February 22, 2012

Biochemistry

Why Weight Watchers is actually a low carb diet

Read Time 12 minutes

Invariably I get asked the question, “If carbohydrates are so bad, why did [so-and-so] lose weight on the [such-and-such] diet?”, where “such-and-such” diet is not a “low-carb” diet. Obviously, this is an important question and a pretty complex one.

There are several layers to this and, frankly, there are some things we can’t fully explain – I’ll always acknowledge this. That said, many of the successes (at least weight-wise, though hopefully by now you realize there is much more to health than just body composition) of popular diets can be explained by a few simple observations. Above is a list of this year’s most “popular” diets, according to Consumer Reports. Popularity, of course, was determined by a number of factors, including compliance with current government recommendations (sorry Atkins), number of people who have tried the diet, and reported success on the diets. So it’s actually quite misleading when the report says it’s reporting on the “most effective diets.”

Keep in mind the average American (i.e., at baseline) consumes about 2,500 to 2,700 calories per day (different sources, from NHANES to USDA will give slightly different numbers for this, but this range is about correct), of which about 450 grams (about 1,750 calories worth or about 65% of total caloric intake) comes from carbohydrates. You can argue that those who are overweight probably consume an even greater amount of carbohydrates. But for the purpose of simplicity, let’s assume even the folks who go on these diets are consuming the national average of approximately 450 grams of carbohydrate per day (in compliance with governmental recommendations, as a percent of overall intake).

Take a look again at the figure below, which shows you how many calories folks are consuming on each diet and, more importantly, where those calories come from. [It’s not actually clear to me how Consumer Reports was able to figure out exactly how much folks eat, beyond self-reporting or diet-book recommendation, mind you. In other words, these numbers could actually be wrong, but it’s what we’ve got for now.]

 

Why diets work

[Note: in a more recent (2017, consumerreports.org) analysis, the following categories were included: initial weight loss, maintenance, calorie awareness, food variety, fruits and vegetables, and exercise.]

You’ll note that people on these diets, including the strictest low-fat high-carb diets, significantly reduce their total amount of carbohydrates (therefore reducing the amount of insulin they secrete). Even the Ornish diet, which is the most restrictive diet with respect to fat and most liberal with respect to carbohydrates, still reduces carbohydrate intake by about 40% from what people were likely eating pre-diet.

The reason, I believe, most of these diets have some efficacy – at least in the short-term – is that they all reduce sugar and highly refined carbohydrate intake, either explicitly or implicitly. No one on the Ornish Diet or Jenny Craig Diet is eating candy bars and potato chips, at least not if they are adhering to it. Hence, these diet plans do “clean up” the eating habits of most folks.

Someone made a great point in response to my post on why fruits and vegetables are not actually necessary for good health. The point was, essentially, that telling people to eat 5-6 servings per day of fruits and vegetables can hopefully drive a beneficial substitution effect. If you tell someone who eats Twinkies, potato chips, and candy bars all day to eat more fruit (and they do), you’ve almost guaranteed an improvement in their health if they eat bananas and apples instead of the aforementioned junk food. That doesn’t mean bananas and apples are “good for you” – it just means they are less “bad for you.” Here’s the kicker, though. We’re led to believe that the reason such folks get leaner and more healthy is because they are eating more fruits or more vegetables or more grains or more [fill-in-the-blank], rather than because they eliminated the most egregious offenders from their diet.

I can’t really overstate this point. I have no intention of engaging in a battle with proponents of plant-based eating or no-saturated-fat diets. I’m reasonably confident that the proponents of these diets are good people who really want to help others and have nothing but the best intentions. But that doesn’t mean we can or should overlook the errors being made in drawing their conclusions. Many people do very well on plant-based (e.g., vegan) diets, for sure. But why are they doing well? That is the single most important question we should be asking ourselves. Why did the people in the China Study who ate more plants do better than those who ate more animals (assuming they did)? Parenthetically, if you actually want the answer to this question, beyond my peripheral address, below, please read Denise Minger’s categorically brilliant analysis of the study.

I know a lot of people who eat this way and, I’ve got to say, these folks do not eat a lot of sugar or a lot of highly refined carbohydrates. In fact, many are so conscientious of their health that they actually have far better carb-habits than most (e.g., which breads they choose, which fruits and vegetables they eat).

While I do plan to write an entire post on this topic of what one can and cannot conclude from an experiment, I do want to at least make the point here: The biggest single problem with nutrition “science” is that cause and effect are rarely linked correctly. Stated another way, it’s one thing to observe an outcome, but it’s quite another to conclude the actual cause of that outcome.

Let me digress for a moment to provide an important example of this phenomenon. One of the most prominent figures in the diet/nutrition space is Dr. Dean Ornish. I don’t know Dr. Ornish personally, and I can only assume that he is a profoundly caring physician who has dedicated his life to helping people live better lives. He is nationally, and internationally, regarded for his efforts.

