The subtitle of this post could just as easily have been: Feed your mitochondria right.

The two videos below pretty much tell the whole sad tale of doctors and nutrition.  Taken together, they confirm the widespread notion that doctors, in general, know very little about nutrition and seem to be proud to keep it that way.

This first video has made the rounds on the internet.  I’ve had it sent to me or recommended to me a dozen times, but I had never watched it until just a few days ago.  I was put off because of its length, which, at a little over 17 minutes, seems like an eternity in internet viewing time.  But I hope anyone reading this post doesn’t make the mistake I did and avoid watching because of the length.  It is a spectacular talk given by Dr. Terry Wahls, a female physician who was struck down by a relentlessly progressive neurodegenerative disorder.  She describes how she was able to restore her health by revamping her diet in in a way designed to properly feed her mitochondria.*  The transformation is almost unbelievable, especially considering the disease she was battling.  If you haven’t already seen this video – watch it.  I guarantee you’ll be glad you did.  And while you watch, pay careful attention to what her diet doesn’t contain much of.

Click here to view the embedded video.

After you’ve seen the above video, take a look at the one below.  It is a little over 2 minutes long and was developed to give doctors – who, for the most part, don’t give a flip about diet – advice they can pass along to their obese or overweight patients.  Watching the longer video above first will give you more context to better appreciate the one below and show you just how lame mainstream medicine can be.

This video came from Medscape, a subscription service for doctors to keep them abreast of all the latest and greatest news and updates from the world of mainstream medicine.

Click here to view the embedded video.

Pitiful, isn’t it?

Links:

The Medscape article containing this video.  (Although Medscape is a free subscription service for physicians, non-physicians can sign up as well.  For free.  Register if you would like to see the article, which is nothing more than a transcript of the video above.)  It is amazing to me that an online newsletter designed for physicians would regurgitate dietary information from a newsweekly and pass it off as serious medical information.  Especially in such a condescending and patronizing way.  The whole thing is infuriating.

The list of the 22 nutritional ‘experts’ who came up with the dietary rankings mentioned.

The US News and World Report article that inspired the video.

Power, Sex and Suicide  A pretty thorough book on mitochondrial function that is accessible to the non-scientist.  I read this book 6 or 8 years ago and learned a fair amount about mitochondrial DNA.  I had been interested in the issue of mitochondrial rehab for a while, and this book filled in some, but not all, of the blanks.  A good place to start if your interested.

Why Are Cells Powered by Proton Gradients?  Full text of a paper written by Nick Lane, the author of the above book, discussing how mitochondria work by creating an energy gradient across the inner membrane.  Accessible to non scientists.

Source of photo of mitochondria at top of post.

* Mitochondria are the little sausage-shaped organelles inside the cells that convert the energy stored in food to ATP, the energy currency of the body. I think the idea of correctly feeding mitochondria is an important one.  If your mitochondria don’t work well, you don’t work well.  I’ve got a couple of posts in the works on this subject of just what does keep the mitochondria fit and what happens when they become unfit.  And what it takes to rehab them if broken.  Based on my own pretty extensive review of the scientific literature over the past few years coupled with my clinical experience, I have a few minor quibbles with Dr. Wahls’ notions of what constitutes a perfect diet for the mitochondria, but I’ve got to say that her results speak for themselves.  I just think her diet could be even better with a little judicious tweaking.

I’m going to tell you about the best low-carb book I’ve ever read. In fact, it’s exactly the book I wish I had written myself.  And I’ll tell you why I didn’t in a bit, but first I want to clear up a few misconceptions I may have spread in my last post.

I get feedback on the posts I write from three sources.  First, MD looks at them and tones them down if I’ve gone off on some sort of political tangent or if I’ve scattered in a bit of too colorful language.  After she gives me the go, I put the posts up and wait to see what the commenters have to say.  The third source for feedback is my friends, some MDs and/or PhDs and some not, who pick up the phone and call me.

MD okayed what I wrote. The readers who commented seemed to realize what I was trying to say.  But the phone calls were a different story.

One friend called to say she had been low-carbing since Jan 1, and when she read my post she became so depressed she almost quit.  “How can you tell people it’s hard,” she said.  “It’s the easiest thing I’ve ever done. I can eat till I’m full.  I’m losing weight; I’m losing the water I’ve been retaining; I feel great.  What a downer that post was.”

I heard different versions of that rant from three other people.  They all wanted to know why I would be idiotic enough to put up such a post right at the time everyone was trying to commit or recommit to losing weight.  Depressing was a word everyone used.

I guess I got off easy with the written comments on the blog.

I didn’t really mean for the post to be a downer.  Really.  I wanted to tell people who might be struggling to lose that MD and I fall prey to all the same problems.  We gained weight over the holidays.  We are back on the straight and narrow.  I was trying to say that we were right in there with everyone else working away to reestablish our own thinner selves.  (In fact, we’ve made great progress in the week or so we’ve been on the plan.)  I just wanted people to be aware that long-term weight loss requires effort and constant vigilance.  And to view the process as a life change and not a quick one-time fix. My goal was to get people to recommit seriously, not to depress them.

Obesity is a medical problem caused by a damaged metabolism, which is why one person, without the damage, can eat the same foods without gaining weight that pack the pounds on someone else.  Once you realize you have the underlying problem that leads to obesity, you simply have to recognize that you have to deal with it for the long term.

Let’s look at it in terms of another medical problem: high blood pressure.  For argument’s sake, let’s ignore the fact that about 80 percent of cases of high blood pressure can be reversed with a low-carb diet, and let’s just assume that the case we’re talking about is responsive only to high blood pressure medication.  If you were the patient with the high blood pressure, and I gave you a pill that brought your blood pressure down to normal, you would consider the medication effective.  Would you then say, Hey, my blood pressure is normal, yippee! now I can quit taking the medicine?   I doubt it.  You would say, Great, the medicine is working.  Furthermore, if you quit taking the medicine and your blood pressure went back up to what it was before you started taking the medicine, would you say the medicine didn’t work?

Of course not.  Your high blood pressure was kept in check with the medicine, and your BP, not surprisingly, went back up when you quit taking the medicine.  The medicine itself was effective.

Same thing with dieting.  If you have an obesity problem that responds to a low-carb diet and you lose to your target weight, then go back to your old way of eating and gain your weight back, it isn’t the low-carb diet’s fault.  You have a problem that responds to a low-carb diet, and you pretty much have to stick with a low-carb diet (although not in nearly as extreme a structure as when you are trying to lose) for the long haul.

Having said all that, I can tell you that in my experience there is nothing that helps people lose weight more quickly and with less deprivation than a good quality, whole food low-carbohydrate diet.  You don’t have to be hungry.  You can eat rich, delicious foods, you’ll get rid of heartburn, drop your blood pressure, ditch excess fluid, and feel remarkably better.  You’ve just got to hang in there until you lose what you need to lose (which process you can speed along if desired with a little Metabosol), then you can loosen up and start adding some of the foods you’ve been foregoing.  And continue to eat them in moderation on maintenance.

Virtually all the studies in the medical literature show that at worst the low-carbohydrate diet equals the low-fat diet in all parameters and at best completely leaves it in the dust.  As far as I’m concerned, there is no faster, safer, more delicious way to lose weight. Hell, a study was just presented recently showing that women who did low-carb just two days a week lost almost twice as much weight as women following a calorically-restricted Mediterranean diet daily.  So, to be clear: Is weight loss tough?  Sure.  Is it easier when you cut the carbs? Absolutely! Low carb rocks!

Which brings me to the book that started this post.  In my opinion, The Art and Science of Low Carbohydrate Living is simply the best how-to book on low-carb dieting ever written.  As I wrote above, it is the book I wish MD and I had written.

The reason we didn’t write it is because a) some of this information wasn’t available when we last wrote a book (much of it is now available thanks to the work of Drs. Volek and Phinney), and b) no mainstream publisher would pay an author for this book.  If a mainstream publisher would buy it, the editor would force the authors to change it.  What do I mean by that?

All books fall into different genres, as they’re called in publishing.  One genre is diet/nutrition books.  So if you come to a publisher offering a diet/nutrition book, it gets pigeonholed into that genre and has to conform structurally to that genre’s standardized format.  Editors of mainstream publishing houses believe that the great mass of readers of nutritional books are not very bright and so have to be served real scientific information in small, small bites and not very many of them at that.  So the genre formula for a diet book is to have the actual diet regimen way up front because these editors don’t believe the readers of these books are smart enough or patient enough to wade through the explanations of why a particular diet works in order to get to the plan.  They want the plan up front within the first couple of chapters so people can get started without really having to read the book.  They also want a ton of recipes and meal plans to fill up the last half of the book.  Squeezed in between the plan and the recipe section is where they want to meat of book cubbyholed, and, in their view, with as little science as possible.

MD and I fought this structure tooth and toenail with Protein Power and ended up beating our editor down by agreeing to write a summary of each chapter called The Bottom Line that explained what each chapter said in non-scientific terms.  (Fortunately, we’ve been able to use this strategy in most of our books.) We worked well with our first editor, but we ended up in the hands of another editor when the paperback came out.  Editor Number Two hated all the stuff on the Paleolithic diet and the data from the ancient Egyptians.  This info was the first time in the popular press that the pre- verses post-agricultural diet was used as an argument for low-carb dieting.  And she wanted to ditch it from the book.  We went postal on her, so she ended up agreeing to leave it but only if we buried it in the very back of the book as an Epilogue.  That was one of the chapters of the book I wrote, and I thought it was pretty exciting information.  So, apparently did many others. But not this editor.  Sadly, she is not unusual.  Most want to conform to the genre.

Drs. Volek and Phinney self-published their book, and, as a consequence, could write it however the flip they wanted.  It is extremely well written and suffers none of the usual flaws of a self published book.  And it lays out the rationale for a low-carb diet as the treatment of obesity and other related disorders in a linear fashion instead of adhering to the typical diet book format.

As I finished writing the above paragraph, I clicked over and checked for comments on my latest post and found one with the following line:

This low-carb world can be a lonely place if one needs a navigator…

I can think of no better navigators than the authors of this book. Both of them have done a large part of the hardcore research on low-carb dieting that is in the medical literature today.  Go to PubMed and enter Volek JS or Phinney SD in the search window, hit ‘Search,’ and you will be rewarded with more peer-reviewed scientific papers on low-carb dieting than you will have time to read.  Many of the experiments described in these papers are explained in easy to understand language in their book.

Disclosure: Both Dr. Volek and Dr. Phinney are friends and colleagues of mine.  But they did not send me a copy of their book for review.  I purchased it from Amazon and paid the full price of $29.95 (it is now $19.95).  I bought it months ago and carried it with me all over Europe and on a half dozen other trips since but didn’t have time to even crack it until I was on the last leg back from our holiday trek.  It sounds cliché, but I couldn’t put it down.  I read and annotated the entire book over the course of two long flights.  Virtually anything anyone could want to know about the science behind low-carbohydrate dieting can be found in this book.

I’ll give you just one example.  It is common knowledge among many nutritionist, doctors and journalists that saturated fats are bad for us.  Most believe eating saturated fats leads to higher levels of saturated fats in the blood, which they inevitably describe as ‘artery-clogging saturated fat’.  Drs. Volek and Phinney, who certainly don’t believe this nonsense, understand adaptation to a low-carbohydrate diet changes the way the human body metabolizes different fats.  Eating more fat on a low-carbohydrate diet speeds up the burning of fat in general and saturated fat in particular.

There are only three things the body can do with saturated fat from the diet (or saturated fat made from dietary carbohydrate — and, yes, the body can and does make saturated fat from dietary carbohydrate).  It can burn them, store them, or convert them to a mono-unsaturated fat.  When people go on low-carbohydrate diets, they reduce their insulin levels, which in turn allows fat to escape from the fat cells to become the body’s primary fuel.

But what happens when a person increases saturated fat intake as part of a low-carbohydrate diet?  Drs. V & P knew that saturated fat burning would increase, but would enough burn to offset the extra amount of saturated fat coming in as part of a high-fat, low-carbohydrate diet?

To find out, they put 20 subjects on a low-carbohydrate diet for 12 weeks and another 20 subjects on a low-fat, high-carbohydrate weight loss diet for the same length of time.  The subjects in the low-carb group consumed three times the saturated fat per day (36 g vs 12 g) as did those in the low-fat group.  The blood from the subjects in both groups was then tested to determine total triglyceride level and specific fatty acid composition.

What did the good docs find?

In the serum samples done at baseline and again after 12 weeks, serum triglycerides  in the low fat group went from 187 to 151 mg per 100 ml, a tidy 19% reduction.  But in the low carb group, the before and after values were 211 and 104, a whopping 51% fall.  Both visually (just looking at the numbers) and statistically, the low carbohydrate group had a much greater (better) reduction in serum triglycerides.

The above should come as no surprise, because everyone knows that a low-carb diet reduces triglyceride levels.  But what about the amount of saturated fat in the blood?

As a proportion of the total, the low carb group had 33% saturates [saturated fatty acids] at baseline and 29% after 12 weeks, whereas the low fat group started at 30 and ended at 29%.  So after 12 weeks of dieting, the proportion of saturated fats in the blood triglycerides was the same for both groups despite the fact that the low carb group was eating three times as many grams per day of saturated fat in their diet.

But there’s more.  Because the low carb group ended up with blood triglycerides of 104 mg per 100 ml compared to the low fat group’s 151, they actually had about 30% less total triglycerides circulating in their serum.  So although the two groups had similar relative proportions of saturates, this means that the absolute serum content of saturates in the low-carb group was 30% lower than the low fat diet group.  So what we found, in a nutshell, is that despite a higher intake of saturated fat, the proportionate blood level of saturated fats did not increase, and their absolute levels fell dramatically with the low carbohydrate diet.

The bottom line on this point is that when our metabolism adapts to a low carbohydrate diet, saturated fats become a preferred fuel for the body, and their levels in blood and tissue triglyceride pools actually drops.

To summarize, a three times higher intake of saturated fats leads to a 30% drop in saturated fats in the blood of those following a low-carb diet as compared to those following a low-fat, high-carb diet.

Which means, of course, that if you want to decrease the artery-clogging saturated fats (should that be what you want to call them) in your blood, a low-fat, high-carb diet, the very diet almost every health care professional recommends for the job, isn’t the way to do it.  All you have to do is simply follow a low-carb diet.

The description of what happens to saturated fats in the blood during a low carb diet took two pages out of a 300 page book, so you can imagine how much content the entire book contains.

There is so much invaluable information in this book that I’m having to fight back the impulse to quote the whole thing.  You’ll learn

why you need more sodium on a low-carb diet and why the sodium prevents lean tissue loss,
why you need to increase fat intake during maintenance,
why a low-carb diet decreases inflammation,
why the low-carb, high-fat diet improves gall bladder function,
why excess carbohydrate converts to saturated fat and how,
what all the lipid parameters mean and how they’re affected by a low-carb diet,
and what the Paleolithic evidence tells us about diet.

And this list is just scratching the surface.  As I read this book, I kept marking parts that I needed to use for this blog.  In going back through, I would have to practically reprint the whole thing to give you just the important parts because the entire book is a gem.

Unlike most traditional diet books, The Art and Science of Low Carbohydrate Living doesn’t contain a lengthy section on how to execute a low carb diet.  There are plenty of books out there – some written by MD and me – that do that.  The book does have about 10 pages of the authors’ favorite recipes for low-carb foods and a seven day meal plan incorporating many of these recipes. (Another disclosure:  The authors recommend Protein Power as a good book on low-carb dieting, but I would have written this review the same had they never mentioned our book.)

The strength of this book isn’t in its meal plans and recipes, although those are delicious, it is in the wealth of information about all aspects of low-carb dieting.  If you have a question, almost any question, about any facet of low-carbohdyrate dieting, this book will have the answer.  And the answer will grounded in science, and in many cases from work done by these two scientists on the front lines of low-carbohydrate research.

As far as I am concerned, if you are planning on going on a low-carb diet and can afford only one book, make The Art and Science of Low Carbohydrate Living that one book.  If you are a long time low-carber, this is the one essential reference book you should have on your shelf.

If you are getting going on a low-carb diet the first part of this year, grab this book before you do another thing.  Once you see the world of benefits that will accrue to you from following such a diet, you will probably be able to overcome any depression that may have been inflicted on you from my last post.  So don’t hold off, grab a copy of this book today.  You will be very glad you did.

The first week of January is the traditional time for overweight people to start a diet.  For years I’ve told my patients (and anyone else who would listen) to fight the holiday eat-a-thon and start the new year at the same weight they started the month of November.  During the time between Thanksgiving and the end of the year, so the media typically reports, the average weight gain is anywhere from five to ten pounds per person.  A study in Nutrition Reviews showed the weight gain to be much less on average but a little over five pounds in those who are already obese.  This same study confirms a belief I’ve had for many years.

The best and easiest way to stay slim is to never become obese in the first place.

What I mean by making this seemingly obvious statement is that when a person goes from being normal weight to being overweight it is an indication that something metabolically has gotten broken.  At this point, no one knows for sure what gets broken, but many (and I count myself in this ever growing group) believe the damage occurs in the mitochondria, the organelles within the cells that are the energy furnaces.  Once whatever it is that gets broken breaks, it is difficult from that point on to lose weight and maintain weight loss without effort.

