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. What helped me gain a tremendous amount of muscle, lose weight, and feel amazing was a low carb version of The Blood Type Diet. I just eat red meat as a type 0, I’m in ketosis 24/7, and i feel amazing.. For vegetarians, the trick is… greens, salads, vegetables. Also a lower frequency of eating is very important.

  2. Excellent framework Peter. I’ve something to share from my career in the Economic Development arena. As a development professional, whenever we want to start a development project in any low-income country, we consider many economic factors. One of these factors is food security. For some reason, we tend to assume that the less carbohydrate (i.e. Rice and wheat) cultivated/imported in a certain country, the more important it’s to invest in food security. Usually, this investment translates to more rice or wheat. So, building on your point of infrastructure, ministries/governments/development institutions actually tend to measure their success based on how much carbs they can feed!! Consequently, obesity, presuming that it boils down to carbs, may become much more widespread globally as we try to alleviate poverty!!!

  3. Left this on your Facebook page as well ….

    I too just watched your TED talk – it was shared by . Very nice. I also made my way over here and found this article. I was really hoping for some answers here as to why I not only cannot lose weight on low carb, but I have gained about 25 pounds. (Most of that gain happened when I was treated for hypothyroid …. unsuccessfully.)

    I feel better on a high fat, low carb natural food diet. I have varied the ratios of macronutrients. I have tried eliminating foods that could be allergens or to which I could be intolerant. I am not sure that I am insulin resistant – my levels have always tested low, when I monitored my blood sugar, it was completely normal, and I lack other indicators of having insulin resistance or metabolic syndrome.

    I am at my wits’ end now. Is there any hope?

    • I believe there is, Lissa, but it’s probably beyond the scope of this interaction to provide any meaningful insight. If it were “obvious” I am sure you would have implemented it successfully already.

    • Well, thanks for your reply. Such as it is …. last ray of hope, gone.

      I know that I will never be able to get back to where I was 10 years ago … slender, healthy, energetic. Something changed in me and 50 pounds just appeared seemingly out of nowhere. And they aren’t going to leave. I have been holding on to the vague hope that I would at least be able to lose some of it, to get to a point where I am no longer scolded by my doctor, looked on with pity by those who knew me back when I was thin and healthy, and judged harshly by everyone else.

      Oh well … might as well go have a pizza and an ice cream sundae, right? No sense in being fat and deprived, at the very least I can enjoy food again.

  4. …………..
    ………….
    ……….. Injestested Fat

    Lisa – I wish you’d cheer up a little

    The body does not like to store Carbs or Protein as body fat – body fat comes from injested fats plus high Insulin – or in some people just from the fat it-self as their body is adept at storing it – but not releasing and burning it –

    If this applies to you – a standard low carb diet will only make you hungry and the more fat you eat – the hungrier you will get until youv;e reached too many calories to lose weight =

    You might try a very low carb and very low fat approch – 120 calories fat -120 calories carbs and the rest of your calories from protein –

    Your protein choices cold be whey protein – or in my veiw less desirable tuna fish or George Foreman grilled meat –

    If you succeed in losing your weight – you can add a little mre fat back in the diet until the point where it starts to increase fat dependent hunger –

    I hope tommorow is a better day –

    • Hi Lisa,

      I share your frustration, but Jeff is correct, I have struggled over the last two and one half years to find the ratio that works for me. Less fat for me seems to work the best. The longer I stay with it the more my body adapts. I too have to put up with a doctor that makes me feel miserable for not being able to lose weight fast enough for him, but I have managed to lose 35+ pounds, reduce my blood glucose to normal, and reduce my BP med. from 20mg. to 10mg. I also have to contend with the psychological aspect of eating. Being an emotional eater I have had to learn to distinguish between mouth hunger and physical hunger. Hey Jeff, your picture does not match your sage -like wisdom :). Thank you for such insightful advice! Hang in there Lisa, and find a more sympathetic doctor, I plan to.

