Case Histories: The Atkins Diet
Dr. Fuhrman's colleague Dr. Steven Acocella, MS, D.C., DACBN, Board Certified Clinical Nutritionist, American College of Lifestyle Physicians, and a Diplomat of the American Clinical Board of Nutrition, discusses the Atkins low-carb high-fat diet-style:
The following case histories are presented to explicate some of the many risks associated with a high fat, high animal protein, low carbohydrate Atkins diet style. I have added background and ancillary information as well as an editorial discussion to aid in the understanding of these cases.
Atkins Case History: Kathy Barnett
Kathy was a healthy 16 year old teenage girl. She had no medical problems and was active and thriving. Like many teens, especially girls, she struggled with excess weight and body image. She decided to peruse the Atkins diet to lose weight. She stood 5 feet 8 inches tall was nearly 200 pounds when she began dieting. Based upon the low-carbohydrate strategy, her diet correctly consisted primarily of meat and cheese. She ate with regularity and did not fast.
A few weeks after beginning the diet, this otherwise healthy girl suddenly and unexpectedly collapsed . Paramedics were dispatched to her high school to render care. Upon their arrival Kathy had no pulse and was not breathing. The electrical activity of her heart evaluated by paramedics revealed that she was in ventricular fibrillation, an exceedingly unusual finding in such a young patient. Inexplicitly, Kathy was in cardiac arrest at 16 years of age. Despite their best efforts, including CPR and defibrillation, paramedics were unable to revive her.
At autopsy examiners could not find any underlying condition that could contribute to or explain her sudden and tragic death. No genetic or anatomic abnormalities of her heart or other organs were found. Kathy had no history of any heart or respiratory related problems. She had no prior complaints or symptoms that could be attributed to nutritional disturbances such as electrolyte or nutrient imbalances. Kathy was not only a medical tragedy but a medical mystery as well. But that was until Dr. Joseph Tobias and his colleagues at University of Missouri, Department of Child Health studied her case.
In an article appearing in the Southern Medical Journal, Dr. Tobias and his team reported on this case and proffer a cause and effect connection between Kathy's untimely death and her lethal diet. The article, titled Sudden Cardiac Death of an Adolescent During Atkins Dieting, focuses on the potential development of a fatal physiological disturbance inherent in this type of diet .
Information provided by Kathy's mother confirmed that her daughter was compliantly on the carbohydrate restricted diet long enough to be in ketosis, the metabolic result of relying on dietary fat to meet the body's energy needs. This is likely where this young girl's fatal medical problem began (Atkins refers to this as the 'induction phase').
Russell and Taegtmeyer demonstrated that active heart muscle relying on ketones for energy lost 50% of contractile function in a matter of hours . Other studies have revealed the development of serious and fatal cardiac arrhythmias resulting from high dietary fat consumption [3, 4].
The most compelling finding in this case may provide the medical smoking gun that clearly implicates the Atkins diet as the cause of Kathy's sudden cardiac death. Electrolytes are micronutrients that are essential for many bodily functions. Critical to normal heart rhythm is the electrolyte potassium. But ketones also use potassium to enter the kidney for excretion. The more profound the state of ketosis the greater the depletion of potassium stores . If there is a concomitant deficit of caloric intake, which leads to further depletion, a serious condition called hypokalemia (critically low levels of potassium) can result. Hypokalemia is directly associated with sudden cardiac death. During resuscitation efforts, when corrected for pH shift, Kathy's serum potassium was 3.8 mEq/L, a critically low level reflective of profound hypokalemia.
While is it difficult to establish an absolute nexus between Kathy's diet regimen and her untimely death a preponderance of all the aspects of the case raises an alarming index of suspicion. This is further supported by literature that reported an increased incidence of sudden cardiac death in patients on high protein diets . The likelihood that the mortality in this case is directly related to this diet style was compelling enough for Dr. Tobias and his collaborators to warn against it in the conclusion of their presentation.
