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.


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.


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?


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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  1. what is a good carb counter app. where you enter the food, the amt and it gives you carbs in grams. I don’t need a fancy graphic, just a reliable database

  2. Peter, I am glad to read that you’re starting to experiment with fasting. I have found this to be one of my single best tools for health. I assume you know quite bit about autophagy at this point, being mediated by B-OHB and all. This also seems to be a key cellular defense against microbes, and I find that a 2-3 day fast can cure most infections if I start as soon as I notice symptoms.

    Once I got keto-adapted, I found that my energy levels increased into 3 days of fasting, dipped in 4-5 days, and then leveled out indefinitely. Exercising within my aerobic capacity was effortless even long into a fast, and given the adaptation I could even hike uphill at a reasonable pace this way. This is also a great way to keep emptying the glycogen tank, to soak up much more glucose than I could with a constant stream of (even low carb) food. I particularly like to begin a fast with sprint intervals, to deplete liver glycogen quickly and get deeper into ketosis, plus maximally ramp up HGH production.

    I’ve collected a handful of citations over the years if you’re curious and haven’t already read them. Keep up the great work! 🙂

  3. I find it interesting that many of the low carb doctors and book sellers are over weight while many of the top plant based doctors and promoters, high complex carbs, are thin and fit. Atkins died from a heart attack 60 pounds overweight on a low carb diet. Here’s a 2 minute YouTube video showing pictures of some of the top promoters of each diet.

    When we look at some of the healthiest cultures in the history they ate high complex carb diets, not low carb diets. And is a persons diet all about losing weight or is it about being healthy? How does the low carb diet stack up against Americans top disease, heart disease, versus a high carb diet such as Bill Clintons diet where he is having great success treating his heart disease just as thousands of others have been doing for years. Some high carb doctors have decades of research and working with patients to prove you can prevent and reverse heart disease with a high complex carb plant based diet. Dr Caldwell Esselstyn is one of the leaders in this research and one of the Drs. Bill Clinton relies on for his diet advice. If low carb was the best diet Bill Clinton would be on it. If there was a drug or procedure to avoid changing his diet to allow him to continue eating meat and dairy BIll Clinton would have done it, afterall he has access to the BEST healthcare in the world, better than any of us could ever hope for.

    When you look at the pictures of the diet promoters and you do your own research you just might find that Bill Clinton has found the answer to the healthiest diet and it’s not low carb.

    • David, I’m sure you’re a smart guy, but comments like this — strange ad hominem attacks — certainly wouldn’t lead anyone to conclude you’re a bright guy. Atkins died of a heart attack 60 pound overweight? At least get your facts right. That is patently false. Not “a bit misinterpreted,” no, categorically false. Of course, even if it were true, would it nullify the science behind the approach? Does the fact that me and a hundred other low carb doctors are thin validate low carb? Of course not. This is such an overly simplistic argument, I’m almost embarrassed for you bringing it up.
      Of course, you may want to ask *why* Bill Clinton is healthier today than he was 10 years ago. List out every change he made in his diet. Start with the elimination of sugar, flour, simple carbs. Sure, he’s eliminated most meat, too. But how do you know which of these changes is the driver of his new found health?
      This is why we rely on things called “clinical trials” not stories of people who are thin or fat or healthy or sick. Stop focusing on what’s irrelevant and get your head into the literature if you are at all serious about this topic.

    • Hi David –

      That’s exactly what I thought about a year and a half ago – Bill Clinton’s a really smart guy, cares a lot about his health, and will get the best advice available. So I spent a few days figuring out what he’s doing, and decided I would revert to a no grain, low-ish carb, low fat vegan diet to lose weight and reduce my risk of cardiovascular disease. While I was adapting to this new diet (which was not exactly new to me because I had been a vegetarian for almost a decade and had tried a low-carb, no fat vegan diet (very hard to maintain due to the level of effort necessary to feed oneself)), I continued to research and came across the blog and youtube posts by Dr. Greg Ellis ( His posts completely changed the direction I was going in and I’ve been LCHF since then, have lost 50 pounds, have improved functioning in all aspects of my life, and have confounded my cardiologist, who can’t argue with my results, although we’ve had our differences.

