Each year, US News & World Report publishes diet rankings based on the opinions of a panel of experts. This year, I served on the panel. In this post, I’ll discuss my general thoughts on the rankings, as well as the fact that the popular ketogenic diet tied for last place among the 40 diets.
The process
Here’s how it works. US News staff summarizes information on each diet– including the diet’s recommendations and what current evidence says about its effectiveness– and provides it to a panel of expert reviewers. This is the same information that is publicly available on each diet’s US News webpage. It’s not perfect but they appear to put in a good faith effort, and they ask reviewers to recommend corrections if anything seems off. On the basis of this information, as well as the reviewers’ existing knowledge and optional literature searches, reviewers are asked to rate the diets in a number of different ways on a scale of 1-5. These scores are then compiled into four areas that are shared with the public:
- How effective is it for short-term weight loss?
- How effective is it for long-term weight loss?
- How easy is it to follow?
- How well does it support general health?
Note that these “diets” also often include lifestyle modification advice, such as physical activity, and these are considered in the scoring. US News also provides an overall score for each diet, which I suspect is an average of the four scores above.
General thoughts
The diet ranking system is necessarily an imperfect process. With 40 diets to review and rank, there isn’t enough time to do comprehensive literature reviews to get the best possible picture of effectiveness for each diet. This less-than-comprehensive approach leaves a certain amount of room for uninformed opinions to substitute for evidence, particularly in areas of evidence that reviewers may not be very familiar with. Still, the information it provides should be more helpful for selecting diets than the current alternatives, like reading Amazon reviews, Googling, or asking your aunt Martha.
The review panel includes people with a diversity of backgrounds, and they don’t agree on everything. This is probably by design. I often agree with the opinions of the rest of the panel, but there are also a number of places where I disagree. I’ll discuss a few of those below. I want to emphasize that the point of the exercise is not for everyone to agree.
For the first time, the Mediterranean diet secured the top spot for best diet overall, tied with the DASH diet. I think this is appropriate. The science of nutrition and chronic disease is complex and uncertain, but in my opinion the Mediterranean diet has more convincing evidence supporting its efficacy for general health than any other diet. It’s also relatively easy to follow, which supports long-term compliance.
However, it’s not really a weight loss diet and there is very little evidence that it causes weight loss as typically applied. Hence, I’m confused about why other reviewers rated it as an effective weight loss diet, especially in the long run. I suspect this has to do with two factors. First, a well-known randomized trial by Shai and colleagues found that a calorie-restricted Mediterranean diet caused weight loss that was similar to a low-carbohydrate diet, and superior to a moderate low-fat diet, over a two-year period (1). Four years after the end of the study (6 years total), people who had been assigned to the Mediterranean diet were maintaining their weight loss better than people who had been assigned the other two diets (2). Second, human nature. When we like something in general, that favorable opinion tends to color our view of more granular aspects of it, even if it isn’t deserved.
I think that if you adopt a standard Mediterranean eating pattern that doesn’t involve calorie restriction, you may lose some weight depending on what diet you’re coming from, but probably not much. I do think the diet shows promise for the long-term maintenance of lost weight, as suggested by the Shai trial.
This issue came up in a few other places as well. For example, the vegetarian diet was ranked fairly well for weight loss. This view seems to be based on observational studies showing that vegetarians tend to be leaner than their meat-eating counterparts. Yet there is little direct evidence that vegetarian diets promote meaningful weight loss, and if you expect to lose a substantial amount of weight just by cutting meat out of your diet, you’re probably going to be disappointed.
The ketogenic diet
The ketogenic diet is a very-low-carbohydrate, high-fat, moderate-protein eating style that forces the body to run almost entirely on fat for fuel. It’s extremely popular right now. Although the popularity of individual diets waxes and wanes, I tend to think that there is usually a nugget of truth underneath the hype.
The ketogenic diet limped in to last place in the rankings, tied with the Dukan diet (a high-protein, low-carb/fat rapid weight loss diet). It was rated by the panel as fairly effective for short-term weight loss, not very effective for long-term weight loss, very unhealthy, and very difficult to follow. Unsurprisingly given its popularity, the snub was not well received by ketogenic diet fans.
I don’t remember exactly how I rated it myself, but here’s the gist of it. I think very-low-carbohydrate diets like the ketogenic diet are some of the more effective diets for short-term weight loss– although no diet is a silver bullet (3, 4, 5, 6). Ketogenic diets also cause weight loss in animal models under tightly controlled conditions (7, 8, 9). I don’t know how effective it is for long-term weight loss and the evidence in humans doesn’t seem very informative to me, but I seriously doubt it’s less effective than diets like Mediterranean and vegetarian that aren’t even weight loss diets (10). In general, my observation is that the more extreme you are on the carbohydrate:fat continuum, the more a diet tends to promote appetite control and weight loss. Very low-carbohdyrate and very low-fat diets both tend to be more effective for weight loss than their more moderate counterparts, and I suspect this also applies in the long run, at least to some extent. This is supported by animal research, which mostly seems to suggest that ketogenic diets can curtail long-term body fat gain (11, 12, 13).
I probably gave it a 2 or a 3 out of 5 in health, assuming that someone is coming from a typical unhealthy diet. The primary reason for this mediocre score is simply that its long-term effects on human health aren’t well known. I can’t really say that ketogenic diets are unhealthy in the long run, but I also can’t say they’re healthy, and that uncertainty makes me feel wary. This concern is compounded by the fact that (to my knowledge) no traditionally-living human population has ever been shown to exist in a state of chronic ketosis, which the diet promotes. Even the arctic Inuit, who traditionally eat a high-fat, low-carbohdyrate diet, were not in chronic ketosis, and the reason is rather troubling for ketogenic dieters: A genetic mutation preventing ketone production spread rapidly throughout the ancestral Inuit population, suggesting that avoiding ketone production conferred a powerful survival advantage (14). Furthermore, few of the people reading this are descended from Inuit and their genomes weren’t shaped by thousands of years of eating the Inuit diet. The vast majority of traditional diets that have been documented contain enough carbohydrate and/or protein to prevent ketosis, although the amount of carbohydrate varies greatly (15). Long-term nutritional ketosis doesn’t appear to be part of the ancestral human metabolic spectrum. Contrary to popular belief, it is probably not Paleo or ancestral. Shouldn’t that worry us a little?