The study I mentioned above showed that the non-obese didn’t really gain anything over the Thanksgiving through New Year’s holidays, and I’m sure it’s not because they didn’t go face down in the fudge.  They didn’t gain because their metabolic systems were working properly.

MD and I both had our struggles with excess weight starting a few of decades ago.  We were both thin, both ate whatever we wanted, and both never gained weight.  Until, that is, our metabolic systems became damaged.  Once that happened, we ballooned, then lost, then have fought it since.  We both have kept our weight under control for years now with a few exceptions here and there by judiciously following a low-carbohydrate diet.  Since we’ve both stayed pretty much in the normal weight range for at least the last several years, we decided to try an experiment over the holidays.  And not over the entire Thanksgiving to New Year’s stretch but for a fairly short stretch between Dec. 20-Jan 2.  We had planned to make a multi-state trek to visit relatives over this period, so we decided that while we were traveling, we were going to eat like normal Americans just to see what would happen.

We didn’t go out of our way to overindulge in anything.  We had a maybe two hamburgers with the bun and had two or three orders of fries (I’m talking about during this entire period – not every day).  We had a Christmas cookie or two, downed several pieces of fudge, drank a bunch of eggnog, ate some fruitcake, and had a couple of bowls of ice cream.  And MD had a little more wine than usual while I probably doubled up on my Jameson.  Other than those indulgences we ate what would be considered sensibly by most people.  We ate some mashed potatoes, grits (we were in the South), beans (not the green bean variety), more fruit than usual and meat of one sort or another.  Pictured below is my plate (which I doubled down on) on New Year’s day.

As you can see, I ate ham, cheese grits, black-eyed peas, curried fruit, and corn bread.

The point of this exercise was to see what would happen to us if we followed a sort of modified typical American diet.  We avoided trans fats and vegetable oils as much as we could and had absolutely no soft drinks.  We had no breakfast cereals of any kind and took it easy on the wheat, but we did eat a little bread occasionally.  Except for the bits of fudge and other Christmas goodies we consumed – all of which were homemade using butter and/or lard as the fat source – we didn’t really go overboard on the sweets.  Our fructose intake was doubtless considerable less than that the average American, especially during that time of year.

So what happened to us during this couple of weeks of much better than average typical American dieting?

We gained weight!  And a fair amount of it.

I don’t know exactly how much we each gained because neither of us ever weighs – we go more by how our clothing fits.  (We didn’t plan on starting this little experiment before we left or we probably would have weighed.  We started it once we were already on the road.)  When I left on the plane, I wore a freshly laundered pair of jeans that fit loosely around my waist and that scrunched up a bit when I tightened my belt.  When we flew home, I wore the same pair of jeans (also freshly laundered), and they were tight around my waist and my belly actually spilled over a little.  MD had the same experience except her weight distribution was a little different.

If I had to guess, I would say we both gained somewhere around five or six pounds.  We were clearly at the top of the range of weight gain as described by the study I linked to earlier, and it happened in two weeks not the six weeks as it did in the study.  Which would indicate that we fall into the obese category, since the obese are the ones who most readily gain weight over the holidays.

But we aren’t really obese, or at least weren’t when we started.  But we obviously have the same metabolic defect that the obese have.  Our metabolic machinery has been damaged.  And even though we’ve keep our weight under control for years, the problem is still there, lurking in the weeds, ready to strike the moment we drop our defenses.

The take home message here is, to paraphrase Wendell Phillips, eternal vigilance is the price of thinness.  At least after you’ve once become obese.

So, MD and I are back on a rigid version of our own program, we are taking Metabosol, and, with the exception of a party we attended last night, are eschewing booze until we get back to our regular sizes.  Some of my GERD symptoms re-appeared during our modified debauch and I was thankful I had an old bottle of out-of-date Protexid to see me through.  One day of solid low-carb, and no more GERD, thank God.  And already after just a few days our clothing is starting to fit again.

If you are one of the many who are committed to a program of weight loss and rehabilitation this January, know that MD and I are right in there with you.

I want to forewarn you, though, that you’ve got to get your head right if you seriously plan to succeed.  Don’t be a Tara Parker-Pope.

I’ve had a number of people send me the link to her long piece in last week’s New York Times Magazine (Parker-Pope is a health columnist for the New York Times) about her struggles to lose weight and to maintain her weight loss once she is finally able to shed a little.  In the article she describes her despair as she tried first this program then that to lose weight.  She fits perfectly the description of so many patients I’ve dealt with over the years.

Once your metabolism is broken, it’s difficult  to lose weight (other than the first time or two you try it) and even more difficult to keep it off.  In order to be successful, you’ve got to make a real commitment and stick to it.  You can’t drift here and there as Parker-Pope has done looking for some magic regimen that is going to ‘melt the fat away.’  It ain’t going to happen.  It takes a lot of hard work and resolve to see it through.  Even with a low-carb diet.

As you can see from the vintage ad above, Tara Parker-Pope is not the first to look for a miracle cure for excess ‘flesh.’  But she is at a bit of a disadvantage in that by virtue of her position she can pick up the phone and call the head of nutrition at Harvard, Yale, Johns Hopkins or any big institution and ask for advice for a column she’s writing.  Unfortunately, the advice she will get from most of these people is totally the mainstream academic party line and more than likely incorrect.  And, if she’s like many patients I’ve dealt with, as soon as she discovers that whatever she is doing entails real work, she will start looking for the next magic fix, only to be disappointed in that.  She will, as she describes, roller-coaster around weight-wise, quickly regaining whatever she loses, and end up fat, sad and miserable.  The only difference between Tara Parker-Pope and the millions of other people out there in her shoes is that she has a powerful platform to express the despair and hopelessness she feels to a large readership.  (I noticed that for a few days her piece was the most emailed of all the articles in the New York Times, which speaks to just how many people are struggling.)

The underlying message of her piece is that she has tried everything, and it has all been for naught.  Her obesity is a condition beyond her control because she has worked with all the greatest minds in the academic world of obesity treatment and has ended up fatter than when she started.

My contention is that if she would undertake a low-carb diet composed of whole foods (with maybe a shake or two thrown in here or there) and stick with it judiciously she would ultimately achieve success.  At least considerably more success than she has achieved thus far.  But if she followed the best low-carb diet known to man and lost to her ideal weight and body fat percentage, she would still have to continue to watch what she eats for the rest of her life if she were to want to maintain her new slim self.  MD and I just proved that over the past couple of weeks.
I have never been able to understand the mindset of people who think that once they lose to their ideal weight and body fat percentage they can then go back to their old way of eating without regaining all the weight they originally put on by their old way of eating.  It baffles me even more that people can lose considerable amounts of weight on a given diet, then go back to their old way of eating, regain all their weight, and view it as a failure of their weight loss diet.  But they do.

I always took a detailed dietary history of all my patients.  Many had been through two or three (or more) weight loss programs before they came to see me.  I would ask them about all the different programs they had tried, and they would list them out.  And most had had some measure of success on one or more (if not all) of these programs, in many cases having lost anywhere from 60-80 or more pounds, but they, almost to a person, considered these programs failures because they had regained their lost weight.

These people, like Tara Parker-Pope, MD and me, and anyone else who has crossed the Rubicon into the land of obesity have dysfunctional metabolic systems that will probably never be completely normal again.  They, like we, will always have to exercise vigilance to maintain what we maintained so easily before the damage took place.

As I wrote above, the easiest way to deal with obesity is to never become obese in the first place.

Which brings me to a real pet peeve of mine.  I want to go for the throats of people who let their kids eat and drink tons of sugary crap and justify it because their kids don’t gain weight from it.  Who knows when the irreversible damage begins to occur?  I feel the same about adolescents and young adults who seem to feel invincible and are face down in all kinds of crap all the time because they never gain weight.  And they assume, stupidly, that they never will.  But when they do, most will struggle with it for the rest of their lives.

In preparation for my own weight loss, I went back an reread a few of my old posts to gain inspiration.  If you are in the let’s-lose-weight boat this month with MD and me, you might want to read them, too.

Here is one of my favorites about a good friend who really committed to losing weight and turned her life around.  The post also tells you why you should gain control not just for yourself but for others.

Another old post gives some psychological insights as to why it can be difficult right now to give yourself over to a low-carbohydrate diet and some psychological tools to make it easier.

Here is one that gives a few more psychological tools to make dieting easier.

Years ago I wrote a regular column for a now-defunct low-carb magazine.  This piece on what it takes to really make a low-carbohydrate diet work may help with your struggles.

There are the two fairly recent posts on all the tips and tricks you can use to start (or restart) a low-carbohydrate diet.

I’m frequently asked on radio, TV and print interviews what my daily food intake is.  A couple of years ago I decided to do a photo diary of a week’s intake of food during a normal week.  The food I ate that week pretty much mirrors the food I eat now with a couple of exceptions.  The quality of the cooked food is better now because almost everything we eat at home is prepared sous vide for obvious reasons.  I go through periods from time to time in which I really like to have shakes for breakfast.  Then I burn out on them and almost can’t bear the thought.  During the non-shake periods I typically eat three eggs and three or four slices of bacon (Mangalitsa bacon if I can get it) every day for breakfast.  During my week’s photo log, I was in a shake phase, so realize that I am not now in shake phase, so it’s bacon and eggs, but that’s about the only difference.  The week’s diet you’ll see if you take a look is what keeps me at my normal weight.  It’s pretty much what I’m back on now minus the booze and a few of the little extra carb tidbits. Plus, I’m scrupulously avoiding wheat just to see what happens.  As soon as I lose the few pounds I picked up and my jeans are loose again, I’ll be back to this diet in full.

• Photo food diary day 1
• Photo food diary day 2
• Photo food diary day 3
• Photo food diary day 4
• Photo food diary day 5
• Photo food diary day 6
• Photo food diary day 7

If you, like we, have been noshing on more carbs than normal over the holidays, then start anew with us this January.  As I have discovered this first few days, the time I spent dallying with carbohydrates over the previous couple of weeks has reinvigorated my long dormant urge to eat even more carbs.  I’m sure I’m not the only one in this boat.  We all have to remember that this urge is one we have to overcome first by effort and ultimately by habit.  I’m back on track.  Hope you are as well.

In the last post we discussed ramping up the fat intake as the single best way to hurry the low-carb or keto adaptation along.  I didn’t mention it in the previous post, but another little secret is to keep an eye on the protein intake. Too much protein will prevent the shift into ketoses because the liver will convert some of the protein into glucose – this glucose will then be used first and slow down the ketogenic process.  Which, if course, prompts the question, how much protein is too much?  As long as you’re getting your protein from meat, especially fatty cuts of meat, you’re probably okay.  If you go for the extremely lean cuts of meat, say, skinless chicken breasts, or if you are supplementing your diet with low-fat protein shakes, you could have a little more trouble low-carb adapting.  If you’re going the shake route, I would recommend you add some coconut oil to the shakes for a couple of reasons.  First, you’ll hasten the keto-adaptation, and, second, the fat it coconut oil will help remove the fat from your liver (which I’ll discuss more later in this post).

A glass of Tinto de Verano pictured at left. A great way to hydrate. (See note at bottom of post.)

As I said, you need to really crank up the fat intake to push yourself over the adaptation divide as quickly as possible.  If you don’t like fatty cuts of meat, you can add a little medium-chain triglycerides (MCT) to your diet.  MCT are absorbed more like carbohydrates and are used quickly by the body.  They are almost never incorporated into the fat cells, so they burn quickly, and any extra that might be hanging around are converted to ketones.  So, MCT will drive the ketone production process.  And so will coconut oil if you prefer that.

You can find MCT oil at most health food or natural grocery stores.  It has never bothered me, but some people can get a little nauseated if they take too much of it, so if you decide to give it a try, start out slowly.  Or go with the coconut oil.

Aside from the occasional carb cravings, which we’ll deal with later, the most common symptoms experienced by those getting started on low-carb diets are fatigue, headaches, light-headedness or dizziness, and cramping.  I would say these four symptoms probably comprise 98 percent of the complaints we get from our patients we put on low-carb diets.  Not everyone experiences these symptoms – especially those who do what we tell them – but of those who do have symptoms, these are almost always the ones they have.  Let’s look at what to do to avoid them or treat them should you already be experiencing on or more.

Electrolytes

The most common cause of virtually all the symptoms listed above is an imbalance in electrolytes.  Following a low-carb diet results in a rapid lowering of insulin levels, which – though a good thing – can create problems in the early days.  We’ll address the electrolytes in the order of importance.

Sodium

When you are overweight and insulin resistant, you have a lot of insulin circulating in your blood most of the time.  This excess insulin does a number of bad things to you.  Gary Taubes wrote an entire book about how excess insulin makes you store fat in your fat cells.  But the story doesn’t end there.  Excess insulin also drives the kidneys to retain fluid, which is why many obese people retain a lot of extraneous fluid and experience pitting edema in their lower legs.

What is pitting edema?

If you push your finger into the tissue in the front (or just to the side of) your shin bone and your finger leaves an indentation – almost a finger print – that takes a while to fill back in, you have pitting edema.  Most overweight people experience this phenomenon late in the afternoon and/or at night after being on their feet all day.  The excess fluid pools around the lower legs and seeps into the soft tissues. In the morning, after the body has been horizontal through the night, the fluid redistributes, and the pitting edema goes away but then reoccurs as the day goes on.  Even people who aren’t all that overweight but who do have elevated insulin levels will have some degree of excess fluid accumulation even if they don’t experience pitting edema as evidence of it.

One of the first things that happens when people go on low-carb diets is a rapid improvement in insulin sensitivity.  Because the low-carb diet starts to quickly banish the insulin resistance, insulin levels fall quickly.  And as insulin falls, the stimulus to the kidneys to retain fluids goes away, and the kidneys begin to rapidly release fluid.  One of the common experiences at the start of low-carb dieting is the incessant running back and forth to the bathroom to urinate this excess fluid away.  Which is both good news and bad news.

The good news is that it’s great to get rid of the excess fluid but it comes at a cost, which is the bad news.  As the excess fluid goes, it takes with it sodium an extremely important electrolyte.  When sodium levels fall below a critical threshold (which can happen within a short time), symptoms often occur, the most common being fatigue, headache, cramps and postural hypotension.

Postural hypotension happens when you stand up too quickly and feel faint.  Or even pass out briefly.  It’s a sign of dehydration.  So if you’ve started your low-carb diet, made your multiple runs to the bathroom, and jump up off the couch to answer the phone and feel like your going to faint (or actually do pass out momentarily) and have to sit back down quickly, you’ve got postural hypotension.  It’s really easy to fix – you simply need to take more sodium and drink more water.  Salt your food more.  Increasing sodium is just another one of the many counter-intuitive things about low-carb dieting.  Just like eating more fat to lower your cholesterol.  You’ve got to start thinking differently.  The low-carb diet is one that absolutely requires more sodium.  A lot more sodium.

If you’ve got the brutal headaches that some people get when starting on a low-carb diet, add sodium.  And drink extra water.

Even if you don’t have pitting edema, postural hypotension or headaches, you still need more sodium if you are starting out on or following a low-carb diet. It’s critically important that you get extra sodium.  I can’t make this case too strongly.

An easy way to get extra sodium along with magnesium and potassium (a couple of other electrolytes we’ll discuss in a bit) is by consuming bone broth.  Unfortunately, you typically have to make the good stuff yourself because it’s difficult to find commercially.  You can get chicken broth and beef broth at most grocery stores, but it’s not nearly as good as the broth you can make yourself.  At the end of this post I‘ll give you a spectacular recipe that we have for a great bone broth we made at our now-defunct restaurant.  It is beyond good.  It requires a little time, but you can make a bunch and freeze it in small containers and keep it forever.

Short of making your own bone broth, you can use commercially available bouillon, which contains plenty of sodium and makes a nice hot drink.  Plop a cube in a cup of hot water and throw it back. Many patients have reported that drinking a cup of hot bouillon helps them get through carb cravings.  It’s easy and convenient, but can’t compare in taste to the real bone broth you make yourself.

In addition to broth, get some Celtic Sea Salt, Himalayan Salt or one of the other grayish, pinkish kind of grungy looking salts and replace your normal salt with these.  And don’t use them sparingly.  These salts have been harvested either from ancient sea beds or obtained by evaporation of sea water with high mineral content and contain about 70 percent of the sodium of regular salt (which has been refined, bleached and processed until it is pretty much pure sodium chloride, often with anti-caking agents added).  The other 30 percent of the volume is other minerals and micronutrients (including iodine) found in mineral-rich seas.  Consuming these salts is not just following a Paleolithic diet using modern food, but, depending upon the origin of the salt, it is consuming the same food your Paleolithic ancestors ate.  I much prefer these salts taste-wise to regular salt, and I salt the heck out of all my food with it.

Magnesium

The low-carb diet doesn’t really cause a massive depletion of magnesium like it does with the sodium and potassium (the next electrolyte on the list), but most people who are overweight, insulin resistant and/or hypertensive or diabetic are deficient in magnesium.  Even people with lipid problems are often magnesium deficient.  In fact, even people who don’t seem to have health problems can often be magnesium deficient because most people don’t get enough.   The last I read on the subject, about 70 percent of people don’t even get the minimum recommended daily intake of magnesium (which isn’t all that high).  So, in my opinion, it’s important to supplement this vital mineral.  Good magnesium levels help regulate potassium as well, so keeping your magnesium adequate helps with your potassium as well.

