June 23

Big Breakfast Bunkum


Last week a host of reports about a study showing that eating a big breakfast brings about a much greater weight loss than eating a smaller breakfast saturated the media. Predictably, the press was all over this report with varying flavors or reporting depending upon the reporters biases. Some, obviously carb biased, reported from a high-carb perspective; others – more well-balanced, no doubt – reported from that bias. Others simply focused on the ‘big.’ Let’s see what’s going on here.
The first thing one must realize is that this is not a paper published in a peer-reviewed journal, this is a poster presentation at a medical meeting, in this case the annual meeting of the Endocrine Society held in San Francisco last week. A while back I wrote at length on the difference between this type of presentation and a paper that has gone through the peer-review process. Poster presentations such as this one go through a sort of peer review process when they are presented in the sense that attendees ask questions and point out weaknesses. But the public never sees this. The public sees the press reports about these presentations without the peer review. Papers that are published run through the peer-review gauntlet before they see the light of day and are ever reported on.
The authors of this study or the university at which they are employed put out a press release on the results of the study. The press, eager to publish offbeat nutritional news, picks it up and runs with it. The gullible public takes it as gospel.
I tried to find the press release by going to the websites of the universities involved, but couldn’t come up with anything. Maybe some industrious readers will have better luck than I. A number of members of the media secured interviews with Daniela Jakubowicz, the lead author, so we can pretty much see where she’s coming from. Interestingly, she has a diet book out in Spanish titled ¡Ni una Dieta más!, which translates to Not Another Diet! The subtitle translates to: The circadian method that revs up weight loss, controls hunger and sweet addiction, and let’s you keep the weight off forever. It looks like this study is an effort to confirm the ideas in her book.
As I say, I couldn’t find the press release, but I did find the abstract of the poster on the Endocrine Society’s website.

[P3-220] Effect of Diet with High Carbohydrate and Protein Breakfast on Weight Loss and Appetite in Obese Women with Metabolic Syndrome.
D Jakubowicz, D Maman, P Essah, Hosp de Clins Caracas, Caracas, Venezuela; Med Coll of Virginia, Virginia Commonwealth Univ, Richmond, VA
Background: Insulin resistance, common in obesity, promotes weight gain. Weight loss diets for obesity are frequently unsuccessful due to a carbohydrate withdrawal effect that exacerbates carbohydrate craving and hunger. We hypothesized that a diet aimed at reducing hunger and carbohydrate craving would support weight loss in obese individuals.
Objective: The purpose of this study was to determine whether a diet consisting of a high carbohydrate and protein breakfast would promote weight loss, increase satiety, and reduce carbohydrate craving in obese women with metabolic syndrome.
Methods: In this 32-week prospective study, 94 obese sedentary women (age 31.67yrs, BMI 33.84kg/m2) with metabolic syndrome were randomized to one of two diets: 1) a strict low carbohydrate diet (LCH; n=46) consisting of 1085kc/day (carb:protein:fat 17:51:78g) with breakfast 290kc (7:12:24g), lunch 425kc (5:21:28g), and dinner 370 kc (5:18:26g) or 2) a LCH diet with the modification of a high carbohydrate and protein big breakfast (LCH+BB;n=48) consisting of 1240kc, (carb:protein:fat 97:93:46g) with breakfast 610kc (58:47:22g), lunch 395kc, (34:28:13g),and dinner 235kc (5:18:11g). The first 16wks aimed on weight loss and the last 16 weeks on weight maintenance (WM). A 3-h meal tolerance test (MTT) was performed with quantification of glucose, insulin and appetite scores (hunger, satiety, fullness, and desire to eat) using 100-mm visual analog scales (VAS) at 0, 30, 60, 120, and 180 min after LCH or LCH+BB breakfast.
Results: Both groups lost weight at 16 wks (LCH: -12.62kg, LCH+BB: -10.63kg, p=NS). During the WM phase, the LCH+BB group continued to lose weight (-7.52kg, p<0.001 vs. 16 wk) whereas the LCH group gained weight (+8.32kg, p<0.001 vs. 16 wk). At 32 wks, the LCH group lost 4.5% of their baseline weight. In contrast, the LCH+BB group decreased baseline weight by 21.3%. AUC for glucose and insulin responses to MTT improved in line with weight loss (p<0.001, NS between groups). Compared with LCH, LCH+BB reduced hunger (p=0.02), increased satiety (p=0.07), decreased desire to eat (p=0.02), and increased fullness immediately prior to lunch (p<0.001). In contrast to LCH, LCH+BB reduced carbohydrate craving scores (P<0.001).
Conclusion: A diet consisting of a high carbohydrate and protein breakfast facilitates weight loss by reducing hunger and diminishing carbohydrate craving. Effective weight loss strategies for obese individuals should focus on controlling appetite and carbohydrate craving.