The animal research on the health impacts of the ketogenic diet is a mixed bag. The diet usually prevents weight gain and its effects on lifespan are either neutral or beneficial in mice, which is reassuring (16, 17). However, it tends to cause fat accumulation and inflammation/injury in the liver and other tissues (18, 19, 20, 21, 22). Its effects on insulin sensitivity in animal models are inconsistent between studies. Rodents don’t naturally develop human-like cardiovascular disease, so they can’t help us understand the diet’s long-term impacts on the heart and blood vessels.
That said, we do have multiple randomized trials of very-low-carbohydrate diets, and they have generally found little evidence of harm, and some evidence of benefit, in people who have obesity and/or diabetes in the short-to-medium term (23, 24, 25). About the worst we can say is that they don’t lower “bad” LDL cholesterol as much as other diets. These findings make it seem less likely that the long-term effects are catastrophic. It’s also hard to deny that some people appear to benefit from the diet– particularly people with blood glucose control problems such as diabetes. If the alternative is having poorly controlled blood glucose, using blood glucose-suppressing drugs, and injecting insulin, I can see how a very-low-carbohydrate diet would start to make sense. We still need studies on whether the diet can prevent the complications of diabetes such as heart attacks. For people who are overweight, have blood glucose control issues, and who react well to it, very-low carbohydrate diets seem like a viable option and they don’t appear to cause obvious harm. We still have uncertainty about the long-term effects of such a diet, but given the alternatives I don’t think it’s unreasonable to try it.
Let’s be honest though– most people can’t stick with it. I agree with the other reviewers on this. The more extreme a diet, the harder it is to adhere to, and the ketogenic diet is extreme. “But wait”, you say, “I’ve been on the ketogenic diet for five years and it’s easy!” That may be true, but randomized controlled trials don’t lie. The average person can’t even stick with the diet for six months, as judged by urinary ketone levels (26, 27). The minority of people who find it easy, get good results, and stick with it are the ones who write about it on the Internet.
For the record, I’m not against the ketogenic diet and I doubt it’s a health disaster for people who tolerate it well. I do think people who adopt it should be aware of the uncertainty about its long-term effects. As with any extreme diet, it has strengths and weaknesses and it’s probably best viewed as a medical intervention akin to drugs and surgery, rather than a tool for supporting general health. I think it’s interesting enough that it deserves further research, particularly in the setting of diabetes.
Nice post. Thanks for explaining your views.
Res diabetes: you will perhaps find it interesting that there have been no studies for those diabetics who maintain A1Cs of 5.0 or below. (Actually 6 and below maybe). My retinopathy did not merely stop, it reversed when I went below 5. Ophthalmologist said I was his only patient who did this. Likewise healing after injuries or surgery. My suspicion is that low carb (me), ketogenic helps to lower BGs, but well dosed insulin can do equally as well. People who eat lots of carbs and use lots of insulin tend to gain weight. I suspect it is the food and not the insulin which is the cause.
If you know of any studies of diabetics who maintain truly normal BGs/A1Cs I would be interested in reading them.
Read Dr Richard K Bernstein’s book. Diabetes Solution. He has maintained normal A1c’s for decades. He’s a type 1, in his 80’s and still practicing. Thousands of diabetics (myself included) follow his teachings. There is also plenty of studies done on PubMed.
Valerie – I too got my info from Dr B. I do eat a few more carbs than he recommends, but not that many.
Informative post, thanks Stephan.
Have you written about the effect of prolonged chewing on satiety? Would chewing each mouthful, say, 40 times increase the effort taken to get the calories?
Also re food combing. Would avoiding mixing fat and carb at each individual meal lower the pleasure factor but still allow a person avoid the craving that might come from missing out on a major food group?
What are your thoughts on moderate consumption of both fat and carbohydrate? Something like 40% carbohydrate and 40% fat? There are a lot of conflicting views on the internet, with some researchers claiming there is no healthy medium. The diet must either be ketogenic or very high carb, to induce a state of carbosis, a term I believe coined by Denise Minger. Does the Randle Cycle play a part in all this? I personally feel better on moderate fat and carbohydrate, and both ends of the extreme spectrum leave me feeling lethargic and cold.
40-40-20 is a completely normal eating pattern, consumed by billions of healthy people, as long as it’s real food of course. However, if you’re morbidly obese, or has some serious health problems, many do seem to benefit from going to either extreme end of the scale. But that doesn’t mean it’s ideal for the great majority of people.
I too feel best when having more fat and carbs. And as long as I don’t bring ultra processed food into the diet, mainting a good body composition is easy.
Hi Robert,
This comment is a bit speculative but I’ll give you my opinion. I think 40:40 carbohydrate:fat is a perfectly healthy diet composition– in fact, I think something like that may even be optimal for someone who is currently healthy and has an appropriate calorie intake and is physically active. If left to their own devices (i.e., few financial constraints), humans in all parts of the world spontaneously gravitate toward a diet that is rich in both fat and carbohydrate, and I think there are good reasons for that. Fat and carbohydrate play different and complementary roles in the diet. Fat is very efficient at delivering energy and can be a good source of fat-soluble nutrients. Carbohydrate foods tend to deliver other types of nutrients and support high-intensity physical activity.
Our cells contain little nutrient/energy sensors (AMPK and mTOR) that measure whether we have enough nutrients to operate at full steam, in terms of fertility, physical activity, immune system, heat production, and other energy-intensive activities. These sensors are only maximally “turned on” when the body is receiving abundant carbohydrate and protein, and perhaps fat as well although I’m not as sure about that one off the top of my head. When these nutrient sensors are partially “turned off”, whether because we’re eating a diet low in calories, protein, and/or carbohydrate, they activate a sort of starvation mode and start to shut things down a bit. That’s not necessarily a bad thing and it may actually have benefits for metabolic health and longevity, but from the perspective of natural selection (reproductive success) it’s no good, which is why the brain pushes us to eat a bunch of everything. This results in most affluent cultures globally eating a fairly similar macro composition.
