April 18, 2012

Nutritional biochemistry

How do some cultures stay lean while still consuming high amounts of carbohydrates?

Read Time 8 minutes

Many of you have asked this question over the past few months, and I’m sure many more of you have at least contemplated this question at some point.  I know I did.

For the sake of this discussion, let’s ignore the fact that the “historically” lean countries (e.g., France, Italy, Japan) are catching up to our levels of obesity and metabolic syndrome, especially in certain affluent subsets.  After all, we did get a 40 year head start on how to eat poorly.   So, let’s ask the question this way:

How does the average person living in, say, Japan stay leaner and healthier than the average American while still consuming >70% of their caloric intake in the form of carbohydrates?  

I don’t claim to know the answer this question, but I’ve got a few ideas.

Before getting to this question I want to mention that I have reorganized a page on the blog, Media, which now has a lot of videos and interviews.  A lot of the questions I get asked are addressed in these videos and interviews (both of me and others), so please check there for answers to your questions. Last week I was interviewed by Ben Greenfield. Ben asked a lot of great questions which many of you have also asked over the past few months. Take a look here and see the questions Ben posed.  If you’re interested in hearing my thoughts, listen to the audio clip from the interview.

Back to the question at hand

These data are a bit dated, but you can see the point: the United States is leading the way in the obesity race, while other countries (including those eating at least as high a total percent of their intake from carbohydrates) are not.  How is this possible if insulin – stimulated by carbohydrate intake – is an important hormone in the body’s drive to accumulate fat?  

This problem has many layers to it, but for the purpose of simplicity (always a danger when aspiring to explain complex phenomena) I’ll limit the discussion to three main points – think of them as the “higher order terms” – in their order of importance.

  1. Lower consumption of sugar
  2. Lower absolute consumption of carbohydrates
  3. More favorable consumption of polyunsaturated fatty acids (PUFA)

These reasons are not independent.  In other words, they are highly correlated and linked to each other, which actually amplifies their effects.

One other point to keep in mind: There is no definitive experiment I will point to that can prove my assertion beyond a reasonable doubt – for that I would need a prospective, well-controlled experiment comparing the eating habits of these countries over decades.  Many things I’m discussing are observational in nature, so you’ll have to really scrutinize my thesis on your own.


Reason #1 — Sugar intake

There is a great disparity between U.S. sugar consumption and the sugar consumption of countries like France, Italy, and Japan (and most countries, actually).  When I say “sugar,” of course, I mean sucrose, high fructose corn syrup, beet sugar, cane sugar, and liquid fructose (e.g., fruit juice) to name just a few forms.  Why does this matter?  If you’re not currently up on the why-sugar-is-bad-for-you data, it’s worth reading this post, and watching the lecture by Dr. Lustig.  For a quicker answer, watch this video from 60 Minutes.

Think of sugar as a “metabolic bully” or the proverbial Trojan Horse of metabolic syndrome – you let sugar in, and before you know it, you have diabetes, heart disease, and cancer.  Consumption of sugar makes us metabolically inflexible as part of a vicious cycle I’ve diagrammed below.  The more sugar you eat, the more insulin resistant you become.  The more resistant you are to the effects of insulin, the more insulin your pancreas needs to secrete in response to all carbohydrates, including the not-so-bad “non-sugar” ones. The more insulin your pancreas needs to secrete to manage your glycemic load, the higher your average insulin levels, which is manifested by higher levels of circulating insulin at all times – fed and not fed. Higher levels of insulin lead to less fat oxidation and more fat storage (from both ingested fats AND ingested carbohydrates – de novo lipogenesis).  This, not surprisingly, leads to greater insulin resistance, and so the cycle continues.  There is a reason “vicious cycles” are called “vicious.”

Vicious cycle



Reason #2 — Total glycemic load

It’s important to keep in mind that the percent of carbohydrate consumed is nowhere near as important as the absolute amount of carbohydrate consumed. Failure to understand this point may be one of the most significant reasons for the calories-are-everything-argument.  Recall my post on why Weight Watchers and most commercial diets are actually low-carb dietsVirtually any diet that reduces caloric intake also reduces glycemic load.  Worth repeating: Virtually any diet that reduces caloric intake also reduces glycemic load. That is, cutting calories almost always means cutting carbohydrates, cutting insulin, and cutting fat storage.  So what does this have to do with folks in Japan eating rice?  While these cultures may consume a higher percentage of their intake from carbohydrates, their actual glycemic load is lower. In other words, they actually consume fewer total carbohydrates in most cases than a typical Westerner (and in the presence of much less sugar!).  Contrast “typical” carbohydrates consumed by these “high” carbohydrate societies:

Photo by plusstory1 (http://plusstory1.tistory.com/28) [CC BY 4.0], via Wikimedia Commons
Photo by Liene Vitamante on Unsplash


Photo by Jonathan Pielmayer on Unsplash

Sure, they eat rice and bread and pasta.  But how much at one time?  And what are they eating it with?

Compare the figure above with that below, showing “typical” American carbohydrate consumptive patterns:


American eating

Are we eating the same amount of pasta per meal as the folks in Italy?  Perhaps, though I don’t think so.  Furthermore, while they make their own pasta sauce out of home-grown tomatoes, garlic, and olive oil, we dump a pound of Prego on ours (the second or third ingredient is nearly always sugar).  While the French are eating baguettes, we’re eating sugar-filled bread.  While the Japanese are eating a small bowl of rice, we’re stuffing our face with a plate of fries and breaded onion rings.

Why does consuming more glucose matter, notwithstanding the point that the glucose we consume is virtually always linked to sugar?  The human body can only store a finite amount glycogen, so any excess glucose we ingest actually does 2 harmful things:

  1. Continues to raise insulin levels, which inhibits fat mobilization,  and
  2. Gets stored as fatty acid, and ultimately ends up as triglyceride in fat cells.  Remember, this is a one-way metabolic street.  When your body turns glucose into fat (technically, we turn acetyl-CoA into malonyl-CoA into palmitate), you can’t turn that fat back into glycogen.

