Features Cover story

Breaking
with bread
Are low-carbohydrate diets an easy route to
weight loss or a recipe for a heart attack?
Clare Wilson investigates

C
OUNTLESS fad diets come and go, As rising rates of obesity and diabetes
but these days there is one we never threaten public health, the questions
stop hearing about. Whether you call around the safety of low-carb diets are
it low-carbing, Atkins, keto or paleo, the becoming increasingly urgent. So, is ditching
principle is the same: cutting down on carbs a safe way to lose weight and stay
starchy food and filling up on fat and protein. healthy – or a recipe for heart attack?
Low-carbohydrate diets are increasingly Low-carb diets first came to fame in the
being endorsed by obesity and diabetes 1970s through New York cardiologist Robert
specialists, and a growing number of trials Atkins, who lost weight himself this way and
show that the approach helps people lose recommended it in diet and cookery books.
weight at least as much as traditional low-fat, His advice to fill up on steaks, cream and
low-calorie regimes. More and more people butter, while shunning most fruit and
are eating this way, not to lose weight, but vegetables, made him a medical pariah.
because they see it as healthier. Critics said people wouldn’t be able to
Yet many doctors warn that low-carbing stick to it, and if they did, it would kill them,
is dangerous. They point to large-scale says Westman, who studied under Atkins.
population studies linking low-carb diets
to increased risk of heart attack, stroke
and premature death. Pass the butter
The puzzling thing is, those warnings don’t For many people, however, low-carb diets
seem to square with findings from clinical clearly work. By the early 1990s, randomised
trials, generally a better kind of medical trials were showing that such diets are at least
evidence than population studies. Several as good as low-fat ones for weight loss, often a
have now shown that low-carb diets generally little better. In one trial, people on a low-carb
don’t raise the levels of “bad cholesterol”, long diet lost an average of 4.4 per cent of their
seen as a major risk factor for heart attack and body weight after a year, compared with
stroke. Even in people who do see a rise, other 2.5 per cent among those in a low-fat group.
markers of heart health usually improve. And contrary to the warnings, people’s
It is so confusing that some wonder if cholesterol levels, and results from other
we have got the causes of heart disease all blood tests, generally moved in the right
wrong. “This has led me to question whether direction. “That was a big moment,” says
I believe in the cholesterol hypothesis at all,” Westman, who led some of those studies.
JASON FORD

says Eric Westman, an obesity specialist What’s the explanation? The central idea
at Duke University in North Carolina. is that weight control requires more than just

32 | New Scientist | 9 January 2021

“Calories from
fat make us
feel fuller
than those
from carbs”

calorie counting. For a start, the same

amount of calories from fat or protein makes
people feel fuller than if they come from
carbs, which explains why people on low-carb
diets report less hunger than those on low-fat
ones. Westman’s studies helped show that,
although most people on low-carb diets don’t
calorie count, they tend to consume just
1200 to 1500 calories a day, much less than
the recommended 2000 calories per day
for women and 2500 for men. “They eat less
because they’re not hungry,” says Westman.
The other key insight is about what
happens when we change the body’s main
energy source. Usually, our cells are fuelled
by glucose, a simple sugar that all other forms
of sugar or starch are converted into. Glucose
is highly reactive, so our bodies normally
keep the amount in the blood within a
narrow range to avoid damage to blood
vessels and cell structures. When glucose
levels rise after eating, we quickly release
the hormone insulin, which tells cells to start
taking up glucose, and using and storing it.
Insulin has a host of other effects, but they
can be summarised as signalling to our
bodies we have had an influx of calories and
we need to stash them away. Crucially, insulin
makes fat cells turn glucose into fat and store
it. But in the absence of glucose, the body has
an alternative fuel source: fat. Depending on
the cell type, stored fat may be turned into
fatty acids or into molecules called ketones,
which can be used for energy. This normally
happens a little overnight, when we go for >

9 January 2021 | New Scientist | 33

 several hours without eating any
carbohydrates.
The raison d’etre of low-carbing is to
minimise insulin release and be fuelled
as much as possible by ketones. For most
people, a shift into what is known as ketosis
happens within a few days of dramatically
cutting carbs. Eating very low levels of carbs
is also known as a ketogenic diet.
As well as people trying to lose weight,
many others have adopted low-carbing or
the keto diet because they see it as a way
of living healthily and prolonging lifespan.
Some adherents believe entering ketosis
has a range of metabolic benefits, including
warding off cancer and Alzheimer’s disease,
although there isn’t good evidence for this.
Neurologists use very low-carb diets to
induce ketosis as a treatment for certain
forms of epilepsy and it is being investigated
in other conditions (see “The keto diet in
medicine”, page 36).

