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Low-carbohydrate diet

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Brown and wholegrain loaves of bread.
A low-carbohydrate diet restricts the amount of carbohydrate-rich foods – such as bread – in the diet.

Low-carbohydrate diets or carbohydrate-restricted diets (CRDs) are diets that restrict carbohydrate consumption. Foods high in carbohydrates (e.g., sugar, bread, pasta) are limited or replaced with foods containing a higher percentage of fats and moderate protein (e.g., meat, poultry, fish, shellfish, eggs, cheese, nuts, and seeds) and other foods low in carbohydrates (e.g., most salad vegetables such as spinach, kale, chard and collards), although other vegetables and fruits (especially berries) are often allowed.

There is a lack of standardization of how much carbohydrate low-carbohydrate diets must have, and this has complicated research.[1] One definition, from the American Academy of Family Physicians, specifies low-carbohydrate diets as having less than 20% carbohydrate content.[2]

Low-carbohydrate diets are associated with increased mortality, and they can miss out on the health benefits afforded by high-quality carbohydrate such as is found in pulses, fruit and vegetables.[3][4] Disadvantages of the diet might include halitosis, headache and constipation, and in general the potential adverse effects of the diet are under-researched, particularly for more serious possible risks such as for bone health and cancer incidence.[5]

Carbohydrate-restricted diets can be as effective, or marginally more effective, than low-fat diets in helping achieve weight loss in the short term.[6] In the long term, effective weight maintenance depends on calorie restriction, not the ratio of macronutrients in a diet.[7] The hypothesis proposed by diet advocates that carbohydrate causes undue fat accumulation via the medium of insulin, and that low-carbohydrate diets have a "metabolic advantage", has been falsified by experiment.[8][6]

It is not clear how low-carbohydrate dieting affects cardiovascular health; any benefit from HDL cholesterol might be offset by raised LDL cholesterol, which risks causing clogged arteries in the long term.[9][10]

Carbohydrate-restricted diets are no more effective than a conventional healthy diet in preventing the onset of type 2 diabetes, but for people with type 2 diabetes they are a viable option for losing weight or helping with glycemic control.[11][12][13] There is little evidence that low-carbohydrate dieting is helpful in managing type 1 diabetes.[1] The American Diabetes Association recommends that people with diabetes should adopt a generally healthy diet, rather than a diet focused on carbohydrate or other macronutrients.[13]

An extreme form of low-carbohydrate diet – the ketogenic diet – is established as a medical diet for treating epilepsy.[14] Through celebrity endorsement it has become a popular weight-loss fad diet, but there is no evidence of any distinctive benefit for this purpose, and it risks causing a number of side effects.[14] The British Dietetic Association named it one of the "top 5 worst celeb diets to avoid in 2018".[14]

Definition and classification

Macronutrient ratios

The macronutrient ratios of low-carbohydrate diets are not standardized.[15][16] As of 2018 the conflicting definitions of "low-carbohydrate" diets have complicated research into the subject.[1][17]

The American Academy of Family Physicians defines low-carbohydrate diets as diets that restrict carbohydrate intake to 20 to 60 grams per day, typically less than 20% of caloric intake.[2] A 2016 review of low-carbohydrate diets classified diets with 50g of carbohydrate per day (less than 10% of total calories) as "very low" and diets with 40% of calories from carbohydrates as "mild" low-carbohydrate diets.[18] In a 2015 review Richard D. Feinman and colleagues proposed that a very low carbohydrate diet had less that 10% caloric intake from carbohydrate, a low carbohydrate diet less than 26%, a medium carbohydrate diet less than 45%, and a high carbohydrate diet more than 45%.[16]

Both high- and low-carbohydrate diets are associated with increased mortality.[3] The optimal proportion of carbohydrate in a diet for health is thought to be 50-55%.[3]

Foodstuffs

A bundle of curly kale leaves.
Like other leafy vegetables, curly kale is a foodstuff that is low in carbohydrate.

