June 16, 2014

Understanding science

Success versus Failure: A stark juxtaposition

What does winning, and losing, look like when confronting public health issues?

Read Time 11 minutes

In April I was part of a panel at the Milken Global Conference, the title of which was something like, “Keys to a healthier and more prosperous society.”  The panel was moderated by Michael Milken, and it was great to meet him and his rock-star staff (especially Shawn Simmons, Paul Irving, and Nancy Ozeas). The other panel members were seasoned vets of the obesity discussion: Troy Brennan (Executive VP and Chief Medical Officer of CVS Caremark), Tom Frieden (Director of the CDC), Lynn Goldman (Dean of the School of Public Health at the Milken School of Public Health, at George Washington University), and Dean Ornish (president and founder of the Preventive Medicine Research Institute). I was the pauper in the group—no big credentials and zip-zero “panel” experience.

A few weeks before panel, we all jumped on a conference call and Michael set the stage for the discussion he wanted to moderate. He pulled no punches. “If you include the indirect cost—lost productivity, for example—the total cost of obesity and its related diseases is $1 trillion per year to our economy. This is unacceptable.”

Who could disagree? Hell, I usually only reference the direct cost of obesity and its related diseases—about $400 billion annually.  But whether we talk about the direct or indirect cost of these diseases, I’ve always found the human cost even greater—every day 4,000 Americans die from four diseases exacerbated by obesity and type 2 diabetes: heart disease, stroke, cancer, and Alzheimer’s disease. Now that is really un-effing-acceptable.

So, back to the panel. The idea of being on a panel kind of freaked me out, even more than the sheer terror and vulnerability of TEDMed. No control. The possible need to be defensive. Sound bites over substance.

I don’t enjoy debates. Nothing comes of them. Just greater and greater polarization. The “winner” isn’t even necessarily the one with the best “facts.” Gary Taubes shared this quote with me recently, which I find really insightful. Dallas Willard, a well-known ecumenical pastor and theologian, was often invited to debate the existence of God and other matters. These invitations included Richard Dawkins himself.  His response: “I don’t debate, but I am glad to enter into a joint inquiry. We will seek the truth together.” That’s the attitude I like.

In the end, I decided to just tell a few (in some cases provocative) stories. Why? Because it’s easy to present reams of data, yet so few people remember the point. (If you want to read an amazing paper on the importance of storytelling, check out this one by one of my former surgical mentors, Curt Tribble. You don’t need to care one iota about training cardiac surgeons to realize the gems in this piece.)

I realized going into this that I would be the contrarian in the group. I don’t claim to know all (or even many) of the answers, but I’m willing to bend over backwards in search of them. I realize folks (from readers of blogs to members of the audience at the Milken Global Conference) want facts, answers, prescriptions. I think we need to know more, first.

Below are the notes I made for myself in the days leading up to the panel. Basically, I wanted to tell a few stories, plus summarize it all (if given the chance). I didn’t actually “practice” this or even take notes up on stage (which I regretted when I realized everyone else was smart enough to bring notes), so if you decide to watch the actual video of the panel, you’ll note that I only vaguely followed what’s written below.

But in my mind, here’s how I thought about it. (I haven’t watched the video and I’ve pretty much forgotten anything I said, but I’m sure what’s written below is better than anything I said. I did send the video to two of the best speakers I know to get their feedback. Their feedback: could have been much better, but not the worst job ever. Lots of work to do for next time. Duly noted.)

How did I find myself interested in this problem?

My arrival at this place is really a coming together of two revelations. First, during my surgical residency at Johns Hopkins, not surprisingly, I was often dealing with the complications from diabetes and obesity in my patients. It slowly became obvious that all I was doing was slapping on the surgical equivalent of Band-Aids without ever addressing the underlying problem. I was treating symptoms and not the actual disease. When I would amputate the leg of a diabetic patient, which I had to do, regrettably, all too often, I knew that my patient was more than likely to be dead within five years anyway.

The second revelation was five years ago—September 8, 2009—to be exact. I remember it so clearly. My sport of choice was marathon swimming, and I followed what I believed to be the iconic healthy athlete’s diet. I had just completed an especially difficult swim into the current from Los Angeles to Catalina Island, becoming one of a dozen people to do that swim in both directions.  After more than 14 hours in the water, I got on the boat to begin the long ride back to Long Beach Harbor, and my wife looked at me, in my speedo, 40 pounds heavier than I am today, and said, “Honey, you’re a wonderful swimmer. But you need to work on being a bit less not thin.”

And not only was I, well, fat, despite all this maniacal exercise, but it turns out I was also pre-diabetic.

