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. Thank you. I look forward to reading each new blogpost. And I very much agree with your thinking and experience as stated in this one. AS a an RN of about 30 years, with the first 15 or so in ER/Critical Care and the last in Public Health/Public Health Mental Health, I have struggled with these questions and spent much of my professional life working at forging solid relationships with patients and forging longer term coaching relationships to assist people in making and persisting in real behavioral change in their lives. I’m happy to say that I’ve seen lots of amazing change along the way, in many lives, and of course, none in some as well.

    I am also a long term low-carb weight-loss *maintainer* success story myself, having weighed 240lbs at 5’6″ in 1999 and weighing 145-148 by 2002. As of Oct 2011 I reached a new goal of 130lbs and will now maintain there for life. Stress and bio-rhythm dysregulation was, imo, the #1 factor in my becoming overweight in my early 30’s, losing it and then becoming obese – morbidly obese in my mid 40’s, as well as being a member of the 30% club and having a genetic predispostion (I am an adoptee and was only recently able to establish the familial obesity history as fact)to obesity. Even without the genetic predispostion, I think that the effects of chronic stress and the physiological dysregulation that shift work effects needs to be addressed more and in more detail. I spent years overworking and working 12-16 hour 7P -7A shifts. In my maintenance years, I have only returned to shiftwork or being on 24 hour call twice, and those were the only timse when I had a significant regain of 16lbs over two years, despite continuing workouts and little change in eating. It was MUCH harder to control my appetite (chronic effects of too little sleep and poor quality sleep and effects on appetite of chronically elevated cortisol which causes real, increased HUNGER at increased intervals!) My profession, about 50% of which is significantly overweight/obese, is illustrative of what I have written here, due, in large part, imo to the high rate of shift work, chronic overtime and inherent stress combined in the profession.

    I would also like to see more emphasis, in time, on *maintenance.* As you are well aware, big loss weight maintainers make up a 1% club. Of all losers, perhaps 3-5% keep it off for 3 years or morem most regaining a at least a 3rd back by year one, and all back by a couple of years or less, with more added on. The subject of maintenance needs much more emphasis. One of the “big secrets” among us maintainers is that to maintain, little to NOTHING you have been doing to lose, can change. There is nothing magical about “arriving.” In many ways, the herculean task is only just beginning because of the myths that everyone, including physicians and nurses believe about weight loss, the number one being that you can go back to whatever “normal” eating meant to you prior to the loss and just eat “sensibly.” This is a big fat lie. And it is essential on the weight loss road to establish a very workable plan that is *enjoyable for life* in the realm of exercise as well. For the vast majority, thinking that it is going to work to set up a weight goal that requires 60-90min or more of intense exercise per day, is a recipe for disaster and injury, with inevitable weight gain while that foot or leg or back heals. And then, an escalating hill of injuries as you come to dread the prison you’ve erected for yourself to maintain what *may* be an unreasonable weight to begin with, or an insistence or adding more and more carbs back in because “the book” said that’s what you do in maintenance.

    OK, I won’t bend your ear any more. But suffice it to say, I appreciate your work. And I’ll be waiting in the wings in hope that you might address some of these issues which are real saboteurs for healthy weight loss maintenance and life! Thank you.

    • Thanks so much for sharing your journey. I think your story and your comments provide a remarkable juxtaposition to the previous comment. I hope this gives people something to think about and contrast. Thanks for the inspiration.

    • I relate to so much of your story! I’m in the 1% club too, and it’s been a journey of changes in exercise routines, eating, weight – meaning, I had to realize I wasn’t meant to be really slender. I still struggle with this, secretly wishing I’ll hit the right kinds of foods for myself that will enable me to be thinner – and healthy. If I cut back on food amounts too much, I’ll lose more weight, but will feel horrible, have no energy, etc. – and that I don’t want. Years ago I even maintained a too-low weight, and had zero energy every single day, until I finally let up a little, and accepted a somewhat higher weight. So, yes, there is an emotional component to all this, perhaps especially for women. We feel the absolute need to be SKINNY! It’s definitely a journey – and this blog is fantastic, and a huge help!

    • Mem,
      I too am an RN, who struggled with the same issues of circadian disruption, elevated cortisol, metabolic disturbances just as you did. I went from an 8 hr PM shift to a 12 hr night shift and gained 50 lbs in a matter of months. I ended up leaving that job since the toll on me was enormous, and culminated with me sitting in a empty room in CCU where I stuck my self on a monitor and watched scary PVCs scroll by. I was so totally stresses out by lack of sleep my heart conduction went haywire. I grabbed a passing cardiologist who sent me home with some ambien and orders to sleep. When I woke up 12 hrs later I turned my resignation.

      It took discovering the South Beach diet to turn my life around. Although not really low carb due to the tremendous amount of dairy, I got rid of the 50 lbs and then some. It stayed off with a quarterly phase one tuneup. Then I noticed that I felt better off all the carbs that phase two entailed, and I just stopped eating them, legumes, and dairy except grass fed butter, kefir, and heavy cream in my coffee. I woke up one morning and discovered I felt so good that I started crossfit at the age of 62. I now do diabetic education through a home health agency. Probably going to get fired for telling people to get rid of their bread, but I found my passion.

      I’m glad you shared your story. We all need to work to eliminate 12 shifts and to teach our fellow caregivers how to manage working bizarre hours. Some people can make the adaptation. You and I are in that category that cannot.

