The problem with naming a diet low carb

What does low-carb mean?  Well, the first thing it means is that something else has more carb.  So what are you comparing it to?   Breakfast cereal?  Angel food cake?  The standard American diet (sAd)?  Anything would be low-carb compared to those.

A whole bunch of folks at the Nutrition & Metabolism Society have been working hard to help people understand that carbohydrate, and not dietary fat, is the main dietary component causing our obesity and diabetes epidemic.  They say we all need to be eating a low-carb diet, and they have the research to prove it.

I agree with a lot of what they say.  But I disagree about what to call it.  I’m sort of saying the same thing as them, because I do believe that carbohydrate [especially refined carbohydrate, manufactured carbohydrate, processed and stripped carbohydrate] is one of the major players in the obesity epidemic.  I just don’t think we should be calling it a low-carb diet.  I admit it; I’m mincing words (instead of garlic).  But if it’s called a “low-carb” diet, that would mean that a high-carb diet is the normal default.

If you call something low,  then there must be a high somewhere.  If you call dessert “blond brownies,” there must be a not-blond type.  And there is.  If you call someone pro-, then everyone else can be presumed to be con-.  So if people advocate a low-carb diet, then what does a high-carb diet look like?  And the answer is — the American diet.  The standard American diet (sAd) consists mainly of illness-producing amounts of refined carbohydrate.  Cereal and toast for breakfast, sandwich and chips for lunch, pasta for dinner.  You want fries with that?  No wonder America has an obesity and diabetes problem.  That diet, the sAd, is profoundly unhealthy.  It causes diabetes, obesity, high blood pressure, arthritis, heart attacks, and strokes.  That’s not okay with me or my patients.  So why would I pick a name that presupposes the sAd is some kind of normal?  I wouldn’t.  That’s my point.

This perspective highlights the difference between absolute and relative comparisons.  Let’s pick an example from something quite familiar to me, the medical industry.  Imagine, for example, that a new medicine came to market that decreased the chance of developing a rare and horrible side effect (say, a severe rash) from 2 in 10,000 to 1 in 10,000.  For every 10,000 people who tried the medicine, the chance of getting the rash would be halved, from two to one.  You could say that the medicine was “twice as safe.”  That’s called a relative comparison.  And while it is true, technically speaking, it’s not the whole story.

The other way to look at this is that, in fact, the chance of developing the horrible rash is already very small, and it becomes slightly smaller if you switch to the new medicine.  That is the conclusion I reach from evaluating the absolute, or actual, numbers.

When we call smart eating a low-carb diet, we are making a relative comparison.  And relative comparisons are notoriously undependable because they don’t take into account where you started.  They tell you where you landed, but not how far you went.

I don’t want to call a diet with healthy amounts of carbohydrate “low-carb.”  What then?  Smart-carb?  Natural-carb?  Garden-carb?  Pre-industrial carb?  I’ve heard some people talking about the Paleo [PAY-lee-oh] (short for Paleolithic) or caveman diet, which presumes that the right amount of carbohydrate would be the amount that the average human ate in that pre-agricultural era.  Why pre-agricultural?  Because that’s before humans began to grow and domesticate grain, especially wheat.  Wheat (along with corn and soy) is the grain used to make large amounts of the processed, food-like products that may be found at the American supermarket.  But Paleo doesn’t feel right either, unless I don’t mind eating the Industrial Revolution diet.

It’s important to remember that all carbs aren’t all-bad.  Not for everyone.  It’s certainly true that some folks are so sensitive to carbs that even an apple a day will make their pants too tight.  Practically the only carbs this group of people can eat comfortably are green vegetables.  But there are lots of other people who can eat all the peaches and lima beans they want.  So, instead of low-carb, I’d like to hear people start saying they eat a low-grain diet, or a low-processed-food diet, or even a low-grain and low-fruit diet.  That’s going to tell me a lot more about how well this person understands his or her own metabolic needs.