  5. I just discovered your website and blog last night and have been reading through the tremendous amount of information on low carb weight loss. (I am a bit confused and overwhelmed but happy to have found this to study!) I wasn’t sure where to post my question, so please forgive if I have gone off topic.
    I have struggled with losing weight most of my life, although I have never been severely overweight, I have fluctuated between being 15-30lbs over what would be considered a healthy, and comfortable weight for me. I’ve tried all the diets from Adkins, (gained 1lb over the 3 weeks I did it), South Beach…never lost an ounce, and Weight Watchers using their old plan before carbs were even used in calculating points. I did have success with WW, losing an average of about a 1.5-2 lbs per month over a 10 month time period. I was able to, and did eat things like low-fat potato chips, bagels, etc., on the plan and exercised approximately 1-2 hours a day most days. Slow but steady, I lost almost 18lbs. That was the fastest and most consistent weight loss I have experienced as an adult woman. I was thrilled! It has been several years since I have followed WW, or any “diet” consistently as I seem to always become discouraged at how much effort and discipline I feel I have to put in, for very little result. (I know, poor me, right?) Since I am not looked upon as being considerably overweight, and I can fit into size 10-12 jeans, I usually just accept that this is it for me but I certainly would love to find an approach that would allow me to transform myself the way you did. I desire a fit looking and feeling body, yet my body fat percentage ranges around 37% right now. I exercise 5-7 days a week in various ways; weight training, biking, HIIT, walking, jogging, and I enjoy it most of the time although there are times when it feels like I have to force myself to put in more hours or increase my intensity because I have eaten a bad meal or two, been on vacation and have gained 5lbs etc. and then suffer with injuries from over-training. Anyway, my question is this: You mention that low carb eating may not result in weight loss for a certain percentage of people. I would like to sink my teeth right into this low carb thing and transform my health and gain the fit body I have always desired. But, before I do so and possibly end up feeling as though I’ve spent a lot of energy, time and money on educating myself, buying and preparing meals, ect…(I can continue doing what I am doing and stay the same, I am looking for change) would you be willing to shed more light on why low carb eating doesn’t result in weight loss for some people. I don’t know if my recent blood work for my annual physical would be helpful, but my Glucose came back at 91 within the normal range of 65-99. Cholesterol total at 196 with HDL at 81 and LDL at 104. Triglycerides at 57 with the range being <150. So does all this normal stuff mean that I am not insulin resistant and a low carb diet may not work for me? By the way, I am a soon to be 50 year old woman, 5' 4.5" tall, went through surgical menopause at 37 y/o and take Levoxyl for hypo-thyroid Hashimoto's disease.

    • It’s hard to tell, Lynne. It takes me a lot of work, unfortunately, to diagnose insulin resistance. Fasting insulin and insulin response to glucose challenge are probably the most helpful numbers.

  6. Thank you, that is all I needed to know. Long description to my question but a simple answer is perfect. I wasn’t sure if the normal levels meant “normal” or whether or not there were further tests to determine IR. I also watched your TED speech today. I was moved to tears, thank you for your work.

  7. Thank you for offering such great insight on obesity. I myself lost 70 lbs 20 years ago using the Atkins book (low carb) but gained it all back because it was so restrictive (i just couldn’t keep avoiding what everyone else around me was eating). I realized this happens to everyone, so I started looking for ways to make the low carb lifestyle work… and after many years of being fat, I have succeeded in losing weight while still eating what I want (not as much as I want, but enough to keep me from being depraved). I saw this amazing video series that explained it so well I started a website so others could see it and learn how I have been able to do it: It’s at: http://SmarterLowCarb.com/life-changing-video/ Hope this helps more people see it.

  8. Thanks for the well thought out argument. You are quite right about accessibility to the wrong types of food playing a major role in obesity. While there are ways around it, on the surface, any low carb diet is quite expensive comparatively (depending on your country of course). Like I said though, there are ways around it.

    One small thing I want to share is the extreme impact blood sugar plays on appetite. I went onto a low carb diet by changing nothing, except drinking water instead of soda, and having no rice/pasta or bread. Otherwise the meals stayed the same (same size meat, just no rice on the side). Even though I was eating far less, my appetite was less ravenous, and I had no cravings. Seems counter-intuitive to most, but it was the reality.

    My only concern was that my weight loss remained quite high, losing on average 1.5KG per week even on week 8. Only needed to lose 20 (18+2 water weight) so already trying to move in the direction of “maintenance” (lost 12)

  9. It is very easy to anwer why people are getting fatter if low-carb works so well: 1) The government has been pushing the wrong kind of diet for 40 years, 2) the medical community and related institutions are wedded to that bad diet, and 3) most fast and “convenient” foods are based on that bad diet. The anti-saturated fat American Heart Association and the pro-carb American Diabetes Association cannot overnight say “Our advice for the last 40 years has been wrong and just the opposite of what it should have been. In reality simple carbs are bad for you and saturated fat is good for you.” Their woefully wrong positions won’t change until those earning a living off this misinformation retire or die. It took at least a generation or two to put this lousy diet in place. It will take a generation or two to get rid of it.