Atkins Case History: Jody Gorran
Jody was an active 50 year old when he decided to do something about his mid-life weight gain.7 He diet shopped and decided on the well advertised Atkins Diet. He liked that it was touted as the "no depravation diet" that excluded hunger, set not limit on the amount of food and included foods so rich that they are not included on any other diet . At the time he had no other health problems other than being moderately overweight. In fact, Jody was compliant at having regular check-ups and screenings. In late December 2000, during a routine colonoscopy Jody also consented to a preventive cardiac CT scan (he had no history, symptoms or complaints of coronary artery or cardiovascular diseases). The results were excellent. Jody's plaque score was 0, no blockage of the coronary arteries. The reports reads, "Normal scan, no identifiable atherosclerosis with very low coronary vascular disease risk." Good news. Furthermore, his cholesterol levels were all well within the safe range at that time, these being - Total Cholesterol 153 mg/dl, HDLc 62 mg/dl, LDLc 81 mg/dl and triglycerides 42 mg/dl. Jody was in great cardiovascular shape with an excellent lipid profile and the CT scan to prove it. But this was all about to dramatically change.
Not long after beginning the Atkins Diet Jody had a repeat blood test. The results showed that he was in ketosis, a metabolic hallmark of one carefully abiding by the Atkins Diet. The lipid profile at that time was reported as: total cholesterol: 230 mg/dl, HDLc 65 mg/dl, LDLc 154 mg/dl and triglycerides 56 mg/dl. Jody had gone from maintaining a safe, low risk lipid profile to a dangerous, elevated risk profile . Concerned about these results he consulted the Atkins Diet book and Atkins Website which addressed and allayed his fears. The Atkins literature reported that a few "fat sensitive" persons may develop a less favorable cholesterol level on a high fat [Atkins] diet. Jody read that, "less than one person in three falls into this [elevated cholesterol] category" And, although Atkins suggests eating leaner cuts of meat and "farmers cheese" as the solution, he states, "But if you're not happy [with these foods] don't bother with it; go back to the regular Atkins diet that you enjoyed more".  This is the Atkins advice rendered specifically to those who develop unhealthy cholesterol levels while on his diet. Relived by the supportive information from his nutritional guru, and pleased with the weight loss results thus far, Jody continued following the "stages" of the Atkins diet for another two years. In fact, a large quantity of his diet consisted of food products directly manufactured and marketed by Atkins, Inc.
In early October 2003, Mr. Gorran was not feeling well. For the first time in his life he began experiencing chest pain that was becoming increasingly severe. Jody consulted noted cardiologist Bruce Martin, M.D. in October of 2003. During his examination Jody's stress test was consistent coronary ischemia. The blood supply to his heart had become compromised. Dr. Martin scheduled an emergent cardiac catherization. The results were shocking. In less than three years Jody had gone from excellent cardiac health (zero blockages of the coronary arteries) to a critical 99% stenotic occlusion of the major coronary arteries. About two years after beginning the Atkins diet, according to Dr. Martin, Jody was on the brink of suffering a life threatening cardiac event. Mr. Gorran underwent immediate surgical repair to remove blockages, stent implantation and was prescribed several medications.
Noted in Dr. Martin's medical records is the recommendation to immediately and completely discontinue the Atkins diet. It specifies that, "Mr. Gorran has been advised to stop the Atkins diet because of the dangers of saturated fat allowed on this diet." A few months following Jody's cessation of the Atkins diet his lipid profile returned to normal levels that were; total cholesterol 146 mg/dl, HDLc 53 mg/dl, LDLc 81 mg/dl and triglycerides 65 mg/dl.
There is abundant, consistent scientific evidence that links excessive total dietary fat, cholesterol and saturated fat to dyslipidemia and the development of heart disease. The preponderance of an overwhelming amount of irrefutable data confirms that dietary saturated fat is especially atherogenic [9-14]. Because the Atkins Diet derives the majority of it's calories from animal sources the saturated fat content is extraordinary high.
Blood flow studies using myocardial perfusion imaging and echocardiograpy were preformed on subjects before and after starting the Atkins Diet. The study showed that blood flow to the heart diminished by an average of 40% after one year on an Atkins high fat diet. Serial blood studies also showed marked increased of inflammatory markers that predict heart attacks . Another study did an intensive review of the Atkins Diet and concluded that the high fat content resulted in the progression of atherosclerosis . Both studies are clearly consistent with the Atkins Diet and heart disease nexus reported in this case.
Dietary fat content of a typical menu by Robert Atkins, M.D. taken from Dr. Atkins' New Diet Revolution and a menu presented by Joel Fuhrman, M.D. in Eat to Live, The Revolutionary Formula for Fast and Sustained Weight Loss - an exemplary diet consistent with the consensus recommendations of the rational evidence-based scientific community [17-18], are in sharp contrast:
|Per Day||Atkin's Menu||Eat to Live Menu|
|Grams of Total Fat||167||19|
|Grams of Saturated||60||2|
|Total Fat Calories||1530||171|
|Saturated Fat Calories||540||18|
|% of Calories from Total Fat||60||10|
|% of Calories from Saturated Fat||21||1|
Clearly the total fat and saturated fat contained in the Atkins diet far exceed the daily intake recommendations cited by every reputable source. It is interesting to note that the fat calories alone for the Atkins Diet are about equal to the total calories for the Eat to Live Diet.