      Now I do suggest that you go to Dr. Greg Ellis’s website and take a look at what a moderate protein and fat diet has done for him. Compare how he looks to the China study doctors, and decide who you’d prefer to look like. Read his story. He’s a bit too much of a self-promoter for my taste, but his heart is in the right place. He’s done decades of independent research, read the studies, has an excellent and appropriate education to assimilate this information, and has come to the same conclusion as Dr. Attia.

      We’re all entitled to our own opinions and conclusions. Live and let live, I say. I’m LCHF forever, it’s changed my life in a positive way I never could have imagined possible.

  4. I am interested in what the leading low carb doctors and spokespersons look like, do they appear healthy? Many of them appear to be overweight. Anyone who sells diet books should be fair game.

    “Stop focusing on what’s irrelevant and get your head into the literature if you are at all serious about this topic.”
    Perhaps you can offer more literature from highly qualified 23 year old bloggers such as Denise Minger, a self described tutor, freelance writer, website designer who is neither a doctor, nurse, nutritionist or scientist to prove which diet is not best. Is this the type of relevant literature you are referring to? Do you consider Denise Minger to be a qualified professional? I’m sure you are smart, very smart, but referring Denise Minger’s rebuttal to decades of serious scientific research given her obvious lack of qualifications doesn’t exactly reflect well on you.

    You are seeking the truth, which is admirable, so I’m fairly confident you are open to posts which provide views in opposition of the low carb diet, which appears to be the predominant diet supported in this blog. If this is a low carb diet only blog please say the word and I won’t post again.

    • David, first of all, anyone is welcome to comment on this blog, regardless of views. So feel free to comment. However, if I may be so blunt, the reason I’m getting short with you is that we’ve already had this EXACT same discussion over a different post a few weeks ago. And I thought we came to a mutual agreement to “agree to disagree.” I explained how epidemiology is not a substitute for clinical trials and referred you to a series of posts (here’s one more, written by a *doctor* since you don’t think Denise is worthy of your time: [By the way, you’re criticism of Denise due to her “obvious lack of qualifications” is a bit disconcerting…it’s not like getting an M.D. or a Ph.D. guarantees someone is smart or critical thinking in nature, both of which Denise has in spades.]

      We then had a long back and forth about Bill Clinton. I won’t repeat it, as I hope you at least remember the point — I’ve now made it twice.

      Finally, out of nowhere come these bizarre ad hominem attacks on Robert Atkins (which, by the way, are 100% incorrect and suggest you’re not doing your homework very thoroughly) and overweight diet book authors. At this point, in my mind, you start to stray from a healthy (but confused) skeptic into the realm of heckler who is uninterested in anything other than wasting my time.

      My time is very valuable. I don’t tolerate people who I perceive to be deliberately wasting it. So consider this your final notification. If you comment again about the China Study, Denise Minger, Bill Clinton, Robert Atkins, or overweight people — don’t expect any response, just a swift “delete.”

      If you’re hear to learn, welcome aboard (even if you question me and remain skeptical). But if you’re here to bicker and snicker and waste my time, see you later. Go some place else. I can assure you others will be far less civil in their responses (check out AC if you’re looking for a verbal colonoscopy…not recommended).