Her comment launched me into a series of nutritional self-experiments. I was already working out three to four hours a day, so the problem couldn’t be sedentary behavior. It had to be what I ate. Over the next year I manipulated my diet until I found what worked for me, which paradoxically didn’t involve eating less, just eating very different from the food pyramid. Along the way I became obsessed with reading the nutrition literature. What I learned was that the evidence supporting our dietary guidelines was ambiguous, at best, and occasionally contradictory. There was a real dearth of evidence to support what seemed like the obvious questions.

I realized then, that if the guidelines didn’t work for me and if I can’t figure this out, with my background as a doctor and someone who studies healthcare, maybe they don’t work for a lot of people. Maybe there are systemic problems here. Maybe these problems were at the root of the ongoing epidemics of obesity and diabetes. Lots of maybes…and not a whole lot of clear, solid, unequivocal answers.

Since then, I’ve made a personal and professional commitment to finding the answers. And if the studies don’t exist to give us unambiguous evidence, then raising the funds and enlisting the researchers necessary to do those studies.

What does success in public health look like?

When trying to understand complex problems, I like to start with success stories, identify patterns and work backwards—reverse engineering success. Consider the following graph.

It shows the death rate from AIDS in the United States between 1981 and 2010. The point of this graph isn’t subtle. Death from AIDS rose steadily and monotonically through the mid-90s and since then has declined steadily. Though people still die from AIDS, this still represents a success story in health policy and science. For those experiencing the personal tragedy of AIDS, this is salvation.

So why did it happen? Well, first, the cause of the disease was correctly identified—the HIV virus—in the mid-80s; and second, by the mid-90s highly active anti-retroviral therapy, or HAART therapy, was able to effectively treat the virus and prevent progression to AIDS.

Again, two things happened: the cause of the disease was correctly identified, and an effective treatment was developed by an enlightened healthcare profession.

This is what success looks like.  Now, let’s compare this story to that of obesity and diabetes.

Do we have this situation under control? The case study of “failure”

Let’s take a look at this figure. It shows the prevalence of diabetes in the United States over the last hundred-plus years. (Thanks to Gary Taubes who dug up these stats while researching his upcoming book.)

In the early 1900s the leading figures in medicine, Sir William Osler at Johns Hopkins and Elliot Joslin at Mass General, did exhaustive analyses of the number of patients with diabetes based on hospital records and census data. As you can see, diabetes was exceedingly rare in the 19th century—somewhere between about 3 and 500 cases per 100,000, depending on the analysis.

By 1970, around the time I was born, that number was up to 2,000 cases per 100,000, and between 1970 and today—at a growth rate of nearly 4% per year—that number has risen to more than 8,000 cases of diabetes per 100,000.

Worse yet, type 2 diabetes is now spreading into demographics previously naïve to the disease, particularly children. I don’t think any of us in this room today would argue that we have this situation under control. So where are we failing? Many of you understand the world of business. If this were a business, we’d be asking a lot of questions at this point, or we would be out of business. Like any business, we have two possibilities. We either look at our business plan (the basic premise for how we’re going to succeed) or the implementation of that plan (the way we operate on a day-to-day basis).  When confronted with a runaway epidemic like this, we have to address the same two basic issues:

Either we understand the underlying cause of this disease and we have a good plan in place, but few individuals have the willpower or wherewithal to avoid the disease—whatever it is…In other words we’re not executing the plan.

Or, we don’t understand the disease in the first place and we’re giving the wrong advice. In other words, we don’t have the right business plan.

In this latter scenario, the failure is not one of personal responsibility, but of our assumptions about the cause of this disease. And these two scenarios have very different implications.

I am not certain which of these is more likely correct, but I do know the risk of ignoring the latter in favor of the former is not a choice we can make any more as a society.

So, maybe the question we should be asking is whether we are right about the environmental triggers of this disease—the underlying cause. Is it as simple as gluttony and sloth and a food industry that overwhelms us with highly-palatable, energy-dense foods, or is there something specific about the quality of the food we’re consuming that triggers these disorders? If we don’t answer this question about what is it in our environment that’s causing this disease correctly, just like we were able to answer it in the mid-80s with HIV’s role in AIDS, we can’t effectively treat the disease. Instead we’re stuck putting on Band-Aids.

Here’s another way to think about it: imagine this panel was on a new crisis in aviation. Planes are constantly crashing—falling out of the sky—and killing 4,000 people a day (just like obesity-related diseases are killing 4,000 Americans a day.) And you’re a pilot and you tell me that surely we understand the principles of flight. Right. Sure, we might suspect user error to be part of the problem. (Maybe the pilots aren’t flapping the wings hard enough!) But, maybe a better idea would be to go back to the drawing board to make sure we really understood this whole aerodynamics thing and we didn’t miss something important?

