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Clinical Guide to
Popular Diets
Clinical Guide to
Popular Diets

Edited by
Caroline Apovian
Elizabeth Brouillard
Lorraine Young
Cover design concept created by Mary-Catherine Stockman, RD, LDN

CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742

© 2018 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-1-4987-7430-7 (Paperback)

     978-0-8153-8104-4 (Hardback)

This book contains information obtained from authentic and highly regarded sources. Reasonable
efforts have been made to publish reliable data and information, but the author and publisher can-
not assume responsibility for the validity of all materials or the consequences of their use. The
authors and publishers have attempted to trace the copyright holders of all material reproduced in
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Library of Congress Cataloging–in–Publication Data

Names: Apovian, Caroline M., editor. | Brouillard, Elizabeth, editor. |

Young, Lorraine (Physician), editor.
Title: Clinical guide to popular diets / [edited by] Caroline Apovian,
Elizabeth Brouillard & Lorraine Young.
Other titles: Popular diets
Description: Boca Raton : CRC Press, Taylor & Francis Group, 2018.
Identifiers: LCCN 2017048956 | ISBN 9781498774307 (pbk.)
Subjects: LCSH: Reducing diets--Evaluation.
Classification: LCC RM222.2 .C51945 2018 | DDC 613.2/5--dc23
LC record available at https://lccn.loc.gov/2017048956

Visit the Taylor & Francis Web site at

http://www.taylorandfrancis.com
and the CRC Press Web site at
http://www.crcpress.com
Contents
Introduction...............................................................................................................vii
Editors........................................................................................................................ix
Contributors...............................................................................................................xi

Chapter 1 The Atkins Diet..................................................................................... 1

Laura E. Matarese and Glenn K. Harvin

Chapter 2 DASH Diet.......................................................................................... 15

Thomas J. Moore, Megan Murphy, and Lin Pao-Hwa

Chapter 3 iDiet..................................................................................................... 35
Susan B. Roberts, Amy Krauss, Madeleine M. Gamache,
and Sai Krupa Das

Chapter 4 The Mediterranean Diet...................................................................... 53

Sally M. Cohen

Chapter 5 The Paleo Diet..................................................................................... 71

Laura Andromalos

Chapter 6 The South Beach Diet......................................................................... 87

Meghan Ariagno

Chapter 7 Vegan Diets.........................................................................................99

Sai Krupa Das, Micaela C. Karlsen, Caroline Blanchard,
and Susan B. Roberts

Chapter 8 The Weight Watchers Diet................................................................ 113

Megan Barnett

Chapter 9 The Zone Diet................................................................................... 127

Catherine Fanning

Index....................................................................................................................... 141

v
Introduction
As most clinicians know obesity rates continue to rise, with the most recent NHANES
data, from 2011–2014, indicating that 36.5% of US adults are considered obese.1 The
health risks of obesity are well researched and documented, including type 2 diabe-
tes, cardiovascular disease, hypertension, stroke, gallbladder disease, osteoarthritis,
sleep apnea, and some types of cancer.2 Modest weight loss of 5%–10% has been
shown to significantly improve obesity-related conditions.3 The physiology behind
obtaining this weight loss is a negative energy balance, however, the diet macronutri-
ent composition for the best results is still debated. The American Heart Association,
American College of Cardiology, and The Obesity Society performed a systemic
review of the literature and found that of the 17 diets with varying macronutrient
composition that have been studied, no diet was superior for weight loss or weight
maintenance. However, the biggest predictor of weight loss was determined to be
adherence to a diet.2 As a clinician, many patients may look to you to recommend
a diet program. Since no one diet has demonstrated superiority, it is important to
understand the available diet plans on the market in order to guide your patients to
the diet right for them; one they will be able to incorporate into their lifestyle for
long-term success.
This book will provide you with a non-biased review of several popular diets that
have been available and marketed for many years. The diets in this review include
The Atkins Diet, The DASH (Dietary Approaches to Stop Hypertension) Diet, the
iDiet, the Mediterranean Diet, Paleo Diets, South Beach Diet, vegetarian diets,
Weight Watchers, and the Zone Diet. Each chapter will give you an overview of the
diet, explain how the diet works, provide current research, illustrate typical results,
list the pros and cons of the diet, and suggest patients that would benefit most from
each diet. Our goal with this book is to assist you in guiding your patients to choose
a diet that is most appropriate for them and one they will be able to follow for long-
term results.