    • A graduate student and I have done an extensive meta-analysis on the effects of shift work on cardiovascular health. We found increases in myocardial infarction, stroke and coronary events which were fairly consistent across studies. The mechanism is likely as you suggested – circadian rhythm disruption, which drives cortisol over-exposure, which then drives overeating of carbohydrate-rich, convenient foods. Thus people get metabolic syndrome, type 2 diabetes, hypertension and acute and chronic vascular diseases. We now know that type 2 diabetes is actually a vascular disease more than anything else – it is also a disease of carbohydrate intolerance (perhaps the purest example we have; polycystic ovarian syndrome is another).

      For every 5 years that nurses perform rotating shift work, the risk of stroke goes up an additional 9%. Scary!

    • I am so grateful for these posts. I have struggled with my weight for years – increasing exercise, decreasing calories, logging my food.. only to see my weight climb. I have had 3 different doctors tell me I am ‘fat but fit.’ I guess that was supposed to make me feel good.

      About 8 months ago, I decided that all the mainstream information about weight loss didn’t apply to me & I must be different. I decided to take drastic steps & I started walking 20,000 steps per day (6-8 mile hiking, up major hills in any weather) logging my calories meticulously and the scale finally started to slowly go backwards. Unfortunately, I got sick twice and by February I had hit my highest weight ever…at 5’8” 215, I was shocked and terrified. I called to make an appointment with a lap-band surgeon when I ran into a friend (with a PhD. in Nuclear Chemistry from Berkley – he is no dummy). He was offering me a ride, but I said that I needed the steps to get healthy. He replied that walking was good for a lot of things, but if I was trying to lose weight, I should read “Why we get fat.”

      I felt so validated when I read that book. Finally, I realized that I can never eat sugar/carbs. NEVER. They are poison to me. I felt so relieved! I had tried for years to go low carb, but I thought it wasn’t healthy for the long haul….I can’t even imagine going back to that way of eating now.

      I weighed in at 185 today. I am eating like a queen, but still logging everything. I realized that I can eat protein, fat & low carb veggies to my fill, but I rarely eat over 1100 calories per day. When I finally accepted that the ‘calorie is a calorie theory’ is wrong, I have managed to get the weight off and feel better. I am comfortable with the knowledge that I will never go back to high carb/low fat eating, but I do feel like I am swimming up-stream.
      I wish there was a local support group or doctor who understands low carb lifestyle, but I am taking comfort from this blog.

      I thank all of you for sharing your experiences and expertise.

    • I would like to second Mem’s request for emphasis on maintenance. I’ve lost 25 kg over the last 3 years, by lowering my carb intake (and learning to enjoy exercise – who knew?), but the self-control war wages on. Some battles I win, some I lose. I would still like to lower my total body fat, even though my weight is now in the “normal” range. However, at this point, reducing carb intake any more seems like a daunting task, from the self-control perspective. I estimate that I consume between 150 and 300 grams of carbs daily, mainly complex. I also tend to wonder how much negative impact an animal-based diet has on the environment/eco-system, and if adhering to such a diet will not affect us negatively in the long run (from without, rather than from within).
      I recently started reading your site, after seeing your outstanding TEDMED presentation. You’re inspiring, yet in a way, difficult. I realize you have a love of numbers and facts, but I feel the need to point out that science is not the only way for you to help people “keep it off” (or just stay healthy). I think it would be extremely helpful to some of us if you wrote about the points you struggle with, and the way you deal with them (because in your presentation, you kind of let it slip that you’re human…). I hope this isn’t too personal a request.
      Thank you for doing what you’re doing.

    • Brian….we need to talk! I started your 3 Week Diet system exactly 21 days ago, and today when I stepped on the scales. I almost had a heart attack! I’ve lost a staggering 35 pounds (15 kilos) in that time. I didn’t even think that was humanely possible!

  2. Thank you, Peter, for this thoughtful post. You made a lot of excellent points here. Since it is hard to find good information from doctors, governmental agencies and the like and as you mentioned, support from friends and family tends to be non-existent, I get a lot of my information and support online.

    Lately, though, I am seeing a trend that I find very disheartening. Many bloggers that I formerly enjoyed following have decided that it is wrong to demonize carbs and are promoting the idea of adding them back into the diet. Not junk foods, but whole foods such as rice and potatoes. They report that they have lost weight, feel happier, sleep better. Most of the posters in the comments section applaud their decision and report that they, too, have lost weight and attained a sunnier disposition by eating more carbs. They often go beyond that to make derisive comments about low-carbing. It’s discouraging to read and neither informative nor supportive for me — I know adding in more starches will only cause my blood sugar and weight to go up — so I generally end up crossing that blog off my reading list. With so little support for low-carbing available anyway, it’s discouraging to lose these formerly good sources. Do you have any thoughts as to why so many people are changing their mind about the proper human diet? If carbs are the problem, how can so many people find good results through eating more of them?

    • Lori, I’ve seen this also, and all I can assume is that — perhaps — for some people, once they have “de-toxed” they can gradually add some carbs back. Would this work for everyone? I doubt it. Ultimately, of course, nothing matters for you more than what is best for YOU, not me, not other bloggers, not your family, not your friends, not your doctor. I’m 100% supportive of the idea that one should experiment to find what works best for them. My experiments led me to where I think I am at my aggregate best, but that might not produce the best results for you. Also, lost in this discussion is what one is optimizing for. Maybe it’s worth being a little less healthy if you can eat foods that give you more variety and pleasure? These are personal decisions. The one point I think worth stressing, though, is that for many people the slope is a slippery one. Once they re-introduce a bit, it becomes easier to add more. How much is too much? Depends on the person and on their goals.

