Currently, there is widespread interest in many different diets. The best-known
diets include the New Atkins diet in the USA, the Dukan diet in France, and in
South Africa the Noakes diet. Two different approaches have emerged, one
focusing on a life-long healthy lifestyle and the other emphasising weight loss.
These are in fact complementary aims, as will be reviewed and reconciled.
Furthermore, besides the dietary approach, there is a valid case for added drug
therapy for selected lipid disorders with the use statins. In addition, new
drugs are emerging that in the future might eventually considerably reduce the
negative health impact of coronary artery disease.
diet, cardiovascular risk, Noakes diet, Banting diet, Mediterranean diet
Lifestyle is life-long
Life-style is life-long in its health implications.
Although diet is only one of the five components of a healthy
diet has recently come to the
When considering overall health,
the most important are non-smoking and regular exercise, followed by body weight and
diet, in order of importance
proposals are based on a series of important studies on over 100 000 US health
professionals over 10 to 25 years, which defined the contribution to health of four
major lifestyle factors, only one of which is diet
Lifestyle: ‘big five’
Reduced all-cause death risk
Exercise 30 min or more daily
Slows the heart rate, lowers BP
Less toxic chemicals released from fat cells
High unsaturated fatty acids, high vegetables and
fruit, low red meat
Red wine preferred, contains melatonin
Remaining 21% may be stress related
While there are many diets to choose from, the majority focusing on weight loss, few
diets have had scientifically solid outcome studies to prove that the diet in
question actually improves health and increases life span. An exception is the
Mediterranean diet, so called because of the very low incidence of heart attacks
observed by Ancel Keys in the Mediterranean islands of Corfu and Crete, thus leading
to the concept that the Mediterranean diet is an ideal diet,
also protecting against heart failure.
Palaeolithic, the oldest diet
What is the paleolithic diet? Mankind evolved over hundreds of millions of years,
therefore the paleolithic diet must have been the standard diet that also evolved
over that time. Studies on the teeth of the paleolithic man, as found in East Africa
(also in its congener from South Africa), showed that the dental bones and teeth had
adapted to process large quantities of low-quality vegetation rather than hard
The paleolithic diet is now
recognised as a nutritional pattern based on the ancient diet of wild plants and
animals that our ancestors consumed over 10 000 years ago.
In the Kitava dietary study on isolated tribes in Papua, New Guinea, who even
recently ate a pre-Westernised diet of 55 to 65% animal foods and 35 to 45% plant
foods, these societies had no incidence of stroke, heart disease, diabetes or
The diet consisted mainly
of fish, grass-fed pasture-raised meats, vegetables, fruits, roots, spices and nuts.
There was no restriction on calories or on the foods to be cooked.
Although the Mediterranean diet overlaps with the palaeolithic diet in terms of
fibre, antioxidants, saturated fat and mono-unsaturated fat, the paleolithic diet
improved glucose tolerance more than did the Mediterranean diet.
Furthermore, this diet is more food
satiating than a Mediterranean-like diet in persons with ischaemic heart
Therefore the paleolithic diet
both preceded the Mediterranean diet and was apparently better, so it may be that
‘the simpler, the better’.
Diet and lipids
Moving on in history, it was the early Cape Town studies that made the link between
fat in the diet and blood cholesterol values. Nearly 60 years ago, Professors John
Brock and Brian Bronte-Stuart from Groote Schuur and the University of Cape Town
Department of Medicine used their specialised metabolic unit to give a high-fat diet
to subjects with an initially low blood cholesterol level
A butter load of 100 grams given daily
increased blood cholesterol by proximately 40% within five days. The addition of
large amounts of olive oil to the butter load restored cholesterol levels to their
prior low levels
. Therefore the type
of fat diet affected blood cholesterol levels.
The decisive further link between circulating cholesterol values and coronary heart
disease came from the Framingham study, which found that higher blood cholesterol
values were associated with increased cardiovascular and total mortality rates.
Over time, the emphasis on selection of drug
therapy via statins has shifted to the blood level of low-density lipoprotein (LDL)
In South Africa in 2000, high blood cholesterol levels have been estimated to have
caused 24 144 deaths (95% CI: 22 404–25 286) or 4.6% of all deaths.
Studies in the Cape Peninsula and in the
South African Indian population support links between lipid abnormalities and
coronary heart diseases.
Severely obese South African white women
have greatly reduced values for serum high-density lipoprotein (HDL) cholesterol or
‘good’ cholesterol, rather than high levels of LDL cholesterol.
