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Second Opinion:
A Diet That Works for You
Hosted by Abigail Trafford
Washington Post columnist
RESCHEDULED Thursday, Feb. 22, 2000; 4:15 p.m. EST

Welcome to Second Opinion, a weekly column and Live Online discussion with Post Health columnist Abigail Trafford. Have you ever been on a diet and gotten discouraged? Join the club. Now there's a kind of dieters' rebellion going on.

There are many popular diets with conflicting claims. High fat or low fat? Potatoes or steak? The point is to find the diet that works for you, for the long term.

Trafford investigates a case of a Washington lawyer and his cardiologist. They went on a low-carb, high protein diet and lost weight. And they also saw their blood levels of cholesterol come down. Their example doesn't prove that this is the best approach. But it shows how important it is for each individual to find a diet that works. For some people the low-fat diet works. For others the high-fat diet works.

Today, Dr. Ramin Oskoui, physician and Washington cardiologist talks to us about his experience and about the challenges of dieting to reduce health risks.

The transcript follows.

Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.

Abigail Trafford: Hello everybody, here we go! Got a story about losing weight? A question about how to do it? Join us now!

Abigail Trafford: Dr. Oskoui, welcome to Health Talk. Tell us your story. First your patient goes on this unorthodox diet. He not only loses weight, his cholesterol levels come down. Then you, the skeptical doctor, goes on the diet, and the same thing happens. What is this diet?

Dr. Ramin Oskoui: This was discussed in your column. My patient had had 2 heart attacks. He tried the standard low fat diet, exercise, and lipid agents and did not have satisfactory cholesterol numbers. He tried a low-carbohydrate diet and dropped his cholesterol quite substantially. He lost weight and feels good

Abigail Trafford: Why do you think this diet works?

Dr. Ramin Oskoui: There is emerging evidence that carbohydrates may result in elevated insulin levels and insulin resistence. Low carbohydrate diets by minimizing insulin production and alter metabolism in such a way as to encourage fat metabolism

Abigail Trafford: A recent report from the Department of Agriculture that reviewed all types of diets concluded that there was no evidence that a low-carb diet resulted in any health benefits such as lowered cholesterol levels. How do you respond?

Dr. Ramin Oskoui: This report was generated before new data was incorporated. Many times government panels are formed by individuals with their own message and they use data that supports it. We saw this for years in the blood pressure arena. Government guidelines recommended beta-blockers and diuretics even though side effects and discontinuations rate were the highest with these drugs. This has also been the case with Government cholesterol guidelines

Abigail Trafford: In fact, that government report said that the opposite kind of diet--a low-fat and plentiful carbo diet--can achieve health benefits and long term weight loss. What is going on here? How do the two diets compare?

Dr. Ramin Oskoui: Every diet needs to be incorporated into a life style that has frequent and adequate cardiac aerobic activity.

Washington, D.C.: I would like to know which diet Dr. Ramin Oskoui Mr. Bayer used to both lower his cholestrol and lose weight. I too have high cholestrol and I will try anything to get a lower number. I am also taking medication. (Zocor)

Thank you!

Dr. Ramin Oskoui: You should speak with your doctor. Zocor is one of several excellent "statin" drugs for cholesterol The doses range from 10 to 80 mg a day based on goal of therapy and tolerance. If exercise and diet are not enough for you. Consider other diet options and dietary conseling in consultation with your physician

Falls Church, Va.: Dr. Oskoui, thanks for taking my question (and congrats on your success!):

I am in my late 20s and I have been 30-50 lbs. overweight all of my life. I have never taken pills or participated in a "program," etc. When I have lost weight, it has always been by eating low-fat and hi-carb, eating LESS and working out. About a year ago, I lost 50 lbs and was almost at my ideal weight.

Then I encountered a lot of stress (job, financial, etc.) and my two years of eating right and working out came to a halt. I haven't worked out in a year and about two seconds ago I ate five chocolate chip cookies.

Dr. Oskoui, I just can't get motivated to try again.

What would you say to someone like me?

Thanks,

Abigail Trafford: Thank you for your story. It's one many people can relate do. Dr. Oskoui, what do you advise?

Dr. Ramin Oskoui: How important is your health. How old are you? Speak to friends and familyu above the age of 60. How they feel and how they are doing from a health standpoint has a lot to do with how they took care of themselves when they were younger

Washington, D.C.: What is the name of the diet that worked for you and Nathan, and did you change your execise habits when you began this diet?