There is evidence that the quality, rather than the quantity, of carbohydrate in a diet is important for health, and that high-fiber slow-digesting carbohydrate-rich foods are healthful while highly-refined and sugary foods are less so.[4] People choosing diet for health conditions should have their diet tailored to their individual requirements.[19] For people with metabolic conditions, in general a diet with approximately 40-50% high-quality carbohydrate is compatible with what is scientifically established to be a healthy diet.[19]

Some fruits may contain relatively high concentrations of sugar, most are largely water and not particularly calorie-dense. Thus, in absolute terms, even sweet fruits and berries do not represent a significant source of carbohydrates in their natural form, and also typically contain a good deal of fiber which attenuates the absorption of sugar in the gut.[20]

Most vegetables are low- or moderate-carbohydrate foods (in some low-carbohydrate diets, fiber is excluded because it is not a nutritive carbohydrate). Some vegetables, such as potatoes, carrots, maize (corn) and rice are high in starch. Most low-carbohydrate diet plans accommodate vegetables such as broccoli, spinach, kale, lettuce, cucumbers, cauliflower, peppers and most green-leafy vegetables.[21]

In 2004, the Canadian government ruled that foods sold in Canada could not be marketed with reduced or eliminated carbohydrate content as a selling point, because reduced carbohydrate content was not determined to be a health benefit. The government ruled that existing "low carb" and "no carb" packaging would have to be phased out by 2006.[22]

Adoption and advocacy

The National Academy of Medicine recommends a minimum intake of 130 g of carbohydrate per day.[23] The FAO and WHO similarly recommend that the majority of dietary energy come from carbohydrates.[24][25] Low-carbohydrate diets are not an option recommended in the 2015-2020 edition of Dietary Guidelines for Americans, which instead recommends a low fat diet.

Carbohydrate has been wrongly accused of being a uniquely "fattening" macronutrient, misleading many dieters into compromising the nutritiousness of their diet by eliminating carbohydrate-rich food.[26] Low-carbohydrate diet proponents emphasize research saying that low-carbohydrate diets can initially cause slightly greater weight loss than a balanced diet, but any such advantage does not persist.[26][6] In the long-term successful weight maintenance is determined by calorie intake, and not by macronutrient ratios.[7][6]

The public has become confused by the way in which some diets, such as the Zone diet and the South Beach diet are promoted as "low-carbohydrate" when in fact they would more properly be termed "medium" carbohydrate diets.[27]

Carbohydrate-insulin hypothesis

Low-carbohydrate diet advocates including Gary Taubes and David Ludwig have proposed a "carbohydrate-insulin hypothesis" in which carbohydrate is said to be uniquely fattening because it raises insulin levels and so causes fat to accumulate unduly.[28][8] The hypothesis appears to run counter to known human biology whereby there is no good evidence of any such association between the actions of insulin and fat accumulation and obesity.[6] The hypothesis predicted that low-carbohydrate dieting would offer a "metabolic advantage" of increased energy expenditure equivalent to 400-600 kcal/day, in accord with the promise of the Atkin's diet: a "high calorie way to stay thin forever".[8]

With funding from the Laura and John Arnold Foundation, in 2012 Taubes co-founded the Nutrition Science Initiative (NuSI), with the aim of raising over $200 million to undertake a "Manhattan Project for nutrition" and validate the hypothesis.[29][30] Intermediate results, published in the American Journal of Clinical Nutrition did not provide convincing evidence of any advantage to a low-carbohydrate diet as compared to diets of other composition – ultimately a very low-calorie, ketogenic diet (of 5% carbohydrate) "was not associated with significant loss of fat mass" compared to a non-specialized diet with the same calories; there was no useful "metabolic advantage".[6][8] In 2017 Kevin Hall, a NIH researcher hired to assist with the project, wrote that the carbohydrate-insulin hypothesis had been falsified by experiment.[28][8] Hall wrote "the rise in obesity prevalence may be primarily due to increased consumption of refined carbohydrates, but the mechanisms are likely to be quite different from those proposed by the carbohydrate–insulin model".[8]

Health aspects

Adherence

It has been repeatedly found that in the long-term, all diets with the same calorific value perform the same for weight loss, except for the one differentiating factor of how well people can faithfully follow the dietary programme.[27] A study comparing groups taking low-fat, low-carbohydrate and Mediterranean diets found at six months the low-carbohydrate diet still had most people adhering to it, but thereafter the situation reversed: at two years the low-carbohydrate group had the highest incidence of lapses and dropouts.[27] This may be due to the comparatively limited food choice of low-carbohydrate diets.[27]