    • I’ve seen this as well. The other thing is that some of the low carb sites are bashing Gary Taubes also. I don’t understand why, isn’t he promoting low carb which is what they advocate as well? Is there a point he/you bring up that is anathema to the “mainstream” low carb community?

      I just had a conversation with my brother about lc paleo etc; I think our whole family is going to go Low Carb btw!

      Great points in your post as well.

    • And don’t forget that bloggers, and the crowd that follows them, get bored with the same-old, same-old. Kurt Harris has just about stopped posting. Now potty-mouth Richard (Free the Animal) has indicated he’s about to change his tune too. And some of the others are just going around in circles – what’s left to say really? The change is usually from low-carb, to Paleo, to Primal, to “more hard core evolution” to “whatever we can think up next.” I say let’s stick to the science, what works for most of us, a life-plan and get on with it.

    • Lori,

      I agree totally with both you and Peter. Some of us cannot tolerate more than small amounts of carbs, and probably will never be able to do so.

    • Isn’t the “trend” to add back “complex” carbs limited to subset of bloggers who are using it for a very specific purpose related to weightlifting / strength training? The way I understand it, if you’re looking to bulk muscle and shred stubborn fat, loading up (moderately!) on carbs in a periodic “re-feed” after a period of low-to-no carb eating appears to be beneficial allegedly due to the interplay between insulin, ghrelin and leptin hormones. In other words they’re still trying to manipulate hormones and metabolism through diet but for a specific purpose not necessarily driven by maximizing weight loss.

      The amount of carb loading you can safely engage in seems to be proportionate to the amount of lean muscle you have, so a fat, soft weakling would be advised to use this as a finishing touch, not the cornerstone of a new diet. This too is not new as it is basically a cyclical ketogenic diet that has been around in the bodybuilding community for some time. I don’t know that adding carbs without the intense weight training precursor would do much for one other than fat mass gain but your mileage may vary.

      Peter, if you’re ever stuck for topic ideas, I’d love to hear an erudite and researched take on this “re-feed” strategy. I believe it is something Mark Sisson also recommended at one point as strategy for attacking stubborn fat loss, could be wrong.

      • I’d love to write it, but I would need to spend some time doing the research, including on myself. The self-experiment Mark Sisson and I have been discussing lately is fasting. I’m actually doing a 24 hour fast today as part of an experiment. I’d also like to talk with some of the other folks who know a lot about this, like Mike Eades, Robb Wolf, and others. I’m all about doing the self-experiments.

    • I know, Lori. It occurred to me the other day that the new crop of bloggers seems to be moving surely and not so slowly to the food pyramid. If they continue in their current direction, I wonder what will distinguish them, eventually, from the status-quo/party line/politically correct thinking already in place.

      Peter, thank you for this blog. It’s one I check every day.

    • I’ve recently done a couple self-experiments in fat-loading and fasting.

      Basically, I eat as much fat as possible in one meal (90%+), and see how long I’m sated for.

      The first time I ate until nausea, and wasn’t hungry again for over 2 days. The second time I just ate until sated, and didn’t feel like eating again for 28 hours.

      These weren’t fasting periods per se – as there was no willpower requirement on my part – I was just legitimately not in need of food for extended periods.

      Details here: http://www.reddit.com/r/keto/comments/rb1j4/fat_loading_and_fasting_self_experiments/

      I intend to do this once every week or two.

      • Ash, keep us posted on this experiment. I’m doing a variation of this myself, though for a different reason. Too soon to comment on exactly what I’m learning, but I find this idea very interesting.

    • Thank you Peter,
      I don’t intend to fast on many of my open water sailing trips but find that when on the ocean, water is the only sustenance I need now that I am ketoadapted. My most recent trip required 24 hours sailing while on a 44 ft boat in 35 kt winds and 10-15ft swells with a short handed crew due to sea sickness (brought on by food consumption). One had taken prophylactic meds and the other had not. The others that ate food, simple carbs in particular, suffered also some form of indigestion. I was able to maintain my strength and focus for the entire time with only water.

      So perhaps a blog topic not related to physical performance:
      Does the ketoadapted state offer a mental performance advantage?

      [Literature on MCT supplementation (especially triglycerides of caprylic acid) suggests improved cognitive function (in a mentally compromised population). Reference available.]

    • Once your weight is where you need it to be, why not add 1/2 cup of quinoa, rice or whatever once in awhile ( while dining out for example). If you start gaining weight dont do it anymore. Everyones different.)

  3. I think changing the food & fat paradigm is like turning around a super tanker. It’s going to take a long time. The embedded dogma is deeply engrained. I know carbs are bad for me and I’m working hard to permanently change my lifestyle to avoid them. The hardest part of low carb is the temptation of wanting to eat the carb’s you’ve known and loved for so long. I find strength in reading your blog and others like it. I’ve read both of Gary’s books and have ordered some others to help educate myself. My HDL’s went from 40 to 45 when going to low carb. Everything that generally happens when going HFLC – happens for me – weight loss, better lipid profile. I’m also able to get off my blood pressure medicine after losing 20 lbs. I’ve lost 20 lbs in a little over 6 weeks and am continuing to lose. Ideally need to lose another 30 to get to where I want to be. On no other diet plan can you lose weight this rapidly and have your health improve. For the past month I haven’t even been able to work out due to foot surgery, so the weight loss is all diet. Thanks and keep up the good work.