Matters of the heart

long chains of sugar molecules. People with
diabetes often measure their blood sugar “Many are
What has recently granted low-carbing more
legitimacy, though, is its effects on type 2
at home, and can see for themselves that
starting the day with bacon and eggs gives starting to
diabetes. This condition occurs when
the body’s cells become less sensitive
less of a sugar surge than toast or cereal do.
Sceptics might say that while a few days of
question
to insulin – a state known as insulin
resistance – which leads to dangerous rises
low-carbing leads to lower blood sugar levels,
it is hard to stick to this way of eating. There
whether ‘bad
in blood sugar after meals. Long term, these
sugar surges contribute to the many health
is mixed evidence on the issue. For instance,
a review of 10 randomised trials found that
cholesterol’
consequences of diabetes, including nerve
damage and kidney and heart disease.
low-carb diets were more effective than low-
fat diets at improving blood sugar control in
really is a
The medical orthodoxy is that, because
diabetes raises the risk of heart disease, it is
people with diabetes over the first year, but
the differences disappeared after that. But
risk to heart
even more important that those affected
avoid saturated fats, found mainly in red
there is evidence that for those who keep it
up, the health benefits can be longer term,
health”
meat and dairy products, because these are such as a study of 128 people with type 2
thought to raise blood cholesterol and lead diabetes who went to low-carb counselling
to blocked arteries. The UK National Health sessions run by David Unwin, a family doctor
Service advice for type 2 diabetes is that in Southport, UK. After an average follow-up
people should keep fat to a minimum and of two years, about half had been able to stop
eat starchy foods like pasta, for instance. taking all their diabetes drugs.
Yet this ignores the fact that people Because of results like these, diabetes
with diabetes may see two benefits from doctors and patient support groups have
GOJAK/GETTY IMAGES

low-carbing. As well as weight loss improving started questioning the low-fat orthodoxy
their insulin sensitivity, avoiding starch and too. Bodies such as Diabetes UK and Diabetes
sugar reduces those harmful blood sugar Australia now say low-carbing is a valid
spikes. Remember that starch is basically option for weight loss. Ten years ago, that

34 | New Scientist | 9 January 2021

would have been unheard of. The American Some elite athletes
Diabetes Association went a step further last and other people
year and said out of all dietary strategies, not looking to lose
low-carbing has the most supporting weight are adopting
evidence for improving blood sugar control. low-carb diets as
Yet, as more and more people have part of a “healthy”
adopted this way of eating, there have been lifestyle
renewed questions over its safety. In some
cases, low-carb diets can lead to an alarming
change in people’s cholesterol levels.
The idea that certain kinds of cholesterol
can cause a build-up of dangerous plaques
within our blood vessels is a pillar of
ANDREAS SOLARO/AFP VIA GETTY IMAGES