On an instinctive level, the human brain doesn’t really want cauliflower-crust pizza or fat-free ice cream, at least as compared to regular pizza and ice cream. It has a strong preference for tons of carbohydrate, fat, and protein all together because that’s presumably what maximized reproductive success in the environment of our distant ancestors. When you have access to food that is exactly what the brain wants, your eating drive is higher. Cutting out fat or carbs creates a less compelling palette for the brain and eating drive is lower. That can be helpful in today’s context, but it’s not really how our distant ancestors operated, unless they were forced to. People rarely eat ketogenic or very-low-fat diets unless they have a compelling reason to do so– it requires overcoming our intrinsic motivation to eat lots of all macronutrients.
So in my view, eating a diet that has abundant fat and carb is exactly what the brain wants and that’s probably because it optimized reproductive success in the ancestral context– which required a high level of physical and cognitive performance, high fertility potential, and good metabolic health. Eating like that can be somewhat risky in today’s context because it’s another variable that pushes us to overeat. But if the diet is whole-food-based, lower in calorie density, accompanied by physical activity and other supportive lifestyle habits, and eaten by someone who is not highly susceptible to obesity, I think it’s probably a very good way to eat. I don’t think there’s anything intrinsically harmful about it.
Ancel and Margaret Keys created the Med Diet after living in Italy for 20 years. Dixon has a good summary.
https://www.google.com/amp/s/howtocureobesity.com/2015/05/08/publication-of-my-book-on-the-discovery-of-the-mediterranean-diet-by-ancel-and-margaret-keys/amp/
What is more interesting to me is how this diet was applied by them in everyday life. Margaret turned her recipes into practice daily. Here is Bob Barnett’s description of a meal when Ancel was over 90.
http://bobbarnetthealth.com/wp-content/uploads/2013/02/AncelKeys.TONICS.pdf
Cocktails, wine, bread, squid, salad, fruit, vegetables and pasta! This is civilized living. Lots of variety, minimal meat, and lots of olive oil.
Both of them lived well past 90 eating this way.
This is quite different from the diet of Emma Morano who lived to be 117 – the longest living Italian on record. When she was around 20, her doctor recommended 2 raw eggs plus one fried per day to deal with anemia. She continued with this for another 90 years or so.
According to https://en.wikipedia.org/wiki/Emma_Morano: “In 2013, when asked about the secret of her longevity, she said that she ate three eggs a day, drank a glass of homemade grappa, and enjoyed a chocolate sometimes, but, above all, she thought positively about the future. She was still living alone in her home on her 115th birthday. In 2016 she credited her long life to her diet of raw eggs and cookies, and to staying single.”
I think getting enough phosphatidylcholine is important. It is generally depleted from our bodies as we get older, and then the organs don´t work so well, resulting in an acceleration of the aging process. It is also part of the reason for the poorer skin. Egg yolks and organ meats supplies an abundance of phosphatidylcholine. Beef brain and beef kidneys about 7 times more than ground beef. Milk is a decent source, while cheese and egg whites are not.
I looked at the limited available information I could get from the diet of over 100 of the longest living persons. Milk and eggs was mentioned quite a few times, but not cheese (or red meat). And so if one consider these diets and adjust for the choline-sparing nutrients like folate (found in foods like leafy greens and leguems) and betaine (spinach, wheat), there´s probably some correlation. Not sure what Keys really ate. I noticed he recommended calf liver at one point. But surely his diet must have been rich in the choline sparing nutrients.
By the way, the longest living person on record, Jeanne Calment, was French and lived to be 122. If you dig deeper into the traditional diets in France and Italy you would find that they included plenty of organ meat recipes (https://www.walksofitaly.com/blog/uncategorized/italys-most-esoteric-cuisine). Interestingly, another researcher, Fred Kummerow, lived to be 102 and was more inspired by the French diet and didn´t have a problem with saturated fats. In 1957 he was the first to publish a paper on the link between heart disease and trans fats, which was largely dismissed and ignored, however to some extent opposed by the food industry. At the same time Keys started the 7 country study, and seemingly didn´t even bother to look into the issue of trans fats. At that time trans fat consumption had gone up severalfold over the past decades and Americans ate as much margarine as butter: https://www.washingtonpost.com/news/wonk/wp/2014/06/17/the-generational-battle-of-butter-vs-margarine/?utm_term=.a116f9ed1a91
Today some people may feel that it´s not so “civilized” to eat the organs, but in my view it is far less civilized to eat just the chicken breast and throw away the rest of the chicken. This is wasteful and unethical and more animals will have to be slaughtered. Organs are also generally very nutrient dense so you can get away with less meat. We may not need much meat, but we want some to avoid getting into a type of lobotomized state resulting for example in depression and in younger persons problems in relation to reproduction, as is sometimes seen in vegans and raw foodists. In a study I think it was shown some sort of u-shaped curve where more or less than 150 grams of red meat 3 x daily increased depression
Sorry, “more or less than 150 grams of red meat 3 x weekly”, not daily.
guiseppe from what I can tell the Keys’ weren’t much of egg eaters. They were mimicking what they saw in an attempt to match the pattern of improved CV health they saw in the Seven Nations study.
The two of them would have been eating the 1940’s version of SAD before WWII. Keys reportedly developed the K ration using foods he bought at the A&P grocery store. He was a smoker until at least the 50’s. So the Med was something they switched to in middle age.
In the predecessor to the Med, Keys had harsh words for the training table diet of UMinn athletes, which consisted of lots of milk and meat. It is effective for rapidly building muscle but the middle aged ex-athletes that kept eating it had high incidence of CV problems. No doubt smoking was a cofactor.
Guiseppe by the late 50’s Keys was treating margarine and shortenng as undesirable hard fats the same as butter. Margaret’s 1950’s recipes use vegetable oils. By the 1970’s they had switched from these seed oils to olive oil.