One of the reasons for his prominence, I believe, is the work he did in the early 1990’s on lifestyle modification and the impact it can have on reversing coronary artery (i.e., heart) disease. In particular, Dr. Ornish was the principle investigator on a trial published in the journal The Lancet in 1990. An abstract of the paper can be found here. But as always, I STRONGLY encourage folks with access (or folks who are willing to purchase it) to read the paper in its entirety. For people who don’t want to read the study completely, or who may not have much experience reading clinical papers, I want to devote some time to digging into this paper. Why? Well, for starters, reading abstracts, hearing CNN headlines, or reading about studies in the NY Times doesn’t actually give you enough information to really understand if the results are applicable to you. Beyond this reason, and let me be uncharacteristically blunt, just because a study is published in a medical journal it does not imply that is worth the paper it is printed on. My mentor at the NIH, Dr. Steve Rosenberg, once told me that a great number of published studies are never again cited (I forget the exact number, but it was staggering, over 50%). Translation: whatever they published was of such little value that no one ever made reference to it again.

I am, to be clear, not implying this is the case for this trial, but I want you to understand why it’s important to read papers fully.

This trial, The Lifestyle Heart Trial, prospectively randomized a group of not-so-healthy patients into two treatment groups: the control group and the experimental group (or what we’d call the “treatment” or “intervention” group).

The experimental group (22 patients) was asked to adhere to the following changes for one year:

  1. Change their diet to a low-fat vegetarian diet (10% fat, though obviously no animal fat; 15-20% protein; 70-75% complex carbohydrates) with several other restrictions (e.g., no sugar, flour, or refined carbohydrates; limited alcohol; no caffeine; limited salt; limited cholesterol intake; no egg yolks)
  2. Smoking cessation
  3. Exercise regimen (minimum of 3 hours per week, at minimum of 30 minutes per session)
  4. Stress management (e.g., meditation, progressive relaxation, breathing modification)
  5. Join social support groups for help with adherence (twice weekly)

The control group (19 patients), obviously, remained under “usual-care” (i.e., no change in lifestyle).

One aspect of this trial that made the results particularly interesting was the use of angiography to actually measure and document the coronary artery lesions (i.e., blockages in the coronary arteries) in the patients before and after the lifestyle interventions. The study was not powered to measure “hard” outcomes (e.g., heart attacks, strokes, cancer, death), so the use of blood markers, physical parameters, and angiography were the best proxies for a reduction in disease risk. In other words, there were not enough subjects in the study to determine a difference in these “hard” outcomes, so we can’t make a conclusion about such events, only the changes in “soft” outcomes. I’m not discounting soft outcomes, only pointing out the distinction for folks not familiar with them.

So what happened after a year of intervention versus no intervention?

First off, and perhaps most importantly from the standpoint of drawing conclusions, compliance was reported to be excellent and the differences between the groups were statistically significant on every metric, except total average caloric intake. In other words, for every intended difference between the groups a difference existed, except that on average they ate the same number of calories (though obviously from very different sources), which was not intended to be different as both groups were permitted to eat ad libitum – meaning as much as they wanted.

Who was “healthier” at the end of a year? The table below shows the changes in both groups. If you want a quick primer on p-values, this is as good a time as any to get one. These tables (i.e., results tables) are a bit cumbersome if you’re not used to looking at them, so let me walk you through one row in detail. Let’s look at HDL cholesterol concentration. In the experimental group, HDL-C fell slightly from 1.00 +/- 0.26 mM (39 +/- 10 mg/dl for Yankees like me) to 0.97 +/- 0.40 mM (38 +/- 15 mg/dl), while it slightly fell from 1.35 +/- 0.52 mM (52 +/- 20 mg/dl) to 1.31 +/- 0.38 mM (51 +/- 15 mg/dl) for the control (i.e., no-intervention) group. It’s hard to tell if this change was statistically significant by inspection, so you glance at the p-value which tells you it was not. (To be exact, the p-value of 0.8316 tells you there is an 83% chance that this difference was random – as a general rule we don’t consider a difference to be statistically significant — meaning we’re going to assume it wasn’t just a chance fluctuation, the roll of the dice — until the p-value is below 0.05, and ideally below 0.01).

Take a moment to look over the rest of the table (or just skip reading it since I’m going to keep talking about it anyway).

 

Ornish Lancet paper

What else was not significantly changed?

  • Triglyceride level
  • Apoprotein A-1 (not surprising, I guess, since HDL particles carry the bulk of apo A1)
  • Blood pressure, both systolic (“top number”) and diastolic (“bottom number”)

What was significantly changed?

  • Total cholesterol concentration (down in both groups, but significantly more in the experimental group
  • LDL cholesterol concentration (same as above)
  • Apoprotein B (again, to be expected given that LDL particles carry apo B)
  • Body weight (this was, as you can see from both visual inspection and the p-value, the most significant change between the two groups)
  • Though not shown in this table, the experimental group also reported less chest pain severity (though chest pain frequency and duration were not statistically different).

What about the angiographic differences? That is, how did the actual measured lesions in the subjects’ coronary arteries change? 

Seven patients were excluded from this analysis: 1 patient in the control group (patient underwent an emergency angiogram in another hospital, but lesion sizes were not measured); and 6 patients in the experimental group (1 died while exercising in an “unsupervised gym,” 1 could not be tested at follow-up due to a large unpaid hospital bill, 1 patient dropped out, 1 patient’s pre-intervention angiogram was lost, and 2 patients did not have adequate overlay of pre- and post-images).   To justify the findings of this trial we need to believe that the exclusion of these seven patients did not alter the conclusions, but we’ll never know.  This disproportionate exclusion of 6 patients from the treatment group and only 1 patient in the control group, for (perhaps) the most interesting outcome, is (perhaps) the most significant methodological flaw of this trial.

