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Is a Low-Carb, High-Protein Diet Sustainable?

Many overweight and obese people acknowledge that their carbohydrate eating habits meet most of the seven diagnostic criteria for substance dependence

Dieting should be viewed as a way of life -- a pattern of eating for proper nourishment. Popular dietary lifestyles maintained for long periods of time include the Mediterranean Diet, Weight Watchers, vegetarianism, Jenny Craig, Ornish, Atkins, and the Paleolithic Diet.1

This column explores the likelihood of following a low-carbohydrate, high-protein approach for the long term. It is a common question patients ask of their healthcare providers.

Carbohydrate Control

Food contains three main types of carbohydrate: starches (also known as complex carbohydrates), sugars and fiber.2 Carbohydrates alone-not fat-increase body weight. Carbohydrates are rapidly digested and quickly converted to blood glucose. After carbohydrates are consumed, insulin is produced to manage the carbohydrates, and if excess carbohydrates are consumed, they are stored as fat.3

Once the body's cells have had their fill of glucose, the liver stores some of the excess for distribution between meals should blood glucose levels fall below a certain threshold. If there is leftover glucose beyond what the liver can hold, it can be turned into fat for long-term storage, so that none is wasted. When carbohydrates are scarce, the body runs mainly on fats. If energy needs exceed those provided by fats in the diet, the body liquidates some of its fat tissue for energy,4 and eating fat doesn't produce weight gain.5-7

Studies examining the effects of low-carbohydrate diet on weight loss and cardiovascular health and the effects of low-carbohydrate diet on type 2 diabetes conclude that the low-fat diet does not improve cardiovascular health.8-15 Evidence shows that the low-fat diet has no scientific support, while the low-carbohydrate diet improves both triglycerides and high-density lipoproteins.8-15

Maintenance of Control

In spite of the health benefits of the low-carb lifestyle,8 it is a challenge to maintain.16 Many overweight and obese people acknowledge that their carbohydrate eating habits meet most of the seven diagnostic criteria for substance dependence.17 Recovery and relapse occur, as with any addiction. Addiction to carbohydrates makes it more difficult to sustain the low-carb lifestyle compared to other dietary lifestyles, just as an alcoholic or drug addict struggles to stay sober.

Mechanisms of addiction have been extensively studied.18-21 According to Koob and Zorilla,20 addiction is a chronically relapsing disorder characterized by compulsion to take or use a substance as well as a loss of control in limiting intake.21

Some diagnostic criteria for substance dependence include the inability to abstain; use despite negative consequences; eating more for longer periods of time than anticipated; and avoiding social events where the food of choice will not be available (or more often when on a low-carbohydrate diet, apprehension about attending events where high-carb foods are the only foods available).22

SEE ALSO: T2DM Patients Ready to Reach A1C Target Faster

Additionally, pervasive advertisement of high-calorie foods, as well as advertisement of high-carbohydrate foods as healthy, makes it difficult to sustain a low-carb lifestyle. Further complicating patients' efforts is continuing promotion of a low-fat diet when science shows that only carbs are converted to fat, and fat doesn't metabolize to fat in the human body.

Resources are available to help patients maintain the low-carbohydrate lifestyle. Examples are Low-Carb Dieting for Dummies (For Dummies; 2003) and the website Healthcare providers can gain expertise in this area by learning about metabolic coaching at

Additionally, help can be found through healthcare professionals and clinics that specialize in weight loss. Many such professionals are members of the Obesity Medicine Association. The organization's website is

Cynthia Hodgins owns TLC Medical Weight Loss Clinic in Austin, Texas. Learn more at


1. Top 10 Most Popular Alternative Dietary Lifestyles. 

2. American Diabetes Association. Types of Carbohydrates.

3. Groves B. Why Eating Too Many Carbs Makes You Fat.

4. Gebel E. How the Body Uses Carbohydrates, Proteins, and Fats.

5. Eenfeldt A. How Carbs Make You Fat.

6. Taubes G. What really makes us fat? Article questions our understanding of the cause of obesity.

7. Voorhes A. Why Are We So Fat? The Multimillion-Dollar Scientific Quest to Find Out.

8. Brehm B, et al. A randomized trial comparing a very low carbohydrate diet and a calorie-restricted low fat diet on body weight and cardiovascular risk factors in healthy women. J Endocrinol Metab. 2003;88(4):1617-1623.

9. Brinkworth G, et al. Long-term effects of a very-low-carbohydrate weight loss diet compared with an isocaloric low-fat diet after 12 mo. Am J Clin Nutr. 2009;90(1):23-32.

10. Howard BV, et al. Low-fat dietary pattern and risk of cardiovascular disease: The Women's Health Initiative Randomized Controlled Dietary Modification Trial. JAMA. 2006;295(6):655-666.

11. Meckling K, et al. Comparison of a low-fat diet to a low-carbohydrate diet on weight loss, body composition, and risk factors for diabetes and cardiovascular disease in free-living, overweight men and women. J Clin Endocrinol Metab. 2004;89(6):2717-2723.

12. Volek J, et al. Comparison of energy-restricted very low-carbohydrate and low-fat diets on weight loss and body composition in overweight men and women. Nutr Metab. 2004;1(1):13.

13. Volek J, et al. Carbohydrate restriction has a more favorable impact on the metabolic syndrome than a low fat diet. Lipids. 2013;44(4):297-309.

14. Wadden T, et al. Four-year weight losses in the Look AHEAD Study: factors associated with long-term success. Obesity. 2011;19(10):1987-1998.

15. Yancy WS, et al. A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial. Ann Intern Med. 2004;140(10):769-777.

16. Tate J. Treating overweight as carbohydrate addiction. Amer J Bariatr Med. 2010;25(2): 13-15.

17. Gearhardt AN, et al. Food Addiction: An examination of the diagnostic criteria for dependence. J Addict Med. 2009;3(1):1-7.

18. American Society of Addiction Medicine. Definition of Addiction.

19. Heller R, Heller R. Carbohydrate Addiction Defined:What is it? Where does it come from?

20. Koob G, Zorilla E. Neurobiological mechanisms of addiction on corticotropin-releasing factor. Curr Opin Investig Drugs. 2010;11(1):63-71.

21. Mathes W, et al. The biology of binge eating. Appetite. 2009;52(3):545-553.

22. American Psychiatric Publishing. Diagnostic and Statistical Manual of Psychiatric Disorders, Edition 5 (DSM-5). Feeding and Eating Disorders.

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I was diagnosed with DM2 my final year of PA school (UC Davis) 18 years ago. It took me about a year to fine tune a low carb approach for this disease and I have had great results with nearly all my DM2 patients. This has become my specialty and my passion. I am the author of "Type 2 Diabetes The Owner's Manual" released in January, 2016 at

Daryl Wein,  PA-C,  Private PracticeNovember 07, 2016
Oakdale, CA

In July of 2015, it was discovered that I had type 2 diabetes. By the end of the month, I was given a prescription for Metformin. I stated the ADA diet and followed it completely for several weeks but was unable to get my blood sugar below 140. With no results to how for my hard work, I panicked and called my doctor. His response? Deal with it. I began to feel that something wasn't right and do my own research. Then I found Rachel's blog . I read it from cover to cover and I started the diet and by the next morning, my blood sugar was 100. Since then, I have a fasting reading between the mid 70s and 80s. My doctor was so surprised at the results that, the next week, he took me off the Metformin. I lost 30 pounds in the first month and lost more than 6 inches off my waist and I'm able to work out twice a day while still having lots of energy. The truth is we can get off the drugs and help myself by trying natural methods.

Royse October 20, 2016


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