November 20, 2013

Mental models


What do passion, persistence, and deliberate practice have to do with our health?

Read Time 8 minutes

One of my readers posted a link to this short talk from TED Talks Education. (You’ll want to watch it to understand the rest of the post.)

I found the talk interesting, and in the talk Ms. Duckworth makes a reference to a Stanford psychologist, Carol Dweck, who has been very influential in my thinking about children and childhood learning.  In fact, when I became a father one of the first books I read (and have since recommended to every parent I know and even my daughter’s kindergarten teacher) is a book by Dr. Dweck, Mindset.

Now, I don’t know if everything Ms. Duckworth says or suggests is correct.  Her work is well outside of my area of knowledge.  But it’s a topic I think about so much, and since watching this video I’ve been reflecting on my life and the implications of this idea to our health.

First, some background

Shortly after my twelfth birthday, boxing fans around the world were given a gift unlike anything before or since, the showdown between Marvelous Marvin Hagler and Tommy Hearns (don’t watch this unless you can handle a violent boxing match). To this day most boxing experts agree the first round of that 3 round war remains one of the — if not the — greatest round in boxing history.  I was a huge Hagler fan, and this fight galvanized in me two things:

  1. I wanted to be a professional boxer (something I pursued relentlessly enough to nearly forgo college), and
  2. I wanted to be just like Marvin Hagler, the grittiest fighter of my generation.

You see, I was not the fastest when it came to hand speed or foot speed.  My punching power was good, but not George Foreman or Sonny Liston good.  There was no special “gift” or talent I had that was ever going to make me the next Mohammed Ali or Mike Tyson.  But, Hagler didn’t seem to possess any God-given ability and, in my 12-year-old opinion, he was the greatest fighter on Earth.  Sure, Sugar Ray Leonard was the media darling and wealthiest fighter of the era, but Hagler was the grittiest. (Anyone tempted to point out that Leonard was awarded the split-decision over Hagler when they met in 1987 need not bother.  In my mind – and the mind of many — Hagler won 115-113.  If you want to read more, here’s a great summary.) He out-trained everyone.  He never got out of shape between fights. He was always ready for combat.  He was pure grit.

So, this became the defining feature and mantra of my youth.  No one was going to out-grit me. I would run 6 to 10 miles at 4:30 in the morning (imagine how dark and cold that was in Canada) because I knew the other guy was still sleeping.  I did 400 push-ups every single night (except one night in 11th grade when I was too sick to move) before bed from age 13 to 18 because I knew the other guy would not.

When I did decide, ultimately, to go to college instead of pursuing a career as a professional fighter (something I attribute to the most influential teacher in my life), it was such an easy transition, because I had already built a mental and emotional infrastructure of grit.

Perhaps because of some deep insecurity I always felt the need to out-grit everyone at everything, even surgery.  In residency, while my peers would (rationally) try to catch a nap any time there was a free moment during call nights, I would practice anastomosing 3 mm Dacron grafts together with 8-0 proline, over and over again. I even built a model heart with a deep mitral valve to practice – a hundred times a day – one of the most difficult stitches in surgery, the “A-to-V” and “V-to-A” sutures through the mitral annulus.

You get the picture.  I was (and remain) a freak.  The ‘why’ is beyond me, though I’ve never stopped trying to understand it. Even when my daughter was only 5, I spent a lot of time talking with her about ‘mastery’ and the joy that comes from the journey of mastering a skill (versus the need to seek pleasure in the outcome or final result).  This is not a natural phenomenon and I think, unfortunately, most of our education is based on the result and not the process.