In my own experience oil works ok in baking. But for flavor and texture hard fats work better. More rewarding, especially for flaky pastries.
thhq,
I should also mention that all “eggs” in nature – from fish, shrimp, snail, goose and so on – have a high choline content. Fish eggs actually supplies much more choline per gram than regular eggs. Traditional people usually eat these eggs and consider them valuable. Weston A. Price found that many of the groups he studied stressed the importance of fish egg consumption in relation to reproduction, both mothers and fathers-to be, during pregancy, and for growing children. The Eskimos, and Indians in Peru used dried fish eggs (try and search http://gutenberg.net.au/ebooks02/0200251h.html for “fish eggs”). We do not eat so much fish eggs anymore, but in Japan it is still widely consumed.
Regarding calf liver, it seems this mentioning came from the book “Eat well and stay well the Mediterranean way”, first published in 1959. It says: “eat less fat meat, fewer eggs and dairy products. Spend more time on fish, chicken, calves´ liver, canadian bacon, Italian food, Chinese food, supplemented by fresh fruits, vegetables and casseroles.” So it reflects what you said about the Keys´ diet.
Kummerow´s diet was different; he had 3 glasses of whole milk most of his life, plus an egg fried in butter for breakfast, but also plenty of fruits and vegetables and some whole grains and potatoes. He stressed the importance of getting enough protein, needed to handle the fat (http://archive.wphna.org/wp-content/uploads/2015/06/WN-2015-06-01-02-72-78-Idea-Fred-Kummerow-My-diet.pdf).
I think studies have suggested a u-shaped curved where more or less than 800 mg calcium/day is associated with increased cvd mortality. But this must be seen in the context of a standard unhealthy diet which does not meet the recommended intake of magnesium, being relatively low in fruits, vegetables, legumes, whole grains, nuts etc. Calcium competes with magnesium for absorption and a lack of magnesium increases cvd risk. Kummerow actually found that even moderately high amounts of vitamin D fed to pigs led to atherosclerosis when the diet was low in magnesium. With enough magnesium it wasn´t a problem. A study found that men with the highest intakes of *both* calcium and magnesium (> 1224 mg Ca and > 386 mg Mg) were protected against metabolic syndrome. The RDA was enough for the women, but not the men (https://www.ncbi.nlm.nih.gov/pubmed/26259506). It should be noted that the bioavailability of the magnesium in milk is much higher than in grains, so the fact that milk has a high 10:1 Ca/Mg ratio can be misleading. Milk is also rich in potassium which can protect against cvd. Cheese is very different, having a 20:1 Ca/Mg ratio and is rich in salt and lacks potassium. Also note that in these studies most of the calcium would have come from dairy products. Without dairy one should be cautious about magnesium (and probably get at least 1.7 Ca/Mg). The Japanese seems to do fine but they also eat only white rice.
There is always the kefir option. Apparently I digest that well, much better than yogurt. I travel to japan often for work, there too, somehow, I digest yogurt very well. Yogurt has similar K content as milk, and so will kefir, which produces less whey.
I will go a bit further than Guiseppe and say that you can cut the meat entirely and just eat offal. It has to be grass fed. Supermarket liver is very not appetizing, probably because it belonged to a diabetic animal (as all CAFO animals are) and is shot through with fat. I am shocked that my meat is basically free. We get a grass fed steer to split among families, and no one wants the liver, the heart, the marrow, and the back fat. I get them all. The farmer charges for the carcass weight, that is, just for the meat.
Another two reasons to eat moderate meat: the two longest living groups, Okinawans and sardinians, gravitate around 200 grams/day or less. For longevity, you definitely want to have low mTOR for good autophagy. You get it with intermittent fasting or with low proteins. There is a reason why vegans, despite their smaller brains and nutrient starvation, live longer than western meat eaters (who average 300+ grams/day).
so offal and shellfish and egg yolks will increase the nutrients per gram of protein. You also spare specifically your methionine by intaking the methyl donors Guiseppe so often posts about. Otherwise methionine, already insufficient in most protein foods, gets used for things other than tissue building.
I agree glib. But it´s also worth considering that organ meats such as liver and lungs can be quite high in iron, which is not ideal for longevity if consumed in excess. Additionally they are rich in cholesterol and so they should not be fried at high temperatures in PUFA-rich vegetable oils, otherwise the cholesterol could oxidize. Also the diet itself should have enough antioxidants from fruits and vegetables etc so as to protect this iron and cholesterol from oxidizing in our bodies. However organ meats are also typically rich in antioxidant nutrients like selenium and sometimes vitamin C. (Nutritiondata.com suggests 100 gram beef kidney supplies around 140 mcg selenium, 7 times more than ground beef, whereas 100 grams of beef lung supplied 40 mg vitamin C).
I just read that 2 billion people worldwide suffer from anemia. It is particularly widespread in the the developing countries. They commonly suffer from a lack of vitamin B12, folate, vitamin A, zinc and iodine. Circulating vitamin D levels are generally low even with much sunshine exposure, the problem likely being that the vitamin D they get from the sun is used up in an effort to try and absorb more of the little dietary calcium they get, and this is further complicated by the consumption of phytic acid rich foods like legumes and whole grains. It is interesting to consider all of this in light of the vegan type of diet, as what can happen for growing children on such a plant based diet if it is not well planned and/or have added vitamin and mineral supplements. It also illustrates the power of organ meats like liver compared with muscle meat; just a small amount of liver would fix many of these nutritional deficiencies (B12, iron, folate, vitamin A, and to a lesser extent zinc) and milk could supply the rest (iodine, calcium, zinc, and some vitamin D). Conversely, even heroic amounts of chicken breast would not fix most of these deficiencies. One solution would be to ship canned dog or cat food made of bone meal, organs and muscle meat to the worst affected countries. A few tablespoons per day of that fare might do wonders. (Considering that 1/3-1/2 of the 500 million or however many dogs and cats are found in households in the developed countries are overweight or obese, there could potentially be a big surplus of this food if the owners decided to put their pets on a calorie restricted diet.)
that is yet another reason why the sweet spot for animal proteins (for longevity, after reaching adulthood) is between 100 and 200 grams a day, with as high a micro-nutrient density as you can get. Animal fats are, IMHO, unrestricted once you eat a big enough salad and perhaps some other functional vegetable foods.
