March 29, 2012

Understanding Science

If low carb eating is so effective, why are people still overweight?

Read Time 9 minutes

I find myself getting asked this question, or some variant of this question, with increasing frequency as I speak and write about the Alternative Hypothesis I find most compelling surrounding obesity and chronic disease.  One implication of the Alternative Hypothesis, as you probably understand by now if you’ve been reading this blog, is that many carbohydrates, especially if consumed at the levels most Americans consume them, promote fat gain.  In other words, overweight people are not the lazy, constantly grazing, weak-willed individuals many in the mainstream have led us to believe.  They just eat the wrong foods (rather than simply too much food).

Remember, I was one of those doctors in the mainstream once upon a time.  While I always tried (and hopefully succeeded most of the time) to treat overweight patients with respect, I silently judged them.  Why can’t you just eat less and exercise more?  Only when I realized, despite my diet which rigorously adhered to formal recommendations and my 3 to 4 hours of exercise per day, that even I was getting too fat for comfort, did I begin to question the Conventional Wisdom of why we get fat.  Of course, not everyone (fortunately) was born with my level of genetic susceptibility to insulin resistance (stated another way, not everyone is born with my level of carbohydrate sensitivity).  In my experience, about 10-20% of the population (my lucky wife included) seem resistant to carbohydrates and maintain exquisite insulin sensitivity, almost independent of diet.   Roughly 30-40% of the population are, conversely, very sensitive to carbohydrates and appear to be quite insulin resistant until nearly the last gram of sugar and most carbohydrates are removed from their diets.  Then there is the rest of population, which includes me.  To varying degrees, we’re somewhere between these two groups.

So back to this question — If carbohydrate reduction is so effective for weight loss, why are so many people still overweight?  Beyond being asked this question, personally (and frequently), one can see the same logic in the academic literature (see comment by George Bray in Obesity Reviews) and in the press (see comment by Gina Kolata in the New York Times).

George Bray: “I thus conclude that if any diet ‘cured’ obesity as their proponents often claim, there would be no obesity and thus no need for the next diet.  Yet the past 150 years, since the publication of Banting’s first popular diet*, have seen a continuing stream of new diet books.”

Gina Kolata: “Low-carbohydrate diets have been popularized periodically since the 19th century. Best-selling book after best-selling book promoted them. Yet if they work so well, why are so many people still searching for an effective way to lose weight?”

*If you have not yet done so, and you’d like to put yourself in the ‘low-carb aficionado’ club, you must spend time reading the work of Banting.

Dr. Bray is generally regarded as one of the most erudite authorities on obesity in the United States, while Ms. Kolata is one of the leading reporters on the topic – so we’re not just talking about “anyone” asking such questions.  Bray and Kolata are both smart and thoughtful people who have devoted much of their lives to thinking about this problem. In other words, we’re actually all on the same “team” – we desperately want to help people lead more fulfilling, healthy lives by improving their eating habits.  But we disagree on this point.

It seems Dr. Bray and Ms. Kolata (and many others) have proposed (implicit in their statements) an interesting “Principle,” below:

If a disease is prevalent, no treatment exists to eradicate it. In other words, if any condition exists, it implies there is no cure for that condition.  The reverse (and logically equivalent) statement is this: if a treatment exists for a disease, no one has the disease.

Is this a valid criticism of carbohydrate restriction?  Perhaps, but to be sure let’s consider a few examples of this Principle.

  • Polio no longer exists in the United States, thanks to the development of two types of vaccines to immunize people against the poliovirus.
  • Smallpox, a viral disease estimated to have taken between 300 and 500 million human lives in total, no longer exists thanks to two vaccines that eradicated the disease in 1979.
  • Breast cancer still exists, and in 2011 claimed the lives of 40,000 women in the United States alone. While there are many treatments for breast cancer (surgery, radiation, chemotherapy, and combinations of these) depending on stage of disease, no cure exists to eradicate it once it is systemic (i.e., spread throughout the body), which is consistent with the Principle. [Remember “logic 101” tells us that if A implies B, no-B implies no-A.]

So far the Principle seems pretty compelling.  Of course, to be an all-singing-all-dancing-universal-truth, there cannot be any exceptions to this Principle.  Do any such exceptions exist?