By going over this abstract we can learn a lot. What we primarily can learn is what is missing in order for us to get the full and entire picture of what is going on.
We learn that 94 pretty obese sedentary women afflicted with metabolic syndrome were randomized to one of two diets, which is good. This is a prospective, randomized study. There is no mention of how these women were monitored or whether they had food provided for them or were simply instructed to follow specific diets.
After 16 weeks, the weight loss phase of the study, the women on the low-carb arm lost 27.7 pounds (12.6 kg) whereas the women on the higher-carb arm (the big breakfast group) lost 23.3 pounds (10.6 kg). I find it interesting that the lower-carb group lost almost 20 percent more weight than did the higher carb group, yet the researchers reported this difference to be non-significant. I don’t believe this. Not with 46 subjects in one arm and 48 in the other. The numbers simply don’t bear that out.
If you look at the caloric difference between the two diets, it turns out that the low-carb subjects were getting 155 kcal less than the higher-carb subjects, calculating out to about 4.96 pounds difference, which is close to the 4.4 pound difference that actually occurred. We can say that the difference in weight loss didn’t really have anything to do with diet composition, but a lot to do with caloric intake. At these low-caloric intakes, calories are what counts. Not diet composition.
Now comes the interesting part of this study, which is the part that isn’t mentioned. The abstract says that after the first 16 weeks of the weight loss phase of the study, the two groups were put on maintenance diets. There is no mention of calories, macronutrient composition, or meal timing. Presumably the big breakfast group continued to skew most of their calories toward the breakfast meal at the beginning of the day, but the abstract doesn’t tell us. This is one of the things that would never, ever fly through the peer-review process.
All we learn is that after the next 16 weeks on the mystery diet, the higher-carb, big breakfast group continued to lose big time, dropping another 16.5 pounds (7.5 kg) while the poor subjects in the low-carb group actually packed on an extra 18.3 pounds (8.3 kg). There is something fishy going on in Venezuela, and it ain’t just Hugo Chavez. There is no way that these two groups could have had anywhere near the same number of calories and had these results be this divergent. It’s impossible, and (to put it in Samuel Johnson’s favorite words) there’s an end on’t.
I suspect the diets were fiddled with to bring about the results the researchers wanted. That’s the only option.
Having said that, let’s look at another aspect of this study that bears scrutiny. The hunger scores were evaluated using a meal tolerance test at 0, 30, 60, 120, and 180 min after breakfast. Now if I were to do this test anywhere from right after breakfast to 3 hours after breakfast and the only data you had to go on was the fact that one group got a breakfast that contained over twice as many calories as the other, which group do you think would be the least hungry over the next few hours: the group with the little breakfast or the group with the big breakfast? This is the test that was done. And reported. And picked up on by the press. This is one for the having-a-keen-grasp-of-the-obvious award.
I’ve seen a number of studies showing that caloric intake skewed to the first part of the day, i.e., a big breakfast, small dinner, seems to result in more weight loss than the same number of calories skewed later in the day, i.e., small breakfast, big dinner, so I don’t have an argument with this idea. The argument I have is that this is a poorly reported study that doesn’t contain enough information to allow an appropriate understanding of what really went on, yet it’s being used by both the press and it’s author to imply something that isn’t necessarily true: that a big, high-carb breakfast is better for you in terms of weight loss than a low-carb breakfast.
Daniela Jabukowiz herself is not a proponent of the low-carb diet. As she said to one of the reporters covering this travesty:

Most weight loss studies have determined that a very low carbohydrate diet is not a good method to reduce weight.

Oh, really. I would think it is just the opposite. Whenever low-carb diets are compared to low-fat diets, the low-carb diets kicks tail. At the very worst, both diets are about even. But the vast majority of studies show the low-carb diet to be superior.
I can pretty much guarantee you that this study will never see the light of day in a peer-reviewed journal. This is confirmed by one of the press members reporting about this presentation who wrote:

Plans to publish the paper in a journal were not announced.