I’m currently aiming for something like 100-150 gm meat/fish per day of which red meat 2x weekly. Unlike you I haven’t access to a variety of high quality organs, so it’s just liver once monthly or something. On top of this 2 eggs or egg yolks and 500 ml milk and a small amount of legumes. For fat mostly olive oil, a small amount of nuts and a decent amount of naturally occurring animal fats, total around 40E% fat. Not sure if this is optimal or not.
Was thinking about the fatty liver in feedlot animals you mentioned. I found that even wild geese can get this from feeding on relatively beneficial (but low protein) foods like olives, acorns, figs and some seeds. https://www.npr.org/sections/thesalt/2016/08/01/487088946/this-spanish-farm-makes-foie-gras-without-force-feeding
I am going in the same direction too. To further limit proteins, iron and phosphorus, I want to eat more ancestral carbohydrates which provide most of the benefits of beans and nuts but without the excess nutrients. I can not find good quality chestnuts and acorns, and of course things as breadfruit are unavailable, so it is going to be more squash and sweet potatoes.
I would do milk as well but I only digest well goat milk and this area is too cold to have many goats. I don’t think it is a matter of A2 versus A1, last time I was in Sardinia I ate fantastic pecorino (all A2), but my nose was completely stuffed. I also note the benefits of high Omega 3 for me, so over time I have to find a way to get more sardines and mackerel (not easy in the Midwest).
Yes, a study suggested > 1400 mg phosphorus/d was associated with increased all cause mortality. I estimated my diet example is at around 1300 mg. An advantage of eating some refined calories like olive oil, honey or white rice is to reduce the phosphorus density of the diet. But as you say, tubers (and fruits) have a low amount of P too. Another solution is to have a salad with for example tomatoes and plenty of olive oil.
In the 7 countries study it appears the Greeks obtaining 40E% fat, most of it from olive oil, and the Japanese, which have used only white rice the past 100 years, by far had the lowest all cause mortality upon follow up.
Problem with cheese is that it lacks so many valuable nutrients found in milk. It is telling that the diet of the 100 longest living persons (justpaste.it/longlifediet) seemingly didn’t include much cheese, even yoghurt, but commonly milk and even ice cream. I also couldn’t find the word beef or red meat mentioned at all, but chicken especially, and also fish and bacon (all low iron), as well as eggs, was mentioned many times.
I think probably milk intolerance has been exaggerated. Just start with a very small amount with a meal, like 1/4 cup and then gradually over the course of a few weeks work up to desired amount (with meals). Goat and sheep milk are more concentrated so 400 ml equals 500 ml cow milk in terms of calcium. If lactose is an issue it may be more related to some underlying digestive disorder, if this is the case then fructose malabsorption is also typically present.
I took a look at the longlifediet link. Unsurprisingly, it is mostly women, and they never like meat. So there may be a bias there.
Good point. I counted only 21 males (out of 100) on the list. But this is still a substantial number of people. Males in general eat more iron rich types of meat than females. I just read that in the US, males consume about 75% more pork and beef than females. For fish and poultry it isn’t a big difference. Interestingly milk was mentioned for two of the three Japanese males («he enjoyed drinking milk every day» and «he ate vegetables and drank milk daily»). Often I hear the argument that Japanese live so long because of low intakes of dairy and saturated fats. But the foods supplying the most iron, like beef, generally are richer in SAFA, and Japanese eat less of those too. Fish is very low in iron (just like dairy).
Forgot to mention that adding 1-3 tsp vinegar per cup of milk (and let it sit for 10 min or so) may be enough to prevent the milk intolerance for most people. I don’t think an excess of lactic acid bacteria are such a great thing and they aren’t found much in our intestines.
Perhaps you do not live in the US, and you have no idea how vile supermarket milk is here. And raw milk is illegal in my state.
No, I don’t live in the US.
One initiative seen some places in central/south Europe (especially Italy) is the raw milk vending machines. Would have been a good idea to do something similar in the US. https://modernfarmer.com/2014/03/americans-envy-europes-raw-milk-vending-machines/
But I still think you can get much of the benefits of milk by drinking pasteurized or even ultra pasteurized milk. If the only option is milk from grain fed sick cows, I agree it would be better to avoid it.
That’s a very useful update on these diets. Really appreciate the overview from your experienced observation. Thank you.
There is actually a systematic review, published last year, on the weight loss efficacy of 20 of the diets in the US News & World report: http://www.mdpi.com/2072-6643/9/8/822 There were most trials of the Atkins diet.
Thanks Erik.
By excluding diets which control calories, this review leaves out Weight Watchers, which is US News’ most effective weight loss diet in 2018.
https://www.usnews.com/info/blogs/press-room/articles/2018-01-03/us-news-reveals-best-diets-rankings-for-2018
US News does not give Atkins a high ranking in any of their categories.
Do you have any views on cutting out wheat as a weight loss strategy? I gave it up a bit over a year ago, not for weight loss reasons but because I found that doing so cured my heartburn, but in doing so, without trying to cut calories etc, dropped about 30lbs within a few months – though about 6lbs of that has subsequently come back. I subsequently found out that that is pretty much in line with William Davis of Wheat Belly fame’s claim that people doing so tend to lose around 25-30lbs, which I thought was interesting. Is there any support in the literature for the idea?
“. Is there any support in the literature for the idea?”
– That is, above and beyond the fact that dietary restrictions tend to lead to some weight loss generally (though usually not, I’d have thought, as much as Davis’s claim).
Hi RP,
The fact that you lost weight doesn’t surprise me (although 30 lbs is pretty good) and there is indirect evidence supporting what you experienced. Wheat is found in many of the most calorie-dense, palatable, lowest-satiety foods in our diet. I can’t speak to your diet specifically, but Americans in general eat a lot of sweet/fat bakery goods (cake, cookies) and bread, usually made from white flour. Most things made from flour have physical properties that drive higher calorie intake by multiple mechanisms. Almost anything you replace cookies, cake, and pastries with will be less fattening, and bread is pretty fattening too in my opinion (whole grain probably less so, but it’s still fairly calorie-dense due to low water content).
