Japanese researchers say low-carb diets are causing premature death. I’m skeptical.
The potentially healthful side effects linked to low-carb eating include reduced weight, higher HDL cholesterol, and lower triglycerides and blood pressure. The Japanese investigators wondered if the improved cardiovascular risk factors seen with low-carb diets actually translate into less heart disease and death.
How Was the Study At Hand Done?
The best way to test long-term health effects of a low-carb diet (or any diet) is to do a randomized controlled trial. You take 20,000 healthy and very similar people—not rodents—and randomize half of them to follow a specific low-carb diet while the other half all eat a standard or control diet. Teach them how to eat, make damn sure they do it, and monitor their health for five, 10, or 20 years. This has never been, and never will be, done in humans. The Nazis may have done it, but it’s not published. In the old days, we could do this study on inmates of insane asylums or prisons.
What we have instead are observational studies in which people voluntarily choose what they’re eating, and we assume they keep eating that way for five or 10+ years. You also assume that folks who choose low-carb diets are very similar to other people at the outset. You depend on regular people to accurately report what and how much they’re eating. You can then estimate how much of their diet is derived from carbohydrate and other macronutrients (protein and fat), then compare health outcomes of those who were in the top 10% of carb eaters with those in the bottom 10%. (We’ve made a lot of assumptions, perhaps too many.)
Of the observational studies the authors reviewed, the majority of the study participants were from the U.S. or Sweden. So any true conclusions may not apply to you if you’re not in those countries. In looking for articles, they found no randomized controlled trials.
The observational studies estimated carb consumption at the outset, but few ever re-checked to see if participants changed their diets. That alone is a problem. I don’t know about you, but I’ve had significant changes in my diet depending on when I was in college and med school, when I was a bachelor versus married, when my income was higher or lower, and when I had young children versus teenagers. But maybe that’s just me.
The researchers looked at all-cause mortality, deaths from cardiovascular disease, and incidence of cardiovascular disease. They don’t bother to define cardiovascular disease. I assume heart attack, strokes, and peripheral vascular disease. (But aren’t aneurysms, deep vein thrombosis, and pulmonary embolism vascular diseases, too?) Wouldn’t you think they’d carefully define their end-points? I would. Since they were going to all this trouble, why not look at cancer deaths, too?
What Did the Investigators Conclude?
Very low-carbohydrate dieters had a 30% higher risk of death from any cause (aka all-cause mortality) compared to very high-carb eaters. The risk of cardiovascular disease incidence or death were not linked with low-carb diets. Nor did they find protection against cardiovascular disease.
Finally, “Given the facts that low-carbohydrate diets are likely unsafe and that calorie restriction has been demonstrated to be effective in weight loss regardless of nutritional composition, it would be prudent not to recommend low-carbohydrate diets for the time being.”
If Low-Carb Dieters Die Prematurely, What Are They Dying From?
The top four causes of death in the U.S. in 2011, in order, are:
- heart attacks
- chronic lower respiratory tract disease
You’ll note that two of those are cardiovascular disease (heart attacks and stroke). So if low-carb diets promote premature death, it’s from cancer, chronic lung disease, or myriad other possibilities. Seventy-five percent of Americans die from one of the top 10 causes. Causes five through 10 are:
- Alzheimer disease
- flu and pneumonia
- kidney disease
Problem is, no one has ever linked low-carb diets to higher risk of death from any specific disease, whether or not in the top ten. Our researchers don’t mention that. That’s one reason I’m very skeptical about their conclusion. If you’re telling me low-carb diets cause premature death, tell me the cause of death.
Another frustration of mine with this report is that they never specify how many carbohydrates are in this lethal low-carb diet. Is it 20 grams, 100, 150? The typical American eats 250-300 grams of carb a day. If you’re going to sound the alarm against low-carb diets, you need to specify the lowest safe daily carb intake.
For most of my career—like most physicians—I’ve been wary of low-carb diets causing cardiovascular disease. That’s because they can be relatively high in total fat and saturated fat. In 2009, however, I did my own review of the scientific literature and found little evidence of fats causing cardiovascular disease.
If you’re looking for a reason to avoid low-carb diets, you can cite this study and its finding of premature death. I’m not convinced. I’ll turn it around on you and note this study found no evidence that low-carb diets cause cardiovascular disease. The risk of cardiovascular disease had been the traditional reason for physicians to recommend against low-carb diets.
Reference: Noto, Hiroshi et al. Low-Carbohydrate diets and all-cause mortality: A systematic review and meta-analysis of observational studies. PLoS One, 2013; 8(1): e55050
4 responses to “Do Low-Carb Diets Cause Premature Death?”
Did you read this paper? The abstract says that it was about “using the low-carbohydrate score” that is not a diet. That is somebody’s straw man.
Hi, Dr. Feinman. Yes, I read it and regret spending so much time on it. Probably two hours total – time I’ll never get back. I owed it to my readers to check it out.
I didn’t notice this is an old paper but I left this at the web site:
The title of the article includes the words “low carbohydrate diets” but no diets were studied. The authors used a made-up “low-carbohydrate score” invented by Harvard School of Public Health. The “low-carbohydrate score” is not recognized by any researcher in low-carbohydrate diets and appears to have been set up as a straw man to attack a diet that has been useful to millions of people. The paper could not have been reviewed by anybody with experience in actually using low-carbohydrate diets.
I and 24 other authors have written a paper in press at Nutrition detailing the 12 Points of Evidence for the use of low-carbohydrate diets as the first line of treatment in diabetes. The results from real trials and accurate definitions provides a good perspective for patients with diabetes.
The paper by Noto and co-authors is very biased and is likely to dissuade people who could benefit from this method detailed in our paper, on the basis of a made-up definition without input from people working in the field. The results even at face value are very weak but given the inappropriate design cannot be considered meaningful.
The paper should be withdrawn because of its lack of scientific accuracy — again, it is not about low-carbohydrate diets — and because of the potential damage to patients seeking medical help.
Thanks for that contribution, Dr. F. It helps explain why Noto et al never specify their lethal level of carbohydrate deficiency. They have no idea.