  4. Something you said in your recent podcast really struck a chord with me. When you transitioned into VLC you were not low enough to get into ketosis and not high enough to fully satisfy glucose needs. I have been trying to play it safe and hit a carb intake range of between 60 – 80 grams per day. For the first time I am wondering if some of the struggles I am having are from eating in a ‘grey zone.’ I am sure I’m not alone in the approach I have decided to take. After listening to your podcast I decided to try nutritional ketosis again and to at least stick it out for 8 weeks. I am on day two and I can cope with the fatigue and the mild but nagging headache, but the insomnia that could be he a deal breaker.

    • For me this was absolutely a problem. When I got to be really low carb, but not low enough in combined carb+protein, I was MISERABLE! I was constantly in a state of about 0.2 to 0.3 mM of B-OHB, and that just wasn’t enough to fuel my brain (and I didn’t have enough carbs to do the job, either).

    • Peter,

      Do you think this was an issue just because of the duration of exercise you put in? So its either go full ketosis or go high carb? I know for me in marathon training and I run about 5-6 hours a week, and while generally very low-carb, I am not consistent enough to stay in ketosis, but I haven’t hit any problems with being in this limbo state. I feel great all the time.

    • I followed the Carbohydrate Addict’s diet for about a year and a half and it scared me off VLC for years! I’m sure I experienced the same thing, too many carbs/protein to enter ketosis fully, too few carbohydrates to supply enough energy (especially to my brain). I lost weight and my blood lipids were better, but the depression and anxiety just weren’t worth it. Now I’m VLC-HF and have never felt better physically, mentally, and emotionally.

    • I had the same experiences, I had the mild headache, the fatigue, etc for maybe 3-4 days. After that, the energy rush I was feeling was actually creating the insomnia, because I would lie in bed with my brain a buzz. After 5ish days, it all came together, but again it coincided (coincidence?) with me reanalyzing my diet, slightly lowering protein, dramatically raising my water intake, and increasing cream intake. The breakthrough to me was making a glass of 50% unsweetened almond milk, 50% heavy whipping cream, and drinking it as a meal replacement.

  5. Thanks Peter for focusing on this important question!

    This is the very reason why low carb diets only score marginally better than low fat or calorie restricted diets in RCT:s based on an “intention to treat” concept.

    It is hard to follow a low carb diet if all the media, your doctor/dietitian, your family, your workmates, friends and neighbors all the time bombard you with messages that this diet will kill you.

    And that is why I think a study on the altenative hypothesis should be conducted in Sweden rather than in the USA. Here we have a much greater acceptance for the LCHF-koncept (about 5 % of the population, a criticall mass adhering to it strictly and another 20 % somewhat adhering to it).

    And the HF-part of the LCHF concept is important here…trying to go low carb without increasing fat intake will almost ever fail.

    • That’s a great idea. I think we will probably start here, for the purposes of logistics, but ultimately these questions should be tested in other countries, on different genetics, also.

  6. Peter,

    Great article… again! Like other posters here, I am finding myself checking your blog every single day, multiple times per day. I know you only post once per week, but I am checking for new comments and make sure that I read every one.

    Praise the LARD! Or in my case, the Beef Dripping! 🙂

  7. With your blog posts, you demonstrate that you believe that the advice given out by the establishment is wrong.

    You mentioned HIV in this article a rew times.

    Have you read “Inventing The Aids Virus” by Peter Deusberg.

    Another example of where the establishment are wrong as to the causes of a disease.

    • I have not read it, but I’m familiar with the anti-HIV-causes-AIDS argument. Nobel laureate Kary Mullis is (or at least was) a proponent of this argument, and I’ve read lots of his stuff. I won’t pretend to be an expert, but the evidence I see for HIV not being the causative agent in AIDS is pretty low. Either way, it’s not really the point of this post, so I’d prefer not to dwell on this point.

    • Thank you for bringing up Duesberg. Ever since 1992, I have read news stories about him. There are a lot of politics in AIDS science. It is very interesting. I’m not sure if there ever is one single story of a disease. Even flu shots are controversial.

  8. I have been following blogs about Low carb for just over two years.

    Once thing I keep seeing is peoples reported improvement in triglyceride levels.

    If someone was to follow a low carb diet (<30 gm pd) what reasons might there be for not achieving the anticipated improvement.

    • Hmmm. Good question. Reduction in circulating TG is one of the first and most pronounced changes in removing carbs. Hard for me to “diagnose” like this but I agree, this is unusual.

    • While reducing bodyfat on LC, trigs may go up temporarily, as FA’s are released from their cells. Should drop as you approach a healthy bf% (10-15% men, 15-20% women).

  9. Peter,

    Great Blog(s). A difficult topic to discuss – very well done. Keep up the excellent work.

    Mark

    • Thanks very much. The reason I was a day “late” on this one is that I couldn’t quite write it down the way it sounded in my head. I hope it still came across ok.

  10. Thank you for the posts. I wish I had a link to an article I read about AIDS. (new Yorker I think), it seems relevant. According to this article:

    Aids cases in different countries in Africa went up as life expectancy went down. And vise versa. The hypothesis being that if you think you are going to die young anyways, why bother. I definitely know people who think they will get fatter and be fat for the rest of their lives – why bother. So many reasons why people don’t act in their best interest.
    Thanks.