That’s how we think we have to look at this problem: 4,000 people in this country are effectively falling out of the sky every single day—dying—and we’re saying we’ve got it all figured out, and people just need to adhere better to our advice. I’m not confident that that’s the solution. Nor should you be.

Is there a policy-based solution to this problem?

Surely policy changes will play a necessary role in restoring our health. But it may be less about ‘how?’ and more about ‘when?’  I’d like to refer to this slide showing per capita cigarette consumption in the U.S. from 1900 until today—the number of cigarettes consumed is shown in grey with death rate from lung cancer superimposed in red.

Smoking and lung cancer

This is another success story. People in this room contributed to that success. The little colored triangles on the grey line are major milestones in science (red), market forces (green), and policy (blue). This is a great example of what one might call the “critical confluence”—scientific elucidation, policy action, market response, and behavioral shift—all coming together to save lives.

But, as in all things in life, algebra included, the order of events matters!

Which came first then? In the case of smoking and lung cancer, it was unambiguous scientific clarity, which in this case happened in the 1940s and 50s and resulted in the 1964 Surgeon General’s report. This information was absolutely necessary to drive the policy action, the market response, and the behavioral shift that followed. Without the knowledge that lung cancer is caused by smoking, no amount of policy or market response would have led to the necessary behavioral shift and so a meaningful reduction in lung cancer incidence.

When we consider the current situation with obesity and diabetes, we may still be missing the equivalent of the scientific clarity linking unambiguously the environmental trigger (smoking) that provided the obvious method of prevention (smoking cessation). And, again, if we think we do have that information, we have to ask why we’ve thus far failed to meaningfully prevent and successfully impact these disorders.

If the death rate from AIDS was still skyrocketing, I think we’d all agree we would either call into question our faith in HAART, or even the premise that HIV causes AIDS, if not both. Yet, in the face of skyrocketing obesity and diabetes, we play the who’s-on-first game all day long pointing fingers at people and industry.

Until we clearly identify the dietary triggers of obesity and diabetes, policies to shift behavior may be misguided and premature, despite their best intentions. Despite our best intentions.

I’m arguing that the policies so far may have been just that. Premature. And based on incomplete or faulty information. In other words, we may have the wrong business plan, but we blame our execution of the plan on our failure.

Parting shot

Today, we’re talking about a problem that touches, directly or indirectly, every single person in this room. It’s a topic that can be confusing and at times polarizing. We can’t lose sight of the big picture, which is easy to do when we just look at this problem through the lens of personal responsibility or will power. Remember, I used to think that “If people just learned to eat ‘right,’ (whatever that is), exercise and control themselves and their diet, everyone would be fine.”  Today I reject that logic and the hubris that fostered it.

In the business world we know that the wrong strategy, no matter how well implemented, gives us little chance of success. Similarly, the right strategy, if poorly executed, often fails. What we need is the right strategy first and then the right execution second. At the moment, it’s hard to argue that we’re not failing with at least one of these two tasks. The question is which one.

Much of the discussion around this topic focuses on the execution; little attention is paid to the strategy or underlying insights that form the basis of the intervention.

Just 40 years ago the prevalence of obesity in this country was about one-third of what it is today, and that of diabetes about one-fifth. Is this all because Americans have become too gluttonous and slothful and the food industry figured out how to make food cheap and addictive enough? That they simply are too lazy and stubborn to do what we’ve been telling them to do—eat a little less, exercise a little more—for fifty years. Maybe. And I trust many good minds are already working on solutions to address that hypothesis.

However, what if the problem isn’t about non-compliance but about the nature of the advice we’re passing along. Maybe it’s our failure in that we have a simple idea about what causes these diseases, and like many simple ideas—paraphrasing Mencken here—it just happens to be wrong. It’s hard to fathom that two out of three Americans are simply too lazy to be active and too stubborn to eat healthy, despite losing their lives and their loved ones to the negative sequelae of these diseases.  I find that hard to believe.

So, what if the problem is that our dietary advice is wrong in the first place? And incorrect dietary advice has resulted in an eating environment where the default for most people is a diet that causes obesity and diabetes?

If HIV or lung cancer were still spiraling out of control—as they were thirty and fifty years ago before the causes were unambiguously identified—the great minds in this country and the world would be leading investigative teams of scientists to figure out what we may have missed in our understanding of the cause of these diseases. We would not be complacent, perhaps because it would be harder to blame these diseases on the victims and their lack of will power. When we fail completely to prevent two devastating disorders for half a century, isn’t it time to investigate what we might have missed—what is it about these disease states that we do not understand? If nothing else, shouldn’t we hedge against the possibility—however slim you think the odds are—that we’re not as smart as we think we are. Those of us who are here today because of our business acumen know the importance of hedges in business. Isn’t it time we did that with obesity and diabetes?

