Letter from PCRM's Nutrition Director to Dietary Guidelines Advisory Committee

January 16, 2004

Kathryn McMurry
Health and Human Services
Office of Disease Prevention and Health Promotion
Office of Public Health and Science, Room 738-G
200 Independence Ave. SW
Washington, DC 20201
Submitted via email: dietaryguidelines@osophs.dhhs.gov

Dear Dietary Guidelines Advisory Committee Members:

The Physicians Committee for Responsible Medicine (PCRM) urges you, the members of the Dietary Guidelines Advisory Committee, to give specific advice regarding safe effective ways to achieve and maintain a healthy weight while reducing chronic disease risk and to warn consumers against the use of high-protein, high-fat, carbohydrate-restricted diets, such as the Atkins Diet, for weight loss in the 2005 Dietary Guideline for Americans.

We recommend guiding individuals to low-fat diets built from plant foods to help them achieve and maintain a healthy weight. According to the USDA commissioned paper “Popular Diets: A Scientific Review,” low-fat and very low-fat diets are effective for weight loss because they lead to a reduction in calorie intake and an increase in fiber, which can help people feel fuller longer.¹ In addition, low-fat, high-fiber, near-vegetarian, vegetarian, and vegan diets have been used effectively for long-term weight control² and to treat and to reduce the risk of heart disease,^3-5 diabetes,^6-8 some cancers, ^9,10 and other chronic conditions.

In addition, the physicians and nutritionists at PCRM ask that you warn individuals about the potentially harmful effects of high-protein, high-fat, carbohydrate-restricted diets in the Dietary Guidelines for Americans. These popular diets are potentially dangerous because they skew nutritional intake toward higher-than-recommended amounts of dietary cholesterol, fat, saturated fat, and protein and very low levels of fiber and other protective dietary constituents and put individuals at risk of compromised vitamin and mineral intake.¹¹ And, when followed over the long term, these dietary patterns are associated with increased risk of colorectal cancer,⁹ cardiovascular disease,^{12, 13} impaired renal function,¹⁴ osteoporosis,¹⁵ and complications of diabetes.¹⁶

Since the Fall of 2002, PCRM has been collecting reports of adverse events from individuals following high-protein, high-fat, carbohydrate-restricted diets through an online registry (www.atkinsdietalert.org/registry.html).

In the accompanying document, we summarize the reports of 429 individuals who experienced health problems while on a high-protein, high-fat, carbohydrate-restricted diet. In brief, 19 percent reported renal problems (stones, severe infections, or reduced kidney function), 33 percent reported cardiac disorders (including coronary artery occlusion requiring stent placement, heart attack, atrial fibrillation, tachycardia, and elevated serum cholesterol concentrations), 9 percent reported gallbladder problems, 5 percent have reported the onset of gout, and 4 percent reported cancer diagnoses. Less serious problems, such as constipation (44 percent), bad breath (40 percent), difficulty concentrating (29 percent), and loss of energy (40 percent) were recorded with higher frequency.

Because of these risks and the scientific evidence showing that these diets are not more effective than other, safer, weight loss methods, we recommend that a warning statement be added to the 2005 version of the Dietary Guidelines for Americans against the use of low-carbohydrate, high-protein diets.^17,18 Nutrition policy statements would best serve Americans by recommending a low-saturated fat, high-fiber, high–complex-carbohydrate diet based on plant foods.

Feel free to contact me should you be interested in discussing this important issue or if we may be of assistance to you. I can be reached at (202) 686-2210, ext. 354, or via email at alanou@pcrm.org.

Sincerely,

Amy Joy Lanou, Ph.D.
Nutrition Director

Literature cited:
1. Freedman MR, King J, Kennedy E. Popular diets: a scientific review. Obes Res. 2001 Mar;9 Suppl 1:1S-40S.
2. Ornish D, Scherwitz LW, Billings JH, et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998;280:2001-7.
3. Ornish D, Brown SE, Scherwitz LW, Billings JH, Armstrong WT, Ports TA. Can lifestyle changes reverse coronary heart disease? Lancet 1990;336:129–33.
4. Esselstyn CB Jr, Ellis SG, Medendorp SV, Crowe TD. A strategy to arrest and reverse coronary artery disease: a 5-year longitudinal study of a single physician's practice. J Fam Pract. 1995;41:560-8.
5. Barnard RJ, Inkeles SB. Effects of an intensive diet and exercise program on lipids in postmenopausal women. Women’s Health Issues 1999;9:155-61.
6. Barnard RJ, Jung T, Inkeles SB. Diet and exercise in the treatment of NIDDM: the need for early emphasis. Diabetes Care 1994;17:1469-72.
7. Crane MG, Sample C. Regression of diabetic neuropathy with total vegetarian (vegan) diet. J Nutr Med 1994;4:431-9.
8. Nicholson AS, Sklar M, Barnard ND, Gore S, Sullivan R, Browning S. Toward improved management of NIDDM: a randomized, controlled, pilot intervention using a lowfat, vegetarian diet. Prev Med 1999;29:87-91.
9. World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, and the Prevention of Cancer: a global perspective. World Cancer Research Fund/American Institute for Cancer Research, Washington, DC, 1997, pp. 216-51.
10. Ornish DM, Lee KL, Fair WR, Pettengill EB, Carroll PR. Dietary trial in prostate cancer: Early experience and implications for clinical trial design. Urology. 2001;57:200-1.
11. St Jeor ST, Howard BV, Prewitt TE, Bovee V, Bazzarre T, Eckel RH. Nutrition Committee of the Council on Nutrition, Physical Activity, and Metabolism of the American Heart Association. Dietary protein and weight reduction: a statement for healthcare professionals from the Nutrition Committee of the Council on Nutrition, Physical Activity, and Metabolism of the American Heart Association. Circulation 2001;104:1869–74.
12. Nestel PJ, Shige H, Pomeroy S, Cehun M, Chin-Dusting J. Post-prandial remnant lipids impair arterial compliance. J Am Coll Cardiol 2001;37:1929-35.
13. Fleming RM. The effect of high-protein diets on coronary blood flow. Angiology 2000 Oct;51(10):817–26.
14. Knight EL, Stampfer MJ, Hankinson SE, Spiegelman D, Curhan GC. The Impact of Protein Intake on Renal Function Decline in Women with Normal Renal Function or Mild Renal Insufficiency Ann Int Med 2003;138:460-7.
15. Feskanich D, Willett WC, Stampfer MJ, Colditz GA. Protein consumption and bone fractures in women. Am J Epidemiol 1996;143:472-9.
16. Gin H, Rigalleau V, Aparicio M. Lipids, protein intake, and diabetic nephropathy. Diabetes Metab 2000 Jul;26 Suppl 4:45-53.
17. Foster GD, et al. A randomized trial of a low-carb diet for obesity. N Engl J Med 2003;348:2082-90.
18. Bravata DM, Sanders L, Huang J, et al. Efficacy and safety of low-carbohydrate diets: a systematic review. JAMA. 2003;289:1837-50.

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