections can cause an acute inflammation of the heart muscle. This would mean that his heart problems for the most part weren't from the kind of cardiovascular disease that could be related to his eating habits.

"He had no record of having a heart attack," Dr. Trager said. "My understanding is that he had no reported true evidence of classical angina" “He did have a history of irregular heart beats." - remember earlier, some limited evidence suggests that low-carb diets may increase risk of atrial fibrillation. 

Now, in terms of his weight, both Dr. Stuart Trager and Veronica Atkins attributed some of Dr. Atkins' weight to his being severely bloated with fluid while in the coma. In fact, his weight was 258 at death but upon admittance to the hospital 9 days prior, he weighed 64 pounds less at 195lbs which would have put him at the lower end of the overweight category. 

Veronica Atkins was quoted by NBC News as saying “My husband was so bloated. He had very slender hands. And when he was in this bed, his hands were like ham hocks, this big. He was bloated, he did look like a balloon.”

The family declined to perform an autopsy, which only caused suspicion to grow that the family was hiding something, but the examiners office did conduct an external examination based on the hospital information. Handwritten comments in the medical-examiner report say that Dr. Atkins had a history of "MI," meaning myocardial infarction, the medical term for heart attack, as well as "CHF" (congestive heart failure) and "HTN" (hypertension). Dr. Stuart Trager says that medical history on examiners reports is often written by less experienced doctors who may not know a patient's detailed history.

Veronica Atkins was furious that her late husbands "personal medical history" was made public. "I have been assured by my husband's physicians that my husband's health problems late in life were completely unrelated to his diet or any diet."

Dr. Patrick Fratellone treated Dr. Atkins from 1999 until 2002, and also worked with the doctor at the Atkins Center. He says Atkins suffered from cardiomyopathy, a chronic heart weakness. But this condition, he says, was caused by a virus not his diet.

Dr. Fratellone was quoted by John Hockenberry at NBC: “I was his attending cardiologist at that time. And I made the statement… When we did his angiogram, I mean, the doctor who performed it, said it's pristine for someone that eats his kind of diet… Pristine, meaning these are very clean arteries. I didn't want people to think that his diet caused his heart muscle – it was definitely a documented viral infection.” Dr. Fratellone: “The man slipped on the ice and had a head injury, so he died. Don't blame his diet.”

Both Veronica and Dr. Trager maintain the position that the Physicians Committee for Responsible Medicine is trying to sabotage Dr. Atkins reputation to promote their own agenda. Now, I did some lateral research to evaluate the credibility of the Physicians Committee for Responsible Medicine - which sounds pretty official, does it not? Ethical? Physician focussed?

The Physicians Committee Responsible Medicine was founded by Dr. Neal Barnard, but contrary to its name, it’s not actually a physician committee - it’s an animal rights group that promotes a plant-based diet, preventive medicine, and alternatives to animal research, and they have been in conflict with the AMerican Medical Association a couple of times. Apparently it has about 150,000 members, but only around 12,000 are physicians, <10%. Dr. Neal Barnard, the founder of PCRM, was quoted by NBC as saying ““The Atkins Website says that his good health and his clean coronary arteries were apparently due to his diet.  An extraordinary claim.  And apparently one that was not at all true. This is not a joke. This is serious business. This is a major public health problem.”

Now, I didn’t see any claims like that on the Atkins website, but it’s entirely possible that they’ve been removed since this whole thing happened. 

Now it would be a major public health issue, in theory, but there is not strong evidence to suggest that a low-carb diet is DANGEROUS and there are millions of people who have followed the Atkins diet. About the Physician Committee for Responsible Medicine, Dr. Trager  says “Here's a group of people who compare eating cheese to heroin, feeding children meat to child abuse. They don't think anyone should eat animal products. And it's clear they'll go to any extreme, any extreme, including giving out records, breaking ethical violations to try to convince people.”

So we’ll probably never know what actually killed Dr. Robert Atkins, but as we know Becca, from years of studying nutrition and the social determinants of health, it is very challenging and borderline impossible to pinpoint one specific cause of health issues  when it comes to non-communicable disease. Even if it was a heart issue that caused Dr. Atkins’ death, it could have been due to a virus, genetic reasons, arterial injury in his childhood, there are so many other factors at play that it would be very challenging to attribute it solely to his diet. 

Veronica Atkins, Dr. Atkins beloved wife, demanded an apology from Mayor Bloomberg for his insensitive remarks, and she got one. She was also quoted as saying “I would say please read the studies. I will devote my life to prove that he was right. I'm going to prove it scientifically. I will not let anything, anybody, denigrate my Bobby.”

So, we’ll never know how Dr. Robert Atkins died, and in my opinion it doesn’t matter because you can’t determine if a diet is effective or safe based on the experiences of one patient - it would be the worst research study of all time, it’s the equivalent of a personal anecdote. There has been plenty of research on low carb diets that show they can be safe in the short term and can result in short term weight loss. 

So what’s the take home message here?! 

The message I - as a future RD - want to make clear here, especially because we’re at the start of a new year, is that you don’t have to embark on a new diet just because it’s the new year. The way you eat doesn’t need to have a name. You can just eat a normal, healthy, balanced diet that includes all the food groups and meet your health goals.

Another take home message is that carbs can be your friend. Really, truly. Low-carb diets have not been shown to be more effective and more sustainable than other dietary patterns, and - in my opinion - you know what’s better than low-carb? Having some carbs and finding a balance that works for you. So if you want to set some realistic goals for the new year, I suggest finding a registered dietitian in your area!