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Could any diet ever be bigger than Atkins? Meet the next challenger, the South Beach diet. We looked at the South Beach diet from all directions, including the foods you can eat, exercise recommendations, and what results you might expect, when we welcomed the diet's developer, Arthur Agatston, MD, on July 23, 2003.

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: You're a cardiologist -- why develop a diet? What was your motivation to create the South Beach diet?

Agatston: Well, we've called it the accidental diet. It was almost a necessity within my practice to develop something new. By following the national guidelines for low-fat, high-carbohydrate eating, my patients were getting heavier, I was getting heavier, and the country was getting heavier. This was in the early 1990s. While we thought the new statin drugs were miracle drugs and might obviate the need for diet, it became clear that while being wonderful drugs, they only prevented about one-third of the heart attacks and strokes that we saw, and didn't do anything about diabetes and obesity. Because of the frustration I had, I looked at both popular diets and the medical literature, which was progressing rapidly, and we came up with our own diet based on good fats and good carbohydrates.

We were amazed at the success we had with our patients not only with improved blood chemistries, but also with rather amazing weight loss. We performed clinical trials; we reported the clinical trials at national meetings and the local press reported on our diet and asked us to put South Florida on the diet, which we did, and that's when it moved from the private academic realm to the public.

Moderator: What are the key elements of the South Beach diet?

Agatston: The key elements are using the good fats -- Mediterranean oils, olive oil, canola oil, the omega-3 fish oils and the oils found in almost all nuts, along with the good carbohydrates, which are the vegetables, the whole-grain breads and whole fruits. That, combined with strategic snacking, controls hunger and prevents the cravings that occur to so many Americans shortly after they finish a meal. The diet is also very flexible, it's simple, and it works. It works without counting calories, without counting grams of fat or grams of carbohydrates.

Member question: What are the biggest differences between this and the Atkins diet?

Agatston: The first difference is our emphasis on the good fats rather than the saturated fats. The saturated fats cause blood to be sticky, they cause vessels to constrict, and they have negative effects on long term on insulin and sugar metabolism. The good fats that we talked about actually help prevent heart attack and stroke and they also improve insulin and sugar metabolism long term. This helps the diet to become a lifestyle with long-term weight loss and improvement in blood chemistries, rather than just a short-term fix.

Another difference with Atkins is we are not counting grams of carbohydrates. We are not so strict in the first phase that we put patients into ketosis. Ketosis often causes excessive water loss early. We found it is unnecessary for significant early weight loss. We teach our dieters to use glycemic index, which is a measure of how fast a carbohydrate raises your blood sugar and if you consume low glycemic index carbohydrates, you can do very well on a high carbohydrate diet.

Member question: If we are not counting anything, does that mean we can eat as much as we want?

Agatston: Yes and no. You do not have to limit portion size, in that you should not leave a meal hungry and you should not feel deprived. However, many of us were taught to always clean our plates. We actually continue to eat, even though we are full and satisfied. So we do recommend that we eat slowly, because it does take awhile for our brain to get the signal that we are getting full. In those who are overweight, studies have shown that it takes the brain longer to receive that signal. So we recommend eating slowly and eating until you're satisfied, but not necessarily finishing everything on your plate.

Member question: You pay a great deal of attention to glycemic index. Isn't that what the Sugar Busters diet is all about? How is this different?

Agatston: The trend over the recent 10-20 years is to concentrate more on carbohydrates, and Atkins taught us that fat does not necessarily make us fat. Other books, including The Zone, Protein Power, and most recently Sugar Busters, have all been going in the same direction. I think Sugar Busters is an excellent book. In our diet we have taken advantage of more recent studies and because of that, I believe our diet has more flexibility as well as more effectiveness in our description on how to use snacking. But I do not want to be critical of Sugar Busters. I think it is excellent and I would be very happy to see more similar books written, because we're developing a general consensus on what has caused the epidemic of obesity and diabetes in the United States. It may take several more books with slightly different explanations to really turn the country around and help end the epidemic of obesity and diabetes.

Member question: Where can we find a listing of glycemic indices for foods? Is this something we can derive from the food labeling or do we need a special resource?

Agatston: At this point you need a special resource. We do have it in our book. It is on our web site, southbeachdiet.com, and it is also in many other popular books. I believe it should be on package labeling, but I think that's several years away.

Member question: What are the differences in the South Beach diet and Dean Ornish's diet?

Agatston: Dean Ornish developed his diet many years ago when it was noted that societies that had very low fat and high carbohydrate diets had no heart disease or stroke. So he tried it with Americans along with an exercise program and other interventions. It is a very restrictive diet, as Dr. Ornish readily admits, and we now know that restricting all fats is not only not necessary, but is counterproductive. The good fats that we have talked about help prevent heart attack and stroke and actually help weight loss and they make our diets palatable and enjoyable.