  11. I’ve been reading “Switch: How to Change Things When Change is Hard,” by Chip and Dan Heath (one of the most useful books I’ve read in the past 20 years), and one of their key messages is that “knowledge doesn’t change behavior.” They back it up with plenty of evidence, but more precisely it’s “knowledge ALONE doesn’t change behavior.” Changing behavior requires first appealing to the emotions in order to give us the momentum and power to change. Knowledge is used to steer that change in the right direction. Another key point they make is that you have to shrink the change by breaking it down into small enough parts so that it no longer seems overwhelming.

    The relevant point here is that teaching people why they gain weight and how they can lose it is only half, or even one-third of the solution. The bigger issue is how to motivate them to change and to sustain that momentum and motivation over time. The Heath brothers point to the need to “script the critical moves,” which means identifying the times of weakness when people tend to lose motivation and slip back into old patterns, and focus on techniques to get people past those hurdles.

    All the knowledge in the world isn’t going to help people to change their behavior. Change is a complex process and we’re resistant to it. Chip and Dan Heath spent years studying successful examples of change to figure out the keys to their success; I highly recommend reading this book if you’re interested in changing your own behavior, making changes in your workplace, or making larger changes in the world.

    • I read it, too. Great you put it on your reading list, Peter. You will like it and maybe improve the way you deliver your/our message.

    • Try Made to Stick by the same authors about marketing. Sounds funny but i think the blog is about marketing health. easy read and some great tips. I work in IT and it has been invaluable in getting my points across in an easy way for other to understand.

    • I, too, ordered the book on your recommendation.I’ve already gained some useful insights in an hour of reading – though I wanted to scream when they talked about the successful effort in W Va to get people to switch to 2% milk from whole by telling them a glass of whole milk contained as much saturated fat as 5 slices of bacon!

      You just can’t get away from this stuff!

    • Switch is a good book, and I do recommend reading it, especially because of all the concrete examples it gives on enacting change, and simple methodology. However, when it comes to the science of willpower it will teach you very little.

      For that I recommend “Willpower: Rediscovering the Greatest Human Strength” by Roy Baumeister and John Tierney. There you actually get some of the science of willpower as well as overviews of some of the popular techniques of personal change. The one topic that I saw brought up in the book that virtually no low carb blogger has picked up on is the role of glucose in willpower. Maybe Peter would have the time to take a stab at it one day.

    • Brad – thank you for the recommendation. I loved “Switch”, and it helps explain why the most popular post on this blog is Peter’s “What I Actually Eat”. People who are trying to implement a LCHF “Switch” need to get crystal clear on what to actually do, thinking in terms of specific behaviors they will change, like salad for lunch, and eggs for breakfast. What Peter actually eats is a call to action, to eat fat shakes and hard cheeses, coffee ice cream and coconut oil – all so we can be lean and healthly like Peter. Mark Sisson’s video on the 2 minute salad is in this same vein – exactly the kind of information most helpful. See http://vimeo.com/1425810.

      I think most of us are sold on the “why”, given how compelling the science is (thank you Gary). What we need to get all of this from the TBU category (true, but useless) to the “this changed my life” category is Chip and Dan Heath’s excellent counsel to “shrink the change”, “build habits” (purchasing and eating), “tweak the environment”, etc. etc.

  12. I’ve been a type 1 diabetic for over forty years, and switching to a low-carbohydrate diet has reduced my need for insulin, provided better control, and stopped a slow but seemingly inexorable weight gain — yet I’m still about sixty pounds overweight and can’t seem to stay under 250 pounds for long. I can’t see myself returning to an ADA style diet, and I now seem tolerant of fasting and hope to be able to eat less without hunger. I have yet to meet a doctor who approves of what I’m doing. There seem to be no resources whatever, on or off line, for the obese type 1. Low-carb has been great help but hasn’t been a magic bullet for me; I hope that I’ll be able to keep eating less and perhaps lose weight that way.

    • Mark, I can only imagine how frustrating this is for you, on so many levels. I wish I knew the answers to these questions. I’m sure there are things you could do to lose at least a portion of the extra weight, and hopefully this blog gives you some ideas, but I can’t be sure you can be completely lean. As far as your doctor goes, though, I wonder if it’s worth finding a doctor who supports you? I feel this is an important relationship and one that needs to be supportive, rather than judgmental.

  13. The argument made by Bray and Kolata is hard to take seriously. The more interesting question is why some, perhaps many, people who radically restrict carbohydrates remain overweight, either plateauing or even partially regaining. Of course Jimmy Moore is the most well known example, and he is trying to figure it out for himself, but one hears these stories fairly often.

    I know Gary has said that low carb allows one to become as lean as one can be, not necessarily truly lean for everyone. I wonder how you would answer this question, or if answers even really exist at this point.

    • This is something I have also wondered. But more important to my mind is what percentage of people experience this. After the question of how effective carb restriction is for weight loss, I would like to see a good study of how effective a reduced carb diet is at sustaining it. Fingers crossed that NuSI will get the ball rolling on some good studies to answer this sort of question

  14. Thanks again for such a great post.I live in the UK where we are also bombarded with messages of low fat and high carb (albeit whole grains) diet solutions. However I recently found a solution to my own weight problems and embarked on a ketogenic diet which helped me to lose 42 pounds in 16 weeks. While the diet involves the use of pre-packaged foods, it also ensures that you receive counselling to deal with your food issues. I have found this combination especially useful.
    So, here I am at my goal weight and about to start the process of reintroducing “normal” food. This is taken at a very slow pace building up carb grams until you reach a plateau. At the end of this process I will discover to what extent I can consume carbs. I suspect that the level will be low for me.
    I agree with the above post, that the journey is really only just beginning once the weight has been lost. But I now recognise the failings of the food available to me.
    Despite reading Gary Taubes and others prior to losing the weight – I also needed the extra support I get in my weight loss group. Doing it alone was too hard.
    I suppose I fell into the third of your groups. I knew the science and the solution – but I lacked the right willpower, support and motivation to push past the emotional connections I had with some foods.
    I suspect that a lack of information is the least of our worries.The main focus should certainly be on offering support to follow through on that advice. After all, people still smoke despite knowing the dangers – as you quite rightly point out.
    Oh, by the way, I am a vegetarian and fully expect to be able to stick to a low carb diet. It really is possible with the addition of eggs and dairy. A post on vegetarians and low carbing would a great addition to your blog. There are plenty of us who believe in low carb diets despite our other ethical beliefs.
    Well done on your blog. You work very hard!