I’ve read countless books on this, both out of desire to better myself and out of a desire to ignite this spirit in my children, and to date the best one I’ve read is The Talent Code, by Daniel Coyle. It’s the only book I’ve ever read where the moment I finished it, I turned to the first page to read it again.   In this book, Coyle argues that grit – practice – may not be enough.  It’s necessary, but not sufficient for mastery. The other component essential for mastery is the right kind of practice — deliberate practice.  This topic is worthy of a book, of course, and not just a few sentences, but suffice it to say, deliberate practice is a very specific type of practice that leads to change. Mastery. While I disagree with this writer’s view that the book, Talent Is Overrated does a better job explaining the concept than The Talent Code, he provides a quick overview for those not familiar with the concept.

How does this apply to our health?

First, if you don’t practice correctly, no amount of practice is going to achieve mastery, whether it’s swimming the 200 IM or playing the piano.  A disciplined approach to eating the wrong foods may be better than an undisciplined approach to eating the wrong foods, but it’s no substitute for the correct approach to eating the correct foods.

In 2009, when I was at the height of my unhealthiness – I was overweight, insulin resistant, and had Metabolic Syndrome – it was not because I was not ‘trying hard enough’ to eat well.  I had all the grit in the world when it came to eating. I wanted so desperately to be lean and healthy. The problem, of course, was that I was not eating the right foods. It’s the difference between gritty practice and gritty deliberate practice.

Second, let’s posit you figure out what the ‘right’ foods are.  Is this sufficient to achieve your health?  Well, here I have to include not just my experience, but the experience of my friends, family, and clients. Some people, once introduced to the ‘right’ foods, experience almost an immediate change.  The pounds melt off. Their biomarkers improve seemingly overnight. They feel rejuvenated and renewed.

Let me assure you, these folks are the exception and not the rule. For most people the pattern of going from metabolically broken to fixed, which often includes a loss of fat mass, is very slow; slow enough that on a day-to-day and even week-to-week basis it seems negligible.

To explain this, I’ll use fat mass as an example, since it’s the metric most people understand best.  In my experience, outside of profound caloric restriction or outright starvation, the typical amount of fat loss I see in a person is about one pound per week, or about 60 g per day.  That might not sound like much, and over a week or day, it’s not. (Though, hold 60 g of almonds in your hand and imagine a net loss of this much fat every day from your collective fat cells, and you can start to appreciate how impressive it is physiologically!)

But, we can’t track fat mass directly, at least not on our bathroom scales, and frankly not even with DEXA scans unless they are really spaced out.  Certainly not at the level of a few hundred grams. Furthermore, our bodyweight – what we typically do track – fluctuates a lot.  In me, for example, it fluctuates by 5 pounds per day.  How, you ask? Water. Not just the difference between what I drink and what leaves my body (urine, perspiration, respiration), but also interstitial accumulation, which manifests as minute amounts of swelling, typically in muscles, and elsewhere, too, often in response to exercise, travel, stress, and even foods I eat.

So, if your bodyweight can fluctuate 5 pounds in a day, is it possible to track 60 g per day of net fat loss? It’s like me blindfolding you and putting 50 pennies in your hand and asking you if there are 49, 50, or 51 there.  No chance.  Furthermore, 60 g is so far outside of the measurement spec of a bathroom scale that even if your weight did not fluctuate much due to fluid shifts, you would never be able to appreciate the net fat loss over the course of a few days and barely over a week.

What does this look like in real life? Consider the graph, below, which shows the actual (and completely achievable) weight loss of a person over 7 months. This person went from 227 lb to 195 lb in 7 months, which represents an average of about 4.6 lb per month, or about 69 g of net fat loss per day (as confirmed by DEXA).  This was not a starvation diet or something radical. This was a change in macronutrients – from a standard American diet to a ketogenic diet — that led to a change in net fat flux. But, the change is subtle over any short period of time.  It’s only over months that the change becomes life-changing.


Now, imagine the day-to-day frustration this person (I know, because I was working with this person) experienced with the fluctuations in scale readings!  It was tempting on many occasions to say, “Forget it, I’m going back to what I was doing before.”  Just like there were many days I didn’t feel like going to swim practice, or days I didn’t feel like deliberately practicing my surgical technique.

