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Looking for Diets in All the Wrong Places
If you met Carmen J. Pirollo, you might not realize that he has a weight problem. He's a square-jawed, animated man, who talks in exclamation points, favors preppy clothes, and—the big hint that he's a bit self-conscious—sometimes doesn't tuck in his shirts. Yet while you may notice his abdomen under that shirt, he is not what you might think of as obese. He does not seem to have any trouble moving, and when he sits down, he does not spill out of his chair. He's not like one of the subjects in those insulting, deliberately humiliating photos that show up in magazine articles or on television programs to illustrate the horrors of the obesity epidemic—those familiar images of round-faced, double-chinned people captured stuffing hamburgers into their mouths or of a fat family lumbering past fast food restaurants, dipping into bags of popcorn or licking ice cream cones.
But Carmen, according to the official standards, is fat—obese, in fact—and he knows it. He's 5 feet 11 inches tall, and at 265 pounds, his body mass index, a measure of body fat based on height and weight, is 37. That is a level at which public health guidelines warn that dire health risks start to mount.
And dieting has become a part of Carmen's life. Over the years, he has tried almost every variation on the dieting theme, losing weight over and over again, only to gain it all back, and more. "I've lost a whole person over my lifetime," he says. In his thirty-two years of professional life as an elementary school teacher at a New Jersey school not far from his townhouse in Philadelphia, he has seen his weight climb and climb and climb despite all his efforts to control it.
But on a chilly evening on the first day of March in 2004, Carmen, at age fifty-five, opened a new chapter in his weight loss history. He began a two-year stint as a volunteer in the extraordinary experiment that was prompted by the small pilot study a few years earlier comparing the Atkins diet with a standard low-calorie one.
The three investigators who did the first study got federal funding to expand it to include 360 obese subjects at their medical centers—the University of Pennsylvania, the University of Colorado, and Washington University in St. Louis—and continue it long enough to get some answers that would hold up to scientific scrutiny. They'll follow each subject for two years, with regular measurements of weight, blood pressure, kidney function, and stamina. They'll periodically question their subjects about satisfaction with the assigned diet, and they'll evaluate the dieters for changes in mood.
The two diet plans could not be more different. The low-calorie diet program is one that few dieters have heard of but that is beloved by academic researchers. It was developed by a member of the club, a university professor, not some self-promoting diet doctor, but a researcher, a psychologist whose goal was to give the best advice for weight loss, whether or not it was what fat people wanted to hear. And it comes with a hefty manual that tells you how to succeed, culling the accumulated wisdom of academic researchers. The diet's name is as earnest as its advice. LEARN, it's called, which is an acronym for "Lifestyle, Exercise, Attitudes, Relationships, Nutrition." And it was the diet with which Atkins would be compared.
Of course, no one signing up for the new study wanted the low-calorie LEARN diet. They were attracted by the idea of a two-year intensive program to help them lose weight and keep it off. They knew their diet, Atkins or low-calorie, would be decided at random. But they were hoping they would get Atkins, the diet that all America at that time, it seemed, was adopting. The Atkins diet was developed by a man so confident in his program that he called it "the new diet revolution."
The Atkins diet plan says that carbohydrates make you fat, so you must strictly limit them. But you can eat your fill of other foods. You will be counting grams of carbohydrates, but how hard is that when you can fill up on foods like steak and eggs? Also, Atkins promises, you won't be hungry. No more going to bed at night feeling famished, hardly able to wait for the next morning when you can eat again. No more obsessing over the next meal, feeling a gnawing hunger even as you finish your meager allotted portions of the meal you are eating. His diet, Atkins stressed, was nothing like those food-deprivation diets that almost everyone who struggles with their weight has tried and tried again. His diet really was a program you can happily follow for the rest of your life. "With Atkins, you'll get the results you've dreamed of without the agony of deprivation," he insists.
LEARN's message is that if you want to lose weight, you have to face up to a punishing reality—you probably will never be eating your fill, and you will always be keeping track of what you are eating and how much. You will always feel that edge of hunger. But the program will teach you how to manage. You will learn to monitor your food, and to stop eating before you are sated. You will learn tricks, like putting your fork down between bites of food, that will slow you down and help you eat less. You will learn to recognize portion sizes: what a 4-ounce piece of steak looks like, or a medium apple, or a 1-ounce slice of bread. And that training will stand you in good stead for the rest of your life as you try to keep your eating under control. "Let's face it—losing weight is hard work and maintaining weight loss can be even more challenging," the LEARN manual bluntly says.
Atkins says that carbohydrates are diet traps, making you put on weight despite yourself. If you greatly reduce the amount of carbohydrates you eat, he promises, your body's metabolism will change so you start burning your own fat for energy and you lose weight.
