July 7

Another China study


I want to give you a few words of advice right up front. Keep this post close at hand so that you can send it out whenever anyone makes one of the following comments to you:

  • The Chinese don’t follow low-carb diets and they’re healthy
  • The Chinese eat a lot of carbs and they don’t get fat
  • The Chinese follow a low-fat diet and they don’t get fat
  • Fruits and vegetables don’t make you fat
  • If vegetables really made you fat, the press would be all over it
  • Researchers never misstate their findings
  • Show me the study!

The current issue (June 2008) of the International Journal of Obesity, published by the Nature Publishing Group (Nature is the most prestigious scientific journal on the planet), contains an article titled Vegetable-rich food pattern is related to obesity in China that is most enlightening and interesting on many levels.
Researchers evaluating the obesity status of the Chinese discovered that

China is facing an obesity epidemic. Between 1992 and 2002, the prevalence of overweight and obesity increased in all gender and age groups and in all geographic areas of the country. Using the World Health Organization body mass index cutoff points, the combined prevalence of overweight and obesity increased from 14.6 to 21.8% during this period. [An increase of about 50%, which pretty much mirrors what has happened in the US, although from a lower starting point.]

What is even more telling is that the prevalence of central obesity, a much more representative measure of overall health, was as follows:

Central obesity was 19.5% in men and 38.2% in women.

In an effort to figure out what is going on researchers evaluated the diets of almost 3000 Chinese men and women (average age 47 yo) from all walks of life and all educational levels living in rural and urban areas. They found the typical Chinese diet to be

characterized by a high intake of vegetables and other plant foods, and thus the intake of carbohydrates and fiber is high.

When these researchers started evaluating the specifics of the Chinese diet, they found themselves ensnared in a thorny thicket of cognitive dissonance. How they hacked their way out shows just how nutritionally biased researchers are today and how they will twist and turn and torture the data (and outright misrepresent it) to make it confirm their biases.
Let’s take a look.
They report early on in the paper that despite the ongoing nutritional transition that the Chinese are going through (brought about by Western influences) that

The average intake of vegetables is still higher than those in the western countries. At a national level, the mean intake of vegetables was 276 g per day in 2002, which is 40 g per day less than 20 years ago.

They then state:

The beneficial association between intake of vegetables and fruits and obesity has been well documented in different populations. In Western populations, high intake of fruits and vegetables is associated with lower intake of energy and a healthy lifestyle and thus a lower risk of obesity. No research has examined the association between obesity and a diet rich in fruits and vegetables in China.

Which they set out to do. It is obvious from the first two sentences of the quote right above what the bias of these researchers is: fruits and vegetables are good for you. And more of them is even better. Problem is that there really isn’t any definitive research showing this, although it is widely believed.
I’m pretty certain that when these people decided to do this study their game plan was to divide the study population into quartiles or quintiles of fruit and vegetable consumption. And I’m sure they figured that those subjects in the quartile or quintile of the highest fruit and vegetable consumption would show the least obesity while those in the lowest fraction would show the most. But it didn’t turn out that way for them.
In fact, it was just the opposite. The researchers did divide the subjects into quartiles (fourths) as a function of fruit and vegetable consumption, and they found that the subjects eating the most fruits and vegetables were the fattest. As they put it:

Increased intake of the vegetable-rich pattern was found to be positively associated with risk of obesity in the study. the prevalence of obesity among women with the highest intake of this pattern was more than double than that of the lowest intake group.
The vegetable-rich food pattern was associated with higher risk of obesity/central obesity in Chinese adults in both genders.

So what do good scientists do when they discover that the data doesn’t conform to their preconceived notions? They change their thinking to fit the data. What do sorry scientists do when the data doesn’t conform to their preconceived notions? They interpret the data so that it does fit with their thinking. Which is just what these researchers did.
The data is pretty clear that those subjects who ate the most vegetables were the most obese. It’s also clear from the data that those subjects who ate the most vegetables also ate the most calories to the tune of about 200 kcal more per day. Now it would be easy and within what the data show to state that those subjects consuming the most calories were the most obese. No one would argue with that. But it flies in the face of the popular idea that you can eat all the calories you want as long as they are fruits and vegetables. Dean Ornish wrote a bestselling book titled Eat More Weigh Less on this very subject.
Our researchers are in a quandary. Their data that they expected to show one thing is not cooperating. And try though they might to legitimately present it, they can’t without somehow contradicting the idea that vegetables (in whatever quantity) are healthful. Where to go? What to do?
What do you think they did?
What all good mainstream researchers do. They blamed it on fat. I’m not kidding.
Here we go right from the paper. As Dave Barry would say: I’M NOT MAKING THIS UP.

The average intake of vegetable oil in China was 33 g per day in 2002, while this figure was only 22 g per day in 1992 and 18 g per day in 1982.
High intake of vegetable-rich food was associated with high energy intake, probably due to the high proportion of energy coming from fat which contributes to a high energy density, which is known to affect obesity prevalence.
In the present study, a positive association between intake of vegetables and vegetable oil was observed.
Stir-fry cooking method in the Chinese population may thus partly explain the positive association between a seemingly vegetable-rich food pattern and obesity…
Thus, when making recommendations on intake of vegetables, the importance of limiting the use of cooking oil as well as cooking method should be emphasized...