If you remember nothing else, remember this: the game is won – or lost – not by the infrequent big changes, but by the frequent, deliberate, and repeatable small ones. This is where grit comes in.

Sure, there are genetic freaks and lucky ones out there, for whom none of this matters. But for the rest of us – because we live in, and are surrounded by, a food environment that is chronically toxic to about two-thirds of us – re-building our bodies requires consistent and deliberate change.

Are there people with all the grit in the world who can’t achieve health? Absolutely. And I put them into two categories:

  1. Those who are not eating the ‘right’ foods for them (recall: I was in this camp until 2009).
  2. Those who have underlying issues – usually hormonal – which are working against them and preventing their fat cells from liberating fat.

I will not get into these categories in great detail, because the topic is beyond the scope of this post and, frankly, it takes me months to diagnose this in people I work with weekly.  So I can’t responsibly spout out blanket statements about ‘fix this’ or ‘fix that.’  However, far and away the most common causes I encounter in my practice for persistent metabolic derangement, often but not always accompanied by adiposity (excess fat), in the presence of seemingly correct eating and true grit are as follows:

  1. An insulin resistant and/or hyperinsulinemic person eating foods that stimulate significant amounts of insulin;
  2. Hypothyroidism (in my book, TSH > 2 accompanied by basal morning axillary temperature below about 97.8 F);
  3. Hypogonadism in men (which I diagnose with not only total testosterone, but also free testosterone, DHEA, and estradiol), or PCOS in women;
  4. Disruption of the HPA axis, most commonly manifested by “adrenal fatigue” and/or elevated cortisol levels.

Again, I’m not going to get into the nuance of these, but I list these to give those folks who believe they are A) eating the ‘right’ foods, and B) full of grit, yet not seeing results, some hope. These issues are fixable, but you need to see a doctor who knows how to fix them.

Fortunately, such situations are very rare! Most people, with the correct dietary intervention, armed with sufficient grit, and the confidence to stay the course, despite the day-to-day and week-to-week fluctuations, will emerge as renewed people.

Parting shot

Unfortunately, as long we live in a world where (i) the conventional wisdom, (ii) dietary recommendations, and (iii) the market forces enabled by them create an eating environment that is not suited to what most of us should eat, we need to guard against the desire to give up when the results are not what we expect in the timeframe we expected.  As a result, about 90% of people who make a dietary change – and even see results – end up gaining the weight back.  Why? I suspect it’s a bit of what I’ve written about here, and two other phenomena:

  1. The fall-off-the-wagon-and-get-discouraged issue, and;
  2. The I’m-better-now-I-don’t-need-to-do-this-anymore issue.

In the former, folks get very discouraged when they make a ‘mistake.’ Rather than immediately getting back on the program, they get frustrated, and over time – sometimes quickly, sometimes slowly – revert back to their old eating habits.

In the case of the latter, there is this belief that once the goal is achieved, one need not continue the practice. It’s like me training for a year to win a time-trial race on my bike, winning the race, and then deciding I don’t need to train anymore and I can still compete successfully. Not going to happen.  If I want to win, I need to train.  If I’m going to train, I need to train deliberately and persistently. Even on the days I don’t want to.  When I miss a workout or have a bad one, I can’t beat myself up over it. I have to let it go and remember that tomorrow is a new day.  The sum of my days determines my success.

Grit by Crystian Cruz is licensed under CC by 2.0

Disclaimer: This blog is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this blog or materials linked from this blog is at the user's own risk. The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard, or delay in obtaining, medical advice for any medical condition they may have, and should seek the assistance of their health care professionals for any such conditions.


  1. Hi Jen,

    I too
    started having weight issues at 14. Peter is right. But don’t be afraid to ask the doctor what his/her thoughts are about low carb. I wish I had a blog like this. Remember, you will have to make some life style changes about your eating habits. Horray for you! Keep reading, even show your endocrinologist this blog. If he agrees with Peter’s comments you know you have found a good one. Best of luck and don’t ever give up.