You probably eat less carbohydrate and more protein now as well, which tends to reduce weight.
I suspect that if you had kept eating wheat but replaced all your flour intake with whole cooked wheat berries (lower calorie density and palatability, higher satiety per calorie), you would have experienced similar results, maybe a bit less. I doubt the gluten per se is the impartant factor. That’s my guess. But I don’t really know for sure, and neither does anyone else.
Well, I’ve been through dietary restrictions in the past, in order to lose weight. Removing wheat from the diet definitely helped me reduce total caloric intake almost without effort (initially). But this is not a long term strategy, unless you are truly intolerant to something in wheat (I am not at all).
What I found best for losing weight were the following strategies:
1- low carb, moderate fat, high protein (you have little choice: protein will be high here)
2- low fat, low processed foods (no particular care about protein)
3- lower everything (same whatever you eat, just less – either portion control or IF)
The easiest by far was 1, so long as it did not last too long (2 months max). You can’t keep that way of eating in the long run for sanity reasons 😀 and I tend to think it is rather unhealthy long term.
The 2nd way was easy to start with but can be annoying at times because sometimes, you just feel like some fatty stuff (bread and butter, fatty meat, etc). I’d say it is better in the long run than 1- if you are not becoming a no-fat nazi. And if you are in a situation that is conducive to regular home-cooking (I am), then it is a matter of habit (both at home and in the grocery store).
The 3rd one is hard. I tend to eat solid meals (no snacking) and eating only 1/2 or 2/3 of it feels like I am not fueling myself enough. You also reduce protein in that way, which in a calorie deficit is probably not a good idea.
For maintaining my lean self, I chose 2- as the long run strategy with some looseness about fat intake once in a while. I combine it with moving (HIIT, weight lifting). I have not regain weight for 6 years now and I am pretty lean with nicely toned muscles – at last (I am a 43 y.o. male who was fat – skinny fat before taking the bull by the horns 6 years ago) 😀
“But this is not a long term strategy”
What makes you say that?
What makes me say that ? I am just talking from personal experience. If you can keep a wheat-free diet in the long run, that’s really up to you, but avoiding wheat itself even though you have no intolerance whatsoever is a little nonsensical in my opinion.
If you know that foods with wheat in them are too tempting (pizzas, cakes, pastries, you name it) then you should know that wheat is not the sole problem, it’s just used as a vehicle for flavors, calorie dense toppings, etc. The problem is the irresistible combo that wheat is involved in.
If you just make dull flatbread, I dare you to eat it plain and grow fat from it 😀
The major issue with wheat is that it induces a sneaky calorie creep-up because it is ubiquitous and made tasty (you heard about the bliss-point that the food industry is always trying to provide via its processed foods). Anything overriding the satiety signals is to be considered carefully before indulging. A shame really because wheat in its least adulterated form is quite healthy (unless you’re celiac). But it has become a liability really … again, a real shame.
The problem with restriction of food types for no other reasons than dieting is the potential for developing an eating disorder. I know it fairly well from my own behavior when I started browsing forums and blogs from diet gurus back in the days I was trying to lose weight by cutting carbs / wheat / sugar / fat / etc. It is not only unnecessary but also potentially dangerous if you do not exercise your critical mind in the face of these dubious claims.
No food deserves to be demonized. Instead, one has to look into his or her own habits (some are not even conscious). For me, it was a lack of physical activity and critical thinking about what I was shopping and doing. Today, I can eat anything I want but I had developed the habit of looking at what I eat and do from a holistic perspective. When you have this habit, you are much more mindful of your actions and what you ingest. So yeah, bring on the pizza, but I will be content with a small slice, which is why I don’t eat very often : most of it is wasted, and I have other foods that have higher priority in my kitchen.
Big freezer TA. That’s where my rewarding foods go, and I meter them out as needed. Easy-to-digest foods support lots of exercise, but are obesity/diabetes inducing if you’re sedentary.
The obesity crisis has been around for 20 years. People have been eating wheat, barley, einkorn, rice, etc for 100,000 years and not getting wheat bellies. IMO grain eating began in the cooking pits (steamed or dry roasted), to gel the starch and make it easily digestable by humans. At Catalhoyuk ca 9000BC there are the first rudiments of cooking vessels (baskets). Lots of grain was present. It was probably hearth roasted and/or used for animal feed.
Thanks for the reply!
In my case I didn’t each that much in the way of pastries or cake, but I did eat a fair bit of pizza and sandwiches, so that helps to explain it, and as you suggest it may be nothing to do with wheat (in particular wholegrain wheat) itself but the types of food wheat tends to turn up in. Thinking about it, the change has also not been entirely confined to wheat, as I also gave up all beer (I tend to think of that as a wheat product, but of course only some beer is made from wheat), which I also drank (though fairly moderately), in case there’s a gluten connection to the heartburn.
Still, I haven’t found it hard to keep up (though I have the heartburn thing as an added motivation, which many don’t), and I thought it was worth mentioning as for me it seems to have worked out as a pretty simple dietary modification that’s led to significant weight loss.
Stephan:
Did you see this response to your review of Taubes book?
https://blog.supplysideliberal.com/post/2018/1/16/the-case-against-sugar-stephan-guyenet-vs-gary-taubes
US News & World Report diet society is right …. the ketogenic diet is the worst of all ….
https://www.eurekalert.org/pub_releases/2018-01/gcrc-awh012318.php
https://www.ncbi.nlm.nih.gov/pubmed/7790697
https://www.ncbi.nlm.nih.gov/pubmed/16793577
Hi Stephan,
I hope you don’t mind if I use this (most recent) post as a forum to pose an unrelated question about something in your book (I wasn’t sure where else to ask it):
You write in the book that “One surprising implication [of Optimal Foraging Theory] is that hunter-gathers don’t often collect or eat vegetables – that is, low-calorie plant foods such as leaves. If you’re a hunter-gatherer it doesn’t make a lot of sense to burn 200 calories collecting 50 calories worth of salad.””