I’ll bet they weren’t.

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  1. I would just like to know if there was actually informed consent in this experiment. It’s hard for me to imagine 46 women who’d really consent to being set up to fail on a starvation diet with just 51g of protein. Was it properly explained to them that their lean muscle mass and bone density would be negatively impacted by this diet and they were practically guaranteed to gain weight when no longer obliged to starve?
    Good point. I figured the post was running on too long, so I didn’t even get to the part about the starvation rations in this study. Thanks for bringing it up.

  2. Nice post Doctor,
    Looks like the LC group didn’t get enough protein: 51g/day vs. 93g/day for the BB group.
    Yep, everything is pretty low.

  3. “I can pretty much guarantee you that this study will never see the light of day in a peer-reviewed journal.”
    C’mon, Mike, if the ACCORD study can get published in New England Journal, this study will probably come out in PNAS. The people who do this kind of work also populate editorial boards and review papers. But, this is just another variation on ‘eat a good breakfast.’ I have always wondered why, if you are trying to lose weight, you would be want to eat a good anything. Also, at least anecdotally, people with a weight problem report that they overeat late at night, so if you work yourself into a caloric hole early in the day, what chance do you stand at night. Looking at the cover of her book, doesn’t ‘adiccion a los dulces’ mean addiction to sweets? Tell me her big breakfast was low in sugar.
    In any case, this is all pretty benign compared to ACCORD. The most astounding thing in ACCORD is that the text says “This study was not designed to test the components of the intervention strategy.” In other words, it wasn’t really a scientific study. It actually sounds like human experimentation without significant prospect of scientific information. Did I overstate the case?
    So, I say let Jabukowiz have her day in the sun and let/s try to do something about the big problems. First step is, again, the petition which I can’t seem to paste into this message but the link is at our website: http://www.nmsociety.org/
    Richard Feinman
    Hey Richard–
    Of course this isn’t even in the same ballpark of idiocy as the ACCORD study, but I still don’t think it will get published.
    I’ll post the petition.

  4. Thanks for taking the time to clarify that study for us which I read yesterday in the BBC. You’d think at least the BBC would have the good judgment to wait for that paper to be peer reviewed first before printing it.
    I’m a big fan of all your books and Protein Power was amongst the first books I read (when it first came out) on the subject of low-carb eating and on eating the ways of our ancient ancestors. It also had the effect of whetting my appetite in doing more research by reading the various books out there on the subject of eating the low-carb way and on diets in general. One of my favorite web sites to visit, besides yours of course, is the Weston A. Price site.
    Personally, I’ve been eating 3-4 eggs (lately fried in coconut oil) every single morning for the last 13-14 years, mainly due to being a bodybuilder. I don’t have much else with the eggs except a cup of black coffee and a TB of Cod Liver Oil. I used to have cheese omelettes…but as you pointed out so succinctly in a recent post…you still have to be careful of the calories. I love cheese, especially in my eggs, and having it around the house I would find myself eating it whenever I felt having a little snack. Needless to say, the weight started creeping up, so I had to swear off eating cheese. Now I’ll only buy it once a month. But what amazes me to this day, and what keeps me from ever changing my daily morning ritual of eating eggs, is how I can go almost all day long without feeling any hunger. I try educating a lot of folks about this phenomenon, but they’re all telling me I’ll be dropping dead of a heart-attack any minute.
    My other meals consist mainly of salads, tuna fish, red-meat/chicken from pastured animals and organic raw dairy from pastured cows.
    Question: Have you had a chance to review Mastering Leptin by Byron Richards as of yet? Of all the books I’ve read lately, this one seems to be one of the best of the bunch to go along with Taube’s Good Calories, Bad Calories. In writing his book he uses over 800 references to make his point. The only thing I’m not crazy about is in seeing him hawk all those supplements on his site. The Rosedale Diet by Dr. Rosedale appears to be another good one based on the leptin theme, but Dr. Rosedale mainly encourages snacking while Richards does not.
    Keep up the great work, Dr. Eades! Looking forward to reading your new book when it comes out later this year.
    Best Regards,
    I’ve browsed both books, but haven’t read either in detail. I suppose I should get around to doing that.