Abigail Trafford: Nathan Bayer chose the diet outlined in the book "Sugar Busters." He excercises everyday. He also takes medication to lower his cholesterol levels. But he says exercise is very important. Dr. Oskoui, your thoughts?

Dr. Ramin Oskoui: Exercise is crucial. More than we may know. There are clearly metabolic effects that occur in people who exercise regularly. I also was more focused on myexercise as well

Rockville, Md.: I'm also a physician -- a general surgeon in Montgomery County. I went on the "Sugarbusters" diet one year ago and lost 40 lbs. in eight months.

I think that this diet is very intuitive. First of all, gastric emptying of carbohydrates is much quicker than for protein or fat, so the low-carb meals keep one satisfied for longer and curb the urge to snack. Secondly is the insulin issue. Any insulin-dependent diabetic patient will tell you that a high-carb meal like pasta will require a higher insulin dose than a high protein meal (i.e., steak). There is also less of a Somogyi effect. Thirdly is the evolutionary question. We have teeth called "canines." We probably evolved as protein eaters (meat, nuts, fruit), and so we do not have the dentition of grain eaters (i.e., cows or horses).

I have turned several nurses and colleagues on to this diet, and one other general surgeon I know also had his cholesterol drop and his need for exogenous insulin disappear.

Abigail Trafford: Thanks for the insights. Dr. Oskoui--your thoughts? For us lay folks,what is the Somogyi effect? The diet outlined in Sugar Busters is a kind of diabetic diet. Maybe you can tell us more about the theory behind it?

Dr. Ramin Oskoui: Diabetic diets are typically low carbohydrate very much like sugar busters. It is nice to hear another physician echo my results

Bethesda, Md.: What is your opinion of the Zone diet? I am currently on it and I lost 20 lbs. Anything I need to be aware of?

Abigail Trafford: Dr. Oskoui--what is the Zone diet? How does it differ from other diets?

Dr. Ramin Oskoui: I don't know enough about the Zone diet to give you good advice on this

Ames, Iowa: Just a comment, but my husband is doing the Weight Watcher's diet and I am too (easier to fix one meal than two). He's lost 20 lbs. in 8 weeks, and I've lost 5-10 (I don't follow the diet religiously because I'm already pretty thin). Anyway, what we've observed in this short time is the very simple (and obvious) connection that, if you consistantly reduce your portion size, YOU WILL LOSE WEIGHT! You'll lose weight faster if you also reduce your fat and sugar intake, but just reducing portions will make a difference. For example, we still occasionally order out for pizza, but we get thin crust, medium size instead large, and purchase from a vendor that doesn't use handfulls of cheese. I never would have believed we could see results so quickly, but we have, and this seems like an eating "style" that we could potentially sustain over time (more family dinners, less eating out, better family nutrition, etc.) unlike the high protein diet.

Abigail Trafford: Thanks for sharing your experience--and good results. Dr. Oskoui, what about the Weight Watcher's program--who is it good for? How does it differ from the diet you went on?

Dr. Ramin Oskoui: The weight Watchers diet is not a low Carb diet but it does work. The long story short is that portion control is a big issue for many people. Sometimes that is all it takes. Low fat diets do work . . . for some people. Others seem to do much better on Low carb diets. Your point is well taken

The District: Dear Dr. Oskoui:

I am wondering your thoughts on dieting without exercise. I was a 149 lb female, 5'4" and joined a gym. I lost I think a total of 4 lbs. Then I stopped exercising and got on a low fat, low carb, high protein diet (actually the Zone). It worked! I am down to 133 and loving life! I have about 10 lbs to go now, and wondering if you think the Zone diet is the way to continue. My thoughts are if it works, don't fix it. But I know exercise is good for my heart. And do you think 125 is a good target for my height? Age 29.

Thanks for your words of wisdom!!

signed, lighter in the district

Dr. Ramin Oskoui: I think for the most part you have found the right way to go. The reason you may not have lost weight is muscle weighs more than fat.
while your weigh sounds good, I would definitely add aerobic and weigh lifting (osteoporosis). I know a number a thin women who smoke . . .I would not consider them healthy. Good luck

Washington, D.C.: My husband, aged 59, 5'8", 190+, has not succeeded in trimming despite longterm efforts including regular exercise and the kind of diet lifestyle .which works for me. He shares an identical body shape (large tummy) and overwieght problem with a brother and three first cousins. Two years ago one of the cousins had lost his extra weight and was sharing his enthusiasm for the high fat, high protein regime which enabled him to lose his weight. Could my husband conclude that there might be a genetic possibility that where other diets have failed him, he might be one of those who could lose with the highfat diet? Thanks.