    • David,
      Have you read Denise Minger’s critique of the China study and really thought about it? I think it would be great if you did that and then posted your thoughts about what she really has to say. Ad hominem attacks are considered a logical fallacy for a reason, because the important thing is what a person is saying and doing, not their age or how many degrees they have. The ability to think rationally is part of being human and it belongs to all of us. She thinks that the conclusions people are drawing from the China study are unwarranted by the data. If you disagree maybe you could show us where you think she’s mistaken instead of saying that she is too young to pay attention to. Lots of people with greater qualifications make big mistakes. If you read about Ignaz Semmelweis you can see that the professors of medicine of his time were making a big mistake in not believing that doctors needed to wash their hands in between patients. There’s no reason to think that the big names of our time are infallible either. It’s hard to try to see the world in a different way than you’e used to; I’m a healthcare provider and I spent years counseling patients to cut down on saturated fats, and I spent years as a vegetarian, and for me, reading Taubes’ book Good Calories, Bad Calories was fascinating but also horrifying because I had to think about how my well-meaning advice, all those years, had been bad. I doubted his conclusions at first but I read some (about a hundred) of the many studies he cites. Maybe you could print out Denise Minger’s critique and really think about it, and let us know. Because I would really be interested to hear what you think of her critique, but it’s kind of mean and irrational to just deride her because of her youth.

  5. Regarding my “ad hominem attacks” I was surprised by your response to my initial post on this page here given the blog page title is “If low carb eating is so effective, why are people still overweight?” I thought the Youtube video I had seen recently was on topic, perhaps I misunderstood the topic. Regarding a certain well known low carb doctor and his health, the information I provided I got directly from a doctor who says he knew the man for more than 10 years.

    Now if we can move on, why did I come to this blog? I wanted to gain useful information. I changed my diet just over 4 years ago because of the information I obtained on how it helps the body to fight disease, especially heart disease. Do you have any information on trials that indicate the low carb diet prevents or reverses heart disease?

    • There are many studies that have examined this question, the largest of which I review in detail in my presentation at UCSD (you can see this is the post “How did we come to believe saturated fat is bad”). To date, also studies that have specifically asked the question you’re asking have not been powered sufficiently to demonstrate hard outcomes (e.g., death, MI). So instead, we look at trials that compare biomarkers (e.g., CRP, apoB, TG, HDL-C). There are plenty of these, many of which I’ve reviewed in detail. Start with Part IX of my cholesterol series.

  6. I think a lot of people who find their way to low carb are those who are already seriously metabolically challenged, and who who have tried and failed so many times that they are willing to buck the “conventional wisdom” to try a diet that is far outside the mainstream. I hate seeing Jimmy Moore called a failure. He started at 410 pounds, clearly not a normal metabolism. He has struggled with weight up and down, but has continued to keep at least 100 pounds off for 8 years, a pretty remarkable achievement. I can empathize with him as I started from a similar spot – nearly 400 pounds. I first did low carb back in the late 90s, and got down to about 275 where I stuck for a long time. With a lot of struggle and starvation and very low carb and tons of exercise I fought my way down to 248 where I stayed for about a day or two, and then in the space of about 3 weeks bounced back up to 275. And there I remained for nearly three years. Over that I tried – more carbs, fewer carbs, more fat, less fat, more exercise, less exercise, no dairy, more protein, less protein …. and the scale never budged. So finally – since at the time it was all about the weight loss for me – I just gave up and fell face-first back into the SAD.

    Until 2006 when I started to develop some health issues and decided to try again. I went back to LC as it was the only diet i had *ever* been able to stick to for longer than 2-3 weeks (about my max with Weight Watchers for example) or lose more than a few pounds. I didn’t even KNOW what I weighed. My scale didn’t go up high enough to register me. After a couple months on the diet I went to the doctor for something unrelated, and they weighed me in at 375. That was in early 2006 and I have been low carbing ever since, nearly 7 years now. Once again I got down to the mid-270s and stayed there a long time. I made an effort and once again fought my way down to the 245-250 range and managed to stay there for a couple months, and then bounced back up to 275 in an 8-day period where I suddenly gained about 3 pounds a day every day for 8 days, no matter what I was eating. And then stopped, and now I have been stuck at 275 ever since. I’ve mostly been around this weight for 3 years again this time around. I’ve done all the things I did before – more fat, less far, more carbs, fewer carbs, more protein, less protein, etc. I take metformin and Armour thyroid (was DXed with hashimoto’s in 2009). And nothing seems to work.