Nature has designed us so that approximately 300 plus of our enzymes require magnesium as a co-factor to make them work properly.  Which tells us that we evolved in a time when magnesium was readily available, otherwise the forces of natural selection wouldn’t have made such wide use of it.

Where did it come from?  I would bet most of it came from the water.  Most natural sources of water have a high magnesium content, so when you drink bottled water and softened and treated water, you get short changed.  Magnesium salts in water are one of the substances that tends to make deposits on your water pipes and makes it difficult to get a good lather with soap.  This problem is solved with water softeners, but the process gets rid of the magnesium.  In the old days when we all drank well water or stream water, we got a lot more magnesium.

Since magnesium is used in 300+ different chemical reactions in the body, a shortage of magnesium can cause problems.  One of the most common ones is an increase in cravings.  Often simply replenishing magnesium gets rid of many of the food cravings people have.

The best way to get magnesium is from supplements.  Get a good chelated magnesium supplement and take 300-400 mg per day.  We’ve found it best to take these supplements in the evening because magnesium is relaxing and taking it in the evening helps you sleep.  About the only problem people ever have with magnesium is loose stools, i.e., the milk of magnesium effect.  If that happens – and it is unwelcome – simply reduce your dosage until your stools normalize.

Purchasing magnesium supplements can be a little tricky because of the way they’re labeled.  First, a chelated magnesium supplement is one that ends with an ‘-ate,’ as in magnesium aspartate or magnesium citrate or magnesium citrimate.  The -‘ate’ ending tells you the magnesium is chelated, which means it’s attached to another molecule (the chelating agent..aspartate, citrate, or whatever) that helps with absorption.  Second, with magnesium supplements, the manufacturers sometimes list the dosage of both the magnesium and the chelating agent combined.  Since the chelating agents are a lot heavier than the magnesium, this labeling often ends up saying the dosage of each pill is, say, 1000 mg of magnesium aspartate.  This isn’t the amount of magnesium you’re going to end up getting because the magnesium is only about 15 percent of the weight of the total pill.

About the only way you can really tell how much actual magnesium your getting is to look on the label on the back and see how much of the RDI (Recommended Daily Intake) the dose is.  The RDI for magnesium is 400 mg per day so if you find the dose of the supplement you are considering contains 50 percent of the RDI, then you know each dose contains 200 mg of magnesium irrespective of what the dosage is on the front of the bottle.  As I say, I recommend 300 to 400 mg of magnesium per day.  The only downside of magnesium is loose stools.  Doesn’t happen to everyone, but does to a few.  For many people the magnesium seems to offset the constipation that some experience when starting a low-carb diet.  If you do experience loose stools, simply back off your dose of magnesium until things unloosen.

Magnesium is natures relaxant.  It makes many people sleepy, so we always recommend taking it at bedtime.

Potassium

Potassium is linked to sodium.  If you lose a lot of sodium through the diuretic effect of the low-carb diet, you’ll ultimately lose a lot of potassium as well.  Keeping your sodium intake up as mentioned above will help preserve your potassium as well.  And keeping your potassium levels up helps to ensure that you don’t lose a lot of lean muscle mass during your weight loss.  Plus, just as with sodium, adequate potassium prevents cramping and fatigue.

You can replace your potassium by taking potassium supplements.  In our clinical practice, we gave all patients starting the low-carb diet a prescription for potassium.  You can get the same dosage by taking four to five of the over-the-counter 99 mg potassium supplements you can purchase at any health food or natural grocery store.

There are a couple of prescription medicines that you’ve got to be aware of if you markedly increase your potassium intake, so if you’re on blood pressure medicines, ask your doctor if it’s okay for you to take potassium.

Before we move on to other supplements we can use to help with low-carb dieting, I want to address the subject of dehydration.

Hydration

A few years ago, I learned the lessons of adequate hydration the hard way, so take this as a cautionary tale and benefit from my painful experience.  I had always pooh-poohed the notion of drinking a lot of water in addition to coffee, tea and other non-caloric beverages because I always figured (and probably have even written in the pages of this blog somewhere) that coffee, tea, etc. are nothing but water with a little flavoring in them.  I mean, if you start out with a glass of water and put tea bag in it, the water doesn’t go away.  It’s still there; it just becomes tea-flavored water.  Well, turns out that’s not actually the case.

My daily ritual was as follows: Get up, stagger to the refrigerator and take a big gulp or two of sparkling water.  Then make my way to the espresso maker and crank out a cup of Americano.  Followed by four or five more Americanos over the course of the morning and early afternoon, interspersed with a gulp here and there of sparkling water.  A snort of Jameson in the early evening, maybe a glass of red wine with dinner and a decaf Americano after dinner.  If I watch a movie or read a book, I usually nurse another glass of Jameson.  I typically take my supplements at bedtime, so I throw back another half glass or so of sparkling water then.  Plenty of liquids, right?

Well, not exactly, as it turned out.

I began developing severe cramps in my hands and feet that I had a hell of a time massaging out.  That was just the beginning.  I started being awakened at night with brutal leg cramps, requiring my springing from the bed and walking them out.  My potassium is too low, thought I, so I started taking potassium.  No change in the cramping situation.  In fact, if anything, it got worse.  I was complaining to a friend who told me calcium had helped his cramps.  So I downed calcium at bedtime.  No improvement.

Another friend told me that tonic water had helped her with cramps, but I only half believed it, so didn’t really try.  Then MD and I had family visit us in Tahoe for skiing.  I upped my booze intake, kept the coffee intake about the same, and probably decreased my consumption of sparkling water (or water of any kind, for that matter).  The cramps increased dramatically.  And what was worse, they stopped limiting themselves to the night.  When MD and I were driving over to Napa one day, the cramps were so severe I could hardly drive.  I had to keep the seat back as far as I could get it so I could straighten my leg when one hit me.  Then my hands started cramping just holding them on the steering wheel.  I pulled off the freeway and made a beeline for a convenience store and grabbed a one liter bottle of diet tonic water and proceeded to chug the entire thing as I drove down the road.  Miraculously, my cramps subsided.  So, I figured tonic water (quinine) was the solution.

One night – after being out of tonic water for a few days and being failed by my bride in resupplying – I had another brutal night of cramps.  The next day I was scheduled for blood donation.  After going through the long list of questions that must be answered verbally (and fighting down the impulse to tell my interrogator that I had recently paid for sex while imprisoned in Africa – those who have given blood lately will know what I mean), I was sent to actually have the blood taken.  The phlebotomist couldn’t find my vein, which had never happened before because I usually have rope-like veins in my forearms.  She asked if I was dehydrated.  I told her I didn’t think so since I had had my normal four of five cups of coffee that morning along with my gulp of water.  She brought me a couple of 16 ounce bottles of water that I drank, and, bingo, there were my veins.  Big and robust as usual.

It finally occurred to me that my cramping problem might be due to dehydration and that the diet tonic that solved the problem did so not because of the quinine but because I was drinking all the water the quinine was dissolved in.  And it occurred to me that the cramping was worse in the middle of the night because a lot of water is lost through the breath at night. (See my second post on the Anthony Colpo Smackdown to read more about this.)  You can lose a couple of pounds during sleep simply by breathing water vapor away, which was, I’m sure, what was happening to me.  I was barely hydrated enough to prevent cramping while awake, but when I slept and my fluid level fell due to my breathing water away, I hit some critical threshold of fluid that kicked off the cramps.

I started rehydrating first thing in the morning and throughout the day.  Now I get up, drink anywhere from 16 to 32 ounces of remineralized water (more about which later) first thing.  Then I head to the espresso maker and start my daily Americano regimen.  But I consume at least 8 ounces of sparkling water after each cup of coffee.  And I drink water after each shot of Jameson and/or glass of wine (or any other alcoholic libation),* and I’m proud to report that I have been cramp free since upping the water.

My brush with cramping misery inspired me to hit the medical literature to read about hydration.  And I learned many wonderful things. For example, I learned coffee is a diuretic (which I already knew but had chosen to forget), but that some acclimation occurs over time.  Still, due to the diuretic effect, you don’t get the full fluid from a cup of coffee that you would from an equal amount of water.  Same with alcohol.  Once I started calculating how much fluid of that I drank throughout the day I was actually retaining, I was amazed that cramping was the worst that happened to me.

I learned that water has a lipolytic effect (fat burning).  I read this in a number of papers that had studied it, and the data clearly showed that those who took in a lot of water had increased lipolysis.  I didn’t deny the data, but I couldn’t figure out the mechanism (and apparently neither could any of the authors because none described it).  I thought on it a while and finally came up with what I think is a plausible scenario.

When you drink water, especially cold water, you require some increase in caloric burning to bring the water to body temperature, but that increase doesn’t amount to all that much (the authors did describe this phenomenon), but you also dilute your blood for a bit until the water equilibrates with the fluid in all the tissues, and effect that takes some time.  During this time, while the blood is more dilute, the concentration of the various substances carried in the blood decreases.  Which would mean that insulin levels would fall.  The typical blood volume is about 5 liters, so drinking a liter of water would increase the blood volume temporarily by about 20 percent, which would mean the concentration of insulin and other molecules in the blood would fall by about 20 percent.  A 20 percent drop in insulin levels would allow fat to escape the fat cells and would facilitate its transfer into the mitochondria for burning.  At least that’s my explanation for the lipolytic effect seen in numerous studies of subjects increasing water intake.

Those starting a low-carb diet are prone to dehydration because excess ketones are gotten rid of via the kidneys along with a lot of fluid.  So, when you start your diet, consciously increase your fluid intake.  Do like I do now and come up with some sort of regimen that ensures you consume plenty of water throughout the day.  You’ll feel better; you’ll avoid cramping; and you’ll actually burn a little more fat.  And don’t make the mistake I did and assume that drinking a lot of coffee, tea, booze or other diuretic fluid is a replacement for water intake.

Since I drink either bottled water or water that comes through our RO filter, both of which are depleted of minerals, I always remineralize my water by adding a pinch of Celtic Sea Salt or one of the other such salts to each bottle.  I add enough so that the water just barely hints of a salty taste.

Supplements

Every patient whom we started on a low-carb diet left our clinic with six supplements:  lipoic acid, CoQ10, Vitamin E, magnesium, a good multi-vitamin and a prescription for potassium. (Now I would add a substantial dose of vitamin D3 to the list, a dose based on vitamin d levels and sun exposure.) We’ve already dealt with the potassium and magnesium, so let’s consider the others.

First, the good multi.  I’m a believer in getting most of what’s needed vitamin- and mineral-wise from food.  And I’m also a believer that I’m an excellent driver.  Yet I always purchase car insurance.  I see a good multi-vitamin as the same thing – cheap insurance against any kind of deficiency.  I would rather have my patients urinating away fifty cents worth of vitamins a day than risk that they have a deficiency in one.  And I feel the same way about myself.  So, find a good multi-vitamin without iron and take it.  Based on the experiences of my own patients, I can almost guarantee you’ll feel better. Why without iron?  Because most people on low-carb diets get plenty of iron in a very absorbable form.  And too much iron isn’t a good thing, so don’t take it in your multi.

Alpha lipoic acid (ALA)

ALA is, next to magnesium, just about my favorite supplement.  It acts as both a fat-soluble and water-soluble anti-oxidant so it can pretty much weasel its way in anywhere in the body and stamp out inflammation.  It protects fatty membranes and even acts as a cellular nutrient.  It also helps the body deal with blood sugar, which helps the whole low-carb adaptation process along.  Many studies have shown an improvement in blood glucose levels and insulin sensitivity with ALA supplementation.  ALA can rejuvenate other anti-oxidants, and has so many virtues that entire books have been written about it.  My standard dose is 300 mg per day for patients starting low-carb diets.  There is a newer, more potent version of ALA available now called r-alpha lipoic acid.  The standard stuff is a combination of the r and l varieties, and since the r isomer is the active one, a supplement made entirely of the r variety is going to be more potent.  And more expensive.  If you use the r-ALA you can take 100 mg a day.

CoQ10

Another superstar supplement, especially for those who have been on or are on statins.  Statin drugs interfere with the body’s synthesis of this important nutrient, and those who have been or are taking statins are usually depleted to some degree.  If you’ve been taking a statin, I would take 300 mg per day of CoQ10.  If you haven’t, 100 mg per day should do.

Vitamin D3

I would also add at least 1000 IU per day of this nutrient.  You need to have your levels checked at some point to make sure you don’t overdo it, but at 1000 IU per day, this is unlikely.  If you do test and find you’re deficient, I would take 5,000-10,000 IU per day until 25 (OH) vit D serum levels are up to at least 50 ng/ml.  Along with all the other benefits vitamin D3 provides (which I have written about elsewhere on this blog), there is some evidence that it even boosts weight loss a bit.

5-hydroxytryptophan

The last supplement I’ll mention is one I’ve had much success with in treating people who tend to have carb cravings late in the day.  5-hydroxytryptophan (5-HTP) is the precursor to serotonin.  Most people who have carb cravings have them because their serotonin levels fall.  Taking 5-HTP will bring them back up.  It also helps with sleep.  Best time to take it seems to be about 4 or 5 PM for those who go to bed at the standard 10-12 PM.  You can move the dose around to find a time that helps the most with your carb cravings yet doesn’t make you sleepy other than when you want to be.  I usually recommend 50-100 mg.  It’s available at most health food stores and natural food grocers.

Fatty liver

The last bit of advice I’ll give is that you need to work to defat your liver as quickly as possible.  The good news is that you can do it quickly on a low-carb diet.  Studies have shown major improvement in just 10 days or so.   It’s important to defat your liver to help you lose weight more quickly because the liver breaks down insulin.  If your blood sugar goes up, the pancreas makes and secretes insulin to drive it down. It does so by driving the glucose into the cells.  At the same time, insulin drives fat into the fat cells and keeps it there.  As long as the insulin is in the circulation, it’s going to be preventing fat from leaving the fat cells.  The liver is the organ that breaks down and gets rid of the insulin.  And a healthy liver does it a lot better than a liver full of fat.

One of the liver’s most important jobs is detoxification of harmful substances.  We all (at least I) consume medications, food and drink that is toxic.  We (I) drink coffee, tea and alcoholic beverages.  The caffeine and alcohol are toxins.  They don’t really hurt us in the quantities that most of us ingest, but they are toxic nevertheless.  The liver detoxifies them.  Same with many drugs – both prescription and over-the-counter.  Tylenol puts a major detoxification burden on the liver.  When you drink coffee, tea, and/or alcohol and take OTC meds, you occupy much of your liver’s detoxification capacity.  Which means it can’t get rid of insulin as well and can’t regulate metabolism in general as well as it does when it isn’t busily detoxing toxins.

So, if you really want to hit it hard in the early phases of your low-carb diet and reach low-carb adaptation at warp speed, I would recommend avoiding – or at least limiting – coffee, tea, alcohol and OTC meds.

I am a huge lover of coffee and alcohol (coffee more so than alcohol despite my constant talk of Jameson) so I know this is a sacrifice.  One way to have it both ways is to switch from caffeinated coffee to decaf espresso.  Decaf coffee to me sucks taste-wise.  But decaf espresso ain’t so bad.  If you don’t want to go completely cold turkey, you can switch from coffee to espresso since espresso has double (or triple) the taste of coffee yet only about half the caffeine.  My favorite way to drink espresso is as Cafe Americano.  I love it so much that I even made a video of how to make it to send to people.  Take a look if you haven’t seen it yet.  It’s the best cup of coffee you’ll ever have. (I have one on the table next to me as I write these words on the patio in Cuenca, Spain.)

That’s about a wrap on my tips and tricks for kicking off a low-carb diet.  I’m sure many of you have tips and tricks of your own.  Please feel free to share them in the comments section.

The bone broth recipe at the very bottom of this post is from our defunct restaurant that I wrote about here.  We had this going on the stove all the time and used it as a base for about half the dishes we served.  It is absolutely spectacular.  I would eat is as a soup (we didn’t serve it that way) and take home bags of it and freeze it.  You can do the same.  I’ll provide the restaurant-sized version so you can either make a large amount in a big stock pot and freeze a bunch of it in individual packages.  Or you can cut it down to a smaller recipe.  If you do, just make sure to cut all the ingredient amounts proportionally.

A note of interest: I wrote the first part of this post flying between San Francisco and Dallas.  The middle part during a flight from Dallas to Atlanta.  And the last part (along with the words I’m typing now) over the Atlantic on a flight from Atlanta to Madrid.  I’ll transfer it to WordPress, put in all the links and photos when I get to the hotel in Madrid.  So you’ll end up with a post that was written about halfway around the world.

Another note of interest: I’m finishing this post in Cuenca, Spain (including some of the edits I made above) because the internet connection in our hotel in Madrid sucked.  The hotel was great, the food was pretty good, but the internet was abysmal.  I kept getting kicked off, so I abandoned all but the most necessary internet functions (email, mainly) until I got to more reliable service.  Here we are in Cuenca where the hotel sucks, the food really sucks but the internet connection is great.