  5. Hey Dr. Mike,
    I received an e-mail from the researcher’s son Dr. Salomon Jakubowicz in Venezuela this week who said the media distorted what her research was really all about. Here’s exactly what he wrote to me in response to my blog post about his mother’s “study”:
    Regarding my mother Daniela Jakubowicz’s study she tried to make a low-carb diet including breakfast for both subjects and controls but the journalists increased the importance of the carbs during breakfast incorrectly calling it a “High-Carb And High-Protein Breakfast.” She does know that protein’s satiety power is bigger than carbs or fats. Your review is challenging although not very respectful for a health researcher.
    So, if the media misinterpreted the data (gee, what a surprise!), then why doesn’t she respond? I contacted her son back and requested a podcast interview with Daniela Jakubowicz to clear the air. We’ll see if she takes me up on this offer.
    I don’t know how much the press distorted her findings, but assuming she was quoted correctly in the articles I linked to, she seems to go along with the brunt of the articles.

  6. Grrrrrrrr!!! I am so tired of being lied to! Seriously! This isn’t a mistake or a simple flaw, this whole ‘study’ is just another giant pile of BS. Being lied to about what was healthy, what would lead to weight loss and what was “good nutrition” is what got me fat in the first place. Finally finding people like you and the Mrs., Doctor Rosedale, Doctor Atkins, and Gary Taubes is what saved me from a life of obesity, hypertension and disease. Thanks again to you and a big BITE ME to the lying scum bags of the world.

  7. Thanks for the tutorial on how to disect this type of sensationalistic reporting that we see all the time. You gave us a step-by-step methodology for uncovering what is a sham and indeed, as you put it, a travesty. I am so angry with the media who just pick up whatever headlines sell their papers/tv shows with no regard for scientific process or ‘checking out the facts’ before feeding masses on this cr@p.
    I just love your blog!

  8. Dr. Eades,
    You are correct on the difference between the means. Embarrassingly I must admit that I’m somewhat of a stat geek. Quick calculations come up with a t-statistic of approximately 3.8. You would have to go out to infinity and at some impractical level of significance to find a t-statistic greater than that. So yes, the differences in weight loss were significant.
    I can’t imagine someone not discovering this so I’m erring on the side of selective results.
    Thanks for running the calculations. I don’t have the software and didn’t want to do it by hand. I could pretty much eyeball those numbers, however, and tell that there was significant difference in weight loss.

  9. Dr. Michael Eades,
    I’m off topic. Sorry. One question and one comment.
    Dr. Barry Sears of the Zone philosophy stated in one of his books that it’s METABOLICALLY IMPOSSIBLE to lose more than 1.5 pounds of fat in one week. I must surmise from this that if you create a calorie deficit from, say, exercise, you will eat more and not lose fat, or lose lean mass, instead of fat? Or I must surmise that extra fat burned will be transformed in to muscle? Or I must surmise that if you’re carb restricted, the fat cells will be open to be released and used, but there’s a limit of how open? Can you think of any reason why he would say this?
    I just read Taubes’ article, “The Scientist and the Stairmaster”. It seems to me that he’s saying that exercise is not the base of the pyramid, to use a Zone diet book analogy. Exercise is a tool, along with fish oil, micronutrients, and stress reduction, to accentuate the base of carb and calorie restriction – as well as It comes back to the commentors calculation:
    Eat low carb = you CAN’T GAIN fat.
    Eat low carb ≠ you WILL LOSE fat. [unless, of course, you create a caloric deficit].
    Exercise helps create that deficit. Sure exercise makes one hungry. So does fasting. So does an emotional stressor, for some. It’s HOW you eat to relieve the hunger. I didn’t see the email that he sent you. But I read his article. From the article, Gary says,
    “They [lean people like Lance A.] are people whose bodies are programmed to send the calories they consume to the muscles to be burned rather than to the fat tissue to be stored…The job of determining how fuels (glucose and fatty acids) will be used, whether we will store them as fat or burn them for energy, is carried out primarily by the hormone insulin…with…LPL…This would explain the slew of recent clinical trials demonstrating that dieters who restrict carbohydrates but not calories invariably lose more weight than dieters who restrict calories but not necessarily carbohydrates…”
    It seems that you all are making the same points. Exercise, particularly in moderation, is not THE silver bullet for weight/fat loss.
    Best Regards, Will D.
    Another choice for the answer to your first question is that he may be wrong. And I think he is. It is not metabolically impossible to lose more than 1.5 pounds per week.
    Gary feels that exercise of any kind will not lead to weight loss. He believes that it will be compensated for by increasing food intake somewhere along the way. I’m not sure I agree. I do believe, however, that a good low-carb diet will take off the avoirdupois much faster than anything else including a lot of exercise.