Photo by PICSELI on Unsplash

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  1. I recently joined a low-carb online forum, and notice a lot of people saying things like “I did low carb a few years back, and lost a bunch of weight, but then [some life event] happened, and I gained a bunch of it back”.

    It’s got me thinking about one criticisms low carbers make: Calorie restriction doesn’t work for most people over the long term.

    If a person fails to abide by a diet, it doesn’t matter what the diet was…it still follows the prototype – start diet; moderate success; stop diet; gain it all back.

    Am I drawing a false equivalent here?

    It seems to me that one could counter the low carber’s argument with the argument that maybe no diet works for *most* people over the long term…and in that respect, the arguments would essentially cancel each other out, and neither side has the upper hand on that point.

    • Hi Tim,
      I don’t agree with that idea.

      When you follow a hypocaloric diet, you are always going to end the diet and you are doomed to gain the weight back. You can’t eat 1200 calories/day forever.

      When you eat low-carb you can follow the diet as long as you want. There is no deadline and there is no reason to gain the weight back because you don’t reduce your metabolism.

      May be you find this insteresting: https://novuelvoaengordar.com/2014/07/24/how-to-avoid-the-rebound-effect-of-the-diets/ (I just translated it from spanish to english)

    • Vicente – Thanks for the link!

      Don’t get me wrong, I completely agree with you; I just think that there’s a subtle distinction between “Low carb diets increase likelihood for long-term success” versus “People fail on hypocaloric diets over the long term; therefore, low-carb diets are better”.

      People can (and do) fail, regardless of dietary changes they make.

      I’m constantly on the lookout for logical fallacies, and I’ve certainly framed this one to beg the question…it could be that I see these arguments being made in the company of people who have already pre-supposed low-carb is the better lifestyle.

    • Tim, I agree with you. Many people don’t stick with low carb long term and have difficulty adhering to any diet. I have been thinking about this a lot lately. I think that ketosis does help one lose weight and also purge other unhealthy organisms in the body, but perhaps it’s best implemented as a cycle. If we think about humans before the modern era, for most there were long periods of time (i.e. winter) where carbs were inaccessible, but during growing seasons carbs were accessible. Our bodies are certainly equipped to deal with carbs, so I’m not sure if I buy the argument that any carb reliance at any point in your life is unhealthy. There may be times when it was perfectly normal to fill up on fruits/vegetables and store some extra weight on your body. Perhaps it is also somewhat genetic, for instance, if you are a descendent of a less agricultural area of the world (Nordic, for example) you may be less able to handle carbs. So the issue, I believe, is more so that we find any weight gain unacceptable, when perhaps it is built into our survival system and a little bit is fine. The good thing about low carb is that it doesn’t mess with your metabolism in the same way as low fat and calorie restriction, so it makes excess weight easier to lose when you stop running on carbs. Just some food for thought… I’m sure it’s a bit more complicated depending on the individual and their health condition.

  2. I am about to turn 70. Looking back at what I now see as metabolic syndrome (including infertility) and insulin resistance I am beginning to understand my individual experience. I was diagnosed with hypothyroidism 20 years ago and depression 3 years ago. I take meds for both and am now a very low carb eater (with 30lb weight loss) My question is any thoughts you have on metabolic/hormonal relationships among these things: inflammation, low thyroid, insulin resistance, function of fatty tissue and depression (fatigue), all of which I still cope with. I am frustrated because I feel it likely that research and “best practice” will not make it to my local M.D. before I am dead. Thank you for your brave work.

  3. TEE – NOT

    Using TEE – total energy expended to explain your argument was probably a mistake –

    Everything besides REE – resting energy expended is exercise – ree + non-ree(or exercise) = tee

    The difference between the LF diet and HC diet using the REE CHART is (120-200) or 80 calories –

    You can’t use the TEE CHART unless exercise – either decreasing it or encreasing it (the only way TEE can change) – is part of your argument

    An 80 calorie decrease in DAILY REE is almost mute –

    Using the REE TABLE about a 1/3 of the group responded poorly to all the diets – (low fat – low glycemic index – low carb) or from almost 150 to 500 calorie drop)

    About 1/3 averaged abouut a 120 calorie drop –

    Another 1/3 went from a 60 calorie drop on the low fat diet too as much as a 200 calorie increase on the low carb diet

    So it seems to hold true that people can be devided into three general groups on how they respond to diet –

    About 1/3 doing poorly on all the diets – another 1/3 group more nuetral but still somewhat poor and 1/3 doing nuetral or just slightly poor on the low fat diet but doing very well on the high fat diet – for this 1/3 group your argument makes a slight amount of sense

    Still – personaly – I do not think any of these chages in calories are what causes rebound weight gain –

    When the majority of people go off planned eating and into the realm of mindless eating – the foods they eat and the amounts they eat change a great deal – they generally over-eat to obtain enough protein 1. – indulging in fats actually increases hunger to the point that they need 2000+ calories to get full 2. and the increase in carbs produces a hormonally created weight gain and whatever fat they do eat it tends to be stored permantently 3.