One housekeeping note: Since the internet has been so unreliable, I have been unable to deal with the 100 or so comments that have accumulated.  I’ll get to them as soon as this post is up.  I did perform one of my most-hated tasks last night and went through the spam filter to fish out legit comments that had gotten snared before deleting the zillions of spam comments.  So if you’ve been waiting a long time for a comment to appear, it was probably one of the handful that I rescued from the sea of spam.  I’ll get it up as soon as I can. Just bear in mind that I’m headed for my next stop, Zaragoza, as soon as I hit the ‘Publish’ button on this post and will be on a forced march for a bit. So, be patient with me on the comments.

This is the restaurant recipe for massive quantities, so you can reduce accordingly.  Just make sure you reduce all ingredients proportionally.

2 oz roasted garlic (weight)
10 oz roasted red onions (weight)
4.5 gallons water (volume)
22 oz tomato paste (weight)
4 oz cilantro with stems
2 pounds chicken back bones (weight)
16 oz tomato pulp (weight)*
6 oz salt (weight) I would use Celtic Sea Salt or other such salt here
1 oz black pepper (weight)
1 oz olive oil (volume)

Roast onions and garlic in olive oil for approximately 15 to 20 minutes.

Add all ingredients to water, chicken and tomato paste.

Let simmer over medium fire until cooked.

Approximate yield is 640 ounces or 5 gallons.

*We used a ton of diced Roma tomatoes in the restaurant for just about everything.  We removed the pulp from these tomatoes before dicing them.  We saved the pulp and used it in the stock.

*Here in Spain I have discovered a wonderful way to drink wine and stay hydrated.  They have a drink called Tinto de Verano (see photo at top), which is half fruity Spanish wine and half sparkling water poured over ice with a slice of orange and slice of lemon thrown in.  It’s kind of sangria lite.  Each time you drink a glass of it, you get half wine and half water, so you rehydrate the water lost from the little alcohol in the half glass of wine.  It’s tremendously refreshing, and I’ve drunk my weight of it since arriving.

As anyone who has done it knows, getting started on a low-carb diet can be a little rough.  Not for everyone, but for some.  All too often these little front-end bumps in the road–coupled with the spirit of the times in which the well-intentioned but ignorant friends and relatives of low-carb dieters tell them their diet is going to croak their kidneys, clog their arteries and weaken their bones–can be enough to make many people abandon the most sincere efforts.  Drawing on my almost 30 years of experience treating patients using the low-carb diet, I can give some tips and tricks for dealing with these difficult early days.

Listen to your body?

The surest road to failure in the first few days of low-carb dieting is to listen to your body.  The whole notion of listening to your body is one of my major pet peeves.  In fact, just hearing those words makes me want to puke.  In my experience, they are usually uttered by females with moist, dreamy looks in their eyes, but not always.  I just read a ton of comments in recent Paleo blog post in which vastly more males than females actually wrote this drivel.

Listening to your body is giving the elephant free rein. If you’re three days into your stop-smoking program, and you listen to your body, you’re screwed.  If you’re in drug rehab, and you listen to your body, you’re screwed.  If you’re trying to give up booze, and you listen to your body, you’re screwed.  And if you’re a week into your low-carb diet, and you listen to your body, you’re screwed.  Actually, it’s okay to listen to it, I suppose, just don’t do what it’s telling you to do because if you do, you’re screwed.

Okay, end of rant.  I just had to get it out of my system.  You just can’t imagine how many times people who have tried low-carb diets then abandoned them early on have said those words to me.  Wait.  I’m about to get started again. Stop!

Low-carbohydrate adaptation

Probably the best explanation of low-carb adaptation (also called keto adaptation) was written by a Lt. Frederick Schwatka (pictured above left) over a hundred years ago.

When first thrown wholly upon a diet of reindeer meat, it seems inadequate to properly nourish the system and there is an apparent weakness and inability to perform severe exertive, fatiguing journeys. But this soon passes away in the course of two or three weeks.

Lt. Schwatka was a doctor, a lawyer, and an explorer of the Arctic, the Great Plains and northern Mexico.  The above quote comes from his book on the unfruitful search for the Franklin party in 1878.  (For all his experience and gifts, and understanding of low-carb adaptation, the good doctor listened to his own body a little too much and did himself in with an overdose of morphine at age 42.) You can read more about Lt Schwatka, low-carb adaptation, and his time with the Inuit in a post I wrote a few years ago.

The period of low-carb adaptation is that time between starting a low-carb diet and feeling great on a low-carb diet.  It can take anywhere from just a day or so to two or three weeks.  During this adaptation period people tend to fatigue easily, experience a slight lack of mental clarity and be tormented off and on by the unbidden lust for carbs that seems to rise up out of nowhere.  Why does this happen early on with a diet that ultimately works so well to increase exercise capacity, mental clarity, and feelings of satiation?

It happens because both your body and brain are going through a profound change in the way they get their energy.  You can’t run your car designed to burn gasoline on biodeisel…unless you install a converter.  Then you can.  We humans have the design for our carb to fat converters coded in our DNA – the low-carb adaptation period is simply the time it takes for the converter to be built and installed.

Our bodies are simply giant piles of chemicals heaped together in a human-shaped form.  Most of the chemicals will react with one another, but only extremely slowly.  If we didn’t have something to help these reactions along, life wouldn’t exist.  The helpers are called enzymes.  These enzymes – which are large folded proteins – catalyze all the chemical reactions that allow us to function.  Mix a couple of body chemicals together and you might have to wait twenty years or more for them to interact or combine in some way to form another body chemical product.  Throw the correct enzyme into the mixture, and you get a reaction in a fraction of a second.

When you’ve been on the standard American high-carb diet, you’re loaded with enzymes ready to convert those carbs to energy.  You’ve got some enzymes laying in the weeds waiting to deal with the fat, but mainly dealing with it by storing it, not necessarily burning it.  All the pathways to deal with carbs and their resultant blood glucose are well-oiled and operating smoothly.  Then you start a low-carb diet.  Suddenly, you’ve idled most of the enzyme force you have built to process the carbs in your diet while at the same time you don’t have a ready supply of the enzymes in the quantities needed to deal with your new diet.  It would be like a Ford automobile factory changing in one day into a plant that made iPads.  All the autoworkers would show up and be clueless as how to make an iPad.  It would take a while – not to mention a lot of chaos – to get rid of the autoworkers and replace them with iPad workers.  In a way, that’s kind of what’s happening during the low-carb adaptation period.

Over the first few days to few weeks of low-carb adaptation, your body is laying off the carbohydrate worker enzymes and building new fat worker enzymes.  Once the workforce in your body is changed out, you start functioning properly on your new low-carb, higher-fat diet.  The carbs you used to burn for energy are now replaced to a great extent by ketones (which is why this time is also called the keto-adaptation period) and fat.  Your brain begins to use ketones to replace the glucose it used to use pretty much exclusively, so your thinking clears up.  And the fatigue you used to feel at the start of the diet goes away as ketones and fat (and the army of enzymes required to use them efficiently) take over as the primary sources of energy.  Suddenly you seem to go from not being able to walk out to get the morning paper without puffing and panting to having an abundance of energy.  Because of this low-carb adaptation period, we never, ever counsel our patients to start an exercise program when they start their low-carb diets because a) we know they’ll be too fatigued to do it, and b) we know that in a short time they will start exercising spontaneously to burn off the excess fat on their bodies once the skids are greased, so to speak.

Anyone with good sense contemplating a low-carb diet would ask the question, How can I make this low-carb adaptation period as short as possible?  Good question.  Why would anyone want to prolong the agony?

The secret to making it shorter is in the second part of what Lt. Schwatka wrote about low-carb adaptation.  Immediately after the above quoted sentences, he follows with:

At first the white man takes to the new diet in too homeopathic a manner, especially if it be raw. However, seal meat which is far more disagreeable with its fishy odor, and bear meat with its strong flavor, seems to have no such temporary debilitating effect upon the economy.

In other words, the white man, used to flour, sugar, boiled meat and all the other staples of the mid 19th century American diet, balked at the consumption of raw meat, especially raw and malodorous seal and bear meat.  And so took it in tiny portions (in a  “homeopathic manner”) instead of going face down in it.  Compared to reindeer meat, both seal and bear meat are loaded with fat, which is why the consumption of those fattier meats didn’t produce the “temporary debilitating effect.”  In those who did eat the fattier meats, the low-carb adaptation period was very short or even non-existent.

Eat more fat

If you want to reduce the time you spend in low-carb adaptation, crank up the fat.  If you go on a high-protein, moderate-fat diet (Schwatka’s reindeer diet), your body will convert the protein to glucose via gluconeogenesis, so you’ll still have glucose to keep the glucose worker enzymes busy and will prolong the conversion to fat and ketones as your primary energy source.

So Rule Number One to reduce the time spent in low-carb adaptation purgatory is: Don’t be a wuss when you start your low-carb way of eating.  Keep the carbs cut to the minimum and load up on the fat. Eat fatty cuts of meat, cooked in butter or lard if you want, and force your body over to using the fats and ketones for energy as nature intended. I mean, don’t try to be noble by eating boneless, skinless chicken breasts – instead insert some pats of butter under the skin of a chicken leg and thigh before cooking, and wolf them with your fingers while the fat drips down your arms.  Do not trim the fat from your steaks – eat them from the fat side in.  If you leave anything on your plate, make sure it’s the meat and not the fat.  If you don’t already, learn to love bacon, and don’t cook it ‘til the fat is all gone: eat it wobbly.  Wallow in Mangalitsa lardo.  And whatever you do, for God’s sake, don’t listen to your body during this adaptation period or you’ll never cross the chasm between fat and miserable on your high-carb diet and slim, happy, energetic and low-carb adapted on the other side.

In my next post, I’ll give you the rest of the tips and tricks to get through low-carb adaptation that MD and I have learned in our combined 50 plus years of taking care of patients on low-carb diet. And I’ll include a recipe worthy of killing for that you can prepare to help you get through.

A little over two years ago I wrote a post on Pentabosol, a weight-loss supplement we and our research partner developed and made available for a number of years.  In that post I mentioned that MD and I were contemplating actively marketing Pentabosol again.  We reformulated the product and changed its name to Metabosol, but our timing was all wrong because at about the same time, we wound up launching our SousVide Supreme project as well.  Never having been in the appliance business, we had not even the most minimal idea as to how much time that venture was going to take.  As a consequence, the weight-loss product project took a back seat and more or less fell between the cracks.  Now that things on the sous vide front requiring our direct attention have slowed down a bit (for us, not for the company) we decided to turn our attention to the nutritional supplement and made an annoying (to us) discovery that may benefit you. (More about which later.) In case you don’t go back and read the old post, let me quickly review the Pentabosol (Metabosol) story.

Pentabosol

NOTE: DUE TO OVERWHELMING DEMAND, WE HAVE JUST RUN OUT OF ALL OF OUR SUPPLIES OF METABOSOL.  THANKS FOR YOUR INTEREST.

MD and I have taken care of overweight patients using low-carb diets in our medical practice for decades.  Our patients had pretty spectacular results with their low-carb diets, but like dieters everywhere, they all wanted to lose weight faster.  For years we had been searching for some kind of nutritional product that could give a boost to our patients’ weight loss without their paying the price of unpleasant side effects.  As a consequence, we ruled out anything with phenylpropanolamine, ephedra, and all the stimulant type products.  Although we used prescription medicines occasionally, we weren’t really sold on them because of the side-effect issue and because we didn’t know what, if any, would be the long-term effects.  We were seeking something that was a natural supplement that had no stimulant effects and that actually worked.

As is my wont, I trawled through the medical literature looking for solutions.  It soon became obvious that although there were a number of natural substances (non stimulants) promoted as weigh loss supplements, these products were not particularly effective.  We looked at all these different supplements and, along with our partner, laid out all the mechanisms by which these products worked.  We then teased out those that drove pathways congruent with the pathways through which the low-carb diet worked.  And we came up with a couple of hypotheses.  First, we thought that these products individually might work a lot better than their study results had shown if used along with a low-carbohydrate diet (virtually all had been studied using low-calorie, high-carb diets), and, second, that these few substances taken in combination might have a synergistic effect not present when taken individually.  We came up with a supplement mixture that we thought might help people following low-carb diets lose weight more quickly.

We decided to make these supplements available to patients in our practice who wanted to boost their weight loss.  We provided them with a written list of supplements that they could gather at most health food stores (since we didn’t carry any of these supplements in the clinic).  The patients who elected to try the regimen did well, but we really had no control group, so we didn’t know with certainty whether our supplement conglomeration worked or not.  We had some difficulty getting a lot of patients to both try the regimen and stick with it once they started, because of the expense and the inconvenience.  The bag of supplements would set them back about $150 a month and required their taking multiple pills multiple times daily.

We felt that our little pilot study, such as it was, justified spending the money to both develop an actual product and to have it clinically tested.  We found a manufacturer to produce a product that was less expensive and more convenient than the handful of pills our patients had been taking daily.  We also sought out and found a facility that did contract clinical testing of products.  And we discovered what the drug companies have known for a long time – randomized, double-blind, placebo-controlled studies, the gold standard of clinical trials, are not inexpensive.  After giving the idea a lot of study, we sucked up and invested the money.

We established the protocols and launched the study.  Subjects were randomized into two groups, both of which went on moderately low-carb diets and both of which were instructed to perform the same type and amount of exercise. One group went on the supplement that we ultimately named Pentabosol, while the other went on a placebo that looked and tasted the same as Pentabosol.  (As an aside, I can tell you that we must have been brain dead when we contracted for this study because by the time all the subjects were recruited and randomized, the actual trial ended up taking place through the Thanksgiving holiday – for sure not the best time to be doing a weight loss study. I have no way of know, of course, but I suspect that had we waited until the first of the following year to do this study, we would have had even better results.)  After the last subjects completed the six week study, the testing facility broke the double-blind codes, analyzed the data, and the director of the lab gave me a call.

It was a memorable call.  He started out by saying: “Well, I’ve got some good news for you and some bad news for you.  Which do you want first?”

Being the eternal optimist, I said, give me the good news.

He said:  “You have got a phenomenal product.  It works like nothing we’ve ever seen.  It works better than some drugs we’ve tested.”

The people on the supplement had lost almost double the weight (71 percent more, to be exact) than those taking the placebo.

As you might imagine, I was thrilled. But not all that surprised based on our reports from our own patients.

“So what’s the bad news?,” I asked.

The bad news, he told me, was that we didn’t have what he thought was a commercial product.  He said that he had to practically horsewhip some people to keep them on it.  He said he thought it didn’t matter how efficacious a supplement was if people wouldn’t take it.

He had a point.  And, admittedly, the first primitive version of our product was pretty rough.  The product … is a powder that you dissolve in water (cold or hot like a tea) and drink.  The early study version mixed about like sand mixes with water.  You had to put it in the water, then swirl the water in the glass while you drank the stuff.  And it didn’t taste all that great.

After badgering our manufacturer to make the product better but obtaining only marginal improvements, we began seeking other manufacturers.  We finally found one that specialized in powders and finally had a product manufactured that was tasty and mixed well.

Metabosol

NOTE: DUE TO OVERWHELMING DEMAND, WE ARE OUT OF OUR SUPPLY OF METABOSOL.

A couple of years ago MD and I decided we needed to give Pentabosol a makeover.  A complaint we had heard over and over was that Pentabosol contained sucralose, an artificial sweetener.  At the time we first made the product, we had no choice.  We did have a choice, I suppose, in aspartame, but we elected to go with sucralose.  The product required a sweetener because one of the components is extremely tart, and without sweetening the product would have been unpalatable.

We  spent some time with the manufacturer and discovered that we could freshen the taste, improve mix-ability, add another flavor and use a natural sweetener instead of sucralose.

We decided to name the new and improved product Metabosol.  It contains all the same active ingredients in the same proportions as Pentabosol, but is naturally sweetened, giving it (to my palate, at least) a cleaner taste.  Those who have tried both products like the taste and consistency of Metabosol better.  And like the fact that there are a couple of flavors: berry and citrus.

How you can take advantage of our lack of attention.

As I mentioned at the start of this post, we did all the improvement work and got Metabosol all ready to launch but put it on the back burner because of our commitment to the sous vide project.  We just got a call from our able assistant, Kristi, who said, guess what? all the Metabosol is going out of date as of the end of May.  This May.  As in about two weeks.

So, if any readers out there would like to give Metabosol a try, it can be ordered through the Products section of our website absolutely free.  With absolutely no strings attached.  All we ask is that you pay for UPS shipping.  And because we don’t have all that many containers left, please only two per person.  Let’s make sure that anyone who wants to can give it a try.

I want to end with a few caveats.

First, we did only one study on Pentabosol / Metabosol.  That study showed significantly increased weight loss in the subjects using the product.  But I’ll be the first to tell anyone that it takes more than one study to prove anything.  We (or someone else) might do a second study and find less or more weight loss.  As far as I know, there is no other study out there evaluating the efficacy of the exact combinations contained in Metabosol.  There is one other study – a pilot study – showing a significant weight loss in subjects following a similar, but much more expensive supplement regimen.  We’ve had over 250,000 people use Pentabosol with a substantial reorder rate, which would indicate that it works.  But we have only the one study.