Excluding these seven patients, the experimental group experienced an overall reduction in coronary artery stenosis (blockage) from a mean of 40% to 37.8%, while the control group experienced a progression in coronary artery stenosis from a mean of 42.7% to 46.1%, which was statistically significant.  This trend also held for larger lesions (i.e., those starting out over 50%).  Most importantly, in my mind, within the experimental group there was a strong correlation between adherence score and lesion regression.  Translation: The more rigorously a patient was compliant with the lifestyle changes, the greater was the regression of their coronary artery lesions.  This correlation is quite suggestive that the lifestyle change was responsible for the regression of coronary lesions.

I know what you’re thinking…Is there a point embedded somewhere in here?  Yes.

Here is my point: This was a well-done trial from the standpoint of testing what it set out to test.  It set out to test if a comprehensive lifestyle change could reduce markers of coronary artery (heart) disease, which it did. But that’s it.  It did not tell us if a comprehensive lifestyle change reduced actual heart attacks, which it very well might have if there were hundreds of patients in the study.  It is equally important to understand what we cannot conclude from this study.  We cannot conclude which element of the lifestyle intervention led to the reduction in markers of heart disease.  We know that in aggregate the lifestyle changes made a positive difference, but which ones actually caused the change and which were bystanders remains unknown.

Let’s take a leap of faith and hypothesize that the dietary intervention (rather than, say, the social support) had the greatest impact on the measured parameters in the subjects.  It’s certainly the most likely factor in my mind.  But what, exactly, can I conclude? Can I conclude that a low-fat vegetarian diet is the “best” diet for reducing the risk of heart disease?  Nope.  I can only conclude that a low-fat vegetarian diet is better than the average American diet consumed by the control group (if you are willing to stipulate that the dietary intervention was the most significant driver of outcome).  Why?  Because that’s what was tested.  Unfortunately, this study (and hundreds like it) can shed no light on which specific aspect of the diet in the experimental group provided the advantage.  Was it the reduction in fat intake?  The reduction in animal protein?  The reduction in sugar?  The reduction in simple, highly refined carbohydrates? Unfortunately, we do not know.

SLIGHT DIGRESSION: Tragically, all of U.S. nutritional guidance and follow-from-it policies, recommendations, and food-based infrastructure were derived from this type of science. Maybe their conclusions are correct.  Is fat bad for us?  Are complex carbs the best thing we can eat?  Though theoretically possible, there is no scientific evidence telling us this.  In fact, there is ample evidence actually suggesting the opposite is true.  Hence, this is why – exactly why – we are founding the Nutrition Science Initiative (NuSI) with a group of scientists who all agree that we need to actually test these hypotheses in the most rigorous manner possible, and only then make dietary recommendations.

How bad is it that nutritional recommendations are based on weak science?

Consider the following hyperbolic example: Imagine a clinical trial of patients with colon cancer.  One group gets randomized to no treatment (we’ll call them the “control group”). The other group gets randomized to a cocktail of 14 different chemotherapy drugs, plus radiation, plus surgery, plus hypnosis treatments, plus daily massages, plus daily ice cream sandwiches, plus daily visits from kittens (we’ll call them the “treatment group”).  A year later the treatment group has outlived the control group.  Great news, to be sure.  The treatment worked!  Here’s the problem…we “conclude” it was the 7th and 9th drugs in the group of 14 drugs, plus the kittens that caused the treatment effect and we enact recommendations based on that.  Are we right?  Sure, it’s possible, but actually it’s quite unlikely.  The only way to know for certain if a treatment works is to isolate it from all other variables and test it (in a randomized prospective fashion, of course).   Do the kind of science we were taught to do in 8th grade.

So what do I think happened in Dr. Ornish’s study?  I think the reduction in sugar and simple carbohydrates played the largest single role in the improvements experienced by the experimental group, but I can’t prove it from this study any more than one can prove a low-fat vegetarian diet is the “best” diet.  We can only conclude that it’s better than eating Twinkies and potato chips which, admittedly, is a good thing to know.

Ok, back to the Consumer Reports “best diet” list I started this discussion around.  Another point you’ll note in this table (up at the very top) is the overall amount of caloric restriction in each diet – an average of about 1,500 calories per day.  The caveat here is that these numbers are self-reported, so everything needs to be taken with more than the proverbial grain of salt.  I know what you’re thinking, “Hey, but you said calories don’t matter – why should it matter how many calories these folks are eating?”  Remember, you can always “force” weight loss by creating energy imbalance.  What I mean by that is you can force an energy imbalance if folks are willing to suffer (e.g., work really hard and/or starve).  The reality TV show, The Biggest Loser, is a great example of this.  Participants on the show are basically starved (under 1,000 calories per day) relative to their expenditure (6 hours per day of exercise at a cost of possibly as much as 4,000 calories per day).  The question is, or at least should be, does this form of “dieting” result in long-term, sustainable weight loss?  The overwhelming evidence is that calorie restriction (i.e., reducing calories significantly below active or deliberate caloric expenditure) results in transient weight loss, not sustained weight loss.  Why?  There are a few reasons, but I think the biggest two are:

  1. People don’t like to be hungry, and if they are reducing their caloric intake by reducing fat intake, they seldom find themselves satiated.
  2. Semi-starvation reduces basal metabolic rate, so your body actually adjusts to the “new” norm and slows down its rate of mobilizing internal fat stores.