    That said – mindless eating cuases great problems for about a 1/3 of people – slight problems for 1/3 of people and no problems fo 1/3 of peple (weight wise)

    The question of why people gain weight – post planned eating – is obvious –

    The real question should be ? What keeps the people who need it on a planned eating program their entire life ?

    The connection between energy output and caloric balance: I difine these as two seperate things because they are – the point is these two seprate things need to communicate with one another –

    1.This communication is best done with low fat beans(soy beans are about 40% fat)

    2. A near or ketogenic diet provides a similarly result

    3. A very very low fat fruit/starch-vegetable high calorie diet also a similar result

    All these methods have an effect in the brain – and promote communication between energy output and caloric balance

    All three of these groups have a definite sort of mindset – they tend to stay on track and plan what they eat –

    which is better than mindless eating ?

  4. How To Eat An Egg

    Having nothing more dutious to do – I thoght I’d ramble and inflict upon you – how to eat an egg –

    Put the whole raw egg with shell in your mouth and chew – that’s how I do it –

    • I run when chased. Or late for a flight. Or playing with my girl. Otherwise, I gave it up in college. Used to run 60+ miles a week growing up, until about age 22.

  5. Haha, that video is hilarious. I bet this is how the conversations at NuSI go down. “I’m a doctor too”. LOL!

  6. Hi Peter,

    I came across your website when I started my keto diet. You have a wealth of information that I have been slowly pouring over the past month.

    I fully understand that you cannot help me without knowing a lot more about my particular case. Here’s my history and my question will be at the end.

    1. I am a South Asian Indian, Male 32 years. I lead a mostly sedentary lifestyle. A couple of weeks back I was diagnosed with Uveitis and further research indicated that I had high inflammation and HLAB27 gene which predisposes me to a host of auto-immune and auto-inflammatory conditions.

    2. There is some research available that seems to suggest cutting out carbs and primarily starch reduces inflammation. I have been in Nutritional Ketosis (at least according to the ketone strips) for about 3 months now. I have been a lifelong vegetarian (by birth) and have occasionally eaten meat over the past 2-3 years. As part of my keto diet, I have started eating a lot more meat. Mainly beef burgers with cheese as I still am getting used to the taste of meat. Since my inflammation started, I added salmon burgers as well.

    Here are my questions
    1. As part of your n=1 experiment, were you tested for any inflammatory markers (EST, C-Reactive Protein, TNF-A etc). Did you notice any changes to any inflammatory markers prior to and after nutritional ketosis ?

    2. I am trying hard to find any link between ethnicity and processing of meat. Have you had any research or are you aware of any research done among different ethnicity that show how ketosis might affect them differently?

    For e.g. I can easily trace about 10 generations of my ancestors due to religious reasons would have been life long vegetarians. I understand that 10 generations is nothing in terms of evolution, but meanwhile could I have lost any enzymes or anything that could prevent me from processing meat. The reason for this is two-fold. It is hard to be on a ketogenic diet and be a vegetarian at the same time 🙂

    3. I am also willing to do a n=1 experiment on myself to try and see if any interventions might work. Is there any organization that you use that helps you with your tests or your doctor works with you to order these ? While I don’t have a lot of money, I believe I could try to improve my parameters.

    I have a lot more questions. I don’t want to take up too much of your time, but any guidance you can give me towards my self-improvement would be invaluable. My email address in case you are interested is d (dot) kiran at yahoo com


  7. Peter, A few minutes ago, I finished watching your TED presentation and felt a connection. I’ve watched hundreds if not thousands of the presentations and there are exactly two of them that have hit me right in the guts. They all have value. But number one was a 50 year old man demonstrating a new method of tying shoes. Changed my life and summed up everything I’ve learned over the past 3 yearsy. Viewing things from a slightly different perspective changes everything. Number two is your presentation. In your talk, you mentioned melanoma, shocking dietary changes, reducing exercise resulting in improvements, etc.