More absolute glucose, regardless of the relative percent, still leads to more fat accumulation.


Reason #3 — Inflammation

While insulin is certainly near the top of the list of pro-inflammatory factors in our bodies, it’s important to keep in mind the role of some other factors whose balance plays a role in inflammation such as eicosapentaenic acid (EPA), docosahexaenoic acid (DHA), and arachidonic acid (AA) to name a few.  I will, in a separate dedicated post, compose a thorough discussion on the metabolism of omega-3 and omega-6 fatty acids. To be clear, the science around this is not fully worked out, and much of what we speculate is based on indirect cause-and-effect inference, coupled with “sound” mechanistic reasoning and, of course, strong observation.  In other words, this is not close to bulletproof logic.

What is known is that diets high in omega-6 polyunsaturated fatty acid (PUFA) (e.g., mostly plant oils like sunflower, canola, safflower, and corn oil) relative to omega-3 PUFA (e.g., fish and fish oils) create a disproportionate ratio of AA to EPA and DHA. When I go through the biochemistry of this (which is super-cool!) it will be obvious why this is true: Eat a huge excess of omega-6 PUFA relative to omega-3 PUFA and your blood and tissues will show a lot of AA relative to EPA and DHA.  Same logic holds in reverse.

What does this mean?

Here’s where the story goes from being “clear” to “less clear,” at least to me. There is reasonable evidence that too little EPA and DHA (omega-3) predisposes us to certain diseases, in particular, cardiovascular disease.  There is some evidence that the relative amounts of EPA to AA and DHA to AA matter, too (i.e., what happens when you eat too much omega-6 PUFA relative to omega-3 PUFA).  What is not clear is if too much AA relative to EPA and DHA (i.e., much more omega-6 than omega-3) leads to clinically significant inflammation in the body that fosters other disease states.  In fact, a case can be made that high amounts of omega-3 PUFA are outright protective from many diseases including the disease spectrum of metabolic syndrome (e.g., diabetes, heart disease, cancer, Alzheimer’s disease), independent of omega-6 PUFA intake.

Observationally, this seems “clear” – societies whose ratio of omega-6 to omega-3 consumption are lowest (e.g., 3-to-1 or better) have far less disease than societies whose ratio is much higher in favor of omega-6 (e.g., 30-to-1).  Of course, this does not prove anything, since uncontrolled observations are just that.  This is how folks like Ancel Keys and Colin Campbell have caused so much trouble and confusion in the field of nutrition.  It is possible that some other factor, beyond this, is resulting in the differential disease pattern.   In other words, it is not clear if this observation is correct because of the relative amounts of omega-3 and omega-6, OR if it is true because of the absolute amount of omega-3, OR if it is true for some other reason? I don’t know (yet), but will continue to work on this.

That said, there is some indirect evidence linking differential consumption of PUFA (i.e., relative differences in omega-3 versus omega-6) with actual disease states.  A paper published in 1993 in the New England Journal of Medicine showed that patients with more EPA/DHA precursors than AA precursors in cell membranes had greater insulin sensitivity and less heart disease (though, obviously, these are linked).  I will review this in much greater detail in a dedicated omega-3/omega-6 post, but I want to point out that there is some evidence beyond just the observational data suggesting more omega-3 and less omega-6 in your diet leads to better insulin sensitivity:

Eating more omega-3 and less omega-6 may lead to more EPA/DHA precursors in cell membranes than AA precursors, which is correlated [not causally linked] with less insulin resistance.

Hence, Western diets, where we don’t consume much omega-3 PUFA, and it is very difficult to avoid omega-6 PUFA (they show up in virtually every processed and packaged food we touch, not to mention all sauces and dressing, and even our grain-fed meat), may predispose us to greater insulin resistance and inflammation.  As you can see in the figure below, a (historically) typical Japanese diet was nearly equal in omega-6 to omega-3, while our diets are typically much higher in omega-6 than omega-3 – BOTH because we don’t eat much omega-3 AND because we eat much more omega-6.  The same is true of a traditional Mediterranean diet.

Let me reiterate: I do not know if the relevant issue is the denominator (i.e., absolute amount of omega-3 consumed) or the ratio (i.e., relative amount of omega-6 to omega-3).

[Personal note: Pending resolution, I do both: I maximize my omega-3 intake and minimize my omega-6 intake to a ratio of about 1:1 with lots of EPA and DHA and little omega-6.  What is not clear to me yet from current data is if I should be minimizing my omega-6 intake.]

Omega-3 vs. Omega-6



What can we learn from this?

I alluded to how multifactorial this issue was, but I hope it’s clearer to you now.  Let me try to summarize why some cultures have historically been able to consume rice and pasta and baguettes but stay leaner and healthier than Americans:

  1. They consume a fraction of the sugar we do.  More sugar consumption leads to greater insulin resistance, more fat creation, less fat breakdown, and more fat accumulation.
  2. They consume less total glucose, AND the glucose they consume is accompanied by less sugar (and less omega-6 PUFA, if it matters).
  3. They consume a ratio of omega-6 to omega-3 PUFA that is much lower than we do.  This may further reduce any insulin resistance brought on by the glucose they do consume (in smaller doses and with less sugar).

Let me close with one personal and anecdote.  When I began my nutritional journey, for over 18 months I still consumed a modest amount of carbohydrate, probably on the order of what a typical person in Japan would consume.  The biggest elimination in my diet was sucrose, HFCS, and “junk” carbohydrates. The results were impressive.  I went from being about 200 pounds at 25% body fat to being 177 pounds at 10% body fat while still consuming some carbohydrates (by that point I was down to maybe 100-150 gm per day).   However, I was able to get leaner (170 pounds, 7.5% body fat) and further improve my risk profile for disease by going below 50 gm per day (i.e., entering nutritional ketosis).  Was this last step of nutritional ketosis necessary? Of course not, but it was a nice way to experience the full spectrum of carbohydrate restriction.  Will I ever go back to eating 100-150 gm per day of the “right” carbohydrates at some point? Probably, provided I don’t go back to eating sugar and stuffing my face with carbohydrates.  It will depend on what I’m optimizing for.