Second, the Metabosol you will receive is almost out of date.  It shouldn’t be a problem, but the manufacturer is required to put a two year expiration on supplements.  We will ship only while the product is still in date, so once the end of May comes, we will take the product off our website until we have a new batch, which will then be at the regular price.

Third, as studied, Metabosol was shown to work only when combined with a low-carb diet and moderate exercise. (We had to control for diet and exercise.) It was designed to enhance the rate of weight loss in those following low-carbohydrate diets and who exercised moderately, and the study indicated that it did.  We have no idea if Metabosol would work without diet and exercise and we don’t recommend that you use it in that way.  It is not a magic bullet.  As we all know, weight loss is a difficult proposition at best – Metabosol is simply designed to help you get to your goal a little faster.

Now, if I haven’t scared you off with all the disclaimers, give it a try on us.  And we would love to learn how it works for you, so don’t hesitate to let us know.

Note: We try to get all of our products shipped the same day the orders come in.  But Kristi, our able assistant, is leaving for a long weekend (it’s her birthday today, so we’ve let her escape the asylum for a bit) and won’t be able to get these Metabosol orders shipped until Monday morning, May 23.

THANKS FOR YOUR INTEREST.  WE HAVE RUN OUT OF OUR SUPPLIES OF METABOSOL.

Okay.  I said I was through with Anthony Colpo, but now I’m going to quote from him once again.  What gives?

What gives is that I’m stuck in the airport in Seattle – my flight to Chicago is delayed for almost four hours because of bad weather in the Windy City.  I figured I would use this time to stick up a quick post about thermodynamics and provide a long quote from Robert McLeod, who writes Entropy Production, a physics (sort of) blog.  As you can see below, he pretty much trashes Bray and other nutritional researchers who blithely use the 1st Law of Thermodynamics to prove the old a-calorie-is-a-calorie notion.  To show the way the average nutritional writer looks at this law, I needed to find a quote.  As it works out, the only thing I have with me is Anthony’s book The Fat Loss Bible, which just happens to have the perfect quote.  So, sorry AC, I’m not really trying to pick on you.  And you certainly aren’t the only nutritional writer who thinks this way – you’re just the only one who has a quote handy I can use.

The First Law of Thermodynamics states that energy can neither be created nor destroyed. It can only be converted from one form to another. In other words, energy just doesn’t just magically disappear; it must be converted to something else. In the case of any excess calories you ingest, they will be stored as fat, used to accommodate an increase in lean tissue mass, or dissipated as heat through thermogenesis. Manipulating the proportion of protein, fat and carbohydrate you eat each day will not excuse you from the Law of Thermodynamics.

This is the way just about all nutritional scientists and writers look at the First Law.  Let’s take a look at how a physicist sees it.  Robert McLeod wrote a long post a while back reviewing Gary Taubes’ Good Calories, Bad Calories.  Near the end of the post, he discusses the energy balance equation and one of our old friends, Dr. George Bray, who gave Gary’s book a bad review in an obesity journal.  (I posted on this same review a couple of times here and here.)

Here’s what he says:

I was somewhat confused to see this [a nutritional description of the energy balance equation] Surely the nutritional scientists did not not really believe this, right? I mean, any idiot undergraduate students knows that the 1st Law is only useful in a closed system, and humans live on the planet Earth, not in an insulated box. Right?

Enter a rebuttal by G. Bray in the journal Obesity Reviews. Bray is a to be a major obesity researcher and one of the 2nd tier villains in the book. Taubes relates a story of Bray excising a section of a British report on obesity, where Bray removed the material pertaining to the relationship between insulin and obesity. He clearly has editorial support to make his case. Bray is one of the second-tier villains in Taubes’ book. Taubes has a footnote (p. 421), which suggests that Bray actively suppressed the carbohydrate-insulin hypothesis.

“According to Novin, when he wrote up his presentation for the conference proceedings Bray removed the last four pages, all of which were on the link between carbohydrates, insulin, hunger, and weight gain. “I couldn’t believe he would make that kind of arbitrary decision,” Novin said.”

Unfortunately, to a physicist this energy balance hypothesis looks like a silly hand-waving exercise, not a serious argument. Frankly I was flabbergasted when I first read this article. This conservation of energy argument is on the same scientific level as the ridiculous “drink cold water to lose weight” idiocy. A human organism is:

1. Not in thermal equilibrium with their environment. Last time I checked I have a body temperature around 38 °C and spend most of my time in 21 °C rooms.
2. Capable of significant mass flows (e.g. respiration).
3. Capable of sequestering entropy (e.g. protein synthesis).

Is wearing a sweater fattening (by insulating you from your environment)? Here’s a quote from the rebuttal,

“Let me make my position very clear. Obesity is the result of a prolonged small positive energy surplus with fat storage as the result. An energy deficit produces weight loss and tips the balance in the opposite direction from overeating.”

According Bray’s thermodynamics argument, wearing sweaters makes you fat. This illustrates the greatest fallacy of trying to apply the 1st Law to a human: it makes the implication that living organisms consume kilocalories for the purpose of generating heat rather than perform useful work (i.e. breathing, contracting cardio and skeletal muscle, generating nervous action pulses, etc.). In reality heat is the waste product of basal metabolism. The first law does not distinguish between different types of energy. Heat, work are all equal under the First Law of Thermodynamics.

Applying the 1st Law to living organisms is Proof by Tautology. Yes, 1 + 1 = 2, but this tells us absolutely nothing about the underlying mechanics. The 1st Law does not (I repeat N-O-T) tell us whether you store excess energy in the form of fat, or bleed it off into the atmosphere by dilating blood vessels next to the skin, sweating, etc. To do so would require an accounting of entropy.

What would a semi-rigorous description of the thermodynamics of a human organism look like? Look at the title strip on the top of the page. See that equation in the background?

[The above is the background of the header of Robert McLeod's blog]

This type of equation would be a bare starting point for energy balance in a complex system like a living organism. Good luck actually accounting for all the terms. Those Σs are sums.

On to the second and, mercifully, final part of the critical review of the metabolic advantage as presented by A Colpo in his book The Fat-Loss Bible. As discussed in the previous post, our friend, like the kid to the left, is focused so intently on his refusal to believe in even the possibility of the existence of a metabolic advantage that he can’t read the literature correctly – not even the very literature he uses to try to prove his own position.  His bias has hypnotized him to the point that he can’t see anything that doesn’t confirm his what he already believes.  And this same bias prevents him from even taking a scientific approach to the problem.

We all fall victim to the confirmation bias and have to fight it constantly.  Gary Taubes thinks I may even have succumbed a little in the earlier post on AC and the metabolic advantage.  He emailed me saying he had read the post and thought it was great up to the point right at the end where I wrote that the data on the whole showed that, if anything, there was a metabolic advantage.  Gary thought the data presented in all the studies in AC’s chart was ambiguous and that I was going out on a limb a little in making the statement that I thought, if anything, that the papers argued for a metabolic advantage.

I disagree.

I decided to base this critique not on the scientific literature at large, but instead on only the papers that AC mustered for his argument.  I intended to make the critique much like a court case in which one side presents the information and the other attempts to counter it.  I didn’t want to go out myself and gather a bunch of papers that confirmed my viewpoint, because then we would have had nothing but a bunch of dueling Ph.Ds, a  bunch of he saids, she saids, that wouldn’t prove anything.  I stuck with the papers AC used and presented my arguments as to why I didn’t think his papers proved his case.  After going back and rereading the post, I still feel that if this ‘evidence’ were presented to a jury, the verdict would come back in favor of my arguments.  If anything, AC’s own ‘evidence’ argues for the existence of a metabolic advantage, and, at worst, certainly doesn’t ‘prove’ that one doesn’t exist.

Since I posted the first part of my critique, AC has responded using his customary restraint and understated gentility designed to appeal to his sort of reader.  His response – as I figured it would be – is merely a listing of even more papers he believes substantiate his claims.  Instead of undertaking a serious scientific inquiry, he is looking for more white swans.  Let me explain.

I wrote a long post a couple of years ago on Sir Karl Popper and the metabolic advantage.  Popper set the standards by which hypotheses should be structured.  A well-stated hypothesis should be able to be falsified.  That doesn’t mean it will be falsified, but it should be structured in a way that it can be.  And real scientists – of which, sadly, there are all too few in the field of nutrition – don’t try to confirm their hypotheses: they try to refute them.

One of the examples Popper used in explaining how a hypothesis should be established involved swans – white and black.  He used the following as an example of a good hypothesis:  All swans are white.  He made the case that this hypothesis cannot be confirmed by simply pointing out more and more white swans.  The hypothesis can be strengthened by doing so, but it can’t be proven.  It can, however, be disproved by the discovery of even a single black swan.  Popper argued that scientists should be working to find black swans instead of simply adding more and more white swan sightings to their data.  The more effort scientists expend to find a black swan without finding one, the more their hypothesis is strengthened.  Diligently searching for black swans is a much more valid scientific endeavor than simply looking for more white swans.

Many scientists don’t want to hunt for black swans, however, because they don’t want to blow up their hypotheses.  The easy way to bolster their hypotheses is to continue to tally up all the white swans they find and forget about looking for black ones.

Which, of course, is what our young friend AC has done and written about in his latest missive.  He tallies up a bunch more white swans and ignores the black ones, even the black ones in hiding in plain sight in his own list of papers.  This failure of his to try to puncture his own hypothesis leads me to believe there exists a large chasm of incomprehensibility between the way AC thinks and the scientific method.

To give but one example of this, AC argues in his book that the studies by Rabast that clearly show a metabolic advantage aren’t valid because, as AC puts it,

Regardless of whether Rabast et al’s findings were the result of water loss from glycogen depletion, pure chance, or some other unidentified factor, they should be regarded for what they are: An anomaly that has never been replicated by any other group of researchers. For a research finding to be considered valid, it must be consistently reproducible when tested by other researchers. As proof of the alleged weight loss advantage of low-carbohydrate diets, the findings by Rabast and colleagues fail dismally on this key requirement.

(In other words, AC is saying: that black swan over there isn’t really a black swan, because all the other swans I’ve pointed out are white.  And since all the others are I’ve pointed out are white, that one can’t be black.  It’s impossible.)

In point of fact, Rabast’s group in Germany has performed a number of studies showing a significant metabolic advantage in subjects in metabolic wards who follow low-carb, high-fat diets as compared to those taking in the same number of calories as high-carb, low-fat diets.  This group pursued this line of inquiry and published a number of studies showing this metabolic advantage.  Suddenly, however, they quit publishing on this subject and turned their attention elsewhere.

While in the research phase for Good Calories, Bad Calories, Gary Taubes interviewed Dr. Rabast about his group’s work, and here is what he said.  They were inspired by an old scientific paper (more about which later) that offered up some data they found interesting and wanted to test themselves.  They did the studies using formula diets, so they could more easily control intake and confirmed the data from the old study.  They continued to perform these studies, all with similar outcomes, until Dean Ornish published his paper on dietary fat and heart disease.  Dr. Rabast and his group decided that Ornish might be correct.  They felt that although their own data showed that high-fat diets brought about substantially better weight loss than low-fat diets of equal calories, their work might encourage people to consume more fat, which, thanks to Ornish and the low-fat movement, they had come to believe may cause heart disease.  So, they abandoned their research on high-fat diets and moved on to other interests.

The study that inspired them to study high-fat diets?  An study from the 1950s done by a couple of British researchers, Dr. Alan Kekwick and Dr. G.L.S. Pawan.  Their famous paper showed a definite metabolic advantage, a black swan writ large, as it were.  And their famous paper is well known to AC, who has a few things to say about it.  As you might suspect, given the results of this study, he declares it not worthy of consideration. Here is what he says in his book after he’s gone through his list of white swan studies, which, of course, are all worthy of mention.

Not-so-worthy mention

There is one metabolic ward trial that due to its short duration did not qualify for inclusion in Table 1a, but still warrants a mention. Incessantly cited by supporters of low-carb diets, this is the famous metabolic ward study conducted in the 1950s by Kekwick and Pawan. The London researchers conducted two experiments. In one of these, they claimed that patients maintained or gained weight on a typical mixed diet of 2,000 calories, yet consistently lost weight when placed on a 2,600 calorie low-carbohydrate diet for periods ranging from 4 to 14 days. In the second of their experiments, they had 14 patients alternate between four different 1,000 calorie diets, spending a grand total of 5-9 days on each diet: 1) 90 % protein; 2) 90% fat; 3) 90% carbohydrate, and; 4) a mixed diet. According to Kekwik and Pawan, all of the subjects in the protein, fat, and mixed diet groups lost weight, with the high-fat group experiencing the greatest weight loss of all. However, despite the very low calorie intake, many of the patients reportedly gained weight during the high-carbohydrate diet! Not surprisingly, the Kekwik and Pawan study is frequently cited by supporters of low-carbohydrate nutrition. That they ignore the studies in Table 1a, yet eagerly embrace a short-term study conducted over 50 years ago, speaks volumes about their complete disregard for rational scientific inquiry. [Italics in the original]

Here’s why: Firstly, it has long been known that in the first week or two of low-carbohydrate dieting, there is often a far greater reduction in water weight due to excretion of sodium and/or glycogen, both of which bind water in the body. Therefore, studies of such short duration are next to useless as indicators of the comparative longer-term weight loss effects of these diets.

Secondly, the Kekwik and Pawan study was a poorly controlled mess. The researchers were even driven to denigrate their study participants, writing: “The first and main hazard was that many of the patients had inadequate personalities. At worst they would cheat and lie, obtaining food from visitors, from trolleys touring the wards, and from neighbouring patients. (Some required almost complete isolation.)” [Italics in the original]

Given that protein and fat have been shown numerous times to exert satiating effects, while low-fat, high-carbohydrate diets (especially the liquid, low-fiber variety!) typically result in ravenous hunger, it’s not hard to guess during which diet the participants may have ‘cheated’ the most!

The researchers also wrote: “The results we report are selected, a considerable number of known failures in discipline being discarded”. Note how the researchers included the words “known failures”; how many failures did they not know about? How many of the patients were crafty enough to sneak extra food without being caught? Why should we trust Kekwik and Pawan’s unlikely results, given their study’s numerous flaws? The answer is simple: Unless you are a famous low- carb diet ‘guru’ who has made millions promising people they will lose extra weight at the same calorie intake by cutting carbs, we shouldn’t! At least not if we believe good science mandates a tightly controlled process of investigation. [Italics in the original]

As we shall see shortly, this commentary is all so much piffle.

(Here is the full-text version of the Kekwick and Pawan study so that you can pull it down and follow along with the rest of the discussion if you like.)

Let us begin.

It is apparent from his critique that AC read the first part of this study, found a black swan, used a bunch of incorrect gibberish and swagger to try to say it wasn’t really a black swan and moved on without ever getting to the important part of the paper. Or, an alternative explanation is that, as with the Leibel study mentioned in my first critique, he either didn’t really read the paper thoroughly or he seriously misunderstood what he read.

Drs. Kekwick and Pawan start off by explaining why they undertook this study in terms that any of us who have struggled with excess weight and found different results with different diets can understand.

Many different types of diet have been successfully used to reduce weight in those considered obese.  The principle on which most of them are constructed is to effect a reduction of calorie intake below the theoretical calorie needs of the body.  Experience with these patients has suggested, however, that this conception may be too rigid.  Many of them state that a very slight departure from the strict diet which can hardly affect calorie intake results in them failing to lose for a time.  Though it is realized that evidence from such patients is notoriously inaccurate owing to their approach to this particular condition, it is too constant a belief among them to be entirely discarded.

Drs. K & P did a number of experiments.  First they kept hospitalized subjects on diets of similar macronutrient composition but differing calories and found that reducing calories made the subjects lose weight.  And, unsurprisingly, the more the calories were cut, the more weight the subjects lost.  Next, the good doctors decided to see if changing the macronutrient composition of the diets made a difference.  They started the subjects on 1000 calorie per day diets of one of the following three structures: 90 percent of calories as carbohydrate; 90 percent of calories as protein; or 90 percent of calories as fat.  The structure of the diets made an enormous difference in how much weight the subjects lose.  As Drs. K & P wrote:

So different were the fates of weight-loss on these isocaloric diets that the composition of the diet appeared to outweigh in importance the intake of calories.

In an effort to confirm their findings, Drs. Kekwick and Pawan went on to a third series of experiments as described here:

…patients…were put on to 2000-calorie diets of normal proportions to show that their weight could be maintained while in hospital at this level and then placed on high-fat, high-protein diets providing 2600 calories per day.  It was demonstrated that these patients on the whole could maintain or gain weight on 2000-calories but, except in one instance, lost weight consistently on a 2600 daily calorie intake.

It’s easy to see why AC doesn’t like this paper.  And we haven’t even gotten to the good stuff yet, which AC doesn’t make mention of in his book.  We’ll get to that in a bit, but before we do, let’s take a look at AC’s critique of this much of the study (which is, apparently,  all he bothered to read). You can read along from the above quote in his book.

His first complaint is that the study is over 50 years old.  I find this a strange complaint, since the first study he lists in his chart of studies ‘proving’ his point was published a mere eight years after this Kekwick and Pawan study.  The Kinsell paper was published in 1964, 46 years ago.  Is there some magic cutoff date at 50 years that makes scientific papers unreliable?