When we call a diet “low-carb,” we are making a comparison with the sAd.  And the sAd is so high in processed carbohydrates that virtually every other diet is an improvement.  Low-carb, therefore, doesn’t tell us much.  It doesn’t say whether the recommendations target all grain, or only processed grain, or all grain and fruit, or all four categories of carbohydrate:  grains, fruits, beans and vegetables.  And it presumes that the sAd has a normal amount of carb.  Which it does not.

Roxanne Sukol is an internal medicine physician who blogs at Your Health is on Your Plate.


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  • Dr Sam Girgis

    Low carb diets are popular because of all the processed sugars that are naturally in the American diet. Everywhere you look, there are sweets and desserts that are made with large amounts of processed sugar. Cardbohydrates are actually an important part of nutrition. Maybe we should call these diets – Low Processed Sugar Diets.

    Dr Sam Girgis

  • aek

    I’m pleased to read this post. You capture most of the current sound science, and you present an important issue that is serving as a barrier to wider adoption of practices which vastly improve and often remediate chronic diet-related health problems.

    I essentially eat the way you’re describing, and it predominates with whole foods: fresh and frozen fruits and vegetables, full fat unsweetened dairy, nose to tail meat (includes offal – organ meats), eggs, fish and seafood, plus moderate amounts of tree nuts, starchy vegetables including white rice, sweet potatoes and potatoes, olive and coconut oils. This diet allows for eating within a wide variety of culturally accepted norms, encourages cooking, gardening, food shopping and eating in social situations, and makes eating enjoyable as opposed to nutritionism where food is treated as medicine or as good/evil.

    You could call this a traditional cultures diet in that it is the style of food consumption pre-western industrialized diets.

  • IVF-MD

    Fantastic post, Dr. Sukol. Most recently, I’ve added some detailed nutritional counseling to my infertility patients, especially those with PCOS / insulin resistance. I negotite with them to promise to keep meticulous logs and daily weights. As the data come in, I am totally convinced of the power of a ZERO-GRAIN diet high in legumes (lentils and beans). Even with no or minimal fat restrictions, these patient generally have weight loss, improvement or no-change in their lipids (despite no egg or fat restriction) and subjectively greater energy, in some cases dramatically!

  • Michael Kirsch, MD

    Nice post, Roxanne. Your explanation of the difference between a relative and an absolute decrease in an outcome is not appreciated by the public. It’s easy to be seduced by promises of a 50% improvement, for example.

  • LissaKay

    How about “controlled carb” diet? I am currently trying to lose the rest of the 60 pounds I gained while following the recommended diet put forth for the last 30 years – low fat, low calorie, no restriction on carbs – so my daily net carb intake is less than 20 grams. Someone else at ideal weight may be able to maintain that weight only if they keep their carb intake under 50 grams per day, none of it made of sugar or grains. Yet another can be losing weight while eating 80 grams of carbs, including some sugar and grains. No single diet or eating plan is right for everyone. There is not a specific number of carbs that is right for weight loss or maintenance for everyone. The idea is to control the carb intake to suit one’s personal tolerance.

    Seeing this increased acceptance of a nutrition plan that controls carbs and allows for the consumption of natural fats without restriction is fabulous, by the way.

    • Lezlee

      I eat a high fat , moderate protein, low carb diet. 30 grams of carbs per day. Have lost 3 inches off my waist, lost one inch off my hips. I bought a glucometer and checked my blood sugar levels one and two hours after meals with everything I eat. Now I know which carbs don’t spike my blood sugar. BTW, I am not a diabetic but was getting into pre diabetes levels before the low carb diet and gaining weight even though I was cycling 60 to 100 miles per week.
      1/2 cup of whole wheat pasta spiked my blood sugar to 140 one hour after ingesting. I don’t think high blood sugar spikes only happen with high glycemic foods.

