I’m not a diet doctor. In fact my career in medicine has been largely devoted to the science of noninvasive cardiac imaging — the development of technology that produces sophisticated pictures of the heart and the coronary blood vessels. This allows us to identify problems and treat them early, before they cause heart attack or stroke. In CT (computerized tomography) scanning all over the world, I’m proud to say, the measure of coronary calcium is called the Agatston Score, and the protocol for calcium screening is often referred to as the Agatston Method. I maintain an active, full-time cardiology practice, both clinical and research.
So how is it that I am also responsible for a weight-loss program that has become a phenomenon here in South Florida, a regimen that’s helped countless women and men — many of them in their twenties and thirties, young enough to be the grandchildren of my usual cardiology patients — get down to string-bikini and Speedo-swim-trunks-shape?
I have to admit, I wasn’t prepared to find myself on the receiving end of so much buzz. I’m now regularly stopped by people who have seen my TV news appearances or read about the diet’s success in newspapers and magazines. Given this city’s worldwide image as a mecca of physical beauty and body consciousness and its role as a chic outpost of the fashion industry, it’s an unexpected position in which to find myself.
This all started as a serious medical undertaking. Back in the mid-’90s I was but one of many cardiologists who had grown disillusioned with the low-fat, high-carbohydrate diet that the American Heart Association recommended to help us eat properly and maintain healthy weight. None of the low-fat regimens of that era seemed to work reliably, especially over the long haul. My concern was not with my patients’ appearance: I wanted to find a diet that would help prevent or reverse the myriad of heart and vascular problems that stem from obesity.
I never found such a diet. Instead, I developed one myself.
Today, I feel nearly as comfortable in the world of nutrition as I do among cardiologists. I speak regularly before physicians, researchers, and other health-care professionals who devote their lives to helping patients eat sensibly and lose weight. Although my interest in diet started from the therapeutic perspective, I see now that the cosmetic benefits of losing weight are extremely important because they so effectively motivate the young and the old — even more than the promise of a healthy heart, it often seems. The psychological lift that comes from an improved appearance benefits the entire person, and keeps many a patient from backsliding. The end result is cardiovascular health — my only goal when this journey began.
What started as a part-time foray into the world of nutrition has led me to devise a simple, medically-sound diet that works, without stress, for a large percentage of those who try it. This program has been scientifically studied (as few diets ever are) and proven effective, both for losing weight and for getting and keeping a healthy cardiovascular system.
Back when this all began, of course, I had no idea what would ensue. All I knew was that many of my patients — more of them every year — were overweight and that their condition was a big part of their cardiac risk. I could treat them with all the newest medications and procedures, but until they got their diet under control we were often fighting a losing battle. Their eating habits contributed to blood chemistry that was dangerously high in cholesterol and triglycerides, the leading factors in blocked arteries and inflammation of the blood vessels. And there was another, not terribly well-understood diet-related problem that they shared, a silent, so-called metabolic syndrome (prediabetes) found in close to half of all Americans who suffer heart attacks.
Searching for the Right Weight-Loss Plan
My journey to disease prevention through diet actually began when my education as a cardiologist did, 30 years ago. During my training in the late 1970s, I looked forward to treating patients with heart disease — despite the fact that we didn’t have many preventive weapons in our arsenal. I asked the most respected cardiologist I knew this question: “What is the best way to prevent heart disease?” His answer: “Pick the right parents.” If you inherited the gene for cardiac longevity, you were likely to live to a ripe old age. If heart disease struck early in your family, there was not much you could do to change your destiny.
Then, in 1984, 1 attended a course at the Heart House in Bethesda, Maryland, the national headquarters of the American College of Cardiology. There, I heard a lecture by a brilliant researcher and charismatic teacher, Bill Castelli, who headed the world-famous Framingham Heart Study. Dr. Castelli told us about the results of the recently completed National Institutes of Health (NIH)-sponsored Lipid Research Clinics Primary Prevention Trial (LPCPPT). This was the very first study to prove that lowering cholesterol could reduce heart attacks. At the time, the only known treatment for high cholesterol was an unpleasant, grainy powder known as a resin, which was taken several times a day before meals. Therefore, we were all very excited when Dr. Castelli told the conference that if we put patients on the very first American Heart Association diet, we could lower their cholesterol and end the scourge of heart disease in America.
We all returned home filled with fervor, ready to guide our patients to restored cardiac health and dietary wisdom. I came back to Miami confident in my newfound knowledge of how to save my patients’ lives. My wife and I even joked that with heart disease out of the picture, I might be better off switching to a growth specialty, like plastic surgery. It wasn’t long before I learned that unemployment as a cardiologist was going to be unlikely.
I began counseling my patients on the low-fat, high-carbohydrate diet advocated by the American Heart Association, but the results fell far below my expectations. Often, there was an initial modest improvement in total cholesterol with mild weight loss. This invariably was followed by a return of cholesterol to its previous level or higher, along with a return of the lost weight. This scenario was not only my experience but also that of my colleagues. It was reflected in the many diet-cholesterol trials documented in the literature: we were unable to sustain cholesterol and/or weight reductions using low-fat, high-carbohydrate diets. There were no convincing studies showing that the American Heart Association diet saved lives.