    Yes I’ve managed to lose 100 pounds, but no one can say that 275 pounds is a good weight for a woman of 5’7″. I stay low carb because I enjoy the food and it’s the only diet I’ve ever been able to say that about. Right now I’m trying to keep my carbs lower, my protein lower and my calories lower (though not super-low, and I get about 75% of my calories from fat). Still nothing is budging.

    I think there are a lot of low carbers like me out there, mostly (like me) post-menopausal women. But I’d hate to use me as an example that low carb doesn’t work. But I have to admit I get pretty discouraged these days.

  7. Dear Mer,

    Do not get discouraged. I too am a menopausal woman of 54 ( and a tall 5’3). I started at 257. After 22months I am down to 210 and stuck. Gain two, lose two. More fat, less fat. Dr. Attia suggested ( for me) to try 70 – 75 gm Protein, 50grams carbs(which I cannot seem to get past 15-25) and as much fat as I need to not feel hungry. I have found that I need to meticulously keep track of my food, calories, protein, fat, and carb intake. I find I need to keep my intake at or just under 1000 calories, with 25-30% of that as Protein, about 65% fat an the rest carbs.
    Lately, I find I am getting hungry when I didn’t before and I am doing that yo-yo 1 pound – 2 pounds up/down.
    I also have not been faithful about recording my daily food intake. In my case, I think I need to push through the initial hunger and see what happens. I do know one thing, I love eating low carb. I wish you the best, stick with it. I just wanted to let you know you are not alone.

    • Ellen, it sure can be a struggle. We need a support group for menopausal women stalled on their diets! I’ll say quite frankly if I had to limit myself to 1000 calories a day I’d just plan throw in the towel. Even 1500 calories feels like “starvation rations” to me. I’m relatively comfortable in the 1700-2100 calorie range. But again, I’m not losing weight! Maybe I do need to cut calories. I’m actually obsessively weighing and measuring every bite I take right now. I feel like a total freak when I take an olive from the fridge and then carefully place it on the scale betore popping it in my mouth. LOL. My goal has been to keep net carbs under 50g daily, my protein under 100g (and preferrably under 90g), and the rest from fat. Although I’ve been low-carbing for 7 years and periodically weighing and measuring my food this time it’s been three weeks straight. The first week I made and effort to cut back on my calorie count and averaged about 1700 calories/day and I did lose 7 pounds (but I had recently gained some weight in a short period so thing I had a lot of water weight to lose. The second week I ate more to appetite and averaged 2000 calories/day – and lost 4 more pounds, probably the rest of the water weight.

      This week my average has been 2100 calories and I’ve lost nothing. I guess the water weight is all gone. I just can’t get my head around the idea of having to starve myself to lose weight. I was listening to Dr. Eric Westman on a podcast last night and he said for stubborn cases people over have to go below 20g of total carbs (not net). I might have to give that a try but it depresses me also as it leaves room for so little variety in the diet, especiall for someone like me who is not crazy about meat in general.

  8. Hi Mer,

    I totally agree, we menopausal Women tend to be the exception to any rule and need support from others like us.
    You must take into consideration that you have 5 inches more of height than me. Also, I do not take thyroid medication. A thousand calories works for me, but I can certainly see where it would not work for you.
    The water retention is driving me crazy, I weigh myself in the morning, after dinner, and just before I go to bed.
    Sometimes I show a 2pound gain in the 2hours from dinner to bed! Then it is gone in the morning! This can go on for weeks, then suddenly I will drop 2-4 pounds all at once. Then the cycle begins all over again. I am finding that because I do not have cravings anymore, I only occasionally miss the variety. Having been a professional chef for 32 years (before making a career change) I am constantly trying to create new ways to work with the food I eat.
    Good Luck, keep reading Dr. Attia’s blog , I am sure there are others who might have even better advice than me.

