Extreme Diets: Fads and Facts

A Medscape Oncolgoy article by Steven Rourke; Reviewed by Anya Romanowski, MS, RD

Sylvester Graham’s Diet

The Presbyterian minister Sylvester Graham (1794-1851) approached diet as moral education, combining his strict religious beliefs with themes common to the temperance movement of the 19th century.^[1-5] He derived dietary principles from his interpretation of the Ten Commandments^[2] and envisaged the stomach as “the helpful minister of your body.”^[1]

Graham’s diet, launched in the late 1820s, is considered by some to be the first “fad” diet.^[4] It preached against the “overstimulation” of certain foods—specifically refined white breads and meats, which Graham believed to be the cause of immoral behavior, gluttony, and promiscuity.^[2] He proposed a plain vegetarian diet; replaced meat with wheat^[5]; and marketed a coarse wholemeal “Graham bread,”^[6] which lead to the eponymous cracker.^[2-5]

Graham travelled throughout the United States and wrote prolifically to promote his beliefs. His radical thoughts made him both a figure of ridicule and a famous man who inspired future diet creators (or “Grahamites”^[5]), including John Harvey Kellogg.^[4]

Despite claiming he could prolong life to 100 years, Graham died at age 57.^[2,4] Among his legacies, he is considered one of the founders of the vegetarian movement in the United States.^[3,4]

Fletcherism

A “lecturer of singular charm,”^[7] Horace Fletcher (1849-1919)—also known as “the Great Masticator”^[1,8]—was a wealthy businessman and self-proclaimed nutrition expert whose diet became a social happening at the turn of the 20th century.^[1,7-9]

According to Fletcher, food—to be eaten only when a person was “good and hungry”—necessitated prolonged mastication to avoid “intense putrification” in the gut and achieve weight loss.^[1] Foods turning into liquid and pooling in the mouth after 100-700 chews were to be swallowed, whereas solids were to be spat out.^[1] And although the diet did not restrict any types of food,^[8] Fletcher himself was drawn to vegetarianism^[7] (perhaps unsurprisingly, given all the chewing).

Fletcher was taken seriously by both the British and American medical professions and had a star-studded following, which included John Rockefeller and Franz Kafka.^[1] However, by the 1920s, Fletcherism fell from favor—perhaps through the pressure of time, boredom, and the diet regimen causing extreme constipation.^[7] After 5 years on the diet, Henry James, an early enthusiast, reported a “sickish loathing of food.”^[1]

As an interesting footnote, a small recent study using electromyography to monitor chewing behavior showed that “higher chewing counts reduced food intake.”^[9]

Hauser’s Cosmetic Diet

Of German Lutheran origin, Benjamin Gayelord Hauser (1895-1984) was the first Hollywood diet guru who amassed wealth and notoriety through choreographed self-promotion in step with the booming movie industry.^[1,10,11] His dietary advice was followed by A-listers, including Greta Garbo.

Hauser associated fat with unhappiness. His diets for “smart women and leaders in fashion and society”^[1] promised beauty through strict restrictions on food intake and a predilection for juices, wheat germ, blackstrap molasses, nuts, yogurts, and brewer’s yeast.^[10]

Hauser marketed his branded diets, including the mending, vitality, and zigzag diets; they stemmed from a diet of herbal tea, salad, fruit juice, and vegetable broth that he claimed had cured him of tuberculosis.^[10] His cosmetic diet combined sulphur- and iron-rich foods with citrus juices to create the “ideal” complexion.^[10]

Hauser published numerous diet manuals, such as Eat and Grow Beautiful (1939),^[1] and became a television and radio personality in the 1950s.^[10] He dropped his claim of holding a medical degree after an investigation by the American Medical Association (AMA),^[1] and despite prosecution by the US Food and Drug Administration for fraudulent product claims, he lived in the Hollywood Hills to the age of 89.^[11]

The Rice Diet

When it was created at Duke University in 1939, the rice diet was an extreme departure from the typical American diet, which at the time consisted of 25% protein, 25% fat, 50% carbohydrates, unrestricted salt, and unlimited calories.^[12]