mainstream medicine. There are several

different types of cholesterol particles in
the blood. One type, called high-density
lipoprotein (HDL), is linked with a lower risk
of heart attacks – this is sometimes known
as good cholesterol. Bad cholesterol is a
type called low-density lipoprotein, or LDL.
Another kind of fatty particles, called
triglycerides, are also thought to be harmful.
Some people on low-carb diets see their
bad cholesterol levels rise significantly. other measures linked with glucose and a US science journalist, who has long been
Although they seem to be in the minority, the insulin response. This was the case for a proponent of low-carbing and has just
number of these “hyper-responders”, as they Bhardwaj’s two hyper-responders. He got written a book called The Case for Keto.
are coming to be termed, is unclear. Westman further reassurance by scanning the arteries This idea isn’t drastically at odds with
estimates that only a tiny fraction of people to their heart to check for any plaques. “You our current understanding of the root
who try such diets will be hyper-responders. see what’s really going on underneath the causes of heart disease. Doctors already
In one of his trials, from 2004, two people out bonnet,” he says. “They were absolutely fine.” recognise that type 2 diabetes, obesity and
of 59 randomised to low-carbing dropped out heart disease frequently co-occur – so much
because their bad cholesterol levels rose. so that the triad has its own name, “metabolic
Westman and others say they most
Guilt by association syndrome”. Yet, rather than heart disease
often learn of this response in people The fact that some people see a rise in their being a disorder of “faulty plumbing” in
who are slim and relatively muscular. bad cholesterol levels on a low-carb diet which our arteries get blocked up because
He believes he may now be hearing about while other measures improve is now leading we consume too much fat, the real problem
more of these cases because low-carbing is some to question whether LDL really is a key could be a predisposition towards insulin
increasingly being adopted as a longer-term determinant of the risk to our hearts. Much resistance, which in turn promotes higher
approach to healthy eating, not simply of the case against this form of cholesterol insulin levels, fat storage and heart disease.
a short-term strategy for weight loss. has been built on population studies done “If that is true, the medical research
You don’t have to be slim and muscular to in the past few decades, which found that community made a terrible mistake,
be a hyper-responder, though. Vipan people with higher LDL levels were more and we’ve yet to fix it,” says Taubes.
Bhardwaj, a family doctor in Wokingham, UK, likely to have heart attacks. Another important strand of evidence that
saw bad cholesterol rise in two out of 38 of his But these kinds of studies can only find made us believe LDL is important was the
patients who began low-carbing for diabetes. correlations between blood markers and success of LDL-lowering drugs called statins,
“It scared the bejesus out of us,” says Bhardwaj. health outcomes, not prove that one leads which reduce heart attack rates, according
What is strange about hyper-responders to the other. It could be that something else to multiple randomised trials, the most
is that while their LDL level goes up, their is the root cause of heart disease, which respected kind of medical study. But several
other health markers tend to move in the increases LDL levels as a side effect. other drugs that lower LDL levels don’t
right direction. These include their HDL, The chief suspect for that something protect against heart attacks, and statins
triglycerides, blood pressure and several else is insulin resistance, says Gary Taubes, have many effects on the body, including >

9 January 2021 | New Scientist | 35

The keto diet
in medicine
dampening low-level systemic As an illustration of how confusing this is
Low-carbohydrate diets may be inflammation. It may be that statins for the public, this particular trial is cited both
controversial as a way to lose actually protect the heart through their as evidence against low-carbing – because
weight, but they have been used anti-inflammatory effects. LDL went up – and in favour of it, because
for decades to treat severe epilepsy Some say it was the arrival of statins that overall risk went down. Scher acknowledges
in children and are being explored got us so fixated on LDL levels. “Doctors only that we don’t yet know how risky it is if
for other conditions. have 5 or 10 minutes with a patient. It’s people on low-carb diets experience their
For epilepsy, avoiding convenient to write a prescription and follow LDL levels rising while other health markers
carbohydrates so the body enters the LDL,” says Bret Scher, a US cardiologist improve. What we need are more studies
a state called ketosis, when cells and medical director for the website, Diet that follow hyper-responders over time to
have to switch to using fat for Doctor, which promotes low-carb eating. see if they are developing heart disease.
energy, causes several metabolic While practising physicians focus on their In the meantime, where does the
changes within brain cells. It may patients’ LDL levels, these days, cardiologists uncertainty leave the average person who
work by making brain cells less who study biomarkers of heart health debate wants to lose a few pounds? The emergence
“excitable” or prone to uncontrolled whether LDL levels really are the most of hyper-responders shouldn’t stop people
firing, or by reducing the damage important indicator, or whether things like from trying low-carbing, says Westman.
to brain cells caused when seizures the ratio of total cholesterol to HDL, or that “That would be crazy, like telling someone
do happen. of triglycerides to HDL, would be more useful. not to take a useful drug because it
Ketogenic diets can be very Hyper-responders would be fine if judged by sometimes has a side effect.”
helpful for children whose seizures either of those metrics: generally their HDL On the other hand, unlike with most
can’t be controlled by epilepsy levels rise and their triglyceride levels fall. medicines, we don’t know how common
drugs, says Bahee Van de Bor, a One trial often used to underscore the this side effect is. Trials tend to report only
spokesperson for the British Dietetic dangers of low-carb diets found that people average LDL changes for the whole group
Association, who has helped with type 2 diabetes saw their LDL levels rise assigned to low-carbing.
children on this diet at Great by about 10 per cent on average after a year Despite the new enthusiasm for these
Ormond Street Hospital in London. on the regimen. However, there was diets among diabetes and obesity specialists,
A keto diet is also being improvement in most of the other 25 health many heart specialists and dietitians remain
investigated as an add-on to markers tracked, such as weight, blood critical. A 2019 joint report on the prevention
standard cancer treatments. pressure and HDL. Participants’ overall risk of heart disease from two US cardiology
It seems to make tumour cells score for heart disease fell by 12 per cent. bodies said low-carb diets are linked with
more sensitive to the effects of
chemotherapy and radiotherapy
because they have often mutated
to become more dependent on A diet rich in protein
glucose for energy. and fat, but low in
The metabolic changes the diet carbohydrates, can
induces in brain cells may also be lead you to burn
protective against neurological more body fat to
conditions such as Alzheimer’s produce energy
and Parkinson’s disease, and
there have been some promising
individual case studies. But, in
these conditions, research is still
at a very early stage.
AAMULYA/GETTY IMAGES