  2. I’ve been reading your blog now for the last six months having stumbled upon it when my daughter who is overweight and has tried every diet and failed, announced that she was now following a ketogenic diet. I am a pharmacist and we use this diet routinely in the Children’s Hospital where I work to help with seizure control. The more I read to determine if this was a safe approach for my daughter the more I was intrigued with the fact that becoming keto adapted could not only help one lose weight but improve cholesterol numbers. So decided to give it a try as well. I was not overweight to begin with but could stand to lose a few pounds. What could stand improvement were my cholesterol numbers. In the last six months I have lost 13 pounds and improved my cholesterol readings as follow:
    May November
    Cholesterol 291 280
    HDL 66 82
    C/HDL 4.4 3.4
    LDL 206 188
    Triglycerides 96 48
    T/HDL 1.45 .585

    My daughter has lost over 50 pounds !!!
    -We have both seemed to stall however. Neither of us has been able to lose any weight for the last few months.
    -Is this typical? What can one do to continue the weight loss.

    My diet now consists of 7% carb, 20% protein, and 73% fat and I track my macros diligently. No matter how I tinker with these macros the scale never budges.

    -Additionally I am curious as to which method you recommend for self testing to determine if you are truly in ketosis. . Urine strips are cheap but I have read are not always accurate.

    -Last but not least, please keep posting the great articles on the science behind this approach to eating. It flies in the face of everything we were taught in pharmacy school and probably all that you learned in med school but it works and is a great alternative to being on statins the rest of ones life. Excellent read.

    • Hi Mindy,

      In my lexicon, your daughter and you are in a neutral balance.. ie: incoming fuel meets caloric demand– at this combination of nutrients. Your body is adjusted to your routine.. allowing it to maintain the current fat stores

      Is your desire to loose more weight a health issue or cosmetic desire to be trimmer? Your blood work per lipid levels are excellent… outstanding. Body imagine is an emotional gauge: formed via social landscape. IMO determine if your goals are realistic… that level of desired leanness something your can maintain in your lifestyle.

      Change your routine to move the scale readings. I skip an evening meal at times.. exercise BEFORE fueling on some morns.. consume near zero carbs.. make sure I eat very low density carbs and usually ONLY prior to exercise. Excess protein is easily broke down into glucose… your level of consumption could be too high.. especially sans the need to rebuild muscle when sedentary.

      Best of Luck!


  3. Peter,

    I stumbled across your blog a week or so and have loved it . . . other than being unproductive at work and unresponsive to my family, because I have been so engrossed in it. Thank you for so generously sharing your experiences with us. I have a quick question: in a few places you have mentioned that you make a mean curry stir-fry, but I have searched and cannot find any recipes on your blog. Would you be kind enough to share your curry stir-fry recipe with us, and any other sugar-free/low carb gems you’ve developed. Thanks in advance.

    • Matt, sorry to get in the way of family–nothing should do that–but glad you’re enjoying the content. I don’t think I’ve posted the recipe, but only for sheer laziness. Part of the problem is that it would sort of require a video, in addition to an explanation. Maybe some day.

  4. Dr. Peter, Within the last 2 weeks I have been ready eagerly your posts. I am very grateful that I found your site. This post in particular has been inspiring to me as I have changed the foods that I eat starting in early October of 2014. I have seen results in a small amount of weight loss. It is a reminder to ” move in the right direction over a long period of time”. Thank you once again for your humility, for using your GOD given brain and talents to help others.

  5. I think I have hypothyroidism- I’m not really sure how to find out exactly what the problem is and what’s causing it?
    I’ve been on a ketogenic diet for about 5 mounts plus a few mounts before of just limiting carbs.(my weight has stabilized after going down from 205 Ib to 157.
    I have a lot of the symptoms- dry skin, fatigue, depressed (when I get weak), I get cold (I would never get cold-I would only take cold showers), and my tsh what 3.3 two mounts ago and a mouth ago I cheched and it went up to 4. I don’t know if it’s caused by low carbs(like dr Chris Kresser says and I’m not converting enough t4 to t3) or if it’s from something else?