Over the years I had suggested most of the highly respected diets out there-going back to Pritikin and then through the various, more recent, heart-healthy low-fat regimens, including the Ornish plan and several American Heart Association diets. Each of them, for different reasons, failed miserably. Either the diets were too difficult to stick with, or the promise of improved blood chemistry and cardiac health remained just that — a promise. Discouraged, I had all but given up on advising my patients about nutrition, because I was unable to suggest anything that actually helped. Like most cardiologists in that period, I turned instead to the statin drugs that were just entering the market, medications that had proven extremely effective in lowering total cholesterol, if not weight.
But I also decided, as a last-ditch effort, that I would devote some serious study of my own to diet and obesity. Like most physicians, I was not particularly knowledgeable in the science of nutrition. So my first task was to research all the weight-loss programs out there, the serious scientific ones as well as the trendy attempts that topped the best-seller lists. As I acquired that education, I was also reading in the cardiology literature about the prevalence of something called the insulin resistance syndrome and its effect on obesity and heart health.
The Science of Success
One side effect of excess weight, we now know, is an impairment of the hormone insulin’s ability to properly process fuel, or fats and sugars. This condition is commonly called insulin resistance. As a result, the body stores more fat than it should, especially in the midsection. Since the dawn of Homo sapiens, we’ve been genetically conditioned to store fat as a survival strategy to see us through times of famine.
The problem now, of course, is that we never experience the famine end of that equation, only the feast. As a result, we store fat but never require our bodies to burn it off. Much of our excess weight comes from the carbohydrates we eat, especially the highly processed ones found in baked goods, breads, snacks, and other convenient favorites. Modern industrial processing removes the fiber from these foods, and once that’s gone their very nature — and how we metabolize them-changes significantly for the worse.
Decrease the consumption of those “bad” carbs, studies showed, and the insulin resistance starts clearing up on its own. Weight begins a fairly rapid decrease, and you begin metabolizing carbs properly. Even the craving for carbs disappears once you cut down on their consumption. Finally, cutting out processed carbs improves blood chemistry, ultimately resulting in lowered triglycerides and cholesterol.
So my eating plan’s first principle was to permit good carbohydrates (fruits, vegetables, and whole grains) and curtail the intake of bad carbohydrates (the highly processed ones, for the most part, where all the fiber had been stripped away during manufacturing). We would thereby eliminate a prime cause of obesity. This was in marked contrast to the Atkins Diet, for instance, which bans virtually all carbohydrates and leaves the dieter to exist mostly on proteins. That regimen also permits limitless saturated fats, the kind found in red meat and butter. These are, as most people know, the bad fats — the ones that can lead to cardiovascular disease, heart attack, and stroke. That hasn’t stopped millions of dieters from adopting the plan. But from the moment I learned of it, the diet set off alarm bells in this cardiologist’s head. Even if you do lose weight and keep it off, your blood chemistry might suffer from eating so much saturated fat.
My plan cut certain carbohydrates, but not all of them. In fact, it encouraged eating the good ones. For instance, I banished white flour and white sugar. But our diet permits whole grain breads and cereals and whole wheat pasta. We also prescribe lots of vegetables and fruits. I had a practical reason for that decision, beyond their obvious nutritional value and the beneficial fiber they provide. Not everyone wants to give up vegetables, fruit, bread, and pasta forever, even in exchange for a regimen that allows a pound of bacon for breakfast, followed by a pound of hamburger (with no bun, of course) for lunch, topped by a thick steak for dinner. And if people want bread, pasta, or rice, a humane eating plan should be able to accommodate that desire.
To make up for the overall cut in carbohydrates, my diet permitted ample fats and animal proteins. This decision flew in the face of the famous diets that had been developed specifically for people with heart problems, like Pritikin and Ornish. For a cardiologist, this was skating on thin ice. But my experience with patients showed that those so-called heart-healthy diets were nearly impossible to stick to, because they relied too heavily on the dieters’ ability to eat superlow fat over the long haul. The South Beach Diet would permit lean beef, pork, veal, and lamb.
The low-fat regimen’s severe restrictions on meat were unnecessary the latest studies had shown that lean meat did not have a harmful effect on blood chemistry. Even egg yolks are good for you contrary to what we once believed. They’re a source of natural vitamin E and have a neutral-to-favorable effect on our balance between good and bad cholesterol. Chicken, turkey, and fish (especially the oily ones such as salmon, tuna, and mackerel) were recommended on my diet, along with nuts and low-fat cheeses and yogurt. As a rule, low-fat prepared foods can be a bad idea-the fats are replaced with carbs, which are fattening. But low-fat dairy products such as cheese, milk, and yogurt are exceptions to this rule-they are nutritious and not fattening.