Dr Walter Kempner (1903-1997), a newly arrived physician who had conducted metabolic studies in his native Germany, designed the diet to control hypertension, and also as a last-chance treatment plan for patients with renal failure.^[12] The “ricers” (patients who adopted the diet) consumed white rice supplemented with fruits, fruit juices, and vitamins. The diet provided a maximum of 2000 calories per day, comprising 4%-5% protein, 2%-3% fat, complex carbohydrates, and a maximum of 150 mg of salt, combined with a restricted fluid intake.^[12]

Of Kempner’s original cohort of 192 chronically ill patients, 25 died, 60 experienced no substantial change in blood pressure, and 107 experienced significant improvement in blood pressure (from 200/112 mm Hg to 149/96 mm Hg).^[12] The diet was well received at the 1944 AMA meeting, though Kempner was criticized for having treated patients before conducting a randomized clinical trial.^[12]

Although the rice diet was partly eclipsed by the advent of hypertension medications, updated versions of it continue to exist today.^[13,14]

Dr Stoll’s Diet Aid and Liquid Diets

“Dr Stoll’s Diet Aid,” sold at American beauty salons beginning in 1930, was one of the first explicitly designed liquid meal replacements.^[15-17] Comprising a teaspoon of milk chocolate, starch, whole wheat, and bran blended in 1 cup of water, the liquid diet was consumed at breakfast and lunch.

The Diet Aid helped pave the way for a massively profitable industry and is part of a broader trend in liquid diets, which have proven to be among the most extreme ways to seek weight loss.^[18]

Among liquid diets, the “juicing diet” is a nutritionally lacking plan that may deliver rapid (and probably short-term) weight loss, while potentially interfering with blood glucose levels and medications and causing undue risk to people with certain preexisting medical conditions.^[19]

Part folklore and part fad from the 1950s, the “cabbage soup diet” is a 7-day plan that promises the loss of 10 pounds. According to a strict outline, participants are allowed one additional dietary component per day along with the soup. The diet contains high levels of sodium and can cause fatigue, muscle loss, and flatulence.^[20,21]

The Zen Macrobiotic Diet

The Zen macrobiotic diet, launched in the early 1960s by the Japanese philosopher George Ohsawa (1893-1966), stems from a multifactorial approach to health and longevity based on the contributions of numerous thinkers, including the 18th-century German physician Christoph Wilhelm Hufeland.^[22]

Macrobiotics is guided by the principles of yin and yang, the interrelationship between opposites. Foods are either yin (creating expansion) or yang (causing contraction) and are categorized into two groups: acid-forming or alkaline-forming. The diet consists of minimally processed, locally sourced, organically grown foods: 40%-60% whole cereal grains (oats, brown rice, wheat, millet, rye, corn, buckwheat); 20%-30% fresh vegetables; 5%-10% beans and bean products; 5%-10% sea vegetables; and a sprinkling of fruit, white meat, fish, seeds, and nuts.^[22]

Like the rice diet, the Zen macrobiotic diet was an extreme departure from practice of the time. It was viewed by some as part of an antiestablishment movement and provoked controversy owing to claims that it was an alternative treatment for cancer.^[22] In the early 1970s, in the absence of supporting clinical trials and data, both the AMA and the American Cancer Society issued stern warnings against the diet.^[22-24] In 1972, the American Cancer Society wrote that the diet “poses a serious hazard to health and is not beneficial in the treatment of cancer.”^[23]

The diet was popular in the 1960s and 1970s and can be seen as a precursor to a number of plant-based, high-fiber, low-fat diets, as well as branches of the organic food movement.