You can certainly see where they’re headed with this. And they don’t disappoint.

In conclusion, we found a positive association between intake of vegetable-rich food pattern and obesity. This association can be linked to the high intake of energy due to liberal use of vegetable oil for cooking vegetables.

There you have it. Fat is the culprit. And although vegetable oils have been the darling fats of the mainstream folks for ages, they don’t hesitate to throw them under the bus when their beloved vegetables are challenged.
But hold on. There is a fly in the ointment here.
There is absolutely no difference in the amount of fat consumed in the group that ate the most vegetables as compared to the group who ate the least. In men the grams of fat were exactly the same in both groups; in women their was a slight difference, but it didn’t reach statistical significance. And as a percent of energy intake (the measurement the mainstream loves), fat intake dropped from 32 percent to 31 percent in both males and females as vegetable intake went up.
You think I’m pulling your leg on this? Researchers publishing in a major journal (and the peers who reviewed them) wouldn’t say all this if it weren’t supported by the data. Right?
Well, here is the chart from the article showing all the data.

Click on it to blow it up to readable size and look down to where it lists the fat intake and come to your own conclusion. Then go back up to the quotes from the article that I have put in bold print. Unbelievable. This is why you never want to panic when you read the press report of a new piece of research. Oh, and BTW, have you noticed how the press has ignored this study?
I saw no mainstream press articles when I Googled; the one article I did see from an online publication picked up the misleading conclusion from the paper.

A Chinese study came up with the — to Americans — paradoxical finding that the more vegetables people ate, the fatter they were.
Why? Because the Chinese in this population in Jiangsu Province were stir-frying their vegetables in “generous” amounts of oil, and the more vegetables they ate, the more energy-dense oil they were eating.

If you’re going to draw any conclusions at all from this data in terms of macronutrient consumption and obesity, it’s got to be that carbs make you fat since the data show that carbs are the macrontrient that increased the most in both men and women with increasing obesity.

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  1. What about all the rice ? Didn’t the researchers notice the rice ?
    They must have. It’s listed on the data chart.

  2. It’s incredible that they should seize on vegetable oil as the culprit, while completely ignoring the fact that those in the Q4 eat almost four times as much fruit and five times as much wheat flour (in women it’s 4.0 liang in Q4 vs. 0.5 liang in Q1).
    There’s also no mention of sugars, and one wonders if the Chinese are drinking more sweetened drinks (particularly sweetened with high fructose corn syrup). I know that in Hong Kong, vending machines with sweetened green tea are everywhere.
    It drives me nuts that people who bemoan the “epidemic” of childhood obesity completely ignore the differences between what North American kids eat today and what we ate 50 years ago. The two things that really come to mind are soft drinks and cereal, particularly sweetened cereal. Sure, we drank Kool-aid, but it was sweetened with cane sugar, and most mothers put a lot less sugar in it than the directions called for (often as a hangover from war-time rationing). As for cereal, the sweetened kind was much too expensive!

  3. It’s interesting that the thinnest group was eating the most rice (by far) and the least wheat (though least carbs overall). The original China Study also found this correlation, though it was buried in the vegan claptrap bias of the author.

  4. Ah…I suppose they count rice as ‘vegetable’ without distinguishing it from vegetables, if you see what I mean. Rice to me is a starchy carbohydrate of the grain family and not a vegetable, but those researchers lumped them all together as a vegetarian diet as opposed to a diet containing meat so they can’t see straight to understand why the Chinese got fat !

  5. Thank you for an excellent rebuttal of the conclusions of this study. unbelievable! I deleted several expletives since this is a family friendly blog.

  6. Also, did the report mention activity at all? Most show no leisure time activity (although their non-leisure time might be more physically demanding).
    This is really amazing. Thanks for the information.
    They didn’t look at physical activity; they evaluated diet only. They did sort of pay lip service to it in one sentence in the Introduction. After stating that there was a developing obesity epidemic in China, they wrote:

    Changes in diet and physical activity are associated with this epidemic.

  7. Thanks Mike! This is a jewel to have and discuss in a mini-nutrition course I’ll teach in August! I’m sure the ‘Asian paradox’ will come up.

  8. Hilarious. Note that the difference in carb calories between Q1 and Q4 is about 150 for men, 130 for women. The difference in fat calories is 0 for men, and about 54 for women. If a “calorie is a calorie”, then where should the reduction come from to treat obesity?
    Wheat flour is significantly different between Q1 and Q4 as well, 5x higher for men and 20x (!) higher for women. There’s also an enormous disparity in both whole grain and milk consumption.
    Finally, more men and women spend time in leisure time and physical activity in Q4 than in Q1.
    So the group that eats more veggies, wheat and grains, and had greater physical activity is also the most obese? Must be the vegetable oil.