    I could stop and simply say beautiful! But, I’ll continue to ramble for a bit. I’m not associated with the medical community at all. I work in the field of meteorology but health is my passion. Thought I knew everything until I hit 40(over 3 years ago). From the age of 20 until 40, I took an ACE inhibitor. Developed hypothyroidism and vitiligo at the age of 35. I’m 6 foot and weighed about 170 until the age of 30. Creeped up to 220 in my 30s. Was on a low salt diet from the age of 13(when first diagnosed with mild hypertension). Was tested extensively(by the VA), when I was 20 in order to determine the cause of my extreme hypertension. At the end of the day, it was considered essential. I’ve also been a chain smoker since the age of 23 and still am today.

    One day, when I was 40, I asked myself a question: just why is drinking 8 glasses of water a day so important? Couldn’t really find a good reason. At this point, I have not consumed one drop of plain water in 3 years. I drank the 8 glasses prior to the age of 40. Noticed positive changes quickly by simply reducing water consumption. If cutting out water has this effect, what else? Increased cigarette smoking, increased coffee intake, reduced exercise, Increased dietary fat, decreased carbs, went crazy with salt, and began consuming fermented foods. Started sunbathing, staring into the sun, and all kinds of other crazy things. Within one year, I had lost 70lbs, the vitiligo that covered most of my legs, feet, hands, and arms was nearly gone. My blood pressure began to drop dangerously low and I dropped both daily meds(thyroid and hypertension). No need for the meds today and my VERY skeptical doctor agreed(not with my actions but the no need for meds).

    At the age of 42, went in for blood tests(6 vials) and plotted time series back to the age of 20. Remarkable! Introduced some exercise earlier this year and participated in masters sprinting this past June. Like the blood tests, it(sprint time) was beneficial data to compare with past times of my youth. At this point, I don’t view the extreme exercise as healthy, but really don’t know? At the very least, it’s a slippery slope.

    Today, I feel as though I know nothing because I thought I knew much and everything was incorrect. This is the sense I got from your presentation. A helluva long winded way of saying you’re not alone!

    Don’t know the origin of this quote, but it feels right:
    True knowledge is knowing the extent of one’s own ignorance.

  8. After about 4 weeks of fine tuning my eating, I am finally in ketosis. I’ve lost 13 lbs. and my energy level is unbelievable. Just as you described in your experience, no more 3pm crashing. I work till 6-7pm and still leave with energy to spare. I have long way to go to get to my goal (45 lbs.). You have changed my life. Thank you!

  9. Dr. Attia,,
    In your opinion do you believe that radiation from medical tests such as multiple CT scans can cause cancer? If so what can be done to combat this type of radiation ? Do you think lthat the belief of less than 100 Msv that the risk is minimal? A lot of patients are not told of the risks of radiation from cr scans . Thank you.

  10. Thank you. So two Ct scans a year could even if it is below the level of 100 msv? Is the 100# per year or during your lifetime?

  11. Dr. Attia,
    Regarding diabetes, once a person has it, wouldn’t a start for better control and more success in helping manage, and perhaps reverse some (perhaps many) cases, if test strips were non-prescription items and less expensive? In my years of dealing with diabetic patients, usually those who fall slightly above low income, a large problem with compliance and other related failures in personal care, testing and owning blood sugar levels is inhibited by not being able to afford test strips, and therefore not renewing prescriptions. What are your thoughts?

  12. Thanks a lot for your great postings, I just found them yesterday and I haven’t stopped reading them. I just landed here by coincidence using the word ‘ketosis’ because I’m thinking about starting a diet called ‘pronokal’ coming from Spain where one only eats their powder proteins with high biological value. On top of that one receives all kind of supplements to take at different times of the day and one needs to eat one spoon of olive oil per day. Since I have never done a diet before, and have 12 pounds to loose I am just wondering if this is right for me… And after reading some of your posts looks that this ketosis stage is the right thing to do, even if I was pretty scared of it, but now, I feel this is what I should do…

  13. Pyramid Caloric Design

    When viewing a 2-dimensional pyramid face on – some things are apparent – it has one top point and two bottom points and is structualy stable in this position –

    Turned upside down with it’s one point on the ground it becomes unstable and will fall down at some point in time(sooner than later) –

    Thisleads into the 1/3 – 2/3 rule a rule that has some different applications —

    The top of are pyramid – the one point – represents maximum calories and the two bottom points resting on the ground – represent two macronutrients of minimum calories

    So– there are three macronutrients and three points of a pyramid – this sort off fits nicely together –

    The point of all this –

    The unstable pyramid (upside down) represents two macrobutrients(maximum calories) — any two – and is here considered to produce bad results –

    1. High Carb and High Fat – (minimum protein)
    Unless calories are very carefully controlled in this setup – for a negative example – 1000 calories Fat – 1000
    calories carb – fat accumulation is fairly certain and since more fat equals more hunger – 2000 calories fat and 2000 xalories carbs is probabaly more likely tp occur – many morbidly obese peoiple eat just this way –