  6. So my dr thinks that if i am insulin risistant i should take metformin, should I tKe it?

  7. Dear Peter, I am a new and quite enthusiastic reader and blogger from Hungary, and I really appreciate the content and style of your website, especially your sense of humor. I have just started ketogenic diet, very similar (and inspired by) yours.

    I have two brief questions.
    1. I have Graves disease for about 18 years, with ophthalmopathy (even with a paralyzed eyelid muscle), with a stubborn incredibly low TSH (0,01-02). Now, as a result of taking pills (Metothyrin) of a low dosage for seven months, this is 0,22. May I expect any change in my TSH level on the long term as a result of permanent ketosis and keto-adaptation? Do you know relevant articles or studies? (My endo says ketogenic diet is only for epileptic children.)
    2. Although I was diagnosed with PCOS years ago, I think I am not insulin resistant, my glucose is very stabile, 90 mg/dl. May I expect any change (lowering) in it?

    Thank you.

  8. Dr. Attia –

    I have ulcerative colitis and have been eating keto-style for the past 2 weeks. I am experiencing a moderate flare. Any thoughts? Are UC and Keto compatible?

    Thank you!

  9. Since you mention MBTI:

    And from the intro: ‘Although very popular in businesses around the world, the MBTI is widely criticized by academics for its methodological weaknesses, poor statistical validity and low reliability.’

    Consultants are smarter-than-average folks, but MBTI is one of the rather not-very-scientific myths that the HR of consulting firms love to spread and tend to be accepted as valid but go unchecked.
    But hey, at least it’s better than astrology, because doesn’t try to be predictive and it’s descriptive in the correct direction based on self-evaluation and not on spurious planet-position correlations with no causal mechanism whatsoever.

    I know. You are resisting to accept it. I know. It looks neat and organized and we humans are suckers for typology and order. As I criticize and reject it, I find myself answering the questions from the ‘What’s your personality type?’ image on the wiki page, just for the hell of it. Noticed that all adjectives are positive? There’s no ‘grumpy, over-sensitive, cold-hearted, disorganized’ labels there, no sir. All people are excellent.

    Greetings from a taurus ESTJ.

    • I’ve looked into this a bit and I think most of the criticism stems from people not actually understanding the uses and limitations of the test. It’s not meant to compete with, say, a Hogan assessment or a Raven score, but if you understand how to interpret the test it provides helpful context in self-reflection and interaction with others you work with closely.

  10. As soon as I read ‘deliberate practice’ I remembered something. This may interest you:

    ‘More than 20 years ago, researchers proposed that individual differences in performance in such domains as music, sports, and games largely reflect individual differences in amount of deliberate practice, which was defined as engagement in structured activities created specifically to improve performance in a domain. This view is a frequent topic of popular science writing—but is it supported by empirical evidence? To answer this question, we conducted a meta-analysis covering all major domains in which deliberate practice has been investigated. We found that deliberate practice explained 26% of the variance in performance for games, 21% for music, 18% for sports, 4% for education, and less than 1% for professions. We conclude that deliberate practice is important, but not as important as has been argued.’

    I know. You rolled your eyes when you read ‘meta-analysis’.

    It’s enough for some suspicion, worth looking into the actual studies. The ‘1%’ in professions, if true, is the seemingly alarming number. And yet I feel you’d resist saying that your repeated suture practices weren’t useful, and they probably were.

    • Thanks, I’ll check it out. This seems like a difficult theory to study, given the “measurement” limitations. But there are two issues being addressed and I think they are being confused. One is the “10,000 hour” rule and the second is the deliberate practice is what matters vs. “just” practice.

