Good Calories, Bad Calories (75 page)

Meanwhile, these nutritionists would readily admit that they didn’t know what caused obesity (why some people ate too much and others didn’t) and that calorie restriction conspicuously failed to cure it. After nearly twenty years in the field, as Jean Mayer wrote in the introduction to his 1968 monograph, Overweight, he was “as aware as any man of the gigantic gaps in our knowledge—and of the likelihood that many of our present concepts may be erroneous.” He also noted, in his discussion of hormonal influences on obesity, that insulin “favors fat synthesis” and that someone who over-secretes insulin could “tend to become hungry as a result.” But when a physician suggested publicly, as Atkins did, that carbohydrates raised insulin levels, that insulin favors fat synthesis, and that a diet lacking carbohydrates might reverse this process, these nutritionists would denounce it, as Mayer himself did in 1973, as “biochemical mumbo-jumbo.”

With the publication of Dr. Atkins’ Diet Revolution and its subsequent censure by the American Medical Association, the nature of the professional discussions on carbohydrate-restricted diets turned from their clinical utility to the reasons to avoid them. The actual science suddenly mattered less than ever.

Atkins was a Cornel -trained cardiologist. Between 1959 and 1963, coinciding with the early years of his practice in Manhattan, he gained fifty pounds.

He eventual y decided to try carbohydrate restriction, he said, “because that’s what was being taught at the time.” His attempt coincided with the 1963

publication in JAMA of a lengthy article by the University of Wisconsin endocrinologist Edgar Gordon, entitled “A New Concept in the Treatment of Obesity.” Gordon was one of the few clinicians of that era who studied fat metabolism and then designed a diet based specifical y on that science.

Gordon’s diet, as described in JAMA, began with a forty-eight-hour fast—“not to produce a spectacular loss of weight, but rather to break a metabolic pattern of augmented lipogenesis”*123 —and then al owed protein and fat as desired but limited carbohydrates to minimal fruits, green vegetables, and a half-slice of bread every day. “The total caloric value is quite high in terms of reducing diets,” wrote Gordon. Atkins later said his attention was caught by Gordon’s observation that his subjects lost weight without ever complaining of hunger.

In his diet, Atkins replaced the two-day initiatory fast with a week or more of complete carbohydrate restriction, under the assumption, as the Atlanta physician Walter Bloom had noted, that the two states were physiological y identical. Atkins said he lost twenty-eight pounds in a month and felt energized in the process. In 1964, while Atkins was personal y reaping the benefits of his diet, he was also working part-time as a company physician with AT&T.

The junior executives noticed his weight loss, so he told them about the diet. Sixty-five of them eventual y tried it, as Atkins told it, and al but one reduced to their desired weight. The sole exception wanted to lose eighty pounds but lost only fifty.

Atkins then started treating obese patients out of his cardiology clinic and developed the diet as he came to prescribe it in his book. He instructed his patients to start off with an initiation period, eating no carbohydrates other than a smal green salad twice a day. Once they were losing weight at a suitably rapid rate, they could begin adding smal amounts of carbohydrates back into their diet until they reached what he cal ed the critical carbohydrate level, when their weight loss either leveled off or could no longer be maintained. Then they would have to back off again on the carbohydrates to experience further benefit from the diet. He also had them check their urine for ketone bodies—with the same ketosticks used commonly by diabetics—to ensure that they remained in ketosis and were stil burning body fat. The reliance on ketosis to initiate and maintain weight loss, and the progressive addition of carbohydrates to the diet, are what Atkins considered his contributions to the clinical science of carbohydrate restriction.*124 His career as a diet doctor grew slowly until 1966, when the women’s fashion magazines began recommending his diet, and his business boomed. After Vogue popularized the diet in 1970, Atkins set out to write Diet Revolution, which was then advertised as “the famous Vogue superdiet explained in ful .”

The gist of Dr. Atkins’ Diet Revolution can be distil ed down to three assertions. The first is that weight could be lost on his diet without hunger, and perhaps without even restricting calories. Atkins said that his patients regularly lost weight eating three thousand calories a day, and that he had one three-hundred-pounder who reduced significantly while eating five thousand. His only explanation was that obesity is caused by the kind of calories we consume and not the quantity, and so if we avoid carbohydrates our bodies function correctly and shed any excess weight. He attributed the absence of hunger to the copious calories, the ketosis (which is probably not the case), the effect of insulin on blood sugar—al overweight people “produce too much insulin,” he wrote, and that lowers blood sugar and makes people hungry—and the secretion of what the British clinicians Alan Kekwick and Gaston Pawan had cal ed fat-mobilizing substance. (Virtual y al hormones, with the exception of insulin, wil mobilize fat from adipose tissue, but none of them wil do so effectively when insulin is elevated.)