    This combination simply does not work –

    2. – High Fat and High Protein – this negative combination fails most often becuase it’s diffucult to limit intake from fat calories when past a certain amount is eaten – 2000 calories is what it takes to get full on fat – add an equal amount of protein or even less and you have a recipe for fat gain –

    3. – High Protein and High Carb – 250 grams protein is about 1400 calories – add 1400 calories carbs to this and excess glucose production from two different sources occurs – plus too many calories – period – it’s a negative combination –

    Okay – these are the bad combinations and there are only three possibility’s –

    Three Good Combinations

    Here only one macronutrient is maximised and the other two macronutrients are minimum as in a stable upright pyramid –

    1. – High Fat – (minimum carb and protein)- this is a standard Keto type diet that even at 2000 calories fat results in fat loss for many people –

    but fails to work for many people also – unless 25% body fat or higher is your idea of fun – there are simply too many calories here for many men and even more women to lose fat beyond a certain point –

    2. High Carb – (minimum fat and protein) – this combo works – examples being Dorian Rider and his Girl-Friend – I myself lost 60 pounds eating three heads lettuce and 1/2 cup peas for six straight months and nothing else – it’s easy to eat very low calorie on this combo –

    3. High Protein – (low fat and low carb) – this a resonable combo also – even extreme amounts of protein (1000 grams or more eaten evenly thru a 24 hour period) – results in zero weight gain and can have a rather dramatic effect on hormones – if you restrict calories following this extreme amount of injested protein (preferably whey protein) – weight loss can be quite certain – this doesn’t need to be done more than like once a month or at most once a week –

    This is a form of glucose – protein produced carb loading that can actually work – as opposed to other methods – which may and probabaly will not work –

    Iv’e eaten 1500 grams whey protein spaced evenly over a 24 hour peroid and nothing else and felt great the next day and lost fat follwong this –

    So to sum up – theirs three good combo’s and three bad combo’s –

    Only one macronutrient should be maximized and the other two mimimized for good results –

    • The Circle

      The circle sits below the pyramid – it’s top arc(the circle) just touching the bottom of the pyramid –

      Geometry and mathmatic’s avoid all shopistry – thank god –

      The circle is most interesting – for only a tiny portion of it’s top arc touches the bottom of the pyramid – the circle sit’s atop a square where only a tiny portion of it’s bottom arc touches the top of the square – what is says is this –

      calories should be limited from 0% to (25% or 30%) –

      In effect – calorie restriction is a Law it’s not something for debate or opinion – period

      Not eating is likely as important as eating –

      As long as calories are limited to between 0 to (25% – 30%) of RMR(resting metabolic rate) anywhere within these marks – should allow anyone to pratice fasting – trickle fasting – where 20 calories is eaten if needed to maintain sanity – once every four hours or so is the most comfortable way to fast(1/3 teaspoon dried coconut flakes – 1/2 teaspoon whey protein – a tiny bite of bakers chocolate) is what I prefer – if you try to fast at a 0 calorie rate you may fail – or not – but just be flexible if needed –

      Daily un-interupted full feeding is not human – never has been and never will be and no amount of ugly rhetoric will ever make it so –

      At ant rate – the geometric shapes and their relationship to one another tellsme all I need to know –

  14. Hi Peter,

    It seems as though the body works as a machine, it needs certain “fuel” to run properly. Some “fuel” is better then others (for different people), and it will run smoothly in the long run.

    Observational studies (nutrition speaking), seems to be incomplete and uninformative, at least what I have read (not all, but when it comes to making decisions for the masses, studies that do not hold a lot of ground are used).

    What would be the perfect (realistically speaking) study?

    Why isn’t there a study with 3,000 people (all volunteers), have a controlled environmental (nothing unethical) and try to find all the information possible rather then “guessing ” through observational studies.

    I found your blog 6 months ago and it has been an eye opener. I apologize if the questions sound “amateurish”.

    Thank you

    • I’ve certainly commented on my view of observational studies. If they find something strongly correlated, it’s worth investigating. When they don’t (which they usually don’t), we sure waste a lot of time on them.

  15. There is a very fundamental problem (with diabetes, for instance) that almost always goes unmentioned. That is the economic problem of addressing these common and severe conditions by medical practice. At the whole societal level it is simply unaffordable, and so much so that it is doubtful that clever policies can solve the problem.

    Dr. Richard Bernstein has suggested the idea of group training for diabetics, recognizing that his own unique (and zealous) practice of intensive care is not economically viable for almost any conventional MD (nor for very many patients, IMO). But that interesting notion alone flies in the face of conventional practice, and it would probably not be enough to generate a viable business model by itself either.

    The economics of food itself is also a huge counterweight to healthy eating, of course. But a bottom-up growth of wisdom regarding healthful diet might take place over time in industrial societies.