REFERENCES
1. Centers for Disease Control and Prevention (CDC). National Center for Health Statistics
(NCHS). National Health and Nutrition Examination Survey Data. Hyattsville, MD:
U.S. Department of Health and Human Services, Centers for Disease Control and
Prevention; 2016. https://www.cdc.gov/nchs/data/factsheets/factsheet_nhanes.htm
2. Jensen M, Ryan D. et al. 2013 AHA/ACC/TOS guideline for the management of over-
weight and obesity in adults. A report of the American College of Cardiology/American
Heart Association. J AM Coll Cardiol 2014;63(25):2985–3023.
3. National Institutes of Health, National Heart, Lung, and Blood Institute. Obesity
Education Initiative. Clinical guidelines on the identification, evaluation, and treatment
of overweight and obesity in adults. Obes Res 1998;6(Suppl 2):51S–210S.

vii
Editors
Caroline Apovian, MD, FACP, DABOM, is professor of Medicine and Pediatrics,
in the Section of Endocrinology, Diabetes, and Nutrition at Boston University
School of Medicine, USA. She is also director of the Center for Nutrition and Weight
Management at Boston Medical Center, USA. Dr. Apovian is a nationally and inter-
nationally recognized authority on Nutrition and Obesity Medicine and has been in
the field of Obesity and Nutrition since 1990. Her current research interests are in:
weight loss and its effects on endothelial cell function obesity and cardiovascular
disease, adipose cell metabolism and inflammation, resolution of diabetes and car-
diovascular disease in the bariatric surgery population, disparities in the treatment
of obesity in underserved populations, and novel pharmacotherapeutic anti-obesity
agents. She is also an expert in the technique for subcutaneous adipose tissue biop-
sies, and has been studying the relationship between adipose tissue inflammation and
obesity for over 10 years. Dr. Apovian was a member of the expert panel for updating
the 2013 AHA/ACC/TOS Clinical Guidelines for the Management of Overweight
and Obesity in Adults, published in Circulation and Obesity journals and was the
Chair of the Endocrine Society guidelines for Medical Treatment of Obesity pub-
lished in the Journal of Endocrinology and Metabolism in 2015.
Dr. Apovian was a recipient of the Physician Nutrition Specialist Award given
by the American Society of Clinical Nutrition. This was for her work on developing
and providing nutrition education to medical students and physicians in training at
Boston University School of Medicine. She has published over 200 original peer-
reviewed articles, chapters, and reviews on the topics of: obesity, nutrition, and the
relationship between adipose tissue and risk of developing cardiovascular disease.
Dr. Apovian has given over 150 invited lectures nationally and internationally and
currently serves as President Elect of The Obesity Society (TOS) for 2016-17.

Elizabeth Brouillard, RD, LDN, CDE, is the Nutrition Manager for The Center
of Endocrinology, Diabetes, Nutrition and Weight Management at Boston Medical
Center. She completed her dietetic degree at the University of Maryland and went
to New Presbyterian Hospital for her clinical internship. She has been a registered
dietitian for 10 years and has focused most of her career on weight management and
diabetes. She obtained a certificate in adult weight management from the Academy
for Nutrition and Dietetic and is a Certified Diabetes Educator. Elizabeth works in
outpatient settings and sees patients every day struggle to make diet and lifestyle
changes for weight loss and glycemic control. Many of her patients have tried several
different diets with varying success in the past and Elizabeth has been able to work
with these patients to determine which diet plan will work best for them based on
their current health, lifestyle, and food preferences.