The Drinking Man’s Diet

At the other end of the extreme diet spectrum in the 1960s, The Drinking Man’s Diet: How to Lose Weight with a Minimum of Willpower—a 50-page paperback published in 1964 by the aerial photographer Robert Cameron (1911-2009)—generated a dedicated following of its own.^[25]

With the Mad Men era of the 1950s drawing to a close and the 1960s “peace and love” mantra gathering steam, this high-protein, high-fat, low-carb diet urged that to safeguard their masculinity, men should eat only “manly” foods.^[25,26] Part diatribe, part diet, it also stipulated that alcoholic drinks could be consumed freely.^[25]

Despite strong criticism from the AMA^[25,27] and a harsh rebuke from the respected nutritionist Frederick Stare of the Harvard School of Public Health,^[26] the diet became a cultural phenomenon that was debated and lampooned into the 1970s.^[24] The book sold 2.4 million copies, has been translated into 13 languages,^[25,26] and is still in print.

As both a cultural phenomenon and a high-protein, low-carb diet, it helped pave the way for the Atkins and Dukan diets.

The Beverly Hills Diet

The Beverly Hills Diet, published in 1981, spent more than 30 weeks on the New York Times best-seller list and sold over 1 million copies. The diet was endorsed by actors and entertainers, including Englebert Humperdinck and Linda Gray.^[28] Its creator, Judy Mazel (1943-2007)—who had no science or nutrition training^[29]—opened a diet clinic in Beverly Hills to promote the diet that had helped her lose more than 70 pounds.^[28]

The diet promises a weight loss of 10-15 pounds after 5 weeks on a fruit-based diet. Following this period, carbohydrates, fat, and protein are slowly reintroduced according to strict rules: Fruit must always be eaten alone; protein may be combined with fat, but not carbohydrates; carbohydrates must not be combined with protein; and beer counts as carbs, wine as fruit, but champagne is “neutral” and can be consumed at any time.^[29]

The diet was strongly criticized in a 1981 JAMA article by Drs Gabe Mirkin and Ronald Shore for its lack of scientific and nutritional grounding and for Mazel’s theory that weight gain is caused by undigested food that gets “stuck” in the body.^[30]

An updated version of the diet was published in 1996. Judy Mazel died of complications of a stroke at the age of 63.^[28]

The Stone Age and Paleolithic Diets

Recent interest in eating like our prehistoric ancestors surfaced in 1975, when the gastroenterologist Walter Voegtlin, MD, proposed the “Stone Age diet,” which featured meats, animal fats, and plants but eliminated dairy and grains.^[31,32] In the 1980s, Stanley Boyd Eaton, MD, published his interpretation of a prehistoric, East African diet, which proposed a similar menu.^[31] Other researchers have explored the health benefits of the traditional Inuit diet.^[33]

But popular interest in “prehistoric diets” took off in 2002 when Loren Cordain, PhD, a professor of health and exercise sciences, published The Paleo Diet.^[34,35] This high-protein diet includes lean meats, fish, fruit, vegetables, some animal fats, eggs, and seeds, while avoiding processed foods, wheat, dairy, grains, legumes, sugar, salt, and potatoes.^[34] Eating like hunter-gatherers—a diet to which he argues we are genetically adapted^[36]—is, according to Cordain, a means to slim down while preventing diabetes, heart disease, and cancer.^[34]

Despite a critical absence of calcium, the diet has shown potential advantages in the reduction of type 2 diabetes and cardiovascular risk^[36] and is one of the many high-protein, low-carbohydrate diets that continue to gather traction.

The Fit for Life Diet

The Fit for Life diet was first marketed in 1985 by “nutrition specialists”^[37] Harvey and Marilyn Diamond. On the diet, Harvey Diamond “overcame a debilitating, longtime digestive disorder, ended his migraine headaches, [and] lost more than 50 pounds.”^[38]

The book describing the diet reached number 1 on the New York Times best-seller list—where it spent 40 weeks—and sold more than 12 million copies.^[37,38]

The diet hinges on the “secrets of timing and food combining that work with your natural body cycles”—appropriation (noon to 8 PM), assimilation (8 PM-4 AM), and elimination (4 AM to noon).^[37] The authors argue that eating foods in the wrong order provokes “rotting” in the stomach”^[39] and categorically separates “dead” foods (such as meat and starch, which “clog” digestion) from “living” foods (such as raw fruits and vegetables, which “cleanse” it).^[39,40] Dairy products are to be avoided at all times.^[39,40]

A day on the diet starts with only fruit and fruit juices. Lunch may consist of “living” foods and dinner of “dead” foods.^[39,40]

The Fit for Life diet has been widely criticized for theories that lack scientific grounding or support from clinical trials.^[38,39] The diet is also likely to provoke vitamin, mineral, and calcium deficiencies,^[39] while potentially causing serious complications in patients with diabetes.