Furthermore, most people can’t do six hours of heavy exercise a day (not to mention the world is full of people who do six hours of physical labor a day and are obese; I was fat doing 4 hours of exercise per day).  The real tragedy of this is that when folks restrict calories and then resume, when they can’t tolerate the discomfort of relative starvation anymore, they usually end up gaining back all, if not more, of the weight they lost in the first place.

Not to beat a dead horse, but I’d be remiss if I didn’t make this point one more time: When someone reduces caloric intake to 1,500 calories per day – even on a “balanced” diet – they are considerably reducing carbohydrate intake in aggregate and almost always disproportionately with respect to the worst offending carbs (e.g., sugars, simple refined carbs).

Ultimately, the question we’re driving at is, why do these diets work? I argue that each of these diets does some good, especially with respect to eliminating the worst offending agents along the insulin-fat-metabolic derangement axes.   The problem, unfortunately, is that the scientific community is completely confused as to why they work.  Most people think the primary reason these diets work is that they reduce fat intake and total calories.

I argue that reduction of fat intake has nothing to do with it and that the reduction of total calories has a transient effect. And, the majority of the benefit folks receive comes from the reduction of sugars and highly refined carbohydrates. But now I’m repeating myself, aren’t I?

 

Photo by Markus Spiske on Unsplash

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155 Comments

  1. Excellent article. After eating a low carb diet for two years I went to the optomotrist. I was wondering if she would say my blood vessels are clogged with fat. No. I am thrilled to say they are very healthy. Thanks again.

  2. Peter –
    When I first looked at Atkins and South Beach, I came to the conclusion that they work because they were just another way of restricting calories. Old Calories in, Calories out theory.

    From the Consumer’s report data listed above, both diets are 1500 calorie-ish. Is there any data where the low-carb/non-calorie reduced diet has been compared?

    Or are we needing to just wait for the new studies?

    Great Blog . . .keep it up.

    • The methodology CR used is really screwy. Peter highlighted some of the nonsense used to define “popular” for the study, and the caloric intake is another piece of hogwash. Atkins is completely silent on the matter of how many calories one should eat, mostly because it’s so individualistic. I for example, vary my calories between 1700 and 2300/day, with no guide but my appetite and exercise plans.

  3. Any “study” that ranks Slimfast, which relies on two shakes a day if I recall from the commercials, among its top picks is completely inane in my view. Talk about not sustainable long-term! I completely agree with all your points, but even paying attention to this article enough to pick it apart gives it more weight (so to speak) than it deserves!

    • Perhaps, but keep in mind how many people are “influenced” by this sort of information? I think I just want to help people understand how to evaluate information, given that we are bombarded with it (and most of it is lousy).

  4. The ornish study included elimination of smoking as an intervention, and they think they can draw any form of conclusions about diet?

    I don’t have access to the study, and your summary/the abstract are not enough to draw conclusions. Still, I would guess that most – if not all – of their great results can be explained solely by the smoking factor.

    • Henry, the first time I read this study (about a year ago), I assumed the same thing before I dug in. The paper says only one patient in the treatment group was a smoker (and she quit). To my reading I could NOT see how many patients in the control group were (and remained) smokers. Because of this, I do believe diet was probably the biggest driver, but again, we just can’t know from this study.

    • Until the study is redone with control groups we won’t know what factors were most important. Social support, yoga, meditation destress and hence give health benefits. We can measure the reduction in stress hormones. Professor Sapolsky (Stanford) has a series of videos on the effect of stress.

      Perhaps a study with the lifestyle changes other than diet, with his diet, no changes, and a low carb Paleo diet
      could answer the questions. Besides it was a *small* study which he has republished many times. He’s gotten a lot of juice out of that lemon.

  5. Peter, fantastic blog posts – very informative. I’ve had a couple patients on the Ornish diet now who decline any dietary alteration because of the ‘science’ in that Lancet paper (and the subsequent follow-up paper in JAMA).

    In a nutshell, what is your opinion on the Mediteranean diet and the Lyon Heart Study done by de Lorgeril? Is this a high carb diet? (My understanding is that the Indo-Mediterranean diet studies in the Lancet turned out to be fraud, so in a sense these confirmatory studies haven’t confirmed anything).

    Thanks for sharing your wisdom with the wider community.

    • Dan, I agree with a previous comment the the semantics of “low carbs” are so vague, that we should probably refrain from throwing it around. There are many issues to discuss with these studies, which I can’t reflect on now. What did the study actually test? How did it test? Can the results be applied more broadly? What *actually* caused the effect? You get the idea…

      • Well….if I could boil it all down to one simple fact and mechanism based on my N=1 experience…..restriction of carbohydrate induces weight loss. I have phased nothing else out of my diet and do not exercise; yet I have lost 32 pounds in the space of 10 weeks. There is also considerable epidemiology that (intentional) weight loss is associated with favorable prognosis and outcomes. Any diet that does not restrict carbohydrate intake – the primary driver of weight gain – is destined to fail.

  6. 1. You have a cat. 🙂 🙂 =^..^=

    2. Having seen all the revisions Weight Watchers has gone through since their beginning, I’d have a hard time believing they got it right *this* time, either.