An extensive body of scientific literature supports the conclusion that the quantity of dietary fat consumption encouraged by Dr. Atkins is clearly atherogenic and that his diet is disease promoting. Additional long term prospective and retrospective studies will further evidence the significant dangers of the Atkins Diet.
This well cited article is about more than the science behind it. These people trusted the promises and guarantees held out to them by a member of the medical nutrition community who continued to ignore the wealth of evidence-based dietary science. The books Kathy and Jody read and the infomercials they watched literally instructed them to disregard the warnings of hundreds of credible health professionals citing the dangers of the Atkins Diet. And these cases are neither anecdotal nor isolated, they're representative. The only conclusion that can be drawn regarding the motivation to promote a diet that thousands of pages of data consistently expose as disease promoting is that it's a pursuit that places profits over people. If a prescription drug is administered to a million patients and it results in the death of a just a few, physicians stop prescribing it and manufacturers stop making it. How many case histories about fatal heart attacks, cancer, kidney failure, stroke and other diseases directly attributable to high fat diets are published before Dr. Atkins' New Diet Revolution is finally pulled off the shelf? If their camp were smart they would place a black box warning right on the covers of Atkins' books to attenuate the torrent of litigation that they're undoubtedly headed for; but what ever defensive steps they take, my expert opinion will prevail. If I could write directly to Dr. Atkins I would send him at note that simply read: Kathy Barnett: 1985 - 2001.
1. Amy Stevens, MD, D. Paul Robinson, MD, Julie Turpin, RD, Ted Groshong, MD, Joseph D. Tobias, MD. Sudden Cardiac Death of an Adolescent During Atkins Dieting. Southern Medical Journal 95(2002):1047.
2. Russell RR III, Taegtmeyer H: Changes in the citric acid cycle flux and anaplerosis antedate the functional decline in isolated rat hearts. J Clin Invest 1991; 87:384-390.
3. Oliver MF, Yates PA: Induction of ventricular arrhythmias by elevation of arterial free fatty acids in experimental myocardial infarction. Cardiology 1972; 56:359-364.
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5. Zeman FJ, Hansen RJ: Diabetes mellitus, hypoglycemia and other endocrine disorders. Clinical Nutrition and Dietetics. Seman FJ (ed). New York, Macmillan Publishing Co, 2nd Ed, 1991, pp 409-410.
6. Surawicz B, Waller BF: The enigma of sudden cardiac death related to diet. Can J Cardiol 1995; 11:228-231.
7. Medical Records cited in the public court pleadings of Jody Gorran v. Robert C. Atkins, et at., Complete case available at: http://www.pcrm.org/news/downloads/health04052_complaint.pdf
8. Robert C. Atkins, M.D., Dr. Atkins' New Diet Revolution, Avon Books 1999, 2002 ISBN 0-06-001203-X.
9. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). National Cholesterol Education Program, National Heart, Lung, and Blood Institute, National Institutes of Health. NIH Publication No. 02-5212, September, 2002.
10. Report of a Joint WHO/FAO Expert Consultation. Diet, Nutrition and the Prevention of Chronic Diseases. WHO Technical Report Series 916, 2003.
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12. Schaefer EJ, Levy RI, Ernst ND, Van Sant FD, Brewer HB Jr. The effects of low cholesterol, high polyunsaturated fat, and low fat diets on plasma lipid and lipoprotein cholesterol levels in normal and hypercholesterolemic subjects. Am J Clin Nutr. 1981;34:1758-1763.
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14. Anderson JW and others. Health advantages and disadvantages of weight-reducing diets: a computer analysis and critical review. Journal of the American College of Nutrition 19:578-590, 2000.
15. Fleming RM. The effect of high-protein diets on coronary blood flow. Angiology 2000;51(10):817-826.
16. White PL. A critique of low-carbohydrate ketogenic weight reduction regimens: A review of Dr. Atkins' diet revolution. JAMA 224:1415-1419, 1973.
17. Gale Publications. A review of Eat to Live. Nutritional Review: quarterly publication, winter edition 2002
18. Huberman, M. Eat to Live: A review. Health Science September 9, 2002