My point is this: Just modifying your diet by the 3 factors I mention in this post — elimination of sugar, less total glucose load, and improved omega-3/omega-6 profile — even if you are not genetically programmed to be lean, will probably deliver 80% of the value in terms of disease risk and body composition.

Photo by Jorge Zapata on Unsplash

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  1. Thank you for reinstating the old font! That other font was impossible to read, Gary uses it on his website also. I have excellent vision, and I still found myself squinting. This one is so much more accessible. A real relief!

  2. It is hard to get good data on Indonesia and Vietnam but I thought I saw in a WSJ article that their rates of diabetes are going down…I am not certain if I am remembering this correctly. Also interesting to note that Indonesia is the biggest consumer of rice per capita, twice that of Japan. Curious to what auto-immune issues they have since I would consider them benign carbs compared to wheat. Purely speculating on these questions but curious if you can offer any insight…since you are discussing cultures. Great stuff as always!

    • Consider the populaton of Indonesia is twice that of Japan, then also consider that the poverty levels in indonesia would indicate that most of the population is on a “low food diet” and the correlation is very understandable. Unless you understand the culture it is easy to treat a country’s population as homogenous, and Indonesia is a prime example where there is no homogenity.

    • I’m from Indonesia and I was recently diagnosed diabetic. Hence I was looking into this diabetic issues and found that the rate of diabetic in Indonesia is actually rising sharply as shown in national TV news and many local health articles. Just google out “Indonesia diabetic rising” and you’ll see the news.

      I would also consider the poor health system here, and that majority of the people cannot afford the luxury of getting checked by doctors just for a symptom of diabetes which is so subtle anyway. Not to mention the low health awareness to do routine medical checkup. Hence diabetes here might actually already epidemic but not detected.

      Indeed rice is our primary staple here. There even goes a saying here: “You have not eaten if you have not eaten rice.” And are we lean? Who says that? I look around and what I see is belly fat.. belly fat everywhere :p

      By the way, this is my first comment in this great blog. My saviour to say the least.
      I have followed LCHF way of living for 6 months now.
      The changes I experience in this 6 months?
      I have my BG under control around 70-90 (fasting or 2 hrs after meal) from previously 240 fasting and 310 2 hrs after meal. My latest HbA1C 3 months ago was 5.8 from 10.1 when I was diagnosed.
      I have ditched my BP medication completely with my BP now around 110/70 from previously 140/110.
      I have lost 18 kgs of weight, and 20 cm of waist circum.
      I have finished a couple of 10 KM run race from only able to walk 3 KM when I start this journey.
      I lift weight daily with incredible increased strength and my body now looks.. well how do I say it.. just say that I’m not embarrassed anymore to go to the public swimming pool in my shorts 🙂

      All this thanks to people like Peter Attia here, Andreas Eenfeldt, and Mark Sisson. So thank you, Peter!

    • Hi Peter, you’re being modest 🙂
      For people with similar personality type as you (I’m INTJ with ambiguous I/E and N/S but very strong TJ), we need people like you who “breaks the code” for us. If it were not for this blog which explained everything clearly but logically, I would not adopt this “crazy sounding” way of eating 🙂
      Not to mention that you use your personal time to do all this self-research and blogging. You Sir deserve every credit 🙂 Cheers.

  3. When I visited Japan in 2000 & 1989 I found that their supposedly sweet pastries had very little sugar in them. I was craving something sugary at the time and their sweets didn’t do it for me. I have been to all 3 of the countries in your post and on the negative end of the scale they tend to smoke much more than in the US. In Rome I was in a local market and they did buy a lot of pre made spaghetti sauce, but it no doubt has less sugar in it than American brands. A lot of seafood in the Japanese and Italian diets as well. They had smoked fish in the traditional Japanese breakfast (that plus salad and rice). What type of oil do you use for cooking? Flaxseed? I didn’t see much of the healthy Omega 3 types in my local grocery store. I got some cold expelled Safflour oil, but now I’m thinking this was a poor choice.

    • Just about every other reference I’ve seen to fish oil and Flaxseed oil says DON’T USE FOR COOKING — evidently heat oxidizes the Omega 3 to create a lot of free radicals, making them harmful instead of good. Seems to be a similar problem with the Omega-6 polyunsaturated oils — “vegetable”, corn, canola, the seed oils, soybean — don’t cook with them, and in fact pretty much avoid them altogether because they’ll skew your desired Omega 6 to Omega 3 ratio.

      A lot of people do cook at lower heat with the monounsaturates … olive, avocado, macadamia. But certainly saturated is a good choice — coconut oil and butter (and ghee works especially well for cooking).

    • To flesh out this discussion, I’ll cite a comment by Dr. Mary Enig: “The idea that cooking with heat damages the oils that are highly polyunsaturated is true and the warning against cooking or frying using fragile oils such as flaxseed oil is valid, but not because trans fats are formed. What is formed under harsh circumstances such as high-temperature cooking and frying is a polymerized oil, and this is because the heat has helped to form free radicals and then various breakdown products. (Flaxseed oil that is still in the ground seed can be heated in baking and it does not become damaged.)”

    • Hello everybody. Just thought it would be interesting to share what i know about the effects of high carb diet among Italians. I work as a registered nurse in Montreal, Canada. And I have noticed over several years of working with elderly patients in Montreal’s Italian community that all of them (with no exception) are diabetic. And this situation of course, is caused by high intake of pasta, pizza, bread, pannetone, cantucini,risoto, gelato, cheese etc. I have understood that dairy products are not good for humans health either.