    3. I wonder if the people doing the self reporting of these various diets (assuming that’s the case) were also calculating their own calories/fat/carbs/protein. And if they did, if the people conducting the studies provided a single resource for all to use. And if they did, if each of the studies used the same resource. As anyone who’s ever tried to track these values knows, the numbers for allegedly the same portion of the same food can vary widely from one database/government publication/diet book to another.

    Very good post, and yet another good reminder that things might not always be as they seem/are reported.

  7. Hi Dr Peter.
    If I stick to your blog I will know more about nutrition than….. well most people and so call experts. There was a TV show (American) that tracked one obese man’s transformation due to a diet I believe was soley based on juice (juicing fresh fruit and veg). Unsure what juice but my question is more the point of what you blog article was. Is this more about what was EXCLUDED than was INCLUDED? We also get these infomertials (Amercian again) with some old fitness legend promoting his fantatsic juicing machine and the benefits of juicing.
    It is just another angle on weight loss.
    Biggest Loser programs (I can now not watch anymore because I disagree fundamentally with the whole approach. It’s like a moral thing with me now) and other diets are not sustainable so therefore cannot be a long term solution. Diet in its traditional meaning is something like – Way of Life. Unsustainable is no way of life?
    It feels good to be educated again.
    Anthony – Brisbane, Australia

  8. This blog is outstanding, but I gotta say… the comments and the follow-up are arguably even more effective. There is definitely something very positive going on here. It’s no wonder traffic is spiking.

  9. Excellent, well written post. You do a great job of showing how confounding factors make it impossible to draw certain conclusions from studies. If 10 variables are changed with respect to a control group and achieve a statistically significant result, we have no way of knowing which variable or combinations of variables were actually what caused the different result. Maybe some of those variables prevented what could have been greater change. Your example with kittens and ice cream sandwiches made me laugh, very good example.

    One other thing regarding the diets that is often neglected, and it drives me crazy, is that the Atkins diet is an all you can eat diet. Weight Watchers certainly isn’t, everyone I know that’s done it is constantly starving and complaining about hunger. It’s probably the social support you get with Weight Watchers that accounts for a lot of the benefit.

    • Weight Watchers practically admits that the social support is what enables people to stick to the diet.

      Hmm, i wonder how many people stay on the Ornish diet without social support.

  10. Correct me if I’m wrong here. In some respects, this Consumer Reports analysis is comparing apples to oranges. Some of the programs, such as Atkins or South Beach, are do-it-yourself programs, originally based on books. Subsequently, online communities and some commercial products have developed. But the programs are not first and foremost commercial.

    Weight Watchers, Jenny Craig, Slimfast, on the other hand, are basically commercial. A quick internet search got me the following: Weight Watchers was owned by Heinz from 1978 to 1999, when it was bought out by Artel Luxembourg. It is now public, with Artel owning 50% of the stock. Jenny Craig is owned by Nestle, and Slimfast is owned by Unilever.

    I don’t know what kind of organizations Jenny Craig or Slimfast have, if any. But WW is something to which one *belongs* as a member. Like many other organizations, there are regularly scheduled meetings and dues requirements. There are even life memberships. If a person moves from one community to another, one can continue to go to meetings in the new community if there is a “chapter” there.

    I don’t know if one would call the WW system “support” or “pressure,” but if more people lose weight on the program, it isn’t necessarily because the diet itself is superior.

    • Wow. Nestle owns Jenny Craig? First they take your money, make you fat, then they take your money and try and make you thin. Brilliant business plan to make money on both sides.

  11. Another great post. I tried weight watchers (at the urging of a couple of friends who had lost well on it) a few years back. I had been doing Atkins and had lost some weight but was amidst a several month stall where I couldn’t get my weight to budge. I never thought of WW as low carb because it gave me so many more carbs than what I had been eating. I switched to weight watchers and put on over 10 pounds in just a couple of months! I was horrified and decided that was enough of a trial for me. Needless to say I went back to a very LC diet!

  12. A suggestion for your website: I, like probably many others, am getting a lot of value out of the questions/comments/answers at the bottom of your blogposts. Would you consider getting a little tracker that would go on the side of each page that lists the latest comments over the entire site? Comments are listed chronologically but often new comments are posted on pretty old posts that people may never see. Just an idea, but I could understand if you thought it would be too cluttered or something.

    • Anu, let me look into a way to make the Q&A better. I agree with much of the feedback – it’s a good forum and there is good info there. Just need to figure out how to make it more accessible.

      • Oh that would be so great! It would make it possible to keep up with all the new comments.

        Anu, I’ve been wondering that too, as I am also finding the comments very informative but stuggling to find the ‘new’ ones because they are scattered all over the posts.

        Thank you Peter for all the time and effort you devote to everyone!!

  13. It seems like this would be an easy thing to test: give a group of people a diet that keeps their carb intake exactly what it was pre-diet (both in terms of absolute quantity of carbs and the type of carbs, i.e., the same ratio of complex carbs to simple carbs), but bring down total calories by reducing fat and protein, and see if they lose weight. That would be an interesting study; there’s still more than one variable at play but at least you could test the hypothesis that diets that reduce total caloric intake are successful because they reduce total carbohydrate intake. If you kept total carb intake the same but varied the other inputs, you could see if that idea holds water.