  9. I didn’t read all of the comments, there were so many, someone may have said this already. I have heard that sugar, the highly refined type you have on your cereal (to be specific but not to discount other sugar from the statement). Sugar is highly addictive and causes similar brain responses
    as recreational drugs. Last I heard this is still being tested on mice . I think any parent who has witnessed their child going from angelic to demonic in the space of a lollipop can guess how this will pan out.
    I wonder if carbohydrate intolerance is apparent during childhood. I personally was a hyperactive child, now I’m a fat adult.

    • Recently, 60 minutes discussed sugar. You can find links to it on this blog (I think). One researcher is looking at how sugar affects the brain. It is remarkably similiar to a person on drugs which didn’t surprise me. Nor did his other statement where it takes more and more of the sweet stuff to get the response first had with only a little bit. Personally, I find that to be very true. My ‘need’ not desire for sugar increased as my tolerance to the effect increased.
      As a child I was normal weight up until the time that puberty started. I ate the same amount of food as my weight increased as before when I was of normal weight. Hormonal changes start long before they are apparent. If you have a defect with regards to carbohydrates then any carbs consumed will add to weight gain since the energy is parceled out to the fat cells and not available for use. I did not overeat. That came much later. You do not become fat by overeating, you overeat because you are fat. I have an idea as to why and I can’t point to any study to back me up Regardless of body size, if you are carb intolerant, the carbs consumed will be directed to the fat cells and not for use as energy by the body. However the body needs a certain amount of energy to keep the body functioning. It will nudge you, demand, yell, entice whatever in order to get you to consume more at one sitting or to eat sooner than needed. It will get the energy needed to continue living but it will also direct most of it to the fat cells. The cycle continues to grow no matter the desire lose the excess weight until the underlying problem, carbohydrate intolerance is addressed. As a growing up child I ended up eating more than necessary in order to give my body enough to do the necessary growing.
      What are the things most readily available to fulfill the need? Carbohydrates in many forms. It isn’t just sugar that is the villain for children and adults. It’s rice and potatoes and corn and bread and high fructose fruit etc. Does this have a deletorious effect on the functioning of the brain. I’m not sure. We know the affect of alcohol and drugs. Sugar, honey, molasses, syrup, etc… do they have the same effect? I think yes but not to the same impairment level as the other two mentioned items.
      I disagree with the idea that children and adults can go from angelic to demonic by eating sugar in form of candy, cookies, cake, etc. Most likely the effect is due more to excitement from a party or trip or anticpated treat not from the ingestion of the sugar. Yet….. Being someone who has big problems with sugar consumption and as a person who tears apart her own reactions in order to understand them better, I think sugar has an effect that I think is akin to a dry drunk. Impaired thinking. Why did I do that thinking. Carbohydrates may be responsible for less ideal thinking in a person who has sensitivity to the effect of this food group. I find it amusing that we all make many attempts to make sugar into less of a poison than it is. Those who don’t have the problem with sugar I hope are grateful they don’t have the problem.
      Because we humans vary so widely in our response to food, it is hard to grasp that what one person does may have a deletorious affect on another. The current state of our government and many medical practitioners to insist we eat more whole grains, fruit may have a disastrous effect on those who are carbohydrate intolerant, insulin resistant, etc. The encouragement to eat more fruit may not bode well for those who are sensitive to the effect of sugar. Even low glycemic fruit may be bad news for some of us. What if vitamin supplementation is needed because we consume carbs. If we didn’t maybe we don’t need to take in that daily vitamin.
      I got off track here in my comment. To consume carbs(sugar, rice, bread, fruit, cakes, donuts, juice, etc.) at a young age and your body has an abnormal hormonal response, you may start to gain weight. Since there are other factors involved in growing up (activity level, food availability, type of food, etc.) a significant weight gain may not happen until early adulthood. Your brain chemistry knows the easiest fix to get is carbs and with sugar in many forms so readily available guess what is easiest to consume. Once on the treadmill it takes more and more of the sweet stuff to get a result. As Dr. Lustig pointed out fructose (part of sugar) goes to the liver first where it has a good chance of being shuffled off to fat cells before it gets to the brain. Then the brain demands more to function.
      Catch twenty two.