    • Use avocado oil. it has a high smoking point more than any other oils, so it is safer to eat, plus it is a healthy fat to consume.

    • I have a question guys – I’ve been told that butter has a very low smoking point and shouldn’t be used in cooking. This is coming form the website T-Nation, I forget which author, but I consider it to be one of the top fitness or s&c sites in the world, I’m sure Peter would agree (if not, would love to hear why).
      They’re not so pro-high fat as we are, but they do recognise the positives about higher fat diets, and in regards to strength training and exercise, sound pretty spot on.
      I do often fry with butter, as mum only recently got some coconut oil (yeah, I’m only 18, 19 this valentine’s day). However, it does turn very brown very easily. This kinda sort makes me worry.
      So – thoughts on butter being bad due to a low smoking point, or does it not matter given it’s saturated with those funky hydrogen dudes?

  4. Keep up the good work. It is nice to hear you not talking in absolutes about issues not proven yet. Thanks for being out there being the voice of uncommon sense

    • This is a funny issues, actually. I spent all of yesterday with Gary. Gary is even more skeptical of the omega story, so he was giving me a very hard time for the 3rd point of this post…

    • Peter, It’s interesting that Gary doesn’t buy into it. I just read an article in which Walter Willet was quoted as saying the whole Omega 6/3 story is a “myth” with no supporting evidence. Looks like those two can finally agree on something! 🙂

      Just out of curiosity, is it the ratio Gary doesn’t buy into, or the benefits of Omega 3, or both?

      • The irony of WW calling it a myth…I’m not exactly sure what Gary’s opposition is, as we spend all of our time talking about NuSI these days. I think Gary’s point which is valid, is that science is not as robust as one would like to make formal recommendations.

  5. Hi Peter. Loved this post (and the pictures). Suggestion/Request- You might consider adding a pdf link for some of these great articles. I, as an internist, would love to hand this sort of thing out to my patients rather my usual “stop eating sugar” and “take fish oil” diatribes.

    • Matt,

      It is pretty easy to make your own PDFs of a web page using something like CutePDF. (Native on Macs) It might be a better options and increase Peter’s traffic (might not be good for his bank balance though) if you handed out cards with eatingacademy.com written on it. 🙂

  6. I hear the argument a lot that “carbs can’t be bad because a billion Chinese people eat rice every day”. I don’t think the average American truly understands the extraordinary amount of sugar and starch they are eating in a typical day. A half cup of white rice with a meal is nothing compared to typical “heart healthy”, carb loaded American meals. My typical breakfast before going low carb: 1/4 box of granola cereal drowned in skim milk and a tall glass of grapefruit juice.

    1/2 cup of white rice has 18g of carbs, 0g of sugar. My typical breakfast had 122g of carbs, 59g of sugar.

  7. Thank you, for you willingness to provide all this well thought out and supported information for free.
    It is greatly appreciated.
    When you have gotten through your current list of posts to come, would love to see a post on alcohol addiction and how it relates to sugar addiction.

    Also for me – and I know this isn’t a money making venture – I would happily donate to the running costs of the website etc, because I have gained so much information and direction over the last few months. Just a thought.

    • Joey, I really appreciate it. The blog currently costs me about $5,000 per year run (that number keeps going up). I’m willing to provide that for free for now. If circumstances change, it’s nice to know there are a few folks willing to help. I’m deliberately keeping ads off, also. Hopefully that makes it easier to enjoy.

    • Count me in for that also. Would love to be a subscriber to the site. The information you provide easily gives me the feeling that this is worth paying a subscription for.

    • Peter,

      Why not move your blog to something like Glogger where you don’t pay the types of fees you are talking about here? Are their limitations with a platform like blogger that you get the benefit of self hosting. (I understand you use a service provider for the blog. Alternatively if you wanted more control, why not consider something like Squarespace.com?

    • Joey, if you haven’t yet seen Robert Lustig’s infamous youtube video, Sugar: The Bitter Truth, you should take a couple of hours and sit through the biochemistry of how the liver deals with sugar, fructose and alcohol. It derives a thesis that sugar/fructose is toxic in the same way as alcohol, but it doesn’t discuss the addiction of it. The 60 Minutes segment from a couple of weeks ago, which Peter linked maybe in last week’s post, is also an interview with Dr. Lustig, but includes a segment on the sugar/cocaine/alcohol addiction effects. It’s fascinating work.

      I, too, would happily lend financial support blogs like this one. You can see the glaring need for large, well-controlled prospective human studies that ask the right questions and present all the findings (unlike Keyes and Campbell) in the difficulty in writing a post such as this one in which the topic is so important but the data is not all clear. In the meantime, careful discussion in blogs such as this, including the value of shared self-experimentation and the experience of what clinicians see with their patients, is vital to the discourse of figuring this all out (plus your graphics are always so good!).

      I’ve been getting close to a more comfortable fatty acid profile by purchasing bulk organic grazed beef, eliminating commercial salad dressing and making my own, buying bulk well-sourced wild fish, and limiting chicken. But it means biting the bullet on the up front costs (including a freezer) that many cannot afford. (Although I have to say that buying this way lowers the serving cost of meals well below supermarket factory farmed cost) I’ve been taking high quality fish oil for years and have never used vegetable seed oils. Because our food supply is so problematic on this fatty acid issue, though, it takes a fair amount of work (and rarely eating out), and it poses some issues for me regarding the sustainability of wild fish. And I often wonder, when suggesting people reduce their carbohydrate with the substitution of increasing fats, including that in fattier protein, if I’m not creating the trading of one problem for another – insulin inflammation for omega-6 inflammation – as most folks are not going to purchase beef or fish other than corn fed factory farmed. It’s a conflict for me, mostly because I see the fatty acid thing right up there with insulin as a first/second order priority.