    I’m agnostic on all this myself; my personal suspicion is that genetics and the body’s current fat content are likely to emerge as key players in how we respond to carbs; clearly there must be genetic differences at play because some populations are able to eat incredibly high-carb diets and remain skinny, and many of us know individuals who eat a diet high in refined carbs but don’t gain weight. My 23-year-old stepdaughter is sedentary, eats a diet consisting mainly of Wonder bread, white rice, pasta, mashed potatoes, cookies, cake, and very little protein or vegetables, and she has trouble getting her weight above 85 pounds. She has a naturally fast metabolism, as do her mother and father. But I’m not making any conclusions, I’m just looking forward to seeing some answers emerge over the next 30 years; I wouldn’t be surprised if it’ll take at least that long to get a conclusive understanding of the many factors that likely contribute to obesity.

    • Brad, you’re absolutely correct. This *IS* entirely testable, just like we test hundreds of other hypotheses in “real” science. This is exactly what the Nutrition Science Initiative (NuSI) will be doing. As to your point about genetics — undoubtedly this is the case, but don’t lose sight of the difference between what you can control and what you can’t. Someone who is born to be (i.e., genetically) 5’8″ may never play in the NBA, but if the practice basketball properly every day, they can still be an incredible basketball player, and far better than someone who is more genetically gifted (e.g., someone who is 6’6″) but never practices.

      • Genetics are one thing, but we also need to have a temporal approach to this problem of carbohydrate consumption. More simply, let’s check in with the 23 year old stepdaughter in 20 years and see how that unmitigated carb consumption is going for her. I suspect if she does not change her diet, her vitals will be less than ideal, and more likely than not she may now be overweight. I believe Lustig and Taubes have touched on the idea of metabolic syndrome, or syndrome X in their work, and I find this fascinating. From what I understand (in my oversimplified way), basically you stress your body at the cellular level through a constant barrage of insulin. This abuse is suspect in a variety of pathologies, from diabetes to the aging process itself.

        In a nutshell, many younger people can “get away” with a level of consumption of carbs and maintain a superficial level of health (e.g. skinny). But at some point insulin resistance and syndrome X demands that the same level of carbs (ignoring calories..not important) consumed now becomes a problem. Due to a variety of mechanisms related to insulin resistance, weight is put on as fat.

        • Absolutely. Could not agree with you more. When I was aged 14-18 I ate — no word of a lie — SEVEN sandwiches (yes, 14 pieces of bread) for lunch every day, plus 2 LITERS of apple juice. In ONE sitting! I was 5% bodyfat. Yes, I was training 6 hours per day, 6 days per week, but I was also (clearly) very insulin sensitive. By the time I was 30, if I looked at carbs I gained weight. So there is no doubt that both genes and father time play a very significant role.

        • Agreed about the temporal element, but it’s also worth acknowledging that millions of American teenagers and those in their early 20s are obese and obviously can’t handle the same kind of diet that my stepdaughter lives on without gaining weight. Why is it that some kids eating junk food get fat while others remain skinny? That’s where I feel genetics is likely to be playing a role.

          Here’s another example: I won the pancake-eating contest in my house when I was a teenager (I ate 16 dinner-plate-sized pancakes), and I’ve always lived on a relatively high-carb diet. Yet at 53 I still fit comfortably into the suit I bought when I was 33; I’m 6’4″ and 180 pounds. But my oldest brother, who was a serious basketball player all through his teens and 20s, has struggled with obesity since his late 30s and his diet isn’t much different from mine.

          I don’t necessarily believe that our body weight is determined by genetics and there’s nothing we can do about it; my brother has successfully lost weight in the past but he’s a stress eater and gains it back periodically. But I do suspect that genetic factors may affect individual susceptibility to weight gain and how different people respond to carbs in the diet.

        • Peter, Brad, GP
          I believe age plays a role as well. But maybe it is epigenetics (rather than genetics).

          I was a national swimmer from 8-16 years. Was a bit on the chubby side during the whole period. Eat huge amounts of food. Just unbelievable amounts really. Every swimmer I knew did the same.

          From 16-26 or so I eat quantities equal to 3-4 adults for each meal and eat a large bowl of ice cream after lunch and dinner and 6 extremely sweet french toasts for breakfast. My teas and coffees were almost sugar syrup.
          I spent an hour a day at the gym, that’s it.

          The days I didn’t go to the gym I lost almost 4 lbs per day (probably because I didn’t eat as much). And usually it was because I wasn’t home so didn’t have my regular french toast etc.

          I had six pack abs. muscle bound and no fat. Couldn’t pinch my waist to get any kind of hold on the skin.

          After that, I stopped eating so much and stopped the ice creams and other deserts and french toasts etc. but started putting on weight gradually. Note that it’s not that I stopped eating all that stuff because I was putting on weight but rather, I stopped eating all that stuff and gradually (over the years) starting putting on weight. (so it must be age)

          15 years later, I was 65 lbs heavier. Didn’t go to the gym all those years (life came in the way) but still fairly active. Didn’t eat junk food, watched how much and what I eat for the most part. I have never been on medication of any kind and don’t any other pills.

          I also moved from India to the US 15 years ago. Got heart burn for the first time in the life literally on the first day (breakfast) and thought eggs were the cause. Years later I discovered it was gluten in bread (eats lots of wheat in India but never had an issue). Got my first headache a few years later. Didn’t know what it was until a friend of mine said, “it sounds like you have a headache”.