I also allowed plenty of healthy mono- and polyunsaturated fats, like the Mediterranean ones: olive oil, canola oil, and peanut oil. These are the good fats. They can actually reduce the risk of heart attack or stroke. In addition to being beneficial, they make food more palatable. They’re filling, too-a major consideration for a diet that promises that you won’t have to go hungry.
Next, I found a suitable guinea pig for preliminary testing purposes, a middle-age man who was having trouble keeping his growing paunch under control: me. I went on the diet. I gave up bread, pasta, rice, potatoes. No beer. Not even fruit, at least in the very beginning, because it contains high levels of fructose, or fruit sugar. But otherwise I was determined to eat as normally as possible, meaning three meals a day plus snacks when I was hungry.
After just a week, I noticed a difference. I lost almost 8 pounds in those first 7 days, and it was easy. I didn’t suffer any hunger pangs. No terrible cravings. No noticeable deprivation.
Almost sheepishly, I approached Marie Almon, M.S., R.D., chief clinical dietitian at our hospital, Mount Sinai Medical Center in Miami Beach, and told her of my experiment. She conceded that the low-fat diet we had been recommending to cardiac patients wasn’t working. So we took the basic principles I had developed and expanded them into an agreeable eating plan.
We settled on a few more guidelines, based on my clinical experience and study of the literature. First, we acknowledged the primary failing of diets we had tried with patients: They’re too complicated and too rigid. A diet may be medically or nutritionally sound, but if it is hard to live with, if it doesn’t take into account how — the whole person operates, not just his or her digestive tract and metabolism — then it is a failure. So this diet would be flexible and simple, with as few rules as possible. It would allow people to eat the way they actually like to eat, while improving their blood chemistry and helping them to lose weight and maintain the loss over the long run. This means a lifetime, not 3 months or a year. Only by accomplishing these goals would this program make the crucial transition from being a diet to being a lifestyle — a way of living and eating that normal human beings can sustain for the rest of their lives.
With that in mind, we decided that we wouldn’t ask people to deny themselves every eating pleasure indefinitely. Typically, once you’ve gone off track on a diet, you’re on your own. The experts never allow for human frailty or tell you how to accommodate the inevitable slips as part of the plan. As a result, people who cheat a little today usually cheat a little more tomorrow, and then it’s a slippery slope down to where the diet’s in shambles, you’ve broken every rule, and you’re depressed, discouraged and back at square one. So we make ample use of desserts devised especially by Marie Ahnon for the program. These treats are delicious, yet use only “legal” ingredients.
We also simply recognized that there will be days when you just need that chocolate ice cream or lemon meringue pie. I’m a chocoholic, so believe me, I understand. This plan would allow dieters to bend or break the rules, so long as they understood exactly what damage they’ve done and how to undo it. If the cheating put a few pounds on, or stalled the weight loss, the setback would be minimal and easily repaired, rather than spelling doom. One beauty of the three-phase structure of the South Beach Diet is that you can move easily from one stage to another. If, while in Phase 2, you go on vacation and overindulge in sweets, it’s easy to switch back to Phase 1 for a week, lose the weight those desserts put on, and then return to where you left off in Phase 2.
Finally, people are practical beings. Diets that require complex menus, or supplements taken at certain times of day, or foods eaten in precise combinations, are just too burdensome to sustain for long. Many popular diets are extremely tricky in that regard, despite the fact that there is no basis in science for such complexity. And so they fail. Most of us lead complicated enough lives without having to be within walking distance of a refrigerator every 2 hours. Nobody wants to carry around a pillbox or a rule book (or both). So this diet would be based on dishes that are easy to make, with ingredients that are commonly found in supermarkets or in most restaurants. The plan requires snacks between meals, but the kind that can be thrown into a briefcase or backpack in the morning and eaten on the run. Our diet is also distinguished by the absence of calorie counts; percentage counts of fats, carbs, and proteins; or even rules about portion size. Our major concern is that dieters eat good carbs and good fats. Once that’s all under control, portions and percentages take care of themselves. By choosing the right carbs and the right fats, you simply won’t be hungry all the time.
Our diet, we decided, would have to be effective regardless of the dieter’s exercise habits. Without a doubt, exercise does increase the body’s metabolism, thereby making the diet more efficient. It is also a critical part of any cardiac health plan. However, the South Beach Diet does not depend on exercise in order to work. You’ll lose more weight, faster, if you are active on a regular basis. But you’ll lose weight even if you’re not.
Flexibility and common sense, guided by real science–as opposed to the pop science that often passes for nutrition these days — were the guiding principles of the South Beach Diet. We hoped we had come up with a workable, practical solution to the obesity that plagued so many people we saw in the office and hospital setting. We believed it would work for most them. But of course, we wouldn’t really know until they tried it.
The excerpt above is from The South Beach Diet: The Delicious, Doctor-Designed, Foolproof Plan for Fast and Healthy Weight Loss by Arthur Agatston, M.D, who is a cardiologist who has served on committees of the American Society of Echocardiology, the American College of Cardiology, and the Society of Artherosclerosis Imaging, where he is a member of the founding board of directors.