    • A single banner ad top (or bottom) of page is unobtrusive. Very effective if you find advertisers directly. One website that has done this is gearslutz.com, (audio-engineering messageboard with 168k registered user). By my math they gross at least $20k/mo

      Just a thought. 😉

  8. I remember reading in “Good Calories, Bad Calories” that the Japanese had the highest rate of stomach cancer in the world. Just another reminder that leanness doesn’t equal health.

  9. Great post as always. Especially looking forward to the Omega 3/6 article; I keep PUFA low because smart people (yourself included) say so, but it will be nice to know the science underlying it.

    Speaking of PUFA, I’d be interested in your opinion on Conjugated Linoleic Acid (CLA). I know its theorized to lower total adipocyte number, but I haven’t seen any definitive studies confirming/refuting this in humans. This seems potentially quite useful in normalizing Leptin for people who have lost lots of weight.

  10. Thank you, Peter – excellent post.
    I’m curious why you didn’t address the potential for genes to play a large role in response to carb load. For ex, Asian cultures were so isolated for so long from other cultures, there have to be some DNA-level issues at hand here. Even if it isn’t about actual NEW genes, there could be an epigenetic factor at play – DNA methylation brought on by the “dance between nature and nuture.” If all of my ancestors over countless generations ate roughly what I eat, chances are my body will have figured out ways to deal with it, even if my actual DNA sequence is exactly the same as someone in northern Vermont.
    That’s not to say the food combinations, lack of sugar, etc, aren’t critical – as you note, this is complex and no doubt our body’s responses to food come about as the result of a correspondingly complex interplay of factors. But given the broad continuum of response we see in US population to food (your wife vs. you, for ex), there has to be some deep, underlying factors as well, don’t you think? (And sorry if I’m being too exacting – you are doing an amazing job of addressing so much complicated material – it’s a tremendous service you’re providing here.)
    BTW, is that picture of the boy with the stack of sandwiches you? 😉

    • Not sure genes play a role. It seems even Asians are not immune to “our” diseases once the eat “our” food. I have never seen credible evidence for genetic protection by race (obviously it exists by person). Today, some children even in Tokyo need gastric bypass for morbid obesity, almost certainly because they are eating like our kids.

    • Actually, even eating our food, those Japanese that retain their culture have less heart disease then those who eat our food but adapt our culture.

      As for genes, it makes sense to me that genes may play a role per race, but proving that might be complex. For instance, American Indians tend to be very susceptible to obesity, heart disease, etc., but is this caused by living conditions/culture or by genes?

      • The data are pretty sketchy, though. The best data I’ve seen were on breast cancer in Japanese women in the US vs. Japan. Same genes, but higher breast cancer in the US. It was more complex, of course, but that was basic idea. Agree, this is complex.

  11. Another great post and I couldn’t agree more. I’m currently in Florence for training, my first time since going LCHF, and the first thing I noticed was the difference in portions. As you said, they might eat pasta and breads but they tend to be a much higher quality and the amount they eat is more akin to a child’s portion in the US. Now if I could only find a way to bring some of the great meats and cheeses from over here back home.

  12. Fantastic job with this, Peter! I’ve been eagerly awaiting this post.

    When I pitch a low-carb diet to friends and they throw the “If carbs make you fat, why are Asian people so thin?” question at me, I almost always point out the error in their logic. Here are my claims (albeit oversimplified):

    If you are overweight or obese, then you are insulin resistant.
    If you are insulin resistant, then carbohydrates make you fat.

    If both of these statements are true, it does NOT hold that carbohydrates make ALL people fat, but it’s a very common logical fallacy people make. In fact, the contrapositive of the chain of conditional statements above explains the observation of thin Japanese people:

    If carbohydrates do NOT make you fat, you are NOT insulin resistant, and you are NOT overweight.

    Therefore, you cannot make a logically sound argument against the statements above by pointing out that some people are NOT made fat by carbohydrates. That’s true! Doesn’t make the statements above any less true! (Can you tell I’m studying for the LSAT?)

    Thanks again for addressing this, Peter!

    • I really think that you’re all wrong about that, the fact that japanese people are thin and eat 70% of there caloric intake with carbohydrates really well explained an other thing, the fact is that you can have the most of your calories out of carbohydrates but that has nothing to do with the amount of food you can eat, that stipulate that the 30% of the calories intake can be a massive quantity of food with no “negative “impact on the glycemic and insulinemic response but have a favorable effect by decreasing the glycemic index and load of the total meal. That’s also why “the percent of carbohydrate consumed is nowhere near as important as the absolute amount of carbohydrate consumed”

    • canola is “bad” for another reason – it’s a seed oil, high in omega 6 and with lotsa nasties that are in all seed oils to one degree or another – antinutrients and the like.

      why consume it when there are sooo many wonderful other good fats to eat?

  13. Using occcam’s razor we could simply say the carbohydrate insulin hypothesis is false. There’s so much information to the contrary of CIH that only those with a vested financial interest continue to defend it (such a low carb product pedalers, ahem-Eades *cough* Moore). For example. Carbohydrate intake has remained stable in the US since 1910: http://1.bp.blogspot.com/-pAXaQJgkPpY/TkR6gZOX96I/AAAAAAAAAz8/hXW8cuW0QPg/s1600/US+macro+intake+%2528kcal%2529+1909-2006.jpg

    Yet obesity epedemic really started in the 80s. How do you account for this using the CIH?

    I do think you’ve identified the key issue, food toxins, in the form of excess sugar (fructose) and linoleic acid (omega 6 oils) but certainly not carbohydrate! Excess energy intake (mostly in the form of added sweatners) also plays a role.

    Personally I can eat well above Mark Sissons carbohydrate curve (of high glycemic carbs including bananas, rice and potatoes) and still remain lean (visible abs), as do the kitavans, as do high-carb bodybuilders.