  9. I’m sorry, I don’t know where else to put this, so I’m commenting here. Did you see this article advocating giving statin drugs to 8 year olds? http://www.americanheart.org/presenter.jhtml?identifier=3049338
    It was covered on the front page of the Indystar today, but I can’t find it on their website to send you a link to that article. The Indystar article made it sound like it would be a great idea for most kids. Statin drugs to 8 year olds! The actual article is, of course, more limited than the media understood.

  10. The total amount of carbohydrate didn’t change that much between quintiles of the veg-rich diet, just over 10%. What did change massively was wheat flour consumption: 5-fold between the 1st and 4th quintile! Between the 1st and 4th quintile, the ratio of rice to wheat flour changes from 7.3 to 0.8! It’s replacing rice as their primary source of carbohydrate.
    I think that probably explains the obesity. The veg-rich food pattern had the strongest link with wheat consumption. It’s amazing how obesity seems to follow on the heels of wheat consumption on a cultural level, throughout the world. I believe there’s something unique about wheat that messes up the feedback loops that regulate the bodyweight set-point.

  11. Did they explain what “active commuting” was?
    They described active commuting as “walking or cycling to and from work.”

  12. sorry i disagree with you doc. i think its copius amounts of vegetable oil used in stir frying. we all know oil makes it more tastier. i also think there is also lack of exercise and more sedentary lifestyles lately. prevelance of desk jobs, stress related to succeed in the ultra competitive workplaces in asia and quickly changing societies are significant components to this issue.
    First, stir frying requires very little oil, which is why a parabolic wok is perfect for it. Second, the data from the study shows that there isn’t a difference between fat intake in the obese group and the non-obese group.

    1. “First, stir frying requires very little oil, which is why a parabolic wok is perfect for it. “.
      You may be correct second, but first you are wrong, or have no idea the secret behind making good fried rice,
      you make it ina wok, and the secret is to use heaps of oil.
      Just becasue it is possible to use less oil in a wok, doesnt mean people do

  13. Hi Dr. Mike,
    I second Anne’s comment about rice. One of my granddaughters recently lived in
    Japan for 10 months as an exchange student. She gained 15 lbs. When we asked
    what happened, she said that the diet in 2 different homes consisted of some fish
    (not too much), a few vegetables (mostly marinated or pickled), and LOTS of rice to
    fill in the “gaps”. She said the grownups strongly pressured her every day to pack
    in the rice. Now she can’t even look at it.

  14. The study makes no mention of rice; do they consider this a vegetable? Common sense says its hard to see how just fruit and vegetables w/o grains of any kind can be the cause of the weight gain. Do you really believe that a diet that was just fruit and vegetables with oil, but devoid of grains would cause these results ?
    Rice intake is shown on the data chart.

  15. Dr Mike, I remember that in your first book you wrote that the Chinese have six times the rate of stroke that North Americans have. So that while it looks like they do better because their rate of heart attack is much lower than ours, people don’t realize that strokes ARE a cardiovascular disease, and the Chinese may be doing worse. Would you please post about the pertinent papers that evaluate that? I was really impressed by that part of the book, since like so many, I had thought the Chinese were healthier than us with our Western diet.
    The stroke figures are in the American Heart Association Statistical data from the year the Protein Power was written. The AHA doesn’t make those old data charts available after the new ones are out.

  16. By the way, isn’t the combination of oil and carbohydrate deadly? It appears to me that so called obesity researchers never seem to make that connection.
    The combination of oil and carbohydrate is deadly only in that it has a taste and mouth feel that humans love, and, consequently, are driven to eat too much of it. No one binges on butter (an oil) all by itself, but add some sugar to it, and you’ve got frosting, which everyone loves and eats to excess.

  17. We have a large international supermarket in the city where I live that imports goods for the Asian, Middle Eastern, and Hispanic communities in our area. A trip through the aisles of such a market will quickly dispel the notion that the rest of the world is eating more healthfully than we are. As those of us in the know tend to shop the perimeter of American grocery stores, it is no different at an international grocery–vegetables, fruits, dairy, meats around the perimeter and every manner of junk food in the middle. If anything, I see more sweets and carb-heavy snacks at this market than at the American ones. Gummi candies with lychee fruit flavoring and sugary bubble tea with tapioca pearls are still junk, despite the exotic names. If the loads of junk food I see at this market is what Asians need to have imported to feel like they are “back home,” then no wonder they are getting fatter both here and over there too. I know the point of your post is that vegetable (i.e. carb) consumption is tied to weight gain, but I would suspect that as the rest of the world moves to imitate our high-profit junk food industry, increased consumption of these products is also a contributing factor to the girth of people wherever processed foods make inroads into the native diet.
    Actually the point of my post is that these researchers totally misinterpreted their own data, which is, unfortunately, an all to common occurrence.

  18. Hi Dr Mike,
    So the stir frying is now not healthy, when a few years ago it was. And 33 g of fat per day is suddenly massive! Do these guys know anything about cooking? You only put a small amount of oil in the bottom of the wok — that’s why they are parabolic, for heavens sake. Then, the traditional fat used in Chinese wok cooking is LARD. Not vegetable oil. Vegetable oil is something the West has forced on the East, and is only available thanks to modern manufacturing.
    I have Chinese in-laws (and Italian, Tibetan, Korean, Scottish and Jewish — this is Australia and we’re very multicultural) and we know how to cook Chinese! And what about all the steamed dumplings? And what about all the sugary-starchy condiments (Oyster Sauce, Hoi Sin, Black Bean Paste, etc.) in the cooking sauces? It’s not the fat!