Second, he claims that on low-carb diets all the weight loss from the first two weeks is water, and since these studies lasted less than two weeks, the difference was all water.

Kekwick and Pawan were a little smarter than Anthony gives them credit for being.  They understood well the notion of water loss.  (As we will see shortly, they understood it vastly better than our young friend.)  They pointed out the following:

During these periods [the different diet studies] the patients were weighed daily and in some of them balance studies were carried out in respect of water, nitrogen, fat, sodium, chloride, and potassium.  Total body-water and the basal metabolic rate were estimated weekly or at the end of each period on the diet.

If you look at the full-text version of the study I linked to above, you can see graphically how this all plays out.  In these studies the weight loss was definitely not all water.

In an effort to be meticulously accurate, not only did K & P monitor all the above carefully, they even went further.  Since these patients were not on formula diets but were on real foods instead, making it more difficult to accurately determine caloric intake, the staff would take representative samples of the foods eaten, blend them into a soup, then analyze samples to make sure the protein, carbohydrate and fat content were as estimated in the food tables.  It was hardly a “poorly controlled mess” of a study.

AC next attacks the study because the researchers admitted as to how difficult it is – even in hospitalized studies – to prevent cheating.

In such a study the difficulties are formidable.  The first and main hazard was that many of these patients had inadequate personalities.  At worst they would cheat and lie, obtaining food from visitors, from trolleys touring the wards, and from neighbouring patients. (Some required almost complete isolation.)  At best they cooperated fully but a few found the diet so trying that they could not eat the whole of their meals.  When this happened the rejected part was weighed, and the equivalent calories and foodstuffs were added to a meal later in the day.  The results we report are selected, a considerable number of known failures in discipline being discarded.

Kekwick and Pawan simply wrote of the difficulties in preventing cheating.  They were on the lookout for it, threw out data they knew was compromised, and compensated for episodes of cheating of which they were aware.  I believe the fact that they recognized cheating as going on and were keeping an eagle eye out for the cheaters makes their data more accurate, not less.

I also find it strange that AC is more than willing to toss data because of cheating in this study and is more than willing to accept data from other studies in which there was probably just as much – if not more – cheating that the authors neglected to mention either by design or because they didn’t realize it was happening.

One other thing that points to the degree into which K & P watched over this study is one that all female readers who have had trouble losing will be familiar with.

Another factor of importance which could not be eliminated was that many patients were women, in whom the retention and the losses of water associated with the menstrual cycle affected the daily weight and the estimation of total body-water.  We were surprised to find how great such factors could be, amounting in one woman to the retention of more than 3 litres of water.

Only a fool or a seeker of white swans only would think the good doctors didn’t monitor this study closely.

Now to the fun part, the part AC probably didn’t read.  And the part that really demonstrates the metabolic advantage.

The first part of this paper, the part AC has critiqued, is only a minor part of the paper.  The majority of the paper is devoted to the efforts the Drs. K & P made to determine what happened to the excess weight lost in dieters on the higher-fat diet.  They checked fat loss in the stool, they checked (as mentioned previously) water loss, they checked about everything they could think of.  You can read in the full version how careful they were.

After sifting through all the data and finding no reason that their results should have been invalid, the docs checked yet one more item.  They looked at insensible water loss.

Insensible water loss is the loss of water we all experience minute by minute that we not aware of.  We know we lose water when we urinate and/or defecate, and we know we lose some water when we visibly sweat, but we are not aware of the large amount of water we are getting rid of through our breath and via sweating that we don’t notice.  And this amount of water we lose is fairly large.

Do this experiment.  Get an accurate scale and weigh yourself immediately before going to bed.  Go ahead and urinate (and do anything else you might need to do) before weighing.  Don’t drink or eat anything, hop in the sack and sleep through the night, then get up and weigh before you urinate in the morning.  I absolutely guarantee that you’ll weigh less than before you went to bed.

If you breathe on a mirror, you will fog it from the water vapor in your breath.  This vapor is water that you lose every single time you take a breath.  You breathe approximately 12 times per minute (while resting), which means you breathe 720 times per hour and 17,280 times per day.  And that’s if you’re at rest.  If you are active, you take a lot more breaths than that.  Probably something in the neighborhood of 20,000-23,000 breaths per day, depending upon activity level.  Each one of these breaths contains water vapor that you are losing from your body, which is why you drink liquids throughout the day.  If you didn’t replace this water, you would become dehydrated.

If you have a fever or if you exercise, you breathe a lot more rapidly and lose a lot more fluid.  Thus, one of the things doctors have to be concerned about in very sick patients with high fevers is dehydration.

You also lose insensible water through constant perspiration.  When you awaken in the morning, if you’ve slept tightly covered up, you’ll notice you’re a little damp.  Not a lot, unless you’ve had a fever, but a little.  This is insensible water that you lost.

I remember how amazed I was the first time I ever looked at my own hand under a dissecting microscope.  Looking at my hand with my naked eye, it appeared normal and dry.  When I stuck it under the scope and looked, I could see little volcanoes of perspiration bubbling up from unseen pores.  It’s part of the way we regulate our temperature, and unless we work up a visible sweat, we never notice.

This loss of insensible water is why we lose weight overnight.  In eight hours of sleep, we breathe out about 5,760 breaths filled with water vapor and we sweat all night.  This water weight usually ends up being between 1 to 2 pounds or even a little more.

If I were to take a bunch of thyroid hormone or take an amphetamine, I can assure you that my metabolic rate would rise and that my insensible water loss would increase.  In fact, insensible water loss is a surrogate for metabolic rate.  If your metabolic rate rises, your insensible water loss rises.  And since insensible water loss can be easily measured, the metabolic rate can be easily estimated without having to do metabolic chamber studies.

Which is exactly what Drs. Kekwick and Pawan did with several subjects on the various diets.

They kept the subjects isolated and under supervision and weighed them on extremely accurate scales throughout the day.

Measurements were made by weighing the patient at intervals of one hour on scales specially constructed for this purpose by Messrs. W. & T. Avery Ltd. which are sensitive to 2 g. over the range of weights concerned.  During these hours no food was taken and neither urine nor faeces voided, and errors due to temperature, activity, and air draughts were avoided as far as possible.

(Scales that are sensitive to 2 g are extremely sensitive.  Two grams weighs about seven one hundredths of an ounce.)

So, here is what the researchers did.  They first fed the subjects the standard diet available to the patients on the ward and discovered what the insensible water losses were throughout the day.  You can see how this came out in the graph below, Fig. 11.

When Drs. K & P put a single patient on the different diets – 90 percent fat, 90 percent protein or 90 percent carbohydrate – and measured the insensible water loss throughout the day, the table below, Fig. 12 shows what happened. There was an increase in insensible loss with the high-protein diet as compared to the high-carb diet, and a much greater increase in insensible water loss with the high-fat diet.

The area of the chart that I colored in is the difference between insensible water loss, which represents a change in metabolism, between the high-carb diet and the other two diets.  This colored part of the chart represents the metabolic advantage of the high-protein and high-fat diets compared to the high-carb diet of the same number of calories.  The peach colored part of the chart represents the metabolic advantage of the high-fat diet as compared to the high-protein diet while the grayish color represents the metabolic advantage, as measured by increased insensible water loss, between the high-protein and high-carb diets.

The researchers wanted to make sure this wasn’t an isolated phenomenon, so they analyzed three other patients and created the graph below, Fig. 13, which mirrors the results in Fig. 12 and demonstrates that this wasn’t an outcome isolated to just one subject.

The ever cautious Drs. Kekwick and Pawan interpreted their findings thus:

The rate of insensible loss appears to be much affected by the type of food, provided that the water and sodium intakes are kept constant throughout the period of observation; whether this increased rate of insensible loss is a measure of bodily metabolic activity must remain in question.  Even if metabolic activity cannot be measured directly, the difference in weight responses seen with these diets does not seem to be completely due either to an altered state of hydration or to a simple deficiency of calories.  We suggest that the rate of katabolism of body-fat may alter in response to changes in the composition of the diet.

And their summary:

As the rate of weight-loss varied so markedly with the composition of the diets on a constant calorie intake, it is suggested that obese patients just alter their metabolism in response to the contents of the diet.  The rate of insensible loss of water has been shown to rise with the high-fat and high-protein diets and to fall with high-carbohydrate diets.  This supports the suggestion that an alteration in metabolism takes place.

If you haven’t already, I would encourage you to read this entire study and make your own judgment.  I’m sure you won’t find it the “poorly controlled mess” that AC does.  In fact, I suspect you’ll find just the opposite.  Unlike most of the studies published today, this one is not loaded with incomprehensible jargon, is delightfully well written and is extremely accessible to those with little medical or scientific knowledge.  You can see for yourself how precise these researchers were and now meticulously they looked for anything that might confound their results.  It would be great if more studies were done this carefully today and written this clearly.

This is the end.  I am through with AC. I’ll leave it to the readers of this post and the previous one on this subject to make their own decisions as to whether or not a metabolic advantage exists for low-carb, higher-fat diets.  I won’t be provoked again into jumping into the mud and wrestling around.  So this is my black swan song on the subject.

I read a quote a few days ago by Nassim Taleb, the author, appropriately enough, of the book The Black Swan and, for my money, the infinitely better Fooled by Randomness that is apropos to this situation:

A good foe is far more loyal, far more predictable, and, to the clever, far more useful than any admirer.

So, to you, Anthony Colpo, I raise my hat. Had you not attacked me out of the blue, I would be less knowledgeable than I am today.  I wouldn’t have bothered to dig into all the ‘white swan’ papers you posted trying to figure out why these researchers got the results they got.  I, like you, would still be mired in the notion that metabolic ward studies are squeaky clean without any hint of sullied data as a consequence of cheating.  Like you, I would still probably be confusing metabolic ward studies with metabolic chamber studies, which are horses of a much different color.  Also, I thank you because I had kind of blown off the Kekwick and Pawan papers (there are others besides this one from The Lancet) as being too old to be worth studying.  You forced me to take another look, and I was delighted at what I found.  And, sad to say, like you, I, too, had read only the first part of the these studies, the parts about the diet comparisons.  It wasn’t until your attack that I actually read this paper all the way through and found the gold mine in the latter pages.

So, AC, I sincerely hope the best for you; I thank you for pushing me into this exercise and wish you godspeed on your journey through life.

I’ve got to apologize in advance for the length of this post, but in order to thoroughly do what needs to be done, it took the space.

Readers of this blog who have been around for a couple of years have been through the Anthony Colpo (AC) fiasco with me.  For those of you who weren’t around at the time, I’ll give a brief – a very brief – overview of what happened so you’ll understand what this is all about.

I wrote a post in September 2007 describing two different diets and their outcomes.  The first was designed by Ancel Keys and was a 1500+ calorie low-fat, high-carb diet; the other, designed by John Yudkin, was a 1500+ calorie low-carb, high-fat diet.  The subjects following the two diets experienced drastically different results.

This post, for whatever reason, inspired AC, a trainer and self-taught nutritional guru from Australia, to go into mad-dog attack mode.  I wasn’t the first person he had gone after, but I became the first to fight back.

Around the same time AC took it upon himself to attack me, he had just published an online book on weight loss that he was beginning to promote called The Fat-Loss Bible.  A more cynical person than I might have thought AC picked this fight in an effort to get some free publicity for himself and his book.  If that was indeed his motivation, he may have gotten a little more publicity than he had bargained for.

I took a look at his book – which I hadn’t realized even existed prior to this kerfuffle – and found it to be much like the ad for the educational software pictured above to the left.  At first glance, it looked reasonable, but upon closer inspection, it had some problems.

I made the offer to readers to dissect AC’s book if that’s what they wanted.  Or I could ignore the whole thing and continue with my regular posting.  A majority in the comments section voted for me to dissect.  I dug into the book, pulled all the papers cited, but subsequently got involved in other stuff and forgot about AC and his book.  He more or less dropped from sight, but has surfaced lately.  I had forgotten all about him, his book and the whole situation, but his new antics have stirred a few readers to ask about the dissection that I promised but never came through with.

So, with that preamble, here it is.

The crux of AC’s objection to me (and a few other people, namely Gary Taubes, Richard Feinman and Gene Fine) is that I (and they) believe there is a metabolic advantage that becomes manifest during low-carb dieting.  AC has taken the position that my idea of the low-carb driven metabolic advantage means that people following low-carb diets can eat all the calories they want and lose massive amounts of weight as long as they keep their carbs reduced.  He accuses me of leading people astray by encouraging them to eat, eat, eat as long as carbs stay low.

I don’t know where he got this idea because I have certainly never said such a thing anywhere.  The metabolic advantage brought about by low-carb dieting is probably somewhere in the neighborhood of a 100-300 calories, which isn’t all that much.  This few hundred calories don’t even come into play until the 1500-2000 calorie range of consumption.  I’ve written about this numerous times and have always used these figures, so, as I say, I don’t know where the idea that I believe the metabolic advantage allows low-carb dieters to eat huge numbers of calories and still lose weight.

I don’t plan to go through The Fat-Loss Bible in its entirety or this post would take on the dimensions of War and Peace.  I’m going to limit my comments to Chapter 1, titled “Myth 1: Don’t Count Calories.”  This first chapter is the one that tells why AC so fervently believes there is no metabolic advantage.

AC sells his book online, but (at least the last time I checked) it can be downloaded only on a PC.  At the time this dispute started I had a PC, which I used to download the book.  Since then, my PC has given up its ghost and I now use Macs exclusively.  So, the copy I have is about two years old.  I don’t know if AC has changed it since; consequently, I don’t know if my critique applies to the book as it exists today.  AC changes his book all the time, updating here and there, and I don’t blame him for it.  I do it with this blog all the time.  I find typos in old posts and sentences that I don’t like.  I change these things all the time and the blog is the better for it, so I don’t blame him if he does the same thing.  But I just want everyone to know that I’m critiquing the book as it was when he launched his attack.

AC firmly believes that a calorie is a calorie is a calorie.  He believes that people lose the same amount of weight dieting irrespective of the composition of whatever diet they’re on.  He believes that a given person will lose exactly the same amount of weight on, say, a 1600 calorie diet whether that diet is a low-carb diet or a low-fat diet or any other kind of diet.  It is the calories that set the weight loss, not the macronutrient composition or any other factor.

I don’t know if AC came to this conclusion then went looking for studies to confirm his bias or if he came to this conclusion because of the studies he read.  The first chapter of his book contains a number of studies he trots out to ‘prove’ his idea that only calories count.

There have been many out patient studies that have shown a metabolic advantage and many that haven’t.  Overall a greater number of studies demonstrating a metabolic advantage exist than studies showing no such metabolic advantage.  The first part of the first chapter of The Fat-Loss Bible goes into great detail describing why such studies are worthless.  He makes a fairly plausible argument as to why people on low-carb diets might tend to overreport consumption while those on low-fat diets may underreport.  If correct, this difference in reporting would create the appearance of a metabolic advantage where none exists.

To solve this problem, AC turns to what he calls

strict ‘metabolic ward’ studies in which, for the entire duration of the study, the participants are confined to a research facility where they can only eat the foods supplied by the researchers.

On the surface this seems to make sense.  Put the subjects under lock and key, give them just the food you want them to eat, and see what happens.  You’re going to have some individual variation, but if evaluate enough subjects and they all end up losing the same amount of weight irrespective of macronutrient composition, then you’ve got some pretty good evidence that there probably isn’t a metabolic advantage.

But as obvious as this appears at first glance, there are problems with this approach.

The first problem is a problem of measurement.  Newton derived his gravitational laws and everything scientists measured obeyed them.  These laws became sacrosanct.  If some observation didn’t conform to Newton’s laws, then the observation was faulty because Newton’s laws were infallible.  Those quirky movements of planets way out on the edge of the solar system were off a little from Newton’s predictions, but, hey, it’s got to be a measurement error somehow.  Then Einstein came along with his theory of relativity, and all the weird deviations conformed to Einstein’s laws.  Newton had been superseded.  Because the caloric differences brought about by a metabolic advantage (at least as I see it) are so small, weighing subjects in pounds and kilograms may miss it.

That’s the first problem.  But there is a problem much greater than that.  One that AC isn’t aware of because he doesn’t really have any real-world experience in doing nutritional studies in a hospital.

When subjects are studied in ‘metabolic wards’ they aren’t locked away and under constant observation.  In fact, often enough, they aren’t even in a hospital at all.  A ‘metabolic ward’ is simply a part of the hospital set aside to do nutritional studies.  And often it isn’t even a specific part of the hospital.  Subjects can be scattered about among the other patients.  Subjects can have visitors, can roam through the hospital, can even go to the cafeteria.  A ‘metabolic ward’ study can mean anything from: careful observation; to check into the hospital for a couple of days; to get trained on the diet then follow it at home; to check in, go to work all day, then come stay in the hospital all night. They are definitely not the strictly-controlled studies AC thinks they are.  He confuses them with ‘metabolic chamber’ studies, which are a horse of a different color.