    Top-down policies are virtually guaranteed to fail. The vested interests already built up will always be more powerful in influencing and corrupting such policy than those of any newcomers motivated merely by ideas of public welfare. It is these same top-down policies that have created the problem, but the days of Ancel Keys (i.e. outsized influence of a few individuals) are also arguably a thing of the past.

    For those of us who have lived most of our lives eating a SAD and have suffered damage to various tissues, I think we must each attempt to cope as best as possible on our own. I am one such.

    The young now have a big opportunity to employ a better diet given the amount of easily accessible info available. But this still takes effort and commitment on the part of each such individual. And it takes a certain independence of thought and behavior. And education and economic wherewithal of each individual.

    The old saw about how the old scientists (or doc’s or whomever) must die out before the new ideas and practices can take over is grossly optimistic. It doesn’t work that way. The old guys are installed in positions of power and influence, and many young guys (and gals) go to work for them and take advantage of associating with them. They inherit the same interests. Thus the torch is passed along, potentially indefinitely. It is much easier to make a living by going along to get along rather than being a zealot or maverick. At the institutional level it is a tough nut to crack.

    And by the way, although I have pored over the research literature on diabetes and think that a lot of good work has been done, we certainly don’t understand this complex and heterogenous condition very well. I wish it were not so. This lack of understanding makes it difficult for anyone to get a toehold in arguing for an ambitious public policy of any sort, and there will naturally be much disagreement about what should be done.

  16. Hi Peter

    I regularly revisit the articles (or ‘blogs’) you write and I hunt lie and low for material of a similar quality online (and in books). In summary, nothing compares, thank you again!

    Are there any resources you can recommend for someone obsessed with the type of questions you ask?

    Particularly anything that discusses energy expenditure and metabolic processes in enough detail to be meaningful without requiring years of study to understand.

    Many thanks


    • I think there are lots of good blogs out there. David Allison has a weekly mailing list of studies that’s mostly full of lame studies, but always has a gem or two.

  17. I think what I realize after reading your post is how the underlying paradigm of our current situation is one of distrust between patient and caretaker/advisor (doctor, nutritionist, policy maker, etc). I spent decades trying to make the low calorie, low fat, aerobic exercise formula work to my advantage. And for some stretches of time, I managed, albeit with a great deal of struggle.
    A few years back, I ended up in the hospital with a.fib, and as it turned out, low thyroid, pre-diabetes, sleep apnea, blood lipids going in the wrong direction, and more than 100 lbs overweight. I admit to a certain amount of despair/frustration with the diet/exercise situation after 10-12 years of perimenopause/menopause and my body’s seeming inability to lose weight. Yet, I still blamed myself.
    I left the hospital with a renewed commitment to addressing the problems at hand. I used the USDA Rate my Plate program to track my eating. I got my saturated fat levels to miniscule proportions. I also tightly controlled my other fats. I was the queen of nonfat eating. I ate nothing but whole grains. I had already eliminated artificial sweeteners. And, after about 4 months, removed all sweeteners. I ate very little meat, and mostly skinless chicken breasts, or fish. My weight barely budged, and the lipids continued their negative path.
    I had found Gary Taubes in my research, and read his “Why We Get Fat” book, and eventually Good Calories, Bad Calories”. I was pissed. I felt betrayed across the board. I decided to try Atkins, even though it scared me to death, for 30 days, and see how I felt. Within two weeks I knew there was no going back. The change in energy was dramatic. My bloodwork history did a dramatic change for the better. I was not hungry all the time. I thought about so much more than what I was going to eat, and when I could eat it. I now eat a diet that I would describe as ketogenic Paleo, with no eggs, dairy, nightshades, and next to no fruit. I feel much better. My inflammation levels are much lower.
    I still have a lot of weight to lose. And this is where life becomes problematic in my relationships with doctors. I find myself being coy about my dietary changes. I tell them I am eating low carb. I am even beginning to say high fat/low carb which causes raised eyebrows. I don’t fully trust that they are on my team. Likewise, I don’t believe they fully trusted me when I told them how fanatically I was following the low calorie/low fat recommendations.
    How do we fix the fix we are in, without addressing this basic underlying distrust of one another? And how comfortable are doctors with changing their recommendations? Are they afraid to open the door to low carb high fat and have to explain the 180-degree turnaround? This is a long post to get to my essential questions. Sorry for that!

    • Thank you Judy for your post. I find myself in exactly the same position. Your post echoed the very same sentiments I am struggling with. I would love to see your post as an article perhaps in Woman’s Day, Good Housekeeping, or even Oprah. Keep up the good work and know there are many more just like you who feel the same.

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