Atkins’s second claim was that his diet was inherently healthy, much more so than a low-fat diet, because refined carbohydrates and starches, not saturated fat, caused heart disease and diabetes. Atkins later said that Peter Cleave’s Saccharine Disease had been a revelation to him. In Diet Revolution he discussed the research from Yudkin, Margaret Albrink, Robert Stout, and Peter Kuo implicating triglycerides as a more significant risk factor for heart disease than cholesterol. He also claimed, on the basis of his experience with “ten thousand” overweight patients, that cholesterol “usual y goes down” on his diet, despite the high saturated-fat content, and that triglycerides invariably decrease.

His third claim was what he cal ed the “cruel hoax” of calorie-restricted diets: “The balanced low-calorie diet has been the medical fashion for so long that to suggest any alternative invites professional excommunication,” Atkins wrote. “Yet even most doctors admit (at least privately!) the ineffectiveness of low-calorie diets—balanced or unbalanced.” Atkins supported his accusation by invoking Albert Stunkard’s 1959 “comprehensive review of the thirty years of medical literature,” and offering three reasons why calorie-restricted diets inevitably fail. First, they “don’t touch the primary cause of most overweight,” which is a “disturbed carbohydrate metabolism.” They also fail because they reduce energy expenditure. “Dr. George Bray,” he wrote, “has demonstrated that people on low-calorie diets actually develop lower total body energy requirements and thus burn fewer calories.” (Although Atkins didn’t say so, this research had led Bray himself to publish an article entitled “The Myth of Diet in the Management of Obesity.”) And, final y, Atkins wrote,

“The main reason low-calorie diets fail in the long run is because you go hungry on them…. And while you may tolerate hunger for a short time, you can’t tolerate hunger al your life.”

Had Atkins wanted to avoid professional excommunication, he might have published something other than a polemic couched as a diet book. But he was feeling “resentment,” he wrote, “that [he] had been duped so long by misinformation given me in the medical literature.” The Diet Revolution was not just advocating a way to lose weight, which Atkins credited, in any case, to Banting, Pennington, Kekwick, and Pawan, but overthrowing the current nutritional wisdom entirely. Unlike Irwin Stil man, whose 1967 mega–best-sel er The Doctor’s Quick Weight Loss Diet was also based on carbohydrate restriction, Atkins wanted “a revolution, not just a diet.” “Martin Luther King had a dream,” Atkins wrote. “I, too, have one. I dream of a world where no one has to diet. A world where the fattening refined carbohydrates have been excluded from the diet.” Atkins deliberately portrayed his diet as diametrical y opposed to the growing orthodoxy on the nature of a healthy diet. Whereas Keys had insisted that the solution to obesity was to convince fat people that overeating was a sin and overeating fat would kil them, Atkins said his patients lost “thirty, forty, 100 pounds” eating “lobster with butter sauce, steak with Bearnaise sauce…bacon cheeseburgers….” “As long as you don’t take in carbohydrates,” Atkins wrote, “you can eat any amount of this ‘fattening’

food and it won’t put a single ounce of fat on you.”

Diet Revolution may have been, as its publisher claimed, the fastest-sel ing book in history. Nonetheless, its “chief consequence,” as John Yudkin noted in 1974, may have been “to antagonize the medical and nutritional establishment.” In fact, Atkins had to antagonize only a very smal and select group of men to have a profound and lasting effect on how we think about obesity and weight regulation. In obesity research, particularly in the United States in the 1970s, the established wisdom was determined not by any testing of hypotheses or even establishing of consensus but by the judgment of fewer than a dozen men who dominated the field: Jean Mayer, Fred Stare, Jules Hirsch, George Bray, Theodore Van Ital ie, Albert Stunkard, George Cahil , Philip White, and perhaps a few others. (And when these men began to retire from the scene in the 1980s, their younger col eagues—Johanna Dwyer, who received her Ph.D. with Mayer; Francis Xavier Pi-Sunyer, who col aborated with Van Ital ie; Kel y Brownel , who worked and studied with Stunkard

—assumed the leadership and perpetuated their beliefs.)