          So it could be a combination of things but primarily age rather than genetics or could it be epigenetics?
          NUTRITION AND THE EPIGENOME

          I believe Ornish showed that gene expression can be changed.

  14. I am on Atkins, and am always told it is dangerous, and they always have a website showing a study to prove their point. Meanwhile, I am getting more than the 5 serving of vegetables a day, haven’t added fruit back in,but more vegetables than I was eating. I am sticking to meat, mostly chicken , with one red meat meal a week. I have lost 113 lbs, and gotten off my diabetes meds. I still have to lower my triglycerides, and raise my HDL, which are both improving with each test, but have a 125 cholesterol, and a LDL of 51. I eat 4 XL eggs a day. I recently got gout, but I now believe it was while cheating, and drinking Pepsi. I noticed the flare-ups occured when I drank pop.. I suspect it is sugar, and have gone back on Induction to clean up my diet, and get losing again. Eating this way has reduced the flare-ups. I got off ALL diabetes meds, close to dropping my cholesterol meds, and my last BP check was 104/61. Yet if I say I am on low carb, people say it is dangerous. I can eat 10 servings a day of vegetables, but if my carbs get too low, it’s dangerous. I think sugar is dangerous, as well as elevated insulin levels, but no one says the diet that had me top out at 361 was dangerous, but the diet that is fixing them is. So, I am frustrated on a daily basis, and a friend showed me this site.

    It is a breath of fresh air to see someone who says what I am thinking. I have seen results, and they are contrary to popular beliefs. I am not going back, just to be ” normal”, and your articles make a lot of sense. Studies can be made to say anything, and I think a lot of them today, are set up to prove a point. They took away the objectiveness in the studies. They knew the answer before they ran them.

    Since I can’t trust whether the studies are unbiased, I am left with personal example. I will stick with no sugar, low carb, high vegetables,slightly elevated protein, and high fat diet that is working for me. I try to avoid saturated fats, drink plenty of water to stay hydrated, and work out 7 days a week. Nothing is going to change my plans, but it is nice to read this, and think maybe I am doing something correctly. It gets depressing when you are continuously told what you are doing is wrong, when you are seeing results.

    Thanks for the great point of view, and the in-depth explanations. Very interesting read!

    • Good story, Russell! If you do some more reading on these various low-carb sites, you’ll probably find that both red meat and saturated fats are considered UN-dangerous. Many of us enjoy both in abundance.

  15. Hi Peter,
    Without putting too much pressure on your already busy schedule, being able to see all new comments on your posts would be VERY APPRECIATED as the comments are also extremely valuable.

    Question – Russell’s post mentioned red meat is only eaten once a week. I eat a lot of red meat especially loaded with fat. My instincts are telling me this is OK but Russell’s post hast me thinking…

  16. Thanks so much for your work on this issue and in this website. I am a practicing general internist, and also have personally struggled with weight. I am currently down 40 pounds from my top weight and have lost gradually over the last 10 years using a variety of diets and exercise. However, I have been struck both personally, and even more, professionally, at how difficult long term weight loss is. I recently was asked to speak to a group of psychologists about weight loss, and I entitled my talk “Don’t Throw Your Big Pants Away”, to try to get across just how poor our long term success rate is with traditional weight loss advice.

    After reading Gary’s books, I have been moving toward low carb recommendations, and am following a low carb diet myself. Here’s my question. As a physician, I have seen most people that follow a low carb diet have the same problem that other dieters have with recidivism — they lose weight, but when I see them a year later, the weight is back (often plus a few more). In your reading/reviews have you seen much evidence that the low carb type diet can be effective for long term weight loss/weight maintenance?

    • Howard, like any treatment, it’s only as good as “compliance” for lack of a better word. The rate of recidivism is so high, I believe, because of poor information. Most people who lose weight on a low-carb diet don’t actually understand WHY they lost weight. Once the weight is off, they start gradually re-introducing carbs back on until they get back to their original weight. Carb reduction is not a “diet” — it’s a way of life, which sounds silly, I know, but if it is viewed as a transient change, then so too will be the health impacts. When you chose to restrict carbs it’s no different than choosing to give up something harmful (e.g., cigarettes). It comes back to information and understanding, which is really why I write this blog. I want people to know WHY.

      • Another problem, I feel, is how little societal support there is for this type of eating. I know that if I did low-fat, or gluten-free, or even vegan, society at large goes out of its way to give me options. Yet a low-carb, or even worse ketogenic, diet is very difficult to stay on when the rest of the world runs on carbs, even when you physically feel great. I face this issue all the time — this weekend a friend has invited me to a crepe party, and I probably won’t go. This gets old fast, as sometimes it feels like a choice between having a social life and eating healthy. When you do slip up, as seems inevitable, the effects can be long-lasting, as getting back into ketosis takes a while.

        • This is a VERY good point. Just ask anyone who is overweight what it feels like to order bacon and eggs in a public place, or heavy cream for their coffee. We will fix this, in time.