      Long winded as usual. Sorry, Peter.

    • As usual was mulling what I said in my post above and it struck me that I forgot to say something that I consider crucial. So hopefully I can make this short and sweet. I see two different issues in how obesity occurs and sugar addiction. The former is a hormonal response to carbs in all forms which can result in the development of obesity. If the body needs more fuel which it can’t get from what ends up stored in fat cells and wont’ be released then the urge develops to overeat and carbs, simple and complex, are the easiest to get, to digest…..though excess protein is also welcome if no carbs (simple or complex) are available.
      The second issue is sugar addiction which, I believe, should be a separate issue from carb intolderance and obesity. Where the former is in the biochemistry of the body and the body doesn’t care where the carb comes from, the brain takes special consideration. It is also responsible for the psychology of being human. It is concerned with thinking and emotions. In some individuals sugar (as sugar or as alcohol) becomes a problem. For some the ingestion of sugar is like being a little bit drunk. There is a subtle alteration in thinking annd acting where with illicit drugs and alcohol it is far more pronounced and deadly. More of the ‘poison’ is desirable because of the chemical response in the brain.
      Sugar, in all its forms, is a double whammy in that it works on the body increasing the likelihood of obesity in prone individuals and it also acts on the brain derailing emotional stability in susceptible individuals. An individual may have one or the other or the double whammy of both. And it seems if you have both, the difficulties aren’t doubled but seem to become tenfold making it much harder to deal with.

      Thanks for reading.

  10. Hi Peter,
    I’m not sure where this question might fit in if at all. In rereading Gary’s book he has a sentence that postulates that even someone following low carb might not lose the weight but may experience better blood test results (better health overall even with the weight still present?) I was wondering if you knew of any study or of anyone investigating this idea. After all, I’ve read several posting where the person laments that the weight doesn’t come off in spite of adhering to a low carb diet. I’m supposing their frustration is compounded because they are still being met with the demands from society and the medical establishment (not only doctors) that they have to lose the weight to increase their level of health. I believe it is possible that certain individuals may experience no weight loss (a hard ‘pill’ to swallow for anyone wanting to lose weight) but if they can be given proof through clinical study that their health would improve if not the weight it may be the key to helping them find it easy to keep adhering to the chosen food plan. It may help the medical establishment to be more open to continue helping individuals who find weight loss nearly impossible but can increase their health fitness without the message that ‘you are doomed to ill health because of the weight’.
    I suspect that sounds like an oxymoron (?) to many who focus on weight being the indicator of fitness and health. By no means I am suggesting that this ‘entitles’ a person to give up as has been suggested in some postings. What I would like to see is health encouraged for all irregardless of size. Don’t jump to the conclusion that a person who is overweight is not healthy. They may be healthier than the lean person internally.
    I read somwhere back in the eighties that certain experts considered overweight and obesity to be symptoms and not the precursor to health issues. Something like obesity does not cause heart disease but rather that obesity occurs along with heart disease or you can substitute diabetes for heart disease because they have a ‘defect’ in common, not that one (obesity) is a cause of the other (diabetes). It’s too bad that this idea never caught on. I think it would ease the self guilt many have and allow them to focus on living life with joy.

  11. Primrose oil has GLA; and the long list of benefits esp. to the skin, that I don’t want to miss. However it is omega-6. Would you say that the benefits outweigh the negative effect of the omega-6? I appreciate other related info on the oil. The one I am taking is cold pressed with 10% GLA.

  12. To Donna. Oct 28.
    Donna, how are your blood tests developing?
    You can always get a calcium score scan, which at least by trackyourplaque is regarded as gold standard for heart disease. Most likely Dr Davies (WheatBelly) is right here!
    In the US (Denver) CSS is available for $99.- and repeating after 1 year would tell you if the calcium score goes down or up (bad). The more calcium in the heart of course the worse. Muscles and blood vessels require zero calcium deposits for optimum functionality. Here in Europe I have not yet found any for less than 300 Euro.