    • Andy, thanks for your comments. Carbohydrate intake has absolutely not been constant in the US since 1910 (or even 1970 for that matter). Look at NHANES and CDC data (and keep in mind, total caloric intake is also rising, so the absolute amount of carb intake is actually going up FASTER than the curves of relative intake show AND then couple this with the QUALITY of carb issue…you get the idea). Also, look specifically at sugar consumption. Your claim that you and some bodybuilders can eat carbs, therefore carbs are not fattening is not relevant and I wouldn’t dispute it. My wife is the same. Read this post for a discussion on this exact fallacy: http://eatingacademy.com/nutrition/gravity-and-insulin-the-dynamic-duo. It’s like my 110 pound wife eating Oreo’s, not gaining an ounce of fat (which she does not), and asserting that Oreo’s are good for everyone. Not at all…she’s just one of the lucky 10-20% of folks with profound carbohydrate (and sugar) resistance.
      Finally, I completely agree with the idea that Occam’s razor explains the obesity epidemic. The simplest change between 1900 and today is the quality of food we eat and the quantity of bad food we eat.

    • High carb bodybuilders use the standard bulk-cut method to grow muscles. You know what it means, right? They eat tons of food to grow fat, then they cut total food intake to grow lean, all the while listing heavy weights. When they try it with a low carb diet, they can’t grow fat no matter what.

    • Yeah, it was a sickening amount of fluid but the amazing thing was my body just seemed to want more and more of the stuff. Sixty four ounce Double Gulps was the typical serving size; it just gradually grew to that amount over time.

      Since then all I drink are iced tea and water and I’m happy to say my consumption has decreased quite a bit. I threw away my old 64 ounce cups and am quite satisfied with a 16-20 oz serving. I probably still drink more fluids than the average person but I’m not peeing all the time so I think I’m drinking the right amount.

  14. Dr. Attia,

    Thanks very much, I really enjoyed this article as well as the others you have written on the effects of sugar. For those of us trying to cut down on our sugar consumption so it is more in line with the Japanese or European diet, or so that we become keto-adapted, what advice can you give on overcoming sugar addiction (which I believe from personal experience is real and dangerous)? Even after 3-4 months of fairly strict low-carb dieting (mostly under 50g/day, always under 100g) I still have extremely large sugar cravings. I’ve tried cutting down on cheat days and artificial sweeteners so my brain doesn’t miss the sensation of sweetness but the cravings are just as intense. When I do allow for a cheat I become ravenous in my sugar consumption. How can I (or we, as Americans) overcome this impulse?

    • I found also eliminating non-sugar sweeteners (e.g., sugar-substitutes) helped, but it’s certainly going to be tougher for some folks. Curious to the experience of other?

    • My experience with sugar addiction–and I resisted the very word for a long time, thinking it entirely bogus until I actually looked at my own behavior and history–is that one can no more “cheat” with a sugar addiction than any other sort. “Addiction” is a real word, not a metaphor. If it is very very difficult for an addicted smoker to have just one cigarette and then just stop again, or an alcoholic to have the occasional drink, why should this “addiction” be any different? Of course, not everybody who eats a lot of sugar is addicted. That goes without saying. But if one finds that having started, it is very very difficult–or impossible–to stop, well, there you are. And the answer is the same one would come to in discussing addiction to cocaine or heroin, or anything else: one cannot use at all. My own experience is that it extremely hard to quit sugar. [I remember one acquaintance who had kicked heroin saying that her struggle with heroin was nothing compared to her struggle giving up sugar.] After a month or so, for me, the cravings (though not always the desire, which is different)start to go away. A few months in and I am OK, but ever vigilant. Were I to have an Oreo cookie today, however, just one little one, I know from my own experience what would result. I have tried that experiment, alas. It might be months or years–this has happened–before I can put it down again. I find artificial sweeteners somewhat problematic as well, though not to the same degree. As Peter points out over and over again, we are all different, and it takes a lot of rigorous honesty to face the reality of how OUR bodies really work. If one Oreo is too many and 1000 not enough, well….There are programs for addictions.

    • I would suggest looking into the possibility of yeast overgrowth. Seems to be a controversial topic, but do your own digging and see if and what may apply to you. Look for “Candida” and yeast overgrowth. Having cheat days with this problem will absolutely 100% nullify all of your low-carb efforts in one go.

    • I had to cold turkey it. NO added sugar or artificial sweeteners at all. Takes about a month to like coffee again. My goal is under 20 carb grams day. That’s taken me from 238 to 188 in 15 months. No juice, no grain, no potato, no corn no sugar. What I like about low carb living is I can understand it. It’s simple. DOn’t do this. Do whatever else you want. That works for me. And I’m never hungry.

    • CS…I truly appreciated your reply – especially “[I remember one acquaintance who had kicked heroin saying that her struggle with heroin was nothing compared to her struggle giving up sugar.]” This comment I believe!

      Oddly enough, I find it corelates with the level of thyroid hormone I am taking. If I am over-dosed then the cravings for fast energy like sugar get worse. I’m waiting for the post “Relationship between hypothydroidism and insulin resistance” like a kid for Christmas!

    • My experience with Sugar addiction lasted until I turned 45. I quit all added sugar and it took me about a year to start feeling comfortable around sweets. I stopped in March 2010, and the first Christmas with my entire family was hell, as my mother always has a table full of sweets. The last Christmas was easy, smell will get me dreaming once in a while, but not to difficult to resist even though my wife and kids still enjoy it every day. I keep eating my own jam on toast with PB (Only Carbs I have kept beside Veggies), but I make my own jam with Xylitol. I do enjoy diet drinks once in a while, and they don’t trigger any sugar needs. Did it work, well went from 309 to 188 pounds and taking part in my first Triathlon this summer.

    • My experience is that artificial sweeteners were really holding back my fat loss.