  • HIV, when progressed to AIDS, is responsible for nearly 2 million annual deaths worldwide (about 16,000 deaths per year in the United States), yet transmission of the HIV virus – the causative agent – is entirely preventable.  Furthermore, the current drug regimen for HIV can prevent nearly all patients with HIV from progressing to AIDS, thereby rendering HIV a chronic disease.
  • Malaria, a disease transmitted by mosquitoes, is responsible for about 1 million deaths worldwide each year, yet this disease can be prevented successfully via two broad strategies: prophylactic treatment with anti-malarial agents (this is typically what folks do when traveling to regions where malaria is prevalent) and use of anti-mosquito “technology” (e.g., nets, DEET).  Furthermore, when a person, despite these measures, contracts malaria, prompt treatment with anti-malarial drugs will cure most.
  • Polio, which has been eradicated in the Western world, is still prevalent in south Asia despite a clear method of prevention.

For the purpose of space and time I’ll stop here with examples, but it turns out there are far more examples of the Principle being violated than being upheld.  In other words, the Principle isn’t actually a Principle.  It’s an idea that is true less often than it is false.  Sort of like the idea dogs and children should never be together (which I used to believe after many years of suturing up the faces of children who had been ravaged by dogs).  I now realize that most children around most dogs are perfectly safe, and adult supervision can make the odds even better.

What is the common theme in each of these examples that defy the Principle?

It’s probably a combination of factors, and they differ across the examples, too. Let me use HIV as an example of this phenomenon.  I did my residency in general surgery at the Johns Hopkins hospital in Baltimore, Maryland.  For those of you not familiar with Baltimore, some background is warranted.  In the final weeks of medical school I took the advice of a friend and read the book, The Corner, by David Simon and Ed Burns.  This riveting true story was the single most valuable book I could have read prior to moving from posh Palo Alto to inner city Baltimore.  Through this book, other books, and eventually my own personal experience, I came to realize how Baltimore had become the heroin capital of the United States.  Furthermore, because of where Hopkins is situated in the city, I would come to spend many years taking care of patients in the emergency room and hospital wards who battled heroin addiction.

As a result of such high rates of heroin addiction, the number of patients walking (or being carried into) the Hopkins ER was very high.  If I recall correctly, and these numbers do change over time, approximately 60% of patients walking (or being carried) into the Hopkins ER were positive for HIV, hepatitis B, and/or hepatitis C.  Each of these diseases is transmitted through blood or other bodily fluids.   Needle sharing and sexual transmission are far and away the most common modes of transmission in the United States today.

Preventing HIV, hepatitis C, and hepatitis B is pretty straight forward today.  If you have sex, especially with “high risk” individuals, do so with a condom.  If you use IV drugs, do not share needles.  One could even go a step further and not use IV drugs at all and not have sex with high-risk individuals (e.g., prostitutes).  [Hepatitis B, while 10x more transmissible than hepatitis C and 100x more transmissible than HIV is the only one of these three viruses for which there currently exists a vaccine.]  While there are other ways these three viruses can get transmitted, practically all (>99% as of 2007) are contracted through these two routes of transmission in the United States.

Furthermore, the treatment for HIV using a treatment regimen called HAART (Highly Active Anti-Retroviral Therapy) has become highly efficacious at preventing HIV from even progressing to AIDS.   In other words, if one contracts HIV today, it’s quite likely to prevent HIV from progressing to AIDS.

How can it be possible, you ask, that anyone can contract a disease that is so easily preventable? Furthermore, for those who have contracted the disease, how can so many go without treatments that would easily render their condition a chronic one – a condition that will not lead directly to their death — rather than a condition that will lead to their death?

Information, infrastructure, and pain

One could (and I’m sure several have already done so) write an entire dissertation on this exact topic.  At the risk of oversimplifying, though, let me briefly explain why I believe a disease that has a preventable cause and effect can still exist.  There are three broad reasons, though they are not all equally contributory nor are they constant for all people (i.e., the dominant reason for one person might be less relevant for another person).

Poor information

While it might be “obvious” to many of us, it’s actually not clear to everyone that a virus can cause a disease like AIDS.  Heck, most folks don’t actually know what a virus even is.  Furthermore, some people do not know how the virus is transmitted or how, exactly, to prevent this transmission.