    • Megan, congratulations on your progress. I agree that a vegetarian can (quite easily) adopt low-carb eating principles, especially if they are able to eat dairy and fish. Here is my BIG warning: When you “reintroduce normal food” I get a bit worried. If you mean, “stop ordering my food and make it myself…,” great. If you mean, “start eating what I used to…,” not fine. If you return to your old eating habits you will, almost certainly, return to your old health.

    • I agree that eggs and dairy are a great way for vegetarians to eat a low carb, moderate protein and high fat diet and it is not boring.

    • This is ti Peter Attia. Vegetarians DO NOT EAT FISH!! So as a vegetarian, I could not incorporate fish into my diet. Pescetarians eat fish but not meat. 🙂

  15. This is so disappointing. Dr. Bray and Ms. Kolata are actually arguing, what I consider, a silly point? “Why isn’t everyone thin if the solution is low-carb?” Do I understand their basic argument correctly? Doesn’t that imply that *everyone* has tried (and stayed) low-carb? The answer is ‘no’. Most people, in my experience, have not and have no intention to do so because “it’s a fad” and “it’s not healthy” and “my doctor told me…”
    It’s understandable in a way. Look at the “hit job” the mainstream medical community did to Dr. Atkins (and even continued to do so after his death).
    So this is the logic of these “informed” people of science?
    God help us.

    • I wish someone would ask Bray and Kolata, “If ‘eat less and exercise more’ is the solution to obesity why is everyone still fat?” After all, that’s a message that everyone has heard and that (sadly) most people accept, and that many, many people have tried. By their own logic –

      “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.”

      – their advice (eat less and exercise more) fails miserably as a treatment for obesity.

  16. You didn’t answer your own question, though. There are many people who remain overweight while in ketosis, just look at Jimmy Moore. In Gary Taubes “Good Calories/Bad Calories” he states that it may be impossible for someone to remain fat while in Ketosis, but that doesn’t seem to be true.
    In anecdotal evidence, I did lose weight on a low carb diet. In fact, I lost 130lbs.
    http://www.marksdailyapple.com/how-i-lost-130-pounds-and-fell-in-love-with-bacon/
    Recently though, while trying to increase my exercise loads, I’ve felt tired and getting crap results. I raised my carb intake to 150 grams of carbs eating “primal/safe” starches, lowered my fat intake, and I’ve lost more weight and look better naked. I can’t understand how this works if the insulin hypothesis is correct.
    Also, you bring up that you eat dairy, but dairy raises your insulin level quite a bit.
    http://www.marksdailyapple.com/dairy-insulin/
    How does this suite the insulin hypothesis, if a raise in insulin causes weight gain?

    BTW, I’m not asking these questions while assuming I know the answer. I’m genuinely curious

    • I addressed your first question in a different response. Basically, just like hair (color, thickness, etc.), profound differences exist in body type and body response. Many people — but not all — do “best” on a diet that removes most carbohydrates. By “best” I mean, body composition and disease risk profile. But this is not true for everyone. If I knew exactly why, I would certainly share it. My frustration with the debate around this point (not your question, of course) is that the discussions around diet and nutrition look/sound/smell a lot like the discussions around religion and politics. It’s “all-or-none” with no effort to nuance and try to understand individual variation.
      A great example of this is your second question about diary. For some, yes, dairy kicks off a horrible cascade of inflammation and insulin secretion. For others, it does not. Even within dairy, there is a huge difference. For example, milk versus cream. Hard cheese versus soft cheese.
      I like what you’ve done — you’ve take control of what works best for you and you’ve been willing to modify and improvise. Keep it up!

    • I think I can shed some light on Jimmy Moore–at one time he maintained a blog containing his menus, which he discontinued last year because, in his words, “When I started this menus blog, the purpose was to show what the diet of a real low-carb dieter looks like on a daily basis. Now after three years of doing this diligently, it’s time to shut it down and spend time doing other aspects of the work I do with ‘Livin’ La Vida Low-Carb’.” Uh, no–the reason was because he ate crap and he HATED people calling him on it, which happened pretty frequently. The menus blog is still up but if you read his blogs these days they pretty much only deal with his upcoming podcasts. But since a lot of people listen to his podcasts and a lot of people want to promote their own sites (including Peter) and everyone’s like “oh, Jimmy’s such a nice guy” the fact that this guy is FAILING at “livin’ la vida low-carb” is ignored. Just as there are vegetarians who lord their “healthy” lifestyles while subsisting on tortilla chips, salsa and Morningstar Farms soy burgers, there are many like Jimmy who lord their “healthy” lifestyles while subisting on processed cheese, spaghetti squash and Atkins bars. I see now that he’s doing “Paleo” and has admitted to gaining weight. Like any addict–and I include myself in that description–he knows what to do. He just doesn’t want to do it.