      • DAvid Boothman

        Lezlee is absolutely correct. Unreasonable as it may sound, whole wheat bread will often result in a higher glucose spike than will white bread. Science is not necessarily intuitive and the problem we have had with National dietary guidelines is the assumption that intuition is superior to controlled studies. Since most people think eating fat makes you fat so fat restriction has been a cornerstone of nutritional guidelines for a generation despite the fact that Metabolism 101 to the best of my knowledge has always taught that insulin is the only fat producing hormone and insulin is produced in direct response to a rise in blood sugar. Lezlee’s weight loss is absolutely to be expected upon shifting to a high fat and consequently lower carbohydrate, lower calorie diet. When you eat a lot of fat you don’t eat as much because you don’t get hungry as often. The interesting aspect regarding this is the cognitive dissonance flourishing in the minds of most diet professionals due to the simultaneous belief in fat being bad and the high health rating value placed upon blood cholesterol tests. If Lezlee has kept track of blood numbers it will be quickly apparent that another outcome of the dietary change is a large drop in Triglycerides and a large increase in HDL. The ratio of the two may have improved by as much as 2:1. Either the dietary guidelines are off base or blood cholesterol tests are a misleading waste of time and money, these two paradigms should be mutually destructive for a logical mind.

        • Lezlee

          Hey thanks David. A person doesn’t have to go to a doctor to get a script for a glucometer. I can’t figure out why folks just go out and buy one and check to see which foods spike blood sugar and insulin. I’m 59 and many of my friends start looking like Jabba the Hut in their late 40′s and 50′s.
          I started gaining weight 8 years ago and this last fall I did a hip to waist ratio and I was high risk!!! I had a close relative who is diabetic visit for Christmas and told us about low carbing and how he lowered his cholesterol and blood pressure from low carbing and high fats and meat. So I started doing my own homework to find out about this.
          I mean I know folks can count calories so why not just count carbs. I do keep blood records and soon I will get a VAP test and HbA1c. Is the population really waiting for an authority figure to confirm that “they” (the government, researchers, I guess) made a big mistake about cholesterol and fat.
          I worked in the medical field for several years and am stunned how people turn their life over to a medical professional without doing their own homework.

          • David Boothman

            Diet? Focus on meat, fish, and dairy if you can tolerate it. Avoid any low fat or reduced fat or processed product. Limit fruit to high nutrient berries such as blueberry sour cherry cranberry and blackcurrant, eat lots of high nutrient vegetables, mostly leafy greens low in starch. Breakfast might be bacon and eggs and sausage with olives, pecans and tomatoes, followed by ricotta 10% fat yogurt with blackcurrants. Lunch, salad & pickled herring or wild hog sausage followed by ricotta cheese and sour cherries. Dinner head cheese and red wine then Alaska salmon and vegetables followed by Kefir and berries. I don’t count calories, don’t know of any animal other than humans that do either., If you eat what you’ve evolved to eat your autonomous self-regulation function operates properly. You can eat junk occasionally without a problem once you are healthy.

        • David Boothman

          Sometimes we are forced to shock people into the real world and I wonder just how many of us are finding this out solely through their own initiative. After I’d studied up enough, I’m an Engineer, I recorded a baseline blood test then embarked upon a very high fat diet, I wasn’t overweight at the start but lost about 3 Lbs. I had another blood test giving results so improved they surprised even me. I conferred with a PhD Nutritionist and fellow member of the Nutrition and Metabolism Society. She had independently undertaken a similar test eating fat to the point she said she began to gag on it. She commenced with excellent health and weight yet her weight dropped slightly and health stats improved further. I began this over 18 months ago and a recent test showed further improvements (TG: 46, HDL:103, CRP below measurable, Berkeley excellent, 68 years old and taking zero medication). Right after I last posted I received an an email from a another Society member with this link to an abstract:

          Finally medical research may be discovering what we already know.