Dr. Ramin Oskoui: Yes

Lexington, Ky.: I am only 24 and have borderline high cholestrol. I have a biweekly cardio workout that is really helping with my weight, but I would really like to bring down that cholestrol level. Particularly because there is a lot of heart disease on my paternal side. Where should I start in bringing down my cholestrol?

Dr. Ramin Oskoui: Increase the exercise to 4 or 5 times a week.

Washington, D.C.: I think that many people think that just because they are eating the right foods, their diet is a good one. I have always eaten rationally, but was consuming 4-5 twenty oz bottles of regular soda a day. When I stopped this 2,000 calorie/day habit, I lost 23 pounds in 8 weeks. I changed nothing else, but the withdrawal from the sugar and ceffeine was excrutiating, but ultimately worth it. People need to look not just at the food, but at what they drink as well.

Dr. Ramin Oskoui: Absolutely.

Memphis, Tenn.: Dear Dr Ramin:

I do not eat a lot of types of meat - really only chicken, turkey and fish - and those not often. I eat a lot of soy meat substitute products. I have ten more pounds to lose and even though I am not overweight, my cholesterol is high 208 last year. I am almost 27 years old. I started a regular exerise program in early December and have worked out 5-6 days a week ever since. I am slowly increasing my pace to jogging/running - most of the time I do run/walk intervals. Each workout I do at least 3 miles.

I have lost 6-8 pounds - but feel as though I have leveled off...need to jump start weight loss again...

Any suggestions?

Abigail Trafford: Sounds like you are aggressively pursuing a program! Dr. Oskoui, what about the issue of cholesterol. What's normal for men and women? Does that change with age? If you have higher than normal cholesterol levels, what should you do? At what point should you take cholesterol-lowering drugs?

Dr. Ramin Oskoui: The soy products may be a problem. A diet diary looking a every thing you eat for 3 days may add some insight.

Abigail Trafford: Dr. Oskoui, how do you know if you're a low-carb person or a low-fat person?

Dr. Ramin Oskoui: Trial and error

Abigail Trafford: Going back to the question of dueling diets--the low-carb verses the high carb diets. Are you saying that both diets work equally well? Does it depend on the person? What factors made one diet better for a person over the opposite kind of diet?

Dr. Ramin Oskoui: It depends on the person
A diet diary recording ever single thing one eats for three days may be quite helpful.

You may be cheating in seemingly inconsequential ways e.g. soda, cookies

Miami, Fla.: Please, please tell me just how to get started. I suppose the way to start is to get the will to start. I always have good intentions but stop, almost before I get started. Is there something magical to just get started. HEEEELPPPPP.

Abigail Trafford: You've hit on one of the most difficult parts of changing behavior: how to get started. Dr. Oskoui, anything magical you can suggest is most welcome. But first talk a little bit about body size. Do we sometimes get too obsessed with our weight--and get too thin to be healthy? Is being a little plump, okay?

Dr. Ramin Oskoui: Read the Carbohydrate Addicts diet. Think how badly you want this. Change has to come from within

Chicago, IL: Dr. Oskoui,

How do you rate the sustainability of this
type of diet over the long term? It makes
sense that people might lose weight while on
it, but is it really feasible to continue
this sort of diet for the rest of one's lif

Dr. Ramin Oskoui: We don't have good long term data. I have several motivated patients who have beeen on this diet for over 2 years

Laurel, MD: Let's face it...the reason low-carb diets work is that they are merely lower in calories. I'm certain that if you have 6 steaks in one meal you're not going to lose weight, just as much as if you eat 5 cookies you're not going to lose weight. So I agree with Ames, Iowa, that it's portion control. Less fat, less sugar, it all amounts to less calories and thusly a loss of weight.

I would think that a balanced diet (proper amounts of carbs, fats, proteins, etc) with regular exercise would be the safest way to lose weight. Sure you lose weight by eliminating carbs, but is that the safest way to lose weight? Aren't there any health risks by eliminating carbs?