Body weight

Studies have shown that people losing weight with a low-carbohydrate diet, compared to a low-fat diet, have very slightly more weight loss initially, equivalent to approximately 100kcal/day, but that the advantage diminishes over time and is ultimately insignificant.[6] The Endocrine Society state that "when calorie intake is held constant [...] body-fat accumulation does not appear to be affected by even very pronounced changes in the amount of fat vs carbohydrate in the diet."[6]

Much of the research into low-carbohydrate dieting has been of poor quality and studies which reported large effects have garnered disproportionate attention in comparison to those which are methodologically sound.[5] Higher quality studies tend to find no meaningful difference in outcome between low-fat and low-carbohydrate dieting.[5] Low-quality meta-analyses have tended to report favourably on the effect of low-carbohydrate diets: a systematic review found that 9 out of 10 meta-analyses with positive conclusions were affected by publication bias.[5]

Cardiovascular health

As of 2016 it was unclear whether low-carbohydrate dieting had any beneficial effect on cardiovascular health, though such diets can cause high LDL cholesterol levels, which carry a risk of atherosclerosis in the long term.[9] Potential favorable changes in triglyceride and HDL cholesterol values should be weighed against potential unfavorable changes in LDL and total cholesterol values.[31]

Some randomized control trials have shown that low-carbohydrate diets, especially very low-carbohydrate diets, perform better than low-fat diets in improving cardiometabolic risk factors in the long term, suggesting that low-carbohydrate diets are a viable option alongside low-fat diets for people at risk of cardiovascular disease.[10]

There is only poor-quality evidence of the effect of different diets on reducing or preventing high blood pressure, but it suggests the low-carbohydrate diet is among the better-performing ones, while the DASH diet performs best.[32]

Diabetes

Overall, the proportion of carbohydrate in a diet is not linked to the risk of onset of Type 2 diabetes, although there is some evidence that a diet containing certain high-carbohydrate items – such as sugar-sweetened drinks or white rice – is associated with an increased risk.[33]

Research into the effectiveness of low-carbohydrate, high fat (LCHF) diets for preventing weight gain and diabetes has produced conflicting results, with some suggestion that diet suitability is not generalizable, but specific to individuals.[11] Overall, for prevention, there is no good evidence that LCHF diets offer a superior diet choice to a more conventional healthy diet, as recommended by many health authorities, in which carbohydrate typically accounts for more than 40% of calories consumed.[11]

There is a lack of evidence of the usefulness of low-carbohydrate dieting for people with type 1 diabetes.[1] Although for certain individuals it may be feasible to follow a low-carbohydrate regime combined with carefully-managed insulin dosing, this is hard to maintain and there are concerns about possible adverse health effects caused by the diet.[1] In general people with type 1 diabetes are advised to follow an individualized eating plan rather than a pre-decided one.[1]

A low-carbohydrate diet gives slightly better control of glucose metabolism than a low-fat diet in type 2 diabetes.[12][34] A 2018 report on type 2 diabetes by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) found that a low-carbohydrate diet may not be as good as a Mediterranean diet at improving glycemic control, and that although having a healthy body weight is important, "there is no single ratio of carbohydrate, proteins, and fat intake that is optimal for every person with type 2 diabetes".[35]

The ADA say low-carbohydrate diets can be useful to help people with type 2 diabetes lose weight, but that these diets were poorly defined, difficult to sustain, unsuitable for certain groups of people and that, for diet composition in general, "no single approach has been proven to be consistently superior".[13] Overall, the ADA recommend people with diabetes should be "developing healthy eating patterns rather than focusing on individual macronutrients, micronutrients, or single foods". They recommended that the carbohydrate in a diet should come from "vegetables, legumes, fruits, dairy (milk and yogurt), and whole grains"; highly-refined foods and sugary drinks should be avoided.[13]

Low-carbohydrate dieting has no effect on the kidney function of people who have type 2 diabetes.[36]