          • Lezlee

            David, thanks for the abstract. On your very high fat diet, what were you eating, meaning what did your plate look like. I am very fond of coconut oil, bacon and sausage. I just started January 13th of this year. I’m waiting until July to get my blood work done. I wanted a good 6 months under my belt.
            I was a skinny kid throughout my life and was a compulsive eater. My grade school teachers told my mother that they thought I had a tapeworm since I ate so much and didn’t gain weight.
            Since eating a low carb diet, this is the first time in my life that I eat normally. When I cut out my breakfast of whole grain oatmeal (no sugar added)
            and replaced it with bacon and eggs, I quit being hungry and compulsively eating everything in sight for the rest of the day. I worked at a treatment center back in the eighties and always thought compulsive eating was an emotional addiction. I took away grains and high carb vegetables and instantly the compulsion stopped.
            In my whole life I have never ever not ate grains until January of this year. I had suspected that I had insulin resistance from my life as a grain eater.
            I must of had an Olympic grade athletic pancreas.

          • Lezlee

            David, thanks for sharing your menu. Here is a link you might appreciate. Low carb forums, blogs, interviews with medical professionals and researchers who are into the low carb.

          • Lezlee

            Also David, don’t you think it’s kind of ironic that so many folks distrust the US government, but when it comes down to the food pyramid, they won’t question it.

  • Lila

    Good article. As a proponent of the paleo diet, I do agree that some people do well with more carbs than with less. Research has shown that humanity has changed about 0.02% from our paleo ancestors, so that must mean that somewhere, someone HAS adapted to a higher carb diet successfully. The flaw, however is the type of carbohydrate. Again research is suggesting that grains are the worst type of carb to be eating. I will also say that legumes are not stars either. I think that beans need to be strictly limited in out diets. They need to be processed too much to become edible and even then cause a lot of problems. I like paleo because it is so simple, really. No processed food, refined “foods”, but a lot of lean protein, veggies, fruit and good fats. How can one go wrong eating that?

    • IVF-MD

      This is important to me, as my patients have been experiencing weight loss, increased energy and some have noticed a decrease in their previous chronic ailments after switching from a low-grain, bean-restricted diet (Atkins?) to a low-grain, high-bean diet. Part of it comes from the easier sustainability and lessened physical hunger of a high-bean diet.

      Can you elaborate on your belief that “I think that beans need to be strictly limited in out diets.”. I don’t understand your explanation on the grounds of beans being processed too much. I guess my two questions would be 1) What constitutes something as being processed too much or too little? 2) Assuming that it is indeed correct that beans are processed “too much”, what exactly are the implications of that?


      • Lila

        Soy beans require a lot of processing before being safe to eat. Soy must be fermented, so that eating any soy product except for soy sauce, miso, tempeh, natto and to a limited extent tofu, should be avoided. Other beans must be soaked for extended periods to get rid of the protective enzymes. Even after soaking many people have digestive problems with beans. Probably the least problematic are lentils. However, if your patients are feeling well eating beans then that’s great. If you want more information regarding soy visit and search the site.
        I personally have problems with beans but since I am a paleo diet follower it is easy for me to leave them out. Our paleo ancestors did not eat legumes. This is one reason why I think they need to be limited. Most of us haven’t changed that much. However I also know that different people do well with different diets and food types. I do better with a higher protein/fat diet than anything else. I know many others who are the same way. I also know a few vegetarians or nearly vegetarians who are doing okay. However I have met people who followed a vegetarian diet, eating soaked beans and other veggies who were not doing well. They had a lot of digestive issues and physical ailments. After changing to a higher protein diet based on animal products their health improved dramatically. I suppose the basic common denominator is for a person to listen to their body and determine for themselves what is best.