  17. Another thing that is important to keep in mind is a recognition of where people are coming from i.e. what is the baseline we’re comparing against. It may never be possible for the person who was 350 lbs to be “thin” by mainstream standards. Sometimes I see mocking comments at the bottom of blogs like yours and Gary’s by people who say things like, oh so if low carb is so wonderful, how come Jimmy Moore is still fat? Even Gary was once asked by a commenter what his weight and height and waist size were, with the implication that he still looked pretty “big.” Personally I’ve lost 60 lbs and gone from a size 16 to a size 6, yet I still wouldn’t say that I was skinny by mainstream standards, and it has become harder and harder to lose weight. I wonder if this is my low-carb setpoint and what determines that, since it seems clear we can’t lose weight forever. I think part of the reason it’s so hard for low-carb to get traction in the world is that the only people who people are willing to listen to when it comes to weight problems are those who’ve never had weight problems themselves — who are ironically probably the ones for whom carbs do the least harm and for whom a low carb eating plan would probably yield the least benefit.

    • The problem with comments like this is that they assume (erroneously) that humans are a homogenous population. Obviously, this is not even remotely true. The questions should NOT be, “Why is so-and-so still overweight if he’s eating a low-carb diet?” The question SHOULD be, “Which diet will help so-and-so be the most healthy he can be (even if that’s not remarkably lean and healthy on an absolute level)?”

    • I think there are 2 reasons the low-carb way of life is relatively unpopular: 1) the media demonizes it and 2) Carbs are addicting and delicious, and most people just do not want to give them up. Admitting the truth about carbs and health is just too tough for people to do, AND STILL continue to eat carbs, so – denial happens. I can understand it.

    • A recent article in the Cleveland Plain Dearler (Dec 18, 2012) about a CWRU professor who disputes claims that there is an obesity epidemic raised some interesting observations that may have some relevance here. One is that the BMI tables have been revised to the point where currently healthy people fit into the overweight obese category even though they are healthy, fit and lean. He pointed out that Brad Pitt would fit into the category of overweight. Too much reliance on these tables makes everyone a little bit crazy about whether they are fat or lean. For myself I am signifcantly overweight with health problems. That can easily be seen by anyone. But I have looked at other people who are active, look good by any standards and the BMI tables rate them as overweight. They are healthy with good cardiovascular health, liver health and brain health. If they are overweight by these tables should they diet to try and get leaner. I don’t think so.
      In the Art and Science of Carbohydrate Living, the authors discuss the issue of diet and diabetes. I’m going on memory here so I hope I’m getting this right. They say that diet may help the diabetic condition but the individual may still be overweight. Further tweaking may allow the person to get leaner. This is where the need for low carb nutritionists are needed. (I haven’t found any in my area) It takes a good eye to see what needs tweaking and it is different for everyone. The thing is they caution that once health or weight loss occurs, the carb intolerant cannot go back to eating carbs like they did before. Restricting carbs is a lifelong endeavor not a temporary one.

      If the blood work is good and you are healthier then you want to stay that way. Going back to old patterns would undo all the good. The bug is that the weight may or may not go down and that is dependent on so many things besides insulin resistance that it becames easier to give up because weight is tangible, ie you can see it. Good health isn’t so tangible so it becomes easier to focus on weight loss rather than good health as a goal. Society puts enormous pressure to look thin. The never too rich or too thin syndrome.

      I know the pressure as I deal with it almost every hour of every day and I’m exhausted by it. Yet what I have been doing has lowered my blood pressure, sugar levels and raised HDL so why don’t I focus on that instead of focusing on I only lost twenty five pounds in the last few months. (Maybe because I have a lot more to lose before I look good 🙂 ) Frm what I’ve read above there are people who ought to be high fiveing themselves for doing so well. But I know the demon of weight and how hard it is to shake it.

      Peter, as always a great post. I read these studies with a much more critical eye now. I just wish people who write stuff in magazines like Prevention and Health did a better job in understanding what is good science and what is questionnable.

      • Donna, this is very important point, which I won’t do justice in my response. Short answer: obesity is actually the wrong target. MetSyn is what we should be worrying about. Obesity is a descent, but far from perfect, proxy.

  18. Thanks for this post Peter. I am going to be presenting on “Weight Loss” at the Weston Price Conference this November and just the chore of thinking of the title for the talk, I am stumbling over the paradox that while the instructions, the information, the rules to follow may be simple, the compliance with those rules is actually quite difficult for many people.

    I loved switching to more meat and more fat, with a little backwards look at bread and a regular lapse with a beer, but I know others who actually have a very difficult time (taste, energy, digestion) making the switch even moderately so. A large factor I believe is remnant fat phobia — it’s hard to digest a heavy protein program, much easier if you eat fat — as well as out-of-shape biliary function. Some folks have just grown up eating veggies and brown rice and lots of fruit and between their nostalgia, accustomed tastes and downright disbelief, weight loss is very challenging for those folks because the dietary switch is difficult.

    • I have a farmer friend who has observed that the feed an animal is raised on, will be highly favoured by it forever. I have to wonder if this applies to humans also – the taste of home might forever be something sugary and carb filled for some. With most mammals, the maternal caregiver teaches the youngster what foods to eat; it then avoids these at its peril in most scenarios in nature.