In the United States today, the group of people who contract HIV primarily because of what I call “poor information” is probably quite low. But in Africa, for example, this probably plays a significant role in transmission.

Poor infrastructure

Even if one realizes how the HIV virus gets transmitted and what the consequences are (i.e., “poor information” is not an issue), another feature – poor infrastructure – can play a role in facilitating spread of the disease.  While condoms and clean needles can greatly reduce the transmission of HIV, accessing them is not always easy, especially if one is on a tight budget, as many folks addicted to heroin are.   And while programs exist to literally give away needles and condoms, not everyone can access them in a time of need.

Pain versus consequence

Why do people use HIV infected needles when they can find clean needles at a shelter?  Why do people have sex with prostitutes without using condoms, even though they can access condoms for free?  I don’t think there is one clear reason or explanation.  Some of it is social support and surroundings.  Some of it is prioritization.  Some of it is pain.  Perhaps the pain transiently ameliorated by heroin or sex is deeper than the long-term cost?

What have we learned?

  1. A disease can exist despite a means of prevention.
  2. A disease can exist despite an effective treatment.
  3. The barriers to prevention and treatment are likely multi-faceted and complex (and highly dependent on the disease).

While I’ve only used HIV (and by extension, hepatitis C and hepatitis B) to illustrate this point, I hope I’ve given you some idea how someone can still “get” a disease, while living in the United States circa 2012, despite all of the good information and infrastructure to prevent it.

As you undoubtedly know, the problem is far worse outside of the United States.  In many parts for the world the people being afflicted with HIV lack even the correct information, let alone a shred of infrastructure to combat the problem.

Back to the original question

How does obesity stack up?  Let’s evaluate using this framework.

Information

Unlike HIV which, at least in the United States, is appropriately understood, the study of nutrition and obesity is a relative debacle.  The formal recommendation of the USDA, AHA, AMA, ADA, and others actually tell us to eat the foods that make approximately two-thirds of us overweight.

Try asking your doctor for help, and you’re likely told to eat less food, eat less fat, eat more grains, and exercise more, stupid.

Infrastructure

Since approximately 1972, U.S. food policy has almost monotonically been shifting further and further towards all but making it impossible to avoid carbohydrates.  Countless books have been written about this topic from many levels from agricultural subsidies to the lobbying powers of those who sell sugar.

The results of these actions are particularly devastating on those individuals who are not affluent.  If you wonder why the economically disadvantaged are more likely to be obese, ponder this:  one can buy ten boxes of ramen noodles for one dollar at most grocery stores.  On a per calorie basis, few things are cheaper than sugar and other carbohydrates.

If you’re hungry in an airport or a mall (or virtually anywhere out of your own home), how easy is it to avoid sugars and simple carbohydrates?

Pain

Like Dr. Rob Lustig has said on many occasions, I don’t believe anyone chooses to be overweight.  I do believe most people who are overweight are so because of poor information and poor infrastructure.  However, these two features are not the only reason.  Many people still smoke cigarettes today in the United States, despite good information (i.e., everyone “knows” smoking is harmful) and good infrastructure (e.g., cigarettes are very expensive and most places don’t allow smoking – the default action is not to smoke).  There’s another reason people smoke.  Similarly, some people will always turn to the wrong foods.  I guess, for some, the acute pleasure food brings outweighs the chronic pain it causes, even when information about food is clear and unambiguous and when infrastructure does not essentially force people to eat the wrong foods.

I don’t know how much of a role this feature will play when the former two features are one day corrected, but I’m sure fixing the former two will go a long way to reversing the epidemic we find ourselves living and dying in.

Should we be surprised that 67% of Americans are overweight and that nearly 10% have diabetes?

We are outright told to eat the foods that make us fat via all formal and informal recommendations. We are surrounded by food infrastructure that makes our “default” eating patterns in line with those (flawed) recommendations. And for those of us who decide to go against the grain and overcome these two enormous hurdles, we are almost assuredly not supported.  In fact, we’re often condemned and ridiculed.

While I greatly respect Dr. Bray’s and Ms. Kolata’s commitment to fighting obesity, diabetes, and their associated chronic diseases, I reject their reasoning for why reducing carbohydrates is not one of the most effective treatments.