  10. Britain (where I live) just doesn’t seem to want to conveniently accommodate the low carb diet or even consider it as a sensible way to eat. You go to any ordinary supermarket or you eat out and carbs and sugar are the staples to pretty much everything. I live in a society obsessed with and addicted to carbs and sugar. It is very hard, especially as a low income person, to stick to this atkins diet I am on. It’s also very antisocial. My family want to go to JD wetherspoon or McDonalds and it’s very difficult to order something that isn’t labelled garden salad, even then it comes back with croutons or insulin rendering dressing when this wasn’t stated on the menu. If I request them to be removed I am looked at like a lunatic. I know that carbs are the reason why I am fat. For years they have been the staple of my diet and I have been doing low calorie and I am stuck at 5’2 and 137lbs with a 30 inch waist. It isn’t the fat or the cheese or the steak I sometimes eat, it’s the oatmeal, the muesli and the couscous and the pasta. Then try explaining all this to your typical Joe Public. They insist that cheese and bacon (luckily for them I don’t even like bacon) make people fat and have even been told by their doctors to reach for a bowl of vegetables with steamed rice if they want to avoid heart disease and a life of obesity, yet many of them are overweight. It must be the forbidden bacon and the fried eggs they have been having recently so they switch to meusili and get even fatter and make up for it with even more ‘complex’ carbs and blame their metabolism or their bone structure. They visit the doctor asking why they can’t lose weight and the doctor just gives them the same advice and assumes they must be stuffing their face all day with saturated fats. They go on to develop health problems, blamed on high fat foods. We live in a society fed on false information when it comes to maintaining weight and when it comes to diet and nutrition. As an apple shaped woman especially carbs and added sugar are literally toxic to me, yet my doctor does not even know this. I think that we should take Sweden as more of an example. They have realised that the low fat and high carb way of eating is unhealthy and ineffective and maintaining a sensible weight and waist circumference and that it’s actually the other way around.

  11. Having tried a variety of diets over the last five years with no real success (I’m about 200lbs and 5′ 5”), I decided last weekend that I was simply going to try and eat low(er) carb and see what happened. I’m not giving myself a headache food planning/ shopping, just avoiding the obvious and seeing where it takes me. Granted I’ve eaten quite a lot of eggs, but also plenty of low carb vegetables instead of rice, pasta or potato, etc.

    I’ve tried carb controlled diets in the past and found them restrictive and misery inducing. So my idea was to do what I can but not turn it into a big thing. Week one is always a bit deceptive I guess (five pounds down) but the real revelation for me has been that I’m suddenly not hungry and craving food all the time. In a matter of days my appetite has TOTALLY changed in a way that I’ve never experienced. It’s been really easy to avoid carb laiden snacks as I’m not feeling the ned to snack. I’ve rapidly come to the conclusion that I’m the type of person who just shouldn’t eat many carbs and it’s really interesting to see how many people have reached the same conclusion.

  12. I have a question, people talk about not being in ketosis, but still being in “fat burning” mode. Doesn’t fat always metabolize into ketones? If you’re burning fat, aren’t you in some degree of ketosis? Or is ketosis defined more by a certain threshold of ketone production?

  13. I’m probably like your wife. I’ve always been able to eat a high-carb diet with absolutely no ill-effects. At age 57, I’m maintaining a 50-pound weight loss on a high-carb diet (300 g carbs, which is 60% of my 2,000 cal allotment). Knock on wood, I have no digestive or musculoskeletal symptoms whatsoever. I feel exactly the same as I did when I was 20. So when I hear all the low-carb this and low-carb that out there, I can’t help wondering if the premise is overstated. Granted, I don’t know if I’m normative or an outlier. Just saying.