      • I think in one of Gary’s books he says losing weight does require sacrifice, but at least let’s sacrifice the right things. I guess what I’m wondering is whether a low carb diet (“diet” as in what you routinely eat, as opposed to a transient weight loss “diet”) is easier to comply with long term than caloric restriction/increasing exercise. It seems like it would be, but anecdotally, I haven’t seen that; people tend to quit low carb eating and go back to their old ways. I think one interesting question would be why don’t more people stay with low carb eating– is it just hard for people to follow, do they get tired of it or do they not understand the concepts. I do think information is key, and I know one reason people quit low carb eating is that other people (including their doctors!) tell them that they are killing themselves eating this way. This is why I am so glad to see you and Gary and others out there providing high quality information.

        • Probably a combination of factors. Why do people use HIV infected needles when they can find clean needles at a shelter? Why do people go back to smoking when they have successfully quit for 6 months? Why do people sleep with prostitutes without condoms, even though you can buy condoms at any drug store? I don’t think there is one over-arching reason or explanation. Some of it is understanding of the problem. Some of it is social support and surroundings. Some of it is prioritization. Having done my residency in the heroin capital of the U.S. (Baltimore) I wanted countless lives ravaged by this drug, even after long periods of abstinence. Why? Probably because the pain it eases is greater than the pain it causes, at least in the short-term.

          Let’s keep asking these questions, though…otherwise we’ll never solve this problem.

      • I recently reread the original Atkins book. Although I’ve read it several times before, I was struck this time with his advice on maintaining weight loss once a person is at a desired weight. The cost is eternal vigilance. Keep an eye on the scale, and before things get too far out of line, go back to square one and fix things.

        While all the low carb books have some information on maintenance, that’s usually the part of the book where things get less exciting. The adding more carbs part can be tricky — in some ways tricker than the induction/intervention phase. That’s where things start to get mushy in terms of what to do next, and with Atkins, a little too fiddley for my taste.

        Maybe what the low carb world needs is a Book II — “How Not to Lose Your Weight Loss.”

    • Susan B. Roberts of Tufts has written an interesting book called The Instinct Diet, in which she focuses on providing people with the tools and understanding they need to maintain their weight loss for the rest of their lives. While one can (and will) quibble with her specific dietary recommendations, the five “food instincts” that she discusses are noncontroversial and are all backed by solid research; her descriptions of those instincts and how you can recognize them and work with them to keep your weight under control are, in my opinion anyway, worth the price of the book. I’m not sure I agree with her food recommendations, but she emphasizes that once you understand the food instincts and how to deal with them effectively, you can apply those lessons to any diet. Interestingly with regard to low-carb, she recommends it but not as the full focus of a sustainable diet, because one of the “food instincts” is that we like variety and a low-carb diet can get monotonous after a few years. She feels that low-carb has an important role to play, but for long-term weight control she favors mixing it up a bit so our “variety” instinct remains satisfied and we don’t slip into old patterns.

    • Never had a problem ordering bacon and eggs at the local coffee shops, of course i live in NYC. Of curse at my favorite coffee shop that bacon and eggs came with toast with “spread”[1] and potatoes probably fried in some unidentified industrial seed oil (J Stanton’s bird seed oils).

      {1] A concoction so vile it can not be called margarine, but it’s so cheap and so must be healthy according to the USDA, Cargill, Monsanto alliance.

  17. Like many who are reading this blog, I have experienced several lovely benefits from removing grains, sugars, etc from my diet, such as improved lipid profile, better sleep, etc.

    What I have not experienced is weight loss. I note the constant exultation of the instant effortless weight loss that many experience and it’s certainly not happening for me. I really resonated with something you (Peter) said in one of your posts (I can’t remember which) that you had a friend who told you that if she ate as you did, she would be subjected to constant ridicule. I feel like I am there now, firmly believing in the science, but my persistent lack of weight loss undermines everything I say to anyone.

    • I understand what you are saying Viktoria, and I’d give anything to have an answer and a solution for you. Just ask yourself this, do you feel better today (overall) than you did, say, a year ago? If so, then you’re on the right track.

      • Certainly I feel better. So I can point to that as a success, and one that I’m not dismissing at all. In some ways it even seems more important for my overall health. I didn’t mean to sound upset in my last post. .

        My doctor is thrilled with my bloodwork. He is completely comfortable with reduced carb diets, thankfully. I’m lucky that he’s very supportive, and we have good discussions about the science.

        I am just unlucky from this particular genetic perspective, and have to adjust my diet more than some.

        As a scientist I understand the process of scientific discovery. Sometimes current understanding is overturned by a single critical experiment. Sometimes it’s whittled away bit by bit until it can no longer be denied.

        I do think that the current process of knowledge dissemination in science, publication in scientific journals, helps contribute to the problem. You can’t publish a paper unless you can point to a conclusion, and publishing is key to career success. The higher profile the journal, the more vigorously the conclusion has to be stated. So you get lots of data published and claims made that don’t necessarily have solid footing. Not to mention how the peer review process skews things.

        As a physicist, I’m more comfortable with systems that have controllable variables. Biology has always weirded me out a little. 🙂

  18. So has the NuSI foundation been formed yet and/or have any kind of website for latest news? Also I was wondering if you know of any ground-breaking research that is taking place right now to cover more ground in making the case for the insulin hypothesis? Is Gary or anyone else up to anything that we should be looking out for? I’m tired of the naysayers and want to really see the calorie in/out hypothesis just go away.

    • Dave, we’re working nearly 24/7 to get NuSI up and running by summer. Lots of stuff planned scientifically, too. I will definitely be writing about this as we get closer to launch.

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