That makes sense, but how does this square with the general logic of ancestral diets? That is, why do vegetables and leafy greens appear to be so good for us (something I presume you’d agree with, but perhaps not) if they weren’t a significant part of our ancestors’ diet?
Why have our bodies evolved to make great use of, and arguably to require for optimal health, something we rarely ate until recently?
Thanks,
RP
Well, I am no expert in these matters but it just seems to me to be common sense: you forage what you can. So if you can’t find a calorie dense foods, you still need to come back with something, right ? yeah, veggies and plants / leaves were probably not a favorite in the camp, but it did provide something to chew …
Ancient brassica vegetables were just greenery. Probably not even eaten until laye Neolithic times. But there are so many forms now, from broccoli to cauliflower to cabbage. They have few calories and scant nutrients. Why did people want to eat them?
Easy to grow? Rewarding? Filling? For whatever reason we can’t get enough of them.
That makes sense, but the book doesn’t just say that HGs don’t prioritise vegetables/leaves, it says that they don’t often eat them.
Hi RP,
Here’s how I think about it: In HG diets, vegetable-like nutrition is built in to non-vegetable foods. They don’t have to eat vegetables to obtain complete nutrition because the calorie-containing plant foods they eat are high in fiber and micronutrients. For example, nuts, fruit, legumes, and tubers, which are often (not always) more fibrous and less caloric than modern versions.
Once you switch to a grain-heavy agricultural diet, the food is less nutritious and the nutrient profile is unbalanced (insufficient specific amino acids, insufficient vitamin C, not enough fiber diversity, polyphenols, etc). This is especially true if the grains are refined, but also true for whole grains. Adding complementary foods like vegetables (and beans, dairy, and meat) to a grain-heavy diet brings it back into nutritional balance.
If we look at the archaeological record, we see that the first agriculturalists were short and had a high prevalence of severe nutrient deficiencies. Yet over thousands of years, as humans adapted agriculturally, culturally, and perhaps genetically to some degree, we found foods that mitigate the shortcomings of grain-based diets and our stature and health rebounded. Vegetables are one of these foods. They provide nutrients you can’t get from grains or animal foods. My theory is that agricultural societies developed “cultural technology” that encourages eating vegetables because it’s healthier in an agricultural context.
But our brains are still in the Paleolithic, which is why most children don’t intrinsically like vegetables and we have to learn to like them through experience. If our nonconscious brain circuits were well aligned with the modern context, we would love the taste of kale so much we’d be happy to eat it plain (no salt, fat).
Thanks so much for the detailed reply. That’s fascinating and makes sense.
BTW I loved the book.
Thanks again,
RP
Thank you Stephan for this post. My son has Type 1 Diabetes and was diagnosed when he was 6 years old. There are those that swear by a ketogenic diet in terms of not only good blood glucose control, but also feel it is a healthier diet for someone with diabetes. The latter is what I am not so sure about and the lack of long term studies on the effects of being on a keto diet for decades, especially during the growth years of childhood, is a concern for me. Also, having my child on a highly restrictive diet, is like adding another burden on top of having diabetes. There is a psychological impact (especially for children) to being on such a restrictive diet and I’m not sure what the fall out from that would be. We are all just making the best choices we can, with the information that we have, but I do wish there was more research in this area.
I am no doc but from everything I read about the subject, keto diets for kids are only meant as a measure against epileptic fits. If your son is normal in this regard, what he probably needs is time-dosed insulin injections. yeah, it’s not cool, but if my kids were type 1, that’s what I would make sure they get. And today, I suspect that exogenous insulin treatments are not that bad in terms of daily comfort.
By the way, remember that normalizing circulating insulin in your child will probably help him NOT waste energy and grow normally. The keto diet is definitely NOT it in that respect, it is known to stunt growth in kids.
Thanks for directing me to the research on keto diets and children with epilepsy which was helpful because there is some long term studies. It does seem that there is some negative correlations for growth in children.
Thank you Stephen and All!
This is a really great “conversation” here (and as a researcher I especially love all the reference links ; ~ )
I found this site by way of a search intending to grok the foundational orientation of US News & World Report in their dietary assessment. I accept the “general thoughts” Stephen presents and especially that this perspective acknowledges the presence of “uninformed opinions” on the diets under evaluation. I agree that it is at least “an imperfect process”. I don’t know that it actually “should be more helpful” than other approaches. I have never looked at any of the “US News” reports over the forty seven years that I have been actively interested in diet and I am the most delighter with my dietary selections – at least over the last seventeen years.
A few days ago one of my research projects led me to Harvard’s school for public health and their praises of the Mediterranean Diet. That inspired my own review of the diet and my great affinity with the perspective presented by Sally Fallon. I deeply appreciate the following critial questions that she raises:
“The question that the believers haven’t asked themselves is this: Was the lean, so-called Mediterranean diet they observed after the war the true Mediterranean diet? Or were they observing the tail end of deprivation engendered by half a decade of conflict? Were the inhabitants of Crevalcore and Montegiorgio abandoning the traditional Mediterranean diet, or were they taking it up again? And did Keys miss the sight of Italians enjoying rich food in the early 1950s because Italians had never done such a shameful thing, or was the visiting professor too poor at the time to afford anything more than plain pizza in a sidewalk cafe?”:
https://www.westonaprice.org/health-topics/traditional-diets/the-mediterranean-diet-pasta-or-pastrami/
Ancel and Margaret could have chosen other diets chef. For the CV benefit I think the Italian peasant diet appealed to them more than the Japanese diet, which has similar benefits. Either way, it was their adherence to this lifestyle for 40 years that had the longevity benefit, vs the Minnesota SAD they previously ate.
The Okinawan diet is celebrated as being one of the best for longevity. But it is not traditional. Sweet potatoes were introduced to Okinawa in the early 1900’s by the Japanese government to improve the diet of the poor malnourished residents. They became a dietary staple.
