1 The Atkins Nutritional Approach is an Effective Tool for Treating Metabolic Syndrome X A GP’s perspective Dr Sarah Brewer

2 Metabolic Syndrome X Metabolic syndrome X is associated with:  Insulin resistance  High insulin levels  Glucose intolerance  Overweight, especially around the waist  High blood pressure  High levels of harmful very low density lipoprotein cholesterol (small dense particles)  Low levels of beneficial HDL-cholesterol  High triglyceride levels  Increased blood clotting factors

3 Metabolic Syndrome X The European Group for the Study of Insulin Resistance defines Metabolic syndrome as:  Insulin levels in the highest 25% of the population range PLUS two of the following:  fasting glucose levels  6.1 mmol/l but  7.0 mmol/l  high blood pressure  140/90 mmHg  plasma triglycerides  2 mmol/l or HDL  1mmol/l  Central obesity: waist measurement greater than 94cm in men or 80cm in women

4 Metabolic Syndrome X  All these clinical factors are important, independent risk factors for heart disease and stroke, and often lead to Type 2 diabetes if left untreated  Recent evidence suggests these traits together interact to produce more damage to artery walls than expected from their additive effects alone  As many as one in five people are believed to have metabolic syndrome in the UK  Metabolic syndrome has been described as a ‘cardiovascular time-bomb’

5 Metabolic Syndrome X  There is excellent evidence that improving single risk factors such as high blood pressure, raised glucose levels or abnormal cholesterol levels can reduce the risk of heart attack and stroke  Research is now investigating whether aggressive diet and lifestyle changes at an early stage in the development of metabolic syndrome might prevent the development of these major risk factors altogether  All the clinical signs associated with metabolic syndrome X can be reduced or even reversed by following a low-carb diet

6 Results of a High-Carb Diet  The underlying cause of metabolic syndrome is insulin resistance in which body cells lose their sensitivity to insulin hormone; this may be linked with obesity  Foods that raise blood sugar levels stimulate the production of insulin to help push excess glucose into adipose cells for storage as body fat  Cells become increasingly insensitive to the effects of insulin when levels are persistently raised, so more and more insulin is produced to help maintain normal blood sugar levels  People with metabolic syndrome are basically over- dosing on glucose and insulin

7 Result of  Carbohydrate Intake

8 The Obesity Epidemic in the UK  Insulin is a storage hormone that actively promotes overweight and obesity  More than half the adult population of England (two thirds of men and half of women) are overweight and 20% of these are obese.  1,000 people in England reach the stage of obesity every day  In 2001, 8.5% of 6 year olds and 15% of 15 year olds were classed as obese due to a combination of over eating and lack of physical activity. Sources: National Audit Office “Tackling Obesity in England,” February 2001 TOAST (The Obesity Awareness & Solutions Trust), March 2000

9 Benefits of Weight Loss Losing 10kg in weight (22lb) has been shown to:   blood pressure by 10/20 mmHg   fasting blood glucose levels by 50%   triglycerides by 30%   total cholesterol levels by 10%   harmful LDL-cholesterol by 15%   ‘good’ HDL-cholesterol by at least 8% For someone who is obese, losing 10kg can reduce their overall risk of premature death by 20% and their risk of diabetes-related death by as much as 30%

10 Evaluation of the Atkins Nutritional Approach  28 people with Type 2 diabetes who could not achieve good glucose control  9 were previously treated with diet alone, 19 were on oral hypoglycaemic drugs (although these were discontinued at the start of the trial).  All followed a low-carb diet supplying 25% of daily energy in the form of carbohydrate for 8 weeks  After 8 weeks, they switched to a diet providing the same amount of energy, but with 55% carbohydrate Gutierrez M et al.. Journal of the American College of Nutrition (6):

11 Evaluation of the Atkins Nutritional Approach  After the first 8 weeks (low-carb) there were significant improvements in blood glucose control and haemoglobin A 1c levels  When they switched back to the so-called ‘healthy’ 55% carbohydrate diet, their glucose control worsened again and their haemoglobin A 1c level rose significantly over the following 12 weeks  Conclusion: a low-carb, low calorie diet had beneficial effects in people with Type 2 diabetes, and may reduce their need to move on to insulin treatment

12 Evaluation of the Atkins Nutritional Approach  A controlled trial funded by the American Heart Association randomised 53 obese females to 6 months of an ad libitum very low carbohydrate diet or a calorie restricted, low fat (30%) diet  Both groups reduced calorie consumption by comparable amounts at 3 and 6 months  Total intake of saturated fat was not excessive  At 3 months the low-carb group consumed 20.7% saturated fat 20.6% monounsaturated fat and 9% polyunsaturated fat  At 6 months the low-carb group consumed 17.4% saturated fat 15.8% monounsaturated fat and 8.2% polyunsaturated fat  The percentage of saturated fat is consistent with other studies following free-living individuals using the Atkins Nutritional Approach