  10. My favorite part of this POS “study” is that they actually miscalculated the calories in their low carb diet (which, of course, doesn’t resemble Protein Power, Atkins, or any other popular low carb diet out there.) (17×4) + (51×4) + (78×9) = 68 + 204 + 702 = 974, or 111 calories fewer than claimed. That’s an 11% difference. That sort of mathematical sloppiness on the part of someone calling themselves a scientist is simply inexcusable.
    Good catch. I didn’t even notice it. Truly sloppy.

  11. Dana got the calorie discrepancy from me. 😀 Still haven’t heard anything from the researcher about an interview since her son says she was misquoted…I guess that tells us all we need to know.

  12. I’m still having a bit of trouble “digesting” this:
    [I]Eat low carb = you CAN’T GAIN fat.
    Eat low carb ≠ you WILL LOSE fat. [unless, of course, you create a caloric deficit].[/I]
    Shouldn’t it be, “… unless, of course, you DON’T create a caloric deficit” ?
    Am I just being dense? It would seem if you eat low carb AND create a caloric deficit, you will lose more than if you eat low carb and NOTcreate a caloric deficit.
    Also, I was intrigued by your statement, “At these low-caloric intakes, calories are what counts. Not diet composition.”
    If I read the quotation from the study correctly, the LC group ate 1086 calories, and the “big breakfast” group ate 1240 calories.
    So, health benefits of LC aside, it doesn’t matter what the ratios of fat, protein, and carbs you eat at this level of calories in terms of weight loss? At what point (caloric-wise) does it start making a difference?
    I’m 5’6, age 53, in menopause (we’ve chatted before) and currently … ugh … 190 pounds (up 40 pounds in the first 18 months of menopause). I’ve done my BMR, etc. and it came to somwhere around 1800 calories per day. Then, to create a caloric deficit, the calculation was to deduct 500 calories per day. That takes me down to about 1300 calories a day. Are you saying that it doesn’t matter if I’m LC or HC (other than being ravenously hungry all the time on HC) at this level?
    By the way, my appointment at Women to Women is in 2 weeks (though I’m seeing a different NP this time). I can’t wait to actually get tested and be treated with the exact dosage of bio-identical hormones that I need. And yes, I’ll go for the creams and gels this time! Thanks once again for steering me in the right direction.
    You had me worried about my equation until I went back and looked at it. It’s the ≠ that’s confusing you. That sign means does not equal. So if you read the sentence with that in mind it says: eating low-carb does not equal losing fat (unless, of course, you create a caloric deficit).
    Yes, you will lose (probably) at the 1300 kcal level irrespective of what kind of a diet you are on. At high calories – as in maintenance – there is a metabolic advantage in that most people can eat a greater number of calories (as low-carb – gotta keep the insulin down) without gaining weight than their metabolic rate would imply that they could. This metabolic advantage doesn’t just appear at the higher calorie intake level. It starts smaller, earlier and builds. So it depends on where (calorically) this starts for you. If it kicks in at the 1200 kcal level you won’t lose as much on HC as you would on LC. In any case, even if you lose the same, you’ll be hungrier and miserable on a low-cal, HC diet.

  13. I have the Big Breakfast Diet book. No where does Dr. say this is a high carb diet. She advices 7 servings of protein for breakfast, carbs and a sweet treat. Her theory, based on the endocrine system which she IS qualified to talk about, is that the day hormones and night hormones require different macros. She says to get your carbs out of the way, in the am. (as do a lot of diets) She does not advocate them at lunch or evening, except moderate fruit. Did you even read the book? The study is posted everywhere and it made sense to me. The study admits that both low-carb and her big breakfast induce weight loss. The trouble is (and always has been) maintenance and keeping the pounds off. And that’s where low-carb and virtually ANY other diet part ways. Staying off of carbs for a lifetime is a delusion. Talk about skewed. I think you are!

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