Historically, limiting carbohydrate consumption was the traditional treatment for diabetes – indeed, it was the only effective treatment before the development of insulin therapy – and when carefully practised, it generally results in improved glucose control, usually without long-term weight loss.[37]

Exercise and fatigue

A low-carbohydrate diet has been found to reduce endurance capacity for intense exercise efforts, and depleted muscle glycogen following such efforts is only slowly replenished if a low-carbohydrate diet is taken.[38] Inadequate carbohydrate intake during athletic training causes metabolic acidosis, which may be responsible for the impaired performance which has been observed.[38]

Ketosis

The ketogenic diet is used to treat drug-resistant childhood epilepsy. It has become a fad diet for people attempting to lose weight.[39] Dieters trying this often do not achieve true ketosis as this requires extreme carbohydrate restriction, and maintaining a ketogenic diet is difficult.[39][11] Some diet advocates make misleading claims that the ketogenic diet can treat or prevent cancer.[14]

The British Dietetic Association note that a medical ketogenic diet is a useful epilepsy treatment, but for weight loss named it one of the "top 5 worst celeb diets to avoid in 2018".[14] Celebrities endorsing the diet include Gwyneth Paltrow and Mick Jagger.[14]

High-quality research shows no long-term weight loss advantage to a ketogenic diet over a low fat diet.[40] There is a lack of data about long-term safety, and low-carbohydrate intake may be associated with increased mortality.[39][40]

Safety

Low-carbohydrate dieting is associated with increased mortality, just as high-carbohydrate dieting is.[3]

As of 2018 research has paid insufficient attention to the potential adverse effects of carbohydrate restricted dieting, particularly for micronutrient sufficiency, bone health and cancer risk.[5] One meta-analysis reported that adverse effects could include "constipation, headache, halitosis, muscle cramp and general weakness".[5]

Ketosis induced by a low-carbohydrate has led to reported cases of ketoacidosis, a life-threatening condition.[1][41] This has led to the suggestion that ketoacidosis should be considered a potential hazard of low-carbohydrate dieting.[5]

In a comprehensive systematic review of 2018, Churuangsuk and colleagues reported that other case reports give rise to concerns of other potential risks of low-carbohydrate dieting including hyperosmolar coma, Wernicke's encephalopathy, optic neuropathy from thiamine deficiency, acute coronary syndrome and anxiety disorder.[5]

Significantly restricting the proportion of carbohydrate in diet risks causing malnutrition, and can make it difficult to get enough dietary fiber to stay healthy.[42]

As of 2014 it appeared that with respect to the risk of death for people with cardiovascular disease, the kind of carbohydrates consumed are important; diets relatively higher in fiber and whole grains lead to reduced risk of death from cardiovascular disease compared to diets high in refined-grains.[43]

History

Early dietary science

In 1797, John Rollo reported on the results of treating two diabetic Army officers with a low-carbohydrate diet and medications. A very low-carbohydrate, ketogenic diet was the standard treatment for diabetes throughout the nineteenth century.[44][45]

In 1863, William Banting, a formerly obese English undertaker and coffin maker, published "Letter on Corpulence Addressed to the Public", in which he described a diet for weight control giving up bread, butter, milk, sugar, beer, and potatoes.[46] His booklet was widely read, so much so that some people used the term "Banting" for the activity usually called "dieting".[47]

In the early 1900s Frederick Madison Allen developed a highly restrictive short term regime which was described by Walter R. Steiner at the 1916 annual convention of the Connecticut State Medical Society as The Starvation Treatment of Diabetes Mellitus.[48]: 176–177 [49][50][51] People showing very high urine glucose levels were confined to bed and restricted to an unlimited supply of water, coffee, tea, and clear meat broth until their urine was "sugar free"; this took two to four days but sometimes up to eight.[48]: 177  After the person's urine was sugar-free food was re-introduced; first only vegetables with less than 5g of carbohydate per day, eventually adding fruits and grains to build up to 3g of carbohydrate per kilogram of body weight. Then eggs and meat were added, building up to 1g of protein/kg of body weight per day, then fat was added to the point where the person stopped losing weight or a maximum of 40 calories of fat per kilogram per day was reached. The process was halted if sugar appeared in the person's urine.[48]: 177–178  This diet was often administered in a hospital in order to better ensure compliance and safety.[48]: 179 