Photo by Markus Spiske on Unsplash

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331 Comments

  1. Author attempts proving hypothesis .. Similar to if NOT Smoking so effective in being Healthy and people still Smoke.. Not Smoking is Not a solution..
    – Not logical
    – Not helpful in evaluating benefits or drawbacks of No Carbs

    • Anya, I’m just reading through the comments on this site now and know it’s been a long time since you posted, so you’re unlikely to return to read my comment. However, it is most certainly “logical” that smoking causes lung cancer in very many people in a population. The hypothesis was never “not smoking keeps people healthy” because there are many determinants of health/disease; obviating any one factor cannot guarantee health. The evidence for cigarette smoking causing lung cancer is among the great success stories of modern health statistics.

      But I do agree that in order for smoking cessation campaigns to be successful in a social/legislative context in which companies are free to market compounds and products evidenced both to cause disease and to be addictive, we would have to address the reasons very many people start or continue smoking in the first place. Since Western culture places a premium on what it perceives to be personal freedom (an irony, given the way many of these drugs affect cognition and decision-making), our citizens and legislators (too often unduly influenced by corporate lobbyists) generally shift the burden of responsibility onto the shoulders of individuals, rather than the large, powerful organizations deciding what is marketed–and how–to the public. It’s a catch-22, and one we’re sadly unlikely to cure soon. However, none of this changes the fact that there is convergent, high-quality evidence that smoking is a very strong population risk factor for lung cancer.

  2. Thank you very much for this insightful article. It is nice to read about this topic in an academic view rather than the “my way is the best way” senario one often finds in articles relating to this subject on the web.
    Please keep up the good work.

  3. I’m not so sure those vaccines cured polio or smallpox. See, eg, the following:

    http://www.amazon.com/gp/product/1480216895/ref=oh_aui_search_detailpage?ie=UTF8&psc=1

    I know people believe this to be true, but the authors of the above book make an interesting argument that vaccines did not eliminate polio or smallpox. Are the authors correct? It’s hard to know.

    Anyway, after being on low carb for well over a year now, it can be difficult to eat this way. I just got back from vacation, and I had to eat some carbs (mainly bread on sandwiches), as there were no restaurants in the area that served anything else. Plus, everywhere you go, low fat permeates everything. Everyone believes in low fat. I ate low fat for many years and I find it’s easier to eat low fat than low carb. Mainly because no one believes in low carb. When I tell people I’m eating low carb, they flip out. In my office, there are two low carb converts including me; everyone else (10+ people) believe we’re killing ourselves. I think they’re taking best as to when we’re going to keel over with heart attacks. 😉

  4. I respect the author, but this post didn’t answer anything at all.

    I will speak from personal experience. To start weight loss, you can get the carbs down and it works very well. You can also do it by cutting calories. Eventually, if you go the low carb route, you will hit a wall and start to gain back weight. You have to get calories down. I have found humans don’t need very many calories. Many of us will pack on pounds just by overeating a small amount. You can learn a lot by watching the tv show Naked and Afraid. Although they try to scare us by saying how the people are going to die if they don’t eat, they never do. Most people can go a long time without food. Our bodies are not really consuming themselves until you are deeply into starvation. Even if you eat 500 calories a day, you will do ok for a few months. Eventually, your body gets used to not eating much. That is the state you want to be in. You can adjust your calories over time to suit your needs.

    One theory in calorie restriction is that humans stay alive because they are always looking for food. It gives them a will and desire to find food and live. So, to live the longest, we should never be full, remain a little hungry. It’s not easy, but the body gets used to it over time. We fail when we give in to societal norms such as being “foodies” and watching the Food Network all day. It takes discipline to stay thin, but thin is how humans function best. If you eat too much sugar or too much food, you’ll get inflammation, diabetes, cancer, heart disease. You can over-do it on fat, too, because you often will end up eating too many calories. The bottom line is keeping calories low and keeping muscle tone up. Muscles help burn calories, keep bones strong, and other biochemical things that keep us well.

    One thing I have found that helps keep focused is to find a hobby or something you like to do and do that instead of eating. We are eating too much and too often. We need to do a lot of intermittent fasting like our ancestors did. But, definitely calorie restriction is probably the healthiest way to eat. The more you raise your insulin, the more you wear out the pancreas’s ability to raise it when needed. Eventually you get diabetes. Just overeating can raise insulin. In fact, it seems that many people can eat carbs without worrying if they are eating calorie restricted. It is hard, so try to not keep a lot food around and try to keep your time occupied with activities other than eating.