    The deposition of fat is a survival mechanism for harsh winters or starvation in general. Yet keeping the same fat on year after year was hardly the intended way. And if earlier diet contained lots of polyunsaturated fats the deposits could now be rather rancid and the body may therefore be reluctant to re-process it? (Ray Peat surely have a view on this!) Is it a reason younger people has it easier to lose weight?
    Yet you may still be right in the thought that body fat is not a symptom of disease at all.
    Although we know that visceral fat is.
    LCHF is said to reduce that first, so you may need to get a ketone meter to get the weight loss on the right track. The only proven method? After Jimmy Moore’s recent success it looks that way. Good Luck!

  13. When you were asking the rhetorical question, why do people eat carbs when they are bad for them, I immediately equated it to: 1) lack of knowledge, 2) lack of money; 3) addiction; 4) culture; 5) brainwashing by the “experts”. I work in public health and one thing that is asked with our health navigators (case managers) do checks on our clients is about fresh fruit and veg and the people invariably say they can’t afford them and they can’t afford to go out of their neighborhoods (no cars or bus passes) to go to a store that sells them even when they do have a little extra money. It’s very sad. I’m in that 30-40% of people – I can do LCHF religiously for weeks and lose 1/2-1 lb a week, but I have one cheat weekend (and I’m talking eating 2 pieces of toast for breakfast with my eggs and meat and a hamburger bun for lunch) and I’ll gain 5 lbs. 😛 1-2 months of LCing down the drain in 1 day!

  14. Dr. Attia, you should paraphrase G.K. Chesterton to Bray and Kolata:

    “It’s not that low-carb diets have been tried and found wanting: it’s that they’ve been found difficult and left untried.”

    Thanks so much for all the great information here!

  15. Hey have you seen the website He says the amount of fat in a carb based food lowers the g.i rating. This means people should have a lot of fat with their carbs if they decide to combine them because it slows the release of insulin. It doesn’t just end up storing more fat because the insulin decides to store more calories.

  16. Peter, I’m not sure where this belongs or even if it is a question that belongs on this blog.
    Recently I read that gastric bypass patients have a four time greater chance of ending up with a substance abuse problem mostly from alcohol. This got me to thinking about low carb eating.

    Gastric bypass patients are instructed to eat high protein and very few carbs. Fat is another issue. Usually the diet has to be low fat becasue of what the bisecting of the stomach accomplishes. I’m wondering if those who adhere strictly to the high protein low carb eating plan and have a problem with carb ‘addiction’ don’t end up needing to find a way to get the carbs hence the choice of alcohol. Some bypass patients (not all) have trouble with the disgestion of carbs after the surgery so they tend to follow the doctors recommendation that carbs be avoided. But alcohol seems to be another matter. Alcohol is considered a carb.but I wonder if the way it is metabolized in the liver makes a difference and therefore some bypass patients find a way to get high carb ‘satisfaction’. I’m not talking a psychological satisfaction but a bio-chem satisfaction no matter what the intention may be by the patient.

    What little I’ve seen about this indicates that the professionals want to treat it as a substance abuse problem. I tend to think that it is a bio chemical problem that has not been addressed by the resulting dietary requirements after surgery.

    My question or rather questions would be if a change is needed to the dietary regime neede by bypass patients which would make it closer to a ketogenic diet so that the body could make the switch to burning ketones rather than glucose. This question is outside the realm of this blog I think. But my other question may be more pertinent to the topic in hand. Do some who go low carb find themselves drinking more alcohol? Using alcohol more liberally than before the changeover to low carb eating. Is the body (brain) so physically demanding carbs in any form than it will sabotage a person’s dedication to eating well to get it? Obviously not everyone who goes low carb develops the problem just as not all bypass patients become alcoholic. I’m wondering if developing a subastnce problem is more an indication of bio chem prolems in the body and not a psycological problem.

    I’m wondering if some of us have a carb ‘addiction’ that is not readily identifiable by current methods except the tried and failed or tried and succeeded method. .