Lipids in diabetes: the role of statins
The ideal approach to nip diabetes in the bud is by testing HbA
in those with the metabolic syndrome or obesity, and then to go for weight loss
induced by combined diet and exercise. In those with established type 2 diabetes
(DM2), a population study in Hong Kong suggested that statin therapy attenuated the
associated increased cancer risk.
diabetes, in a large study with 215 725 person-years of follow up, statin use before
the diagnosis of diabetes reduced diabetic retinopathy (hazard ratio 0.60, 95% CI:
< 0.0001), diabetic neuropathy (HR 0.66, 95% CI:
< 0.0001), and gangrene of the foot (HR 0.88, 95%
Regarding the general adult population, statins are recommended as first-line
therapy in those up to and including 75 years of age, who have clinical
atherosclerotic cardiovascular disease (ASCVD) (
Exercise versus drugs
In studies on the secondary prevention of coronary heart disease and pre-diabetes,
randomised trials on exercise interventions suggest that exercise and many drug
interventions are often potentially similar in terms of their mortality benefits,
rehabilitation after stroke, treatment of heart failure, and prevention of
This important observation
reinforces the essential role of exercise in any programme aimed at overall
Banting first linked diet to mortality
Banting in his pamphlet
in 1869 emphasised
the role of diet in weight loss, stating that: ‘The dietary is the principle point
in the treatment of corpulence.’ The key points in the Banting diet were his method
of reducing obesity by avoiding fat, starch and sugar in the food. Therefore the
proposal that the Banting diet is similar to the Noakes high-fat diet3 appears to
need re-appraisal. Banting also made wider overall claims that the diet was ‘a
simple remedy to reduce and destroy superfluous fat; it may alleviate if not cure
gout; prevent or eradicate carbuncles, boils, dyspepsia, makes life more enjoyable,
and promotes longevity’. One interesting small but important point is that Banting
took the fat off the gravy. For these reasons, it seems preferable to separate the
Banting diet from the Noakes low-carbohydrate, high-fat diet.
Israeli study and new Atkins diet
The low-carbohydrate, high-fat diets that were introduced by Atkins and his
have had very wide
influence. Some of the key features are as follows, with the relevant book pages
given in brackets:
• Protein intake though high has recommended protein ranges (51).
• Fat intake though also high, has a desirable range (70).
• Vegetables including avocadoes are the basis of the permitted carbohydrate
In a major landmark Israeli diet, the new Atkins diet was compared with others from
the same Israeli population group in a dedicated communal restaurant where the food
intake could be monitored.
In the group
given the new Atkins diet, besides weight loss, the blood cholesterol pattern showed
some favourable changes.
In the comparative group taking a calorie-limited Mediterranean diet, similar changes
were found in weight loss and blood lipid levels. However, the Mediterranean diet
was calorie limited whereas the Atkins group had a spontaneous loss of appetite. The
molecular mechanism to explain the appetite loss is not clear. Reservations are that
there was no placebo group and the study was too short to judge any clinical effects
on cardiovascular events.
A broadly similar conclusion was reached in a meta-analysis of diets of varying
carbohydrate and lipid composition. The new Atkins diet is one of several
reduced-calorie diets that have all resulted in clinically meaningful weight loss,
regardless of which macronutrients they emphasised.
What about high-fat weight-losing diets?
The two potential problems with high-fat diets lie in their adverse effects on the
blood lipoprotein pattern, and on the impairment of specific mental functions, as
observed by Kieran Clarke in Oxford students. In the Oxford study, a short-term,
highfat, low-carbohydrate diet led to higher circulating free fatty acid (FFA)
concentrations, impaired patterns of myocardial high-energy phosphate metabolism,
and decreased cognition in healthy subjects.
The site of these deleterious effects on the brain was the hippocampus. In the heart,
sophisticated non-invasive nuclear imaging techniques measured levels of high-energy
phosphate compounds, which were relatively low in those taking the high-fat diet.
The proposal was that elevated circulating FFA levels were underlying the cognitive
and cardiac abnormalities. Therefore Clarke and her associates concluded that
high-fat, low-carbohydrate diets are potentially detrimental to the human heart and
For these reasons, there are arguments to support the view that the diet overweight
persons could best start with is a new Akins type of diet for weight loss, coupled
with an exercise programme, and then move onto the Mediterranean-type diet to
achieve lifelong health benefits, thereby avoiding the cognitive and cardiac changes
of high-fat diets. Therefore starting a diet to lose weight, such as the new Atkins
or Noakes diet, is complementary with a later switch to the long-term Mediterranean
diet. As these diet types come in sequence, they are not competitive.
A safe prediction is that there will be more editions of existing major books (Atkins
in the USA, Dukan in Europe, Noakes in South Africa) besides new diet books. New
lipid-lowering pharmaceutical agents are already being tested in large new
outcomes-based studies on their preliminary promise.
The best self-help policy may well be to start with a dedicated programme for weight
loss however achieved, whether by the new Atkins or Noakes diet, but associated with
sufficient exercise. The next step would be to move on to the modified Mediterranean
aimed at living longer and living
Looking to the far future, having both fish and meat in the daily diet of large
populations would need substantial resources, which will be increasingly limited as
the human race expands. Maybe the answer will lie in novel fresh nutritional sources
such as algae-based diets.
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