    1. When I took vegetable oils out of my diet, I replace them with butter, lard and coconut oil. I use lard and a little Bragg for my stir fries. People have asked how I manage to make such good stir fries. Since I was using the Bragg first, I think it must be the lard.

  19. One post above mentioned the fact that some doctors are now recommending statins for very young children. Serve them in the cafeteria, I say! Wash them down with a Mountain Dew.

  20. bev, your granddaughter is not asian i am guessing. our genetic makeups are attuned to what food we eat. so if you are white say and went to japan to eat, eat rice in the quantity the locals eat, obviously your system is not used to. and obviously she will pack it it. our genes have adapted over generations to what we eat and the conditions we live in. secondly she is a teen if she is going as a exchange student, if i can make that guess again, and teens we know have notorious foodhabits to start with.
    the world now obviously is very different with intermingling and globalization. i will stress the point i made earlier that lifestyle changes along with diet play a big factor in our obesity at the moment. the societies in asia are going tremendous and dynamic changes in the last ten to twenty years. this includes eating, living and mental habits. you have to look at it holistically to get the whole picture….diet is a small portion of this. mental conditions, nuclear families, work pressures, stress from over population and pollution what not…all are need to be accounted for.

  21. A few people have commented on the proposal by the Pediatric Association to start giving children with any heart disease risk factors, including obesity, statins. This should open up a huge market to resuscitate sagging statin sales. The statement by Dr. Frank Greer in the media article has to be a candidate for the most astoundingly absurd statement of the last century:
    “The academy has long recommended against reduced-fat milk for children up to age 2 because saturated fats are needed for brain development.
    (COMMENT: How about ‘essential’?)
    “But now we have the obesity epidemic and people are thinking maybe this isn’t such a good idea,” said Dr. Frank Greer of the University of Wisconsin, co-author of the guidelines report, which appears in the July edition of Pediatrics, the group’s medical journal.”
    One one hand the ‘experts’ recognize that saturated fat is essential for brain development. Then they do an about face and take the position that consuming the saturated fat required for brain development is “not such a good idea”.
    Here’s one more beauty from the same article:
    “He (Dr, Greer) has worked as a consultant to Abbott Laboratories and Merck & Co., but not on matters involving their cholesterol drugs.”
    COMMENT: Yeah, OK. He works for Abbott but not on statin matters. So he is not biased or in conflict.

  22. @GC: Uh…I’m sure there’s some small variation among populations in terms of food tolerances but your assumptions on this one are not very well founded. The Japanese have not even been eating rice for long enough to make a serious dent in human evolution; even within written history millet was the primary grain. Rice has been with the Japanese for longer than potatoes have been in Europe, but not by long.
    Incidentally, when I was an exchange student in Japan many of us white kids lost weight and my one Japanese-Canadian friend packed on the pounds (it was like an entire nation of grandma’s home cooking to her, y’know). I think the difference for us American and Aussie kids was primarily portion size.

  23. in case anyone cares 1 liang = 50 grams.
    other possible titles for this article:
    -Physical activity associated with obesity in China
    -Higher-carb diets associated with obesity in China
    -Diets higher in animal fats negatively correlated with obesity in China
    All would have been more accurate than the title that was used.

  24. sasquatch said:
    [quote]I believe there’s something unique about wheat that messes up the feedback loops that regulate the bodyweight set-point.[/quote]
    Look at http://high-fat-nutrition.blogspot.com/ Peter explains very thouroughly the problem with wheat. Gluten is very, very, very bad for anybody consuming it (not only for coeliac).

  25. Dr. Mike,
    I know you’re not surprised by this. I don’t think bias like this can ever be stopped but how can it at least be stemmed? Ignoring scientific studies, “anecdotal epidemiology” (without a true study design, there is overwhelming positive evidence) is strongly in favor of low-carb.
    In their heart of hearts, do they actually believe what they are saying/seeing? Or are they so entrenched as to not allow themselves to admit it?
    I do indeed think that in their heart of hearts they believe this nonsense. They just can’t make the data cooperate with what they ‘know’ is right. Read this post to see why.

  26. The average intake of vegetables is still higher than those in the western countries. At a national level, the mean intake of vegetables was 276 g per day in 2002, which is 40 g per day less than 20 years ago.
    I’m not sure where they get that statistic from….looking at China’s food balance sheets (from the FAO), in 1982 it was physically impossible for the average person in China to even find 316g of vegetables a day as their food supply only provided 163g of vegetables each day (59.46kg per person annually in the food supply in China, 1982)

  27. People eating more wheat, weighing less? Not enough information here to suggest Celiac. Whoops.
    Speaking of crummy studies, here’s one where researchers came to the conclusion that a sarcopenia-friendly diet is protective against heart disease in obese post-menopausal women.
    They almost seem to be suggesting sarcopenia as a defense against insulin resistance. Although they admit that the women who had sarcopenia were just as insulin resistant as the women were just obese, even though the women with sarcopenia had less visceral fat.
    I saw this study when it came out and thought it a little beyond the pale. Multiple other studies have shown that post-menopausal women with greater lean body mass live longer and have a better quality of life than those who are sarcopenic.