36 | New Scientist | 9 January 2021

 lasted long enough to know which approach
helps people keep weight off long term.
Indeed, a recent review of many different
kinds of diet – including low-carbing, low-fat
and Mediterranean – concluded that most
people put nearly all their lost weight back
12 months after they started anyway.

Whatever works
Of course, not everyone can stick to a
low-carb diet; some find they miss their
bread, rice and pasta. Mike Lean at the
University of Glasgow, UK, who worked with
Taylor on the meal replacement diet strategy,
says his obesity clinic now offers advice on
both low-fat and low-carb diets. “People can
use whatever they are better able to lose
weight with, low-fat or low-carb,” he says.
“We have found no difference in weight loss.”
The idea that different people might do
better on different foods is supported by
more recent research suggesting that there
higher death rates. “The evidence is still
weak about the long-term cardiovascular “Despite is no such thing as a single healthy diet that
works for everyone. Instead, our individual
safety of the ketogenic diet,” says Donna
Arnett at the University of Kentucky, one enthusiasm genetics, habits and gut microbiomes may
all influence how our bodies deal with the
of the guideline authors.
“There is conflicting evidence,” says Tracy for these diets, nutrients in our diet.
Yet even if the most we can say in favour
Parker, a dietitian for the British Heart
Foundation. “We know saturated fat does many heart of low-carb diets is that they work for weight
loss and are safe for most of the population,
increase your blood cholesterol.” Parker
says that if people are determined to reduce
specialists that would still be a marked change from the
previous orthodoxy that saturated fat is an
their carb intake, the safest bet is to replace
carbohydrates with oils from plants and
remain critical” inevitable route to a heart attack.
At the moment, there are more
fish. However, she admits that would make questions than answers. But even before
what is already a restrictive diet even more low-carbing came along, there were
so, because people would have to avoid not growing concerns that the cholesterol
only all starchy and sugary foods, but also theory of heart disease was on shaky
meat and dairy products. ground. Now hyper-responders are making
It isn’t as though low-carbing is the only it look even wobblier. “There’s a chance
way to lose weight, says Roy Taylor, a that this subset of patients could upend
diabetes specialist at Newcastle University the philosophy that LDL is the most
in the UK. Taylor has pioneered the use of important risk factor for heart disease,”
meal-replacement shakes to help people says Scher. “I’m cautiously optimistic.” ❚
KAREN BEARD/GETTY IMAGES

quickly slim down on a low-calorie, low-fat

diet, and has shown that if people with type 2
diabetes can lose about 15 kilograms this way, Clare Wilson is biomedical reporter
they can also put their disease into remission. at New Scientist and author of the
Unfortunately, none of the trials that have Health Check newsletter. Follow her
compared low-carbing with low-fat diets have @ClareWilsonMed