LEARN says that the source of your calories is not the issue—it is how many you are eating that matters. Consuming too many calories is what makes you fat, and if you want to lose weight, you have to count them rigorously every day. There are no forbidden foods, but your goal is to eat healthfully, so you are to choose foods consistent with the U.S. Department of Agriculture's food pyramid while keeping careful track of your calories. That means keeping a food diary, weighing and measuring what you eat, and choosing foods that are low in fat. It means a diet that emphasizes fruits, vegetables, grains, and cereals.
The advice embodied in LEARN is pretty much what has been urged upon Americans for decades, yet it is advice that few have followed. STRIVE FOR 5 say the cheery signs in Wegmans food markets, a chain of supermarkets in the Northeast, exhorting customers to eat five or more servings of fruits and vegetables each day. But if you just turn your head, you will see the warm loaves of bread piled behind the bakery counter, the cheese breads and oil-coated focaccias next to the long loaves of French bread, which, as almost every dieter knows, are made without fat. And scattered about the aisle of apples— thin-skinned red McIntoshes, next to speckled Cameos, next to shiny green Granny Smiths, next to a pile of ovoid Pink Ladies—are little plastic pots of caramel dip. Life is hard for the resolute.
But the LEARN program was never supposed to be the academics' answer to fad diets that promise miracles. It began about as modestly as a diet can, as part of a Ph.D. dissertation by a young psychology student at Rutgers, New Jersey's state university. The year was 1976, and the student, Kelly Brownell, was testing the hypothesis that dieters would be more likely to succeed if their spouses got involved with their weight loss program. The idea was to help spouses be enablers, and not dissuaders, by teaching them to keep temptations out of the house, to prepare low-calorie foods, and to help the dieters eat three measured meals a day with only preplanned snacks in between.
So Brownell wrote a diet-and-behavior-modification program for all the dieters in his study to follow and a companion program for spouses. His plan was to recruit overweight people and, in keeping with the rigors of scientific research, assign them to different programs. One group would get the diet program and behavior modification program along with a companion program for their spouses. Another group would get the diet program and behavior modification, but their supportive spouses would have no special instructions or training. There also would be a third group of dieters, people who wanted to lose weight but whose spouses said they were completely uninterested in helping in any way. Those subjects would get the same diet and behavior modification as the others, but in all likelihood, they would get no additional help or support at home.
The program manual was all-important to the study because it was the key to making sure that everyone got the same weight loss advice, no matter who administered it. The three groups of subjects would meet with different facilitators, so Brownell had to be certain that they were told exactly the same things about diet and behavior modification.
"We basically wrote a protocol on how to deliver treatment for obesity," Brownell says.
The study got under way. Brownell recruited ten obese men and nineteen obese women, with an average age of forty-five and an average weight of 208 pounds. The weight loss treatment phase of the study lasted ten weeks, with weekly ninety-minute sessions on diet and behavior modification. That was followed by six months of a maintenance program, with monthly meetings.
As Brownell expected, people did best when their spouses were actively involved—that group lost, on average, 20 pounds in the first ten weeks and another 10 in the six months that followed, losing twice as much as the group whose spouses were not cooperative or those whose spouses were involved but were not taught how to help.
Brownell's dissertation went smoothly—he handed in his neatly typed Ph.D. thesis, he sailed through the requisite grilling by faculty members, and his study was published in 1978 in Behaviour Research and Therapy. He ended up with a faculty position at the University of Pennsylvania, where he continued his research on how to lose weight and maintain weight loss. But, to his surprise, the manual that he wrote for his dissertation was becoming a hit at academic medical centers.
"One of the most interesting outcomes was that people wanted this book on how to do behavioral therapy. We started to copy it and send it out, but we were breaking our bank just sending it out. We started asking people to pay for photocopying, and then we started revising it, making it longer because we were learning more. Soon we started to ask, Should this get published?"
But publishing the manual as a book was problematic, Brownell realized. What was the point—to have his book become part of the vast ocean of diet books that appear each year and then vanish, out of print? To have his book, if he was lucky, appear on a table of new books in bookstores, then move to the store's shelves, first displayed face out, then with just its spine showing, and then piled in a remainder bin? And were eager dieters really going to grab a book about a program called LEARN, a program that says that weight loss should be slow and steady and that maybe you will never get to the weight you think is your goal, but losing even a few pounds is good for your health?
"Diet books have a short half-life. You have to have a gimmick, and you have to do what Atkins did, find a diet that makes people lose weight really fast," Brownell says. (He says the Atkins gimmick is to place such stringent restrictions on what people can eat that they end up eating many fewer calories simply because so many of their favorite foods are off-limits.)