The Rotation Diet

The rotation diet—which involves diet, exercise, and behavior modification—was launched in 1986 by Martin Katahn, PhD, a professor of psychology and director of the Weight Management Program at Vanderbilt University, who lost (and kept off) 75 pounds.^[41] Katahn has written several peer-reviewed articles as well as top-selling diet books, which include the T-Factor diet.^[41,42]

The diet rotates between varying degrees of calorie restriction over a 3-week period (periods of 600, 900, and 1200 calories per day for women and 1200, 1500, and 1800 calories for men), followed by a period of maintenance (from 1 week to 1 month). It claims an average weight loss of 13 pounds in 3 weeks^[41] and instances of people losing 1 pound per day.^[42]

According to Katahn, a rotating diet halts metabolic adaptation^[43]—a principle that has since been shared by other weight-loss programs, such as the zigzag diet,^[44] and has grown popular among bodybuilders.

Although the low caloric intakes have been criticized as extreme, the rotation diet has been well received by some nutritionists.^[43] The concept of rotation has also been adopted in diets for food allergies.

The Blood Type Diet

The blood type diet prescribes food and exercise according to blood type^[45,46] and is based on the theory that “knowing your blood type is an important tool for understanding how your body reacts to food, your susceptibility to disease, [and] your natural reaction to stress.”^[45]

The diet was published in 1996 by Dr Peter D’Adamo, a naturopathic physician and expert in glycobiology, who believes that blood type is “the key that unlocks the door to the mysteries of health, disease, longevity, physical vitality, and emotional strength.”^[45] Eat Right 4 Your Type has been translated into 65 languages and sold 7 million copies.^[45]

A study published in 2013 by Dr Leila Cusack (Belgian Red Cross-Flanders) and colleagues concluded that “no evidence currently exists to validate the purported health benefits of blood type diets” and that proper randomized clinical trials were needed to further investigate.^[47]

In a 2014 trial, Dr Jingzhou Wang from the Department of Nutritional Sciences at the University of Toronto found that “adherence to certain ‘Blood-Type’ diets is associated with favorable effects on some cardiometabolic risk factors, but these associations were independent of an individual’s ABO genotype, so the findings do not support the ‘Blood-Type’ diet hypothesis.”^[48]

Intermittent Fasting and the 5:2 Fast Diet

The principle of intermittent fasting—popularized in several branded diets—is to eat normally for a specific period (frequently 5 days) and either fast or drastically reduce calorie intake for a shorter period (often 2 days).^[49]

The 5:2 Diet Book was written in 2012 by Kate Harrison, a novelist and journalist who lost 31 pounds on the diet and has written five related books that have been translated into 20 languages.^[50]

Harrison’s diet has been criticized for causing weakness and low energy on fasting days.^[49] The British Dietetic Association considers that only limited evidence exists to support the diet and that weight loss is similar in patients who are on the Mediterranean diet.^[51]

Studies by Dr Mark Mattson indicate the potential advantages of intermittent fasting on brain function^[52] and for “improving general health, and preventing and managing major diseases of aging.”^[53]

A small trial published in March 2018 by Dr Rona Antoni and colleagues compared “the effects of intermittent energy restriction and continuous energy restriction on postprandial glucose and lipid metabolism following matched weight loss.”^[54] Although showing no statistically significant difference in time taken to achieve a 5% weight loss, it found “a superiority of intermittent energy restriction in reducing postprandial lipaemia.”^[54]

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