    GB

  14. My doctors are a bit puzzled and me too, so I have a question out of curiosity for you. Could a 36 year old woman which has been all her life at the underweight limit could be insulin resistant? I had gestational diabetes with my second pregnancy (never been properly tested with my first pregnancy, but baby was normal weight) and realize after, by home testing, that I am glucose intolerant, I can go as high as 10mmol/l at 1 h post meals (my maximum was actually 12.5mmol at two months postpartum, but then there was some improvement). My doctors mentioned possible LADA and MODY, but somehow I don’t think this to be the case (hopefully). I actually got the chance to do two measures on my mom and dad last fall, dad seemed normal, mom seemed to be very similar to me, ie normal between before meals, but going high after meals. I read about PCOS and insulin resistance, but I am not sure I am a good candidate for this (my mom even less). I would bet on some genetical insulin resistance on my mother side of family, but my doctors seemed to think such a thin person has zero chance of being insulin resistant. I was educated since childhood to eat low fat and not too much meat because my mom had some gallbladder issues, which means I was on a high carb diet all my life (not sugar, but starches and visibly not really a lot since I never put much weight on). I now try to restrict to about 40g carbs per meal, because this usually keeps me under 6mmol/l at all times and I find this a good target, but I want to know more about what’s going on with me. Blood tests come out optimal, I have low blood pressure, it really seems I just have this glucose intolerance, but I want to understand where it’s coming from. Note that my OGTT came as 4.8 at 2h two months postpartum, but they did not want to measure at 1h and stupid me did not have my meter with me (never thought they will not measure at 1h…and if I eat 75g of carbs from starches at home my blood sugar will be high for 2-3 hours afterwards). I am actually not sure my moms anomaly has the same source as mine or if it’s not evolving faster in me. My mom it’s still very thin at 63 and seems in good health. I must say I have been really really severally sleep deprived for the last 4 years (my fist was a very poor sleeper and my second it’s still very young) and I know lack of sleep can play a big role, I also have very strong reactions to stress (got this from my mom) and I had a lot of emotional stress from family issues the year prior to my second pregnancy and lost a lot of weight, but I don’t think I will become ‘normal’ again when the kids grow older. Also since I had kids I seem to store ‘all’ the fat on my body on the front of my belly, it’s not really much, but compared to the rest of my body it makes a striking picture.

  15. I suspect this might be a missing piece of the puzzle as to why we make poor choices about our health (e.g. have unprotected sex). Dr Dan Ariely, a behavioural economist (Tedx Talk below, very informative, 18min) has done studies in how people make decisions when the pay-offs are immediate and the pay-back is far off in the future.

    An example from the talk to save time: He contracted Hep C through a bad blood transfusion. The treatment (he simply called it “interferon” and left it at that) involved self-injecting the medication, 3 times a week for a year and a half. Each injection would be followed by vomiting and high fever. It was extremely unpleasant in the short-term and the long-term pay-off was far off into the future as well as uncertain. His way around it was to give himself an immediate reward post injection (in his case watching movies – I would choose something else). After a year and a half, he found out he was the only candidate in the clinical trail who stuck it out. (He was also cured!)

    https://www.youtube.com/watch?v=PPQhj6ktYSo

    I am very interested in this topic because I help high school students study maths and an average 16 yr-old has a tough time making the right choice when faced with 20min math homework vs. 2 hours of TV. I have been looking for more constructive ways to help them deal with the problem than simply label them as “lazy” and yelling at them.

    On to a question only tenuously related to the the above: I think that people keep asking you what you eat for a very simple reason. They would like to try the ketogenic diet but lack the knowledge and the know-how to put together a plan of some sort. You say that every person is different and that the ketogenic diet might not be for everyone. Fair enough. You also say that it is necessary to educate oneself in order to make the right choices. Couldn’t agree more.

    From all the video-watching and blog-reading it is very clear that your intention is to make a positive difference in people’s lives…which you have done. I’ve pointed quite a few of my friends in your direction and they said it helped. What I’d like to point out is that this is an incredibly complex topic. The vast majority of people are not able to take principle into action very easily and they look for heuristics, sometimes in the wrong places (copying your diet to the letter).

    So my question is, what are the guidelines I could follow to give this diet a try? What I have in mind are questions like the following:
    How long should I try it to see if it works? Is a month sufficient? 6 weeks?
    What are warning signs I should look out for (reasons to stop immediately)?
    The “zone of misery” kicked my butt last time I tried, how do I get around it?
    What are the most common problems people encounter when they first start this diet and what are good strategies for dealing with them?
    What are the common mistakes people make?
    I’ve looked up a list of foods that are high fat, low carb as well as oily sources of proteins, worked out the amount of protein, fat & carbs I “should” eat (138g, 197g, 31g), thought about what might work with my lifestyle and set up a plan with which to start (adjustments to be made as needed). Is that a good approach? Any suggestions to build on that?