The opportunities to cheat in a ‘metabolic ward’ study are, for the most part, as great as the opportunities to cheat in an outpatient study, especially since many of the subjects are outpatients most of the time.  There is a difference though.  When people are on outpatient studies they are more likely to at least admit their cheating and record what they cheat with than they are in ‘metabolic ward’ studies.  Some of the studies AC sites are formula diet studies in which shakes made of specific caloric and macronutrient composition are provided to subjects throughout the day.  (Or are given to them to consume outside the hospital at work or wherever.)  These are the kinds of programs you wouldn’t want to report cheating on.  And these subjects do without question cheat.  The fact that the data is reported as coming from a ‘metabolic ward’ study gives it a veneer of accuracy that it doesn’t really deserve.

AC gathered up a bunch of these ‘metabolic ward’ studies – 17 to be exact – that he uses to prove his point that there is no metabolic advantage and that only calories count.  He lists these studies in a chart (reproduced below), then proceeds to go through them one at a time.

On the ones that confirm his bias, he spends little time.  Just a brief description typical of this one describing the first study.

In a paper aptly titled ”Calories Do Count”, Kinsell and co-workers admitted five obese subjects to a hospital metabolic ward, then fed them liquid formula diets.  The diets ranged in protein content from 14 to 36 percent, fat from 12 to 83 percent, and carbohydrate from 3 to 64 percent.  The calorie content of the various diets was held constant for each patient irrespective of diet composition.  As they switched from one diet to another, each patient continued to lose weight at a similar pace.  Concluded the researchers: “…it appears obvious that under conditions of precise consistency of caloric intake, and essentially constant physical activity, qualitative modification of the diet with respect to the amount or kind of fat, amount of carbohydrate, and amount of protein, makes little difference in the rate of weight loss. [Italics in the original]

This is a great study to start with because it contains many, many flaws that AC is blinded to by his own confirmation bias.  It’s a terrible study.  Let me show you why.

Here is the first paragraph of the study.  And I’m not kidding.  This is directly quoted from the paper.

The accumulation of excess adipose tissue is a malady which affects many people.  That undue preoccupation with the pleasures of the table contributes to the disease has geen [sic] generally accepted in most quarters; or, to express the matter differently, majority opinion has held that the first law of thermodynamics applies to the human machine quite as predictably as it does to inanimate machines.  Despite this body of “official opinion” one finds many obese individuals who are either convinced that their food intake completely fails to explain their adiposity, or who spend time and money in the search for the magic potion or pill which will enable them to consume food in any quantity but still maintain or achieve a slim figure.

Do you think there might be just a little bias in this author and his co-workers?  From this first paragraph one sees by the reference to the first law of thermodynamics the set of the sail of these researchers.  Plus it’s pretty clear that these researchers don’t like overweight people and think obesity comes from a “preoccupation with the pleasures of the table…”  How do you suppose their data is going to turn out?

First of all, were these five subjects inpatients in a metabolic ward or did they just pick up their formula and take it home.  Did the live in the hospital or just spend the night?  No information is given.
Here is the sum total of the information given on the ‘metabolic ward’ status of the first patient described:

His weight on admission to the metabolic ward was 270 pounds.

Was he admitted to the ward where he stayed full time for the full 70 days of the study?  I doubt it, and I’ll describe why in a bit.  Or was he admitted for his initial workup then released to continue his diet at home.  I suspect the latter.  Whatever the situation, this is all the study says about it.

Here are the descriptions of how the rest of the subjects entered the study:

Second subject:

Weight on admission to the study was 227 1/2  pounds…

Third subject:

At the time the study was undertaken her weight was 199 pounds…

Forth subject:

At the time the study was undertaken, her weight was 211 1/2 pounds…

Fifth subject:

Patient GTAY was a 61 year old white female with a history of diabetes for more than 20 years.  She had received insulin in the past but could be maintained in a satisfactory diabetic control with diet and tolbutamide.  Milky fasting plasma was discovered in July 1962.  Other findings included evidence for coronary and peripheral atherosclerosis, and diabetic retinopathy.  She had partial removal of a goiter 40 years ago, but was essentially euthyroid during her stay in the metabolic ward.

The study in this patient was actually directed toward evaluation of her hyperlipidemia, but she is included in this report since she was maintained on quantitatively constant, eucaloric regimens containing high fat and high carbohydrate respectively, and also received both saturated and unsaturated fat.

This last patient wasn’t even accepted into the study as a subject for a diet study but more or less added after the fact.

There were five subjects in this study that lasted for anywhere from 65 to 77 days.  We can’t really tell which subjects went how long. Nor can we really tell if it was an inpatient study or just one where the subjects checked in.  Nor do we know how much weight each lost over how long a period.  We know the starting weights and that’s about it.

The data as displayed looks like data collected in an inpatient study, but the paper itself only implies that it is.  As you might imagine, inpatient studies are tremendously expensive, and, consequently, authors tend to make sure readers of the study know they are inpatient studies.  In this paper, we have to guess.

If these are truly inpatient studies for 65 to 77 days, we need to address another point: the quality of the subjects in such studies.  Who do you know who would have the time or inclination to spend two to two and a half months in a hospital full time?  People who are willing to spend the time in such facilities are usually not the most reliable. They are typically unemployed with little education and, for the most part, are imbued with a lack of understanding as to how important their rigid adherence to the protocol truly is.  I will be the first to say that not everyone who has ever volunteered for such a study falls into this category, but, unfortunately, many do. I’ll let a couple of the authors of these metabolic ward studies expound on this fact a little later.

The age range of these subjects is from 25 to 61. All of the subjects in this trial save one have serious medical problems and are under treatment with multiple drugs.  The one who doesn’t have serious problems is a 25 year-old male who has “been grossly obese since childhood.”  These are not the subjects you would want in a study of this nature.

The subjects getting the most calories got 1200 per day while those getting the least consumed 800 calories per day.  As I’ve written before, if calories are kept ultra low, all the calories – irrespective of composition – are going to be used for energy.  And under those circumstances, you would expect there to be no metabolic advantage.  And you would expect weight loss to pretty much follow a trajectory driven solely by caloric deficit, which is pretty much what happens in this study.  But it’s difficult to tell because of how terrible this study is presented.  There is a starting weight, but no ending weight for the subjects.  And, although the Methods section reports that the study lasted from 65 to 77 days, my calculations based on the data provided shows the study lasted from 64 to 82 days.  Which are we to believe?  Without an ending weight for the subjects and a precise number of days under caloric restriction, how do we really know how much they lost verses how much they should have lost given the number of calories they were getting?

And we have this other little tidbit thrown in when discussing the results of one patient, RTEA, who was a 26 year old female with “a history of resection of a cystic chromophobe adenoma of the pituitary…followed by radiation”:

Rate of weight loss was greater during the last 2 weeks on the high fat, high protein intake than during either of the other 2 dietary periods.  This probably does not have significance on view of the “stair case pattern” of weight loss.

Say what?  So they do have a subject that shows greater weight loss (and late in the program rather than early), yet they toss off the data with a bunch of weasel words implying that it probably isn’t significant.

I suggest you pull down the full text of this study at the bottom of this post so you can see for yourself how terrible it is.

I’m certainly not going to go through all 17 of the studies in this fashion because this post would then truly gargantic, but I wanted to go into this one at length to show that so-called ‘metabolic ward’ studies, those AC terms the ‘gold standard’ of medical research can be very, very flawed.  I, for one, would not want to be making any categorical statements based on the data contained in this study we just evaluated, that’s for sure.  If AC weren’t so blinded by his own confirmation bias, he would have laughed this study off.  If I had used it to ‘prove’ a metabolic advantage – based on the one patient described above who had more weight loss on the high-fat diet – he would have had a field day.

Next, let’s turn our attention to the Liebel et al study.  It’s number 11 down the chart if you’re counting.  Here’s what AC says about it:

Leibel and co-workers took 13 subjects, determined how many daily calories each needed to maintain his/her weight, then proceeded to feed them, in crossover fashion, diets differing in their macronutrient content.  Despite wide variations in protein, fat, and carbohydrate intake, the subjects maintained their weight irrespective of diet type.  This included two subjects who followed low- and high-carb diets (15 percent and 75 percent carbohydrate, respectively) for a minimum of 34 days each.

That’s it.  That’s AC’s commentary on the study.  I suppose readers are meant to believe that this study showed that it was all a matter of calories with no difference in terms of weight lost versus macronutrient composition of the diet.

The Leibel et al paper is a great one because it shows just how sloppy AC is in his presentation of data and, no doubt, in his own evaluation of the medical literature.

Go back and reread AC’s description of how the study was done.  Looks like Leibel et al did a hands-on study of these subjects, right.  Well, that’s not exactly how it worked.  Here is what really happened as reported by Leibel et al:

The records of all subjects studied by the Lipid Laboratory of the Rockefeller University Hospital between 1955 and 1965 who were fed lipid-formula diets of various carbohydrate (CHO) and fat composition were reviewed.

Leibel et al didn’t do squat in terms of studying subjects.  They went back through 40-year old records of subjects who had undergone formula feeding in the 1950s and 1960s to drag out records of 13 subjects (they actually drug out 16, but three were of children) who met their experimental parameters.  They weren’t looking for evidence of a metabolic advantage; they were looking to see if fat intake irrespective of calories made people gain weight.

Out of the countless studies done in those early years, they wanted to see if any could show that fat intake increased weight gain to a greater extent than the calories consumed as fat.  As they put it in the Introduction to their paper:

One group of investigators concluded that “fat intake may play a role in obesity that is independent of energy intake.”

The Leibel et al paper was published in 1992, the time in which the low-fat mantra was at its zenith.  It was a time that many people who should have known better were telling us we could eat all we wanted as long as we limited fat.  Fat makes us fat, we were told.  Cut it and you lose.  What Leibel et al were trying to show in this paper was that the weight gain or loss effects of fat were a function of the calories contained in the fat, not some other magical property that makes people gain weight above and beyond calories.

Before we get to the interesting data in this study, let’s take a look at what the guy who actually did this work had to say.  Leibel’s group went through old formula feeding studies done by Edward H. Ahrens, M.D., the head of the formula feeding lab at the time and the lead author of all the old papers referenced by Leibel.  Says Dr. Ahrens about the subjects in the inpatient studies:

Thirty-eight of forty patients were observed continuously under strict metabolic ward conditions; four of the forty [I know, the math doesn’t add up] were sufficiently motivated and intelligent to follow the regimen at home. (Ahrens EH et al 1957)

A couple of points here.  First, if four subjects out of 40 were “sufficiently motivated and intelligent” to be sent home with formula and instructions, what does that say about the other 36 (or 38)?  Which is to my point earlier about the quality of subjects recruited into metabolic ward studies.  Second, were some of the patients whose data was used for the Leibel paper those who were sent home?  If so, it blows AC’s notion of being unable to rely on any data gathered from free-living subjects.

Dr. Ahrens in another paper describing his 15 years of experience using formula diets says this about cheating in metabolic ward studies:

Such cheating is a natural (but dismaying) consequence when a patient’s dissatisfactions with any part of the ward routine are not quickly enough appreciated by the ward personnel.  Anticipation of the discontent is the clinician’s daily concern.  The closer the relationship between the patient and his medical attendants, the less likely cheating is to occur.  We have detected [my italics] cheating in only eight patients; undoubtedly others have gone undetected, but we feel the problem has been surprisingly minor. (Ahrens, EH 1970)

These are the subjects under lock and key.  The people running the study have to maintain constant vigilance to prevent cheating.  How about those who only check into the metabolic ward to sleep and spend the rest of their days at work or home?  And those are the subjects who make up most of the metabolic studies you read about.

One last interesting point about the Leibel paper.  The subjects they looked up in their retrospective analysis had undergone experiments during which they were given formula in amounts sufficient to maintain their weight.  As they lost or gained weight, their caloric intake was increased or decreased to compensate so that their weight stayed about the same.  According to the old papers about the original studies, the researchers tried to keep the subjects from fluctuations greater than one kg.  One kg equals two pounds.  If there was a metabolic advantage, it would probably show up within this two pound range and would be considered insignificant in terms of how this study was presented.

Some of the subjects, however, did lose or gain weight. Leibel et al then adjusted their caloric intake on paper to compensate for the weight differential.  In other words, if a patient lost weight on a given number of calories of a precise formula in the original study, Leibel et al would adjust the intake (40 years after the fact) to compensate for the weight loss.

One subject, a 55-year-old male with a BMI of 32, maintained his weight on a high-carb formula at 2871 calories per day.  The same subject then required 3501 calories to maintain his weight on a 70% fat, 15% carbohydrate diet.  Sounds like a metabolic advantage to me.

There were two papers in AC’s list of 17 that did show what could be considered a metabolic advantage.  In other words, subjects on the low-carb diet lost greater amounts of weight than subjects on low-fat, high-carb diets of the same number of calories.  These are two of the three studies by Rabast et al that are the 4th and 6th studies on the list of 17 shown above.

How did AC deal with this seeming refutation of his notion that no metabolic advantage exists?  By typical AC flimflammery.

In their 1981 study, Rabast et al observed significantly greater potassium excretion on the low-carbohydrate diets during weeks one and two.  A considerable amount of potassium inside our bodies is bound up with glycogen, so the greater potassium losses in Rabast’s low-carbohydrate dieters may indeed be a reflection of greater glycogen, and hence water losses.  Until recently, potassium excretion was often used a a marker or lean tissue loss; in Rabast’s study, this would indicate that the low-carbohydrate diet subjects lost more lean tissue.  As lean tissue holds a considerable amount of glycogen, this would again point to glycogen-related water loss as the explanation for the allegedly “significant” differences in weight loss. [Italics in the original] If the low-carbohydrate groups maintained greater lean tissue and/or glycogen losses at the end of the study, then this would easily explain their greater weight loss.

Regardless of whether Rabast et al’s findings were the result of water loss from glycogen depletion, pure chance, or some other unidentified factor, they should be regarded for what they are: An anomaly that has never been replicated by any other group of researchers.  For a research finding to be considered valid, it must be consistently reproducible when tested by other researchers.  As proof of the alleged weight-loss advantage of low-carbohydrate diets, the findings by Rabast and colleagues fail dismally on this key requirement.

Wow!  Where do we start?

First, AC didn’t mention Rabast’s 1979 study in which 117 patients were admitted to the hospital and studied on formula diets.  I assume these subjects were hospitalized round the clock because in the body of the paper it states:

…and as the patients were under constant supervision differences in food intake between the two groups could be excluded.

Unlike the Kinsell study (the first of AC’s 17 I described in detail above), the authors of this study were expecting a different outcome.  As discussed, Kinsell was obviously biased going in against the notion of anything other than calories count.  Rabast et al went in biased against low-carb diets:

The popularity of so-called ‘fad’ diets, low in carbohydrates and relatively high in fat, has continued to spread, especially among lay groups.  The caloric intake is only slightly limited, if al all; alcohol is allowed most of the time, and fat is consumed in the form of saturated fatty acids.  However, this kind of dieting, which must always be carried out on a long-term basis, has proved harmful.  The cholesterol intake can lead to severe health damage and clearly contributes to atherosclerosis.

After keeping the 117 subjects on low-carb vs high-carb diets of the same number of calories for 25 – 50 days, and probably hoping to find that those on the low-carb diet didn’t lose any more weight than those on the low-fat diet, the subjects on the low-carb formula diet lost considerably more weight than those on the low-fat diets.  Here are the graphs from the paper.

After going through all the data, Rabast et al conclude

Differences in fluid and electrolyte balance could not be measured but marked fluctuations can occur.  However, the change in body water and electrolytes could only be considered in short-term studies as the cause of the differences in weight loss.  Variation in the depletion of the glycogen pool is also a feasible explanation, as up to now, sufficiently long-term studies have not been reported.  However, the glycogen pool can be restored even under fasting conditions.  Therefore, an increased rate of metabolism presents itself as the most feasible explanation. [my italics]

The 1981 Rabast study that AC does comment upon refutes his commentary on the difference being due to greater fluid loss from the low-carb diet.

Potassium excretion during the low-carbohydrate diets was significantly greater for as long as 14 days, but at the end of the experimental period the observed differences no longer attained statistical significance.  At no time did the intake and loss of fluid and the balances calculated therefrom show significant differences.  From the findings obtained it appears that the alterations in the water and electrolyte balance observed during the low-carbohydrate diets are reversible phenomenon and should thus not be regarded as causal agents.

As to AC’s comment that the work of Rabast et al should be ignored because it has never been replicated by another group of researchers, I’ll leave to you to decide the validity of that.  There have been a number of such studies, including ones (as I’ll describe in a moment) in AC’s own list that confirm what Rabast found.  The 1979 Rabast paper discussed earlier lists 17 of them.

Hang in there; we’re almost through.  If I have to read all these papers and type all this stuff, the least you can do is stick with me ‘til the end.

Most of these studies don’t list the amounts of weight lost by the subjects because most of them aren’t designed to really look at weight loss.  Most are designed to look at other metabolic parameters such as protein sparing or branch chain amino acid use or nitrogen balance and the authors weren’t particularly interested in how much weight the subjects lost.  The authors mention that the two groups of subjects lost similar amounts of weight.  Other than the Rabast studies that we’ve already discussed, only four studies listed the weight lost over the course of the study by the subjects on either low-carb or high-carb diets.  In none of these cases did the weight loss difference reach statistical significance, so AC is presenting them as if there is no difference.

But in reality, there was a difference.  It just wasn’t statistically significant.