      • Lila

        I forgot to add a reply regarding processing. From what I have read, learned, experienced…. the less processed a food is the better it is for us. Most veggies and fruits don’t need anything more than a good washing and they are ready for us to eat. Some are helped by being cooked (i.e. artichokes, tomatoes). Meat and eggs can be eaten raw too and were, but today, unless one is intimate with the source of the product it isn’t recommended.
        Foods that require additional processing beyond cooking to make them digestable are less than optimal for us. Legumes and grains must be soaked to minimize digestive upset. Grains, that are not soaked, equal poor digestion, and blocked vitamins and minerals. We no longer soak grains in the US and so have seen a huge increase is poor health. But even soaking may not be enough for many of us. For a couple of years I followed the Nourishing Traditions of Sally Fallon and ate grains and beans that had been soaked or sprouted. I did not do well. As soon as I eliminated grains and beans my health improved. I have heard and seen this from others too. I found that when I ate foods close to as found in nature, minimally processed, the better I did. This is why I’ve embraced paleo. My one exception is dairy. I do think dairy is healthy for many people, if it is eaten raw. I’ve seen some remarkable changes in people’s health when drinking raw milk. However it is very difficult to obtain in many states in the US since the FDA and USDA have outlawed the sale of raw milk. .

      • Lezlee

        Just get a glucometer and check your blood sugars one and two hours after eating and see which carbs spike your blood sugar. I cannot eat beans because of the spikes in blood sugar. I also quit having gas, bloating and IBS doing a 30 gram carb diet.

  • ww

    If I tell someone I am on a Low Carb diet they will assume certain things (bacon, bacon and more bacon) that aren’t necessarily true. Therefore, I tell people I am on a Nutrient Dense diet. I then describe the foods that are dense in nutrients, like meats, green vegetables, nuts, coconut milk, berries and even fat. I then explain that sugars, breads, white rice, potatoes have very little nutritional value.

  • DAvid Boothman

    I’m not sure it requires a name. The goal surely is to persuade many people to try reducing carbohydrates and experience a positive outcome. Experience has shown most people that Diets do not work so in naming one you might as well write its epitaph as well. Most people currently eat a less than ideal diet because the typical North American diet departs a long way from the evolutionary diet and evolution has not cooperated in rapidly adapting the species to keep up with the dietary changes brought about by the introduction of crop cultivation over the past 10,000 years. Nothing succeeds like success and an encouragement to cut down carbohydrates generally leads to some loss of excess weight and a feeling of improved health. And since the individual is not regimented by a defined and named Diet the improvements tend to shift the persons actual diet continually in the right direction. This approach is particularly appropriate in the current climate in which many people have had just about enough of official diet experts who have consistently disappointed, now for more than a generation. However persuading them to eat more fat may be quite another issue and there are after all on three primary macronutrients.

  • connley landers

    Good information. It reinforces results that Dr. Daphne Miller talks about in her book The Jungle Effect, which chronicles the results of some of her patients who she has follow the American Indians, tres hermanas, or “three sisters”, (corn, beans and squash) eating style. As a nutritionist, i’ve writen about what I call the Walden Food Plan that, as the name implies, is a simplify, simplify, simplify routine that uses the same ideas.

    • Lezlee

      The only thing is that the way Ranchers fatten up their cattle is feeding them grains which includes corn.

  • mgrim

    I love this article! As an RD, I cringe when I hear people say “low-carb”. In addition to everything the author says, claiming “low-carb” gives folks a false sense that they’re doing good for their body, when they don’t fully understand what that means and that they may be missing the whole point about how some sources of carb affect their metabolism.
    Personally I avoid high fructose corn syrup, among other things.

  • gioacchino aj patuto,MD

    when i was a child i watched the ” outer limits” on tv. many times our evolution was depicted with massive craniums and small body types.
    if i could produce a new edition it would be called ” the inner limits”. that would depict the human evolution as large body types and small craniums!!!
    too late to think of high or low any food group!!!!
    the american population has and will be ignorant to proper dieting……..
    there are plenty of cultures out there that have showed the world how to eat, but we are still trying to figure out something that has been part of our evolution…..
    that— has always been the “american fault”…

  • Dorothy Green

    “The American culture is and will continue to be ignorant of
    proper eating”.