    Cheers

  16. I found this page after watching your video and wondering if you weren’t telling my life’s story about the battle with diabetes and obesity. My battle with obesity as been lifelong. I think you are spot on that different people have differing metabolic makeup and what works for some may not work for others.
    I have been obese since my teens and developed type 2 diabetes about 6 years ago. I am 59, 5′ 10” and over 300. I have yoyo dieted all of my life. In 2010, I was at 420 lbs. and knew I had to do something, so I started with cutting down on carbs, particularly refined sugars and fast food, and I joined the Y to get exercise. I lost about 30 lbs over a year but stopped after that. In the fall of 2011, my hubby had a heart attack and I tried diet changes that would hopefully help both of us. I lost another 20 lbs and stopped. I maintained the weight loss, but I could not lose. In the August of 2012, I was diagnosed with breast cancer, the stress of which took 20 off of me, and 3 weeks after the diagnosis I was hospitalized for and AVM in my small bowel and had a bowel resection to remove it. During the 3 weeks in the hospital my diet was primarily ice chips, so that took another 20 off of me. The mastectomy followed the resection 5 weeks later. I did not do chemo because the risk was higher than the benefit it would have given me. I spent the winter recovering from all of this and the following February I began eating more healthily and I set a goal to walk the Strides Against Breast Cancer 5k in October ’12. By summer I had lost a total of 90 lbs (from the 420).
    I developed pain in my hips by mid-summer which put me into phyisical therapy and I had to stop walking. The week after the therapy ended, I began walking again and I broke my foot, (Two weeks before the Strides 5k) which put me in a cast for 6 weeks and a boot for 3 more months because it did not heal completely. I should have had surgery on it to begin with. In mid January of this year, after finishing with bone stimulation therapy on my foot, I joined the Y because I had gained 20 lbs over the winter and I wanted to begin losing again.
    This time, it has been much harder to do. I am working out 60 minutes, 5 days a week, swimming laps 3 days and doing strength and cardio on the other two. This is considerably more strenuous than the walking I did last year but it is tailored to keep the stress off of my joints and feet. I have lost 12 of the 20 I gained, about 4lbs. a month.
    My oncology nutritionist recommended a book entitled “Intuitive Eating” and although you do follow a “diet” of sorts it appears to me that yours has been an intuitive journey of finding out what works well for your body. I have been on the road at times where I no longer crave the foods that I give up, but at some point, that craving returns. It never truly stays away and I fall back into old habits easily. The thought behind Intuitive Eating is that depriving ourselves of what we like causes those lapses occur.
    I have changed from refined sugars to fresh fruit and I love it. It has essentially taken the place of the sweets that I craved. My glucose levels are now normal, but still with medication. I hope that if I can lose more weight that the glucose will drop even more and I can get off of the medication. I just don’t feel ready to give up bananas and apples so I don’t think I could do what you do at the level you do it. But I want to make more tweaks and see what happens.
    I especially like the fact that you do not present this as “the magic cure” for obesity. I too think that research is vital and hopefully there will be more findings in the future that will help us end this cursed problem.
    I know that genetics are a major key to it because I come from two families that are opposites. My mother’s family is plagued with metabolic syndrome and my dad’s family had very little of it. His mother died at 102 and ate lard, fried foods, sweets, almost anything she wanted. She was overweight at times, but not obese. Dad had more struggles than anyone in his family and I wonder if the diets he used did more harm than good.
    Anyway, I was delighted to hear that an actual MD was questioning the current thinking about nutrition and obesity. My breast surgeon hounds me about my weight and yet the oncology nutritionist frowns on “diets”. Hum….what’s a mother to do???

  17. Correct me if I’m wrong, Peter, but didn’t Carbsane debunk all of this years ago? (Shhh. Don’t tell anyone. Secretly she rocks my world.)

  18. Hi Peter. I read one comment you mentioned about fasting. Muslims fast 29-30 days during their holy month of Ramadhaan. Its not that I’m promoting my religion… its just because with many Muslims… they fast a great many days throught out the year. For instance… we are encouraged to fast on Mondays and Thursdays…. or if we’d like, fast one day, and not fast the next, and then fast the next day, and not fast the next. Etc. Etc. Maybe you can do an experiment on them, or maybe try it yourself to see the benefits.

    The Ramadhaan month just ended tho… We however don’t do 24 hours fasts. Its just from dawn to dusk (depending on the region of the world, this can be a very long time [e.g. summer in the USA] or a very short time [e.g. winter in the USA]). Just a thought… I myself would like to know to see what benefits might arise from that kind of month-long fast, or even the encouraged fasts (e.g. the alternate days and Mondays and Thursdays).

    Ok. have a good one and please keep up your excellent and unbiased work! 😀

  19. People are still overweight despite they are in “low carb” diet” because they think they’re eating the “right” food, when in fact, they are not. Great blog, Peter. It’s very informative. Keep up the good work! I really enjoy reading all your articles. I look forward to reading your future posts.

  20. One thing I would like to touch upon is that fat reduction plan fast can be carried out by the correct diet and exercise. People’s size not merely affects appearance, but also the quality of life. Self-esteem, melancholy, health risks, in addition to physical capabilities are influenced in extra weight. It is possible to just make everything right and still gain. Should this happen, a condition may be the primary cause. While an excessive amount food instead of enough work out are usually at fault, common medical conditions and widespread prescriptions can greatly increase size. Thanks a bunch for your post here.

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