  28. Sooo, are you going to comment on this latest nonsense (re: child-hood use of statins)? I’m sure it will be worth the wait…..
    Yep, I’m going to comment.

  29. @Kim;
    sorry i disagree with your conclusions. all these exchange students stuff is for temprorary effects. and you are students/teens when your habits are not exactly disciplined. one can draw all kinds of conclusions from a teenage exchange time in different country.
    i grew up in asia so i know what i am talking about with rice. i grew up on a rice, wheat diet, veggie diet and no meat or eggs or fish. and we were very healthy for the most part. we didnt have cars, we went everywhere by public transport, walk, bicycle etc. our meals were very low in cheese, oil and butter, my point is that now as people’s lifestyle change this is not the case. and in asia, there is now more of the three ingredients in everything…that is cheese, oil and butter.
    i dont buy the parabolic container argument that for stir fry you consume less oil. it is absolutely ridiculous the amount of oil i have seen in many of the stir frys.
    i think people can draw all sorts of conclusions, spin they want to suit their way of thinking. you are looking for everything from the low-carb view. obviously your slant is towards that. the issue is much more complex. its not linear, one cant make simple arguments like eating veggie and fruits causes weight gain. that is silly…
    Irrespective of how much oil you’ve seen being used in stir frying, the data from this study – which is what this post is about – clearly shows that the amount of fat consumed is the same in the subjects consuming more vegetables as it is in those consuming less.

  30. Hi Mike,
    Thanks for another great post. I see a few people talking about Japan here, and since I’m currently living in Japan (plus lived in Shanghai, China for the first 4 months of the year)… I can say that there is a BIG difference between the two countries. Japanese people are amazingly thin… considerably thinner than Chinese people (on average of course)… FAR below most western countries, and definately no comparison to the US (and even Australia where I’m originally from).
    Amongst my friends, the average Japanese girl here weighs around 50kg… average guy around 60kg (they’re not afraid to tell me how much they weigh)… and one of the things that stands out considerably to me is in the swimming pool I have seen many middle age men (50-60 year old) who have six-packs! I doubt this is because they work out so much, they don’t appear to be ultra-fit, but Japanese people are in a league of their own when it comes to fat levels (at least out of all the countries I’ve traveled to).
    My friends eat rice almost every meal… and most as I said are very skinny.
    There is, however, a growing problem with people getting fatter. My assumption has always been that this is because of Western food which is very popular here now, and very refined (cakes, pasta, fast food etc). It’s not uncommon to see McDonald’s packed with young teen girls, however, again most of them are skinny! I asked my friends how these girls stay so skinny, and she says they wouldn’t go to McDonald’s more than once or twice a month. Not sure if this is true or not.
    One big thing here is that people have very high-standards for themselves for their weight. My girlfriend is 170cm tall and weighs 52kg, and is athletic (a Yoga instructor)… and even she is very strict about her diet because she thinks she’s got too much fat (I offered her my skin-calipers to confirm she wasn’t — she’s 17% +/1 1%) — but that didn’t changed her mind.
    Japanese food — except for the rice — is very low carb. I eat Japanese food all the time because I love it… I just don’t have rice except for the weekends when I’ll eat sushi. I’ve never gained weight here, and I think it would be very hard to do so in Japan without stuffing out on rice (or dramatically overeating) — or eating western food — as I can’t think where else you’d get the carbs from, and the portion sizes are fairly small.
    Thanks again for an interesting post Mike,

  31. Loran Cordain’s Paleo Diet (which you have endorsed in the past) suggests that most people have no problem with eating lots of fruits and vegetables. Does the correct interpretation of this study suggest this is incorrect?
    I generally follow Cordain’s ideas, cutting back drastically on grains but eating lots of fruits and veggies and I have no trouble with weight.
    You’re putting words in my mouth. I’m in complete agreement with Loren Cordain in terms of drastically cutting back on grains, but I disagree with his recommendation to avoid saturated fat. I think his diet is a little carb heavy and saturated fat light.
    This post on the study of the Chinese and vegetable intake isn’t meant to bash vegetables, but to show how researchers squirm when their data doesn’t fit their preconceived notions.

  32. Thanks Doc. This is a great post! I’m forwarding it to my Mom. I’m slowly winning her over to a low-carb diet (I hope).
    Will you ever be posting on topics/research about common health conditions that make weight loss more difficult, like adrenal or thyroid problems?
    I’m sure at some point I’ll be posting on these topics. They’re not on my list of posts coming up in the next couple of weeks, though.

  33. gc, i live in asia (south korea) and i can tell you that korean diets are not filled with cheese or or butter. in fact, you have to search real hard to find these items (and i do). but koreans are getting fatter and suffering from all the associated maladies. the worst skin and teeth you can imagine. you can blame it on the “western diet”, if, by a western diet, you mean lots of sugar and flour.