One thing we haven´t discussed in relation to the longevity is stature. Shorter people generally live longer and this is thought to be one reason why females live longer than males (i.e. males are about 8% taller than females and have 8% shorter life expectancy at birth). https://www.ncbi.nlm.nih.gov/pubmed/12586217, https://www.ncbi.nlm.nih.gov/pubmed/1600586, https://www.ncbi.nlm.nih.gov/pubmed/26366551
All these long living people, from Sardinia, Okinava etc seems to have been very short statured. I found that Okinavan females at age 80 were just 142 cm, males 150 cm. The Kitavans studied by Staffan Lindeberg – free of modern disease – were just 150 cm for females and 161 cm for males.
Stature is one obvious thing that have changed over the past 100 years, and it correlates with an increased incidence at least of degenerative diseases.
Aside from the suggested “island effect” causing reduced stature in for example Sardinia and Okinava, I think probably diet could play a role. I´m not sure people were short statured only because of a lack of calories. Lindeberg found that the Kitavans had a surplus of food, for example. But lack of absorbable calcium could have been an issue.
This can happen with whole grain rich diets (high in phytic acid and magnesium, low in calcium). However in some countries/cultures this is balanced via higher intake of vitamin D, from seafoods, and some dairy products. In Okinava it seems they were eating mostly sweet potatoes, which has more absorbable calcium than whole grains. The Kitavans obtained most of their calories from tubers, plus some seafood and coconut products (their diet supplied about 20% of energy as saturated fats).
Proper reproduction is difficult on whole grain (and legume) rich diets, which is probably a reason why hunter gatherers do not eat them. However if the whole grains are soaked/fermented or cooked in a calcium rich medium like lime stone (calcium hydroxite), as is done in some traditional cuisines, they may become a suitable food, especially if some seafoods (vitamin D) and dairy (calcium) is added to the diet.
Not sure about the pygmies. The males are only 150 cm and life expectancy is very short. Whether it´s genetics or diet (like excessive intake of mongongo nuts or something).
Interesting observation on stature guiseppe. Unfortunately that’s not something we can do much about….
I pay attention to physical markers that I can change. Waist to upper thigh ratio as low as possible (mine is currently a little below 1.5) with minimum thigh circumference 24″, HDL above 50, systolic blood pressure below 130, 25 BMI, and a minimum 9 score on the sitting rising test.
https://www.usatoday.com/story/news/2015/02/26/sitting-rising-test-life-expectancy-fitness/24076407/
Yes, we shouldn’t forget about exercise! From what I’ve understood both Kummerow and Keys swimmed a lot, in my view the best type of exercise (at least in natural waters).
Re stature, http://www.happyhealthylonglife.com/happy_healthy_long_life/2010/12/ancel-keys.html suggests that Ancel Keys was only 171 cm (5ft7.5in). Perhaps that could have played a role in his longevity too.
The article also mentions that his typical retirement diet included 2% fat milk both for breakfast and lunch, and also jam for breakast and cookies and a sardine sandwich (rich in calcium from the bones I presume) for lunch. Likely they had some additional milk and cheese as part of the large multi course dinner. It seems unlikely that his diet was low in dairy and calcium as you kind of insinuated. I think if using his example we should be very careful to represent it accurately and not cherry pick to make it fit what is today politically correct (like what for example Walter Willett of Harvard recommends). In the Chinese population it has been indicated that < 1.7 Ca/Mg ratio is associated with increased cvd, cancer and general mortality when Mg is above the RDA. https://www.ncbi.nlm.nih.gov/m/pubmed/23430595/ I’m pretty sure the Keys’ diet supplied more Mg than the RDA, and then the amount of dairy could be extremely important, and there could be a world of difference between consumption of one and two glasses of milk. Vitamin D from sunshine in Pioppi and seafoods could however have indirectly increased the ratio.
A couple years ago I asked Henry Blackburn about Key’s physical characteristics. Here is his response:
On Dec 24, 2015, at 11:07 PM, Henry Blackburn wrote:
Why does anyone live to 100?
He had moderately long-lived parents.
He was active all his life but not a sportsman.
He always walked rapidly. Always moving about.
Crafts and builder around home.
I don’t know his measurements but he was 5ft.6 or 7
very muscular. Probably 180 lbs in his middle age.
Smoked “socially” pipe and rare cigarette and stopped early.
Grew up in California with fruits and veggies and you know how he loved and raised and prepared and enjoyed a Med. diet, some wine during much of his life.
Never overate. Tea and coffee modest.
A prodigious professional focused productive dynamic career. A few close friends. Spoke his mind, usually
bluntly. Close family.
Best, Henry Blackburn
https://www.sevencountriesstudy.com/about-the-study/investigators/henry-blackburn/
This article is what prompted me to contact Blackburn.
http://www.startribune.com/in-defense-of-u-research-the-ancel-keys-legacy/267581481/
Thanks thhq. In the link I posted above it was suggested his cholesterol was 209, but it does’t say when that was. I assume he didn’t use any pharmaceutical drugs?
That’s as far as I dug into it.
I was looking into other longevity cases at about the same time. It is difficult to get basic information about an individual’s physical measurements and daily diet. Harland Sanders, who lived to 90, was one of those. It was hard to find pictures of him eating his KFC, and I only found one reference to him eating a meal, which was a sandwich. So I infer that he wasn’t gorging on his fried chicken. He also traveled a lot, marching in parades everywhere. His whole restaurant enterprise started after he retired, so he stayed very active at an age where most people become sedentary.
So far as bacon and eggs go, Linus Pauling ate them for breakfast and lived to 93….but he also took megavitamins….go figure….
I see references linking the ketogenic diet with studies looking at the Atkins Diet. These two ways of eating aren’t the same. To my knowledge, few if any studies of ‘ketogenic diets’ replicate what a well formulated ketogenic diet looks like in humans in the real world. The studies often have too high a carbohydrate content and/or utilize less than healthy fats.
I’m not a fan of one-diet-fits-all, and I agree that staying in nutritional ketosis long term is a challenge, but I’ve personally had great success using it intermittently, including the resolution of a life-long sleeping disorder (idiopathic hypersomnia).