13 Evaluation of the Atkins Nutritional Approach  Mean levels of blood pressure, lipids, fasting glucose and insulin improved in both groups  Even through the low carb dieters ate more calories per day by 6 months, compared with those on the low fat diet (1302 Vs 1247) they lost significantly more weight and body fat  The low-carb group lost more weight (8.5kg vs 3.9kg) and more body fat (4.8kg vs 2kg) than the low fat group with no adverse effect on cardiovascular risk factors  ‘A very low carbohydrate diet is more effective than a low fat diet for weight loss and, over 6 months, is not associated with deleterious effects on cardiovascular risk factors in women’

14 A Calorie is Not a Calorie?  This trial, and others, suggest that a low carbohydrate diet provides a metabolic advantage  ‘For the greater weight loss in the low carbohydrate diet to result from decreased calorie consumption alone, the group would have had to consume 300 fewer calories per day over the first 3 months compared with the low fat diet group’  ‘Although the inaccuracy of dietary records for obese subjects is well documented, it seems unlikely that a systematic discrepancy of this magnitude occurred between groups of subjects who were comparably overweight.’ Quotes: Brehm et al, J Clin Endocrinol Metab 2003, 88(4):

15 Evaluation of the Atkins Nutritional Approach  The researchers concluded that: ‘For the greater weight loss in the low carbohydrate diet to result from decreased calorie consumption alone, the group would have had to consume 300 fewer calories per day over the first 3 months compared with the low fat diet group’ Consider calorie reduction Consider metabolic advantage

16 Evaluation of the Atkins Nutritional Approach  One year, controlled trial involving 63 obese men and women  Average BMI 34kg/M 2  Randomised to either a low-carb (high protein, high fat) diet, or a conventional low calorie, low fat diet  Those on the low-carb diet had a statistically significant greater weight loss for the first 6 months (7% body weight versus 3.2% body weight), and maintained greater weight loss at 12 months (even though carb intake had been increased greatly) although not statistically significant Foster GD et al, New Eng J Med 2001; 348;21:

17  There was little difference in the LDL-cholesterol between the two groups  Both diets significantly decreased diastolic blood pressure and the insulin response to a known intake of glucose  Those on the low-carb diet had greater improvements in serum triglycerides and HDL-cholesterol than those on the conventional diet  These beneficial changes were as good as can be obtained with some medications Evaluation of the Atkins Nutritional Approach

18 Evaluation of the Atkins Nutritional Approach The researchers concluded:  ‘The low-carbohydrate diet was associated with a greater improvement in some risk factors for coronary heart disease’  ‘… the changes are greater than those expected from a moderate weight loss alone’

19 Evaluation of the Atkins Nutritional Approach  132 severely obese subjects randomly assigned to a low-carb diet or a calorie and fat restricted diet 6/12  Mean BMI 43 kg/M 2  39% had diabetes, 43% metabolic syndrome  Of the 79 subjects that completed the study (low fat dieters were twice as likely to drop out), those following a low-carb diet lost more weight than those on the low fat diet (5.8kg vs 1.9kg) irrespective of their use or non-use of drugs to lower blood glucose or cholesterol levels Samaha FF et al N Engl J Med 2003; 348:21,

20 Evaluation of the Atkins Nutritional Approach  Nine out of 64 people starting the low carbohydrate diet eventually lost at least 10% of their body weight compared with only 2 out of the 68 people who started on the low fat diet  Triglyceride levels  by over 20% for those on the low-carbohydrate diet versus only a 4%  for those on the low fat diet  Insulin sensitivity was measured in the people with diabetes and was found to have improved more in those following the low- carb diet

21 Evaluation of the Atkins Nutritional Approach  The researchers concluded that: …. being assigned to the low-carbohydrate diet was an independent predictor for improvements in triglyceride levels and insulin sensitivity

22 Evaluation of the Atkins Nutritional Approach  These studies provide important information for doctors caring for people who are obese, especially if they also have metabolic syndrome X or diabetes Type 2  Focussing on low-fat diets has not worked, frequently resulting in increased caloric consumption and weight gain  Low fat diets providing  30% fat have been shown to result in conversion from large fluffy LDL particles to the atherogenic sub type made up small dense particles in those individuals genetically predisposed  Well controlled, peer reviewed research has demonstrated that following a controlled carbohydrate approach results in significantly decreased triglyceride levels, increased HDL, and decreased LDL levels in many people, as well as a reduction in postprandial triglyceride levels

23 Metabolic Syndrome X A low carb diet can reverse factors associate with Metabolic syndrome X:  Insulin resistance  High insulin levels  Glucose intolerance  Overweight, especially around the waist  High blood pressure  High levels of harmful very low density lipoprotein cholesterol (small dense particles)  Low levels of beneficial HDL-cholesterol  High triglyceride levels  Increased blood clotting factors

24 Low-Fat Diets Have Failed  Anticipated outcomes have not been achieved  Obesity, metabolic syndrome, diabetes and heart disease are all increasing  Alternative solutions need to be explored  Controlling carbohydrates ( ANA) has been scientifically validated and is worthy of further research

25 Science Supports the Atkins Nutritional Approach  More than 400 published, peer-reviewed studies support the concepts underlying the Atkins Nutritional Approach  In the last three years, 19 studies focusing on the ANA have all supported the safety and efficacy of the controlled carbohydrate approach  Information on all these studies and supporting scientific information is available for review at