The other problem is that when you severely restrict fats and increase carbohydrates, if you include the wrong carbohydrates you will gain weight and worsen your blood chemistries. So if you can follow the Ornish diet but have only the good carbohydrates, you can be successful, but very few Americans can tolerate this over the long term.

Member question: Do you have to follow the exact menus at the back of the book for the Phase 1 part or can you create your own menus?

Agatston: You can mix and match and create your own menus. We believe that both for the short term and particularly the long term, variety is very important, as well as individualizing the meal plans for each person. It is absolutely fine to mix and match. What is important is to understand the basic principles of the diet. Those who understand the principles best are most successful long term. On our web site, southbeachdiet.com, there are a great variety of recipes, both our own and wonderful recipes and ideas contributed by others.

Member question: I don't like eggs. What sort of food could I substitute, especially for breakfast, while on the South Beach diet?

Agatston: Well, after the first phase -- slow-cooked oatmeal, high-fiber cereals, such as All Bran, Fiber One, Uncle Sam's, and there are others which are fine. In the first phase a low-fat cheese or lean meat can be used, such as Canadian bacon.

Member question: If you do not like fish, what are ways you can substitute and still make the diet work?

Agatston: Well, you can substitute lean meat, chicken, beans, and lentils. In fact, you can be vegetarian. We do have a vegetarian form of the diet. The one thing we do believe that the omega-3 fish oil is very important for overall health and also helps long-term weight loss. So if you are not a fish lover, then we do recommend omega-3 fish oil supplements.

Member question: I use ground flaxseed every day to up my fiber intake and help control IBS. Would this be allowed in Phase 1 of the diet?

Agatston: Yes. Flaxseed is excellent oil, and having the ground flax seed gives both fiber and the flax seed is a type of omega-3 oil.

Member question: Are the good fats labeled polyunsaturated and monounsaturated?

Agatston: Monounsaturated fats are the olive oil and canola oil. They also have some omega-3. The polyunsaturated can also be omega-6, which is less good than omega-3 or monounsaturated. An example of omega-6 is corn oil. The biggest problem with polyunsaturated is the trans fats. These are the hydrogenated and partially hydrogenated oils found in baked goods. These are polyunsaturated, but they are man made and they raise our bad cholesterol and lower our good cholesterol and are worse than saturated fats. So just polyunsaturated does not give you enough information.

Member question: What dosage of omega-3 fish oil do you recommend?

Agatston: The most active ingredient that we look for in omega-3 oils is EPA. We like one to two grams of EPA daily as a general rule. For different people there may be different optimal doses. It is important to read the label and to see how much EPA is in the supplement; the more EPA the better.

Member question: How does milk fit into this diet? How much can you have, if any?

Agatston: The predominant sugar in milk is lactose, and it actually has a relatively low glycemic index. Diary fat, in general, has some sugar associated with it, but again has a relatively low glycemic index. In the second phase of the diet, milk can be added, but each individual should monitor his or her own response. It is important to note what foods cause cravings or hunger soon after a meal. We teach that in Phase 2 individuals should educate themselves as they add foods back into their diet.

Member question: Are all veggies OK to eat (except white potatoes)? Are there any veggies that I should avoid? I'm thinking of beets, yams, or anything else you can think of.

Agatston: A baked potato, any white potato increases your blood sugar faster than table sugar. The very starchy vegetables including corn or vegetables with sugar such as beets do have relatively high glycemic indexes. The important thing in general with vegetables is to eat a good variety. This will ensure that you get all the wonderful vitamins, minerals and antioxidants that are offered in vegetables and which helps not only with weight loss, but also preventing heart attack, stroke, and cancer.

Moderator: For those of you asking about grits -- grits are corn and now you have your answer.

Member question: So bread is gone forever except for stuff like pita bread, whole grain, etc.?

Agatston: Yes. The pecking order for bread is basically whole grain, which is usually the darkest and heaviest bread, then pita bread, then pumpernickel bread, then rye bread, and then sourdough bread and then white bread. Sourdough bread has an advantage, in that it is acidic, and this helps slow digestion.

Member question: What types of fruits are best on the diet?

Agatston: Fruits that have the lowest glycemic index are grapefruit, apples, whole oranges, and berries. The acidic fruits also have the extra advantage of helping to slow digestion and therefore the rise in blood sugar. We recommend avoiding processed fruit juices. Fresh squeezed is best, but even better is the whole fruit. The difficult fruits are the tropical fruits, bananas, pineapples; mangos have the highest sugar content.

Member question: I have impaired glucose tolerance and my doctor is pushing me to lose weight. I also have hypothyroidism, which makes it very hard to lose weight. Could the South Beach diet be a safe and effective diet for someone like me?