    What bwilders me is that the response to the study that bypass patients may develop an abuse problem is to assume that it is psychological only. I lean more towards thinking it is a biochemical issue that becomes a psychological issue with repeated dosings. And if some individuals frind themselves straying back to carbs, is it not mor likely a physical response rather than a pyschological one.

    I’m just not sure where the line should be drawn. I’m tired of being told my eating habits are emotional issues when I feel more certain they are biological in origin first with the emotional part coming later.

    I hope this makes some sense. I’ve been ruminating about this since I read about the study. Maybe some of your readers can shed some insight.


    • Donna, these are really great questions. I must admit, my bias is leaning more and more towards biologic/physiologic drivers (versus emotional), and this even includes eating disorders. Check out the work of Leslie Simm at Mayo Clinic. The bigger question I struggle with is the “division of labor” between with periphery and central system. Is the body in charge of the brain? Still not sure.

  17. People get fat on low-carb diets because they eat stupid stuff like mayonaisse or bacon and decide to take in over 300 grams of fats.

    In all reality, if you keep protein and fats the same and not overcompensate, you can easily cut calories from carbs and lose weight. I don’t think you should be scared of carbs, though especially since insulin sensitivity is relatively easy to increase.

    • Mayo maybe stupid (and often it is sweetened) because many versions contain large quantities of vegetable oils. The problem with these is that polyunsaturated fat in biochemical studies seems to be the biggest factor in causing LDL to degrade into form that are likely infilitrate the walls of blood vessels. I don’t think bacon is the cause of anyone’s weight gain by itself (though would be happy to self experiment ;>). One way you can put one on weight eating low carb is , I suspect, because of excess protein.

      The point that Taubes in WWGF that I think is important is that the alternative hypothesis is not that “low carb” is “the answer” but that the correct scientific paradigm (aka the alternative hypothesis) is that weight and appetite and activity are all complexly regulated systems (hormones like insulin but certainly others being key components of these systems). Perhaps the most common disregulator is dietary carbs, but
      1) it is not the only one and (stress, lack of sleep, etc all show in the literature,
      something CICO doesn’t explain vary well )
      2) once the addressing the low hanging fruit of carbs,
      it may be much more complex to reduce weight past
      the new, healthier equilibria (aka set points).
      3) These further reductions may, in fact very likely is my guess,
      may have limited impact in terms of improving health/reducing risk

      Besides all the good comments on adequate fat intake, salt, calorie
      counting, thyroid function, etc. for all those doing “advanced” low carb
      dieting, I would add the issue of choline. Chris Masterjohn has an interesting
      post on this. Iiuc, choline is essential to the liver’s metabolism of fat.

      As for thyroid function, I have a suspicion that since most people by default assume
      vegetables are always healthy, we may get ourselves into trouble. Many vegetables
      – especially raw – are goitrogenic (i.e. suppress thyroid function). The same is true of
      nuts (again, especially if raw). Something to keep in mind.

  18. I went to the supermarket yesterday and couldn’t find real plain yoghourt (all the fat and no sugar added). Everything was 0%, “low fat”, etc. Sugar content in a 6oz bottle: 23 grams. Who was buying that? overweight people. No comments.

  19. Peter,
    It is my understanding that one of the reasons we require as much water-soluble vitamins as we do is because of the glucose-based metabolism. E.g., glucose inhibits vitamin C metabolism in cells; many B’s are important for glucose metabolism.

    Since seeing your IMHC talk and having a better since of the details of ketosis (particularly that the body
    is still using – actually trading off between ketones and glucose) does this mean that mean that vitamin C
    metabolism is also cycling contrary to glucose levels? Just curious.

    • I don’t know the specific answer(s) to your questions, but it has been well documented that Inuit, despite not consuming much vit C, did not have scurvy, probably due to lack of glucose interference, though it’s possible there is something else going on (though the role of vit C and proline in collagen synthesis is well understood).

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