  34. Kaiser Permanente has just released the results of a study in which 1,700 participants adhered to a low fat diet high in fruits and vegetables in combination with a program of regular exercise. Those who kept a diary lost twice as much weight as those on the same diet who did not keep a dairy. Those who kept a diary wrote down what they ate and an estimate of the portion sizes to keep track of the number of calories. Although the articles did not state that those who kept diaries ate less fruits and vegetables than those who didn’t it is reasonable to assume this was the case.
    The results of this study seems to contradict the theory that eating fruits and vegetables in combination with a low fat diet will result in weight loss and that the more fruits and vegetables one eats the more weight they will lose. This study suggests that this was clearly not the case. Since the diet was a low fat in fat by design the researchers can not fall back on fats and vegetable oils to explain the differences in weight loss. But then again, one should never underestimate the manner in which data can be twisted and misrepresented.

  35. If anything the Kaiser Permanente study is a damming indictment of the metabolic inadequacy of the low fat, high (vegetable/fruit) carbohydrate diet, the satiating effect of which is so poor that the only way the participants in the study could adhere to the diet was to track every bite of food they consumed.
    Having been a carboholic until I started low carbing 3.5 years ago I can attest to the fact that carbohydrates are truly addictive. On my old high carb ways I was well known for my ability to consume enormous amounts of food at a sitting which I often did. And I snacked frequently during the day. On a low carb diet I typically eat 2 modest meals a day with no snacks. My satiety is so good that I experience little, if any, hunger. Of late I have even stopped my morning weigh-in ritual because my weight never goes up or down more than a pound or two.

  36. There is no evidence at all that diet had anything to do with weight gain, and even less evidence to support fat was the reason. The fat intake was constant across all quartiles. Perhaps “plant foods” were the reason for the disparity, perhaps not. It might be true that people who have glucose metabolism defects tend to increase their intake of plant food slightly. The increase was so modest it is hard to believe that it was causational (rather than a symptom of a preexisting metabolic dysfunction). Since the increase in carbohydrate calories was just extra, and no other intake changed, this seems to suggest the people who are likely to have metabolic syndrome are also likely to eat more carbohydrates (a reasonable assumption).
    The idea that fat was the cause is outright ridiculous. While it is true adding fat to a carbohydrate diet will cause insulin resistance and metabolic syndrome, that did not occur here. Fat inake was constant. Carbs increased – most notably carbs from wheat flour which is literally 5xs as high as the healthiest quartile. Fruit increased (it does not specify fresh or not) almost 4 times as much from the healthiest quartile. Vegetables are 50% higher. Hmmm… flour, fruits, vegetables, I’m imagining pastries and non-traditional modern foods.
    It’s probably not the carbs per se, because the least healthy group actually ate the LEAST rice. Rice consumption declined along with health. This trend in rice consumption may be a marker for the modernization of eating.
    The highest quartile tended to eat more animal foods, especially milk and eggs. This to is a marker for a deviation from traditional eating, more modern diets, and may imply lifestyles that are more stressful, less sleep, and likely to induce the metabolic syndrome.
    Looking honestly and objectively at this data, it seems to ME that the only fair conclusion to be drawn is this:
    -Increasing calories from carbohydrate correlates with obesity
    -In chinese people, a trend toward decreasing rice, increasing wheat flour, whole grains & potatoes (root veg), fruit & vegetables, milk & eggs correlates with obesity
    -Less education correlates with better health (possibly a marker for traditional lifestyle and a lack of stressful work that can create metabolic syndrome)
    -Higher income correlates with healthier weight, and lower income correlates with obesity (a consistent finding, and possibly a marker for stress and metabolic syndrome triggers)
    Honestly looking at this data I am to think that stressors to the body and mind probably correlate most with obesity :
    Higher education (stressful jobs),
    lower incomes (stressful life),
    Eating numerous foods that are not traditional (possibly takeaway foods and pastry, which may be a result and indicative of stressful modern living).

  37. @GC: Portion size is a low-carb concept how? It’s particularly funny that you’re apparently arguing I as a white person *should* have gained weight on a rice-based diet except that my undisciplined teen-age ways somehow made the reverse happen.
    In any case, neither your experience nor mine impacts the actual history of rice agriculture or the pace of human evolution. Even if we say for the sake of argument that all of East Asia suddenly started eating rice in modern quantities/proportions 3000 years ago (which we know is not the case), that’s still an exceedingly short amount of time to claim that real divergent evolution occurred. And if somehow it did, what would be the selection pressures, exactly, that would make successful rice cultivating people less likely to store calories from rice (i.e. get fat) than non-rice-cultivating people?

  38. I have been living in Taiwan for 5 years, and I watch the skinniest people consume large amounts of carbs and sugar on a daily basis. They don’t get fat. I have to watch every bite I put in my mouth and I exercise like a madwoman. It drives me crazy!

  39. Since when are vegetable oils, wheat flour, and rice considered fruits or vegetables? Am I missing something here?

  40. If I read the chart right, the thinnest quarter of people at twice as much rice.
    The charts aren’t laid out by thin verses obese; they are laid out in terms of vegetable consumption. Those in the quartile with the least vegetable consumption did eat more rice.