Modern low-carbohydrate diets

Further information: Atkins diet

In 1967, Irwin Stillman published The Doctor's Quick Weight Loss Diet. The "Stillman diet" is a high-protein, low-carbohydrate, and low-fat diet. It is regarded as one of the first low-carbohydrate diets to become popular in the United States.[52] Other low-carbohydrate diets in the 1960s included the Air Force diet[53] and the Drinking Man's Diet.[54] Austrian physician Wolfgang Lutz published his book Leben Ohne Brot (Life Without Bread) in 1967.[55] However, it was not well known in the English-speaking world.

In 1972, Robert Atkins published Dr. Atkins Diet Revolution, which advocated the low-carbohydrate diet he had successfully used in treating patients in the 1960s (having developed the diet from a 1963 article published in JAMA).[56] The book met with some success, but, was widely criticized by the mainstream medical community as being dangerous and misleading, thereby limiting its appeal at the time.[57]

The concept of the glycemic index was developed in 1981 by David Jenkins to account for variances in speed of digestion of different types of carbohydrates. This concept classifies foods according to the rapidity of their effect on blood sugar levels – with fast-digesting simple carbohydrates causing a sharper increase and slower-digesting complex carbohydrates, such as whole grains, a slower one.[58]

1990s – present

In the 1990s, Atkins published an update from his 1972 book, Dr. Atkins New Diet Revolution, and other doctors began to publish books based on the same principles. This has been said to be the beginning of what the mass media call the "low carb craze" in the United States.[59] During the late 1990s and early 2000s, low-carbohydrate diets became some of the most popular diets in the US. By some accounts, up to 18% of the population was using one type of low-carbohydrate diet or another at the peak of their popularity.[60] Food manufacturers and restaurant chains like Krispy Kreme noted the trend, as it affected their businesses.[61] Parts of the mainstream medical community have denounced low-carbohydrate diets as being dangerous to health, such as the AHA in 2001[62] and the American Kidney Fund in 2002[63] Low-carbohydrate advocates did some adjustments of their own, increasingly advocating controlling fat and eliminating trans fat.[64]