    Probably true UNLESS something as strong as the tobacco model is instituted VERY SOON. This is going to take an enormous amount of political will and backing by taxpayers who bear the burden of the ever increasing healthcare costs. Our income taxes will be raised to pay for the cost of chronic preventive diseases (CPD) very soon as our elected politicians cannot or will not think and act outside of the box.

    The US became a model for the world in reducing cigarette smoking from 65% to 20% by the message, education and the revenue collection after long battles with the tobacco industry. Tobacco smoking, while still a major cause of chronic preventive diseases (CPD) has been outpaced by CPD caused by aAd.

    The same battle must be fought with the Big Food multinationals and their supporters within the beltway and out on the Agribusiness land (nothing here resembles a farm with big red barn). Their basic foothold is in the US where it is easy to sell High Risk food and their message of yummy and cheap stuff to put into your mouth is far more pervasive than porn, meth and cocaine put together.

    The stats show the US is world leader in CPD- the biggest RISK is sAd (love that acronym).

    So forget lo hi carb, fat, etc. labels. It is the RISK that matters.

    sAd is a HI RISK diet.
    Paelo is close to 0 RISK diet.

    The substances BIG food scientists use to manipulate the taste of their Hi Risk products are sugar, fat and salt – not the natural sugar found in honey or whole fruits, not the natural good fats found in fish, coconuts, avocados but you know – most of us now know – its the corn and all its cousin oils and sugars from cane and beets – refined like coco leaves are refined into cocaine. They are mixed together with bad fats and enough salt so that a grocery store is like one big bar with a bartender giving you “salted peanuts so you’ll buy another drink.” In most cases it’s sugary soda. The refined grains are a conduit for the sugar, fat and salt. While not the best nutrition, they wouldn’t cause us to overeat without the added sugar, fat and salt.

    The winners are Big food, Big Pharma and the medical -industrial complex. The losers – taxpayers and those who are fighting non – CPD where the research is not profitable like making drugs for CPD.

    I like the word RISK as an acronym also – Reduction in Sickness Kitty – as a name for the tax that must be levied on processed sugar and fat and salt added to foods, It can be done now that we have Nutritional Facts. It is the only fair tax. And the tax for cigarettes should also be added to RISK as should marijuana taxes. Now, they are in general funds that can be used at will by politicians.

  • Lila Hanft, Ph.D., M.S.S.A

    Your article and Michael Hirsch’s comment about the importance of distinguishing relative and absolute decreases brought to mind an old Rita Rudner joke about buying only food marked “Less fat.” Sometimes, she said, she’d wonder:
    “Less fat than what? A great big ole cup ‘o fat?!”

  • Dorothy Green

    Lila, I see your point – let me expand my idea

    I see the food packages with a tax value per gm of sugar and fat and 100 mg sodium along side the Nutritional Facts. I call it a RISK tax.

    Rita Rudner would see this, say, on a Twinkels’s package of 2 as and additional $.08 RISK tax. (Based on my preliminary calculations)

    For people that eat occasional twinkel like food – no big deal – for those who eat a lot – pay more – higher risk of diabetes – like paying upfront for risk of lung disease from cigarettes

    For the government- stop subsidizing corn syrup and grain fed for animals

    For the manufacturers – prices of unhealthy food should rise, demand will fall and they might start thinking of how to make tasty nutritious food – including cows.,

    For taxpayers – an annual healthcare tax credit of a portion of the RISK $$$$. The rest of money to subsidize local organic farms, urban farms, the education of eating healthy, school nutrition programs etc.

    I tend to think other countries will adopt something like this long before the US because they have a higher regard for all the citizens (pubic health) of their country than the US.

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