  41. I began increasing my fat intake. I cook with coconut oil, butter, peanut oil. I add extra butter to my vegetables. I also supplement my diet with a ketogenic cocktail of other oils: flaxseed oil, MCT and EPA, recommended by Dr. McCleary in his Brain Trust Program. I am losing weight and I have an outstanding blood lipid profile. So in my honest opinion, those Asians who gained weight because of the oil added to their food, just are not using enough oil.;-)
    Another part of the study should inform us how often did these people eat? Meal frequencies also makes a difference as I have experienced from intermittent fasting. I am sure that there are some modern cultures who eat 1 to 2 meals a day instead of 3 meals plus in-between-snacks. In other words did all participants in this study eat identical meal frequencies or did they vary. I strongly believe that this would also make a difference. I guarantee you that if I were to eat 2,000 calories in a day and split those calories up between 3 meals and 2 snacks, I would gain weight. Whereas dividing these calories into 2 meals or even 1 meal…I would lose weight. Of course, every one of these calories would be low carb.
    I saw a documentary on TV of how Sumu wrestlers build girth. This was several years ago, before carbs were a concern for me. All I recall from that documentary was that these wrestlers consumed tons of rice. Not scientific but it is an observation.
    Frankly, the more I read about fats, the more I believe that fat is the most important nutrient we can consume worlwide.

  42. I think there’s some misunderstanding of this study. First, they sorted the subjects into 4 “food patterns” and used regression analysis to show that the “vegetable rich” pattern (as a whole, not by quartiles) was associated with increased vegetable oil intake. They say “data not shown.”
    The table then sorts the 4 groups into 4 quartiles. For all but the vegetable-rich group, they show only energy intake (this part of the graph doesn’t show on the link given here). So there’s no way to compare fat intake in the other groups with the fat intake in the vegetable-rich group except to take their word for it (“data not shown”). Very confusing.
    But they do say at the end, “The fact that we found no differences in energy percentages from fat across quartiles of this pattern [the vegetable-rich group] may suggest that the total energy intake rather than the role of fat in explaining the association is the most important factor.”
    I didn’t average the energy across all quartiles of all the 4 groups. I have other things that seem more pressing.
    I personally find all studies like this murky when you group foods into categories based on preconceptions, like a “prudent diet” including fish and chicken and fruits and vegetables and an “unhealthy” diet containing red meat and hot dogs and fast food and luncheon meats and then conclude that red meat is unhealthy and chicken is healthy because the latter group (who were undoubtedly eating a lot of french fries with their hot dogs and fast food) didn’t do so well.
    Hi Greta–
    Good points. I hate the idea of these so-called ‘factor-analysis’ studies myself. I didn’t post on this one in an effort to show that eating more vegetables makes one fat, but to show how the authors misrepresented their data. If you go through the study carefully – as you obviously have – then you find all kinds of weasel phrases such as the one you mentioned where they do kind of represent their data accurately. But, overall they out and out misstate what the data show, and a casual reading or a reading of the abstract only gives one the wrong impression of what the study really says.

  43. But I don’t think they *do* misstate what the data show. The vegetable-rich group apparently ate more fat than the other groups. There was no difference in animal fat intake between groups, so it must have been the vegetable oil that was increase.
    It’s only *within* the vegetable-rich group that the fat intake is identical.
    The problem is that they don’t show the data that show that the vegetable-rich group ate more fat than the other groups. We have to take their word for it. They say the regression coefficient was 1.40 (95% CI = 0.41, 2.40). I’m not a statistician. I know that for relative risks, if the CI overlaps 1.0, it means the results aren’t significant, as they could be 1.0. I don’t know if this is also true for regression coefficients.
    Hey Greta–
    Sorry it took me awhile to get this comment up, but I wanted to take the time to review a hard copy of the study to see what you were talking about. As I understand it, the researchers were looking at subjects in what they determined was the vegetable-rich food pattern and not comparing between the vegetable-rich food pattern and other patterns. Within the vegetable-rich food pattern the men showed no difference in vegetable oil consumption among the quartiles whereas the women did show an increase with increasing energy and vegetable (and fruit) intake. But you are absolutely correct in stating that the relative risk isn’t significant because the CI overlaps one. Which is the point I was trying to make. The authors are trying to pin the blame on vegetable fat when statistically there is no basis for it. Maybe you read it differently, but that’s my impression.

    1. The map appears to show the TOTAL number of deaths from cardiovascular disease per country, not a percentage of the population. Which seems to make this graph pretty useless for comparing rates of disease per country.

  44. I spent a month in Asia last Christmas. The majority of Asians are very slim. Even those with a bit of weight on them are at most chubby by our standards. During my entire trip I only saw three people I would classify as obese.
    They seem to eat a lot of vegetables and rice so I really don’t know how they stay so slim. The only possibility I can come up with is that their portions are small. However portion size is driven by appetite which is driven by insulin. So their insulin levels must be pretty well controlled IMHO. Hence they stay thin.