Statistical significance as it pertains to weight loss is a function of both number of subjects and amount of weight loss.  If I enroll 10 obese subjects in a weight-loss study and put five subjects on one diet and five on another, observe them for four weeks, and find that one group has lost an average of 2 pounds more than the other, that probably won’t be a statistically significant difference.  Why?  Because with only five subjects in each arm of the study, it requires a much larger weight loss to show a statistically significant difference.

If I do the same exact study, but enroll 100 subjects with 50 in each arm, and get exactly the same results – a two pound differential – then I achieve statistical significance.  The more subjects, the smaller the difference in outcomes it takes to reach significance.

In the case of these metabolic ward studies, the numbers of subjects are small.  As we’ve discussed, it is extremely expensive to keep subjects hospitalized 24 hours per day.  Consequently, most metabolic ward studies don’t enroll very many subjects.

I went through all the papers in AC’s list and found four (aside from the Rabast that we’ve already discussed) that list both starting and ending weights for the subjects.  I’ve listed them in the chart below.

As you can see, the study with the largest number of subjects had only 22 subjects in each arm.  These studies all use a caloric intake that is lower than would be expected to produce any kind of a metabolic advantage because all are at an almost starvation level.  Yet, as you can see, three out of the four show a greater weight loss in the low-carb arm than in the low-fat arm of the study.  Equal caloric intake, greater weight loss with the low-carbohydrate diet.  But, due to the small number of subjects, the difference doesn’t reach statistical significance.

If we had these same findings and same difference in weight loss between the two diets with a larger number of subjects, we would indeed have a significant difference.  If we did a meta-analysis of these studies, we might find that adding the subjects together would end up showing a significantly difference in weight loss.  Even though these differences don’t add up to statistical significance given the number of subjects involved, you can see the definite trend.

But what about the Piatti study, the one that showed the low-fat diet producing more weight loss than the low-carb?  I have it marked with an asterisk for a reason.  The paper by Piatti et al titled Hypocaloric High-Protein Diet Improves Glucose Oxidation and Spares Lean Body Mass: Comparison to Hypocaloric High-Carbohydrate Diet looked at how 25 obese women fared in terms of lean body mass and insulin sensitivity.  They were put on 800 kcal diets for 21 days.  It was found that the low-carb diet spared more muscle tissue and improved insulin sensitivity more than the low-fat diet of an equal number of calories.

Since the authors weren’t specifically studying weight loss, they didn’t really randomize the subjects by weight but did so by other parameters.  As it turned out, the group on the low-fat, high-carb diet were much heavier than those that ended up in the low-carb arm.  The average starting weight of the subjects in the low-fat arm was 213 pounds (96.8 kg) whereas the starting weight of those on the low-carb arm was 191 pounds (86.8 kg), a significant difference.  It would stand to reason that subjects starting off at 213 pounds on a 800 calorie diet would lose more over 21 days than subjects starting out at 191 pounds and following the same diet, and indeed they did.

This post has gone on way, way too long, but I think it’s pretty obvious that these studies fail to ‘prove’ that a metabolic advantage does not exist.  I would say, if anything, that they ‘prove’ just the opposite.

Just so you can go through these studies yourselves if you so desire, I’ve put them all up on Scribd.  The links are below to the full text of all.

The next post will a) be much, much shorter and will b) go into detail on a beautiful study that AC totally disses in his book.  We’ll look at his diss and what the study really says.  That should put paid to AC.

All the papers referenced by AC listed below.  All full text.

Kinsell et al

Grey Kipnes

Rabast et al 1979

Rabast et al 1981

Yang et al

Bogardus et al

Hoffer et al

Leibel et al

Vazquez 1992

Vazquez 1994

Vazquez 1995

Piatti et al

Golay et al

Myashita

Synchronicity strikes again.  The seeds of this post were sown when Gary Taubes emailed me about a study published in early 2009 in the New England Journal of Medicine (NEJM) that I had seen at the time, briefly skimmed and tossed aside as worthless.  Gary agreed that the study was of little value, but notice that it contained a peculiar statement by the authors, an interesting admission about HDL, the lipophobe’s favorite lipoprotein.  And not only had the authors made this strange admission, but so had another prominent lipophobe who wrote the accompanying editorial.

I pulled the study, read it more thoroughly and still found it mediocre at best.  But I did come across the strange HDL statements that Gary had mentioned. (More about which later.)

As I was shaking my head over the amount of money spent on what was a truly abominable study, the synchronicity occurred.  I got a ding that I had a new email.  It was a notice from the American Heart Association telling me that this august body had deemed the very study I was holding in my hands as one of the ten most important papers published in 2009.  The sheer stupidity of it nearly took my breath away.

Before we get into the study – which we won’t get into very deeply because, believe me, there’s not much depth – I want to use a parable to show just how silly this study is.

Let’s set our story in the wonderful country of Stupidland where a debate has been raging about the feeding of dogs.  A vociferous old woman who kept dogs had been insisting that different breeds of dogs eat different amounts of food  The majority of the populace were of the opinion, however, that all breeds eat the same amount (it is Stupidland, after all) and looked down their noses at those who  believe a chihuahua may eat less than a collie.  To put an end to the bickering, scientists at Stupidland U ( who were believers in the all-dogs-eat-the-same doctrine) decided to do a definitive study.  They went to the Stupidland pound and procured a German Shepherd, a Labrador Retriever, an Irish Setter and an Alaskan Malamute.

They provided the four dogs with pleasant accommodations and all the food they wanted to eat.  The scientists carefully measured every gram of food eaten by each dog and recorded it.  At the end of the two year study, they reviewed the data and confirmed what they already suspected to be the case: the different breeds of dogs ate just about the same amount.  They did notice one little disparity, however: the larger dogs ate a little more than the smaller dogs, but they were able to correct for that by controlling for size.  Their paper proving that different breeds of dogs ate the same amount of food was accepted for publication in one of Stupidland’s most prestigious scientific journals, The Stupidland Journal of Veterinary Medicine.  Buried deep within the paper was a sentence few noticed stating that size was a biomarker for food consumption by dogs.

The Stupidland press picked up on the study and headlines proclaimed that all breeds of dogs eat the same amount.  The mainstream Stupidlanders nodded their heads sagely; they, after all, had been right all along.  But the old woman, who didn’t actually live within the borders of Stupidland, but who lived close enough to cause trouble, kept insisting that different breeds of dogs didn’t eat the same amounts.  She had a beagle and she had a Great Dane, and she had kept careful records of the food consumption of both. She insisted that the Great Dane not only ate more than the beagle, but that it ate a huge amount more. She would bend the ear of anyone who took the time to talk to her, and her data was so persuasive that she was beginning to make converts.  Just as the population of Stupidland was once again starting to wonder about the dog breed verses food enigma, the Stupidland Heart Association came out with its annual bulletin announcing that the paper by the brilliant scientists from Stupidland U showing that all breeds of dogs ate the same was the most important paper of the year.  The old woman’s first impulse was to attack the Stupidland Heart Association for its sheer stupidity, when suddenly a sense of calmness and clarity settled over her.  She experienced a spiritual awakening (just as did the Grinch in another tale) and finally realized the real meaning of Stupidland. She took her dogs and moved far away, leaving the denizens of Stupidland alone to marinate in their stupidity.

The paper that inspired this parable was published in Feb 2009 in the New England Journal of Medicine and titled Comparisons of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates.  (This is another one of those studies the editors feel is so important that they provide the full text free of charge as a public service.)  The authors include Frank Sacks, George Bray, Steven Smith and an entire rogue’s gallery of lipophobes.  All the usual suspects, as they say.

What the NEJM study sets out to demonstrate is that different breeds of dogs different weight-loss diets of varying macronutrient compositions all bring about the same loss of weight.  According to these authors, it doesn’t matter if you go on a low-carb, high-fat diet or a low-fat, high-carb diet, you’ll lose the same amount of weight.  Doesn’t matter how the protein, fat and carbohydrate stack up in your weight loss diet, you’re going to lose the same amount of weight.  So, you can go to the bookstore, stand by the diet-book shelf, close your eyes and pick.  Whatever diet book you end up with won’t matter because you’ll lose the same amount of weight regardless of which one you choose.  And, even more importantly – again, according to the authors of this study – whichever diet book you select will help reduce your heart disease risk factors.

As Dave Barry says: “I AM NOT MAKING THIS UP.”  It’s right there in black and white in a study done at Harvard and published in the New England Journal of Medicine.

What’s more, the American Heart Association (AHA) deemed this study to be one of the top ten most important studies published in 2009.  And they put it #1 on their list.  Now they said that they listed these ten studies in no particular order – and you can call my cynical -  but I’m just betting that they put this one right at the top for a reason.

Said the president of the AHA, Dr. Clyde W. Yancy

We all thought the statement made in that study was pretty profound. It really dismissed the notion that there’s something clever about weight loss, [showing] that it really is about calorie consumption or, to make it even more straightforward, portion control. You can spend a lot of time wringing your hands about which diet and the composition of which diet, but it really is a simple equation of calories in and calories out.

Give me strength.

My disgust aside, you may be thinking:  Why isn’t the study valid?  If they did analyze all those diets and found them to bring about the same results, what’s the problem?

The problem is that the diets they used in the studies were similar.  They didn’t vary all that much in carbohydrate.  The diet with the highest carb intake contained 65 percent of calories as carbohydrate while the lowest carb diet was made up of 35 percent.  To put this into the gram figures we’re all used to, the highest-carb diet contained 325 gram of carb while the lowest-carb version contained 175 gram of carbohydrate.  Now, as those of us who have ever followed a low-carb diet know, 175 gram of carbohydrate does not a low-carb diet make.  Granted, it’s lower in carb than the diet with the 65 percent of calories as carb, but it doesn’t even approximate a low-carb diet.  As I’ve written before, you’ve got to get the carbs substantially below 100 g per day before good things start happening metabolically.

What this study has done is to study roughly similar diets for two years and pronounce that all produce about the same results.  What the authors (and, apparently the AHA) want you to take away from this study is that real, honest-to-God low-carb diets don’t perform any better than low-fat, high-carb diets.  Which, as most of us know from bitter experience, is not the case.

There are major problems in doing studies such as this one that make their outcomes suspect.  And these problems aren’t necessarily the fault of the researchers – they are simply a fact of life.

When you try to do a dietary study by recruiting people who want to lose weight then randomizing them to a particular diet, you are asking for trouble.  If you run the study out over a long period of time – two years, for example, as this study did – you are asking for even more trouble.  People go into diets with a lot of enthusiasm and pretty rigorously stick to them at first.  But as time goes on, people tend to cheat a little, then cheat a little more and pretty soon find themselves pretty much trending back toward and finally squarely back on whatever their regular diet was before they started the study diet.  (Sadly, it’s not just subjects in studies who follow this pattern, but is the fate typical of most dieters.)  For this reason, after time, all the people in all the different arms of the study are eating about the same thing.  This is why you always see the charts showing weight loss and macronutrient composition start out wildly diverging then converge as the end of the study draws near.  In other words, they all end up consuming the same diet, so they all end up with about the same result.

How can researchers overcome this dismal outcome.  Well, you can put out the call for people who really believe in low-carb diets to fill one arm of the study.  And recruit people who love the Ornish diet for another, and the Zone for another.  These subjects are more likely to stay enthused and stick with their respective regimens for the duration of the study.  But then you haven’t randomized your sample and you will be accused of generating worthless data because your sample groups self selected.

The other way, of course, is to randomize subjects into various diet groups, then put them under lock and key for a year or two and feed them like you would lab animals.  Another impractical solution from a cost perspective if in no other reason.

It’s extremely difficult – virtually impossible, I would say – to conduct accurate studies on diet over a long period of time with a large number of subjects.  Consequently, it is nonsensical to rely on the data from such studies to make the case for anything other than how difficult these studies are to carry out.  I certainly don’t think for all the reasons above that the study in question merits being listed as one of the top ten studies of 2009 by anyone, much less the AHA.

In their discussion of this mishmash of questionable data, however, the authors did make a most interesting statement.  Almost an admission, if you will, of the superiority of a lower carb diet.  This statement is what Gary emailed me about.

(Before we go on with this, I have to make this aside.  HDL and LDL and IDL (intermediate density lipoprotein) and VLDL (very low density lipoprotein) aren’t really cholesterols.  Even though we often refer to them as LDL cholesterol and HDL cholesterol, they really aren’t.  These different groups of letters refer to transport proteins that carry cholesterol through the blood, not to cholesterol itself.  Cholesterol is cholesterol.  It is a specific molecule that doesn’t change.  Cholesterol is a waxy lipid (fat) that virtually every cell in the body synthesizes (because is it so important).  Cholesterol, like all fats, is not soluble in water and therefore can’t dissolve in blood (which is a watery substance), which means that the body has to package cholesterol in a form in which it can be transported from place to place in the blood.  The body attaches a specific protein (a lipoprotein) to cholesterol to make it dissolve in the blood.  The names LDL, HDL and the rest refer to the specific type of lipoprotein being discussed.)

Here’s what the authors wrote:

There was a larger increase from baseline in the HDL cholesterol level, a biomarker for dietary carbohydrate [my italics], in the lowest-carbohydrate group than in the highest-carbohydrate group (a difference in the change of 2 mg per deciliter at 2 years)…

Even Martijn Katan, a lipophobe if there ever was one, and the author of a number of anti low-carb diatribes that I’ve taken to calling the Katanic Verses echoes the same fact – carbohydrates drive HDL down – in an editorial he wrote about the above paper.

…compliance was assessed with objective biomarkers.

The authors used the difference in the change in HDL cholesterol levels between the lowest- and highest-carbohydrate groups to calculate the difference in carbohydrate content between those diets.

Now the differences weren’t all that spectacular, but the drop in HDL in those on the higher carb diet was there and noticed by the researchers.

I find this extremely revelatory because if there is one lipid parameter a lipophobe loves, it’s HDL.  And here you have an entire cluster of lipophobes admitting that HDL varies as the inverse of carbohydrate intake.  Take any of these folks individually – or, heck, take ‘em together – and they’ll tell you that low-carb diets are bad because they give you too much fat.  Yet they admit that their beloved HDL goes up when carbs go down.  Doesn’t make a lot of sense, does it?

When these folks compared these fairly similar diets they found that all of them reduced the risk for heart disease.  They used the fact that HDL went up on the lower-carb diets to deem them heart healthful; and they pronounced the higher-carb diets as heart healthful, too, because the LDL declined on those.

As Yogi Berra said: “You can observe a lot by just watching.”  And they watched LDL go down on the higher-carb diets and HDL go up on lower-carb diets.  But the reverse of the Yogi-ism is also true: you can also fail to observe if you don’t watch.

This refusal to watch is what really gets my dander up.

The researchers whose names are listed at the top of this paper are all affiliated with prestigious institutions.  I am quite sure that there is not a single one of them who is unfamiliar with the work over the last 15 years or so of Ronald Krauss, the researcher who made the discovery of the differences between LDL particle sizes. (The same Krauss, by the way, who published the paper about the meta-analysis of saturated fat and heart disease much in the blogosphere currently.) Krauss and his team showed that large, fluffy LDL particles aren’t particularly harmful whereas the small, dense LDL particles are the ones that cause the problems.  He also discovered that increasing carbohydrate in the diet caused LDL to shift to a smaller, denser pattern while decreasing carb and adding fat made LDL change to the larger, fluffier non-problematic kind.  (You can read a nice review of LDL particle size in this article published in the popular press.)

If you reduce carbs and add fat to the diet, not only does your HDL go up, but your LDL makes a particle size change for the better.  However, when you increase carbs and reduce fat, your HDL goes down and your LDL goes down too, but it changes for the worse. So even though the high-carb, low-fat diet decreases LDL, it doesn’t decrease risk – it increases it because even though LDL is lower, it is made up of a dangerous particle size,which negates any possible value of the fall in LDL.  All of these researchers know this.

Why didn’t they check LDL particle size on these subjects?  Had they done that, they would have found that those subjects on the higher carb diets would have lowered their HDLs and althought they lower levels, would have shifted to more of the dangerous, smaller, denser LDL particles.  They couldn’t have then made the case that not only did all diets work the same where weight loss was concerned but they all decreased heart disease risk.  They would have had to say that although all diets brought about the same degree of weight loss, the lower-carb diets clearly reduced the risk factors for heart disease the most.  And that’s an admission I suspect they didn’t want to make. Therefore they refused to observe.

I don’t know what the deal is with these folks.  Why don’t they simply tell it as it is?  Do the long-term lipophobes who have ridiculed low-carb diets for years and built their careers on the rickety edifice of the low-fat diet not want to admit they were wrong? That’s understandable, I suppose, but what about the young ones?  Why are they stampeding over the low-fat cliff like Gadarene swine?  Do the younger lipophobes not want to offend the older ones?  Why do they fail to reconcile their theories with what amounts to basic biochemistry and physiology?  Whatever the reason, they are fighting a losing battle.  Ultimately the truth will out and when it does, all these people who have tenaciously clung to the low-fat, high-carb fantasy will be – like the phrenologists and other failed theorists of the past -  so much detritus in the history of medicine.  And their books and papers will be displayed as curiosities of the boneheaded thinking of an earlier day. A sad but fitting fate.

Photo: Set of phrenological heads, England  circa 1831
via The Pollo Web