    • This is a very interesting point about favoring the food we are raised on. I know I love my mother’s cooking more than anybody else on the planet. When I visit it is impossible to remain VLC while I’m there, and I don’t even try anymore. So I gain 10 lbs in less than two weeks…

  19. Excellent and articulate post! Thank you for your effort and insight, which is so desperately needed. In my work, as a worksite wellness consultant, I see one additional missing piece. While bad information is certainly all encompassing and pervasive in the US, I believe individuals lack the “skills” to accommodate any new or relevant information. The low-fat diet has become the default system and in order to change that, new skills must be developed. It’s much like learning a new language. A gradual process of words, then sentence structure, followed by grammar and eventually comprehension. It takes time and as we know our society expects immediate results, with little critical thinking. Individuals need assistance now in how to build skills around, shopping, meal planning, cooking and actually the “how to” not the “what” of the low carb life. It is challenging, because they also have to have the will, like you, to go against the grain.

    • Great point! You’re absolutely right. A subset of the “bad information” problem is that most people don’t have the training to think critically about how to assimilate information overload.

    • I would add that people (I’m thinking diabetics specifically) don’t have the tools, either, to help them learn at an early stage. If your doctor gives you a pat on the head, says watch your diet and exercise it’s not sufficient. Once I bought my own glucose meter and a nice big supply of strips and started experimenting, it became very clear which foods were bad for me. I suspect that many obese people might also benefit from seeing what foods actually do to them. I’ve been low carbing for 5 years. It brought my blood sugar down to normal range and keeps it there. I haven’t lost weight on this diet since the first year, but I know if I started adding carbs I’d lose my blood sugar control and gain weight quickly. I wish meters and strips were more accessible for everyone.

    • Jan, it’s even worse than a pat on the head for diabetics. The codified instruction they receive from their diabetes educators in hospital diabetes self-management programs involves a dietary protocol of high carbs (certainly much higher than anything we consider low carb, and managing the effects of that with medications), calories in – calories out mentality, and an absolute assumption that their diabetes will progress to reliance on insulin. These *are* the tools that are given to diabetics. It’s crazy, and diabetes educators are at high risk of losing their jobs if they diverge from the protocol in any way.

      On better accessibility of meters and strips, Walmart brand of Reli-On meters and strips is quite reasonable. Strips cost less than half of most others, and sometimes they just give the meters away. I’ve checked their accuracy against my other meters and they’re the same. I was led to them by a doc who posted on a blog, maybe Dr. Eades’ blog, that he’s found them valid.

      I’ve been on the fence in the last few months, tho, if BG is really a valuable number, especially for prevention. It seems a whole host of things go wrong (insulin resistance, for example) before glucose starts to go up. I know some docs, like Dr. Bernstein and Dr. Davis (Wheat Belly) rely on BG, but I think it’s often too hard to tell what exactly is causing any particular BG reading at any particular time. I also know that the medication protocol that diabetics use is a direct gram carb for unit of meds relationship, but I don’t buy it because of the variations I see. I also have to try and evaluate BG in complicated scenarios where a lot of variables are at play – people who are on meds including insulin who see me in a post-prandial state usually, of who knows what kind of mixed meal. I always have them do a pre and post exercise BG, but it’s mostly to make sure they’re not hypo and also to condition them on the extremely positive benefit of exercise if their numbers are high (exercise is always good for a drop of 100 points if blood sugar is high, but by that, I mean diabetic high). But I don’t see any direct relationship usually between a particular meal and a particular BG, which is how the diabetic is trained in their medication literature, and also how many non-diabetics use blood sugar readings to track their reactions to certain foods. I’m not making the claim that self-monitoring of blood glucose is not effective for non-diabetics, I’m just saying that based on the diabetic readings I see, I’m unable to determine any efficacy in looking at a meal and a reading.

      I’m pretty much of the belief now that as long as a person’s insulin resistance isn’t too bad yet, the insulin concentration will rise high enough to keep the blood sugar pretty normal, so post-prandial blood sugars will look pretty normal in someone who’s not already diabetic no matter what. Peter’s situation with his OGTT is an example of this. I’d love to hear details about what you found regarding specific foods (or meals) and specific variations in your blood sugar to let you know which foods weren’t working for you. And I’m always looking for information to challenge any conclusions that I’m on the way of drawing, so your input would be helpful to me.

  20. Great stuff, as usual. I am one of these folks you refer to that needs to find a happy medium with carbs. I originally dropped from 215 to 155 (at 5’10”) using a strict CRON (caloric restriction) type approach. The weight loss was easy and my hyper-obsessive personality make the calorie counting, etc. fun in a perverse sort of way. However, I could never understand why I would then GAIN weight so easily if I spent a few days eating 1700 calories instead of my typical 1500. I am pretty active, so there should have been plenty of calorie burning going on. After reading Lustig, Taubes, yourself, and then a bunch of stuff from the Paleo community, I quickly realized that my CRON diet was so high in carbs (even if they were usually not highly processed), that I must have been in a major storage mode when my insulin levels went up. Now I have the opposite problem. I am eating high protein, low processed carb, no sugar (somewhat paleo in my approach, so I eat plenty of whole fruits and veggies) and I cannot stop losing weight! I am down to 153 without caring about calorie counting – that is too light for me, so I gotta add some more carbs back in, I think. As a PhD chemist, I am all about doing good experiments, and like you, I don’t mind doing them on myself. However, it is turning out to be way harder to find my metabolic happy place than I thought!

    Anyway, thanks for dropping knowledge on us – I look forward to the next post.

    • You sound like the ideal candidate for the rice and potatoes modification that the paleo sphere is doing recently.

      Just avoid wheat (and sugar of course) like the plague.

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