Yet academic researchers wanted the LEARN program, and Brownell wanted to provide it. He decided to form his own publishing company, American Health Publishing Company. By publishing the manual himself, he could keep his book in print, revise it every year, and make it, he says, "user friendly."
"We put all the expertise in there, but in an engaging, optimistic, even humorous format," Brownell says. There are cartoons—Cathy and Garfield are particular favorites. And scattered little boxes of text give helpful hints with headlines like "Did You Know?" ("Did You Know? Underestimating your daily caloric intake by as little as 100 calories a day can add more than 10 pounds of body weight each year.") It looks like a high school textbook, not a typical diet book, and there are no inspiring tales of dramatic weight loss or lives transformed by the diet. The chapters end with little quizzes, and dieters are given homework, like a form at the end of Chapter 2 in which to write down what they ate; what time they ate it; their "feelings"; their activity, if any, while eating; and the calorie count of each meal. They get a list of the calorie content of foods, and they get advice on sticking to the diet that is not particularly revolutionary but, Brownell says, has proven to be useful—keep tempting foods out of the house, shop when you are not hungry, keep records of what you are eating, get regular exercise.
Brownell also took pains to be strictly ethical about his program. As founder of the company, he explains, "evaluations by me would be a conflict of interest." But other academic groups evaluated the program, with results, Brownell said, that varied from place to place and context to context.
"Sometimes it was the main treatment. Sometimes it was used in the control group. Sometimes it was used with medications. Sometimes you get very skilled people using it, and sometimes you don't." So it remained on the scene, familiar to obesity researchers, unknown to most of the public, rarely criticized, generally accepted, and with an air of wholesome, earnest healthfulness. It was, of course, nothing like the story of the Atkins diet.
More than a decade before Brownell wrote his program, a New York cardiologist, Robert C. Atkins, was trying to lose weight. He read about a low-carbohydrate diet in the Journal of the American Medical Association and tried it on himself in 1963. It worked, he said— pounds just evaporated. So he decided to remake himself as an obesity doctor. He turned his medical practice into an obesity clinic, putting his own patients on the diet. Then he wrote a book promoting it. Published in 1972, Dr. Atkins' Diet Revolution told people they could eat all the fatty foods they wanted as long as they kept a tight rein on their carbohydrates. By keeping their carbohydrate levels down, Atkins said, people would keep their insulin levels down and would keep hunger at bay. The book was an immediate bestseller, and immediately raised the ire of academic medical experts, who said the diet was crazy and dangerous and that its high fat content would lead to high cholesterol levels, which in turn would cause heart attacks and strokes.
In 1973, the American Medical Association's Council on Foods and Nutrition published a blistering critique of the diet, calling it a "bizarre regimen," saying Atkins's ideas were "for the most part without scientific merit," and adding that while Atkins claimed that the diet would activate a fat-mobilizing hormone, removing fat from storage, no one had ever found such a hormone in human beings.
In April 1973, Atkins was called to testify before the Senate Select Committee on Nutrition and Human Needs. He appeared with his lawyer and said he stood by everything in his book, including his advice that pregnant women could safely go on the diet. Leading obesity and nutrition experts were appalled, testifying that Atkins's diet was dangerous and that they were aghast at the idea of telling pregnant women to follow it. "If I were a fetus, I would forbid my mother to go on such a diet," Karlis Adamsons, an obstetrician at Mount Sinai Medical Center in New York, told the Senate committee.
The diet's popularity waned after that, but then it waxed again. Atkins kept it before the public eye with his bestseller Dr. Atkins' New Diet Revolution, published in 1992 and again in 1999. Along the way, he founded a company, Atkins Nutritionals, to sell foods and supplements. But nothing about his program, his self-promotion, or his company sat well with academic medical experts, and his program retained a whiff of the unsavory, of quackery.
That began to change shortly before Atkins's death on April 8, 2003, after a fall resulting in a head injury. It was a time when everyone, it seemed, who had ever struggled with his or her weight was on a low-carbohydrate diet.
The low-carbohydrate fad began with a remarkable development, an article in The New York Times Magazine that seemed to vindicate the doctor and his diet. Written by Gary Taubes, a freelance writer who himself was on the Atkins diet, it was published on July 7, 2002, to immediate controversy in some circles and acclaim in others. The magazine's cover featured a juicy steak, glistening with fat and topped with a pat of melting butter. "What If It's All Been a Big Fat Lie?" the article was titled, and it argued that, in fact, fat does not make you fat. Carbohydrates are the culprit. The obesity epidemic was caused by the emphasis on low-fat diets, which, paradoxically, made people overeat.