  5. I started a low-carb diet (no less than 10 and no more than 40 a day) on January 3rd. I have what is called premature ovarian failure (diagnosed 10 years ago at the age of 36). Since being diagnosed, I went from 135 pounds to 160 pounds in a matter of 5 years (or less). Being 5’3″, you can only imagine how uncomfortable that can be (going from a loose size 8/10 to a size 12 that is quite snug…refused to go up any more). I know only 1% of the female population have this condition, and I wouldn’t wish it on my worst enemy because of the issues it causes (weight gain, infertility, and osteoporosis for me).

    I also started walking on my treadmill again for 30-35 minutes every other day as of about a week ago, along with light weights for my arms and doing stretching and crunches after I walk. Well, since January 3rd, I have lost a total of 9.8 pounds. Nothing else I have done ever worked in the past 5 years to lose weight, even exercise combined with eating less. Found that was what I was doing wrong…and eating the wrong things. I remember the days before my POF diagnosis where I could lose weight without really trying. It was quite depressing not being able to make that scale budge downward, until now.

    Truthfully, I do not miss bread, pasta, or the other high-carb foods that are a no-no now. Had my first bite of cauliflower today (first time ever in my life), and I actually really liked it (with cheese, of course). I’m not the big cook, but I do enjoy cooking when I have time. Well, this way of eating makes you have to cook a lot more. I don’t mind so much (my back and feet do, though), and I’m loving the foods. Can’t wait to be able to zip up my leather coat again (used to be loose on me, but now can’t even get either side of the zipper to come close to where I can zip it).

    I cannot wait to go back to my doctor in July and have her see the big difference in my weight. I know she will be as happy as me.

    • UPDATE: I lost a total of 30 pounds by the end of May, 2016. I have not felt this good in many, many years. I am now back into my size 8 jeans. I know that it would not hurt to lose a little more, due to my height and bone structure, but I am comfortable at this weight (131-135) pounds. I had actually started out at 165 pounds on January 3rd (per the digital scale…the dial/analog scale is always 5 pounds off for some reason). I went to see my doctor a few weeks ago, and she was so proud of me and told me to keep it up with the low-carb because it is obviously the only thing that will work for me. I have added in 100% whole wheat bread (Sarah Lee Delightful…13 net carbs per 2 slices), but only eat that maybe a couple of times a week. I only use real butter…none of that oil-based stuff that isn’t even close to being as good as butter. I have come to realize that I am carb sensitive because, any time I have more than 50 grams of carbs a day, I swell up like a balloon (water retention) and gain weight again…having to drastically cut carbs for a week to get back down to where I was and to get rid of the fluid buildup. Carbs are inflammatory, especially for me.

  6. I accidentally stumbled across this. It makes SO much sense. But also, even being informed, it’s really not informed enough. Don’t eat processed foods.. yes, of course, but I don’t think anybody taught us what a “carb” was in childhood. How do you know what naturally occurring foods are low carb? And then the whole structure of eating is changed. It is very difficult to try to re-wire your brain into thinking about a “meal” into something so different, especially in the South.

  7. Very interesting article I found on argument for using Ketogenic diets to treat diabetes.
    http://www.nutritionjrnl.com/article/S0899-9007(14)00332-3/pdf

    While focused on diabetes, several points confirm the scientific evidence that Ketogenic diets are healthy in general. Namely, that compared to low fat diets people lose more and keep the weight of longer from ketogenic diets, while most people just gain weight lost on low fat diet. Also the article discusses the complete lack of evidence that high fat diets are bad for your heart.

    Based on overwhelming evidence from studies nutritionist should be recommending Ketogenic diets for anyone with weight, blood sugar, neurological, inflammation, or cancer issues. Unfortunately, I doubt the government will ever drop their support for including large amounts of carbohydrates in your diet and continue their “eat more whole grains” mantra. The reason is simple — if people didn’t eat rice, wheat , and corn, large numbers of the population would starve. Carbohydrates are not the healthiest source of nutrition, but best way to feed lots of people–cheaply, and lots of people is exactly what we have in the world today. If people suddenly turned their noses down at carbs, It would be an economic disaster and they likely would be faced with starvation or eating carbs option because the price of butter and meat would sky rocket.