Dr. Ramin Oskoui: The health risks remain undefined. There is more to it than caloric intake however

washington, dc: What do you think about the Atkins Diet? I lost 48 pounds 2 years ago. But I gained most of it back. Now I'm attempting it again. What do you think.

Dr. Ramin Oskoui: The most restictive of the low carb diets. Try the Carbohydrate Addicts diet it is less restrictive with exercise

Dupont Circle: Dr. Oskou:

How many grams of protein and carbs was your patient on? Relative to his weight at the outset of the diet?

Thanks

Dr. Ramin Oskoui: I don't know precisely. Abigail do you?

Kenilworth, N.J.: I eat a low-fat, high fiber diet, yet I have high cholesterol (285) with HDLs too low to warrant the total number. My diet is purely personal preference; however, occasionally I do like to eat a little cheese, ice cream, or chocolate, or butter the slice of bread.

I'm wondering if there could be a correlation between the body making up the cholesterol level because not enough fatty foods are consumed, much in the same way that the body compensates by retaining water when not enough water is consumed.

Please advise, and if possible, please send me a sample of the high-fat diet.

Dr. Ramin Oskoui: No I suspect you have a significant genetic component to your cholesterol. Low HDL can occur in patients who smoke, take certain HIV drugs, testoterone suppl as well. You should discuss this with your Internist

Falls Church, Va.: My blood cholosterol level is borderline do I need to go on a low fat diet. I am 49 years old and I weigh 165 lbs. My blood pressure is normal.

Abigail Trafford: Does the viewer need to go on a low-fat diet? Or a low-carb diet?

Dr. Ramin Oskoui: What is your height. If you are 6 feet tall this may be OK. More important than the total is the good and bad chol (HDL and LDL)

Abigail Trafford: Let's go back to cholesterol levels. What's normal? And when should someone consider cholesterol-lowering drugs? Do you usually recommend medications plus a diet and exercise program?

Dr. Ramin Oskoui: Total chol < 200
HDL chol > 35
LDL chol < 130
If less than 2 risk factors for coronary disease

If diabetic, or with known CAD or PVD we have more ambitious goals and want to see lower values. Drugs as well as diet are necessary the majority of the time

Memphis again: Can you explain why the soy products could be a problem? I eat a soy patty at least 5 times a week and soy sausage patty for breakfast 5 times a week...

Thanks for your insight!

Dr. Ramin Oskoui: The may suppress HDL indirectly and have unclear effects on LDL chol

Rockville, Md.: Dr. Oskoui, I'd like to commend you for making changes that positively affect your health. I am an obese person, and am currently losing weight on a low-fat diet. I'm not weighing myself, because slow weight loss is demoralizing in ways, but my clothes are getting looser and I'm feeling better -- hooray!

My question is this -- how much does a relatively small weight loss (15-20 lbs.) improve overall health? Is losing a little weight beneficial, or do you have to get into the normal range to gain health benefits?

Dr. Ramin Oskoui: Every little bit counts. Definitely keep pushing. There is benefit especially with exercise even if weigh remains stable

Washinton, D.C.: Hello --

I have PCOS and was told that the low carb/high protein approach can work for me. I haven't tried it yet. Do you have any evidence that this diet works well for PCOS patients?

Abigail Trafford: Polycistic Ovarian Syndrome--. Dr. Oskoui?

Dr. Ramin Oskoui: Theoretically it should work. I am not aware of any specific studies

Washington, D.C.: Dr. Oskoui,

What effect does time have on a diet? Do you find that when you eat is as important as what you eat?

Dr. Ramin Oskoui: Eating after exercise is better
Usually eating earlier in the day is better

Anchorage, Alaska: I have an 11-year-old son who is overweight and has a total cholesterol of 190. With a family history of heart disease, we know this issue needs to be addressed. I see his weight impacting the choices he is making, e.g., not trying out for football because he can't make the weight limit or refusing to go rock climbing at the gym because he is too big. What is the best approach to help him? How involved should I be in monitoring his food choices? We offer lots of healthy foods at home and we try to exercise as a family regularly.

Dr. Ramin Oskoui: You need to be very involved in a way that is supportive and doesn't diminish his selfesteem. Childhood diabetes is on the rise. Keep it up. The family thing is good

Cedar Rapids, Iowa: I have always read and heard that Weight Watchers offers the healthiest, most sensible diet plan (not too many or too little carbs, proteins, etc.) I have heard it offers the balanced approach to food. What do you know about this diet, way of life and is the approach by Richard Simmons similar to that of Weight Watchers? Thanks.