Lorraine Young, RD, MS, CNSC, LDN, is the Clinical Nutrition Manager (CNM)
and Home Nutrition Support Dietitian at Boston Medical Center (BMC). This posi-
tion is part of the Department of Endocrinology, Diabetes and Nutrition. She is also

ix
x Editors

an Instructor of Medicine at Boston University School of Medicine. She is responsible

for the management of all in-patient Clinical Nutrition Services and dietitians for both
adult and pediatric patients as well as two pediatric outpatient dietitians. Clinically,
she manages all home parenteral and complex enteral patients discharged from the
hospital or referred to the Endocrinology, Diabetes and Nutrition Department, which
includes many short bowel patients and patients with Inflammatory Bowel Disease.
She has over 35 years of experience in the field of Nutrition Support as well as
in conducting clinical research with one of the original developers of parenteral
nutrition in the United States. These research projects included work with intrave-
nous and enteral glutamine and growth hormone in critically ill patients. She also
manages complex bariatric surgery patients who may have developed complications
and may require specialized nutrition therapies. She is a co-investigator on an NIH
funded R21 to study the Effects of Metabolic Support immediately post-trauma with
Dr. Peter Burke, Director of BMC’s Trauma Center. She has been involved as a con-
sultant in an International Research Program with AFINS project (Abbott Fund in
Nutritional Sciences) whose goal is to improve inpatient Clinical Nutrition Services
in Vietnam. She has published extensively with over 50 publications in the clini-
cal nutrition field. She was the first recipient of the Dietitian’s in Nutrition Support
Research Award and was also a recipient of the Massachusetts Young Dietitian
Award in the 1980s. As the CNM at the hospital, she also serves as a teacher, lec-
turer, and mentor to the hospital nutrition and medical staff.
Contributors
Laura Andromalos Glenn K. Harvin
Clinical Nutrition Division of Gastroenterology,
Virginia Mason Medical Center Hepatology and Nutrition
Seattle, Washington Brody School of Medicine
East Carolina University
Meghan Ariagno Greenville, North Carolina
General and GI Surgery
Brigham and Women’s Hospital Micaela C. Karlsen
Boston, Massachusetts Nutritional Epidemiology
Laboratory
Megan Barnett
Jean Mayer USDA Human Nutrition
Department of Endocrinology, Weight
Center on Aging
Management, and Nutrition
Tufts University
Boston Medical Center
Boston, Massachusetts
Boston, Massachusetts

Caroline Blanchard Amy Krauss

Energy Metabolism Laboratory Energy Metabolism Laboratory
Jean Mayer USDA Human Nutrition Jean Mayer USDA Human Nutrition
Center on Aging Center on Aging
Tufts University Tufts University
Boston, Massachusetts Boston, Massachusetts

Sai Krupa Das Laura E. Matarese

Energy Metabolism Laboratory Division of Gastroenterology,
Jean Mayer USDA Human Nutrition Hepatology and Nutrition
Center on Aging Brody School of Medicine
Tufts University East Carolina University
Boston, Massachusetts Greenville, North Carolina
Catherine Fanning
Nutrition Boston Medical Center Thomas J. Moore
Boston, Massachusetts Boston University School of
Medicine
Madeleine M. Gamache University in Boston
Energy Metabolism Laboratory Boston, Massachusetts
Jean Mayer USDA Human Nutrition
Center on Aging Megan Murphy
Tufts University e-Havior Change, LLC
Boston, Massachusetts Waban, Massachusetts

xi
xii Contributors

Lin Pao-Hwa Susan B. Roberts

Department of Medicine Energy Metabolism Laboratory
Nephrology Division Jean Mayer USDA Human Nutrition
Duke University Medical Center on Aging
Center Tufts University
Durham, North Carolina Boston, Massachusetts
 1 The Atkins Diet

Laura E. Matarese and Glenn K. Harvin

CONTENTS
Overview..................................................................................................................... 1
How the Diet Works.................................................................................................... 1
The Atkins Plan........................................................................................................... 2
Current Research......................................................................................................... 6
Effects of Carbohydrate Restriction for Individuals with Type 2 Diabetes
and Metabolic Syndrome.................................................................................... 6
Effects of Carbohydrate Restriction on Cardiovascular Disease........................... 8
Weight Loss, Compliance, and Recidivism........................................................... 9
Typical Results.......................................................................................................... 10
Pros and Cons....................................................................................................... 10
Is This Diet Right for You?....................................................................................... 11
Conclusion................................................................................................................ 11
References................................................................................................................. 11