  11. Hi Peter,
    I have been VLC/Keto and doing, probably too much IF, for the last few years. I have taken to CrossFit over the past two years and training over the past year has increased to at least once a day, sometimes two training sessions a day, 5-6 days a week. I am most likely hypo-caloric most days. Recently, based on the way I’ve been feeling I think I may be experiencing adrenal fatigue and/or reduced thyroid fxn. My question is can I remedy this simply by increasing my carbohydrate intake? Or do I need to see a specialist? I know you can not give medical advice and I apologize if my question qualifies as that, it was more meant to seek your general advice based on what you’ve seen previously. Thanks for all the time you’ve put into this blog you started a few years ago. I’ve been an avid follower and reader since the beginning and have thoroughly enjoyed every last bit of it. I feel like I embarked on an incredible journey and am excited to see where you take it next. All the best

  12. Hi
    First of all, thank you so much for Your inspiring Way of explaining the ketogenic diet.
    I am following you from Denmark. I have been ketogenic since september 2014 and I am still a bit confused as to how much I should eat / how many calories I should eat. Some say eat, eat, eat more calories or Your body will Think you are starwing, others say limit your intake.
    I am 168 cm / 49 kg and just looking to stay the same – does 1650 kcal Sound right?
    Hope you will take the time to give me a short feed back. Thank you so much for helping me (and preventing that I go back to my old dukan diet Way of eating)

  13. Peter, I came across your podcast today from the Tim Ferris show. I am also fat but fit. However, my blood work sucks. Tri Glyceride, 400, Chol. 299, Chol/HDL Raio 7.4 . I am also, 200 at 5’6″. My doctor keeps prescribing me more meds instead of addressing the problem, which I know realize thanks to you, is my diet.
    I am going to incorporate more fat and cut way back on carbs. Thanks for sharing your story and creating this blog. It might have just saved my life.

  14. Oh your blog is addictive!
    I’ve been on this way of eating now for 4 months and it’s wonderful – I haven’t had any sugars at all and haven’t missed anything.
    However, recently I’ve hit a health problem and I’m now uncertain what I’m suppose to do in the way of food. While I try to work it all out I’ve been eating as usual, only just lowering the consumption of red meat in favour of poultry (which I’m not sure is correct anyway).
    I have kidney stones. These are heredity I believe, as my father had them (killed him at the age of 42). I have very little information about him or his medical history other then that. (actually died after one of his many operations when they had to use invasive surgery to get to the stone)
    My stones have been described by my surgeon as “matrix” and that my kidneys are “stone formers”. I can’t ask him about diet because he is horrified at the fact that I eat no fruit (except berries) no “high grain bread” and that I think it’s ok to eat fat. So – he is a great surgeon and wonderful with my kidneys, but not so much with diet.
    And everything I look at online is contradictory! Most agree that low fat high carb is the way to go. That ain’t happening!
    Can you give me ANY advice on a way to adjust my diet to keep the formation of (matrix) stones to a minimum while staying on a low carb high fat diet?
    Thank you
    Eliza Leahy

    • You need to request a 24-hour urine collection so all of your urinary electrolytes can be evaluated. If there is an imbalance that promotes stone formation, you can likely correct it with a supplement or cocktail of supplements.

  15. Since you mentioned the “Talent Code” by Daniel Coyle published 2009, I was wondering if one of the other books you’ve read was “How Children Succeed” by Paul Tough published 2012? With limited time, I’m going to pick one of those and give it a read. It also mentions Grit so it caught my attention. Thanks for the blog and all the great info. I love the science!

  16. For those who are weight-stable on LCHF what other measures can or should be taken to reduce weight?

  17. Hi, Peter- it would be great if you could write more on the topic of prevention. I’m a 23 year old woman and am supremely alarmed by the growing number of people my age who have suddenly ballooned into puffy versions of themselves and the number of people who are beginning to become sick with chronic diseases. In addition to fasting, meditation, and exercise, what should young people be focusing on in order to establish healthy routines for longevity?

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