Dr. Ramin Oskoui: No diet is perfect. Try it and see. I have a strong bias toward low carb diets given my own anecdotal experience.

Germantown, Md.: My 2-year-old daughter was born with Pulmonary Atresia and a small ASD. She had surgery last year to create a ventricular outflow patch. She's been doing very well since, though it looks like we are heading for one more surgery this year.

My question is how concerned we should be about her diet at this point. Our cardiologist hasn't put any restrictions on her, but I'd like your opinion on where diet fits into the management of children with congenital heart defects. Is it important at this point to limit her fat intake?

Dr. Ramin Oskoui: I would not restrict her diet. She needs it to grow and tolerate the stress of surgery. Speak specifically to her Cardiologist. There may be other issues that I am not aware of.

Washington, D.C.: What would be the best diet for me if I love pastas, bread and dairy products? I'm a healthy 29-year-old black female, 5'4" weighing between 145-150 with no kids (yet). I would like to lose roughly about 10-15 pounds before I have kids or get older. Please let me know what type of foods I should start eating, or better yet stop to be at an ideal weight of around 135-140.

Ms. Medium, but not well done! :-

Dr. Ramin Oskoui: Do cardio 4 - 5 x a week for at least 30 min
Cut out the starch

Dupont Circle: Why I agree that it is important to be healthy, shouldn't you also caution people about over-dieting? There is a difference between being healthy and being sucked into an unrealistic view of beauty. I don't think that a 29 year-old woman who weighs 129 pds needs to lose weight!

Aren't you contributing to this problem?

Dr. Ramin Oskoui: Yes. You are correct.
Weight fluctuations are particularly unhealthy and should be avoid.
Don't blame me for the latest cover on Sports Illustrated. We do have a unhealthy attitude that is reflected in Hollywood.

Bethesda, Md.: I am a 33 year-old woman, 5'4, 130, small frame. I recently noticed that my appetite has increased substantially. I mean, I am ALWAYS hungry. I try to eat veggies and fruit but I find that a bagel a cream cheese stays with me longer and I'm not so hungry anymore. I try to stay away from it but my stomach feels so empty it hurts. What are good snacks that stay with you but don't stay on your thighs?

Dr. Ramin Oskoui: I am not a dietician.

I would imagine chewing gum would be helpful.

Wish I could be more helpful

Springfield, VA: HI. I think I eat too much. Like i come home from school and as much as i try to think, "don't eat" i can eat anyway. Is there anyway for me to curb this? I am a juvenille type 1 Diabetic(about 7 years) and in moderately good control except fot this eating problem. I'm not over weight, but i'd like to shed some pounds. I think that my over-eating has something to do with my inabliity to do so.

Dr. Ramin Oskoui: Tough nquestion.

Try to do something that gets you out of the house . . . like studying in the library or exercising.

Bowie, Md.: I have such a hard time sticking to a diet. I have been very fortunate and have never need to watch my weight until my 30s. Thanks for your input.

Abigail Trafford: Does something happen to the body around the age 30? Around age 50? Are these danger ages for putting on pounds?

Dr. Ramin Oskoui: Metabolism slows as one ages

Bailey's Crossroads, Va.: I'm a 56-year-old male with a lifetime of perfect health and high cholestrol (275), although the high density is also high (50-60).

Last spring I had an ultrascan of the cartoid (sp? -- along the neck) arteries, and they were perfectly clean.

Question: Can this result be taken as strongly, or weakly, indicative of the condition of the arteries around my heart? Is there any correlation between their condition and the condition of the rest of the circulatory system?

I should add that I tend to consume a lot of fruits, vegatables and nuts (pecans and walnuts). I try to limit my meat consumption while rotating through beef, chicken, pork and fish (and eat more than I'd like). I am about 20 pounds overweight after 10 years of couch potato, and 20 years of handball 3/4 times a week before that.

Thanks again.

Dr. Ramin Oskoui: Lack of peripheral vascular dusease bodes well. 50% of those with carotid disease have significant coronary disease. Are you diabetic, is there a family HX of coronary disease, do you smoke, what is your LDL chol.? Don't take anything for granted.

Abigail Trafford: Our time is up. Thanks very much. Join us next week on Tuesday. We'll talk about the crisis in nursing.