OVERVIEW
Despite the fact that there are well over 1000 published weight-loss diets in the lay lit-
erature, few have attracted as much attention as the Atkins Diet. The late Dr. Robert
C. Atkins developed this low-carbohydrate, high-protein weight-loss plan which was
publicized in his best-selling book, The Atkins Diet Revolution.1 Dr. Atkins promoted
the plan as not only a quick weight-loss diet but as a change in eating for a lifetime.
The diet was extremely popular allowing individuals to consume large quantities of
meat and high-fat foods without considering caloric restrictions. Critics referred to
the diet as a high-protein, high-fat, low-carbohydrate ketogenic diet which could be
potentially harmful. Early claims on both sides were often fueled by perception and
personal biases without scientific evidence. Eventually, the emergence of numerous
clinical trials appeared in the scientific literature demonstrating the efficacy and
safety of the Atkins Diet.

HOW THE DIET WORKS

Historically, obesity has been considered to be a result of an imbalance in caloric
intake versus expenditure. The idea was simple: when individuals take in more calo-
ries than they expend, the result will be weight gain. Given the growing incidence of

1
2 Clinical Guide to Popular Diets

obesity worldwide, however, it has become clear that this represents an over-simpli-
fication of a complex disease whose cure is more complicated than simply creating
a caloric deficit. Physiologically, carbohydrate restriction, as opposed to a negative
energy balance, is responsible for initiating the metabolic response to fasting.2 The
Atkins hypothesis is that dietary carbohydrate, particularly from simple sugars,
causes hyperinsulinemia, leading to insulin resistance, obesity, and the metabolic
syndrome. Excess carbohydrate prevents effective lipolysis with resulting lipogene-
sis. Low carbohydrate diets reduce the dietary contribution to serum glucose thereby
lowering insulin levels. Insulin is a potent stimulator of lipogenesis and inhibitor of
lipolysis. Lowering insulin levels allows the utilization of stored body fat for energy.
Severe carbohydrate restriction leads to a progressive depletion of glycogen stores
eventually switching metabolism to lipolysis. With a reduction in dietary carbohy-
drate, there is a corresponding increase in dietary protein and fat. This leads to the
production of ketones which act as an appetite suppressant and contribute to an over-
all voluntary caloric reduction.3,4 It has been proposed that inefficient protein and fat
oxidation leads to additional energy loss since more adenosine triphosphate (ATP)
is required to oxidize these macronutrients.5 Lipolysis is maintained despite excess
calories because glycerol from fat is needed as a gluconeogenic precursor.2 The car-
bohydrate level required to produce the metabolic shift from lipogenesis to lipolysis
has been debated, but it is thought to be between 20 and 50 g of carbohydrate per day
in the initial phases of the diet. This contrasts sharply with the typical carbohydrate
content of the Western diet which often exceeds 300 g per day comprising large
quantities of simple, rapidly hydrolyzed carbohydrates.

THE ATKINS PLAN

The foundation of the Atkins Plan is a reduction of carbohydrates. The diet has
evolved over the years to currently offer two options (Table 1.1). With Atkins 20™,
the starting point (Phase 1, Induction) is 20 g of “Net Carbs” (carbohydrate minus
grams of fiber) per day. The Atkins 40™ allows a starting point of 40 g of Net Carbs
per day. Both plans allow for an increase in carbohydrates. One plan adds foods one
at a time and the other raises the carbohydrate portion-size allowance as individuals
approach their weight loss goals (Table 1.1).
The Atkins 20TM (the original plan) includes a four-step process beginning with
a two-week induction phase with carbohydrates restricted to 20 g Net Carbs per day
(Table 1.2). The carbohydrates are derived primarily from low-glycemic, nutrient-
dense, fiber-rich carbohydrates such as leafy green salads and other non-starchy
vegetables. The client is instructed to consume 4–6 oz. of protein at each meal and
enough natural fat to feel satiated. Trans fats are eliminated. The protein is derived
from a variety of sources to include meat, fish, poultry, eggs, and vegetable-based
proteins such as tofu. Adequate fluid (water preferred) intake along with exercise
and a complete multivitamin/mineral supplement is recommended in order to obtain
optimal nutrition. Dairy intake is limited because of its carbohydrate content, there-
fore, calcium supplementation is recommended.
The second phase of the program is referred to as the ongoing weight loss
phase. During this phase, carbohydrates are added into the diet in the form of
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