When these men came of age in their careers, in the 1950s and early 1960s, obesity research was a new and expanding field of science. It had been reinvented in the United States after World War I , and the National Institutes of Health was just beginning to provide money for research. These men fil ed the expanding vacuum. They al came out of the Northeastern academic corridor—Harvard, Yale, Columbia, Rockefel er, the University of Pennsylvania

—and they al knew each other. Van Ital ie befriended his classmate Stunkard on their first day of medical school at Columbia; he then went to work with Mayer at Harvard and enlisted Stunkard’s help to test Mayer’s theory of hunger, and so Stunkard got to know Mayer as wel . Philip White received his doctorate with Mayer at Harvard and remained in Stare’s department until 1956, when he became secretary of the American Medical Association’s Councils on Foods and Nutrition and wrote an influential nutrition column for JAMA. Van Ital ie then became a member of White’s council and initiated its 1973 public condemnation of Atkins and al similar carbohydrate-restricted diets. White edited the article. If you weren’t in the club, you had little influence.

(“The Mississippi River is very deep, or at least it used to be,” is how the biochemist and diabetologist Gerald Grodsky of the University of California, San Francisco, described the inability of West Coast investigators to influence medical wisdom in the 1960s and 1970s.) These individuals became the field’s “leading authorities,” as the newspapers would cal them. They hosted the conferences, edited the textbooks, chaired the committees, and determined research priorities. By the end of the 1970s, they had determined what clinicians and researchers in the field would believe, at least in the United States, and what they stil believe overwhelmingly. When McGovern’s committee held its post-facto hearings in February 1977 to address the Dietary Goals for Americans, only members of this club testified on obesity*125 (Mayer had been the committee’s consultant), and they al embraced the committee’s recommendation of a national diet richer in carbohydrates and poorer in fat. Although Van Ital ie also testified that he was unaware of any research to support their opinions: “Thus, what I am saying is an assumption rather than a statement of established fact,” he acknowledged.

None of these authorities actual y specialized in the clinical treatment of obesity except Stunkard, who did so as a psychiatrist treating an eating disorder. Nor were they necessarily the best scientists in the field. Fred Stare and Philip White never studied obesity at al . Cahil ’s research on fat metabolism and fuel partitioning was seminal, but he didn’t see why it should be relevant to human obesity. Stunkard’s primary contribution to obesity research through the 1970s was his observation that the obese rarely lose weight on diets, and if they do, they don’t keep it off. But he never noted, and as a result neither did anyone else, that the only dietary studies he addressed in his seminal analysis were of semi-starvation, so what he had confirmed was that semi-starvation failed, not that al diets did.

Van Ital ie and Bray deserve a disproportionate share of the responsibility for effectively removing the concept of the fattening carbohydrate from the nutritional canon, and thus the carbohydrate-restricted diet as wel . Virtual y everything we believe about what constitutes an effective weight-loss diet can be traced back to the 1970s and the efforts of these two men.

Before Van Ital ie decided to write what he cal ed the AMA-sponsored “denunciation” of Atkins in 1973, his only substantive involvement in the science of obesity, as either a researcher or a clinician, was his work with Mayer twenty years earlier. In the intervening years, he had worked on intravenous feeding of hospital patients and dietary influences on cholesterol, among other subjects, but he returned to the subject of weight in 1971, only when one of his post-docs developed an interest in the subject. This led to what Van Ital ie considered his primary contribution to obesity research, the development of a feeding machine to study food intake: “You could basical y feed yourself by pushing a button,” Van Ital ie explained. “The machine would deliver a measured quantity of formula diet into your mouth, and then keep a record of how much you took.”

Van Ital ie felt that Diet Revolution was ful of what he cal ed “gross inaccuracies,” and that there were far too many reasons to believe that the diet could be dangerous to disseminate it so widely. There may have been some personal enmity as wel : Van Ital ie had been chief of medicine at St. Luke’s Hospital in New York when Atkins had served under him as a cardiology resident in the late 1950s. Van Ital ie said he didn’t work with Atkins closely enough to know him personal y, but he did not find him “an appealing personality” nonetheless. Stunkard, talking about al his col eagues in the field, said,