    Meanwhile, I eat my butter, meat, and veggies and try to explain the benefits to those who will listen. For others, Let them have their “healthy” grains, unless they want to educate themselves

  8. I am very much encouraged by your post. I just wanted to say that. I will keep fighting to lose the weight. I felt like you cared.

  9. Seems to me–no disrespect meant to this site’s author–that it’s obvious that diseases can and do exist despite effective treatments, and that the reasons for this may seem complex (economic factors, psychosocial factors…). However, the bottom line is that despite the ubiquitous claims of “cures” for obesity, even when these so-called cures acre relatively cheap and widely available (free information, low-cost processes…), obesity persists and its population morbidity rates globally are growing. The factors that facilitate obesity, we either do not want to or cannot circumvent. The “complexity” of the problem lies, at least in the West, in what it means, emotionally and cognitively, to be human, and how we deal with day-to-day stress. I think one of the reasons free, research-corroborated interventions fail for so many that these interventions haven’t turned obesity trends around is that the interventions cannot address root causes of behavior that precipitate obesity. It’s not enough to tell people what they must do. People’s deep needs have to be addressed so they are ABLE to engage curative interventions. And this, no one–no intervention–is effectively doing.

    Again, no disrespect meant to this site’s author or others for whom particular interventions happen to be working. I mean to speak only from a very broad populational perspective.

  10. Can someone explain my scenario? Whenever I eat low-carb high fat, I gain weight and “balloon” up. I thought it was coincidental so I tried it again multiple times but I noticed my weight goes up only on low-carb high fat diets. I, however, always get back in shape on the complete opposite (high-carb lowfat) which is why I switched to a vegetarian/vegan lifestyle. Over half of my diet comes from carbs. Another thing to add… On the low-carb high fat diet I was never full, even when over calorie maintenance of around 1700. I even ended up binging multiple times. But on the high-carb lowfat (current) diet/lifestyle, I feel full easily. I have trouble reaching 1200 calories, and my fiber is through the roof lol.

  11. I don’t disagree with a lot of this article, however, the main question in the title isn’t really valid. You could say the same about the traditional calorie controlled diet. “If counting calories works, why are people still over weight?” I don’t know many people who have actually tried low carb, despite me standing infront of them as living proof (lost 80+ lbs). They don’t like to give up their comfort foods, therefore its easier to count calories and just eat less but still have them, despite never losing weight (or putting it back on quickly). I think there’s actually only a small percentage of people who have tried low carb properly and stuck with it. People view most diets as temporary things, where as they really should view them as lifetime changes. I don’t miss bread, pasta or rice anymore. And I still have the odd potato without any problem. Most days I only eat dinner, other days I eat lunch and dinner but I never eat breakfast and I’m never hungry until the afternoon. My ratios of fat, protien and carbs are usually 70, 25, 5 respectively. 4 years on, 80+lbs down (lost in the first year mostly) my weight stays stable with little effort. I walk for an hour most days and play badminton weekly but thats all.

  12. I can answer the Question the headline poses, and also ask a better question.
    If low carb eating is so effective, why are people still overweight?
    People became overweight, not by eating low carb, but by eating all the carbs and whatever else they wanted, eating low carb is very effective at reversing obesity. Join any ketogenic group or forum, you will see normal obese people dropping pounds, making their blood pressure, blood tests, and lab work normal, all by reducing carbs. I’m one of them, so are my friends and family.
    The question is why is the food industry allowed to sell edible garbage, not worthy of being labeled food?
    Just like the tobacco industry, the food industry is knowingly responsible for preventable deaths.
    The American Heart Association has their name on sugar filled garbage, or carbage as we like to call it.
    I’ll trust a group of people with experiences, over any abbreviated biased organization, that can easily be persuaded by lobbyists.

  13. between dr Attia and dr Valter longo I am really confused, both seem to conduct lots of valid research, reaching similar results regarding ageing, inflammation markers , cancer and degenerative diseases, however, their approach is very different. low carb vs high crab high fibre diet of dr longo.
    the only thing they have in common beside results, is fasting.

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