Agatston: Yes. Those who do the best on the diet are those who do have insulin resistance. Anybody whose weight or weight gain have been concentrated in the middle, in the belly, and whose weight gain has been during adulthood, are especially ideal candidates for the South Beach diet. Low thyroid can certainly be an impediment, but it is usually very easily treated with medication.

Member question: As a chronic kidney stone sufferer, would the South Beach diet be safe for me?

Agatston: Yes. If you have a special medical condition like kidney stones, depending what the kidney stone is made of, there may be special doctor instructions, but they can always be incorporated into the South Beach diet because of the diet's flexibility.

Moderator: Are there any special medical conditions that would preclude trying this diet?

Agatston: No, there are no special medical conditions, but if a dieter is on medications for high blood pressure, for diabetes, for heart failure, then adjustments of medication may be necessary as the diet is started or it may be preferable to begin in Phase 2. So for anybody on medications, we recommend consultation with their physician when beginning the diet.

Member question: Isn't this a cholesterol-laden diet? Will it not raise already high levels?

Agatston: No. We do allow eggs, which have cholesterol, but recent studies have shown that cholesterol in the diet, such as in eggs, in the egg yolk, does not raise our bad cholesterols significantly, and it does raise our good cholesterols. Studies from the Harvard School of Public Health have shown that at least seven eggs per week are healthy and more eggs per week were not studied. Lean meats, which have some cholesterol and some saturated fat, also have minimal effects on bad cholesterol. As far as shellfish, the amount of cholesterol is similar to chicken and is not a problem. We have extensive experience of the overall improvement of blood chemistries with the diet.

Member question: How does this diet work for teenagers?

Agatston: Another good question. We are going through an almost unbelievable epidemic of obesity in our teenagers. We are now commonly seeing adult onset diabetes in those who are not yet adults. Although more exercise is certainly important for overweight teenagers, the adoption of the South Beach diet would completely reverse this dangerous trend.

Member question: How long can you safely stay on the Phase 1 part of the diet?

Agatston: Phase 1 is to get rid of carbohydrate cravings. Once this is accomplished, it is fine to begin Phase 2. For those who are quite overweight, they often are doing very well on Phase 1, they are not hungry and do not want to leave it. The rapid weight loss in Phase 1 also gives a very positive feedback. The problem with staying on Phase 1 and losing too much weight too rapidly is that you lose muscle and bone mass, which is very metabolically active. If you lose muscle and bone mass, you will be burning fewer calories while you are sleeping. For this reason we recommend exercise, which helps to maintain muscle and bone mass and therefore a higher metabolism or higher metabolic rate. We recommend moving to Phase 2 at least by the third or fourth week. The more there is to lose, the longer it is okay to stay on Phase 1, but we still like to see movement to Phase 2 at least by the third or fourth week.

Member question: For those who do not need to lose a lot of weight, can they go straight to Phase 2?

Agatston: Yes. The principles of the South Beach diet, the good fats and the good carbs, with all the wonderful natural vitamins and minerals, is the healthiest diet for all of us even if we are not trying to lose a pound. For those with not much weight to lose, we definitely recommend beginning with Phase 2.

Member comment: Dr. Agatston, thank you for this eating plan. It's been great so far!

Member question: I lost 10 pounds on the first two weeks of South Beach diet. Then I didn't lose any more weight during the next four weeks, but stayed on the program. Why did I stop losing weight? Is this common?

Agatston: Depending on how much weight there is to lose, people will plateau. Sometimes wrong carbohydrates are sneaking in and sometimes they have reached a particular set point for their metabolism, and sometimes their conception of ideal weight is unrealistic. But plateauing is common, and if there is definitely more weight to lose, then returning to Phase 1 will often help.

Also, where weight loss has been rapid, it is possible that metabolism has diminished due to some loss of muscle and bone mass. In this case, we recommend more exercise, including some weight-bearing exercise to help increase muscle and bone mass and thereby increase metabolism.

Member question: With more studies on the effectiveness of the low-carb/good-fat diets, is the government getting the message that this is a better method for healthy lifestyle?

Agatston: Good question. I think it is. We studied our diet versus the State 2 Hearth Association Diet in 1995 and 1996. The most recent Heart Association recommendations are much closer to what we recommend than were the Step 2 Diet in the 1990s. National recommendations are made by committees, and such guidelines tend to progress very slowly, but they are clearly moving in the right direction. I have found that doctors around the country in their own practices are concentrating much more on limiting the processed carbohydrates. So we are making progress.

Member question: So if everything you eat is on the low to moderate index, you should be able to maintain your weight?

Agatston: Yes. Our experience is that long-term weight loss is possible and painless. We do anticipate that everybody will fall off the wagon at times, and that's the time to return to the strict phase. But by understanding the principles and varying the diet phases, you can be successful for long term and make the diet into a healthful and satisfying lifestyle, not just a diet.

Moderator: Thanks to Arthur Agatston, MD, for sharing his expertise with us.