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Which is better for you - a low carbohydrate diet or a high-fat diet?
So many fad diets demonize one macronutrient at the expense of the others, and lately the nutrient people love to hate have been carbohydrates, whether that's the Atkins diet or the Paleo diet.

Quality counts!
I've been saying for years - no, decades - that it's the quality of the calories you put in your mouth and body that really count. Since I'm an allopathic, evidence-based physician talking about health and nutrition, people assume that I'm all about weight loss. The truth is, I'm not.

Long term high protein diets: bad for you?
I'm a practicing physician: I see patients every day. When I counsel my patients about their diet, I want to meet them where they are, in the world they live in, with the real challenges they face. I'm not interested in what might be a "perfect" diet: I'm interested in helping my patients make realistic dietary changes that they can live with for the long term for the sake of their, yes, long term health.


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It's the quality of the carbohydrates that counts

a bowl of whole grain pasta with spinach and tomatoes

One of the earlier versions of my diet plan was called "The Quality Calorie Diet." This reflects my belief that it's the quality of the calories that you consume that counts, not just total calories. After all, if only the number of calories counted, you could survive on 2,000 calories a day of Cheetos® or chocolate and be just as healthy as if you were eating 2,000 calories a day of fish, brown rice, and kale.

Using data gathered through the Health Professionals Followup Study and the Nurses' Health Study, both large-scale, long-term surveys of nearly 3 million health professionals, authors affiliated with Harvard and the University of Maryland looked at the quality of the carbohydrates people reported consuming and their experience of cardiovascular disease (Am J Clin Nutr 2018;107:257-267).

For the purposes of their analysis, the authors excluded survey participants who started their respective studies with a diagnosis of diabetes, cardiovascular disease, or cancer, as it was likely that their diagnosis would have some effect on their eating habits.

Using the food-frequency questionnaires gathered every two years, the authors analyzed the types of carbohydrates the participants consumed, looking not only at total carbohydrates or total fiber consumed but breaking out those analyses by types of fiber (vegetable? fruit? cereal fiber?) and classifying the quality of those carbohydrates by ratio of carbohydrates to fiber (and sub-types of fiber). This classification can be a bit counter-intuitive: a higher ratio of carbohydrates to fiber is actually worse for you than a lower ratio of carbohydrates to fiber - brown rice, for example, will have a lower ratio of carbohydrates to fiber than white rice. According to the American Heart Association, "fiber-rich whole grains" are defined as those with a carbohydrate-to-fiber ratio of LESS THAN 10:1.

The diet of those survey participants who experienced a heart attack (whether they survived or not) were then compared with those who did not. In their analysis the researchers took into account age, Body Mass Index, race, family history of heart attack, smoking status, amount of physical activity, multivitamin or aspirin use, whether women used hormone replacement therapy if they were postmenopausal, and total daily caloric intake.

Unsurprisingly, total carbohydrate intake was not associated with an increased risk of heart attack, but total cereal fiber intake was associated with a 20% lower risk of heart attack. The highest carbohydrate-to-cereal fiber ratios (that is, ratios with higher numbers of carbohydrates compared to fiber levels) meant a 20% increase in risk of heart attack as well.

What this means for you

Carbohydrates are not bad for you: poor-quality carbohydrates are bad for you! Here's a guide to the best-quality carbohydrates to keep in your pantry.

First posted: March 14, 2018