  45. “They seem to eat a lot of vegetables and rice so I really don’t know how they stay so slim. The only possibility I can come up with is that their portions are small.”
    I can think of another possibility. Perhaps a carb heavy diet based on whole grains, fruits, and veggies isn’t as fattening as some people believe.

  46. There’s those “whole grains” again. Does anybody actually eat “whole grains”? I’m pretty sure that nearly all whole grain food (and almost certainly those wheat-based foods consumed by the most obese quartile) are made via industrial processing of grains, i.e. they don’t resemble anything like “whole grain” by the time they’re going in people’s mouths. Rice is one of the major exceptions, and rice does contain less of the anti-nutrients found in grains.
    I’m still waiting for someone to explain just what precisely is healthy about “healthy whole grains”.
    Hey Dave–
    If you want to know everything there is to know about whole grains, go to this site and pull down the pdf from #7 on the list. It’s Loren Cordain’s long, comprehensive paper on cereal grains. Well worth reading.

  47. Lol! Let me utter a quick laugh at the idea that Chinese people are by default healthy.
    I AM Chinese. Now I know this is just anecdotal, but here’s my family’s medical history: My beloved maternal grandmother had heart disease her whole life and eventually died of it. My paternal grandmother has type II diabetes; her second son, my uncle, died of a blood clot in his forties. My mother’s side has heart problems, and my father’s side has blood problems. On top of all this, at only 21 years of age, I have a nasty apple shape — not the most becoming on a woman. I’ve had this shape all my life, despite being a competitive swimmer and eating a traditional Chinese diet at home.
    I’ve visited China several times and it is true that the people look slimmer. However, this is in large part because their frames are much smaller. If you look at the middle age, they’re nontrivially thick around the middle. Also (again anecdotal) it seems to me that heart trouble is a big deal there in the elderly. My hypochondriac grandfather is always taking some preventative or another for his heart.
    As for me, there is hope! I started Protein Power two months ago and am feeling well for the first time in a decade. Low-carb is definitely the way to go!
    P.S. My father’s family is originally from Shandong. From what I understand, it’s the “Italy” of China, consuming a lot of wheat flour — dumplings, noodles, etc. I wonder whether they have more problems there or not.
    Thanks for providing us all with the interesting nutritional and disease history. Most people, it seems, appear to think that Asians have no health problems whatsoever. And are all thin. Thanks for setting the record straight, at least as it concerns those whom you’ve observed.

  48. By the way, another anecdote:
    When my parents reminisce about the poverty of the Cultural Revolution, they often talk about the scarcity of meat. They had little to eat but rice and vegetables and they said they were never full. My mother enviously remembers a wealthy family who fed their two children a whole chicken every morning. She remembers that the children grew very robust and healthy.
    From what I know of my mother’s diet while pregnant, I’m sure I was born with a ridiculous amount of insulin resistance. Moral I’m taking away from this: Eat meat!

  49. I think you may want to be careful about the implication that it’s “vegetables” that are the problem when the study category is “vegetables and fruit”. The leafy green vegetables Chinese eat have very few calories, and little dietetic effect except on blood pH. The fruit, on the other hand, has plenty of carbohydrates, causing the associated insulin spikes and hunger.
    Joyce: yes, Shandong is in the north; very wheat intensive. My mother is from Canton where they eat rice instead; no heart attacks that I know of on that side of the family, though I think I had a degree of insulin resistance until I went on a low carb diet.

  50. From what I know of my mother’s diet while pregnant, I’m sure I was born with a ridiculous amount of insulin resistance. Moral I’m taking away from this: Eat meat!

  51. Joyce is correct. So what if some Asians in Asia are skinny. What makes you think they are healthy?
    I have Chinese friends who are thin but have health problems. One of my Chinese co-workers is having an operation for a tumor – and she’s one of the thinnest people at work!
    My mother is Chinese and she developed heart disease after moving to the city and began eating more Western foods – vegetable oil, wheat, sugar, processed foods. She’s been skinny her whole life, but her heart wasn’t healthy.
    However, my great grandmother was a centenarian! She ate loads of lard and meat. Yes traditional Chinese cooking uses lard not vegie oil. She was thin till the day she died (at age 100) and was walking around doing stuff before she passed away.
    You have two women in the same family who are both skinny, one who lived on rice, lard, meat, eggs and fish – the other on wheat/rice, vegetable oil, little meat, veggies and some tofu. Who lived to 100, disease-free, with natural death? My great grandmother who ate a mostly paleo diet.
    My grandmother is still alive =) she’s pretty healthy and she also eats similar to my great grandmother. Although it pains her to remember the Cultural Revolution where there was little meat to be had – but she made up for it in the 1980s.
    My mother is returning to her roots and eating like my great grandmother did. It’s funny because I’m teaching HER how to eat traditionally when it’s usually the other way around. It’s hard, because she still thinks saturated fat is bad and she’s addicted to wheat products (bread, pastry, cookies, biscuits). She’s starting to refrain from buying that stuff.

  52. Excellent post. Thanks Dr. Mike.
    Also interesting in the data table was that the group most prone to obesity got far more of their fat from veggie sources and veggie oil (PUFA’s & n-6 galore), and much less of their fat from animal sources.

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