      In early February I was eating low carb but my weight loss was stalled and my energy levels were crashing in the afternoons after eating a low carb lunch. At lunch I was drinking a massive amount of Diet Pepsi (> 100 oz) and I began to wonder if that was the problem. So I quit Diet Pepsi the next day.

      The results were pretty amazing – in 6 weeks I’d lost 14 lbs of fat and gained 6 lbs of lean muscle mass. Additionally my energy levels were consistent throughout the day and the texture of my stool improved (gross but true).

      While I know Aspartame doesn’t cause an increase in blood sugar I wonder now if it does cause an insulin response. I would drink the stuff throughout the day but was really heavy at lunch (free refills). I think perhaps my insulin levels were consistently high as a result and would actually cause low blood sugar after my lunch binge.

      I haven’t checked out my theory with my glucose meter because I really don’t want to drink any more of the stuff (the “cold turkey” headache was pretty bad). Regardless, I feel much better these days without it and I think it might be something to try if your fat loss has stalled.

    • On sugar/carb addiction, there are theories that come from alcohol addiction and eating disorders regarding the role of sugars and carbs on the brain, and when they are withdrawn, the brain experiences a depleted state of the neurotransmitters that the sugar/carbs/alcohol were masking. There aren’t any good studies that I know of, but amino acids are widely used among recovering individuals with good results from self reports. Can’t say if this is placebo effect, or that people with addictions just like taking stuff (which they do), but do some research on L-glutamine and L-tryptophan for sugar and carb cravings.

    • @ Bob Johnston — wait a minute. You’re saying you were drinking more than 100 ounces of diet soft drink just at lunch? As in, the equivalent of 8 cans of soda? How could you get that down? I’d wonder if the problem wasn’t the use of artificial sweetener per se but, you know, such massive quantities of ANYTHING.

    • Bob,

      Did you try replacing the 100oz Diet-Pepsi intake with the same amount of water or non-sweetened fluids?

      I am trying no-sweeteners at the moment, where I used to have around 1.5ltrs per day of diet lemonade (no caffeine at all) per day. So far after a week I have not noticed any differences though… unfortunately.

      I will try it for another week anyhow.

    • At my business I have many gracious customers who like to bring us treats as a token of appreciation. Yesterday alone we had people bring doughnuts, 6-pack of beer, Reese’s Peanut Butter Cups, and frozen yogurt (“oh, don’t worry it’s not fattening like ice cream”… sigh…) I appreciate the thought, but sometimes I feel like a heroin addict in a world where 90% of the population are drug dealers.

    • Sam, the only sweetness left in my diet is daily 85% dark chocolate, 3 – 6 grams per day, plus a packet (sometimes two) of Stevia per day.

      Sometimes out of the blue I start craving that chocolate, it is a nearly irresistible impulse. I found out by accident that having some fat instead made those cravings vanish. For example, I might have a cup of decaf coffee, add a tablespoon or two of coconut oil, with a few drops of Stevia. The chocolate cravings disappeared.

      Purely anecdotal, of course, but worth a try!

      If you ever just have a hankering for some chocolate, another treat besides the 85% is to add some unsweetened cocoa powder to a cup of coffee, add some coconut oil if you want to, add a packet of Stevia or 6 – 8 drops, stir well as you sip, and enjoy.


    • @Sam R

      Is it possibly chromium debt? Chromium is used up in metabolizing sugar. May need to replenish body stores (200-400 mcg per day, give the body time to recover).

      Many people push chromium picolinate, but I find GTF just fine.

    • There was an interesting study on artificial sweeteners that I commented on over at SuppVersity. Unfortunately, it was in rodents. It basically showed that the effect is on subsequent meal satiety. Also, unfortunately, such a study has not been done in humans, and I doubt that the lo-cal sweetener industry dares to sponsor one.

    • Pregnant with my fifth child, I discovered I was anemic. I was eating pretty well considering I wasn’t low-carb at that point, but adding iron to my diet made a huge difference. Sugar cravings almost completely disappeared. Baby is 3 months, I’m still on iron, and virtually no cravings. I’ve been wondering if a lot of people on a “normal” American diet could be anemic.

  15. Greetings Peter & WOI Readers:

    Sincere apologies for an OT question! I did not know where else to ask.

    I would prefer (i.e., need,) to substitute Sea Salt for Bouillon. What would be an equivalent “dose” per meal and/or daily? Any other considerations for such an adjustment?

    Thank you very much !


    • Peter,

      I’m drawing attention to this because it’s a minor inconsistency in your table “Regular supplements I consume every day”, on the most popular post “What I actually eat”.

      In the column next to “Bouillon (chicken, beef or vegetable)” you say “2-4 grams per day”. Note, you don’t specify “of sodium”, which I infer from the context. (Surely you don’t mean 2-4g of bouillon, for example.)

      Some readers might find that insufficient (information, as well as too little sodium chloride), and I’m not sure it’s enough to direct the reader to “titrate”, which I take to mean, “take as much as you need, adjusting as necessary”. How do we know how much we need? Do we take as much as the palate allows? Take as much as makes the headache, or nighttime leg cramps, go away, for example? I recognize that a reliable “dosage” is not indicated for everyone–you are not acting as a doctor–and perhaps that’s why you offer a range. And perhaps a range of 4g-15.5g of sodium chloride [sic] would be fine too, and this is all moot.

      2-4g of sodium, supplementing your already salted food, to make a range of 4-6g sodium per day, represents quite a lot of salt (4-6g sodium is found in 10.3-15.5g of sodium chloride). That’s a little more than I would reach for, if proceeding by taste buds alone (I do all my own cooking, and rarely eat out).

      A minor detail, amid such a wealth of information on you site, for which I am profoundly grateful.

      • This is much more art than science. I use about 2 or 3 teaspoons of bouillon. Each teaspoon contains about 900 mg of sodium. My total daily intake of sodium, from bouillon plus food, is about 4 to 6 gm per day.