See also

References

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  40. ^ Ullah W, Hamid M, Mohammad Ammar Abdullah H, Ur Rashid M, Inayat F (January 2018). "Another "D" in MUDPILES? A Review of Diet-Associated Nondiabetic Ketoacidosis". Journal of Investigative Medicine High Impact Case Reports. 6: 1–8. doi:10.1177/2324709618796261. PMC 6108016. PMID 30151400.
  41. ^ "Healthy Weight—The truth about carbs". National Health Service. 19 December 2018.
  42. ^ Hu T, Bazzano LA (April 2014). "The low-carbohydrate diet and cardiovascular risk factors: evidence from epidemiologic studies". Nutrition, Metabolism, and Cardiovascular Diseases. 24 (4): 337–43. doi:10.1016/j.numecd.2013.12.008. PMC 4351995. PMID 24613757.
  43. ^ Morgan, William (1877). Diabetes mellitus: its history, chemistry, anatomy, pathology, physiology, and treatment. {{cite book}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)
  44. ^ Einhorn, Max (1905). Lectures on dietetics. {{cite book}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)
  45. ^ Banting, William (1869). Letter On Corpulence, Addressed to the Public (4th ed.). London, England: Harrison. Retrieved 2 January 2008. {{cite book}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)
  46. ^ Groves, Barry (2002). "William Banting Father of the Low-Carbohydrate Diet". The Weston A. Price Foundation. {{cite web}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)
  47. ^ a b c d Steiner, Walter R (1916). "The Starvation Treatment of Diabetes Mellitus". Proceedings of the Connecticut State Medical Society: 176–184. 124th Annual Convention {{cite journal}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)
  48. ^ Allen, Frederick M; Fitz, Reginald; Stillman, Edgar (1919). Total dietary regulation in the treatment of diabetes. New York: The Rockefeller Institute for Medical Research. {{cite book}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)
  49. ^ Another publication of similar regimen was Hill, Lewis Webb; Eckman, Rena S (1915). The Starvation Treatment of Diabetes with a series of graduated diets as used at the Massachusetts General Hospital. Boston: W.M. Leonard. {{cite book}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help) This was so well received that it went into revised editions, eventually becomingThe Allen (Starvation) Treatment of Diabetes with a series of graduated diets (4th ed.). Boston. 1921. p. 140.{{cite book}}: CS1 maint: location missing publisher (link)
  50. ^ Also see "Discussion on the Modern Treatment of Diabetes". Transactions of the Medical Society of London. 45: 3–16. 24 October 1921.
  51. ^ 1967: the Stillman diet – History Of Diets, Part 12 – protein diet Men's Fitness. June 2003
  52. ^ Air Force Diet. Toronto, Canada: Air Force Diet Publishers. 1960.
  53. ^ Jameson, Gardner; Williams, Elliot (2004). The Drinking Man's Diet. San Francisco: Cameron. ISBN 978-0-918684-65-3. {{cite book}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help). See also Farnham, Alan (2004). "The Drinking Man's Diet". Forbes.com. {{cite web}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)
  54. ^ Lutz, Wolfgang; Allan, C.B. (2000). Life Without Bread (1st English language ed.). McGraw-Hill. ISBN 978-0-658-00170-3. {{cite book}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)
  55. ^ Gordon, Edgar; Goldberg, Marshall; Chosy, Grace (October 1963). "A New Concept in the Treatment of Obesity". JAMA. 186 (1): 50–60. doi:10.1001/jama.1963.63710010013014. PMID 14046659. {{cite journal}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)
  56. ^ "A critique of low-carbohydrate ketogenic weight reduction regimens. A review of Dr. Atkins' diet revolution". JAMA. 224 (10): 1415–9. June 1973. doi:10.1001/jama.1973.03220240055018. PMID 4739993.
  57. ^ Jenkins DJ, Wolever TM, Taylor RH, Barker H, Fielden H, Baldwin JM, Bowling AC, Newman HC, Jenkins AL, Goff DV (March 1981). "Glycemic index of foods: a physiological basis for carbohydrate exchange". The American Journal of Clinical Nutrition. 34 (3): 362–6. doi:10.1093/ajcn/34.3.362. PMID 6259925.
  58. ^ "PBS News Hour: Low Carb Craze". Pbs.org. Retrieved 18 December 2011.
  59. ^ Reinberg, Steven. "Americans Look for Health on the Menu: Survey finds nutrition plays increasing role in dining-out choices". Archived from the original on 28 September 2007. Retrieved 28 September 2007. {{cite web}}: Unknown parameter |deadurl= ignored (|url-status= suggested) (help)
  60. ^ Schooler, Larry (22 June 2004). "Low-Carb Diets Trim Krispy Kreme's Profit Line". Morning Edition. National Public Radio. Retrieved 18 December 2011. {{cite web}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)
  61. ^ St Jeor ST, Howard BV, Prewitt TE, Bovee V, Bazzarre T, Eckel RH (October 2001). "Dietary protein and weight reduction: a statement for healthcare professionals from the Nutrition Committee of the Council on Nutrition, Physical Activity, and Metabolism of the American Heart Association". Circulation. 104 (15): 1869–74. doi:10.1161/circ.104.15.1869 (inactive 20 September 2018). PMID 11591629. These diets are generally associated with higher intakes of total fat, saturated fat, and cholesterol because the protein is provided mainly by animal sources. ... Beneficial effects on blood lipids and insulin resistance are due to the weight loss, not to the change in caloric composition. ... High-protein diets may also be associated with increased risk for coronary heart disease due to intakes of saturated fat, cholesterol, and other associated dietary factors.{{cite journal}}: CS1 maint: DOI inactive as of September 2018 (link)
  62. ^ The American Kidney Fund: American Kidney Fund Warns About Impact of High-Protein Diets on Kidney Health: 25 April 2002
  63. ^ "Atkins diet boss: 'Eat less fat". BBC News. 19 January 2004. Retrieved 12 September 2007.
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