Atkins was gleeful, proclaiming on his Web site that he had been proved right after all those years of derision:
Sunday, July 7, 2002, was one of the most gratifying days of my life—and one that validated the controlled carbohydrate nutritional approach to weight management and good health. This watershed article in a mainstream consumer publication accurately describes the scientific basis and effects of a controlled carbohydrate lifestyle, mirroring my conclusions from 40 years of clinical experience: The low-fat belief system causes individuals to over-consume high carbohydrate foods, which in turn has contributed to the current epidemics of both obesity and diabetes.
For months afterward, television shows, magazines, and other newspapers discussed the low-carbohydrate hypothesis, reciting dieters' reports that they had shed pounds nearly effortlessly when they gave up carbohydrates and dutifully noting nutritionists' excoriations, their fears that the diet was unhealthy, that it would promote heart disease, and that weight loss with this diet would never be sustained.
Meanwhile, the latest edition of Atkins's book, Dr. Atkins' New Diet Revolution, appeared in paperback and shot onto bestseller lists. It was, of course, nothing like the earnest LEARN manual.
In the Atkins books, the message is exuberance, enthusiasm, cheer-leading. The books feature inspiring case histories of people Atkins says were typical dieters who followed his program. He says he gave them pseudonyms. He also provides no details to convince a skeptic that what the dieters said was true, or even that these patients really existed. But their stories helped drive home the message. This diet, Atkins was saying, really works.
So, in his New Diet Revolution he tells of "Tim Wallerdiene," who lost 122 pounds in nine months and kept the weight off for two and a half years. His cholesterol level went down, and so did his blood pressure. The back and neck pain that had plagued him was gone. "I'm a better dad and husband," he proclaims. "My old phrase used to be, ‘No, I'm not up for that.' Now I love to play with my children."
Atkins makes exciting promises: "Lose weight! Increase energy! Feel great! This book will show you how it's done."
And he claims that the diet passed scientific muster. "Atkins works because, as an increasing body of scientific evidence shows, it corrects the basic factor that controls obesity and influences risk factors for certain diseases. That risk factor is insulin."
Then, in May 2003, the small pilot study comparing the Atkins diet with a low-calorie one appeared in the New England Journal of Medicine. For doubters, for those who worried that a low-carbohydrate diet might not be safe, that publication, in the nation's most prestigious medical journal, gave the diet a new legitimacy. It said that over the short term, at least, those who followed the diet did not end up with soaring cholesterol counts and they even seemed to lose more weight than the low-calorie group.
For the three researchers who conceived of the pilot study, those data inspired them to start their larger study. For millions of overweight Americans, the study inspired them to start a low-carbohydrate diet on their own.
By the time the Penn study began in 2004, low-carbohydrate diets were booming. Twenty-six million Americans claimed they were on one. At that time, when enthusiasm for the diets knew no bounds, sales of books promoting low-carbohydrate diets and specialty low-carbohydrate foods and beverages were expected to reach $30 billion. The low-carbohydrate dieters said they did not care if they were getting 40 percent of their calories as fat, nor did they care if the diets restricted their consumption of fruits, vegetables, pasta, and bread. What mattered was that everyone, it seemed, knew someone who had been on a low-carbohydrate diet and raved about it, proudly proclaiming that they had easily, effortlessly, lost weight.
Meanwhile, nutritionists were still warning that a calorie is a calorie and low-carbohydrate diets could be dangerous to your health.
And a few academic researchers were warning that the constant blame-the-victim message, the notion that anyone could be thin if they really wanted to or if they found the right diet, was not only demoralizing fat people but leading to a society in which prejudice against the overweight and obese has become the last remaining socially acceptable one. Telling fat people that substantial weight loss was imperative, as nutritionists and public health groups and physicians did, and telling them that there was a diet that would make them thin, as Atkins and other diet promoters did, was not helpful.
"Obese people get a level of abuse now that could not even be considered with any other group," says Jeffrey Friedman, an obesity researcher at Rockefeller University. Looking like a stereotypical rumpled scientist, long and lanky with no significant weight problem, Friedman is speaking not from personal experience but from his own research that showed him that sustained and substantial weight loss is problematic for nearly everyone. And he despairs over the plight of fat people.
Excerpted from Rethinking Thin by Gina Kolata.
Copyright © 2007 by Gina Kolata.
Published in First edition, 2007 by Farrar, Straus and Giroux.
All rights reserved. This work is protected under copyright laws and reproduction is strictly prohibited. Permission to reproduce the material in any manner or medium must be secured from the Publisher.