  16. Thanks for this great post, as always, Peter! 🙂 Sometimes I get tired of the old “but the Japanese eat all that rice and they’re not fat!” because it’s such a simplistic argument. I’m glad to see you tackling it so succinctly. (FWIW, after all I’ve read, I’m with you on the omega 6/omega 3 thing, even if Gary isn’t! 😉 )

    I spent three and a half years recently living in Japan and working in a company where I was the only white chick and nobody spoke English. (I speak Japanese – I was their translator.) I essentially integrated as much as a white person can, and got a lot of insights about how the Japanese live in general, including how they eat. The last 6 months or so of that time was when I first went low-carb, and I didn’t try to hide it or anything — I made a point of being happy to talk about it. Most people were open and curious, but it was interesting to see some people’s reactions to me suddenly cutting out rice, amongst other things! (One colleague told me point-blank “oh, we Japanese are different, we need our carbs” while filling her bowl with rice. :))

    What I found interesting to observe though is that the Japanese are catching up on the obesity rates, and I see this as being directly related to diet. A friend of mine once joked, “we gave Japan milk and they got taller, and then we gave them McDonalds and they got fatter” — but it’s kind of true.

    The traditional Japanese diet has lots of fresh vegetables, lots of fish and seafood in general, is more accepting of organ meats, and has a decent amount of fermented foods. Even today most young Japanese know how to cook a variety of traditional meals and prefer to eat at restaurants that serve Japanese food when going out. Yet at the same time, there are more and more fast food restaurants (McDs, KFC, and Japanese equivalents like Moss Burger) and more and more convenience stores (“conbinis”). At a conbini you can buy a prepackaged dinner for like 500yen and they’ll heat it in the microwave for you on the spot, so you can eat it right away. You can guarantee the quality of those is crap, not to mention a great deal of them these days are pasta based (ie Western style). Also, there’s been a huge surge in bakeries and other Western style desserts, meaning suddenly there’s a lot more bread products available — and the Japanese eat bread as a luxury, not a staple, so they’re usually sweet products laden with sugar. (Think cinnamon sugar rolls or maple syrup sugar bread, not sliced bread, although they’ll eat that too.)
    Couple that with the ever increasing workload, where everyone goes into work early, comes home late, and has little time to do anything, and the end result I see if that often people grab a bread product from the conbini and eat it at their desk for breakfast, and then get a conbini dinner or fast food meal on the way home from work. If they’re lucky and their office has a cafeteria they might get one good traditional freshly cooked meal a day (we did, but our company was good in that regard) or else they’ll do the conbini for lunch as well. Traditional foods get relegated to dinners with co-workers or friends (which may often include a lot of alcohol) or maybe weekends when they’re less tired.
    And, like America and other Western countries, more and more tasty snack foods are being made available all the time, meaning more people are getting addicted to them in just the same way; everything from chocolates to cookies to chips. The Japanese are fast veering away from everything traditional, and it’s not doing them any favours.

    I lived in a generically suburban area, and I had a lot of time to just look at the people living around me, and I like people watching anyway, and I found it striking to look at the generational difference of weight — the younger a person was, the more likely it was that they were overweight or obese. The older population was still overwhelmingly lean, but as soon as you got down to the 40-somethings, then the 30-somethings, then the 20-somethings, then the teens… each generation was more overweight as a whole, and I can’t tell you the number of overweight babies I saw. It still was nothing compared to America or Australia (my home) but it still was enough to stand out to me.

    To make a broad generalisation, the Japanese used to all be either skinny or sumo wrestlers. But that’s not true any more, and I blame the encroaching Western diet. I imagine this is true in any of these supposedly “skinny” countries — the more they introduce the Western love of sugar and refined wheat products into their diet, the fatter they get. To me, this just brings home the message once again that it is sugar and refined carbs that are doing the biggest damage.

    (Also, coming home to Australia after three years in Japan was a shock — when the hell did everyone HERE get so damn fat? XD)

  17. Peter, after a year of gradual sugar and starch reduction, I’ve moved to a very low carb diet for the last 3-4 months and feel great. I eat mostly eggs, nuts, avocado, salmon, vegetables, cheese, full-fat yogurt, some meat, and some (but not too much) fresh fruit. I lost about 10 pounds (down to 137 and 5’6″, 30-year-old female) and am down to a size 2-4 from a 6-8. I just had a cholesterol test, and my LDL and total are somewhat elevated (total 264, HDL 86, LDL 165, triglycerides 65). I’m guessing that LDL is probably the good kind (large fluffy), but still, do you think I should be concerned about the high LDL?

    • Sorry, Carol, I’m trying (not always well) to avoid giving direct medical advice, as I’m not permitted. However, I’d ONLY recommend having a lipid NMR done. The test you’ve done does not give any relevant information.

    • worth remembering that statistically, LDL cholesterol has never correlated with heart disease risk in women. HDL/trig ratio is probably the best predictor based on the standard panel, and your ratio is excellent (note I’m not a doctor legal blah)

      • But guys, if I only teach you 2 things, please make sure one of them is that LDL-P is all that really matters. Everything else is a guess. Some guesses are ok (e.g., TG/HDL-C) and some are not as good (e.g., LDL-C). Why gamble with a life?

    • Engrave this on a plaque, Carol, & give to your doctor: “The standard LDL recommendations do not apply to pre-menopausal women. They may have some application to post-menopausal women who already have demonstrated heart issues. Women exist and we are different.”

  18. Another factor may be cultural approaches to food — if one group of people tends to eat only during meals (eg, as traditionally in France, according to Michael Pollan), while another group tends to eat a lot of snacks between meals (as in the US), and if the food industry manages to define “snack” almost exclusively in terms of carb-heavy foods (bread or candy rather than cheese or nuts) then the second group is going to never really have many hours during the day when their insulin levels drop.

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